This policy does not provide benefits for the following services, supplies or charges:

• Benefits for pre-existing conditions are excluded until any pre-existing waiting periods have been met;
• Pharmaceuticals, drugs and drug compounds except for generic drugs for SimplyBluePlus policyholders;
• Services and supplies related to behavioral health, including alcohol and substance abuse;
• Services or supplies that are determined to not be medically necessary and appropriate or have not been authorized by BlueCross BlueShield of Tennessee;
• Benefits for conditions which are listed in the benefit exclusion rider, if applicable, are excluded;
• Illness or injury resulting from war and covered by veteran’s benefits. Other coverage for which the member is legally entitled and which occurred before the member’s coverage began under this policy;
• Non-medical self treatment or training;
• Staff consultations required by hospital or other facility rules;
• Services which are free;
• Services required as a result of an attempt or commission of a felony by the member;
• Any work-related illness or injury unless resulting from self-employment;
• Personal and convenience items and services such as: 
  (1) barber and beauty services; (2) television; (3) air conditioners; (4) humidifiers; (5) air filters; (6) heaters; (7) physical fitness equipment; (8) saunas; (9) whirlpools; (10) water purifiers; (11) swimming pools; and (12) tanning beds. Other recreational equipment including: (1) weight loss programs; (2) physical fitness programs; or (3) self-help devices which are not primarily medical in nature, even if ordered by a practitioner. Motorized scooters, deluxe or enhanced equipment. In all instances, the most basic equipment needed to provide the needed medical care will determine the benefit;
• Services or confinements that occurred before the member’s effective date for coverage under this policy;
• Services or supplies received in a dental or medical department maintained by or on behalf of a member’s employer, mutual benefit association, labor union or similar group;
• Telephone or e-mail consultations, or charges for failure to keep a scheduled appointment;
• Services for providing requested medical information or completing forms;
• Court-ordered examinations and treatment, unless medically necessary;
• Room, board and general nursing care rendered on the date of discharge, unless admission and discharge occur on the same day;
• Charges in excess of the maximum allowable charge for covered services or any charges which exceed the lifetime maximum;
• Charges for services performed by you or your spouse, or your or your spouse’s parent, sister, brother or child, are not covered;
• Normal pregnancy, delivery or routine newborn nursery care unless covered by maternity rider;
• Routine foot care;
• Custodial, domiciliary or private duty nursing services;
• Services or supplies that are designed to medically enhance a member’s level of fertility in the absence of a disease;
• Assisted reproductive technology (ART), such as GIFT, ZIFT, invitrofertilization and fertility drugs;
• Elective abortions;
• Services, supplies or prosthetics primarily to improve appearance;
• Surgeries and related services to change gender;
• Services and supplies to detect or correct refractive errors of the eyes;
• Eyeglasses, contact lenses and examination for the fitting of eyeglasses and contact lenses;
• Any service stated in Attachment A of the SimplyBlue or SimplyBluePlus Policy as a non-covered service or limitation;
• Services or supplies not listed as covered services under Attachment A, Covered Services of the SimplyBlue or SimplyBluePlus Policy;
• Services or supplies that are experimental or investigational in nature including, but not limited to: (1) drugs; (2) biologicals; (3) medications; (4) devices; and (5) treatments;
• Services or supplies related to cosmetic services, including surgical or other services, drugs or devices. Cosmetic services include, but are not limited to: (1) removal of tatoos; (2) removal of moles; (3) facelifts; (4) blepharoplasty; (5) keloid removal; (6) dermabrasion; (7) chemical peels; (8) rhinoplasty; (9) breast augmentation; and (10) breast reduction;
• Removal of impacted teeth, including wisdom teeth;
• Services or supplies for the reversal of sterilization;
• Hearing aids;
• Prosthetics primarily for cosmetic purposes, including but not limited to wigs, or other hair prosthesis or transplants;
• Items to replace those that were lost, damaged, stolen, or prescribed as a result of new technology;
• Supplies/drugs that can be purchased without a prescription;
• Any drug that is purchased outside the United States except those authorized by BlueCross BlueShield of Tennessee;
• Any quantity of prescription drugs which exceed that specified by BlueCross BlueShield of Tennessee Pharmacy and Therapeutics Committee;
• Handling fees;
• Services or supplies related to obesity, including surgical or other treatment of morbid obesity;
• Human growth hormones, except for: (1) treatment of absolute growth hormone deficiency in children whose epiphyses have not closed; and (2) treatment of patients with "Turner" syndrome, including the drugs, (1) Genotropin; (2) humantrope; (3) Norditropin; (5) Saizen (6) Serostim; (7) Somotropin; and (8) Protropin (Somarem);
• Office visits and physical exams for: (1) school; (2) camp; (3) employment; (4) travel; (5) insurance; (6) marriage or legal proceeding; and (7) related immunizations and tests;
• Treatment of sexual dysfunction including, but not limited to, erectile dysfunction (e.g. Viagra), delayed ejaculation, anorgasmia and decreased libido; and
• Massage therapy.

This page is a summary and is not all inclusive. Your policy provides a complete list of benefits, limitations, exclusions and provisions.  Certain medical conditions may be excluded.