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Dental Services (hospital or ambulatory surgical facility services and anesthesia)

Diabetic Self-management

Educational Training

Equipment

Experimental/Investigational

Eye Exam

inations

Foot Care

Gene Manipulation Therapy Genetic Testing or Counseling

Government Agency

Hair Loss

Hearing Examinations and Hearing Aids Holistic Therapies Hypnosis Infertility Treatment, Artificial Insemination, Intrauterine Insemination, In-vitro Fertilization, or Reversal of Sterilization Luxury, Deluxe, or Convenience Items Massage Therapy Maternity Benefits

Medical Records

Hospital services and supplies for dental care and treatment and dental or oral surgery are not covered unless the inpatient hospital stay is determined medically necessary by Intracorp. Outpatient hospital, ambulatory surgical facility, or anesthesia services are not covered unless determined medically necessary by Blue Cross & Blue Shield.

Outpatient diabetic self-management training/education and medical nutrition therapy are not covered, except as provided through the disease state management program of the Plan. Educational training or cognitive therapy is not covered unless otherwise specified in this Plan Document. Equipment that has a non-therapeutic use (such as humidifiers, air conditioners or filters, whirlpools, wigs, vacuum cleaners, fitness supplies, etc.) is not covered. Experimental/investigational treatments, procedures, facilities, equipment, and supplies are not covered, as determined by Blue Cross & Blue Shield or Intracorp.

Routine eye examinations, eyeglasses, or contact lenses or fittings for them are not covered. Palliative or cosmetic foot care is not covered.

Not covered. Not covered.

Services or supplies provided by the U.S. or any other

government agency, at no charge to the patient, are not covered. Services and supplies for the treatment of hair loss are not covered. Not covered.

Not covered. Not covered. Not covered.

Not covered.

Not covered. Charges or expenses related to the pregnancy of a dependent other than the spouse are not covered. Fees for medical records and claim filing are not covered.

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