* Exclusions and limitations apply to all plans, unless otherwise noted.

1. Not Medically Necessary. If services requiring Prior Authorization by Blue Cross of Idaho are performed by a Contracting Provider and benefits are denied as not Medically Necessary, the cost of said services are not the financial responsibility of the Insured. However, the Insured could be financially responsible for services found to be not Medically Necessary when provided by a Noncontracting Provider.
2. In excess of the Maximum Allowance.
3. For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures, unless necessary to treat an Accidental Injury or unless an attending Physician certifies in writing that the Insured has a non-dental, life-endangering condition which makes hospitalization necessary to safeguard the Insured's health and life.
4. Not prescribed by or upon the direction of a Physician or other Professional Provider; or which are furnished by any individuals or facilities other than Licensed General Hospitals, Physicians, and other Providers.
5. Investigational in nature.
6. Provided for any condition, Disease, Illness or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers' Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party.
7. Provided or paid for by any federal governmental entity except when payment under the Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity where its charges therefore would vary, or are or would be affected by the existence of coverage under the Policy, or for which payment has been made under Medicare Part A and/or Medicare Part B, or would have been made if an Insured had applied for such payment except when payment under the Policy is expressly required by federal law.
8. Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared.
9. Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured's household.
10. Received from a dental, vision, or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group.
11. For Surgery intended mainly to improve appearance or for complications arising from Surgery intended mainly to improve appearance, except for:
    1. Reconstructive Surgery necessary to treat an Accidental Injury, infection or other Disease of the involved part; or
    2. Reconstructive Surgery to correct Congenital Anomalies in an Insured who is a dependent child.
12. Rendered prior to the Insured's Effective Date; or during an Inpatient admission commencing prior to the Insured's Effective Date, subject to the requirements of the Health Insurance Portability and Accountability Act of 1996.
13. For personal hygiene, comfort, beautification (including non-surgical services, drugs, and supplies intended to enhance the appearance), or convenience items or services even if prescribed by a Physician, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs, spas, hot tubs, whirlpool baths, waterbeds or swimming pools and therapies, including but not limited to, educational, recreational, art, aroma, dance, sex, sleep, electro sleep, vitamin, chelation, massage, or music.
14. For telephone consultations, and all computer or Internet communications; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses or for mileage, transportation, food or lodging expenses billed by a Physician or other Professional Provider.
15. For Inpatient admissions that are primarily for Diagnostic Services, Therapy Services, or Physical Rehabilitation, except as specified in the Policy; or for Inpatient admissions when the Insured is ambulatory and/or confined primarily for bed rest, a special diet, behavioral problems, environmental change or for treatment not requiring continuous bed care.
16. For Outpatient Occupational Therapy; Inpatient or Outpatient Custodial Care; or for Inpatient or Outpatient services consisting mainly of educational therapy, behavior modification, self-care or self-help training, except as specified as a Covered Service in the Policy.
17. For any cosmetic foot care, including but not limited to, treatment of corns, calluses and toenails (except for surgical care of ingrown or Diseased toenails).
18. Related to Dentistry or Dental Treatment, even if Medically Necessary, including but not limited to, dental implants, appliances, or prosthetics, or treatment related to Orthodontia and orthognathic Surgery and any surgical or other treatment of temporomandibular joint syndrome including pain, treatment, or diagnostic testing or evaluation related to the misalignment or discomfort of the temporomandibular joint (jaw hinge), including splinting services and supplies; or for alveolectomy or alveoloplasty when related to tooth extraction.
19. For hearing aids or examinations for the prescription or fitting of hearing aids.
20. For orthoptics, eyeglasses or contact lenses or the vision examination for prescribing or fitting eyeglasses or contact lenses, unless specified as a Covered Service in the Policy.
21. For any treatment of either gender leading to or in connection with transsexual Surgery, gender transformation, sexual dysfunction, or sexual inadequacy, including erectile dysfunction and/or impotence, even if related to a medical condition.
22. Made by a Licensed General Hospital for the Insured's failure to vacate a room on or before the Licensed General Hospital's established discharge hour.
23. Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury.
24. Furnished by a facility that is primarily a place for treatment of the aged or that is primarily a nursing home, a convalescent home, or a rest home.
25. For Acute Care, rehabilitative care or diagnostic testing or evaluation of Inpatient or Outpatient Mental or Nervous Conditions, Alcoholism, Substance Abuse or Addiction, or for Pain Rehabilitation, except as specified as a Covered Service in the Policy.
26. Incurred by an enrolled Eligible Dependent child for care or treatment of any condition arising from or related to pregnancy, childbirth, delivery, or an Involuntary Complication of Pregnancy unless specified as a Covered Service in the Policy.
27. For weight control or treatment of obesity or morbid obesity, even if Medically Necessary, including but not limited to Surgery for obesity. For reversals or revisions of Surgery for obesity, except when required to correct an immediately life-endangering condition.
28. For an elective abortion, unless to preserve the life of the female upon whom the abortion is performed .
29. For use of operating, cast, examination, or treatment rooms or for equipment located in a Contracting or Noncontracting Provider's office or facility, except for emergency room facility charges in a Licensed General Hospital, unless specified as a Covered Service in the Policy.
30. For the reversal of sterilization procedures, including but not limited to, vasovasostomies or salpingoplasties.
31. Treatment for infertility and fertilization procedures, including but not limited to, ovulation induction procedures and pharmaceuticals, artificial insemination, in vitro fertilization, embryo transfer or similar procedures, or procedures that in any way augment or enhance an Insured's reproductive ability.
32. For Transplant Services and Artificial Organs, except as specified as a Covered Service in the Policy.
33. For acupuncture.
34. For Chiropractic Care, except if specifically provided as a covered service in the policy.
35. For surgical procedures that alter the refractive character of the eye, including but not limited to, radial keratotomy, myopic keratomileusis, Laser-In-Situ Keratomileusis (LASIK), and other surgical procedures of the refractive-keratoplasty type, to cure or reduce myopia or astigmatism, even if Medically Necessary. Additionally, reversals, revisions, and/or complications of such surgical procedures are excluded, except when required to correct an immediately life-endangering condition.
36. For Hospice Home Care, except as specified as a Covered Service in the Policy.
37. For pastoral, spiritual, bereavement, family and/or marriage counseling.
38. For homemaker and housekeeping services or home-delivered meals.
39. For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation.
40. Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under the Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage.
41. For a routine or periodic mental or physical examination that is not connected with the care and treatment of an actual Illness, Disease or Accidental Injury or for an examination required on account of employment; or related to an occupational injury; for a marriage license; or for insurance, school or camp application; or for sports participation physical; or a screening examination, except as specified as a Covered Service in the Policy.
42. For immunizations, except as specified as a Covered Service in the Policy.
43. For breast reduction Surgery or Surgery for gynecomastia.
44. For nutritional supplements, nutritional replacements, nutritional formulas, prescription vitamins and minerals.
45. For alterations or modifications to a home or vehicle.
46. For special clothing, including shoes (unless permanently attached to a brace).
47. Provided to a person enrolled as an Eligible Dependent, but who no longer qualifies as an Eligible Dependent due to a change in eligibility status that occurred after enrollment.
48. Provided outside the United States, which if had been provided in the United States, would not be a Covered Service under the Policy.
49. Furnished by a Provider or caregiver that is not listed as a Covered Provider, including but not limited to, naturopaths.
50. For Outpatient pulmonary and/or cardiac rehabilitation.
51. For complications arising from the acceptance or utilization of noncovered services.
52. For the use of Hypnosis, as anesthesia or other treatment, except as specified as a Covered Service.
53. For arch supports, orthopedic shoes, and other foot devices.
54. Any services or supplies furnished by a facility that is primarily a health resort, or sanatorium, residential treatment facility, transitional living center, or primarily a place for Outpatient treatment or residential facility care of Mental or Nervous Conditions.
55. Contraceptives, oral or other, whether medication or device, except when specified as a covered service.
56. For wigs and cranial molding helmets.
57. For surgical removal of excess skin that is the result of weight loss or gain, including but not limited to association with prior weight reduction (obesity) surgery.
58. For the purchase of Therapy or Service Dogs/Animals and the cost of training/maintaining said animals.
59. * In HSA and PPO Plus Plans: For treatment or other health care of any Insured in connection with an Illness, Disease, Accidental Injury or other condition which would otherwise entitle the Insured to Covered Services under this Policy, if and to the extent those benefits are payable to or due the Insured under any medical payments provision, no fault provision, uninsured motorist provision, underinsured motorist provision, or other first party or no fault provision of any automobile, homeowner's, or other similar policy of insurance, contract, or underwriting plan.
    
    In the event BCI for any reason makes payment for or otherwise provides benefits excluded by the above provisions, it shall succeed to the rights of payment or reimbursement of the compensated Provider, the Insured, and the Insured's heirs and personal representative against all insurers, underwriters, self-insurers or other such obligors contractually liable or obliged to the Insured, or his or her estate for such services, supplies, drugs or other charges so provided by BCI in connection with such Illness, Disease, Accidental Injury or other condition.
60. * In PPO BASIC Plan: For allergy injections and allergy testing.
61. * IN PPO BASIC Plan: For growth hormone therapy.
62. * In HSA Plan: Incurred by the Insured for the care or treatment of any conditions arising from or related to pregnancy, childbirth, or delivery, except as provided specifically in this Policy for Involuntary Complications of Pregnancy.