Benefits of this plan are not available for care rendered during the first two years for conditions existing within two years before the effective date of coverage. This exclusion does not apply to a participant:

1. Who was continuously covered for an aggregate period of 18 months under creditable coverage if the previous coverage was in effect up to a date not more than 63 days before the effective date of the participant's coverage under this contract, excluding any waiting periods; and
2. Whose most recent creditable coverage was under a group health plan, a governmental plan or a church plan.

If a participant's most recent prior creditable coverage was under a group plan, a governmental plan or a church plan, but he does not have aggregate creditable coverage totaling 18 months, we will credit the time the participant was previously covered under creditable coverage if the previous coverage was in effect at any time during the 18 months preceding (a) the first day coverage is effective under this contract if there is not a waiting period; or (b) the day the applicant files a substantially complete application for coverage if there is a waiting period.

Benefits of the medical portion of this plan are not available for:

• Services or supplies not medically necessary for the treatment of a sickness, injury, condition, disease, or bodily malfunction; any experimental/investigational services and supplies.
• Any charges more than the allowable amount as determined by us.
• Any services or supplies for which benefits are, or upon proper claim would be, provided under Workers' Compensation Law.
• Any services or supplies covered in whole or in part by any laws of the United States (including Medicare), a foreign country, state or political subdivision.
• Charges for services and supplies provided which require our approval when approval is not given.
• Services or supplies for which you are not required to make payment or for which you are not legally required to pay without this or any similar coverage (except treatment of mental illness or mental retardation by a tax supported institution).
• Any services or supplies provided by a person who is related to you by blood or marriage.
• Treatment of injury or sickness because of war, acts of war, or while on active or reserve military duty.
• Any charges because of suicide or attempted suicide.
• Charges resulting from failure to keep a scheduled visit with a physician or other professional provider, for completion of any insurance forms, or for acquisition of medical records unless requested and received by us.
• Room and board charges during a hospital admission for diagnostic or evaluation procedures unless the tests could not have been done on an outpatient basis.
• Services or supplies provided during a hospital admission or an admission in a facility or other provider beginning before the patient's effective date, or services or supplies provided after the termination of the participant's coverage, except as provided in the contract.
• Dietary and nutritional services, except a nutritional assessment program provided in and by a Hospital and approved in advance by us; any services or supplies provided by a licensed dietitian.
• Custodial care.
• Routine physical examinations (including a routine Pap smear), diagnostic screening, or immunizations, except (1) mammography screening, (2) childhood immunizations, (3) certain tests for the detection of prostate cancer, or (4) preventive care as provided in the contract.
• Services or supplies (except medically necessary diagnostic and/or surgical procedures) for treatment of the jaw bone joints, muscles, or their related structures with appliances or splints, physical therapy, or alteration to eliminate pain or dysfunction.
• Services or supplies provided to correct congenital, developmental or acquired deformities of the jaw bone after a participant's 19th birthday.
• Any items of medical-surgical expense provided for dental care and treatments, dental surgery, or dental appliances, except (1) oral surgery, (2) congenital defects of a dependent child, or (3) services made necessary by accidental injury occurring while the participant is covered under this contract.
• Cosmetic, reconstructive or plastic surgery unless caused by injury, congenital defects of a dependent child, reconstructive surgery following cancer surgery, or breast reconstruction surgery following mastectomy.
• Refractive surgery, or eyeglasses, contact lenses or, hearing aids, or examinations for the prescription of them; or examinations for detecting visual sharpness or level of hearing, except as provided under preventive care.
• Mental and nervous disorders, except organic brain disease as defined in the contract.
• Medical social services; any outpatient family counseling and/or therapy, bereavement counseling, vocational counseling, or marriage and family therapy and/or counseling; any services or supplies provided by a licensed master social worker-advanced clinical practitioner, a licensed professional counselor, or a marriage and family therapist.
• Treatment of adolescent behavior disorders, including conduct disorders and oppositional disorders.
• Occupational therapy services that do not consist of traditional physical therapy modalities and are not part of a physical rehabilitation program.
• Travel, whether recommended by a physician or other professional provider, except ambulance services as provided in the contract.
• Treatment of obesity or weight, including surgical procedures, even if other health conditions might be helped by the reduction.
• Any services or supplies for inpatient allergy testing, or any testing or treatment for environmental sensitivity or clinical ecology, or any treatment not recognized as safe and effective.
• Any services or supplies provided with chelation therapy, except treatment of acute metal poisoning.
• Any services or supplies for sterilization reversal (male or female), transsexual surgery, sexual dysfunction, in vitro fertilization services, or artificial insemination.
• Routine foot care as described in the contract.
• Any speech and hearing services except (1) extended care expense and (2) preventive care as provided in the contract.
• Any services or supplies for reduction mammoplasty.
• Services or supplies for acupuncture, videofluoroscopy, intersegmental traction, surface EMGs, manipulation under anesthesia, and muscle testing through computerized kinesiology machines such as Isostation, Digital Myograph and Dynatron.
• Services or supplies for treatment of chemical dependency; services or supplies provided by a licensed chemical dependency counselor or a licensed psychological associate.
• Any prescription antiseptic or fluoride mouthwashes, mouth rinses, or topical oral solutions or preparations; or any Retin-A or pharmacologically similar topical drugs for participants age 25 and older.
• Any prescription drug products for smoking cessation; for example, nicotine gum or nicotine patches.
• Maternity care.
• Orthodontic or other dental appliances; splints or bandages provided by a physician in a non-hospital setting or purchased "over-the-counter" for support of strains and sprains; orthopedic shoes which are a separable part of a covered brace, specially ordered, custom-made or built-up shoes, cast shoes, shoe inserts designed to support the arch or affect changes in the foot or foot alignment, arch supports, elastic stockings and garter belts.
• Services or supplies provided for or in conjunction with a condition which has been specifically excluded for a participant.
• Any drugs and medicines purchased for use outside a hospital which require a written prescription for purchase, other than injectable drugs administered by or under the direct supervision of a physician or other professional provider, except as provided under the prescription drug program.
• Any services or supplies not specifically defined as eligible expenses in the contract.

The benefits provided under the prescription drug program are not available for:

• Drugs which do not by law require a prescription order from a provider (except injectable insulin); and drugs, insulin, or covered devices for which no valid prescription order is obtained.
• Devices or durable medical equipment of any type (even though such devices may require a prescription order), such as, but not limited to, contraceptive devices, therapeutic devices, artificial appliances, or similar devices (except disposable hypodermic needles and syringes for self-administered injections).
• Administration or injection of any drugs.
• Vitamins (except those vitamins which by law require a prescription order and for which there is no non-prescription alternative).
• Drugs dispensed in a physician's office or during confinement while a patient in a hospital, or other acute care institution or facility, including take-home drugs; and drugs dispensed by a nursing home or custodial or chronic care institution or facility.
• Covered drugs, devices, or other pharmacy services or supplies for which benefits are, or could upon proper claim be, provided under the Workers' Compensation Law.
• Covered drugs, devices, or other pharmacy services or supplies covered in whole or in part by any laws of the United States (including Medicare), a foreign country, state or political subdivision.
• Any services provided or items furnished for which the pharmacy normally does not charge.
• Drugs for which the pharmacy's usual and customary charge to the general public is less than or equal to the copayment amount provided under this plan.
• Contraceptive devices, contraceptive materials, infertility medication, and fertility medication (except oral contraceptive medications which are legend drugs).
• Any prescription antiseptic or fluoride mouthwashes, mouth rinses, or topical oral solutions or preparations; and any Retin-A or pharmacologically similar topical drugs for participants age 25 and older.
• Drugs required by law to be labeled: "Caution - Limited by Federal Law to Investigational Use," or experimental drugs, even though a charge is made for the drugs.
• Covered drugs dispensed in quantities in excess of the amounts stipulated in limitations on quantities dispensed or refills of any prescriptions in excess of the number of refills specified by the physician or by law, or any drugs or medicines dispensed more than one year following the prescription order date.
• Legend drugs which are not approved by the U.S. Food and Drug Administration (FDA) for a particular use or purpose or when used for a purpose other than the purpose for which FDA approval is given.
• Fluids, solutions, nutrients, or medications (including all additives and chemotherapy) used or intended to be used by intravenous or gastrointestinal (enteral) infusion or by intravenous injection in the home setting.
• Drugs prescribed and dispensed for the treatment of obesity or for use in any program of weight reduction, weight loss, or dietary control.
• Drugs, the use or intended use of, which would be illegal, unethical, imprudent, abusive, not medically necessary, or otherwise improper.
• Drugs obtained by unauthorized, fraudulent, abusive, or improper use of the identification card.
• Drugs used or intended to be used in the treatment of a condition, sickness, disease, injury, or bodily malfunction which is not covered under the program, or for which benefits have been exhausted.
• Rogaine, Minoxidil or any other drugs, medications, solutions or preparations used or intended for use in the treatment of hair loss, hair thinning or any related condition, whether to facilitate or promote hair growth, to replace lost hair, or otherwise.
• Any smoking cessation prescription drug products, including, but not limited to, nicotine gum or nicotine patches.

Disclosure Statement
This insurance is provided by Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.