Preexisting Condition Limitation
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:

Who was continuously covered for an aggregate period of 18 months, with a lapse in coverage of not more than 63 days prior to effective date, excluding any waiting period, and

Whose most recent coverage was under a group plan, a govermental plan, or church plan.

If a participant 's most recent creditable coverage was under a group health plan, a government plan or church plan, but does not have aggregate creditable coverage totaling 18 months, Blue Cross and Blue Shield of Texas will credit the time the participant was previously covered under creditable coverage if the previous coverage was in effect 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.

Additional Limitations and Exclusions
An application and medical underwriting are required. The individual health insurance plans are subject to limitations and exclusions. PPO Select is a service mark of the Blue Cross and Blue Shield Association.

Benefits under the 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 the Workers' Compensation Law.

Any services or supplies covered in whole or in part by any laws of the United States, a foreign country, state or political subdivision.

Charges for services and supplies provided which require the approval of Blue Cross and Blue Shield of Texas 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 professional other 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 Blue Cross and Blue Shield of Texas; any services or supplies provided by a licensed dietitian.

Custodial care.

Routine physical examinations (including a routine Pap smear), diagnostic screening, or immunizations, except mammography screening or well-child 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 jawbone 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, or reconstructive surgery following neoplastic (cancer) surgery.

Eyeglasses, contact lenses, hearing aids, or examinations for the prescription of them; or examinations for detecting visual sharpness.

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 is not part of a physical rehabilitation program.

Travel, whether recommended by a physician or professional other 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) well-child 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 provided my a licenced chemical dependency counselor; or a licennced 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 pysician 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.

Any services or supplies not specifically defined as eligible expenses in the contract.

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.

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