Like most health care plans, Blue Advantage, Blue Advantage Saver and Blue Options HSA have some limitations and exclusions. When your application is approved, and you become a member, you will have access to your benefit booklet online. It will contain detailed information about plan benefits, exclusions and limitations.

This is a partial list of benefits that are not payable.

• Not medically necessary
• Investigational in nature or obsolete, including any service, drugs, procedure or treatment directly related to an investigational treatment
• Any experimental drug or any drug not approved by the Food and Drug Administration (FDA) for the applicable diagnosis or treatment. However, this exclusion does not apply to prescription drugs used in covered phases II, III and IV clinical trials, or drugs approved by the FDA for treatment of cancer, if prescribed for the treatment of any type of cancer for which the drug has been approved as effective and accepted in any one of the following:
  1. The National Comprehensive Cancer Network Drugs & Biologics Compendium
  2. The ThomsonMicromedex DrugDex
  3. The Elsevier Gold Standard's Clinical Pharmacology
  4. Any other authoritative compendia as recognized periodically by the United States Secretary of Health and Human Services
• Side effects and complications of noncovered services, except for emergency services in the case of an emergency
• Not prescribed or performed by or upon the direction of a doctor or other provider
• For any condition, disease, illness or injury that occurs in the course of employment, if the employee, employer or carrier is liable or responsible for the specific medical charge (1) according to a final adjudication of the claim under a state's workers' compensation laws, or (2) by an order of a state Industrial Commission or other applicable regulatory agency approving a settlement agreement
• Injections by a health care professional of injectable prescription drugs which can be self-administered, unless medical supervision is required
• For inpatient admissions primarily for the purpose of receiving diagnostic services or a physical examination. Inpatient admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy
• For care in a self-care unit, apartment or similar facility operated by or connected with a hospital
• For custodial care
• For domiciliary care or rest cures, care provided and billed for by a hotel, health resort, convalescent home, rest home, nursing home or other extended care facility, home for the aged, infirmary, school infirmary, institution providing education in special environments, in residential treatment facilities, except for substance abuse treatment, or any similar facility or institution
• For respite care, whether in the home or in a facility or inpatient setting, except as specifically covered by your health benefit plan
• Received prior to the member's effective date
• Services received either before or after the coverage period of your health benefit plan, regardless of when the treated condition occurred, and regardless of whether the care is a continuation of care received prior to the termination
• For telephone consultations, charges for failure to keep a scheduled visit, charges for completion of a claim form, charges for obtaining medical records, and late payment charges
• Incurred more than 18 months prior to the member's submission of a claim to BCBSNC, except in the absence of legal capacity of the member
• For cosmetic services, which include removal of excess skin from the abdomen, arms or thighs, except as specifically covered by your health benefit plan
• For any services that would not be necessary if a non-covered service had not been received, except for emergency services in the case of an emergency
• For benefits that are provided by any governmental unit except as required by law
• For services that are ordered by a court that are otherwise excluded from benefits under this health benefit plan
• For care that the provider cannot legally provide or legally charge or is outside the scope of license or certification
• Provided and billed by a licensed health care professional who is in training
• Available to a member without charge
• For care given to a member by a provider who is in a member's immediate family
• For any condition suffered as a result of any act of war or while on active or reserve military duty
• In excess of the allowed amount for services usually provided by one doctor, when those services are provided by multiple doctors
• For palliative, cosmetic or routine foot care
• For dental care, dentures, oral orthotic devices, palatal expanders and orthodontics except as specifically covered by your health benefit plan
• For dental implants
• Dental services provided in a hospital, except as specifically covered by your health benefit plan
• For any treatment or regimen, medical or surgical, for the purpose of reducing or controlling the weight of a member or for treatment of obesity, except for surgical treatment of morbid obesity
• Wigs, hair pieces and hair implants for any reason
• Received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group
• For sexual dysfunction unrelated to organic disease
• Treatment or studies leading to or in connection with sex changes or modifications and related care
• Music therapy, remedial reading, recreational or activity therapy, all forms of special education and supplies or equipment used similarly
• Hypnosis except when used for control of acute or chronic pain
• Acupuncture and acupressure
• Surgery for psychological or emotional reasons
• Travel, whether or not recommended or prescribed by a doctor or other licensed health care professional, except as specifically covered by your health benefit plan
• Heating pads, hot water bottles, ice packs and personal hygiene and convenience items such as, but not limited to, devices and equipment used for environmental control
• Devices and equipment used for environmental accommodation requiring vehicle and/or building modifications such as, but not limited to, chair lifts, stair lifts, home elevators, and ramps
• Standing frames
• Personal computers
• Air conditioners, furnaces, humidifiers, dehumidifiers, vacuum cleaners, electronic air filters and similar equipment
• Physical fitness equipment, hot tubs, Jacuzzis, heated spas, pool or memberships to health clubs
• Eyeglasses or contact lenses
• Orthoptics, vision training, and low vision aids
• Radial keratotomy and other refractive eye surgery, and related services to correct vision except for surgical correction of an eye injury. Also excluded are premium intraocular lenses or the services related to the insertion of premium lenses beyond what is required for insertion of conventional intraocular lenses, which are small, lightweight, clear disks that replace the distance-focusing power of the eye's natural crystalline lens
• Routine hearing examinations and hearing aids or examinations for the fitting of hearing aids except as specifically covered by your health benefit plan
• Evaluation and treatment of developmental dysfunction and/or learning differences
• Medical care provided by more than one doctor for treatment of the same condition
• Clomiphene (e.g., Clomid), menotropins (e.g., Repronex) or other drugs associated with conception by artificial means
• For maintenance therapy. Maintenance therapy includes services that preserve your present level of function or condition and prevent regression
• For massage therapy services
• For holistic medicine services
• For services primarily for educational purposes including, but not limited to, books, tapes, pamphlets, seminars, classroom, Web or computer programs, individual or group instruction and counseling, except as specifically covered by your health benefit plan
• For genetic testing, except for high risk patients when the therapeutic or diagnostic course would be determined by the outcome of the testing
• Services whose efficacy has not been established by controlled clinical trials, or are not recommended as a preventive service by the US Public Health Service, except as specifically covered by your health benefit plan
• Shoe lifts and shoes of any type, unless part of a brace
• For any condition, disease, ailment, injury or diagnostic service to the extent that benefits are provided or persons are eligible for coverage under Title XVIII of the Social Security Act of 1965, including amendments, except as otherwise provided by federal law
• For conditions that federal, state or local law requires to be treated in a public facility
• For vitamins, food supplements or replacements, nutritional or dietary supplements, formulas or special foods of any kind, except for prescription pre-natal vitamins or prescription vitamin B-12 injections for anemias, neuropathies or dementias secondary to a vitamin B-12 deficiency
• Ear piercing
• Collection and storage of blood and stem cells taken from the umbilical cord and placenta for future use in fighting a disease
• Services, supplies, drugs or equipment used for the control or treatment of stammering or stuttering

Your coverage may be canceled by BCBSNC for failure to pay premiums and for false statements on your application, among other reasons. Coverage for dependent children ends at age 26. Members will be notified 30 days in advance of any change in coverage. A waiting period for coverage of pre-existing conditions may apply to your coverage.¹ These pages contain available benefits only. They are not your insurance policy. Your policy is your insurance contract. If there is any difference between these pages and the policy, the provisions of the policy will control.

Pre-existing conditions are defined as those for which medical advice, diagnosis, care or treatment was received or recommended within the 12 months prior to the date that this coverage begins. You may receive credit toward the 12-month waiting period, if we receive your completed application within 63 days of the termination of your previous creditable health coverage.