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Guaranteed Issue

Providing the Coverage You Need For Pre-Existing Conditions

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You’ve lost health coverage through TennCare.

Your employer is dropping its employee health insurance plan.

You’re changing jobs and your new company does not offer health insurance.

You are about to exhaust your COBRA coverage.

Your job has been transferred overseas.

If you find yourself in any of these situations and you have a medical condition that requires ongoing

care and treatment, health insurance may be available to you without a waiting period for a

pre-existing condition or a benefit exclusion rider. The Health Insurance Portability and Accountability

Act of 1996 (HIPAA) requires that insurance companies offer health plans without exclusions or

limitations on pre-existing medical conditions to individuals who meet certain qualifications.

Guaranteed Issue

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Qualifications for Guaranteed Issue Health CoverageYou may apply for guaranteed issue coverage if:

• You have had creditable coverage for a minimum of 18 months and you have exhausted all available COBRA or state continuation benefits;

• You are not eligible for Medicare A or B, Medicaid, TennCare or other group coverage;• Your previous health coverage is no longer available to you; • Your coverage has not been canceled due to fraud or non-payment of premiums;• And you have not had a lapse in coverage for more than 63 days.

What Types of Coverage are Considered Creditable Coverage?The following types of coverage count as creditable coverage. The required 18 months of creditable coverage can be from a combination of these types of coverage:

• Employer-sponsored health plan• COBRA• Government health plans (such as TennCare, TRICARE, CHAMPUS or CHAMPVA)• Church plans• Tennessee Rural Health (TRH) plans• Short-term health plans

Your most recent coverage must be through an employer-sponsored plan or a government or church plan. Although TRH and Short-term plans qualify as creditable coverage, you cannot move directly from one of these plans to a guaranteed issue plan.

Guaranteed Issue Coverage From BlueCross BlueShield of TennesseeBlueCross BlueShield of Tennessee offers two guaranteed issue choices: SimplyBlue Guaranteed Issue and Personal Health Coverage Guaranteed Issue.

Guaranteed Issue

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SimplyBlueTM Guaranteed Issue

SimplyBlue Guaranteed IssueSimplyBlue Guaranteed Issue is a low-cost health insurance product that provides basic medical coverage subject to a deductible and coinsurance. You can enhance your coverage by choosing a SimplyBluePlus Guaranteed Issue plan that includes copays for two office visits for illness or injuries, and limited coverage for generic drugs. Access to Blue Network S ProvidersAs with all BlueCross BlueShield of Tennessee individual health plans, you are free to choose any health care provider you wish without referrals. However, you always receive the highest level of benefits when you use network providers.

With SimplyBlue, you can save money by choosing providers from Blue Network S, which includes medical centers and providers throughout the state. However, members in some areas may have to travel greater distances to receive in-network care. For example, Blue Network S members who live in rural areas of middle Tennessee may be required to travel to Nashville to receive in-network services. Or, Blue Network S may only include certain highly-specialized providers in one urban center, requiring a member to travel from Chattanooga to Nashville.

Please visit bcbst.com for a list of current Blue Network S providers. SimplyBlue Plan Options

Note: Coinsurance applies to maximum allowable charges. Out-of-pocket maximums for in-network and out-of-network covered services are separate and do not combine. Any balance of charges (difference between billed charge and the maximum allowable charge) does not apply to your deductible and out-of-pocket maximums.

In-Network Deductible Coinsurance Out-of-Pocket Maximum (Includes Deductible) Self-Only Family Plan Pays You Pay Self-Only Family $1,500 $3,000 80% 20% $6,500 $13,000

$2,500 $5,000 80% 20% $7,500 $15,000

$3,500 $7,000 80% 20% $8,500 $17,000

Plan Code

Self-O

nly

Fami

ly

Out-of-Network Deductible Coinsurance Out-of-Pocket Maximum (Includes Deductible) Self-Only Family Plan Pays You Pay Self-Only Family $3,000 $6,000 60% 40% $19,500 $39,000

$5,000 $10,000 60% 40% $22,500 $45,000

$7,000 $14,000 60% 40% $25,500 $51,000

Plan Code

Self-O

nly

Fami

ly

T1S T1F

T2S T2F

T3S T3F

T1S T1F

T2S T2F

T3S T3F

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SimplyBlueTM Guaranteed Issue

Note: Benefits are only paid on medically necessary and medically appropriate covered services. See your policy for complete coverage details. Certain services require prior authorization. Out-of-network benefits are provided at 50 percent of the maximum allowable charge when prior authorization is not obtained. See the last page of this brochure for plan exclusions.

One Deductible and Out-of-Pocket Maximum for Family CoverageAll family members’ expenses contribute to one deductible and out-of-pocket maximum. Therefore, the full family deductible must be met before benefits are paid on any family member’s claim. Covered Wellness and Preventive Services

• Well-child care, to age 6, including appropriate immunizations, vision and hearing screenings, and other appropriate diagnostics.

• Annual well-woman exams including pap smears and any follow-up care. • Mammograms. • Prostate screening. • Other preventive health services for members age 6 and over including:

º Adult well care º Childhood immunizations º Blood pressure screenings º Periodic cholesterol screenings º Periodic screening sigmoidoscopy and colonoscopy º Flu shot º Tetanus-diphtheria (Td) booster º Pneumoccocal immunization º Recommended adult immunizations and immunizations not received in childhood º Prescribed X-rays and lab screenings associated with preventive care º Speech and hearing screenings performed by physician during the preventive health exam º Immunizations needed for foreign travel.

Note: Some of these services are not needed every year or may be appropriate only for people of particular age groups, gender, or those who meet other specific health criteria.

Covered Services Subject to Deductible and Coinsurance• Medically necessary and appropriate services in a practitioner’s office.• Diagnostic services. • Injections.• Inpatient hospitalization including room and board in a semi-private room, general nursing care, medications,

injections, diagnostics and special care units. • Outpatient facility services, including outpatient surgery centers, hospital outpatient centers and outpatient

diagnostic centers. • Emergency care services.• Skilled nursing and rehabilitation facilities (30-day annual limit).• Therapeutic services including physical therapy, speech therapy, occupational therapy and manipulative

therapy (20-visit limit per year per therapy). Therapeutic services for cardiac and pulmonary rehabilitative services (36-visit limit per year per therapy).

• Durable medical equipment, prosthetics and orthotics. • Home health services (40-visit limit per year; prior authorization required).• Ambulance services. • Hospice services. • Organ transplants.• TMJ (non-surgical).

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More Benefits With SimplyBluePlusIn addition to the benefits previously described, SimplyBluePlus plan options offer you more benefits to help you stay well and budget your health care dollars.

$30 Copay for Office VisitsMedically necessary treatment for illness or injuries at your network physician’s office. (Limit two per calendar year.)

Generic Prescription Drug Coverage SimplyBluePlus also provides benefits to help cover the cost of your prescription drugs when you choose a generic drug. Just pay a $15 copay and visit a participating pharmacy from the RX03 pharmacy network. Please visit bcbst.com for a list of RX03 network pharmacies.

Note: Coinsurance applies to maximum allowable charges. Out-of-pocket maximums for in-network and out-of-network covered services are separate and do not combine. Any balance of charges (difference between billed charge and the maximum allowable charge) does not apply to your deductible and out-of-pocket maximums.

In-Network Deductible Coinsurance Out-of-Pocket Maximum (Includes Deductible) Self-Only Family Plan Pays You Pay Self-Only Family $1,500 $3,000 80% 20% $6,500 $13,000

$2,500 $5,000 80% 20% $7,500 $15,000

$3,500 $7,000 80% 20% $8,500 $17,000

Plan Code

Self-O

nly

Fami

ly

T4S T4F

T5S T5F

T6S T6F

Out-of-Network Deductible Coinsurance Out-of-Pocket Maximum (Includes Deductible) Self-Only Family Plan Pays You Pay Self-Only Family $3,000 $6,000 60% 40% $19,500 $39,000

$5,000 $10,000 60% 40% $22,500 $45,000

$7,000 $14,000 60% 40% $25,500 $51,000

Plan Code

Self-O

nly

Fami

ly

T4S T4F

T5S T5F

T6S T6F

SimplyBluePlus Plan Options

SimplyBluePlus Guaranteed Issue

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Personal Health Coverage Guaranteed Issue

Personal Health Coverage Guaranteed IssueIf you need more complete coverage, please consider Personal Health Coverage Guaranteed Issue. These plans offer lower deductibles, copays for generic and brand-name drugs, coverage for behavioral health services and the option to purchase maternity coverage for an additional monthly premium. Access to Blue Network PAs with all BlueCross BlueShield of Tennessee individual health plans, you are free to choose any health care provider you wish without referrals. However, you always receive the highest level of benefits when you use network providers.

With Personal Health Coverage Guaranteed Issue, you will also have access to our broadest provider and pharmacy network. Please visit bcbst.com for a current list of network providers.

Separate Individual and Family Deductibles and Out-of-Pocket MaximumsUnlike SimplyBlue plans, everyone covered under your Personal Health Coverage plan has an individual deductible and out-of-pocket maximum. Once the family deductible level has been met through a combination of all family member claims, only coinsurance applies for all claims. The family out-of-pocket maximum works the same way.

* Note: Coinsurance applies to maximum allowable charges. Deductibles and out-of-pocket maximums for in-network and out-of-network covered services are separate and do not combine. The member coinsurance amounts for behavioral health benefits do not apply to the out-of-pocket maximum. Copays and any balance of charges (between billed charge and the maximum allowable charge), do not apply toward your deductible or out-of-pocket maximum.

H31

H32 H32M

H37 H37M

Plan Code

With

out

Mater

nity

Plan Code

With

Mater

nity

With

out

Mater

nity

With

Mater

nity

H31

H32 H32M

H37 H37M

In-Network Deductible Coinsurance Out-of-Pocket Maximum (Includes Deductible) Individual Family Plan Pays You Pay Individual Family $500 $1,500 80% 20% $1,500 $3,500

$1,000 $3,000 80% 20% $2,000 $5,000

$2,500 $7,500 80% 20% $3,500 $9,500

Out-of-Network Deductible Coinsurance Out-of-Pocket Maximum (Includes Deductible) Individual Family Plan Pays You Pay Individual Family $1,000 $3,000 60% 40% $4,000 $9,000

$2,000 $6,000 60% 40% $5,000 $12,000

$5,000 $15,000 60% 40% $8,000 $21,000

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Note: Benefits are only paid on medically necessary and medically appropriate covered services. See your policy for complete coverage details. Certain services require prior approval. Out-of-network benefits are provided at 50 percent of the maximum allowable charge when prior approval is not obtained.

Covered Services Subject to Deductible and Coinsurance• Medically necessary and medically appropriate services in a practitioner’s office.• Routine diagnostic services. • Injections.• Inpatient hospitalization including room and board in a semi-private room, general nursing care, medications,

injections, diagnostics and special care units. • Outpatient facility services, including outpatient surgery centers, hospital outpatient centers and outpatient

diagnostic centers. • Emergency care services.• Skilled nursing and rehabilitation facilities (30-day annual limit).• Non-routine diagnostic services. • Therapeutic services including physical therapy, speech therapy, occupational therapy and manipulative

therapy (20-visit limit per year per therapy). Therapeutic services for cardiac and pulmonary rehabilitative services (36-visit limit per year, per therapy).

• Durable medical equipment, prosthetics and orthotics. • Home health services (40-visit limit per year).• Ambulance service. • Hospice. • Organ transplants.• TMJ (non-surgical).• Behavioral health programs including coverage for inpatient (60 percent coinsurance applies) and outpatient

services (50 percent coinsurance applies) for care and treatment of mental health disorders and substance abuse disorders (20-day annual inpatient services limit; two episodes per lifetime limit on substance abuse treatment).

• Sterilization.

Personal Health Coverage Guaranteed Issue

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$10/$35/$50 Prescription Drug CopaysPersonal Health Coverage Guaranteed Issue offers a $10 copay for generic drugs, a $35 copay for preferred brand name drugs and a $50 copay for non-preferred brand drugs when you use Pharmacy Network RX03 pharmacies. For a current list of preferred brand-name drugs and network pharmacies, please visit bcbst.com.

Please note: if you purchase a brand-name drug and a generic equivalent is available, you will pay the $10 generic drug copay plus the difference between the cost of the brand-name drug and the generic drug. See the example below:

Covered Wellness and Preventive Benefits • Well-child care, to age 6, including appropriate immunizations, vision and hearing screenings, and other

appropriate diagnostics. • Annual well-woman exams including pap smears and any follow-up care. • Mammograms. • Prostate screening. • Other preventive health services for members age 6 and over including:

º Adult well care º Childhood immunizations º Blood pressure screenings º Periodic cholesterol screenings º Periodic screening sigmoidoscopy and colonoscopy º Flu shot º Tetanus-diphtheria (Td) booster º Pneumoccocal immunization º Recommended adult immunizations and immunizations not received in childhood º Prescribed X-rays and lab screenings associated with preventive care º Speech and hearing screenings performed by physician during the preventive health exam º Immunizations needed for foreign travel.

Note: Some of these services are not needed every year or may be appropriate only for people of particular age groups, gender, or those who meet other specific health criteria.

Maternity Benefit RiderIf you are thinking about starting a family, consider purchasing a maternity benefit rider for coverage of prenatal care, delivery services and routine newborn nursery care at the hospital.

With the rider, eligible maternity services will be covered subject to your plan’s deductible and coinsurance. The maternity rider is only offered at the time of initial enrollment or under the qualifying events of marriage or loss of employer-sponsored coverage. You can drop maternity coverage at any time without terminating your coverage. However, once you drop the maternity coverage, you cannot re-apply unless you have a qualifying event.

Brand-Name Drug Cost $76.19 Generic Equivalent Drug Cost - $25.00 Cost Difference $51.19 Plus Generic Copay +$10.00 You Pay $61.19 Plan Pays $15.00

Personal Health Coverage Guaranteed Issue

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Optional Coverage

Optional Coverage – DentalInclude Personal Dental Coverage with your Guaranteed Issue health plan – or add coverage after your policy has been activated – for just $26.50 per adult and $14.60 for dependents ages 2 through 17. Keep in mind that you cannot have another dental policy in place.

Plan Features

• Choose any dentist you like, but you can save more by using a network dentist• Largest dental PPO network in the state• Low $50 calendar year deductible per person ($150 deductible per family) and annual maximum of

$1,000 per person once the deductible has been met• Preventive and diagnostic services are not subject to the deductible

Covered Dental Services

• Diagnostic and preventive services (two exams and two cleanings in a 12-month period)• Restorative services and major restorative services like crowns and onlays* • Endodontic services • Periodontic services* • Removable and fixed prosthetics* • Oral surgical services• One complete and one panoramic X-ray in a 36-month period; two bitewings (X-rays) in a 12-month period• Children may have one fluoride treatment in a 12-month period

* 12-month waiting period applies to these services. These benefits are payable up to the Maximum Allowable Charge. You may still be responsible for part of this cost. This is a summary of services. Complete coverage details are included in the policy.

Exclusions on Dental Services

• Cosmetic procedures, orthodontic services, prescription drugs, dental implants, mouth guards

This is only a partial list. A complete list of limitations and exclusions is included in the policy and can be requested from your agent or BlueCross BlueShield of Tennessee sales representative.

Optional Coverage – Personal VisionBluePersonal VisionBlue coverage can be added to new or existing individual medical or dental policies. Take advantage of thousands of network providers, including many leading optical retailers including LensCrafters, Pearle Vision, Target Optical, Sears, JC Penney and more. If Personal VisionBlue coverage is terminated, it may not be re-added to the same policy.

Member Advantages

• Low monthly premiums• Annual eye exams covered at a low copay from network providers• Additional savings of up to 40 percent off retail price for frames and lenses• Unlimited discounts after benefits have been used

Plan Options

Your choice of two plans gives you even more flexibility:• Exam Only: $5.81 per member – features a low copay on exams and discounts on materials like glasses and

contact lenses• Exam+ Materials (annual routine vision exam and materials): $14.50 per member – includes copays

for exams and materials with a frame and contact lens allowance

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Getting Started

Who Is Eligible for Coverage?• Those who meet the qualifications for guaranteed issue coverage under HIPAA previously outlined.• Residents of Tennessee.• Dependent children 25 years old or less. • Foreign residents living in the U.S. with proof of a Green Card or a school or work visa.

How To Apply.• Select the Guaranteed Issue plan that’s right for you.• Fill out the application enclosed. Indicate the code of the plan you wish to purchase on your application. • Determine the appropriate rate for your policy.• Include your first month’s premium payment with your application.• Return the completed application to your insurance agent or in the envelope provided.

When Will Your Coverage Begin?If your application is received after your prior coverage has terminated, your guaranteed issue coverage will begin the day after we receive your application. If you submit your application before your existing coverage ends, your guaranteed issue coverage will begin the day after your current coverage terminates.

Your application must be received by BlueCross BlueShield of Tennessee within 63 days of your loss of creditable coverage for you to be eligible for a guaranteed issue policy.

If you elect to purchase Personal Dental Coverage at initial enrollment, your dental policy will be effective on the same day as your health policy. If you add Personal Dental Coverage after your medical effective date, your dental coverage will be effective the first day of the month after your change application has been received by BlueCross BlueShield of Tennessee.

You can terminate your dental coverage at any time without terminating your Guaranteed Issue coverage. Personal Dental Coverage automatically terminates when your Guaranteed Issue coverage terminates.

Your first month’s premium is due with your completed application. BlueCross BlueShield of Tennessee can cancel your coverage back to the effective date if the check received does not clear the bank or your credit card payment is declined.

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SimplyBlue Coverage Exclusions

This policy does not provide benefits for the following services, supplies or charges:

1. Pharmaceuticals, drugs and drug com-pounds except for generic drugs for SimplyBluePlus policyholders;

2. Services and supplies related to behavioral health, including alcohol and substance abuse;

3. Services or supplies that are determined to not be medically necessary and appropriate or have not been authorized by BlueCross BlueShield of Tennessee;

4. Illness or injury resulting from war and covered by veteran’s benefits. Other coverage for which the member is le-gally entitled and which occurred before the member’s coverage began under this policy;

5. Non-medical self treatment or training;

6. Staff consultations required by hospital or other facility rules;

7. Services which are free;

8. Services required as a result of an at-tempt or commission of a felony by the member;

9. Any work-related illness or injury unless resulting from self-employment;

10. Personal and convenience items and services such as: (1) barber and beauty services; (2) television; (3) air condition-ers; (4) humidifiers; (5) air filters; (6) heaters; (7) physical fitness equipment; (8) saunas; (9) whirlpools; (10) water purifiers; (11) swimming pools; and (12) tanning beds. Other recreational equipment including: (1) weight loss programs; (2) physical fitness programs; or (3) self-help devices which are not primarily medical in nature, even if ordered by a practitioner. Motorized scooters, deluxe or enhanced equip-ment. In all instances, the most basic equipment needed to provide the needed medical care will determine the benefit;

11. Services or confinements that occurred before the member’s effective date for coverage under this policy;

12. Services or supplies received in a dental or medical department maintained by or on behalf of a member’s employer, mutual benefit association, labor union or similar group;

13. Telephone or e-mail consultations, or charges for failure to keep a scheduled appointment;

14. Services for providing requested medi-cal information or completing forms;

15. Court-ordered examinations and treat-ment, unless medically necessary;

16. Room, board and general nursing care

rendered on the date of discharge, un-less admission and discharge occur on the same day;

17. Charges in excess of the maximum al-lowable charge for covered services or any charges;

18. Charges for services performed by you or your spouse, or your or your spouse’s parent, sister, brother or child, are not covered;

19. Normal pregnancy, delivery or routine newborn nursery care;

20. Routine foot care;

21. Custodial, domiciliary or private duty nursing services;

22. Services or supplies that are designed to medically enhance a member’s level of fertility in the absence of a disease;

23. Assisted reproductive technology (ART), such as GIFT, ZIFT, invitrofertilization and fertility drugs;

24. Elective abortions;

25. Services, supplies or prosthetics primar-ily to improve appearance;

26. Surgeries and related services to change gender;

27. Services and supplies to detect or cor-rect refractive errors of the eyes;

28. Eyeglasses, contact lenses and examina-tion for the fitting of eyeglasses and contact lenses;

29. Any service stated in Attachment A of the SimplyBlue and SimplyBluePlus Policy as a non-covered service or limi-tation;

30. Services or supplies not listed as covered services under Attachment A, Covered Services of the SimplyBlue and SimplyBluePlus Policy;

31. Services or supplies that are experimental or investigational in nature including, but not limited to: (1) drugs; (2) biologicals; (3) medications; (4) devices; and (5) treatments;

32. Services or supplies related to cosmetic services, including surgical or other services, drugs or devices. Cosmetic services include, but are not limited to: (1) removal of tattoos; (2) removal of moles; (3) facelifts; (4) blepharoplasty; (5) keloid removal; (6) dermabrasion; (7) chemical peels; (8) rhinoplasty; (9) breast augmentation; and (10) breast reduction;

33. Removal of impacted teeth, including wisdom teeth;

34. Services or supplies for the reversal of

sterilization;

35. Hearing aids;

36. Prosthetics primarily for cosmetic pur-poses, including but not limited to wigs, or other hair prosthesis or transplants;

37. Items to replace those that were lost, damaged, stolen, or prescribed as a result of new technology;

38. Supplies/drugs that can be purchased without a prescription;

39. Any drug that is purchased outside the United States except those authorized by BlueCross BlueShield of Tennessee;

40. Any quantity of prescription drugs which exceed that specified by BlueCross BlueShield of Tennessee Pharmacy and Therapeutics Committees;

41. Handling fees;

42. Services or supplies related to obesity, including surgical or other treatment of morbid obesity;

43. Human growth hormones, except for: (1) treatment of absolute growth hormone deficiency in children whose epiphy-ses have not closed; and (2) treatment of patients with “Turner” syndrome, including the drugs, (1) Genotropin; (2) Humatrope; (3) Norditropin; (4) Nutropin; (5) Saizen; (6) Serostim; (7) Somatropin; and (8) Protropin (Somatrem);

44. Office visits and physical exams for: (1) school; (2) camp; (3) employment; (4) travel; (5) insurance; (6) marriage or legal proceedings; and (7) related immunizations and tests;

45. Treatment of sexual dysfunction including, but not limited to, erectile dysfunction (e.g. Viagra), delayed ejaculation, anorgasmia and decreased libido; and

46. Massage therapy.

This brochure is a summary and is not all inclusive. Your policy provides a complete list of benefits, limitations, exclusions and provisions. Certain medical conditions may be excluded.

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Personal Health Coverage Exclusions

This policy does not provide benefits for the following services, supplies or charges:

1. Services or supplies that are determined to not be medically necessary and ap-propriate or have not been authorized by BlueCross BlueShield of Tennessee;

2. Illness or injury resulting from war and covered by veteran’s benefits. Other coverage for which the member is legally entitled and which occurred before the member’s coverage began under this policy;

3. Non-medical self treatment or training;

4. Staff consultations required by hospital or other facility rules;

5. Services which are free;

6. Services required as a result of an at-tempt or commission of a felony by the member;

7. Any work-related illness or injury unless resulting from self-employment;

8. Personal and convenience items and services such as: (1) barber and beauty services; (2) television; (3) air condition-ers; (4) humidifiers; (5) air filters; (6) heaters; (7) physical fitness equipment; (8) saunas; (9) whirlpools; (10) water purifiers; (11) swimming pools; and (12) tanning beds. Other recreational equipment including: (1) weight loss programs; (2) physical fitness programs; or (3) self-help devices which are not primarily medical in nature, even if ordered by a practitioner. Motorized scooters, deluxe or enhanced equip-ment. In all instances, the most basic equipment needed to provide the needed medical care will determine the benefit;

9. Services or confinements that occurred before the member’s effective date for coverage under this policy;

10. Services or supplies received in a dental or medical department main-tained by or on behalf of a member’s employer, mutual benefit association, labor union or similar group;

11. Telephone or e-mail consultations, or charges for failure to keep a scheduled appointment;

12. Services for providing requested medi-cal information or completing forms;

13. Court-ordered examinations and treat-ment, unless medically necessary;

14. Room, board and general nursing care rendered on the date of discharge, un-less admission and discharge occur on the same day;

15. Charges in excess of the maximum al-lowable charge for covered services or any charges;

16. Charges for services performed by you or your spouse, or your or your

spouse’s parent, sister, brother or child, are not covered;

17. Normal pregnancy, delivery or routine newborn nursery care unless covered by maternity rider;

18. Routine foot care;

19. Custodial, domiciliary or private duty nursing services;

20. Services or supplies that are designed to medically enhance a member’s level of fertility in the absence of a disease;

21. Assisted reproductive technology (ART), such as GIFT, ZIFT, invitrofertil-ization and fertility drugs;

22. Elective abortions;

23. Services, supplies or prosthetics pri-marily to improve appearance;

24. Surgeries and related services to change gender;

25. Services and supplies to detect or cor-rect refractive errors of the eyes;

26. Eyeglasses, contact lenses and exami-nation for the fitting of eyeglasses and contact lenses;

27. Any service stated in Attachment A of the Personal Health Plan Policy as a non-covered service or limitation;

28. Services or supplies not listed as covered services under Attachment A, Covered Services of the Personal Health Plan Policy;

29. Services or supplies for the reversal of sterilization;

30. Hearing aids;

31. Prosthetics primarily for cosmetic purposes, including but not limited to wigs, or other hair prosthesis or trans-plants;

32. Items to replace those that were lost, damaged, stolen, or prescribed as a result of new technology;

33. Supplies/drugs that can be purchased without a prescription;

34. Any drug that is purchased outside the United States except those authorized by BlueCross BlueShield of Tennessee;

35. Any quantity of prescription drugs which exceed that specified by BlueCross BlueShield of Tennessee Pharmacy and Therapeutics Commit-tees;

36. Handling fees;

37. Services or supplies related to obesity, including surgical or other treatment of morbid obesity;

38. Human growth hormones, except for: (1) treatment of absolute growth

hormone deficiency in children whose epiphyses have not closed; and (2) treatment of patients with “Turner” syndrome, including the drugs, (1) Genotropin; (2) Humatrope; (3) Norditropin; (4) Nutropin; (5) Saizen; (6) Serostim; (7) Somatropin; and (8) Protropin (Somatrem);

39. Office visits and physical exams for: (1) school; (2) camp; (3) employment; (4) travel; (5) insurance; (6) marriage or legal proceedings; and (7) related immunizations and tests;

40. Treatment of sexual dysfunction including, but not limited to, erectile dysfunction (e.g. Viagra), delayed ejaculation, anorgasmia and decreased libido; and

41. Massage therapy.

This brochure is a summary and is not all inclusive. Your policy provides a complete list of benefits, limitations, exclusions and provisions. Certain medical conditions may be excluded.

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BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield AssociationThis document has been classified as public information

BlueCross BlueShield of Tennessee1 Cameron Hill Circle | Chattanooga, TN 37402

bcbst.com

COMM-429 (1/11)