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Bariatric Surgery (Weight Loss Surgery)
Charges for surgical procedures to effect weight loss in order to treat morbid obesity will be covered under this Plan only if the participant requesting the procedure meets the following criteria as defined by the National Institutes of Health:

• The candidate for surgery has severe obesity that has persisted for at least the last two years, defined as any of the following:

1. A body mass index (BMI) greater than or equal to 40; or
2. A body mass index (BMI) greater than 35 in conjunction with any of the following medical conditions that indicate severe co-morbidity:
   1. Coronary heart disease; or
   2. Type 2 diabetes mellitus; or
   3. Clinically significant obstructive sleep apnea; or
   4. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90mmHg diastolic despite optimal medical management;

3. Member has completed growth (18 years of age or documentation of completion of bone growth); and
4. Member has attempted weight loss in the past without successful long-term weight reduction

Examples of covered bariatric surgical procedures include Laparoscopic Roux-En-Y Gastric Bypass (LGBP), Laparoscopic Vertical Banded Gastroplasty LVBG), Laparoscopic Adjustable Banding (LB), Laparoscopic Bileopancreatic Diversion (LBPD), Laparoscopic BPD & Duodenal Switch (LBPD/DS), Standard Roux-En-Y Gastric Bypass (GBP), Distal Roux-En-Y Gastric Bypass (DGBP), Vertical Banded Gastroplasty (VBG), Silastic Ring Gastroplasty (SRG), Gastric Banding (GB), Banded Gastric Bypass (BGB), Biliopancreatic Diversion (BPD), and Biliopancreatic Diversion & Duodenal Switch (BPD/DS - BPD). The physician/surgeon will determine the appropriateness of the bariatric surgical procedure based upon the participant's clinical findings and in consultation with the surgical candidate. Any surgical treatment plan for morbid obesity must be approved, in advance, by Blue Cross in order to ensure that the proposed services are medically necessary and appropriate and that the Participant meets the criteria set forth above.

Infertility Treatment - Lifetime Maximum Benefit of $5,000 Per Couple for In Vitro Fertilization - Artificial Insemination
Treatment for infertility consistent with established medical practices by a licensed Doctor of Medicine is a covered expense subject to the benefits and limitations stated below.

• For the purpose of this benefit, infertility means either:
  1. The presence of a demonstrated bodily malfunction recognized by a licensed medical physician as a cause of infertility; or
  2. Because of a demonstrated bodily malfunction, the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.
• Initial diagnostic tests furnished in connection with infertility are a covered expense. Covered expense included doctors services and all necessary laboratory expense.
• The following are excluded from coverage:
  1. For or incident to intersex surgery (transsexual operations);
  2. Sexual dysfunctions;
  3. Sexual inadequacies, including but not limited to reversal of surgical sterilization; or
  4. For any resulting complications of any such procedures
• Benefits will be paid the same as for any other illness as explained in the Summary of Hospital and Medical Benefits sections entitled "Deductible" and "Copayment" respectively. The combined lifetime maximum of $5,000 is included in the overall $1,000,000 lifetime maximum, not as an additional maximum.

Hospice Care - Lifetime Maximum Benefit $15,000
Services for hospice care are a covered expense for a terminally ill participant who does not have a reasonable prospect for cure and who has a life expectancy of 6 months or less, as certified by the attending physician. A hospice care program means a coordinated plan or inpatient and home health care, which treats the terminally ill person and family as a unit. Care must be provided by a team made up of medical personnel, counselor, and other individuals with special training and can include homemakers who work in conjunction with the hospice care program. Covered services include the following.

• Inpatient care, including semi-private room and board, doctors services, inpatient skilled nursing care, respiratory therapy, life support systems, pain therapy, drugs and medicines, psychological counseling, and spiritual support.
• Outpatient hospice care including nursing care given at home, visits by hospice staff personnel, physical and respiratory therapy, oxygen and the rental of medical equipment for the patient's care, medicine and drugs, and homemaker services.
• Up to a $1,000 benefit maximum for professional counseling sessions with the patient and/or family members during the period of hospice care.
• Up to a $500 benefit maximum for bereavement counseling sessions with the patient's family members for help in coping with the death of the patient within three months following the patient's death.
• Benefits will be paid the same as for any other illness as explained in sections one and three above entitled, "Deductible" and "Copayment" respectively. The combined (inpatient and outpatient) lifetime maximum of $15,000 is included in the overall $400,000 lifetime maximum, not as an additional maximum.

Supplemental Accident Benefit
If, within 90 days after an accidental injury, you have any expenses for the following services, the Plan will pay the charges at 100% up to a maximum of $300.00. This benefit is not payable for sickness, but applies to hospital and medical bills due to accident only.

• Hospital, surgical and medical services
• Private duty services or a Registered Nurse
• Laboratory and X-ray examinations
• Doctors medical and surgical treatment
• Physical therapy
• Ambulance service

Chiropractic Treatment and Physical Therapy
For outpatient and non-hospital chiropractic care by a licensed chiropractor (D.C.) the Plan pays up to a maximum of 50 visits combined maximum with physical therapy per calendar year for necessary care not to exceed $35.00 per visit after the deductible.

Charges for outpatient physical therapy, by a licensed physical therapist, the Plan pays up to a maximum of 50 visits combined maximum with chiropractic treatment visits per calendar year for necessary care not to exceed $35.00 per visit after the deductible. This benefit is only payable when physical therapy has been prescribed in writing by a medical doctor.

Acupuncture
Charges for Acupuncture by a licensed Acupuncturist, up to a $40.00 allowance per visit once every week only subject to plan deductible and co-insurance.

Contraceptives