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Comprehensive Blue PPO III and HSA Blue PPO II have exclusions, limitations and terms under which the insurance policy may be continued or discontinued. The Comprehensive Blue PPO III and HSA Blue PPO II insurance plans are age and sex rated, meaning premiums are based on the age and sex of the oldest covered person. Premiums are also based on whether you choose individual or family coverage and your deductible selection. The Company’s determination to provide or refuse coverage will be based upon the answers to the health questions on the application as well as additional verifying medical information the Company may require. Conditions existing prior to the effective date of the Comprehensive Blue PPO III and HSA Blue PPO II insurance policies are not covered until the policy has been in effect for 12 months, except for dependents age 18 or younger. There is NO credit given toward the pre-existing condition period for prior health insurance.

Tobacco Users: The Comprehensive Blue PPO III and HSA Blue PPO II rates provided are discounted non-tobacco user premiums. An additional 20 percent will be applied to any standard risk tobacco user’s amount of premium.

Benefits and Services Not Included: If elected, maternity coverage benefits will not be paid within the first 12 months of coverage. No benefits or services of any kind are provided for maternity care, obstetrical care, in vitro fertilization, artificial insemination, and other infertility-related procedures unless maternity coverage is elected. Conditions existing prior to the effective date of the policy are not covered until the policy has been in effect for 12 months, except for dependents age 18 or younger. Injuries or diseases caused by war; dentistry (except for some oral surgery); eye refractions, eyeglasses or hearing aids (for HSA Blue PPO II), unless needed because of accidental injury; cosmetic surgeries, unless needed because of accidental injury; services or supplies not medically necessary; medical or hospital services collectible under Workers Compensation or any law providing benefits for dependents of military personnel; services rendered in government hospitals; intentionally self-inflicted injuries; inpatient services, if they could have been performed safely and adequately on an outpatient basis; services and supplies which are experimental or investigational in nature; benefits provided under Medicare or other government programs (except Medicaid); services of social workers, unless included as part of the daily room and board allowance; radial keratotomies or epikeratophakia or any services performed to correct nearsightedness; hospital and physician services for rest cures; services by an immediate relative (spouse, parents, children, brother, sister or legal guardian); dietary supplements when used in connection with weight reduction programs. Benefits and services are not included for any treatment (surgical or non-surgical) for weight loss. Renewal may be refused by class.

Limitations of Hospital Benefits: Arkansas Blue Cross does not require pre-admission certification for in-state hospital admissions. Notification only is required for out-of-state or out-of-network hospital admissions at the time of admission by calling the toll free number on the back of your ID card. Services rendered in a hospital outside of the United States of America will be paid at the sole discretion of the Plan.

General Coverage Limitations: Home health care is limited to 40 visits per calendar year; outpatient physical therapy, occupational therapy and respiratory therapy are limited to 45 visits per calendar year; ambulance coverage is limited to $1,000 per trip for ground and water; and $5,000 per trip for air (one trip per year for air ambulance); durable medical equipment is subject to the deductible and 20 percent coinsurance, and does not apply to the calendar-year coinsurance maximum. All organ transplants, except kidney and cornea transplants, are subject to prior approval. Spinal manipulation is limited to 6 spinal manipulations per calendar year. Hearing aid coverage with Comprehensive Blue PPO III is limited to $1,400 per ear for each three-year period.

Mental Illness Not Covered with HSA Blue PPO II: HSA Blue PPO II does not provide coverage for mental health services, including treatment for alcoholism, drug addiction and psychiatric conditions. Mental health drugs are also not covered under HSA Blue PPO II. This includes prescriptions which treat such mental health problems as attention deficit disorder, attention deficit-hyperactivity disorder, depression or insomnia.

Subrogation: If benefit payments are made for which a third party may be liable, Arkansas Blue Cross is entitled to recovery out of payments made by that third party to the full extent of benefits paid.

Medical Underwriting: This health insurance is medically underwritten. To be approved for coverage and issued a policy, you must answer health questions and pass medical underwriting. Based on medical underwriting, there may be an additional premium surcharge added. In addition, exclusions related to medical conditions or lifestyle choices (e.g., hazardous hobbies or foreign travel) may be added to your policy. Medical exclusions cannot be added for dependents age 18 or younger.

Coordination Against Group and Major Medical Coverage: Benefits for services or supplies available to you under any other group or blanket disability insurance, Union Welfare Plan, employer or employee benefit organization, self-insurance or any other non-regulated group disability benefits plan, major medical policy, or no-fault automobile liability insurance will be coordinated so that the total amount of benefits payable from all these plans combined does not exceed 100 percent of actual medical expenses.

IMPORTANT NOTE: Your premium will be accepted after coverage has been approved and a billing statement forwarded. This outline of coverage provides a brief description of the important features of the Comprehensive Blue PPO III and HSA Blue PPO II insurance policies. The outline is not the policy, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you read the policy carefully. Changes to this policy only may be made during the annual open enrollment period or as a result of a qualified life event. Since applications for our Comprehensive Blue PPO III and HSA Blue PPO II insurance policies take time to process and you are not guaranteed the coverage you request, we advise you to keep your current coverage in effect until we notify you that your application has been approved.