The GeoBlue Xplorer Plan does not provide benefits for:
Expenses incurred prior to the beginning of the current Period of Coverage or after the end of the current
Period of Coverage except as described in the Extension of Benefits
Hospitalization, services and supplies that are not Medically Necessary.
Services or supplies that are not specifically mentioned in this Certificate
Services or supplies for any illness or injury arising out of or in the course of employment for which benefits
are available under any Workers’ Compensation Law or other similar laws whether or not you make a claim for such
compensation or receive such benefits.
Services or supplies that are furnished to you by the local, state or federal government and for any services or
supplies to the extent payment or benefits are provided or available from the local, state or federal government
whether or not that payment or benefits are received.
Conditions caused by or contributed by:
An act of war;
he inadvertent release of nuclear energy when government funds are available for treatment of Illness
or Injury arising from such release of nuclear energy;
A Covered Person participating in the military service of any country;
A Covered Person participating in an insurrection, rebellion, or riot;
Services received for any condition caused by a Covered Person’s commission of, or attempt to commit a
felony or to which a contributing cause was the Covered Person being engaged in an illegal occupation.
Services or supplies that do not meet accepted standards of medical and/or dental practice.
Investigational Services and Supplies and all related services and supplies.
Routine physical examinations, unless otherwise specified in this Certificate.
Services or supplies received during an Inpatient stay when the stay is primarily related to behavioral, social
maladjustment, lack of discipline or other antisocial actions that are not specifically the result of Mental
Cosmetic Surgery and related services and supplies, whether or not for psychological purposes, except for the
correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors or
diseases that occur after your Coverage Date.
Services or supplies for which you are not required to make payment or would have no legal obligation to pay if
you did not have this or similar coverage.
Charges for failure to keep a scheduled visit or charges for completion of a claim form.
Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this
Plan. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes (except when joined
to braces) or shoe inserts, including orthotics; air purifiers, air conditioners, humidifiers; exercise
equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and
supplies; correction appliances or support appliances and supplies such as stockings
Special braces, splints, specialized equipment, appliances, ambulatory apparatus, battery implants, except as
specifically mentioned in this Certificate.
Blood derivatives that are not classified as drugs in the official formularies.
Eyeglasses, contact lenses or cataract lenses and the examination for prescribing or fitting of glasses or
contact lenses or for determining the refractive state of the eye, except as specifically mentioned in this
Treatment to change the refraction of one or both eyes (laser eye correction), including refractive keratectomy
(RK) and photorefractive keratectomy (PRK).
Hearing aids, including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone
Anchored Hearing Aids (BAHAs), except as covered under this Plan as shown in the Schedule of Benefits section. A
hearing aid is any device that amplifies sound.
Treatment of flat foot conditions and the prescription of supportive devices for such conditions and the
treatment of subluxations of the foot.
Routine foot care, except for persons diagnosed with diabetes, including the cutting or removal of corns or
calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized
Illness, Injury or symptoms involving the feet.
Immunizations, unless otherwise specified in this Certificate.
Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of
enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or
maintenance care which is provided after the resolution of the acute medical problem and when significant
therapeutic improvement is not expected.
Non-medical counseling or ancillary services, including but not limited to Custodial Care services, education,
training, vocational rehabilitation, behavioral training, gym or swim therapy, legal or financial counseling,
biofeedback, neuro-feedback, hypnosis, sleep therapy, employment counseling, back to school, return to work
services, work hardening programs, driving safety, and services, training, educational therapy or other
non-medical ancillary services for learning disabilities, developmental delays or intellectual disabilities.
Diagnostic Service as part of routine physical examinations or check-ups, premarital examinations, determination
of the refractive errors of the eyes, auditory problems, surveys, case-finding, research studies, screening, or
similar procedures and studies, or tests which are Investigational unless otherwise specified in this
Procurement or use of prosthetic devices, special appliances and surgical implants which are for cosmetic
purposes, the comfort and convenience of the patient, or unrelated to the treatment of a disease or injury.
Services and supplies rendered or provided for human organ or tissue transplants other than those specifically
named in this Certificate.
Investigational or experimental organ transplantation including animal to human organ transplants.
Consultations performed by you, your spouse, parents or children.
Medical and Hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise
eligible under this Plan.
Charges for the services of a standby Physician.
Medical and surgical services, initial and repeat, intended for the treatment or control of Obesity, except for
treatment of clinically severe (Morbid) Obesity as shown in Covered Expenses, including: medical and surgical
services to alter appearance or physical changes that are the result of any surgery performed for the management
of Obesity or clinically severe (Morbid) Obesity; and weight loss programs or treatments, whether prescribed or
recommended by a Physician or under medical supervision.
Treatment for hair loss.
Growth hormone treatment for children with familial short stature (short stature based upon heredity and not
caused by a diagnosed medical condition).
Dental treatment, dental surgery, dental prostheses and orthodontic treatment unless otherwise specified in this
Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part
of the implantation or removal of dental implants.
Medical aids unless otherwise specified in this Certificate.
Services and treatment related to elective abortions.
Infertility, Assisted Reproduction And Sterilization Reversal
Treatment of infertility, including procedures, supplies and drugs;
b. Any assisted reproduction techniques, regardless of reason or origin of condition, including but not
to, artificial insemination, in-vitro fertilization, and gamete intra-fallopian transplant (GIFT) and
or indirect complications thereof. Please Note: This exclusion does not apply to the diagnosis of
the surgical correction or a condition causing infertility. This would be treated the same as any other
Expenses incurred for, or related to gender reassignment surgery.
Any services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to,
treatment of erectile dysfunction (including penile implants), anorgasmia, and premature ejaculation.
Nutritional counseling or food supplements, except for treatment of Phenylketonuria (PKU) and other inherited
metabolic diseases and diabetes.
Telephone, e-mail, and Internet consultations unless specifically approved by the Administrator due to limited
resources while located in a country outside of the United States.
Whenever coverage provided by this Certificate would be in violation of any U.S. economic or trade sanctions,
such coverage shall be null and void.
The exclusions listed above is a consolidated version of the plan exclusions. Please view the plan
the full list and limitations of the plan.