WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 71 Part 6 Limitations and Exclusions Your coverage in this health plan is limited or excluded as described in this part. Other limits or restrictions and exclusions on your coverage may be found in Parts 3, 4, 5, 7, and 8 of this Subscriber Certificate. You should be sure to read all of the provisions that are described in this Subscriber Certificate, your Schedule of Benefits, and any riders that apply to your coverage in this health plan. Admissions That Start Before Effective Date This health plan provides coverage only for those covered services that are furnished on or after your effective date. If you are already an inpatient in a hospital (or in another covered health care facility) on your effective date, you or your health care provider must call Blue Cross Blue Shield HMO Blue. (See Part 4.) This health plan will provide coverage starting on your effective date but only if Blue Cross Blue Shield HMO Blue is able to coordinate your care. This coverage is subject to all of the provisions that are described in this Subscriber Certificate, your Schedule of Benefits, and any riders that apply to your coverage in this health plan. Benefits from Other Sources No benefits are provided for health care services and supplies to treat an illness or injury for which you have the right to benefits under government programs. These include the Veterans Administration for an illness or injury connected to military service. They also include programs set up by other local, state, federal, or foreign laws or regulations that provide or pay for health care services and supplies or that require care or treatment to be furnished in a public facility. No benefits are provided by this health plan if you could have received governmental benefits by applying for them on time. This exclusion does not include Medicaid or Medicare. Cosmetic Services and Procedures No benefits are provided for cosmetic services that are performed solely for the purpose of making you look better. This is the case whether or not these services are meant to make you feel better about yourself or to treat your mental condition. For example, no benefits are provided for: acne related services such as the removal of acne cysts, injections to raise acne scars, cosmetic surgery, and dermabrasion or other procedures to plane the skin; electrolysis; hair removal or restoration (except as described in Part 5 for scalp hair prostheses); and liposuction. (See Part 5 for your coverage for reconstructive surgery.) There may be services that are usually considered cosmetic services but that meet Blue Cross Blue Shield HMO Blue’s criteria for coverage in certain situations, as defined in BlueCross Blue Shield HMO Blue medical policies or medical technology assessment criteria. Custodial Care No benefits are provided for custodial care. This type of care may be furnished with or without routine nursing or other medical care and the supervision or care of a physician.

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