Underwriting Guide
Individual Health Coverage
Underwriting Guidelines for New Business
Introduction
The information and guidelines contained in this Underwriting Guide are
provided to assist you in achieving faster and more accurate processing of
applications and underwriting. This guide contains a general overview of
current medical underwriting guidelines and is subject to change at any time.
This guide is for Authorized Agents’ use only and this material is the
property of Blue Cross and Blue Shield of Texas (BCBSTX), a Division of
Health Care Service Corporation.
This information is confidential and may not be reproduced or used in any
form or by any means, electronic or mechanical, including photocopying, or
by any information storage and retrieval system, without written permission
from an officer of Hallmark Services Corporation.
Hallmark Services Corporation is a wholly-owned subsidiary of Health Care
Service Corporation serving as an administrator in the individual health
insurance markets and is committed to offering an exceptional level of
quality services.
Table of Contents
New Business Application - Dos and Don’ts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Eligibility Requirements (age, residency, dependents). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Height/Weight Charts and Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
Automatic Decline List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-8
Reconsideration Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Health Underwriting Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-31
Unacceptable Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-35
Coverage Exclusion Riders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36-40
Occupation Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Back Cover
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Enrollment Application Dos and Don’ts
Processing time can be reduced by following these guidelines:
Do…
submit applications online, this will reduce your processing time by 3 to 4 days and will ensure that the
application is complete.
Do…
use the electronic underwriting opinion form to help answer underwriting questions.
Do…
go to bcbstx.com and Blue Access for Producers to make sure you’re using the most recent version
of applications.
Do…
answer ALL application questions and provide complete details.
Do…
obtain all signatures and dates from ALL applicants age 18 or older.
Do…
ensure all applicants meet age requirements (see page 3).
Do…
ensure all applicants meet residency requirements (see page 3).
Do…check the height/weight chart (see pages 4 & 5) to determine whether the applicant’s weight is eligible
for consideration.
Do…
include a residential street address for applicants who wish to use a PO Box for their mailing address.
Do…
ensure that correct social security numbers are provided.
Do…review the Medical Conditions List (see pages 10-31) to obtain advance guidance as to whether a specific
medical condition would warrant declination or may possibly be ridered.
Do…ensure a copy of legal guardianship court documents are attached along with the application when applicable
(including applications for dependents submitted by a guardian, grandparent, aunt or uncle, etc.).
Do…
advise your client NOT to cancel any current health coverage until BCBSOK has activated the new coverage.
Do…
list all forms of treatment received for a condition.
Don’t…
submit an application with a signature date after the actual date of completion.
Don’t…
submit an application that was signed 30 days or more ago.
Don’t…
submit an application that has wording cut-off, is illegible, or is of poor copy quality.
Don’t…
use white-out, pencil, or multiple ink colors on the application.
Don’t…
alter any questions.
Don’t…
alter any answers without the applicant initialing & dating the alteration.
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Eligibility Requirements
Age Requirements
• A
ll applicants must be less than age 65 as of the policy effective date.
• Dependents must be less than age 26 as of the policy effective date.
• A
newborn child must be at least 60 days old and have had their well-child exam to be considered for coverage
(Applies to Temp policies only).
Residency Requirements
• All primary applicants must be a resident of Texas, unless a court ordered dependent.
• Applicants with a PO Box as an address must also provide a residential street address.
Eligible Dependent Requirements
• A spouse.
• A common law spouse.
• A natural child.
• A stepchild whose primary residence is the applicant’s household.
• A legally adopted child.
• A grandchild whose primary residence is the applicant’s household, to whom the applicant is legal guardian
or related by blood or marriage, regardless of whether the applicant treats the grandchild as a dependent for
federal income tax purposes.
• A child for whom the applicant has received a court order requiring the applicant to provide health insurance
for the child.
• Other legal dependent child under court documentation.
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Height and
Weight
Charts
Adult Height and Weight Chart - Ages 19 and older
Male
Height
(Ft In)
Weight
Accept
4-8
4-9
4 – 10
4 – 11
5-0
5-1
5-2
5-3
5-4
5-5
5-6
5-7
5-8
5-9
5 - 10
5 - 11
6-0
6-1
6-2
6-3
6-4
6-5
6-6
6-7
6-8
78 - 130
80 - 135
83 – 140
86 – 145
89 – 150
92 – 155
95 – 160
98 – 165
101 – 170
105 – 176
108 – 181
111 – 187
115 – 193
118 – 198
121 – 204
125 – 210
129 – 216
132 – 222
136 – 228
140 – 235
143 – 241
147 – 247
151 – 254
155 – 260
159 – 267
Female
Weight 25%
premium
adjustment
131 – 166
136 – 172
141 – 178
146 – 184
151 – 191
156 – 197
161 – 204
166 – 210
171 – 217
177 – 224
182 – 231
188 – 238
194 – 245
199 – 252
205 – 260
211 – 267
217 – 275
223 – 283
229 – 291
236 – 299
242 – 307
248 – 315
255 – 323
261 – 331
268 – 340
Decline
Height
(Ft In)
Weight
Accept
167
173
179
185
192
198
205
211
218
225
232
239
246
253
261
268
276
284
292
300
308
316
324
332
341
4-8
4-9
4 – 10
4 – 11
5-0
5-1
5-2
5-3
5-4
5-5
5-6
5-7
5-8
5-9
5 - 10
5 - 11
6-0
6-1
6-2
6-3
6-4
6-5
6-6
6-7
6-8
76 - 128
79 - 133
81 – 137
84 – 142
87 – 147
90 – 152
93 – 157
96 – 162
99 – 167
102 – 173
105 – 178
109 – 184
112 – 189
115 – 195
118 – 200
122 – 206
125 – 212
129 – 218
132 – 224
136 – 230
140 – 236
143 – 243
147 – 249
151 – 256
155 – 262
Weight 25%
premium
adjustment
129 - 157
134 - 163
138 – 169
143 – 175
148 – 181
153 – 187
158 – 193
163 – 199
168 – 206
174 – 212
179 – 219
185 – 226
190 – 232
196 – 239
201 – 246
207 – 254
213 – 261
219 – 268
225 – 275
231 – 283
237 – 291
244 – 298
250 – 306
257 – 314
263 – 322
Decline
158
164
170
176
182
188
194
200
207
213
220
227
233
240
247
255
262
269
276
284
292
299
307
315
323
Height and Weight Chart - Ages 15 through 18
Male
Female
Height
(Ft In)
Weight
Accept
Weight 25%
premium
adjustment
4-8
4-9
4 – 10
4 – 11
5-0
5-1
5-2
5-3
5-4
5-5
5-6
5-7
5-8
5-9
5 - 10
5 - 11
6-0
6-1
6-2
6-3
6-4
6-5
6-6
6-7
6-8
78 - 130
80 - 135
83 – 140
86 – 145
89 – 150
92 – 155
95 – 160
98 – 165
101 – 170
105 – 176
108 – 181
111 – 187
115 – 193
118 – 198
121 – 204
125 – 210
129 – 216
132 – 222
136 – 228
140 – 235
143 – 241
147 – 247
151 – 254
155 – 260
159 – 267
131 – 166
136 – 172
141 – 178
146 – 184
151 – 191
156 – 197
161 – 204
166 – 210
171 – 217
177 – 224
182 – 231
188 – 238
194 – 245
199 – 252
205 – 260
211 – 267
217 – 275
223 – 283
229 – 291
236 – 299
242 – 307
248 – 315
255 – 323
261 – 331
268 – 340
4
Weight
premium
adjustment
> 25%
167
173
179
185
192
198
205
211
218
225
232
239
246
253
261
268
276
284
292
300
308
316
324
332
341
Height
(Ft In)
Weight
Accept
Weight 25%
premium
adjustment
4-8
4-9
4 – 10
4 – 11
5-0
5-1
5-2
5-3
5-4
5-5
5-6
5-7
5-8
5-9
5 - 10
5 - 11
6-0
6-1
6-2
6-3
6-4
6-5
6-6
6-7
6-8
76 - 128
79 - 133
81 – 137
84 – 142
87 – 147
90 – 152
93 – 157
96 – 162
99 – 167
102 – 173
105 – 178
109 – 184
112 – 189
115 – 195
118 – 200
122 – 206
125 – 212
129 – 218
132 – 224
136 – 230
140 – 236
143 – 243
147 – 249
151 – 256
155 – 262
129 - 157
134 - 163
138 – 169
143 – 175
148 – 181
153 – 187
158 – 193
163 – 199
168 – 206
174 – 212
179 – 219
185 – 226
190 – 232
196 – 239
201 – 246
207 – 254
213 – 261
219 – 268
225 – 275
231 – 283
237 – 291
244 – 298
250 – 306
257 – 314
263 – 322
Weight
premium
adjustment
> 25%
158
164
170
176
182
188
194
200
207
213
220
227
233
240
247
255
262
269
276
284
292
299
307
315
323
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Height and Weight Charts
Juvenile Height and Weight Chart - Male and Female
Ages 0-2
Height
(Ft In)
Ages 3-9
Weight
Weight Minimum premium
Weight Maximum adjustment
at or above
Height
(Ft In)
Ages 10-14
Weight
Weight Minimum premium
Weight Maximum adjustment
at or above
Height
(Ft In)
Weight
Weight Minimum premium
Weight Maximum adjustment
at or above
16
4-9
10
30
18-40
41
48
44-92
93
17
4-10
11
31
19-41
42
49
47-96
97
18
5-11
12
32
20-42
43
50
49-100
101
19
5-12
13
33
21-43
44
51
52-104
105
20
5-14
15
34
22-44
45
52
54-108
109
21
6-16
17
35
23-47
48
53
56-113
114
22
7-19
20
36
24-50
51
54
59-117
118
23
8-21
22
37
25-52
53
55
61-122
123
24
9-23
24
38
26-54
55
56
63-126
127
25
10-25
26
39
28-56
57
57
66-131
132
26
10-26
27
40
30-58
59
58
69-135
136
27
12-29
30
41
31-61
62
59
71-140
141
28
13-31
32
42
32-64
65
60
74-144
145
29
14-34
35
43
34-68
69
61
78-150
151
30
15-36
37
44
35-71
72
62
81-155
156
31
17-38
39
45
37-75
76
63
84-161
162
32
18-40
41
46
38-78
79
64
87-166
167
33
20-41
42
47
40-82
83
65
91-171
172
34
21-42
43
48
42-86
87
66
94-176
177
35
22-45
46
49
44-90
91
67
97-181
182
36
23-48
49
50
46-94
95
68
100-186
187
37
25-51
52
51
49-98
99
69
103-191
192
38
26-54
55
52
51-103
104
70
107-196
197
39
28-57
58
53
54-107
108
71
110-201
202
40
29-59
60
54
56-111
112
72
113-206
207
55
59-115
116
73
117-211
212
56
61-120
121
74
120-216
217
57
64-124
125
75
123-222
223
58
66-128
129
76
126-228
229
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General Information on Height and Weight
• I f the applicant has lost weight within the past year (through diet, exercise or medication use), one-half of the
weight lost will be added to the current weight for underwriting purposes. Once the weight loss has been
maintained for at least one year, the current weight will be used.
- Example – applicant is female, 5 feet 7 inches and 180 pounds. She has lost 40 pounds during the last
12 months. Add 20 pounds to the current weight of 180 equaling 200 pounds – this adjusted amount requires
the Standard rate.
• Some height/weight situations may require additional information via a telephone interview and/or medical records to
complete the underwriting assessment. Based on height/weight ratio, the applicant may receive the standard rate or a
decline decision.
• Certain medical conditions can be impacted by excess weight, and may result in declination at weights lower than
the maximum listed in the chart. This list covers some of the most common conditions, but is not all inclusive.
- High blood pressure
- Diabetes (diet controlled)
- Arthritis or gout in weight-bearing joint(s)
- Joint replacement (due to trauma) or artificial spinal disc implant
- Sleep apnea
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Automatic Decline List
The Automatic Decline List below provides a basic list of conditions that warrant declination. This list is not all-inclusive;
however, applicants with any of the following conditions are ineligible for coverage. These limitations do not apply to
participants under 19 years of age.
Addison’s Disease
Coronary Artery Disease / Coronary Heart Disease
Adrenal Insufficiency
Coronary Thrombosis
AIDS
Crest Syndrome
ALS (Amyotrophic Lateral Sclerosis)
Crigler-Najjar Syndrome
Alveolar Proteinosis
Cystic Fibrosis
Alzheimer's Disease
Delirium Tremens
Amyloidosis
Dementia
Angina Pectoris
Dermatomyositis
Angioplasty
Dextrocardia
Ankylosis
Dysplastic Nevus Syndrome
Aortic Regurgitation / Insufficiency / Coarctation
Ebstein’s Anomaly
Aortic Stenosis
Ehlers-Danlos Syndrome
Arnold-Chiari Malformation
Eisenmenger’s Complex
Arteriosclerosis Obliterans (ASO)
Familial Mediterranean Fever
Ascites
Gastric Bypass and Lap Banding
Atherosclerosis
Gaucher’s Disease
Athletic Heart Syndrome
Gehrig’s Disease
Bipolar Disorder
Heart attack
Bypass Surgery
Hemochromatosis
Cardiomyopathy
Hemodialysis or Peritoneal Dialysis
Cardiovascular Heart Disease
Hemophilia
Carotid Insufficiency
HIV Positive
Central Sleep Apnea
Hip Replacement (unless due to trauma)
Cerebral Vascular Accident or Disease (CVA)
Huntington’s Chorea
Chagas' Disease
Hydrocephalus
Christmas Disease (Factor IX Deficiency)
IHSS (idiopathic hypertrophic subaortic stenosis)
Chronic Renal Failure
Ischemic Heart Disease
Cirrhosis of Liver
Intermittent Claudication
Congestive Heart Failure or Disease
Korsakoff’s Psychosis
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Leukemia
Pregnancy (if current, or an expected parent)*
Liver Atrophy
Psychotic Disorders
Marfan’s Syndrome
Pulsus Alternans
Mitral Stenosis
Paroxysmal Ventricular Tachycardia (PVT)
Multiple Sclerosis
Reiter’s Syndrome
Muscular Dystrophy
Relapsing Polychondritis
Myasthenia Gravis
Retinitis Pigmentosa
Myocardial Infarction, Ischemia, or Insufficiency
Rheumatic Heart Disease
Nephrocalcinosis
Rods (if located in the spine for a reason other than
Spinal Curvature)
Nephrosclerosis
Scleroderma (generalized or systemic)
Nephrotic Syndrome
Sickle Cell Anemia
Neurofibromatosis
Sjogren’s Syndrome
Neuromyositis
Stokes-Adams Syndrome
Organic Brain Disorder
Stroke
Organ Transplants (except corneal)
Systemic Lupus Erythematosus (SLE)
Osteogenesis Imperfecta
Systemic Sclerosis
Pacemaker
Tetralogy of Fallot
Parkinson’s Disease
Thrombocytosis
Pending surgery of any kind
Transient Ischemic Attack (TIA)
Penile Implants or Prostheses
Transplants of any organ (except cornea)
Periarteritis Nodosa
Transposition of the great vessels
Peripheral Neuropathy
Tricuspid Atresia
Pervasive Development Disorder
Valve Replacement
Polycystic Kidney Disease
Ventricular Fibrillation
Polycystic Liver Disease
Von Recklinghausen’s Disease
Polycythemia Vera
Wandering Atrial Pacemaker
Polymyositis
Wegener’s Granulomatosis
Polyneuritis
Wernicke’s Disease (encephalopathy)
Polyneuropathy
Wilson’s Disease
Porphyria
Portal Hypertension
Post-Thrombotic Syndrome
*May apply for coverage after the post-partum checkup has been completed and applicant is released from her physician’s care.
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Reconsideration Information
Reconsideration of Rate due to Non-Tobacco Use
Members may request a rate review on an existing policy of both if the following have occurred:
• The member must not have used any form of tobacco, cessation aid, or nicotine substitution product within
the last 12 months; and
• The member must have had a complete medical examination by a physician within the previous 12 months.
Members must submit a fully completed, signed and dated ‘Prior Tobacco Use Questionnaire’, which must
be completed by the member’s physician. All requests are subject to underwriting approval of the member’s
BCBSTX claim history and the questionnaire.
Please note that the member will not be eligible for a rate review if there is an existing medical condition.
Reconsideration of Rate due to Weight Loss
Members may submit an application for current consideration of rates if both of the following have occurred:
• The member must have maintained a weight within the preferred range for at least 12- consecutive months
prior to the request; and
• The member must have the results of a complete medical examination by a physician within the previous 12
months available for review upon request.
All requests for reconsideration are subject to underwriting approval of the member’s medical history, including
BCBSTX claim history.
Please note that the member will not be eligible for a rate review if there is tobacco use or another existing
medical condition.
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Health Underwriting Guidelines
This Health Underwriting Guidelines contain a general outline of representative health conditions and the anticipated
underwriting actions for these conditions. Both conditions covered or not covered by this guide are reviewed by the
Underwriting department to determine the appropriate underwriting action. This guide is not a complete underwriting
manual and guidelines are subject to change at any time. The anticipated action listed is not guaranteed.
This guide indicates the anticipated underwriting action, such as whether the underwriter will generally:
• decline
• rider (contingent certain criteria are met)
• accept
• accept with premium adjustment (contingent certain criteria are met)
Combinations of conditions and/or medications may result in a decline. In certain instances, a condition may warrant a
premium adjustment and a coverage exclusion rider.
The column entitled Criteria provides guidance as to the type of additional information the underwriter will
consider when making a decision. Providing this information on the application may facilitate processing of your
client’s application.
The Health Underwriting Guidelines start on the following page. (These limitations do not apply to participants under
19 years of age.)
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TX - Medical Condition Guide
Preferred
Rider
Decline
Premium
Adjustment
Criteria
Accept after 2 consecutive normal pap smears, OR if pap
result is ASC-US or LSIL then accept with 1 follow-up normal
pap or negative colposcopy.
X
Rider if follow-up testing has not been done.
X
Accept if no testing / surgery discussed and 1) controlled
by dietary measures or OTC meds, or 2) controlled with one
daily medication, or 3) treated with prescribed medication as
needed, or 4) if treatment is no longer needed.
X
Condition
A
Abnormal Pap Smear
(No Malignancy)
Acid Reflux (GERD)
Accept with premium adjustment if controlled with
two medications.
X
Decline if not well controlled or if surgery or further testing is
recommended, or within 6 months of surgery, or if multiple
surgeries performed.
X
Accept if unoperated and no symptoms within past 3
months OR if operated and fully recovered.
X
Rider all others.
X
Rider any internal fixation if inserted within the last 3 years,
or if there are any complications or plans for removal of the
fixation.
X
Accept if treated with OTC or oral medication.
X
Acne
Rider all others, including if treated within the last 12 months
with phototherapy, pulsed light therapy, laser, dermabrasion,
or chemical peel; or if contemplating treatment.
X
Addison’s Disease
Decline all cases.
X
Adrenal Insufficiency
Decline all cases.
X
AIDS
Decline all cases.
X
All applicants must have a complete physical exam and
labs within the last 12 months to be considered. If history of
alcoholism, must be abstinent for at least 5 years. If history of
alcohol abuse, must be recovered at least 5 years.
Decline if any treatment within 5 years, or if any related
impairments or residuals (cirrhosis, pancreatitis, neuropathy,
psychiatric disorders, etc.) or if no physical exam with labs
performed within the last 12 months.
X
Accept if presently controlled with over the counter (OTC)
medications, allergy shots, prescription medications,
inhalers or sprays OR history of with no further symptoms or
treatment required.
X
Decline if frequent or daily use of oral steroid(s).
X
ALS (Amyotrophic Lateral Sclerosis)
Decline all cases.
X
Alzheimer’s Disease
Decline all cases.
X
Accept if recovered after amputation of only fingers/toes due
to trauma.
X
Rider if one arm and/or one leg amputated over 1 year
ago due to trauma, no complications, with or without a
prosthesis.
X
Decline amputation of an arm or leg within 1 year, or those
with complications or follow-up needed.
X
ACL Tear
Alcoholism/Alcohol Abuse
Allergies, Allergic Rhinitis, Hay fever
Amputation
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Rider
Decline
Anemia, Iron Deficiency
Premium
Adjustment
Anal Fissure
X
Rider if present, or if multiple occurrences, or if surgery
planned or recommended.
X
Accept if controlled confirmed by testing, no suspicion of
malignancy, no internal bleeding, adequate medical workup
completed.
X
Decline all others, including if treated by blood transfusion
within the last 5 years.
X
Other types of anemia are given individual consideration
depending on the exact type and cause.
Criteria
Accept
Accept if single occurrence without surgery and recovered,
or surgically corrected and completely recovered.
Condition
Aneurysm
Decline if present.
X
Angina Pectoris
Decline all cases.
X
Angioplasty
Decline all cases.
X
Ankylosis
Decline all cases.
X
Anorexia Nervosa
Accept if completely recovered for at least 4 years, normal
weight maintained, psychotherapy discontinued, no other
psychiatric condition.
X
Decline all others.
X
Accept if recovered or controlled with no more than 2
medications, no ER treatment in past 12 months, no history
of hospitalization for psychiatric condition, counseling no
more than twice a month.
X
Decline all others.
X
Decline all cases.
X
Appendicitis
Accept if completely recovered, or if no recurrent attack
within 6 months if unoperated.
X
Decline all others.
X
Arnold-Chiari Malformation
Decline all cases.
X
Arteriosclerosis / Atherosclerosis
Decline all cases.
X
Osteoarthritis
Accept if 1) no symptoms, or no more than mild symptoms,
and 2) no treatment with oral steroids, immunosuppressants or
narcotics, and 3) no more than 2 steroidal injections per year.
X
Decline all others.
X
Rheumatoid
Accept if mild, no current symptoms or limitations,
controlled for a minimum of 1 year with over the counter
(OTC) medications only.
X
Decline others, including 1) if any history of joint surgery, or 2) if
any use within 7 years of the following: steroids, methotrexate,
gold shots, Plaquenil, or combinations of multiple medications
including non-steroidal anti-inflammatory medications
(NSAID’s) and pain relievers.
X
Anxiety / Minor Depression
Aortic Regurgitation, Insufficiency,
Coarctation, or Stenosis
Arthritis
Ascites
Decline all cases.
X
Asperger’s Disorder
Please refer to Autism.
X
Accept if controlled by no more than 3 inhalers (1-2 can be
steroid inhalers), oral steroid use less than 30 days per year,
no tobacco use within the last 12 months, or is exercise
induced and controlled with occasional medication.
X
Decline others, including those with more than one ER
treatment within past 12 months, or hospitalization within
the last 1 year, or those with more than mild symptoms and
tobacco use within 12 months.
X
Asthma, Hyperactive Airway Disease
(HAD), Reactive Airway Disease (RAD)
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Rider
Decline
Premium
Adjustment
Decline all cases.
X
Atrial Septal Defect
Accept if defect closed (confirmed by testing), or if surgically
repaired at least 1 year ago with no complications.
X
Attention Deficit Disorder (ADD),
Attention Deficit Hyperactivity Disorder
(ADHD), Hyperactivity Disorder,
Hyperkinetic Disorder, Minimal Brain
Dysfunction
Autism
Accept
Athletic Heart Syndrome
Condition
Criteria
Decline all others, or if type is an ostium primum defect.
X
Accept if controlled with no more than 2 medications, no
impairment of daily activities, and no hospitalization within
1 year.
X
Decline others.
X
Accept if currently treated with no more than 2 medications,
no ADL impairments, no behavioral issues requiring
treatment, does not require a personal aide, symptoms are
stable/ well controlled, and no pending, recommended or
current hospitalization.
X
Decline all others.
X
B
Back Disorder (Due to a Disc Problem)
Back Sprain, Back Strain (Including
Whiplash, Back Muscle Spasms)
Please refer to Disc Disorder.
Accept if completely recovered with no residual symptoms;
no further testing or treatment needed.
X
X
Decline all others.
Accept if surgically removed or no longer present.
X
Rider if present.
X
Barrett’s Esophagus
Accept if present, diagnosed more than 2 years ago,
monitored no more than once per year OR history of ablation
more than 1 year ago or resection more than 3 years ago
X
Decline all others.
X
Basal Cell Carcinoma (Of the Skin)
Please refer to Skin Cancer.
Accept if completely recovered from a single episode with
no residuals.
X
Decline if present, or if history of multiple episodes, or if any
residuals.
X
Baker’s Cyst
Bell’s Palsy
Benign Prostatic Hypertrophy (BPH)
Please refer to Prostatic Enlargement
Bipolar Disorder
Decline all cases.
X
Accept if no longer present and no residual incontinence.
X
Rider if present, or if residuals after surgery.
X
Bladder Prolapse
Blood Pressure (High or Elevated)
Blood Clot
Boeck’s Sarcoidosis
Bone Spur
Please refer to Hypertension.
Accept if no current medication, no edema, no residual
problems, and 1) if single episode, recovered at least 1
year since date of last treatment, or 2) if multiple episodes,
recovered at least 5 years since date of last treatment for the
most recent episode.
X
Decline all others, including those who have had clots in
more than one location or if the clot migrated.
X
Accept if complete recovery for at least 5 years, no residuals,
Stage 1 or 2 only, no tobacco use within 12 months, no
hypercalcemia, and no systemic involvement.
X
Decline all others.
X
Accept 1) if no longer present, or 2) if present in the wrist,
elbow or shoulder and no symptoms for the last 2 years.
X
Rider all others, including those with any residuals after
surgery.
X
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bcbstx.com
Rider
Decline
Breast Implants, Mammoplasty,
Mastoplasty
Breast Reduction / Macromastia
Bronchitis
Buerger’s Disease (Thromboangiitis
Obliterans)
Premium
Adjustment
Breast Cyst
X
Criteria
Accept
Accept 1) if benign and no longer present, or 2) if present
but confirmed as benign by biopsy, needle aspiration or
ultrasound, no suspicion of malignancy, and no more than
annual follow-up recommended.
Condition
Decline all others.
X
Accept if removal of breast implants without replacement
and no complications.
X
Rider if placed for cosmetic purposes only and no
complications.
X
Decline others, including if part of reconstructive surgery
resulting from disease, sickness, injury, or deformity.
X
Accept 1) if present but no symptoms or discussion of
surgery, or 2) if surgery performed more than six months
ago.
X
Rider all others.
X
Note: If chronic bronchitis, refer to Chronic Obstructive
Pulmonary Disease (COPD).
Accept if a single episode, or infrequent episodes with
complete recovery between attacks.
X
Decline if with another respiratory impairment other than
asthma and/or allergies.
X
Accept if no symptoms within the last 5 years and no
tobacco use within the last 12 months.
X
Decline all others.
X
Bulimia
Accept if completely recovered for at least 4 years, normal
weight maintained, psychotherapy discontinued, no other
psychiatric conditions.
X
Decline all others.
X
X
Bundle Branch Blocks (Heart blocks)
Accept if 1) incomplete right block, or 2) left anterior
hemiblock, or 3) complete right block if congenital; no
symptoms, diagnosed under age 30, no other cardiovascular
disease, and stable EKG testing.
Decline if left bundle branch blocks or left posterior
hemiblock.
X
Accept if 1) operated with complete recovery and no
residuals, or 2) unoperated with no symptoms or treatment
within 2 years.
X
Bunion (Hallux Valgus)
Bursitis (Tendonitis, Tennis Elbow)
Bypass Surgery
Rider all others.
X
Rider any internal fixation if inserted within the last 3 years,
or if there are any complications or plans for removal of the
fixation.
X
Accept if 1) single episode with complete recovery and no
complications, or 2) multiple episodes in the same location
after 2 years of complete recovery and no complications.
X
Rider all others, including if multiple episodes in the
same location within 2 years, if chronic, or if with residual
symptoms after surgery.
X
Decline all cases.
X
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bcbstx.com
Decline
Rider
Criteria
Premium
Adjustment
Accept
Condition
C
Cancer (Other Than Skin)
Varies based on the exact type of cancer, location, any lymph
node involvement, degree of invasion &/or metastasis, time
elapsed since recovered and last treated, any recurrence, results
of annual follow-ups, etc.
Carcinoma in situ, cervix
Accept if operated with complete recovery at least one year
ago.
Decline all others.
X
Cardiomyopathy
Decline all cases.
X
X
Cardiovascular Heart Disease
Decline all cases.
X
Carotid Insufficiency
Decline all cases.
X
Carpal Tunnel Syndrome (CTS)
Accept if 1) operated and fully recovered, or 2) if present, but
no surgery is anticipated or recommended.
X
Cataract
Cerebral Vascular Accident (CVA),
Cerebral Vascular Disease
Rider all others.
X
Accept if only one eye affected, unoperated and no
treatment needed other than observation, or if surgically
corrected.
X
Rider most cases if both eyes affected, or if onset as a child,
and all others unless caused by diabetes, radiation exposure,
intraocular or systemic disease.
X
Decline if caused by diabetes, or intraocular or systemic
disease.
X
Decline all cases.
X
Cervical Dysplasia
Please refer to Abnormal Pap smear.
Chagas’ Disease
Decline all cases.
X
Accept if 1) fully recovered without recurrence of symptoms
after gallbladder removal, or 2) if unoperated and fully
recovered from a single attack at least 2 years ago or from
multiple attacks ending at least 5 years ago.
X
Cholecystitis (Gallbladder Inflammation)
Cholelithiasis (Gallstones)
Cholesteatoma (Ear)
Cholesterol, Elevated
(Hypercholesterolemia, Hyperlipidemia)
Chondromalacia
Choroidal Nevus
Chronic Fatigue Syndrome (CFS)
Chronic Obstructive Pulmonary Disease
(COPD)
Chronic Pancreatitis
Rider all others.
X
Accept if fully recovered without recurrence of symptoms
after gallbladder removal.
X
Rider if unoperated.
X
Decline if surgically treated but without complete removal of
the gallbladder.
X
Accept if removed at least one year ago with no complications.
X
Rider if present or if removed less than one year ago.
X
Accept if at least age 30. Individual consideration is given to
applicants under 30 years old. Each case is evaluated based
on age, type of treatment, and current test results of total
cholesterol, HDL, and triglyceride levels.
X
Accept if unoperated and asymptomatic at least 6 months, or
if surgery done and fully recovered.
X
Rider if symptomatic within 1 year, or if surgery done within 1 year.
X
Rider if stable over the last 5 years, no malignancy or vision loss.
X
Decline all others.
X
Accept if fully recovered for at least 5 years and no residual
problems or related conditions.
X
Decline all others.
X
Decline if 1) smoking within the last 12 months, or 2) treated
with oxygen, or 3) if short of breath on less than strenuous
exercise, or 4) if with asthma or hypertension.
X
Decline all cases.
X
Chronic Renal Failure
Decline all cases.
X
Cirrhosis of Liver
Decline all cases.
X
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bcbstx.com
Rider
Decline
Premium
Adjustment
Decline all cases.
X
Coccydynia
Accept if completely recovered and 1) single episode, or 2)
operated.
X
Rider all others.
X
Decline if 1) surgery within 3 years, or 2) present, or 3)
not controlled, or 4) underweight, or 5) any use of certain
medications for maintenance within the last 2 years, such as
Azithroprine, Canasa, Infliximab, Lialda, Remicade, steroidal
medication.
X
Accept if completely recovered for at least 1 year and no
further treatment anticipated.
X
Rider all others.
X
Decline all cases.
X
Accept 1) if no treatment needed other than contact lenses,
2) recovered from corneal transplant at least one year ago, or
3) condition is no longer present.
X
Rider 1) if corneal transplant less than one year ago, 2) if
treatment needed other than contact lenses, 3) if ulcer or
erosion is present, or 4) if chronic keratitis.
X
Decline if multiple episodes of ulcer and most recent episode
is within 6 months.
X
Coronary Artery Disease
Decline all cases.
X
Crest Syndrome
Decline all cases.
X
Accept if free of symptoms or episodes for at least 7 years.
X
Decline if symptoms or episodes within 7 years or any use
of certain medications for maintenance within the last
2 years, such as Azithroprine, Canasa, Infliximab, Lialda,
Remicade, steroidal medication.
X
Cubital Tunnel Syndrome
Please refer to Ulnar Nerve Palsy.
Cushing’s Syndrome or Disease
Decline all cases.
X
Accept if 1) present at least 1 year, not increasing in size, and
no treatment needed, or 2) excised, or 3) no longer present.
X
Rider all others.
X
Decline all cases.
X
Accept if single episode or multiple episodes at least 6
months apart, fully recovered, no ongoing treatment with
antibiotics, no more than 1 dilation.
X
Rider if multiple episodes less than 6 months apart and within
1 year of last episode, no persistent urinalysis abnormalities, no
more than 1 dilation.
X
Colitis, Ulcerative
Congenital Malformation of Hand
or Foot
Congestive Heart Failure or Disease
Corneal Disorders
(Corneal Transplant, Ulcer or Erosion;
Keratoconus)
Crohn’s
Cyst (Epididymal, Ganglion, Pilonidal,
Scrotal, Sebaceous, Synovial)
Cystic Fibrosis
Cystitis (Bladder Infection, Urinary
Tract Infection)
Cystocele / bladder prolapse
Criteria
Accept
Claudication, Intermittent
Condition
Decline all others.
X
Accept if no longer present and no residual incontinence.
X
Rider if present, or if residuals after surgery.
X
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Accept
Rider
Decline
Premium
Adjustment
Criteria
Accept if mild or moderate, no complications, no underlying
serious condition, and no implant discussed, or if implant
surgery at least 2 years ago.
X
Rider all others, including within 2 years after implant
surgery.
X
Deep Vein Thrombosis (DVT)
Please refer to Blood Clot.
Dementia
Decline all cases.
X
Depression, Minor
Please refer to Anxiety / Minor Depression.
Deviated Septum
Accept if 1) no treatment, or controlled with OTC medication,
or 2) seasonal use of non-steroid medication, or 3) if
operated and asymptomatic at least 12 months.
X
Rider all others, including if surgery discussed.
X
Accept if controlled by diet only (no insulin or medication),
diagnosed over age 30 and at least 6 months ago,
no heart condition, no cerebrovascular condition, no
peripheral vascular condition, no elevated blood pressure,
not overweight, no kidney disease, no neuropathy, no
retinopathy, no repeated skin infections, no urinary
abnormalities, and cholesterol not elevated more than 240.
X
Decline all others.
X
Accept if operated by a single surgery with complete
recovery and no recurrence of symptoms for over 2 years and
no artificial disc or internal fixation is present (pins, plates,
cages, rods, or screws)
X
Rider the disc disorder if unoperated, or operated within 2
years, or with mild residuals or recurrence of symptoms.
X
Rider any artificial disc or internal fixations that are present
in the back.
X
Decline all others, including multiple surgeries on the same
or different discs.
X
Accept if single episode, unoperated and complete recovery
OR if operated and recovered more than 1 year.
X
Varies based on which joint, cause, how long recovered, and if
any residuals.
For shoulder, refer to Shoulder, Separated or Dislocated.
Other joints, due to trauma:
Rider if recurrent, or if within 1 year of surgery.
X
Rider any internal fixation if inserted within the last 3 years,
or if there are any complications or plans for removal of the
fixation.
X
Accept if 1) unoperated and recovered from a single attack,
or recovered at least 3 years from multiple attacks, or
2) operated and fully recovered for at least 2 years after
removal of affected area.
X
Rider if unoperated and recovered from multiple attacks
ending 1-3 years ago.
X
Condition
D
Deafness
Diabetes
Disc Disorder of the back or spine
(Including any Herniated, Protruding,
Ruptured, Bulged, or Slipped Disc)
Dislocation
Diverticulitis / Diverticulosis (Of the
Colon)
Diverticulum, bladder
Decline all others.
X
Accept if removed with no residuals.
X
Rider all others.
X
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bcbstx.com
Rider
Decline
Premium
Adjustment
Marijuana
Accept if no treatment within 2 years, no current use, no past
or current use of other drugs, and with normal physical exam
and lab results within 12 months.
X
Decline if treated within 2 years, or if current exam including
labs was not done within 12 months.
X
Other Drugs
Accept based on date of last use and full recovery for a
minimum of 5-7 years, and with normal physical exam and
lab results within 12 months.
X
Decline if current use, or if any use of IV drugs within 10 years, or if
multiple rehabilitation attempts within last 10 years, or if current
exam including labs was not done within 12 months.
X
Accept if operated, recovered, and no residual problems.
X
Rider all others.
X
Decline all cases.
X
Ebstein’s Anomaly
Decline all cases.
X
Eczema
Accept if no complications and no treatment with oral
steroids or methotrexate.
X
Ehlers-Danlos Syndrome
Decline all cases.
X
Eisenmenger’s Complex
Decline all cases.
X
Emphysema
Decline if 1) smoking within the last 12 months, or 2) treated
with oxygen, or 3) if short of breath on less than strenuous
exercise, or 4) if with asthma or hypertension.
X
Accept if 1) treated by hysterectomy with both ovaries
removed and no residuals, or 2) treated by other type of
surgery at least 2 years ago and no recurrence of symptoms,
or 3) unoperated, no symptoms, and controlled by
contraceptive or NSAID’s for at least 1 year.
X
Decline all others, including if symptomatic, or multiple
surgeries, or if any use of Lupron, Lupron Depot, Danazol,
Cyclomen, Danocrine, Danol within the last 3 years.
X
Enuresis (Bed-Wetting)
Accept if 1) no longer present, or 2) present but testing
confirms no underlying cause, no treatment needed or use of
prescription medication only.
X
Enteritis (Regional)
Please refer to Crohn’s.
Accept if single episode and fully recovered.
X
Rider if chronic or recurrent.
X
Decline if present and cause unknown.
X
Please refer to Seizure.
Accept if no underlying condition, no cardiovascular disease
other than hypertension/high blood pressure and solely
treated with oral medication.
X
Drug Abuse
Dupuytren’s Contracture
Dysplastic Nevus Syndrome
Criteria
Accept
For any past drug use, all applicants must have a complete physical exam
and labs within the last 12 months to be considered.
Condition
E
Endometriosis
Epididymitis
Epilepsy
Erectile Dysfunction
Accept with premium adjustment if no underlying condition,
no cardiovascular disease other than hypertension / high blood
pressure and treated with testosterone gels, patches or injections.
X
Decline if treated with injections, penile implant or
prosthesis, or vacuum device.
X
Rider if present. May be declined if due to disease - varies based
on exact diagnosis.
X
Familial Mediterranean Fever
Decline all cases.
X
Fatty Liver
Individual consideration required.
Fibrocystic Breast Disease (FBD,
FCBD), Cystic Mastitis
Accept if no biopsy advised, diagnosis by exam only with
normal mammograms (if completed)
X
Eye Prosthesis
F
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bcbstx.com
Rider
Decline
Fibromyalgia
Premium
Adjustment
Fibroid Tumor (Uterine)
X
Rider all others.
X
Accept if 1) no physical therapy within the last year, 2) no
more than minimal limitation to daily functions and not
disabling, 3) no more than one prescription medication,
4) no use of narcotics, steroids, or injections, 5) less than 5
manipulations monthly, and 6) no psychiatric conditions
such as depression or anxiety.
X
Decline all others.
X
Criteria
Accept
Accept if treated by hysterectomy, or testing confirms no
longer present, or post-menopausal and no symptoms.
Condition
G
Gallbladder Inflammation
Gallbladder Polyp
Please refer to Cholecystitis.
Accept if surgically removed.
X
Rider if present.
X
Gallstone(s)
Please refer to Cholelithiasis.
Gangrene
Decline if present or if due to a cause other than infection or
trauma.
X
Accept as long as no further testing recommended and
either controlled or recovered.
X
Gastritis
Decline all others, including if H. pylori infection present.
X
Gastroesophageal Reflux Disease
(GERD)
Please refer to Acid Reflux.
Gaucher’s Disease
Decline all cases.
X
Gehrig’s Disease
Decline all cases.
X
Accept if recovered, no residuals, no complications, and
1) recovered at least 1 year from a single episode, or 2)
recovered at least 2 years if multiple episodes. Female
applicants must also have had 2 subsequent normal pap
smears.
X
Rider most others.
X
Accept if well-controlled with or without medication, or if
recovered at least 3 months following surgery.
X
Rider all others.
Rider unless extends into chest area or if hyperthyroidism is
present.
X
Decline all others.
X
Accept if currently over age 30, controlled, not overweight. If
HBP is also present, can be considered if both conditions have
been controlled for at least 6 months.
X
Genital or Venereal Warts, HPV
(Condyloma Acuminatum)
Glaucoma
Goiter (Enlarged Thyroid)
Gout, Gouty Arthritis
Gynecomastia
Decline all others, including those related to alcohol use.
X
Accept if operated, benign and complete recovery.
X
Rider most others if unoperated and benign.
X
Accept if 1) operated and completely recovered with no
residuals, or 2) unoperated with no symptoms or treatment
within 2 years.
X
Rider all others.
X
Rider any internal fixation if inserted within the last 3 years,
or if there are any complications or plans for removal of the
fixation.
X
H
Hammertoe
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bcbstx.com
Rider
Decline
Headaches, Migraines
Head Injury, Concussion
H. Pylori or Helicobacter Pylori
infection
Hemangioma of the skin
Hemorrhoids
Hepatitis
Hernia (Excluding Esophageal or
Hiatal Hernia)
Premium
Adjustment
X
Rider if headaches controlled with no more than 2 current
medications; if triptan and/or narcotic cannot be used more
than 10 days per month total
AND within the last 12 months: 1) no more than 1 ER
treatment, 2) no hospitalization.
X
Decline all others, including if testing is planned or
recommended.
X
Accept if no residual problems or complications, no skull
fracture, no hemorrhage, and 1) recovered at least 3 months
if no loss of consciousness, or 2) recovered at least 1 year if
unconscious 1-48 hours.
X
Decline if any residuals or complications.
X
Decline if present.
X
Criteria
Accept
Accept if no ER treatment within 12 months other than at
time of initial diagnosis, 2) no hospitalization
Condition
Accept if no longer present and no residuals.
X
Rider all others.
X
Accept if 1) occasional OTC medications are used, or 2)
surgery was performed at least one year ago with no
recurrence.
X
Rider all others.
X
Decline most cases. Individual consideration given if fully
recovered from acute hepatitis if Type A, B, or E and current
liver function tests are normal.
X
Note: If esophageal or hiatal hernia, refer to Acid Reflux.
Accept if surgically corrected and fully recovered without any
recurrence.
X
Rider most others.
X
Herniated Disc
Please refer to Disc Disorder.
Herpes Type I
Accept if no treatment required other than over the counter
medication. Otherwise, refer to Herpes Type II.
X
Accept if 1) diagnosed at least 12 months ago, 2) no
prophylactic medication within the last 12 months, 3) no
non-genital locations.
X
Rider if 1) daily or prophylactic medication taken within 12
months, or 2) diagnosed within 12 months.
X
Accept if no more than 2 episodes, recovered, no residuals.
X
Decline most others.
X
HIV Positive
Decline all cases.
X
Hodgkin’s Disease
Decline all cases.
X
Accept if recovered, no residuals, no complications, and
1) recovered at least 1 year from a single episode, or 2)
recovered at least 2 years if multiple episodes. Female
applicants must also have had 2 subsequently normal pap
smears.
X
Rider most others.
X
Herpes Type II
Herpes Zoster (Shingles)
HPV (Human Papillomavirus)
Huntington’s Chorea
Hydrocele
Hydrocephalus
Decline all cases.
X
Accept if operated and fully recovered.
X
Rider if unoperated.
X
Decline all cases.
X
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bcbstx.com
Accept
Rider
Decline
Hyperparathyroidism
Hypertension (Elevated Blood
Pressure)
Premium
Adjustment
Criteria
Accept if removal of all abnormal tissue at least 3 years ago,
calcium and parahormone levels have returned to normal, no
residuals, and no urinary abnormality.
X
Decline most others.
X
Note: Applicant must supply blood pressure readings and dates
for last 12 months on the application. Generally readings above
140/90 are of concern.
Accept if controlled by no more than 3 medications;
diagnosed at or after age 30; no diabetes, kidney
disease, COPD, emphysema, and no other cardiovascular
abnormalities.
X
Condition
Decline all others, including if any complications.
X
Hyperthyroidism
Please refer to Thyroid Gland Disorders.
Hypospadias / Epispadias
Accept if no complications after surgery, or if no discussion
of surgery.
X
Rider if surgery discussed or if any complications.
X
Hypothyroidism
Please refer to Thyroid Gland Disorders.
Hysterectomy
Accept most cases if no malignancy and a minimum time
frame has been met depending on the underlying condition.
X
Decline all cases.
X
Accept if unoperated and no symptoms within the past 3
months OR if fully recovered from surgery.
X
I
IHSS (Idiopathic Hypertrophic
Subaortic Stenosis)
Iliotibial Band Syndrome
Rider all others.
X
Immune Deficiency Disorders
Decline all cases.
X
Impotence
Please refer to Erectile Dysfunction.
Incontinence (Urinary)
Accept if symptoms are minor, treatment is conservative and
surgery has not been recommended.
X
Rider most others.
X
Notes:
* If an individual is ineligible for coverage due to infertility
treatment, coverage on the spouse will be withdrawn.
* The underlying cause of infertility requires individual
consideration.
Accept if all testing and treatment was completed at least
3 years ago, no complications, and no plans for further
treatment.
X
Decline all others, including if future treatment is anticipated
or planned.
X
Infertility (Female or Male)
Inflammatory Bowel Disease (IBD)
Insomnia
Internal Fixation (i.e. Pins, Screws,
Wires, Cages, Rods, Plates)
Please refer to Crohn’s.
Accept use of one medication.
X
Decline others.
X
Accept if no longer present, or if present for at least 3 years
in a location other than the hip, back, or spine.
X
Rider if present less than 3 years, or if located in the hip, back
or spine.
X
Decline all others, including if any complications or further
surgery needed.
X
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bcbstx.com
Rider
Decline
Irritable Bowel Syndrome (IBS)
Premium
Adjustment
X
Decline if not controlled, or any use of certain medications
for maintenance within the last 2 years, such as Asacol,
Azulfidine, Infliximab, Pentasa, Remicade, Rowasa,
Sulfasalazine, or steroidal medication.
X
Accept if replacement of a single finger, toe or elbow due to
trauma.
X
Rider other locations if replacement of one joint due to
trauma, and no complications.
X
Decline all others, including if joint replacement is planned
or recommended.
X
Please refer to specific condition.
Accept if no longer present, or if present but no symptoms,
no complications, and no planned or recommended
treatment.
X
Rider all others.
X
Accept if fully recovered, and 1) solely due to contact lens
wear or foreign body, 2) no herpes simplex infection or
connective tissue disease, and 3) single episode or no more
than occasional episodes.
X
Rider if chronic.
X
Decline all others.
X
Accept.
X
Accept if two or fewer attacks, complete recovery, and no
other urinary conditions.
X
Decline if any residuals or other urinary conditions, of if chronic.
X
Accept if completely recovered and 1) one or two episodes
with the last occurring at least 2 years ago, or 2) three or more
episodes with the last occurring at least 5 years ago.
X
Rider if 1) stone(s) present in only one kidney, or 2) one or
two episodes with the last occurring within 2 years, or 3)
three or more episodes with the last occurring within 5 years,
or 4) or current use of preventive medication.
X
Decline all others, including nephrocalcinosis.
X
For DONORs only, Accept if all testing normal, remaining kidney
functions properly, and no adversely related conditions.
X
Decline all others, including those who receive a kidney
transplant.
X
Accept if unoperated and no symptoms within 3 months OR
if operated and fully recovered.
X
Rider all others.
X
Rider any internal fixation(s) if present less than 3 years, or if
any plans for removal, or if any complications.
X
Accept if unoperated and no symptoms within 3 months OR
if operated and fully recovered.
X
Criteria
Accept
Accept if recovered and 1) controlled by diet without
medication, or 2) controlled by antispasmodic or
anticholinergic medication such as Levsin or Levbid.
Condition
J
Joint Replacement
Joint Surgery
K
Keloid
Keratitis, Keratoconjunctivitis
Keratosis (Actinic, Seborrheic, Senile,
Solar)
Kidney Infection (Pyelonephritis)
Kidney Stone (Renal Colic,
Nephrolithiasis)
Kidney Transplant
Knee - Ligament injuries
(ACL tears, etc.)
Knee - Meniscal Tear (Torn Meniscus,
Torn Knee Cartilage)
Rider all others.
X
Knee Replacement
(One or Both Knees)
Please refer to Joint Replacement.
Korsakoff’s Psychosis
Decline all cases.
X
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bcbstx.com
Rider
Decline
Premium
Adjustment
Criteria
X
Accept
Condition
L
Lattice Degeneration
Accept if incidental diagnosis and no treatment needed.
Rider all others.
X
Lazy Eye (Amblyopia)
Accept if not due to any other condition.
X
Legionnaire’s Disease
Accept if recovered, no residuals, no current treatment, no
complications, and all x-ray abnormalities resolved.
X
Decline all others.
X
Leukemia
Decline all cases.
X
Lipoma
Accept if 1) present for at least 3 years and no treatment
needed, or 2) no longer present and complete recovery.
X
Rider all others.
X
Liver Atrophy
Decline all cases.
X
Lou Gehrig’s Disease
Decline all cases.
X
Lupus Erythematosus (Systemic)
Decline all cases.
X
Lyme Disease
Decline if present or if any residuals.
X
Accept if diagnosed within 5 years, incidental finding and no
treatment needed.
X
M
Macular Degeneration
Rider all others.
X
Marfan’s Syndrome
Decline all cases.
X
Melanoma (Malignant)
Accept if fully recovered at least five years and thickness was
no greater than 1.5 mm.
X
Decline all others.
X
Accept if recovered at least 5 years, no symptoms, normal
weight, and no related problems.
X
X
Menetrier’s Disease (Hypertrophic
Gastropathy)
Meniere’s Disease
Decline most others.
Accept if recovered or if controlled for at least 2 years and
testing has been completed to exclude any underlying
serious disease.
X
Rider if controlled less than 2 years and testing has been
completed to exclude any underlying serious disease.
X
X
Decline all others, including if testing has not been
completed.
Meningitis
Meniscal Tear (Torn Meniscus, Torn
Knee Cartilage)
Decline if present, or with recurrence and/or residuals, or if
mycotic or tuberculous meningitis within the last 3 years.
X
Accept all others.
X
Please refer to Knee - Meniscal Tear.
Varies based on cause, number of episodes, time elapsed since
last episode, whether controlled or not, and type of treatment.
Accept if 1) at least 3 months since full recovery or controlled
with hormonal therapy, or 2) if surgery performed and no
residuals.
X
Decline if not well controlled, or if further testing, treatment,
or surgery recommended, or if any residuals.
X
Migraines
Please refer to Headaches.
Mitral Stenosis
Decline all cases.
X
Menstrual Irregularities
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Rider
Decline
Premium
Adjustment
Accept if no heart enlargement, no other cardiovascular
impairment (excluding MVP), trace or mild only. Complete
medical records would be required.
X
Decline all others.
X
X
Mitral Valve Prolapse (MVP)
Accept 1) if no symptoms and solely treated with
prophylactic antibiotics, or 2) no symptoms but with a
click and/or mild murmur and no medication other than
prophylactic antibiotics, or 3) if symptoms controlled by
medication for at least 6 months and no further symptoms.
Decline if symptomatic, or if more than a mild murmur, or if
medication (other than prophylactic antibiotics) was started
within 6 months.
X
Mononucleosis
Accept if complete recovery, no complications, and no
chronic fatigue syndrome within the last 5 years.
X
Decline all others.
X
Morton’s Neuroma
Accept if 1) asymptomatic with orthotics or NSAID’s only, or
2) injected or operated over 1 year ago.
X
Rider all others.
X
Multiple Sclerosis
Decline all cases.
X
Muscle Spasm (Of the Back)
Accept if completely recovered with no residual symptoms;
no further testing or treatment needed.
X
Decline all others.
X
Muscular Dystrophy
Decline all cases.
X
Myasthenia Gravis
Decline all cases.
X
Myocardial Infarction, Ischemia, or
Insufficiency
Decline all cases.
X
Criteria
Accept
Mitral Valve Insufficiency or
Regurgitation
Condition
N
Nephritis
Decline if chronic
X
Nephrosclerosis
Decline all cases.
X
Nephrotic Syndrome
Decline all cases.
X
Neurofibromatosis
Decline all cases.
X
Neuromyositis
Decline all cases.
X
O
Organic Brain Disorder
Decline all cases.
X
Organ Transplants (Except Cornea)
Decline all cases.
X
Accept if surgically corrected, or if no surgery is
recommended.
X
Orthognathic Disorders
(Jaw Malformations)
Osgood-Schlatter Disease
Osteitis Condensans Ilii
Rider all others.
X
Rider any internal fixation(s) if present less than 3 years, or if
any plans for removal, or if any complications.
X
Accept if treated conservatively and no physical therapy or
surgery has been recommended, or if no longer present.
X
Decline if currently symptomatic and physical therapy or
surgery has been discussed.
X
Accept if fully recovered.
X
Rider all others.
X
Osteogenesis Imperfecta
Decline all cases.
X
Osteopenia
Accept.
X
Osteoporosis
Accept if mild, no symptoms, no compression fractures,
incidental finding, and not due to Cushing’s disease,
hyperthyroidism or steroid usage.
X
Decline all others.
X
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bcbstx.com
Rider
Decline
Ovarian Cyst
P
Premium
Adjustment
Otosclerosis
X
Rider all others.
X
Accept 1) if spontaneous disappearance at least 6 months
ago, or 2) if benign and fully recovered after surgery.
X
Rider 1) if present and malignancy definitively ruled out, or 2)
if within 6 months of spontaneous disappearance.
X
Decline all others.
X
Accept
Accept if surgically corrected and no complications.
Condition
Criteria
Pacemaker
Decline all cases.
X
Paget’s Disease (Of the Bone)
Decline all cases.
X
Periarteritis Nodosa
Decline all cases.
X
Parkinson’s Disease
Decline all cases.
X
Pending (scheduled) surgery of
any kind
Decline all cases.
X
Penile Implants or Prostheses
Decline all cases.
X
Peripheral Neuropathy
Decline all cases.
X
Peripheral Vascular Disease
Decline all cases.
X
Accept if surgically corrected and fully recovered for at least
1 year, and no recurrence.
X
Rider if present or within 1 year of surgery without
recurrence.
X
Peyronie’s Disease
Decline all others.
X
Accept if no surgery planned or recommended, OR if
operated and fully recovered with no residual symptoms.
X
Rider all others.
X
Accept if completely recovered with no predisposing
pulmonary or systemic disease.
X
Pneumonia
Individual consideration is given for multiple episodes,
depending on the time elapsed between episodes.
Decline all others.
X
Polycystic Kidney Disease
Decline all cases.
X
Polycystic Liver Disease
Decline all cases.
X
Polycystic Ovarian Disease/Syndrome
(PCOS)
Accept 1) if postmenopausal, or 2) if hysterectomy done
with both ovaries removed, or 3) after successful pregnancy
with no plans for future treatment, or 4) if treated with birth
control pills for at least 2 years and no further testing or
treatment planned or recommended.
X
Decline all others, including if any fertility treatment within
3 years.
X
Polycythemia Vera
Decline all cases.
X
Polymyositis
Decline all cases.
X
Polyneuritis / Polyneuropathy
Decline all cases.
X
Accept if no follow-up colonoscopy or colon screening was
recommended to be performed within the next 2 years.
X
Rider if follow-up recommended within 2 years.
X
Plantar Fasciitis
Polyps, Colon or Rectal
Decline if present.
X
Decline all cases.
X
Varies based on underlying condition.
Post-Operative Status
Decline if not completely recovered or if ineligible based on
underlying condition.
X
Pregnant or an Expectant Parent
(Mother or Father)
Decline until post-partum exam has been completed and
released from physician care.
X
Porphyria
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Accept
Rider
Decline
Prostatic Enlargement / Benign
Prostatic Hypertrophy (BPH)
Prostatitis
Prostatic Stone
Psychotic Disorders
Premium
Adjustment
Criteria
Accept if unoperated with no more than slight enlargement,
no symptoms, and urinalysis normal or if operated and fully
recovered at least 2 years ago.
X
Rider 1) if unoperated and more than slight enlargement, or
if symptomatic, or with abnormal urinalysis, or 2) if operated
and recovered within 2 years.
X
Condition
Others given individual consideration.
Accept if infrequent episodes of short duration.
X
Rider if chronic within 3 years.
X
Accept if removed, urinalysis is normal and no residuals.
X
Rider if present.
X
Decline all cases.
X
Pulsus Alternans
Decline all cases.
X
Pyelonephritis
Please refer to Kidney Infection.
Rider if recurrent episodes and last episode within 4 years. If
with a disc disorder, refer to Disc Disorder.
X
Accept if surgically repaired and no complications.
X
R
Radiculitis / Radiculopathy
Rectal fistula / prolapse
Rectocele
Respiratory Syncytial Virus (RSV)
Restless Legs Syndrome
Rider all others.
X
Accept if no longer present and no residual incontinence.
X
Rider if present or if residuals after surgery.
X
Accept if completely recovered for at least 3 months, and any
recommended prophylactic treatment has been completed.
X
Decline all others.
X
Accept if well controlled with one medication
X
Accept with premium adjustment if well controlled with 2
medications.
X
Decline all others.
X
Retinal Detachment
Accept if 1) diagnosed at least 1 year ago and no treatment
needed, or 2) if single episode, operated and completely
recovered.
X
Rider all others.
X
Retinal Tears or Holes
Accept if 1) diagnosed at least 1 year ago and no treatment
needed, or 2) if single episode, operated and completely
recovered.
X
Rider all others.
X
Rett Syndrome
Please refer to Autism.
X
X
Rheumatic Heart Disease
Decline all cases.
Rheumatoid Arthritis
Please refer to Arthritis.
Accept if treated with OTC or oral medication.
X
Rider all others, including if treated within the last 12 months
with phototherapy, pulsed light therapy, laser, dermabrasion, or
chemical peel; or if contemplating treatment.
X
Accept if 1) unoperated and no symptoms in the last 5 years,
or 2) operated, recovered and no residual symptoms within
the last 6 months.
X
Rider all others.
X
Rosacea
Rotator Cuff Tear
S
Sciatica
Refer to Intervertebral Disc, if related to a disc disorder.
Rider if multiple episodes of unknown cause, no disc disorder
or involvement, and last episode within 4 years.
X
Accept all others.
X
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bcbstx.com
Rider
Decline
Premium
Adjustment
Rider 1) if degree of curvature is 30 degrees or less, and
symptoms or non-surgical treatment have occurred within 5
years, or 2) if history of one surgery with complete recovery
at least 3 years ago.
Rider any internal fixations present, including rods.
X
Decline 1) if surgery done within 3 years, or 2) if multiple
surgeries or complications. or 3) if under age 21 and degree
of curvature is greater than 30 degrees.
X
Sebaceous Cyst
Accept 1) if no longer present, or 2) if present for at least 1
year, no treatment needed, and not increasing in size.
X
Rider all others.
X
Seborrheic Keratosis
Accept.
X
Varies based on the exact type of seizure, date since last seizure,
any loss of consciousness, treatment, age, etc.
Grand mal / generalized seizures
Accept if compliant with medications, and seizure-free for at
least 1 year.
X
Decline most others.
X
Petit mal / focal or partial seizures
Accept if last seizure was more than 12 months ago with no
loss of consciousness; or more than 3 years ago with any loss
of consciousness.
X
Rider if last seizure was 6-12 months ago with no loss of
consciousness; or if last seizure was 1 to 3 years ago with any
loss of consciousness.
X
Decline most others.
X
Please refer to Atrial or Ventricular Septal Defect.
Accept if 1) unoperated and no symptoms in the last 5 years, or
2) operated and fully recovered for at least 1 year with no residual
symptoms, or 3) if a tear has been operated and fully recovered
for at least 6 months with no residual symptoms
X
Criteria
Accept
X
Condition
Accept if at least age 21, no more than 30 degrees of curvature on
X-ray, and no symptoms or treatment within 5 years
OR
Accept if ages 19-20, no more than 16 degrees of curvature
on X-ray, and no symptoms or treatment within 5 years.
Scoliosis, Kyphosis, Lordosis
Seizure
Septal Defects
Shoulder Disorders (Frozen Shoulder,
Impingement, Rotator Cuff tear,
Rupture)
Shoulder, Separated or Dislocated
Sickle Cell Anemia
Sinusitis
Sjogren’s Syndrome
Skin Cancer (Non-Melanoma):
basal cell, squamous cell, Bowen’s
disease and other variants
Rider all others.
X
Rider any internal fixation(s) if present less than 3 years, or if
any plans for removal, or if any complications.
X
Accept 1) if unoperated, single occurrence and recovered for
at least 3 months, or 2) if operated and fully recovered for at
least 2 years with no residual symptoms.
X
Rider all others, including if any residuals after surgery.
X
Rider any internal fixation(s) if present less than 3 years, or if
any plans for removal, or if any complications.
X
Decline all cases.
X
Accept unless surgery planned or recommended.
X
Rider if surgery planned or recommended.
X
Decline all cases.
X
Note: If melanoma, refer to Melanoma.
Accept 1) if under 2 cm and completely removed with no
recurrence, or 2) if 2 cm or larger and completely removed at
least 5 years ago.
X
Rider 1) if any recurrence, or 2) if 2 cm or larger and removed
within 5 years.
X
Decline 1) if present or 2) with metastasis, or 3) if the excised tumor
extended to muscle, bone, cartilage, or other deep structures.
X
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bcbstx.com
Rider
Decline
Sleep Apnea
Premium
Adjustment
X
Decline all others, including if type is central sleep apnea, is
disruptive to
normal activities.
X
Criteria
Accept
Note: Use of CPAP is acceptable if meets criteria listed below.
Accept if obstructive or mixed apnea no surgery discussed,
no motor vehicle or industrial accidents related to apnea,
and no history of heart disease, atherosclerotic disease,
arrhythmia, alcohol abuse, or chronic lung disease.
Condition
Accept if operated and fully recovered.
X
Rider if present.
X
Spastic / Overactive Bladder
Accept if symptoms are minor, treatment is conservative and
surgery has not been recommended.
X
Rider most others.
X
Spinal Stenosis
Accept if 1) no symptoms and incidental finding, or 2)
unoperated and asymptomatic at least 5 years, or 3) if
operated over 5 years ago with no residuals.
X
Rider all others.
X
Spondylolisthesis
Accept if 1) asymptomatic and incidental finding, or 2)
operated at least 5 years ago with no residuals.
X
Rider all others.
X
Spondylosis
Accept if 1) no symptoms and incidental finding, or 2)
unoperated and asymptomatic at least 5 years, or 3) if
operated over 5 years ago with no residuals.
X
Rider all others.
X
Stokes-Adams Syndrome
Decline all cases.
X
Sprain / strain:
Accept if fully recovered and no residual symptoms.
Ligament injury or tear:
Accept if 1) unoperated and fully recovered for at least 1
year with no residual symptoms, or 2) operated and fully
recovered for at least 6 months with no residual symptoms.
X
Spermatocele
Strain / Sprain, Ligament Injury
or Tear
(Other than Back, Knee, or Shoulder)
Strabismus
Rider all others.
X
Accept if no treatment is needed OR managed with
nonsurgical treatment and no surgery is planned or
recommended.
X
Rider if surgery is planned or recommended, or if any
residuals following surgery.
X
Stress Incontinence
Please refer to Incontinence (Urinary).
Stroke
Decline all cases.
X
Suicidal Ideation
Suicide Attempt
Accept if last ideation was at least 2 years ago.
X
Decline if less than 2 years ago.
X
Accept if single attempt at least 3 years ago, or multiple
episodes with most recent at least 5 years ago, recovered, no
residuals
X
Decline all others.
X
Systemic Lupus Erythematosus (SLE)
Decline all cases.
X
Systemic Scleroderma or Sclerosis
Decline all cases.
X
Accept if 1) operated and fully recovered, or 2) if present, but
no surgery is anticipated or recommended.
X
Rider all others.
X
T
Tarsal Tunnel Syndrome
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bcbstx.com
Accept
Rider
Decline
Temporomandibular Joint Disorder
(TMJ)
Tendonitis / Tenosynovitis
Tennis Elbow / Epicondylitis
Testosterone Deficiency
Tetralogy of Fallot
Thoracic Outlet Syndrome
Thrombocytosis
Thyroid Gland Disorders
Tobacco Use
Tonsillitis / Adenoiditis
Tourette’s Syndrome
Premium
Adjustment
Criteria
Accept 1) if completely recovered, or 2) mild symptoms and
controlled by conservative methods (mouth guard, over the
counter medications, acupuncture or manipulation therapy),
or 3) if treated with NSAID’s, mild anti-depressants or physical
therapy.
X
Decline all others, including if surgery is planned or recommended.
X
Accept if 1) single episode with complete recovery and no
complications, or 2) multiple episodes in the same location
after 2 years of complete recovery and no complications.
X
Rider all others, including if multiple episodes, if chronic, or
with residuals after surgery.
X
Accept if 1) single episode with complete recovery and no
complications, or 2) multiple episodes in the same location
after 2 years of complete recovery and no complications.
X
Rider all others, including if multiple episodes, if chronic, or
with residuals after surgery.
X
Accept if onset more than 6 months ago and no treatment
needed or advised.
X
Condition
Accept with premium adjustment if onset within 6 months, or
if treated with testosterone gels, patches, or injections.
X
Decline all cases.
X
Accept if fully recovered for at least 2 years following surgery, or
if fully recovered following non-surgical treatment.
X
Rider if surgically corrected within 2 years, recovered with
no more than minimal residuals or if present and no surgery
planned or recommended.
X
Decline all others, including if multiple surgeries.
X
Decline all cases.
X
Overactive Thyroid (Hyperthyroidism)
Accept if treated with 131I (radioactive iodine) or total
thyroidectomy over 1 year ago.
X
Decline if present, and untreated, or with radioactive iodine
ablation or surgery planned or recommended
X
Rider if treated with thyroid replacement medication (past or
current), if present and treated with anti-thyroid medication,
if history of and treated with 131I (radioactive iodine), or
total thyroidectomy within 1 year.
X
Underactive Thyroid (Hypothyroidism)
Accept if controlled on medication for at least 1 year; no
history of hyperthyroidism, goiter, or nodule; no cretinism or
congenital hypothyroidism.
X
Rider if 1) treated with medication for less than 1 year or 2)
with benign nodule or goiter; and no cretinism or congenital
hypothyroidism.
X
Decline all others.
X
Accept at tobacco user’s rate if use of any type of tobacco
product, nicotine substitution product, or tobacco cessation
aid within the last 12 months.
X
Accept if 1) operated and fully recovered, or 2) unoperated,
infrequent episodes, and no discussion of surgery.
X
Rider if chronic, or if surgery discussed or recommended, or if
residuals after surgery.
X
Accept if non-disabling, non-disruptive, no treatment
needed, and no other psychological conditions.
X
X
Accept with premium adjustment if controlled with 1-2
medications.
Decline all others.
X
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bcbstx.com
Decline
Rider
Premium
Adjustment
Criteria
Accept
Condition
Transient Ischemic Attack (TIA)
Decline all cases.
X
Transplants, Organ
Decline all cases.
X
Transposition of the Great Vessels
Decline all cases.
X
Accept if benign essential tremor, non-disabling, no other
neurologic symptoms, and testing confirms not caused by an
underlying disease.
X
Decline if treated with clozapine or surgery, or if due
to an underlying disease including multiple sclerosis,
Parkinson’s disease, a central nervous system disorder, or
hyperthyroidism.
X
Tremor
Tricuspid Atresia
Tuberculosis (Pulmonary)
Decline all cases.
X
Accept if: 1) exposure without disease and subsequent TB
testing negative, or 2) infected but without active disease,
no symptoms, all prophylactic drug therapy completed and
subsequent chest X-ray or culture is negative.
X
Decline if disease is present, or if all recommended treatment
was not completed, or if subsequent test results are not
negative.
X
Others given individual consideration based on length of
recovery.
U
Ulcerative Colitis
Ulnar Nerve Palsy
(Cubital Tunnel Syndrome)
Undescended Testicle(s)
Urethral Stricture / Stenosis
Urethrocele
Urinary fistula
Please refer to Colitis.
Accept if 1) unoperated, asymptomatic, and fully recovered
for at least 2 years, or 2) operated and no residuals or
recurrent symptoms.
X
Rider if any symptoms, if surgery planned or recommended,
and all others.
X
Accept if surgically corrected and fully recovered or if fully
resolved without surgery.
X
Rider if present.
X
Accept if corrected by dilation, latest urinalysis is normal,
and 1) recovered from 1-2 episodes for at least 2 years, or 2)
recovered from 3 or more episodes at least 3 years.
X
Rider if latest urinalysis is normal and 1) 1-2 episodes within
two years, or
2) 3 or more episodes with the last occurring within 3 years.
X
X
Decline all others.
Accept if no longer present and no residual incontinence.
X
Rider if present or if residuals after surgery.
X
Accept if operated and fully recovered with no
complications.
X
Rider all others.
X
Accept if completely recovered for at least 2 years, not on
maintenance antibiotics, no kidney damage (confirmed by
testing), and no hypertension.
X
Rider if present, or if recovered without surgery less than 2
years ago.
X
Decline all others, including those with injections of synthetic
material, or if treated surgically or with Deflux or collagen
injection within 2 years.
X
Urinary Tract Infection (UTI)
Please refer to Cystitis
Uterine Fibroids
Accept if treated by hysterectomy, or testing confirms no
longer present, or post-menopausal and no symptoms.
X
Rider all others.
X
Urinary Reflux
30
bcbstx.com
Rider
Decline
Premium
Adjustment
Uterine Prolapse
X
Rider all others.
X
Accept if operated and fully recovered.
X
Rider all others.
X
Criteria
Accept
Accept if no urinary disorder and either 1) unoperated with
no discussion of surgery, or 2) operated and fully recovered.
Condition
V
Vaginal Fistula
Valve Replacement
Decline all cases.
X
Accept if operated and fully recovered.
X
Rider all others.
X
Accept if onset date was over 5 years ago and no symptoms,
or if treatment completed over 1 year ago and no remaining
varicose veins are present.
X
Rider 1) if onset within 5 years, no complications and no
surgery recommended, or 2) if treatment was completed
within the past year, or 3) if any varicose veins are still
present following treatment.
X
Decline if surgery is planned or recommended, or any history
of complications or other circulatory problems, or if location
is other than lower extremities.
X
Ventricular Fibrillation
Decline all cases.
X
Ventricular Septal Defect
Accept if defect closed (confirmed by testing), or if surgically
repaired at least 1 year ago.
X
Decline all others.
X
Accept if 1) benign positional vertigo, or 2) recovered from
single episode over 1 year ago.
X
Decline if unknown cause and either present or recurrent
episodes.
X
Varicocele
Varicose Veins / Varicosities
Vertigo / Benign Positional Vertigo
Vitreous Detachment / Degeneration
Vocal Cord Polyps, Laryngeal Polyps
Accept if onset more than 3 years ago.
X
Rider most others.
X
Accept if operated and recovered for at least 2 years.
X
Rider most others.
X
X
W
Wernicke’s Disease
Decline all cases.
Accept if fully recovered and no residual symptoms.
X
Decline all others.
X
Wilson’s Disease
Decline all cases.
X
Wolfe-Parkinson-White syndrome
Accept if 1) no symptoms and no treatment needed, or 2)
treated with medication with no symptoms in last 5 years, or
3) treated with ablation and no symptoms in last 2 years.
X
Decline most others.
X
Whiplash
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bcbstx.com
Unacceptable Medications
Current use of the following types of medications will warrant declination. These medications lists are NOT all-inclusive
and are subject to change.
Abacavir
Antabuse
Azathioprine
Certolizumab
Abatacept
Antagon
Azidothymidine (AZT)
Cetrorelix
Abiraterone
Antithrombin
Azilect
Cetrotide
Acamprosate
Apidra
Aztreonam
Cetuximab
Acarbose
Apo-Benztropine
Baraclude
Chlorambucil
Accretropin
Apo-Chlorpropamide
Belatacept
Chlorpromazine HCL
Acova
Apo-Fluphenazine
Belimumab
Chlorpropamide
Actemra
Apokyn
Benlysta
Cibalith-S
Actimmune
Apo-Morphine
Benztropine
Cidofovir
Actoplus Met
Apo-Perphenazine
Betaseron
Cimzia
Actos
Apo-Thioridazine
Biperiden
Clomid
Adalimumab
Apo-Trifluoperazine
Bivalirudin
Clomiphene Citrate
Adcirca
Apo-Zidovudine
Boceprevir
Clopidogrel
Adcretis
Arava
Bosentan
Clozapine
Adefovir
Arcalyst
Bravelle
Clozaril
Afinitor
Ardeparin
Brentuximab vedotin
Agalsidase
Argatroban
Brilinta
Coagulation factor VIII
complex
Agenerase
Arginine
Bromocriptine
Cogentin
Aglucosidase
Aricept
Byetta
Cognex
Akineton
Arimidex
Cabazitaxel
Combivir
Aldazine
Arixtra
Cabergoline
Complera
Aldurazyme
Aromasin
Camcolit
Comtan
Alefacept
Artane
Campath
Copaxone
Alemtuzumab
Arzerra
Campral
Copegus
Amantadine
Canakinumab
Cotazym
Amaryl
Asparaginase Erwinia
chrysanthemi
Canasa
Coumadin
Amethopterin
Atazanavir
Carbaglu
Creon
Amevive
Atripla
Carbex
Crixivan
Amprenavir
Atryn
Carbidopa-Levodopa
Crizotinib
Ampyra
Aurolate
Carbolith
Cycloset
Anakinra
Aurothioglucose
Cardoxin
Cyclosporine
Anastrozole
Avandamet
Carglumic acid
Cymevene
Anatensol
Avandaryl
Cayston
Cytovene
Angiomax
Avandia
Celance
Cytoxin
Anisindione
Avonex
Cerezyme
Dalfampridine
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Dalteparin
Entanercept
Fosamprenavir
Hivid
Danaparoid
Entravirine
Foscarnet
Hizentra
Daonil
Epivir
Foscavir
Humalog
Darunavir
Epoetin
Fragmin
Humira
Delavirdine
Epogen
Fuzeon
Humotrope
Denosumab
Epzicom
Galantamine
Humulin
Denzapine
Erbitux
Galsulfase
Hydroxychloroquine
Deponit
Eribulin mesylate
Ganciclovir
Idursulfase
DiaBeta
Erwinaze
Ganirelex Acetate
Ilaris
Diabinese
Eskalith
Genotropin
Iloperidone
Didanosine (DDL)
Etrafon
Gilenya
Imiglucerase
Digitek
Etravirine
Glatiramer acetate
Immune globulin
Digoxin
Euglucon
Glibenese
Imuran
Dihydrochloride
Everolimus
Glimepiride
Inamrinone Lactate
Disulfiram
Exelon
Glipizide
Incivek
Donepezil
Exemastane
Glucagon
Increlex
Dopar
Exenatide
Glucobay
Indinavir
Dornase alfa
Extavia
Glucophage
Infergen
Dostinex
Exubera
Glucophage XR
Infliximab
Dozic
Fabrazyme
Glucotrol
Innohep
Duetact
Fanapt
Glucovance
Inocor
DuoVil
FazaClo
Glyburide
Insulin products
Duralith
Felbamate
Glynase PresTab
Intelence
Dygase
Felbatol
Glyset
Interferon
Eculizumab
Femara
Gold Sodium Thiomalate
Intron-A
Edurant
Fentamox
Gold-50
Invega
Efalizumab
Fentazin
Golimumab
Invirase
Efavirenz
Feraheme
Gonal-F
Ipilimumab
Effient
Fertinex
Halaven
Isentress
Elaprase
Fingolimod
Haldol
Istodax
Eldepryl
Fluphenazine
Haloperidol
Jantoven
Emblon
Folex
Janumet
Emsam
Follistim
HCG/chorionic gonadotropin alpha
Emtricitabine
Follitropin Alfa
Hepalean
Jevtana
Emtriva
Folotyn
Enbrel
Fomivirsen
Enfuvirtide
Fondaparinux
Enoxaparin
Fortamet
Entacapone
Forteo
Entacavir
Fortovase
Heparin
Heparin-Leo
Hep-Lock
Hep-Pak
Hepsera
Herceptin
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Januvia
Juvisync
Kaletra
Kemadrin
Kemstro
Kineret
Kutrase
bcbstx.com
Kuvan
Maraviroc
Nitrogard
Peginterferon
Ku-Zyme
Mecasermin
Nitroglycerin
Peg-Intron
Lamivudine
Mellaril
Nitroglyn
Pegvisomant
Lanoxicaps
Memantine
Nitrol
Pergolide
Lanoxin
Mesoridazine
Nitrolingual
Pergonal
Lanreotide
Metaglip
Nitrong
Peridol
Lantus
Metformin HCL
Nitrostat
Permax
Larodopa
Methadone
Nitro-Time
Permitil
Laronidase
Methoblastin
Nolvadex
Perphenazine
Latuda
Methotrexate
Norditropin
Pioglitazone HCL
Ledertrexate
Micronase
Normiflo
Plaquenil
Leflunomide
Miglitol
Norvir
Plavix
Lemtrada
Miglustat
Novo-AZT
Pradaxa
Lepirudin
Milophene
Novo-Chlorpromazine
Pralatrexate
Leukeran
Milrinone Lactate
Novolog
Pramlintide
Levemir
Mini Diab
Novo-Ridazine
Prandase
Levodopa
Minitran
Novo-Trifluzine
Prandimet
Levodopa-Carbidopa
Miradon
NTS
Prandin
Lexiva
Moditen
Nulojix
Prasugrel
Lialda
Monoparin
Nutropin
Precose
Linagliptin
Multiparin
Octreotide
Prezista
Lipram
Myozyme
Ofatumumab
Priadel
Liraglutide
Naglazyme
Omnitrope
Procrit
Lithane
Naloxone/Buprenorphine
Onglyza
Procyclidine
Naltrexone HCL
Onsolis
Prolastin-C
Orencia
Prolia
Orfadin
Prolixin
Orgaran
Provenge
Ovidrel
Pulmozyme
Paliperidone
Pump-Hep
Palivizumab
Raltegravir
Pancrease
Raptiva
Pancreaze
Rasagiline
Pancrelipase
Razadyne
Panokase
Rebetol
Parcopa
Rebetron
Parlodel
Rebif
Pazopanib
Refludan
Pegasys
Remicade
Lithicarb
Lithium
Lithizine
Lithobid
Lithonate
Lithotabs
Lodosyn
Lopinavir/Ritonavir
Lovenox
Loxapac
Loxapine
Loxitane Modecate
Lurasidone
Lutropin alfa
Luvens
Namenda
Natalizumab
Nateglinide
Navane
Nelfinavir
Neosar
Neupro
Nevirapine
Nitisinone
Nitradisc
Nitro-Bid
Nitrodisc
Nitro-Dur
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Reminyl
Sinemet
Tinzaparin
Vivitrol
Repaglinide
Sipuleucel-T
Tipranavir
Votrient
Repronex
Sitagliptan
Tocilizumab
VPRIV
Rescriptor
Sodium oxybate
Tolcapone
Warfarin
Retrovir
Solganal
Tracleer
Warfilone
ReVia
Soliris
Tradjenta
Wilate
Reyataz
Soltamox
Transderm-Nitro
Xalkori
R-Gene10
Somatropin
Transiderm-Nitro
Xarelto
Rheumatrex
Somavert
Trastuzumab
Xenazine
Ribasphere
Stalevo
Trexall
Xgeva
Ribavirin
Starlix
Trexan
Xyrem
Rilonacept
Stavudine
Triavil
Yervoy
Rilpivirene
Stelara
Tridil
Zalcitabine
Riomet
Stelazine
Trifluoperazine
Zaponex
Ritonavir
Suboxone
Trihexyphenidyl
Zavesca
Rituxan
Sumatuline Depot
Trilafon
Zelapar
Rituximab
Sunitinib maleate
Trizivir
Zelboraf
Rivaroxaban
Sustiva
Truvada
Zenpep
Rivastigmine
Sutent
Tysabri
Zerit
Roferon
Sylatron
Ultrase
Ziagen
Romidepsin
Symlin
Unihep
Zidovudine
Rosiglitazone
Symmetrel
Uniparin
Zorbtive
Rotigotine
Synagis
Urofollitropin
Zortress
Sabril
Tacrine
Ustekinumab
Zytiga
Saizen
Tamofen
Valcyte
Salazopyrin
Tamoxifen
Valganciclovir
Salofalk
Tasmar
Vandetanib
Sandimmune
Telaprivir
Velaglucerase alfa
Sandostatin
Tenofovir
Velosulin
Sapropterin
Teriparatide
Vemurafenib
Saquinavir
Tetrabenzine
Victoza
Saxagliptin
Tev-tropin
Victrelis
Selegiline
Thioprine
Videx
Selzentry
Thioridazine
Vigabatrin
Semi-Daonil
Thiothixene
Viokase
Serenace
Thiothixene HCL
Viracept
Serentil
Thorazine
Viramune
Serophene
Ticagrelor
Viread
Serostim
Ticlid
Vistide
Simponi
Ticlopidine
Vitravene
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TX - Coverage Exclusion Riders
Blue Cross and Blue Shield of Texas offers many coverage exclusion riders for certain conditions that would otherwise
be declined or offered with a premium adjustment. This section provides you with the specific rider language used
for each of these riders. Each rider addresses a single condition or a very small set of closely related conditions.
Any complications that are covered by the rider are also spelled out. This specificity is somewhat different from
riders that may be used by other companies.
The detailed nature of the rider language will serve to enhance our current underwriting guidelines. We will continue to
underwrite all applications in a manner consistent with our current practices and offer coverage with or without a rider in
those situations whenever appropriate.
Important Information About Blue Cross and Blue Shield of Texas Coverage Exclusion Riders
1. No more than three coverage-exclusion riders will be placed on any one applicant.
We have intentionally limited the number of exclusion riders on any single individual to three, so that our offer of modified coverage is still meaningful. There will always be those applicants whose medical history precludes us from making any offer, even with a rider.
2. Coverage-exclusion riders are permanent.
There are selected situations in which the policyholder may request reconsideration, i.e., removal of a rider, after a five (5) year period has elapsed (beginning with the effective date of the policy). If removal is approved, it will be effective as of the current date.
For those situations where it is possible to remove a rider after five years, removal will not be automatic.
Removal must be requested by the policyholder in writing and will be subject to company approval at the time
the request is made.
3. Current members requesting an upgrade may receive a coverage exclusion rider on their new policy if approved.
When this occurs, the member will have a limited time to decide whether to accept the new upgraded policy with
the rider(s) or keep their existing coverage without the rider(s).
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Coverage Exclusion Rider List
The following is a list of our current Coverage Exclusion Riders along with the exact rider text. Keep it handy for reference.
Rider
Acne
Time Limit Rider Language
5 years
Amputation
Permanent
Anal Fissure
5 years
Anal/Rectal Disorder
5 years
Back or Spinal Disorders, Radiculities
Baker’s Cyst (Popliteal Cyst)
Permanent
5 years
Brachial Palsy (Erb’s Palsy)
Permanent
Breast Implants, Mammoplasty
Permanent
Breast Reduction or Macromastia
Permanent
Bunion (Hallux Valgus)
Permanent
Bursitis/Tendonitis
5 years
Carpal Tunnel Syndrome
5 years
Cataract
Permanent
Cervical Disorder(s)
3 or 5 years
Cholesteatoma
5 years
Choroidal nevus
Permanent
Coccydynia
5 years
Colon Polyps/Papilloma
5 years
Congenital Malformation (hands/
feet)
Permanent
Any form of acne or rosacea, including any diagnostic procedure,
treatment or operation for or complications thereof.
Any injury to, disorder of, operation for, diagnostic procedure or
treatment performed on the remaining portion of [the left / the right /
both] [affected limb(s)], including initial or replacement of prosthetic
devices and/or the repair of prosthetic devices.
Anal fissure, including any diagnostic procedure, treatment or operation
for or complications thereof.
Any disease or disorder of the rectum or anus, including fistula-in-ano
and ischiorectal abscess, and any diagnostic procedure, treatment or
operation for or complications thereof.
Any injury, disease, or disorder of the spinal column including the vertebrae,
intervertebral discs, ligaments, muscles, radiculitis, and any diagnostic
procedure, treatment or operation for or complications thereof.
Baker’s cyst (popliteal cyst) of the [left knee / right knee / knees], including any
diagnostic procedure, treatment or operation for or complications thereof.
Any injury to, disease or disorder of [the left / the right / both] arm(s) and
shoulder(s), including any diagnostic procedure, treatment or operation
for or complications thereof.
Any disorder of intramammary implants, including any diagnostic procedure
or treatment for or complications necessitating capsulectomy, capsulotomy,
replacement or removal of partial or intact implants or implant material.
Macromastia or enlarged breast(s), including any diagnostic procedure,
treatment or operation for reduction of the breast(s) and any
complications thereof.
Bunion (hallux valgus) of both feet, including any diagnostic procedure,
treatment or operation for or complications thereof.
Bursitis, tendonitis, synovitis, tenosynovitis of the [affected joint(s)], including
any diagnostic procedure, treatment or operation for or complications thereof.
Carpal tunnel syndrome, including any diagnostic procedure, operation,
or treatment for or complications thereof.
Cataract(s) of the [left eye / right eye / eyes] including blindness or
impairment of vision, and any diagnostic procedure, treatment or
operation for or complications thereof.
Any disease or disorder of the uterine cervix including malignancy or
metastases, and any diagnostic procedure, treatment or operation for or
complications thereof.
Cholesteatoma of the [left ear / right ear / ears], including any diagnostic
procedure, treatment or operation for or complications thereof.
Choroidal nevus or nevi, or any disease or disorder of the [left eye/ right
eye / eyes], including choroidal melanoma, blindness or impairment of
vision, and any diagnostic procedure, treatment, prosthesis, or operation
for or complications thereof.
Coccydynia and any sprain or strain of the coccyx, including any diagnostic
procedure, treatment or operation for or complications thereof.
Colon polyp(s), papilloma, tumor or neoplasm including malignancy and
metastases, and any diagnostic procedure, treatment or operation for or
complications thereof.
Congenital malformation of the (left hand/foot, right hand/foot, hands/
feet), including any diagnostic procedure, treatment or operation for or
complications thereof.
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Rider
Corneal Disorder(s)
Time Limit Rider Language
Permanent
Cubital Tunnel Syndrome
5 years
Cyst, Lipoma, etc.
5 years
Cystitis
5 years
Cystocele, Rectocele, Urethrocele
5 years
Deafness, Hearing Loss
Permanent
Deviated Septum
Permanent
Dislocation
Permanent
Diverticulosis, Diverticulitis
Dupuytren’s Contracture
5 years
Permanent
Epididymitis, Orchitis
5 years
Exostosis
5 years
Eye Disorder
5 years
Eye Prosthesis
Gallbladder Disease
Glaucoma
Gynecomastia
Permanent
5 years
Permanent
5 years
Hammertoe
Permanent
Headaches
Permanent
Hemangioma
5 years
Hemorrhoids
5 years
Hernia
5 years
HPV or Genital Warts
Hydrocele
Hypospadias or Epispadias
Permanent
5 years
Permanent
Corneal ulcer, corneal transplant, blindness or impaired vision due to corneal
disorders of the [left eye/ right eye/ eyes], including any diagnostic procedure,
treatment or operation for or complications thereof.
Cubital tunnel syndrome or ulnar nerve palsy of the [left arm / right arm /
arms], including any diagnostic procedure, treatment or operation for or
complications thereof.
Cyst, tumor, or neoplasm of the [affected area], including any diagnostic
procedure, treatment or operation for or complications thereof.
Cystitis, trigonitis or any disease or disorder of the urinary bladder, including any
diagnostic procedure, treatment or operation for or complications thereof.
Rectocele, cystocele, or urethrocele, including any diagnostic procedure,
treatment or operation for or complications thereof.
Deafness or hearing loss of the [left ear / right ear / ears], including any
diagnostic procedure, treatment, implant, device, prosthesis, or operation
for the improvement of hearing or complications thereof.
Deviated nasal septum, including any diagnostic procedure, treatment or
operation for or complications thereof.
Any dislocation of the [affected joint] including the adjacent bones, and any
diagnostic procedure, treatment or operation for or complications thereof.
Diverticulosis or diverticulitis of the colon, including any diagnostic
procedure, treatment or operation for or complications thereof.
Dupuytren’s contracture of both hands, including any diagnostic
procedure, treatment or operation for or complications thereof.
Epididymitis or orchitis, including any diagnostic procedure, treatment or
operation for or complications thereof.
Any disorder of the [affected bones], including any diagnostic procedure,
treatment or operation for or complications thereof.
Any disease or disorder of the [left eye / right eye / eyes] including
blindness or impairment of vision, and any diagnostic procedure,
treatment or operation for or complications thereof.
Any disorder resulting from the enucleation of the [left eye / right eye
/ eyes] including insertion of prosthesis, and any diagnostic procedure,
operation or treatment for or complications thereof.
Any disease or disorder of the gallbladder or biliary ducts, including any
treatment or operation for or complications thereof.
Glaucoma including blindness or impairment of vision, and any diagnostic
procedure, treatment or operation for or complications thereof.
Gynecomastia, including any diagnostic procedure, treatment or
operation for or complications thereof.
Hammertoe(s), including any diagnostic procedure, treatment or
operation for or complications thereof.
Migraine or headache, including any diagnostic procedure, treatment or
operation for or complications thereof.
Hemangioma(s) of the [affected area], including any diagnostic procedure,
treatment or operation for or complications thereof.
Hemorrhoids, including any diagnostic procedure, treatment or operation
for or complications thereof.
Abdominal hernia, including any treatment or operation for or
complications thereof.
Condyloma acuminatum, genital verrucae, genital warts, or venereal
warts, including any diagnostic procedure, treatment or operation for or
complications thereof.
Hydrocele, including any diagnostic procedure, treatment or operation for
or complications thereof.
Hypospadias or epispadias, including any diagnostic procedure, treatment
or operation for or complications thereof.
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Rider
Time Limit Rider Language
Internal Fixation
Permanent
Joint Replacement or Prosthesis
Permanent
Keloid
5 years
Kidney or Urinary Tract Disorder
Permanent
Knee Disorders
Permanent
Macular Pucker
5 years
Meniere’s Disease
Permanent
Morton’s Neuroma
5 years
Osteitis Condensans Ilii
Permanent
Otosclerosis or Ear Disorder
5 years
Ovarian Cyst(s)
5 years
Papilloma, Polyp(s)
5 years
Peyronie’s Disease
5 years
Plantar Fasciitis
5 years
Prostate Disorders
5 years
Prostatic Stone
5 years
Prostatitis
5 years
Rectal Disorders (Fistula, Prolapse)
Retinal Detachment
5 years
5 years
Retinal, Lattice, Macular
Degeneration
Permanent
Retinal or Macular Defects
Permanent
Shoulder Disorders
Permanent
Sinusitis
5 years
Skin Cancer, Neoplasm or Dysplasia
5 years
Internal fixation of the [affected bone(s)], including any diagnostic
procedure, removal, replacement or complications thereof.
Any diagnostic procedure, treatment or operation of [the left / the right
both][affected joint(s)] and prosthesis, including removal, revision,
replacement or complications thereof.
Keloid or scar of the [affected area], including any diagnostic procedure,
treatment or operation for or complications thereof.
Any disease or disorder of the kidney or urinary tract including renal
failure, and any diagnostic procedure, treatment or operation for or
complications thereof.
Any injury to or disease of the [left knee / right knee / knees], including any
diagnostic procedure, treatment or operation for or complications thereof.
Any disease or disorder of the [left eye / right eye / eyes] including
blindness or impairment of vision, and any diagnostic procedure,
treatment or operation for or complications thereof.
Meniere’s disease/syndrome or hydrops of the ears, including any
diagnostic procedure, treatment, implant, device, prosthesis, or operation
for the improvement of hearing or complications thereof.
Morton’s neuroma or interdigital neuroma, including any diagnostic
procedure, treatment or operation for or complications thereof.
Osteitis condensans ilii, including any diagnostic procedure, treatment or
operation for or complications thereof.
Otosclerosis or any disease or disorder of the [left ear / right ear / or ears],
including deafness, and any diagnostic procedure, treatment or operation
for or complications thereof.
Any disease or disorder of the ovaries including workup for infertility, and any
diagnostic procedure, treatment or operation for or complications thereof.
Papilloma, polyp, tumor or neoplasm of the [affected area], including any
diagnostic procedure, treatment or operation for or complications thereof.
Peyronie’s Disease, including any diagnostic procedure, treatment or
operation for or complications thereof.
Heel spur or plantar fasciitis of both feet, including any diagnostic
procedure, treatment or operation for or complications thereof.
Enlargement of the prostate gland, including any diagnostic procedure,
treatment or operation for or complications thereof.
Prostatic stone(s) or calculi, including any diagnostic procedure, treatment
or operation for or complications thereof.
Prostatitis, including any diagnostic procedure, treatment or operation for
or complications thereof.
any disease or disorder of the anus or rectum including fistula or prolapse
Detached retina or any injury, disease or disorder of the [left eye /years
right eye / eyes], including blindness, and any diagnostic procedure,
treatment or operation for or complications thereof.
Retinal degeneration and any detachment or injury, disease or disorder
of the [left eye / right eye / eyes], including blindness or impairment
of vision, and any diagnostic procedure, treatment or operation for or
complications thereof.
Retinal or macular tear(s) and hole(s) of the [left eye / right eye / eyes], including
any diagnostic procedure, treatment or operation for or complications thereof.
Any disease or disorder of [the left / the right / both] shoulder(s), including any
diagnostic procedure, treatment or operation for or complications thereof.
Sinusitis and any disease of the nasal structures or sinuses, including any
diagnostic procedure, treatment or operation for or complications thereof.
Any form of skin cancer, cancerous or dysplastic growth of the skin,
neoplasm or malignant tumor of the skin including metastases, and any
diagnostic procedure, treatment or operation for or complications thereof.
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Rider
Spermatocele
Time Limit Rider Language
5 years
Spinal Deformity (scoliosis, etc.)
Permanent
Spondylolisthesis
Permanent
Spondylosis
Permanent
Sprain, Strain, or Ligament Injury
Stones (Urinary) (Kidney Stones, etc.)
5 years
Permanent
Strabismus
5 years
Tarsal Tunnel Syndrome
5 years
Tennis Elbow (Epicondylitis)
5 years
Thoracic Outlet Syndrome
Permanent
Thyroid Disorders
5 years
Tonsil or Adenoid Disorders
5 years
Undescended Testicle(s)
5 years
Urethral Stricture/Stenosis
5 years
Urinary Bladder or Urethral Disorder
5 years
Urinary Diverticulum, Diverticulosis
5 years
Urinary Incontinence Overactive Bladder
Urinary Reflux, Kidney Reflux,
Vesicoureteral Reflux
Urinary Tract Fistula
5 years
Permanent
Uterine Fibroids, Leiomyomas,
Myomas
Uterine Prolapse or Displacement
Permanent
Vaginal Fistula
Permanent
Varicocele
Varicose Veins, Varicosities
Vitreous Detachment or
Degeneration
5 years
Permanent
5 years
Permanent
5 years
Spermatocele, including any diagnostic procedure, treatment or
operation for or complications thereof.
Curvature of the spine, including scoliosis, lordosis, and kyphosis, including any
diagnostic procedure, treatment or operation for or complications thereof.
Spondylolisthesis, including any diagnostic procedure, treatment or
operation for or complications thereof.
Spondylosis, including any diagnostic procedure, treatment or operation
for or complications thereof.
Any ligament injury, tear, sprain or strain of [the left / the right /both]
[affected area(s)], including any diagnostic procedure, treatment or
operation for or complications thereof.
Urinary calculus or stone, including any diagnostic procedure, treatment
or operation for or complications thereof.
Strabismus or any disorder of the external ocular muscles, including any
diagnostic procedure, treatment or operation for or complications thereof.
Tarsal tunnel syndrome or tibial nerve entrapment of the [left leg / right
leg / legs], including any diagnostic procedure, treatment or operation for
or complications thereof.
Tennis elbow (epicondylitis), including any diagnostic procedure,
treatment or operation for or complications thereof.
Thoracic outlet syndrome, cervical rib syndrome, or scalenus anticus
syndrome, including any diagnostic procedure, treatment or operation for
or complications thereof.
Any disease or disorder of the thyroid gland, including any diagnostic
procedure, treatment or operation for or complications thereof.
Tonsillitis, adenoiditis, or enlargement of the tonsils or adenoids, including any
diagnostic procedure, treatment or operation for or complications thereof.
Undescended testicle(s) or any associated hernia, including any diagnostic
procedure, treatment or operation for or complications thereof.
Urethral stricture or stenosis, including any diagnostic procedure,
treatment or operation for or complications thereof.
Urinary stress incontinence, including any diagnostic procedure,
treatment or operation for or complications thereof.
Diverticulum, diverticulosis or any disease or disorder of the urinary
bladder, including any diagnostic procedure, treatment or operation for
or complications thereof.
urinary incontinence or overactive bladder
vesicoureteral reflux, urinary reflux, or any disease or disorder of the
kidney or urinary tract
Fistula of the urinary tract, including any diagnostic procedure, treatment
or operation for or complications thereof.
Fibroid tumor(s) of the uterus, including any diagnostic procedure,
Leiomyomas, treatment or operation for or complications thereof.
Uterine displacement or prolapse including correction of any rectocele
or cystocele, and any diagnostic procedure, treatment or operation for or
complications thereof.
Fistula of the vagina, including the urinary bladder and/or rectum and
connecting fistula, and any diagnostic procedure, treatment or operation
for or complications thereof.
Varicocele, including any diagnostic procedure, treatment or operation for
or complications thereof.
Varicose veins, varicose or stasis ulcers, or phlebitis, including any diagnostic
procedure, treatment or operation for and complications thereof.
Vitreous detachment or degeneration, including any diagnostic
procedure, treatment or operation for or complications thereof.
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Occupation Guide
Applicants with the following occupations are generally not eligible for coverage.
This list is NOT all-inclusive.
• Asbestos Removal / Remediaton
• Aviation and Air Transportation (Commercial/Charter
flights acceptable) Stunt Pilots, Test Pilots
• Blasters and Explosive Handlers
• Meat Packers / Processors
• Mining (all types)
• Offshore Drillers / Workers
• Oil and Gas Exploration/Drilling Workers (Supervisory
and landman position are acceptable)
• Professional Athletes
• Baseball, BMX Bikers, Hockey, Basketball, Soccer,
Football, Jockeys, Wrestling
• Professional Race Car Drivers
• Professional Rodeo Performers
General Information
Evidence of Insurability
Uninsurable Applicants/Dependents
Satisfactory evidence of insurability is required for all adult
applicants. Coverage is not in effect until approved by
BCBSTX and all requirements are received. Requirements
include, but are not limited to: premium, and/or a signed/
dated amendatory endorsement.
If any person listed on the application is declined, coverage
will be issued on the remaining applicants if instructed to do
so on the application.
Underwriting Opinion
The completeness and accuracy of all application
information is very important and is a crucial part in
helping keep health care affordable. Please remember that
the health history portion of the application applies to any
health conditions the applicant, or named dependents, have
now or ever had. The application must be completed by the
applicant(s) and all questions must be answered truthfully
and completely. This includes information provided during
the telephone interview and height and weight data.
Coverage may be terminated if there is any material representation
affecting coverage following issuance of a policy.
Misrepresentation
If you would like an opinion as to how Blue Cross and Blue
Shield of Texas might consider a particular applicant’s health
history before submitting a fully completed application,
you may submit an Underwriting E-Opinion request via
hscil.com. Select the TX Agent Home link, then select
Underwriting E-Opinion.
Additional Information Needed
Review of the applicant’s medical history (current
application, prior application(s), prior phone interviews,
prior medical records, claim history and claim files) may
warrant the need for additional information to be obtained.
To ensure efficient and effective customer service, Hallmark
Services Corporation has contracted with RSA Medical to
obtain additional information required by Underwriting. RSA
Medical conducts both telephone interviews and orders medical
records at the direction of Hallmark Services Corporation.
Appeals
Additional medical information may be submitted to appeal
any decision of decline, rider, or premium adjustment,
but the request must be in writing. The new or corrected
information will be reviewed for possible reconsideration.
We cannot guarantee a change in the original decision.
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bcbstx.com
Contact Information
Resources
Services
Contact Information
Completed application and underwriting
correspondence
Mail to:
BCBSTX
Hallmark Services Corporation
PO Box 3236
Naperville, IL 60566-7236
Overnight delivery only:
BCBSTX
Hallmark Services Corporation
1100 Warrenville Road, Suite 300
Naperville, IL 60563
Hallmark Services Corporation
Health underwriting questions and
application status
Health contract and policy changes, policy
issue and premium billing information
Health claims questions
Blue Cross and Blue Shield of Texas
Preauthorization for benefits
Provider Network Information
Provider Finder:
Forms, including Producer Supply
Order Form
Producer Service Unit
Advertising guidelines and
pre-approved ads
Producer assistance and training
Commissions Department
Questions regarding:
• Commission
• Agent of record
• Errors & omissions update
• License update
42
Producers call:
(888) 697-0679
Members call:
Members call:
888) 697-0683
(800) 441-9188
800) 252-8815 or
Fax:
(800) 492-0742
Fax Referral
(800) 572-0864 or
Department:
(800) 462-3272
bcbstx.com/onlinedirectory/index
BlueChoice and
(800) 441-9188
ParPlan for Texas:
BlueCard – Out of
(800) 810-2583
State Network:
Producer website:
yourcmsupplyportal.com
Producers call:
(800) 531-4457
Producers call:
(855) 782-4272
Fax:
(918) 549-3039
bcbstx.com
bcbstx.com
47388.0412
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association