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Benefits are not provided under the Plan for the following:
- Any charges for services or supplies that are not Medically Necessary.
- Any portion of the expenses for covered medical services or supplies that exceed the Reasonable and Customary Charge as defined in the Definitions section.
- Any bodily Injury or Sickness arising out of or in the course of employment or which is compensable under any Workers’ Compensation or Occupational Disease Act or law.
- Any charges made by a Hospital unless the hospitalization is recommended and approved by a Physician.
- Surgery or medical treatment to improve or preserve physical appearance but not physical function. Cosmetic Surgery or treatment includes, but is not limited to removal of tattoos, breast augmentation, or other medical or surgical treatment intended to restore or improve physical appearance. The Plan does cover Medically Necessary reconstructive procedures which are necessary to correct damage caused by a congenital birth defect or an Injury, as provided in Item 24 under Covered Expenses. The Plan does cover reconstructive surgery after a mastectomy, as provided in Item 28 under Covered Expenses.
- Dental care and treatment except that necessitated by bodily Injury to sound, natural teeth.
- Eye examinations and eyeglasses except as provided under the Optical Benefits. However, the first pair of glasses purchased after cataract surgery is paid under the Major Medical Benefit.
- Routine physical examinations and immunizations, except as specifically provided under the Wellness Benefit for the Employee and spouse, and except for routine child and adolescent exams and immunizations provided until age 26 for eligible dependents.
- A bodily Injury or Sickness caused by war or by any act of war, declared or undeclared, or by participating in a riot or as the result of the commission of a felony by an eligible person, except that the Plan will cover Injuries and Sickness resulting from domestic violence.
- Expenses for services provided without charge to the covered individual under any government-provided plan or program (including, without limitation, TRICARE (formerly known as CHAMPUS) and VA programs) established under the laws or regulations of any government, including the federal, state, or local government or the government of any other political subdivision of the United States, or of any other country or any political subdivision of any country; or under any plan or program in which any government participates other than as an Employer, unless the governmental program provides otherwise.
- Charges made by a Physician, Registered Nurse (RN), Licensed Practical Nurse (LPN), Physiotherapist or any other Provider who is related to you or your Dependent or who ordinarily resides with you or your Dependents.
- Charges made for Outpatient treatment of Mental or Nervous Disorders and/or Substance Abuse, unless provided by a Psychiatrist, Psychologist, Mental Health Counselor, Substance Abuse counselor, or Social Worker with a master’s degree or higher who is:
- Legally licensed or legally authorized to practice or provide care or treatment for such conditions under state law or the jurisdiction where the services are rendered;
- Acting within the scope of that license, and
- Not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.
- Charges exceeding the maximums shown in the Schedule of Benefits for Outpatient or Inpatient treatment of Mental or Nervous Disorders and/or Substance Abuse.
- Expenses for naturopathic, naprapathic, and/or homeopathic services or treatments/supplies. Expenses for chelation therapy, except as Medically Necessary for the treatment of acute arsenic, gold, mercury, or lead poisoning, and for diseases due to clearly demonstrated excess of copper or iron.
- Expenses for medical or surgical treatment of weight-related disorders and obesity (except as provided in Item 16 of the Covered Expenses), including but not limited to: gastric by-pass procedures, intestinal bypass and reversal procedures, weight loss programs, dietary instructions, Prescription Drugs and any complications thereof, even if those procedures are performed to treat a co-morbid or underlying condition.
- Charges for smoking cessation programs, treatments or devices, except as provided under the Wellness Benefit.
- Medicines or drugs that can be obtained without a Physician’s prescription.
- Foods and nutritional supplements including, but not limited to: home medications, formulas, foods, diets, vitamins, herbs and minerals (whether over the counter or prescription) except when provided during hospitalization.
- Expenses related to prevention of pregnancy including but not limited to: drugs or medicines such as birth control pills, emergency contraceptives; devices, such as condoms, intrauterine device (IUD) or diaphragm; and implantable birth control devices such as Norplant. However, Medically Necessary contraceptives may be covered if approved by the Fund’s Contracted Medical Claim Review Provider, and if used to treat a specific medical condition.
- Any expense or charge for the promotion of fertility, except as provided in the Schedule of Benefits and Item 30 of the Covered Expenses section. Expenses not covered for the promotion of fertility include, but are not limited to the following:
- Reversal of voluntary sterilization,
- Payment of medical services rendered to a surrogate for purposes of childbirth,
- Costs associated with CRYO preservation and storage of sperm, eggs and embryos. However, procedures which use the CRYO preserved substance may not be excluded,
- Selected termination of an embryo. However, if the life of the mother would be in danger if all embryos were carried to full term, termination is covered,
- Non-medical cost of an egg or sperm donor,
- Travel costs not Medically Necessary, or
- Experimental infertility treatments. However, if an infertility treatment includes elements not experimental in nature along with those which are, the non-experimental services are covered as long as they are listed in the Schedule of Benefits and Item 30 of the Covered Expenses section.
- Genetic testing and counseling, except as otherwise covered under the Plan, including:
- Pre-parental genetic testing intended to determine if a prospective parent or parents have chromosomal abnormalities that are likely to be transmitted to a child; and
- Prenatal genetic testing intended to determine if a fetus has chromosomal abnormalities that indicate the presence of a genetic disease or disorder and performed using fluid or tissue samples obtained through amniocentesis, chorionic villus sampling (CVS), fetoscopy and alphafetoprotein (AFP) analysis in pregnant women. However, amniocentesis is covered if recommended by the patient’s Physician.
- Any expense or charge for orthoptics, eye exercises or vision training and supplies, except as provided under the covered expenses.
- Vision therapy and orthoptics for perceptual or visual motor coordination problems due to conditions such as minimal brain dysfunction, integrative dysfunction, dyslexia, etc. and problems with the interpretation of visual input to the brain and the reaction and output of the brain in response to such stimuli.
- Expenses for memberships in or visits to health clubs, exercise programs, gymnasiums and/or facilities for physical fitness programs, including exercise equipment.
- Expenses for construction or modification to a home, residence or vehicle required as a result of Injury, Sickness or disability, including without limitation: construction or modification of ramps, elevators, chair lifts, swimming pools, spas, air conditioning, asbestos removal, home traction unit, air filtration, handrails, emergency alert system, etc.
- Any expense for a mechanical heart implant.
- Foot care treatment for:
- Weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, except open cutting operations, and
- Corns, calluses or toenails, except the removal of nail roots and routine foot care from a podiatrist for individuals with diabetes or a neurological or vascular disorder affecting the feet.
- Rest cures, domiciliary care, convalescent care or custodial care, which is care provided primarily for convenience or to assist the patient in the activities of daily living when the constant attention of trained medical personnel is not required. Also excluded are expenses for the services of private duty nurses, except when Medically Necessary.
- Acupuncture, acupressure or hypnosis, unless performed by a licensed Physician for a Medically Necessary reason.
- Non-surgical treatment of the temporomandibular joint dysfunction (TMJ or TMD).
- Expenses for hair removal or hair transplants and other procedures to replace lost hair or to promote the growth of hair, including prescription and non-prescription drugs such as Minoxidil, Propecin, Rogaine, Vaniga; or for hair replacement devices including, but not limited to wigs, toupees, and/or hairpieces or hair analysis (regardless of diagnosis).
- Rehabilitation therapy expenses including expenses for:
- Education, job training, vocational rehabilitation and/or special education for sign language,
- Massage therapy, rolfing and related services,
- Inpatient rehabilitation facility services provided to an individual who is unconscious, comatose or otherwise incapable of conscious participation in the therapy services and/or unable to learn and/or remember what is taught including but not limited to coma stimulation programs and services,
- Maintenance rehabilitation,
- Speech therapy (unless it is due to stroke and surgery on vocal chords or neurological Injury). Speech therapy for functional purposes including but not limited to: stuttering, stammering and conditions of psychoneurotic origin, or for developmental speech delays, and
- Treatment of delays in childhood speech development unless as a direct result of an Injury, surgery or result of a covered treatment.
- Personal comfort items and expenses for patient convenience including but not limited to: care of family members while the covered individual is confined to a Hospital or other covered healthcare facility or in bed at home, including: guest meals, television, rental of DVDs or VCRs or devices to play them, telephone, personal hygiene items, barber or beautician services, house cleaning or maintenance, shopping, birth announcements, photographs of new babies, etc.
- Expenses for an autopsy and any related expenses.
- Expenses for preparing medical reports, bills or claim forms; mailing, shipping or handling expenses; and charges for broken/missed appointments, telephone calls and/or photocopying fees.
- Expenses for educational services, supplies or equipment including, but not limited to computers, software, printers, books, tutoring, visual aids, auditory aides, speech aids, programs to assist with auditory perception or listening/learning skills, programs/services to remedy or enhance concentration, memory, motivation or self-esteem, etc., even if they are required because of an Injury, Sickness or disability of a covered individual.
- Expenses that exceed any Plan benefit limitation, Annual Maximum Plan benefits or overall Lifetime Maximum Plan benefits.
- Expenses for services or supplies for which a third party is required to pay because of the negligence or other tortious or wrongful act of that third party. See the provisions relating to subrogation, reimbursement, and third party liability in Reimbursement Policies and Procedures for an explanation of the circumstances under which the Plan will pay benefits until it is determined that the third party is required to pay for those services or supplies.
- .Expenses for any medical services, supplies, or drugs or medicines determined to be Experimental or Investigative as defined in the Definitions section.
- Expenses for and related to non-emergency travel or transportation (including lodging, meals and related expenses) of a healthcare Provider, Participant or family member of a covered individual.
- .Expenses for any Physician or other healthcare Provider who did not directly provide or supervise medical services to the patient, even if the Physician or healthcare Provider was available to do so on a stand-by basis.
- The following behavioral health exclusions:
- Expenses for hypnosis, hypnotherapy and/or biofeedback, except as determined to be Medically Necessary and as provided by a licensed Physician.
- Expenses for behavioral healthcare services related to: adoption counseling; autism; court-ordered behavioral healthcare services; custody counseling; developmental disabilities; dyslexia; learning disorders, family planning counseling; genetic testing and counseling (see also the exclusion regarding genetic testing and counseling in Item 21 of this section), marriage, couples, and/or sex counseling; mental retardation; pregnancy counseling; transsexual counseling; and vocational disabilities.
- The following custodial care expenses:
- Expenses for care that is custodial in nature, regardless of where care is provided including without limitation: adult day care, child day care, services of a homemaker, or personal care, sitter/companion service.
- Services required to be performed by Physicians or other covered Providers are not considered to be provided for custodial care services, and are covered if they are determined Medically Necessary. However, any services that can be learned to be performed or provided by a family member who is not a Physician or other covered Provider are not covered, even if they are Medically Necessary.
- Pharmaceuticals requiring a prescription that have not been approved by the U.S. Food and Drug Administration (FDA) or are not approved by the FDA for the condition, dose, route and frequency for which they are prescribed (i.e. are used “off-label”) or are Experimental and/or Investigative as defined in the Definitions section.
- Take-home drugs or medicines provided by a Hospital, Emergency Room, Outpatient Surgical Center, or other healthcare facility.
- Expenses for and related to hearing examinations, the purchase, servicing, fitting and/or repair of hearing aid devices including: implantable hearing devices such as cochlear implants; and special education and associated costs in conjunction with sign language education for a patient or family members, except as provided under the Hearing Aid Benefit.
- Expenses related to cryostorage of umbilical cord blood or other tissue or organs.
- Expenses for all medical or surgical services or procedures, including Prescription Drugs and the use of prophylactic surgery, when the services, procedures, prescription of drugs, or prophylactic surgery is prescribed or performed for the purpose of:
- Avoiding the possibility or risk of a Sickness, disease, physical or mental disorder or condition based on family history and/or genetic test results; or
- Treating the consequences of chromosomal abnormalities or genetically transmitted characteristics when there is an absence of objective medical evidence of the presence of disease or physical or mental disorder.
- Expenses for medical, surgical or Prescription Drug treatment related to transsexual (sex change) procedures including preparation for any complications resulting from these procedures.
- Expenses for surgical correction of refractive errors and refractive keratoplasty procedures including, but not limited to, Radial Keratotomy (RK) and Automated Keratoplasty (ALK), or Laser In Situ Keratomileusis (LASIK).
- Orthokeratology lenses for reshaping the cornea of the eye to improve vision.
- Expenses for Durable Medical Equipment, except as provided in Durable Medical Equipment.
- Growth hormone, (except as Medically Necessary for Dependent Children).
- Charges for the services of Non-Physician Providers that are not covered under Items 12 and 34 of the Covered Expenses section. The services of an Assistant Surgeon who is a Physician will be covered by the Plan.
- Room and board charges incurred for stays off the premises of the facility at which you are receiving treatment.