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PREVENTIVE AND WELLNESS BENEFITS: EXCLUSIONS

Some health care services are not covered by the Plan. The following is an example of services that are generally not covered.

  • Office visits, physical examinations, immunizations, and tests when required solely for the following:
  • Sports
  • Camp
  • Employment
  • Travel
  • Insurance
  • Marriage
  • Legal proceedings
  • Routine foot care for treatment of the following:
  • Flat feet
  • Corns
  • Bunions
  • Calluses
  • Toenails
  • Fallen arches
  • Weak feet
  • Chronic foot strain
  • Rehabilitative therapies
  • Dental procedures
  • Any other medical service, treatment, or procedure not covered under this Plan
  • Any other expense, bill, charge, or monetary obligation not covered under this Plan, including but not limited to all non-medical services expenses, bill, charges, and monetary obligations. Unless the medical service is explicitly provided by this Schedule of Benefits or otherwise explicitly provided in the Summary Plan Description (SPD), this Plan does not cover the medical service or any related expense, bill, charge, or monetary obligation to the medical service.
  • Claims unrelated to treatment of medical care or treatment.
  • Cosmetic surgery unless authorized as medically necessary. Such authorization is based on the following causes for cosmetic surgery: accidental injury, correction of congenital deformity within six (6) years of birth, or as a treatment of a diseased condition.
  • Any treatment with respect to treatment of teeth or periodontium, any treatment of periodontal or periapical disease involving teeth surrounding tissue, or structure. Exceptions to this exclusion include only malignant tumors or benefits specifically noted in the schedule of benefits to the Plan Document.
  • Any claim related to an injury arising out of or in the course of any employment for wage or profit.
  • Claims which would otherwise be covered by a Worker’s Compensation policy for which a participant is entitled to benefit.
  • Any claim arising from service received outside of the United States, except for the reasonable cost of claims billed by the Veterans Administration or Department of Defense for benefits covered under this Plan and not incurred during or from service in the Armed Forces of the United States.
  • Claims for which a participant is not legally required to pay or claims which would not have been made if this Plan had not existed.
  • Claims for services which are not medically necessary as determined by this Plan or the excess of any claim above reasonable and customary rates when a PPO network has not been contracted.
  • Charges which are or could be reimbursed by any public health program irrespective of whether such coverage has been elected by a participant.
  • Claims due to the use of illegal drugs.
  • Claims due to an act of war, declared or undeclared, not including acts of terrorism.
  • Claims for eyeglasses, contacts, hearing aids (or examinations for the fitting thereof) or radial keratotomy.
  • Elective, voluntary abortions, except in the case of rape, incest, or congenital deformities of the fetus as determined through prenatal testing, or when the life of the mother would be threatened if the fetus were carried to term.
  • Travel, unless specifically provided in the schedule of benefits.
  • Custodial care for primarily personal, not medical, needs provided by persons with no special medical training or skill.
  • Claims from any provider other than a healthcare provider as defined in the Plan Document unless explicitly permitted in the schedule of benefits.
  • Investigatory or experimental treatment, services, or supplies unless specifically covered under Approved Clinical Trials.
  • Services or supplies which are primarily educational.
  • Claims due to attempted suicide or intentionally self-inflicted injury while sane or insane, unless the claim results from a medical condition such as depression.
  • Claims resulting from, or which arise due to the attempt or commission of, an illegal act. Claims by victims of domestic violence will not be subject to this exclusion.
  • Claims from any provider other than a healthcare provider as defined in the Plan Document unless explicitly permitted in the schedule of benefits.
  • Investigatory or experimental treatment, services, or supplies unless specifically covered under Approved Clinical Trials.
  • Services or supplies which are primarily educational.
  • Claims due to attempted suicide or intentionally self-inflicted injury while sane or insane, unless the claim results from a medical condition such as depression.
  • Claims resulting from, or which arise due to the attempt or commission of, an illegal act. Claims by victims of domestic violence will not be subject to this exclusion.
  • Claims with respect to any treatment or procedure to change one’s physical anatomy to those of the opposite sex and any other treatment or study related to sex change.
  • Claims from a medical service provider who is related by blood, marriage, or legal adoption to a participant.
  • Any claims for fertility or infertility treatment.
  • Claims for weight control, weight reduction, or surgical treatment for obesity or morbid obesity, unless explicitly provided in the schedule of benefits.
  • Claims for or disability resulting from reversal of sterilization.
  • Claims for telephone consultations, the completion of forms, or failure to keep scheduled appointments.
  • Recreational or diversional therapy.
  • Personal hygiene or convenience items, including but not limited to air conditioning, humidifiers, hot tubs, whirlpools, or exercise equipment, irrespective of the recommendations or prescriptions of a medical service provider.
  • Claims due to participation in a dangerous activity, including but not limited to sky-diving, motorcycle or automobile racing, bungee jumping, rock climbing, rappelling, or hang gliding.
  • Claims that arise primarily due to medical tourism.
  • Podiatry.
  • Supportive devices of the foot.
  • Treatments for sexual dysfunction.
  • Aquatic or massage therapy.
  • Claims arising while legally intoxicated under the influence of illegal drugs, irrespective whether a criminal charge arose, unless the claim arose due to a drug addiction.
  • Biofeedback training.
  • Ambulance services.
  • Skilled nursing facilities.
  • Durable medical equipment and prosthetics.
  • Home health care or hospice care.
  • Residential facility – for charges from a residential halfway house or home, or any facility which is not a health care institution licensed for the primary purpose of treatment of an illness or injury.
  • Claims for temporomandibular joint syndrome.
  • Claims for biotech or specialty prescriptions.
  • Any claim which is not explicitly covered in the schedule of benefits.
  • Genetic testing unless explicitly covered in the schedule of benefits.
  • Outpatient hospital services unless explicitly covered in the schedule of benefits.
  • Inpatient hospital services unless explicitly covered in the schedule of benefits.
  • Organ transplants.
  • Emergency Room visits in excess of twenty-four (24) hours.
  • Claims for cosmetic surgery, not related to mastectomy reconstruction, to produce a symmetrical appearance or prosthesis or physical complications which result from such procedures.
  • Chiropractic care.
  • Radiation and chemotherapy.
  • Dialysis.
  • Acupuncture.
  • Alternative medicine/homeopathy
  • Children dental and vision.
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