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|In Network||7350 Value||5000 HSA||5000 Classic||3500 Classic|
|Network||PHCS (Search Network)
Select PHCS, then the practitioner only network
|PHCS (Search Network)
Select PHCS, then the practitioner only network
|PHCS (Search Network)
Select PHCS, then the practitioner only network
|PHCS (Search Network)
Select PHCS, then the practitioner only network
|Summary of Benefits||View SBC
|Max out of pocket||$7,350/$14,700||$7,350/ $14,700||$7,350/ $14,700||$7,350/$14,700|
|Primary||$50||Deductible then 20%||$45||$45|
|Specialist||$100||Deductible then 20%||$90||$90|
|Urgent Care||$100||Deductible then 20%||$90||$90|
|Preventive Care||100%||Covered 100%||Covered 100%||100%|
|Diagnostic Test||100%||Deductible then 20%||20% coinsurance||20% coinsurance|
|Hospitalization||Deductible then 100%||Deductible then 20%||Deductible then 20%||Deductible then 20%|
|Emergency Room||Deductible then 100%||Deductible then 20%||Deductible then 20%||Deductible then 20%|
|Mental health outpatient||Deductible then 100%||Deductible then 20%||Deductible then 20%||Deductible then 20%|
|Mental Health inpatient||Deductible then 100%||Deductible then 20%||Deductible then 20%||Deductible then 20%|
|Maternity||Deductible then 100%||Deductible then 20%||Deductible then 20%||Deductible then 20%|
|Rx||Discount Card||Discount Card||15/65/100||15/65/100|
|Specialty Rx||Not covered||Not Covered||Not Covered||Not covered|
|Out of Network|
Pharmacy Drug Charge
Participating pharmacies have contracted with the Plan to charge Covered Persons reduced fees for covered
Prescription Drugs. Magellan Rx is the administrator of the pharmacy drug plan.
The copayment is applied to each covered pharmacy drug or mail order drug charge and is shown in the
schedule of benefits. Any one pharmacy or mail order prescription is limited to a 30-day to 90-day supply. For
Plan Years beginning on or after January 1, 2015, copayments will apply toward satisfaction of the Plan's
Maximum Out-of-Pocket amount.
If a drug is purchased from a non-participating pharmacy, or a participating pharmacy when the Covered
Person's ID card is not used, the amount payable in excess of the amounts shown in the schedule of benefits
will be the ingredient cost and dispensing fee.
Deductible does not apply to prescription drugs.
The percentage payable amount is applied to each covered pharmacy drug or mail order drug charge and is
shown in the schedule of benefits.
Mail Order Drug Benefit Option
The mail order drug benefit option is available for maintenance medications (those that are taken for long
periods of time, such as drugs sometimes prescribed for heart disease, high blood pressure, asthma, etc.).
Because of volume buying, Magellan Rx, the mail order pharmacy, is able to offer Covered Persons significant
savings on their prescriptions.
Covered Prescription Drugs
(1) All drugs prescribed by a Physician that require a prescription either by federal or state law. This
includes contraceptives, but excludes any drugs stated as not covered under this Plan.
(2) All compounded prescriptions containing at least one prescription ingredient in a therapeutic
(3) Insulin and other diabetic supplies when prescribed by a Physician.
(4) Injectable drugs or any prescription directing administration by injection, if medically necessary.
Limits To This Benefit
This benefit applies only when a Covered Person incurs a covered Prescription Drug charge. The covered drug charge for any one prescription will be limited to:
(1) Refills only up to the number of times specified by a Physician.
(2) Refills up to one year from the date of order by a Physician.
Expenses Not Covered
This benefit will not cover a charge for any of the following:
(1) Administration. Any charge for the administration of a covered Prescription Drug.
(2) Appetite suppressants. A charge for appetite suppressants, dietary supplements or vitamin
supplements, except for prenatal vitamins requiring a prescription or prescription vitamin
supplements containing fluoride.
(3) Consumed on premises. Any drug or medicine that is consumed or administered at the place
where it is dispensed.
(4) Devices. Devices of any type, even though such devices may require a prescription. These include
(but are not limited to) therapeutic devices, artificial appliances, braces, support garments, or any
(5) Drugs used for cosmetic purposes. Charges for drugs used for cosmetic purposes, such as
anabolic steroids, Retin A (covered through age 21) or medications for hair growth or removal.
(6) Experimental. Experimental drugs and medicines, even though a charge is made to the Covered
(7) FDA. Any drug not approved by the Food and Drug Administration.
(8) Growth hormones. Charges for drugs to enhance physical growth or athletic performance or
appearance, unless medically necessary.
(9) Immunization. Immunization agents or biological sera.
(10) Impotence. A charge for impotence medication.
(11) Inpatient medication. A drug or medicine that is to be taken by the Covered Person, in whole or in
part, while Hospital confined. This includes being confined in any institution that has a facility for the
dispensing of drugs and medicines on its premises.
(12) Investigational. A drug or medicine labeled: "Caution - limited by federal law to investigational
(13) Medical exclusions. A charge excluded under Medical Plan Exclusions.
(14) No charge. A charge for Prescription Drugs which may be properly received without charge under
local, state or federal programs.
(15) Non-FDA use. A charge for FDA-approved drugs that are prescribed for non-FDA-approved uses.
(16) Non-legend drugs. A charge for any medication that can be purchased over-the-counter.
(17) No prescription. A drug or medicine that can legally be bought without a written prescription. This
does not apply to injectable insulin or to over the counter drugs that are prescribed by a Physician
as required for Standard Preventive Care.
(18) Refills. Any refill that is requested more than one year after the prescription was written or any refill
that is more than the number of refills ordered by the Physician.
Note: Exclusions related to prescription drugs may not be limited to this list.
Note: Any treatment, charges, and/or medical provider reimbursement not covered by Reinsurance
Note: All exclusions related to Prescription Drugs are shown in the Prescription Drug Plan.
No payment will be eligible under any portion of this Plan for expenses Incurred by a Covered Person for the
expenses or circumstances listed below. If an expense is paid that is found to be excluded or limited as shown
below, the Plan has the right to collect that amount from the payee, the Covered Person or from future benefits
and any such payment does not waive the written exclusions, limitations or other terms of the Plan.
(1) Abortion: Expenses for elective abortions will not be considered eligible
(2) Acupuncture. Services, supplies, care or treatment in connection with acupuncture.
(3) Adoption: Expenses related to adoption will not be considered eligible.
(4) After hours services. Additional charges, billed by the physician, for after hour, extended hour, or holiday
(5) Alcohol. Services, supplies, care or treatment to a Covered Person for an Injury or Sickness which
occurred as a result of that Covered Person's illegal use of alcohol. Expenses will be covered for Injured
Covered Persons other than the person illegally using alcohol and expenses will be covered for Substance
Abuse treatment as specified in this Plan. Also excluded for the Member only are charges for Injuries or
Illnesses resulting from an accident where the Member is the driver and deemed to be under the influence of
alcohol or drugs (DUI). This exclusion does not apply if the Injury resulted from an act of domestic violence or a
(6) Alternative Medicine or Complementary Medicine: services and supplies related to alternative or
complementary medicine, including but not limited to acupressure, acupuncture, aroma therapy, bioenergial
synchronization technique (BEST), contact reflex analysis, holistic medicine herbal therapy, hypnotism, iridology (study of the iris), naturopathy, Reike therapy, Rolfing, thermography, or other forms of alternative treatment as defined by the National Center for Complementary and Alternative Medicine of the National Institutes of Health or any similar or successor organization;
(7) Autopsies: Expenses related to autopsies will not be considered eligible
(8) Autotransfusions. Charges for Autotransfusions or cell saver transfusions occurring during or after
(10) Blood or Other Body Tissue and Fluids, Including Storage. Blood, and the storage and banking of
autologous and cord blood, body tissue and fluids
(11) Breast Surgery. Surgery for male breast reduction is NOT COVERED, except when associated with
breast reconstructive surgery in connection with a Medically Necessary mastectomy as set forth in Section 3.14
of this Certificate
(12) Close Relative: Expenses for services, care or supplies provided by a person who normally resides in the
Covered Person’s home or by a Close Relative will not be considered eligible.
(13) Complications: Expenses for care, services or treatment required as a result of complications from a
treatment or procedure not covered under the Plan will not be considered eligible.
(14) Convenience/Comfort Items: Expenses for personal hygiene and convenience items will not be
(16) Cosmetic Procedures: Expenses for Cosmetic and reconstructive procedures will not be considered
eligible, except as specified under Schedule of Benefits and Medical Covered Charges section of the Plan.
(17) Counseling: Expenses for religious, marital, or relationship counseling will not be considered eligible,
except as specified under Schedule of Benefits and Medical Covered Charges section of the Plan.
(18) Custodial Care: Expenses for Custodial Care will not be considered eligible, except as specified under the
Home Health Care and Hospice Care benefits.
(19) Dentistry -The plan does not cover general dental services, defined as operations on or treatment of the
teeth and immediately supporting tissues. Such general dental services include but are not limited to,
restoration, correction of malocclusion and/or orthodontia, repair or extraction of erupted teeth or impacted
teeth, dental X-rays, analgesia, other professional or hospital charges for services or supplies in connection
with treatment of or operations on the teeth or immediately supporting structures or any ancillary medical
procedures required to support a general dental service. However, the plan will cover: a) expenses related to
the emergency treatment of sound natural teeth as set forth in the document (excepting implants, bridges,
crowns and root canals even if necessitated by or related to trauma to sound natural teeth), b) General
Anesthesia and Associated Medical Costs as set forth in this document c) Impacted Wisdom Teeth as set
forth in this document
(20) Developmental Delays: Expenses in connection with the treatment of developmental delays, including, but
not limited to speech therapy, occupational therapy, physical therapy and any related diagnostic testing will not
be considered eligible. This exclusion will not apply to expenses related to the diagnosis, testing and treatment
of autism, ADD or ADHD and to expenses covered as a preventive service under the Schedule of Benefits and
Medical Covered Charges section of the Plan.
(21) Devises or Computers: Expenses to assist in communication and speech
(22) Educational or vocational testing. Services for educational or vocational testing or training. This does
not apply to any diabetic education that may be covered under the Plan.
(23) Employment, Insurance, or License related care. Physical exams or immunizations or any other treatment
required for enrollment in any insurance program, as a condition of employment, for licensing, or other similar
purposes. However, this exclusion does not apply to the Company’s health plan sponsored screenings.
(24) Exercise Programs: Exercise programs for treatment of any condition will not be considered eligible,
except for Physician-supervised cardiac rehabilitation and occupational or physical therapy covered by the Plan.
(25) Experimental or not Medically Necessary. Care and treatment that is either Experimental/Investigational
or not Medically Necessary. For Plan Years beginning on or after January 1, 2014, this exclusion shall not apply to the extent that the charge is for a Qualified Individual who is a participant in an approved clinical trial with respect to the treatment of cancer or another life-threatening disease or condition. The Plan shall not deny, limit or impose additional conditions on routine patient costs for items and services furnished in connection with participation in the clinical trial. However, this provision does not require the Plan to pay charges for services or supplies that are not otherwise Covered Charges (including, without limitation, charges which the Qualified Individual would not be required to pay in the absence of this coverage) or prohibit the Plan from imposing all applicable cost sharing and reasonable cost management provisions. For these purposes, a Qualified Individual is a Covered Person who is eligible to participate in an approved clinical trial according to the trial protocol with respect to the treatment of cancer or another life-threatening disease or condition, and either: (1) the referring health care professional is a Network Provider and has concluded that the individual's participation in such trial would be appropriate; or (2) the Covered Person provides medical and scientific information establishing that the individual's participation in such trial would be appropriate.
(26) Eye care. Radial keratotomy, lasik surgery or other eye surgery to correct vision problems that are
alternately correctable by vision lenses. Also, routine eye examinations, including refractions, lenses for the
eyes and exams for their fitting (unless specified in the Schedule of Benefits). This exclusion does not apply to
aphakic patients and soft lenses or sclera shells intended for use as corneal bandages or as may be covered
under the well adult or well child sections of this Plan.
(27) Foot Care: Expenses for routine foot care, treatment of weak, unstable or flat feet will not be considered
eligible. Treatment (including cutting or removal) of toe nails or superficial lesions of the feet including corns,
calluses and hyperkeratosis, other than removal of nail matrix or root, except when required to treat diabetes; or shoe orthotics, except when required to treat diabetes; electroshock wave therapy for treatment of plantar
fasciatis, except to treat diabetes;
(28) Foot Orthotics, arch supports or other foot support devices, elastic stockings, garter belts or similar
devices shoes including any casting or fitting charges except as stated in the Schedule of Benefits or Covered
Charges section of the Plan.
(29) Gleevec: Expenses for the prescription drug, Gleevec, will not be considered eligible.
(30) Governmental Agency: Expenses for services and supplies which are provided by any governmental
agency for which the Covered Person is not liable for payment will not be considered eligible. In the case of a
state sponsored medical assistance program, benefits payable under this Plan will be primary. Benefits payable
under this Plan will also be primary for any Covered Person eligible under TRICARE (the government
sponsored program for military dependents).
(31) Growth hormone therapy. Charges for growth hormone therapy.
(32) Hair Loss: Expenses for hair loss or hair transplants will not be considered eligible.
(34) Hazardous Hobby: Expenses for any condition, Illness or Injury, or complication thereof, arising out of
engaging in a hazardous hobby or activity will not be considered eligible. For the purposes of this Plan,
“hazardous hobby or activity” is defined as an unusual activity characterized by a constant threat of danger,
such as skydiving, auto racing, hang gliding, bungee jumping. This does not include common recreational
activities, such as water or snow skiing, jet skiing, horseback riding, boating, motorcycling, snowmobiling, allterrain vehicle riding and team sports.
(35) Holistic Treatment Expenses for holistic treatment including acupressure, acupuncture, aromatherapy,
hypnotism, alternative therapy (art, music, dance, horseback) and rolfing will not be considered eligible.
(36) Homeopathic Treatment: Expenses for naturopathic and homeopathic treatments, services and supplies
will not be considered eligible.
(37) Hyperhidrosis: Expenses related to surgical treatment of excess sweating will not be considered eligible
(38) Hypnotherapy: Expenses for hypnotherapy will not be considered eligible.
(39) Illegal acts. Charges for services received as a result of Injury or Sickness occurring directly or indirectly,
as a result of an Illegal Act, or a riot, or public disturbance. For purposes of this exclusion, the term Illegal Act
shall mean any act or series of acts that, if charged, prosecuted and convicted of a criminal offense, a sentence to a term of imprisonment in excess of one year could be imposed. This exclusion does not apply if the Injury resulted from an act of domestic violence or a Medical Condition.
(40) Illegal Occupation/Felony: Expenses for or in connection with an Injury or Illness arising out of an illegal
occupation or commission of a felony will not be considered eligible. This exclusion will not apply to Injuries
and/or Illnesses sustained due to a medical condition (physical or mental) or due to an act of domestic violence.
(41) Impotence. Care, treatment, services, supplies or medication in connection with treatment for impotence.
(42) Late submission. Charges for care, treatment, services or supplies which were incurred more than 12
months prior to the date the charges were submitted to the Plan for payments
(43) Learning disabilities. Care, supplies, and services for the treatment of autistic disease of childhood,
developmental delay, learning disabilities, hyperkinetic syndromes, behavioral problems or mental retardation,
except as specified.
(44) Maintenance Therapy: Expenses for Maintenance Therapy of any type when the individual has reached
the maximum level of improvement will not be considered eligible.
(45) Marital or pre-marital counseling. Care and treatment for marital or pre-marital counseling.
(46) Massage Therapy: Expenses for massage therapy will not be considered eligible.
(47) Medically Necessary: Expenses which are determined not to be Medically Necessary will not be
(48) Missed Appointments: Expenses for completion of claim forms, missed appointments, cancelled
appointments, or telephone consultations will not be considered eligible, except as shown in the Scheduled of
(49) Motor vehicle injury. Charges incurred for the care or treatment of any injury sustained as a result of or
related to any motor vehicle accident to the extent that such care or treatment for that injury is covered by any
plan, program, policy or other arrangement providing insurance coverage for vehicles. Injury while driving or
riding in any organized automobile or motorcycle race or speed contest
(50) Negligence: Expenses for Injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or
malpractice on the part of any licensed Physician will not be considered eligible.
(51) Never Events: Expenses for serious preventable adverse events (“Never Events”) will not, in any event, be considered eligible. These Never Events include:
(a) Surgery performed on the wrong body part;
(b) Surgery performed on the wrong patient;
(c) Wrong Surgical procedure performed on a patient;
(d) Unintentional retention of a foreign object in a patient after Surgery or other procedure;
(e) Inoperative or immediate postoperative death in an ASA Class I patient;
(f) Patient death or serious disability associated with the use of contaminated Drugs, devices, or biologics
provided by the healthcare facility;
(g) Patient death or serious disability associated with the use or function of a device in a patient in which
the device is used for functions other than as intended;
(h) Patient death or serious disability associated with intravascular air embolism that occurs while being
cared for in a healthcare facility;
(i) Patient death or serious disability associated with patient leaving the facility without permission;
(j) Patient suicide, or attempted suicide resulting in a serious disability, while being cared for in a healthcare
(k) Infant discharged to the wrong person;
(l) Patient death or serious disability associated with a medication error (e.g., error involving the wrong
drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparations, or wrong route of
(m) Patient death or serious disability associated with a hemolytic reaction due to the administration of
ABO-incompatible blood or blood products;
(n) Maternal death or serious disability associated with labor and delivery in a low-risk Pregnancy while
being cared for in a healthcare facility;
(o) Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the
patient is being cared for in a healthcare facility;
(p) Death or serious disability associated with failure to identify and treat hyperbilirubinemia (condition
where there is a high amount of bilirubin in the blood) in newborns;
(q) Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility;
(r) Patient death or serious disability due to spinal manipulative therapy;
(s) Artificial insemination with the wrong donor sperm or wrong egg;
(t) Patient death or serious disability associated with an electric shock while being cared for in a healthcare
(u) Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the
wrong gas or is contaminated by toxic substances;
(v) Patient death or serious disability associated with a burn Incurred from any source while being cared for
in a healthcare facility;
(w) Patient death associated with a fall while being cared for in a healthcare facility;
(x) Patient death or serious disability associated with the use of restrains or bedrails while being cared for
in a healthcare facility;
(y) Any instance of care ordered by or provided by someone impersonating a Physician, nurse, pharmacist,
or other Provider;
(z) Abduction of a patient of any age;
(aa) Sexual assault on a patient within or on the grounds of a healthcare facility; and
(bb) Death or significant Injury of a patient or staff member resulting from a physical assault (i.e. battery)
that occurs within or on the grounds of a healthcare facility.
(52) No Legal Obligation: Expenses for services provided for which the Covered Person has no legal
obligation to pay will not be considered eligible. This exclusion will not apply to eligible expenses that may be
covered by state Medicaid coverage where federal law requires this Company’s plan to be primary.
(53) Non-Covered Procedures: Expenses for services related to a non-covered Surgery or procedure will not
be considered eligible regardless of when the Surgery or procedure was performed.
(54) Non-Covered by Medicare or Medicaid: services, supplies or drugs not approved for reimbursement by
the Centers for Medicare and Medicaid Services or any successor organization;
(55) Not Performed Under the Direction of a Physician: Expenses for services and supplies which are not
prescribed or performed by or under the direction of a Physician will not be considered eligible.
(56) Not Recommended by a Physician: Expenses by a Hospital or covered residential treatment center if
hospitalization is not recommended or approved by a legally qualified Physician will not be considered eligible.
(57) Nutritional Supplements: Expenses for nutritional supplements, vitamins, and mega-vitamins or other
enteral supplementation will not be considered eligible, except as specified under Schedule of Benefits and
Medical Covered Charges of the Plan. Over-the-counter nutritional supplements or infant formulas will not be
considered eligible even if prescribed by a Physician.
(58) Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a
part of the treatment plan for another Sickness. Specifically excluded are charges for bariatric surgery, including but not limited to, gastric bypass, stapling and intestinal bypass, and lap band surgery, including reversal unless otherwise stated in the Schedule of Benefits for Morbid Obesity.
(59) Occupational. Care and treatment of an Injury or Sickness that is occupational -- that is, arises from work
for wage or profit including self-employment.
(60) Off-label drugs. A charge for FDA-approved drugs that are prescribed for non-FDA-approved uses.
(61) Operated by the Government: Expenses for treatment at a facility owned or operated by the government
will not be considered eligible, unless the Covered Person is legally obligated to pay. This does not apply to
Covered Expenses rendered by a Hospital owned or operated by the United States Veteran's Administration
when services are provided to a Covered Person for a non-service related Illness or Injury.
(62) Oral Nutrition Products or Supplements. Oral nutrition products or supplements used to treat a
deficient diet or to provide an alternative source of nutrition in conditions such as, but not limited to, obesity,
hypo or hyper-glycemia, gastrointestinal disorders, etc., including, but not limited to, lactose free foods; banked
breast milk; and/or standardized or specialized infant formulas.
(63) Orthopedic Therapies: Expenses for acupuncture will not be considered eligible.
(64) Outside the United States (U.S.): Expenses for services or supplies if the Covered Person leaves the
U.S. or the U.S. Territories for the express purpose of receiving medical treatment will not be considered
(65) Over-the-Counter (OTC) Medication: Expenses for any over-the-counter medication will not be
considered eligible. Expenses for drugs and medicines not requiring a prescription by a licensed Physician and
not dispensed by a licensed pharmacist will not be considered eligible, except as otherwise covered as a
preventive services under the Schedule of Benefits and Pharmacy Covered Charges section of the Plan.
(66) Personal comfort items. Personal comfort items or other equipment, such as, but not limited to, air
conditioners, air-purification units, humidifiers, electric heating units, orthopedic mattresses, blood pressure
instruments, scales, elastic bandages or stockings, nonprescription drugs and medicines, and first-aid supplies
and nonhospital adjustable beds.
(67) Personal and Athletic Trainer Services. Services provided by a personal or athletic trainer
(68) Plan design excludes. Charges excluded by the Plan design as mentioned in this document.
(69) Plan Maximums: Charges in excess of Plan maximums will not be considered eligible.
(70) Plan Allowable Fee: Expenses in excess of the Plan allowable fee charge will not be considered eligible.
(71) Podiatric orthotics. Over the counter or custom made shoes, shoe inserts, arch supports and other foot
orthotics to control foot function except as otherwise stated in the Schedule of Benefits.
(72) Prior to Effective Date: Expenses which are incurred prior to the effective date of your coverage under
the Plan will not be considered eligible.
(73) Private Duty Nursing: Expenses for inpatient private duty nursing will not be considered eligible except as
otherwise stated in the “Covered Services” section of this document.
(74) Radioactive Contamination: Expenses Incurred as the result of radioactive contamination or the
hazardous properties of nuclear material will not be considered eligible.
(75) Radiation Therapy: Expenses for services for dermatitis or similar skin conditions
(76) Recreational and Educational Therapy: Expenses for recreational and educational services; learning
disabilities; behavior modification services; any form of non-medical self-care or self-help training, including any related diagnostic testing; music therapy; health club memberships; aquatic or pool therapies; will not be
considered eligible. This exclusion will not apply to expenses related to the diagnosis, testing and treatment of
autism, ADD or ADHD.
(77) Refractive Errors: Expenses for radial keratotomy, lasik Surgery or any Surgical Procedure to correct
refractive errors of the eye will not be considered eligible, unless otherwise stated in this document.
(78) Relative giving services. Professional services performed by a person who ordinarily resides in the
Covered Person's home or is related to the Covered Person as a Spouse, parent, child, brother or sister,
whether the relationship is by blood or exists in law
(79) Replacement of Component Parts or Modification of a Prosthetic Device within five (5) years of obtaining
a new or other replacement part(s) unless incident to the Member’s growth for a Member who is under the age of nineteen (19) years.
(80) Required by Law: In any case where an individual is required by law to maintain insurance coverage (or
to maintain any other security or reserve amount in lieu of insurance coverage), expenses of a Covered Person that would be paid by such insurance coverage are not eligible expenses, regardless of whether the individual is in fact covered under such coverage. For purposes of any required automobile, motorcycle or other vehicle coverage, otherwise eligible expenses below the minimum required coverage or the actual coverage elected, whichever is higher, will be excluded from coverage under this Plan.
(81) Reversal of Genital Surgery. Surgical procedures to reverse genital surgery
(82) Riot/Revolt: Expenses resulting from a Covered Person’s participation in a riot or revolt will not be
considered eligible. This exclusion will not apply to Injuries and/or Illnesses sustained due to a medical condition (physical or mental) or domestic violence.
(83) Routine care. Charges for routine or periodic examinations, screening examinations, evaluation
procedures, preventative medical care, or treatment or services not directly related to the diagnosis or treatment of a specific Injury, Sickness or pregnancy-related condition which is known or reasonably suspected, unless such care is specifically covered in the Schedule of Benefits or required by applicable law.
(84) Safety devices. For drivers and all passengers: charges for the treatment for injuries incurred when not
wearing appropriate safety restraints and/or motorcycle helmets, when legally required.
(85) Screening exams. Charges for exams required by an insurance company to obtain insurance, required by
a governmental agency, or required by a company in order to begin or continue working.
(86) Services before or after coverage. Care, treatment or supplies for which a charge was incurred before a
person was covered under this Plan or after coverage ceased under this Plan.
(87) Self-Inflicted Injury: Expenses for Injury or Illness arising out of attempted suicide or an intentional selfinflicted Injury will not be considered eligible. This exclusion will not apply if self-inflicted Injuries result from a medical condition (physical or mental) or act of domestic violence and the benefits for such Injuries are normally covered under the Plan.
(88) Sexual Dysfunction/Impotence: Expenses for services, supplies or drugs related to sexual
dysfunction/impotence not related to organic disease will not be considered eligible. Expenses for sex therapy
will not be considered eligible.
(89) Sex Transformation: Expenses in connection with sex transformation will not be considered eligible.
(90) Speech Therapy except as required for treatment of a speech impediment or speech dysfunction that
results from Injury, stroke, cancer, Congenital Anomaly, or Autism Spectrum Disorder.
(91) Stand-by Physician: Expenses for technical medical assistance or stand-by Physician services will not be
(92) Sterilization: Expenses for male sterilization and the reversal of elective sterilization will not be considered
(93) Surgery for the Jaw: Expenses for orthognathic will not be considered eligible.
(94) Surrogate: Expenses relating to a surrogate pregnancy of any person who is not covered under this Plan,
including but not limited to pre-pregnancy, conception, pre-natal, childbirth and post-natal expenses, will not be
(95) Telephone. Charges for telephone or email completion of claim forms, or any charges associated with
(96) Third Party Responsible: expenses related to a Sickness or Injury for which a third party is or may be
responsible, unless such expenses are advanced as provided in the provision entitled Subrogation.
(97) Transportation Services. Stretcher van and/or wheelchair van transportation services
(98) Travel: Expenses for travel will not be considered eligible, except as specified under Schedule of Benefits
and Medical Covered Charges.
(99) Vivo or In Vitro fertilization: Expenses for any other fertilization procedure, test, treatment or drug;
(100) Vision Therapy: Expenses for vision therapy will not be considered eligible
(101) Wage or Profit: Expenses for or in connection with any Injury or Illness which arises out of or in the
course of any occupation for wage or profit (including self-employment) will not be considered eligible.
(102) War: Expenses for the treatment of Illness or Injury resulting from a war or any act of war or terrorism,
whether declared or undeclared, civil war, hostilities or invasion, or while in the armed forces of any country or
international organization will not be considered eligible.
(103) Weight Loss: Surgical and non-surgical care and treatment of obesity and/or morbid obesity including
weight loss or dietary control, whether or not it is in any case a part of a treatment plan for another Illness, will
not be considered eligible, except as otherwise covered as a preventive service under the Schedule of Benefits
and Medical Covered Charges section of the Plan. Exclusion does not apply Morbid Obesity benefit, listed in
Schedule of Benefits.
(104) Weekend Admissions: Expenses for care and treatment billed by a Hospital for non-Medical Emergency
admissions on a Friday or Saturday will not be considered eligible, unless Surgery is scheduled within 24 hours.
(105) Worker’s Compensation: Expenses for or in connection with any Injury or Illness which arises out of or in
the course of any occupation for which the Covered Person would be entitled to compensation under any
Worker's Compensation Law or occupational disease law or similar legislation will not be considered eligible.
Expenses for Injuries or Illness which were eligible for payment under Worker's Compensation or similar law and have reached the maximum reimbursement paid under Worker's Compensation or similar law will not be eligible for payment under this Plan.