EXCLUSIONS

No benefits are payable under the Plan for:

1. Services provided that require Pre-Certification, if Pre-Certification is not obtained, for the following:
1. All types of non-obstetrical diagnostic scans including ultrasound; CT scans, MRIs and PET scans;
2. All hospitalizations and all outpatient surgery, regardless of the location, except for mastectomies and lymph node dissections and other procedures that may be exempt under applicable law;
3. All emergency hospital admissions must receive certification from the Plan within the first working day after admission;
4. All home health care and hospice care, and related medical equipment used in the home;
5. DME (durable medical equipment) costing $1,000 or more;
6. Sleep studies;
7. Chemotherapy/radiation and wigs;
8. Specialty medications/Injectables costing $500 or more;
9. Pain management medications costing more than $500 in a twelve month period unless the patient is in a Hospice Program;
10. Hearing aids must be Pre-Certified by Sacramento Ear, Nose and Throat (see page 27);
11. Inpatient or outpatient mental health/psychiatric/counseling care; and
12. Substance abuse treatment (see page 34).
13. Speech and occupational therapies;
14. Acute inpatient rehabilitation;
15. Maternity stays in excess of 48 hours for vaginal delivery and 96 hours for a Cesarean section; and
16. Genetic testing (other than amniocentesis) and metabolic pharmacologic testing.
2. Services, supplies, and treatment not prescribed by a physician or surgeon legally qualified to practice in the state in which services are provided;
3. Services, supplies or treatment not medically necessary for treatment of injury or illness (except as otherwise specifically provided);
4. Charges in excess of usual and customary charges as defined by the Plan;
5. Charges incurred as the result of complications from procedures or treatments which are not covered by the Plan;
6. Charges that you or your dependents are not legally required to pay, or would not be required to pay in the absence of this Plan;
7. Claims not submitted within 12 months after expenses were incurred, except in the absence of legal capacity;
8. Charges for the completion of claim forms;
9. Charges for missed or broken appointments;
10. Interest on unpaid balances;
11. Dental care or treatment, or dental x-rays, except for tumors or cysts or medical services incurred as the result of an accidental injury to natural teeth, or as otherwise specifically provided (dental benefits are provided as described on page 36);
12. Charges for diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves and other tissues unless approved in advance by the Plan;
13. Procedures that are considered by the Plan to be experimental procedures or that are not in accordance with generally accepted medical standards in the United States;
14. Transplants except as approved in advance by the Plan (see "Organ/Tissue Transplants," page 24);
15. Organ acquisition charges relating to any transplant procedure, unless the organ recipient is covered under this Plan and such expenses are not covered under the donor’s insurance;
16. Services rendered outside the United States, unless such services are billed using CPT codes in U.S. dollars and would have been covered if provided in the United States;
17. Eye refractions, except as may be required as the result of an accidental bodily injury (vision benefits are provided as described on page 41);
18. Orthoptics and vision training;
19. Professional or other services from a person who lives with the patient or is related to the patient or patient’s spouse;
20. Custodial care;
21. Personal comfort, beautification, or convenience items or services;
22. Cosmetic surgery, unless required for:
1. Accidental injuries,
2. Reconstructive surgery because of congenital disease or anomaly of an eligible dependent child that has resulted in a functional defect, or
3. Reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection or other disease of the involved part, including, in the event of mastectomy:
1. reconstruction of the breast on which the mastectomy has been performed,
2. surgery and reconstruction of the other breast to produce a symmetrical appearance, and
3. prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas.
23. Wigs, unless pre-certified by the Plan as required as the result of a disease or the treatment of a disease which is covered by the Plan, at 90% up to maximum benefit of $500 every three years;
24. Any treatment of obesity, or services and supplies primarily for weight loss or control, unless necessitated as the direct result of a specifically identified and diagnosed condition of disease origin;
25. Gastric bypass or gastric stapling procedures;
26. Nutrition or diet counseling by any person other than a registered dietician or physician. Nutrition or diet counseling shall be covered for the following conditions or when approved in advance by the Plan:
1. Diabetes,
2. Cardiovascular disease,
3. Pediatric metabolic disorders and cystic fibrosis, or
4. Certain metabolic disorders such as malabsorptive disease, ulcerative colitis, or Crohn’s disease;
27. In-vitro fertilization, artificial insemination, infertility treatment, or any charges associated with the direct inducement of pregnancy (however, necessary services and supplies to diagnose infertility are covered);
28. Reversal of sterilization procedures;
29. Charges in connection with pregnancy or pregnancy-related conditions of a dependent child;
30. Routine hospital care for newborns, except while the mother is hospital confined;
31. Elective abortion for a dependent child;
32. Services associated with sex transformations and resulting complications;
33. Penile implants unless required as a result of injury or an organic disorder;
34. Professional services, except as specifically provided herein, rendered for study of behavioral characteristics, or vocational testing or counseling;
35. Treatment for learning disabilities, educational problems, therapy or surgery for sexual dysfunction or inadequacies, or psychiatric admissions that are primarily to control or change the patient’s environment, except as specifically provided;
36. Treatment for mental health conditions in excess of 20 outpatient visits per year or 30 inpatient days per year;
37. Treatment for chemical dependency or alcoholism (there is a separate Employee Assistance Program, described on page 34 of this booklet);
38. Myofunctional therapy;
39. Work-related injury or illness covered under Workers’ Compensation, occupational disease, or similar laws;
40. Expenses incurred while in military service or resulting from declared or undeclared war or armed aggression;
41. Confinement in a hospital owned or operated by the federal government, except usual and customary charges otherwise payable and incurred at a Veterans Administration facility or by a covered person as an armed services retiree (or such person’s dependent) for services or supplies unrelated to military service, which will be paid at the Out-of-Network benefit level and will not be coordinated with Medicare;
42. Travel expenses, whether or not recommended by a physician, except as specifically provided;
43. Physical therapy in excess of $3,000 per year;
44. Chiropractic care in excess of $1,500 per year, including x-rays and massage therapy related to chiropractic treatment;
45. Massage therapy, unless performed by a licensed massage therapist as part of a written chiropractic treatment plan;
46. Immunizations, examinations or reports required for:
1. obtaining or continuing employment, or
2. insurance purposes, or
3. government licensing (including marriage license and pilot’s license);
47. Preventive care in excess of $300 per year, when services are provided by an Out-of-Network provider;
48. Orthotics in excess of $400 per pair, or not ordered by your medical doctor and made specifically for your personal use. Orthotics in excess of one pair every four years for adults or in excess of one pair for every two full shoe size increases for children up to age 19, and
49. Any charges or medical claims for which a third party may be liable or legally responsible.
50. Health care services and expenses that arise out of a criminal act by the covered person or an intentionally self-inflicted injury that is not the result of a mental illness. Injuries resulting from an act of domestic violence or from a mental health condition are not excluded solely because the source of the injury was an act of domestic violence or a mental health condition.