Section 6. General exclusions - things we don't cover
The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. The fact that one of our covered providers has prescribed, recommended, or approved a service or supply does not make it medically necessary or eligible for coverage under this Plan.

We do not cover the following:
  • Services, drugs, or supplies you receive while you are not enrolled in this Plan;

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  • Services, drugs, or supplies not medically necessary;

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  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice in the United States;

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  • Experimental or investigational procedures, treatments, drugs or devices;

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  • Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest;

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  • Procedures, services, drugs, and supplies related to sex transformations, sexual dysfunction or sexual inadequacy, e.g., Viagra, Muse, Caverject, penile prosthesis;

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  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;

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  • Services or supplies for which no charge would be made if the covered individual had no health insurance coverage;

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  • Services, drugs, or supplies you receive without charge while in active military service;

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  • Services or supplies furnished by immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption;

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  • Services or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs and physical, speech and occupational therapy rendered by a qualified professional therapist on an outpatient basis are covered subject to plan limits;

  • Services and supplies not specifically listed as covered;

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  • Any portion of a providers fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives (does not require the enrollee to pay) a deductible, copayment or coinsurance, the Carrier will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived;

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  • Charges which the enrollee or Plan has no legal obligation to pay, such as: excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/or B (see page 17), doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare (limiting charge) (see page 18), or State premium taxes however applied;

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  • Dental treatment, including X-rays and treatment by a dentist or oral surgeon except to the extent shown in Section 5(g);

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  • Dental appliances, study models, splints and other devices or services associated with the treatment of temporomandibular joint (TMJ) dysfunction;

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  • Eyeglasses or hearing aids, or examinations for them, except as shown in Section 5(a);

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  • Treatment of learning disabilities;

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  • Marital counseling;

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  • Practitioners who do not meet the definition of covered provider on page 9, Section 3;

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  • Charges for services and supplies that exceed the Plan allowance;

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  • Services in connection with custodial care as defined on page 75;

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  • Services in connection with: corns; calluses; toenails; weak, strained, or flat feet; any instability or imbalance of the foot; or any metatarsalgia or bunion, including related orthotic devices, except as listed on page 30, Section 5(a);

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  • Services by a massage therapist;

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  • Services by a naturopathic practitioner;

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  • Services and supplies for cosmetic purposes, e.g., Retin A, Minoxidil, Rogaine;

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  • Treatment of obesity or weight reduction, except for treatment of morbid obesity as listed on page 35, Section 5(b);

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  • Safety, hygiene, convenience, and exercise equipment and supplies;

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  • Fees for medical records not requested by the Plan;

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  • Handling charges/administrative charges or late charges, missed appointment fees, including interest, billed by providers of care;

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  • Telephone and on-line medical consultations;

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  • "Never Events" - Are errors in patient care that can and should be prevented. We will follow the policy of the Centers for Medicare and Medicaid Services (CMS). The Plan will not cover care that falls under these policies. For additional information, please visit www.cms.gov, enter Never Events into SEARCH. 

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