What the Medical
Plan Doesn't Cover
Although the plan covers most medical expenses, some costs are not covered, such as:
services or supplies for an illness or
injury incurred in the course of any employment;
services or supplies for an illness or
injury which is covered under Workers' Compensation or a
similar law;
services, supplies or treatments that are
not medically necessary;
charges for services or supplies above the
usual and customary limits;
any operation or treatment of the teeth or
the supporting tissues of the teeth except:
- removal of tumors;
- treatment of malerupted impacted wisdom teeth;
- treatment of accidental injury to sound natural teeth (including their replacement) due to an accident occurring while covered under this plan; and
- inpatient hospital charges for oral surgery while a registered patient if medically necessary;
cosmetic surgery, except:
- operations necessary to repair disfigurement due to an accident that occurs while you are covered by this plan; - the medically necessary treatment of a congenital anomaly in an eligible dependent child who is covered by this plan;
- for reconstructive breast surgery if a mastectomy has been performed while covered under this plan;
- for operations necessary to repair disfigurement due to surgical treatment of an illiness if such operation improves or restores bodily function and the surgical treatment was covered by the plan;
hearing aids or exams for their fitting;
eyeglasses or contact lenses and the exam
for their fitting or for determining the refractive state of
the eyes;
surgical correction of refractive errors;
charges related to an intentionally
self-inflicted injury or illness while sane or insane;
services or supplies for illness, injury
or mental or nervous conditions caused by war or an act of
war;
charges in connection with illness or
injury related to military service;
services performed on or after the date
you or a covered dependent elect Medicare as primary coverage
if you continue to be actively employed;
the treatment and prescription of
supportive devices, including orthotics, the treatment of
foot conditions such as cutting, trimming or paring of corns
and calluses and routine foot care;
Outpatient Occupational Therapy and
Outpatient Speech Therapy to acquire function or to maintain
a level of functioning for a person who has not previously
reached the level of intellectual, speech, motor or physical
development normally expected for the covered person's
age;
whole blood or derivatives that are
donated;
personal convenience items;
routine physical exams, including annual
gynecological exams and school physicals;
expenses for you or your dependent if
enrolled in
an HMO;
services or supplies for any custodial care;
charges for telephone consultations, for
completing
a claim form, or for failure to keep a scheduled appointment;
penalties
for not complying with the Medical Advisor Review Program;
charges for services in a nursing home
and/or sanitarium;
non-prescription drugs, except insulin;
marital, cognitive, investigational or
educational therapy;
immunizations and inoculations;
well-baby care, except for inpatient
hospital nursery care immediately following the birth of a
covered dependent;
retainers, mouth guards, dental exams,
prophylaxis and orthodontia for any temporomandibular joint
(TMJ) disorder;
acupuncture;
treatment or classes for smoking
cessation, including patches, hypnotism, etc.;
health club charges or fees;
charges for drugs, devices, procedures or
medical treatments that are considered experimental by
generally accepted medical practice (see page PPOM-54 for a
definition of experimental).
charges for supplies or programs to help
the Participant lose weight (except Surgical Procedures that
are Medically Necessary);
charges for services, supplies or
treatments not necessary for treatment of Injury, Illness or
mental and nervous conditions;
charges for medications used for
contraceptive purposes; and
charges for chiropractic visits in excess
of twenty (20) visits per year, and in excess of three (3)
modalities per visit.
November 2002