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Last updated 7/31/2014
• Sterilization procedures for women and patient education and counseling related to contraception for all
women with reproductive capacity. (Although these are technically excluded from your group’s health plan
insurance coverage, We will pay for them as preventive services, as required by federal regulations.)*
• Travel immunizations.*
• Acupuncture.*
• Behavioral health therapy services provided in the home.
• Chelation therapy for atherosclerosis.
• Coma stimulation programs.
• Dry needling.
• Holistic medicine and any other form of alternative medicine.
• Low Level Light Therapy.
• Massage therapy.
• Prolotherapy.
• Swim or pool therapy, unless Prior Authorization is obtained.
Non-Medical
• Administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics.*
• Court-ordered care, unless Medically Necessary and otherwise covered under this Certificate.
• Educational services, except for diabetic self-management classes.
• Internet and phone consultations, including all related charges and costs.
• Missed appointment charges.
• Telephone consultation charges by or between providers.
• Charges or costs exceeding a benefit maximum or Maximum Allowable Fee where applicable.
• Expense incurred before the supply or service is actually provided unless prior approved by Our Medical
Affairs division.
• Services, treatment, and supplies provided to a Member while the Member is held or detained in custody of
law enforcement officials, or imprisoned in a local, state, or federal penal or correctional institution.
• Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay.
• Service for hospital or medical care not listed in this Certificate.
• Services, treatment, and supplies provided in connection with any illness or injury caused by: (a) a Member’s
engaging in an illegal occupation or (b) a Member’s commission of, or an attempt to commit, a felony. (Note
that this exclusion does not apply to the treatment of injuries that result from an act of domestic violence, to
the extent that such treatment would otherwise be covered.)
• Services provided by members of the Subscriber’s Immediate Family or any person residing with the Subscriber.
• Services or supplies for, or in connection with: a non-covered procedure or service, including complications,
regardless of when a non-covered procedure or service is or was performed; a denied Prior Authorization; or
a denied admission.
• Services or supplies not Medically Necessary, not recommended or approved by a provider, or not provided
within the scope of the provider’s license.
• Services and supplies rendered outside the scope of the provider’s license.
• Services or items required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while
performing military service.
• Services to the extent a Member receives or is entitled to receive any benefits, settlement, award, or damages
for any reason of, or following any claim under, any Workers’ Compensation Act, employer’s liability insurance
plan, or similar law or act. “Entitled” means the Member is actually insured under Workers’ Compensation.
* Indicates language that will likely vary in your policy.