Ineligible Medical Expenses

No benefits are payable for the following expenses:

• Services, supplies and treatment that are not medically necessary, as defined by the Plan;
• Charges which are in excess of the Reasonable and Customary charges (as defined) for services, supplies and treatment;
• Charges which are in excess of the contracted allowable charge for In-Network benefits;
• Expenses for work related injuries, illnesses or medical expenses covered under Workers’ Compensation or any state or Federal Law (unless benefits are denied and the appeal process has been exhausted);
• Hospital charges for personal or comfort items such as personal care kits and other items which are not for the specific treatment of an injury or illness;
• Services rendered during confinement in a hospital owned or operated by the Federal Government, unless you would be required to pay such charges in the absence of coverage;
• Loss due to war, either declared or undeclared, or loss suffered while engaged in military service;
• Expenses which were incurred before you became eligible for benefits and expenses which were incurred after your coverage terminated;
• Expenses you or your dependents are not required to pay;
• Expenses in excess of the Plan’s annual and lifetime limits;
• Expenses for eyeglasses or contact lenses and charges for eye surgery or treatment primarily to correct refractions;
• Dental work or treatment, except for the accidental injury to sound natural teeth occurring while covered or for the treatment of cysts and tumors or cancer of the jaw or mouth;
• Charges for hearing aids or any device which assists in hearing;
• Charges related to cosmetic surgery unless caused by an accidental bodily injury occurring while covered or reconstructive surgery due to congenital disease or anomaly of a dependent child which has resulted in a functional defect;
• Charges related to breast augmentation for cosmetic purposes;
• Routine physical examinations, except as provided for elsewhere;
• Transportation, except for licensed professional ambulance services;
• Expenses related to an injury sustained when it is determined the covered individual was intoxicated under the laws of the state where the accident occurred or the result of being under the influence of a drug, unless the drug was prescribed by a physician and used strictly as prescribed;
• Intentionally self-inflicted injury or injury sustained in the commission of a felony, unless the injury is the direct result of a medical condition (such as mental illness or depression);
• Expenses for outpatient treatment of Mental and Nervous disorders unless provided by a licensed clinical psychologist or psychiatrist, limited as shown in the Schedule of Benefits;
• Charges for preparing medical reports, itemized bills or claim forms, handling, mailing, shipping expenses or sales tax;
• Charges for missed appointments or “no show” fees;
• Membership fees or costs associated with health clubs, weight loss programs and smoking cessation programs
• Infertility treatment and services including In Vitro Fertilization (IVF), Gamete Intra Fallopian Transfer (GIFT) or any other variations of these types of procedures;
• Charges associated with the collection, washing, preparation or storage of sperm for artificial insemination and charges for cryopreservation of donor sperm and eggs;
• Charges for a reversal of a voluntary sterilization;
• Charges for routine foot care, including service for calluses, corns or toenails, unless medically necessary;
• Convalescent care or nursing homes; and
• Experimental treatments or services.

The Plan benefits outlined in this booklet are subject to change.  Contact the Fund Office to confirm whether a service or procedure is an Eligible Medical Expense or an Ineligible Medical Expense.