Genuine care. Optimal health.

All benefits described below are excluded or limited under this Plan for all types of services. We cover some benefits only as follows. You pay for additional services. We do not cover the following benefits.  We may pay for care while deciding whether or not the care falls within the Excluded Services listed below. If it is later determined that the care is excluded from your coverage, we will recover the amount we have allowed for benefits. You must give us all documents needed to enforce our rights.

General Limitations

We cover certain benefits only as follows:

Behavioral Health Services

• Applied behavioral analysis limited to the following diagnoses:

• • Autistic disorder – childhood autism, infantile psychosis, and Kanner’s syndrome;
  • Childhood disintegrative disorder – Heller’s syndrome;
  • Rett’s syndrome; and
  • Specified pervasive developmental disorders – Asperger’s disorder, atypical childhood psychosis, and borderline psychosis of childhood.

• Autism Screening and Developmental Screening limited to well-child visits.
• Psychosocial education limited to daily living and social skills education.

Cardiac Rehabilitation Services

• Limited to 36 visits per event.

Chiropractic Care

• Limited to 15 visits per year.

Cosmetic Services

• Treatment, item, supply, drug, procedure, or any portion of a procedure performed primarily to improve physical appearance limited to:

• • Breast reconstruction after a mastectomy;
  • Improve function of a malformed part of the body; and
  • Repair due to an accidental injury.

Dental Services

• Dentistry or dental processes to the teeth and surrounding tissue limited to:

• • ER services to treat accidental injury to the jaw, sound natural teeth, mouth, or face.
  • Surgery to improve function of the jaw, mouth, or face resulting from a birth defect. Does not include dental work.

• General anesthesia/IV sedation for dental services limited to a Member who:

• • Has a medical or emotional condition that requires Hospitalization or general anesthesia for dental care;
  • Is severely disabled;
  • In the judgment of the treating Practitioner, is not of sufficient emotional development to undergo a Medically Necessary dental procedure without the use of anesthesia; and
  • Requires Inpatient or Outpatient services because of an underlying medical condition and clinical status or because of the severity of the dental procedure.

DME, orthotic devices, and prosthetic appliances

• Breast pumps limited to:

• • One per year for women who are pregnant or nursing.
  • Purchase or rental of breast pump and related supplies.

• Corrective lenses and fittings limited to pair of basic non-designer frames and single vision lenses or contact lenses following cataract surgery.
• Footwear limited to:

• • Shoes, shoe inserts, arch supports, and supportive devices for Members diagnosed with diabetes or a blood circulation disease.
  • Orthopedic or corrective shoes permanently attached to a Denis Browne splint for children.

• DME rentals:

• • Knee walker or kneeling crutch rentals limited to 4 months.
  • Oxygen and oxygen equipment rentals limited to 36 months and remaining Medically Necessary.
  • Other DME rentals limited to 13 months.

• Hearing aids limited to:

• • One basic hearing aid per ear every 48 months unless Medically Necessary to replace more often.
  • Four additional ear molds per year (two molds for each ear) for children less than two years of age.

• Orthotic devices limited to:

• • Braces for the leg, arm, neck, back, or shoulder;
  • Back and special surgical corsets;
  • Splints for the extremities; and
  • Hernia trusses.

• Replacements, repairs, and adjustments for orthotics and prosthetics limited to:

• • Normal wear and tear; and
  • Due to a significant change in your physical condition.

• Wigs and scalp prostheses limited to one synthetic wig or scalp prosthesis per year when required due to loss of hair resulting from chemotherapy or radiation therapy.

Foot Care

• Routine care limited to Members with diabetes or a blood circulation disease.

General Care or Hospital Services

• Hospital private room limited to isolation to prevent contagion per the Hospital’s infection control policy.

General Limitations

• Sexual dysfunction services limited to drugs and supplies for post-prostate surgery indications.

Genetic analysis, services, or testing

• Limited to counseling and testing for women whose personal or family history or ancestry is associated with a higher risk for deleterious mutations in BRCA 1 and BRCA 2 genes.
• Limited to testing for Members with a cancer diagnosis for treatment plan purposes.

Hearing services

• Cochlear® surgery and basic devices limited to Members at least 18 months of age or for pre-lingual Members with minimal speech perception using hearing aids.

Home Healthcare

• Limited to 100 visits per year.

Obstetrical care

• Costs resulting from normal, full-term delivery out of our network, limited to emergencies.

Physical, occupational, and speech therapy

• Rehabilitation Services limited to 60 Outpatient visits, combination of therapies. Outpatient visits include office visits and/or rehabilitation Outpatient Facility visits.
• Habilitation Services limited to:

• • ASD treatment – Physical, occupational, and/or speech therapy services for the following diagnoses:
  • Autistic disorder – childhood autism, infantile psychosis, and Kanner’s syndrome;
  • Childhood disintegrative disorder – Heller’s syndrome;
  • Rett’s syndrome; and

Specified pervasive developmental disorders – Asperger’s disorder, atypical childhood psychosis, and borderline psychosis of childhood.

• Cleft lip and cleft palate treatment – Otologic, audiologic, and speech therapy.

Prescription Drugs

• Drugs prescribed or given to you by Out-of-network doctors in nonemergencies limited to those prescribed by dentists.
• Epinephrine autoinjectors limited to four per year.
• Glucometers limited to two per year.
• Inhaler extender devices and peak flow meters limited to three per year.
• Medication prescribed for parenteral use or administration, allergy sera, immunizing agents, and immunizing injectable drugs limited to immunizations covered under Preventive Care guidelines and given to you at a Network pharmacy.
• Non-prescription contraceptive jellies, ointments, foams, or devices limited to those that are FDA-approved and prescribed by a Network doctor for a woman.
• Prescription Drugs for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy, hyporgasmy, or decreased libido limited to post-prostate surgery indications.
• Prescription Drugs for the treatment of sexual dysfunction, including erectile
• dysfunction, impotence, and anorgasmy, hyporgasmy, or decreased libido limited to post-prostate surgery indications.
• Prescription diaphragms limited to two per year.
• The Pharmacy and Therapeutics Committee’s standard quantity limits, prior authorization criteria, and step therapies apply.
• Smoking cessation products limited to:

• • Two full 90-day courses of FDA-approved tobacco cessation products per year, if prescribed by your PCP.
  • Members who are at least 18 years old.

• Specialty Drugs limited to a one-month supply.

Preventive Care

• DEXA scans for bone density screening limited to one every 24 months.
• Limited to USPSTF, HRSA, and CDC guidelines.
• Routine exam for adults limited to one per year.
• Routine exam for children and well-child care limited to the American Academy of Pediatrics (AAP) schedule.
• Tobacco cessation limited to two attempts per year.

Pulmonary rehabilitation services

• Limited to 36 visits per event

Skilled Nursing Facility care

• Limited to 100 days per year.

Temporomandibular joint dysfunction

• Non-surgical treatment limited to a lifetime maximum of $1,500.

Vision

• Diabetic eye exam limited to one per year.
• Glaucoma test limited to one per year.
• Routine services limited to one check-up, including eye refraction, per year.
• Treatment for orthoptics or visual training limited to a diagnosis of mild strabismus.

Excluded Services

We do not cover the following benefits. We may pay for care while deciding whether or not the care falls within the Excluded Services listed below. If it is later determined that the care is excluded from your coverage, we will recover the amount we have allowed for benefits. You must give us all documents needed to enforce our rights.

Behavioral health services

• Education, tutoring, and services offered through a school/academic institution for the purpose of diagnosing or treating a learning disability, disruptive, impulse-control, or conduct disorder.
• Wilderness therapy.

Dental services

• Correction of occlusive jaw defects, dental implants, or grafting of alveolar ridges.
• General or preventive dentistry.
• Non-emergency procedures that involve the teeth or their supporting structures.
• Replacement, re-implantation, and follow-up care of teeth, even if the teeth are not saved by emergency stabilization.
• Treatment of soft tissue to prepare for dental procedures or dentures.

DME, orthotic devices, and prosthetic appliances

• Additional warranties.
• Bandages, pads, or diapers.
• Bionic and myoelectric prosthetics.
• Changes to your home or vehicle.
• Clothing and devices available OTC.
• Continuous passive motion devices.
• Equipment that serves as comfort or convenience.

• • For example, portable oxygen concentrators.

• Equipment or devices not medical in nature such as:

• • Braces worn for athletic or recreational use
  • Ear plugs
  • Elastic stockings and supports
  • Garter belts

• Jacuzzi/whirlpools.
• Mattresses and other bedding or bed-wetting alarms.
• Multiple DME items for the same or like purposes.
• Power-operated vehicles that may be used as wheelchairs.
• Purchase or rental of equipment or supplies for common household use such as:

• • Air-cleaning machines or filtration devices
  • Air conditioners
  • Beds and chairs
  • Cervical or lumbar pillows
  • Grab bars
  • Physical fitness equipment
  • Raised toilet seats
  • Shower benches
  • Traction tables
  • Water purifiers

• Upgrade features to enhance basic equipment.

General Excluded Services

• Care or services provided outside the GlobalHealth Service Area if the need for such care or services could have been foreseen before leaving the Service Area.
• Charges for injuries resulting from war or act of war (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer.
• Custodial care, respite care, homemaker services, or domiciliary care.
• Drugs, therapies, and technologies:

• • Before the long-term effect is known or proven; or
  • That are not more effective than standard treatment.

• Drugs, eyewear, devices, appliances, equipment, dental work, or other items that are lost, missing, sold, or stolen.
• Drugs or other items that have been damaged or rendered unusable due to improper handling or abuse.
• Elective enhancement procedures, services, supplies, or medications, including but not limited to:

• • Anti-aging
  • Athletic performance
  • Cosmetic purposes
  • Hair growth
  • Sexual performance

• Lodging and meals.
• New procedures, services, supplies, and drugs that have not been reviewed and approved by GlobalHealth.
• Personal or comfort items.
• Private duty nursing.
• Screening services requested solely by you, such as commercially advertised heart or lung scans.
• Separate charges for missed or canceled appointments, penalty or finance charges, maintenance and/or record-keeping, record copying, or Case Management
• Services for travel, insurance, licensing, employment, school, camp, sports, premarital, or pre-adoption purposes.
• Services, other than Hospital Services for behavioral health, for which you do not allow the release of information to GlobalHealth.
• Services received while outside of the U.S. (50 states and territories).
• Services received without an authorization when one is required. Complications arising from those services.
• Services resulting in whole or in part from an excluded condition, item, or service.
• Services that are provided as a result of Workers’ Compensation laws or similar laws.
• Treatment of any kind which is excessive or not Medically Necessary.
• Treatment of any kind received before your start date of coverage or after the time coverage ends, even if authorized.
• Treatment, supplies, drugs, and devices for which no charge was made. Treatment, supplies, drugs, and devices for which no payment would be requested if you did not have this coverage.
• Treatment for injury resulting from extreme activities including, but not limited to:

• • Base jumping
  • Bungee jumping
  • Bull riding
  • Car racing
  • Skydiving
  • Motorcycle/BMX racing and/or stunts

• Treatment for disabilities connected to military service for which you are legally entitled and to which you have reasonable accessibility (that is, services through a federal governmental agency).
• Treatment for which the cost is recoverable under any other coverage, including Workers’ Compensation, Occupational Disease law, school/academic institution, or any state or government agency.

Genetic analysis, services, or testing

• Genetic counseling and testing for family planning or disease identification purposes.

Immunizations

• Unless also a Preventive Service, shots you must have for:

• • Employment;
  • The military;
  • Travel; or
  • A vocational school or institute of higher education.

Obstetrical and Infertility services

• Alternative programs for delivery such as home delivery and use of midwives and birthing centers.
• Cost of donor sperm or donor egg.
• Cryopreservation or storage of sperm (sperm banking), eggs, or embryos.
• Elective abortions.
• Expenses related to surrogate parenthood.
• Genetic counseling and genetic Screening.
• Home uterine monitoring.
• Hysterectomies for the purpose of contraception.
• Insemination procedures and all services related to insemination.

• • Gamete Intrafallopian Transfer (GIFT)
  • In Vitro Fertilization (IVF)
  • Intracervical Insemination (ICI)
  • Zygote Intrafallopian Transfer (ZIFT)

• Reversal of a sterilization procedure.
• Services associated with these procedures.

Physical, occupational, and speech therapy

• Acupuncture/acupressure.
• Kinesiology or movement therapy.
• Massage therapy.
• Recreational therapy including, but not limited to:

• • Animal-facilitated therapy
  • Music therapy

• Rolf technique. 

Prescription Drugs

• Drugs prescribed for a non-FDA approved indication, dosage, or length of therapy.
• Products available without a prescription (OTC). Including but not limited to:

• • Dietary supplements
  • Foods
  • Formulas
  • Medications for irrigation
  • Non-preventive care drugs
  • Saline

• Compounded drugs

Transplants

• Artificial or non-human organ transplants.

 Vision

• Computer programs of any type, including, but not limited to, those to assist with vision therapy.
• Insurance for contact lenses.
• LASIK, INTACS, radial keratotomy, and other refractive surgery.
• Lens upgrades.
• Non-prescription lenses.
• Special multifocal ocular implant lenses

Weight Loss

• Commercial weight loss programs or OTC weight loss products.
• Bariatric surgery when related to weight loss alone.