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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 limited to well-child visits.
• Compulsive disorders treatment limited to programs for feeding and eating disorders.
• Developmental Screening limited to well-child visits.
• Psychiatric or psychological treatment for developmental disorders, limited to mental retardation, pervasive developmental disorder and other specific developmental disorders, such as autism, Rett’s, or Asperger’s.

 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:
• Repair due to an accidental injury;
• Improve function of a malformed part of the body.  Does not include dentistry or dental processes; and
• Breast reconstruction after a mastectomy.

 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.
• Improve function of a malformed part of the body resulting from a birth defect.
• 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.
• Corrective lenses and fittings following cataract surgery limited to:
• First set of basic frames and lenses; or
• One set of contact lenses.
• Foot care limited to:
• Routine foot care, 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.
• Hearing aids limited to:
• One aid per ear every 48 months unless Medically Necessary to replace more often.
• Four additional ear molds per year for children less than two years of age.
• Orthotic devices limited to:
• Members with diagnoses pertaining to peripheral vascular disease or diabetes.
• 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.

 Experimental or Investigational therapies

• Drugs, items, devices, and procedures limited to:
• Off-label uses of certain drugs used in the study or treatment of cancer; and
• Certain investigational uses of drugs, including chemotherapy for cancer treatment, if given to you as part of an Approved Clinical Trial.

 General care or Hospital Services

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

 Genetic analysis, services, or testing

• Limited to counseling and testing for women whose family history is associated with a higher risk for deleterious mutations in BRCA 1 and BRCA 2 genes.

 Home Healthcare

• Limited to 100 visits per year.

 Physical, occupational, and speech therapy

• Rehabilitation Services limited to 60 combined Outpatient visits per year for:
• Physical therapy;
• Occupational therapy; and/or
• Speech therapy.
• ASD Treatment – Physical, occupational, and/or speech therapy services 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.

 Prescription Drugs

• Inhaler extender devices, peak flow meters, Ana-Kits, and EpiPens limited to three per year.
• The Pharmacy and Therapeutics Committee’s standard quantity limits, prior authorization criteria, and step therapies apply.
• Specialty Drugs limited to a one-month supply.
• 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.
• Drugs prescribed or given to you by Out-of-network doctors in non-emergencies limited to those prescribed by dentists.
• 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 diaphragms limited to two per year.
• Biological sera, 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.
• Prescription Drugs for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy, hyporgasmy, or decreased libido limited to post-prostate surgery indications.

 Sexual dysfunction

• Limited to drugs and supplies for post-prostate surgery indications.

 Skilled Nursing Facility care

• Limited to 100 days per year.

 Vision

• 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

Behavioral health services

• Education, tutoring, and services for the purpose of diagnosing or treating a learning disability, disruptive, impulse-control, or conduct disorder.

 Dental services

• General dental services.
• Procedures that involve the teeth or their supporting structures.
• Correction of occlusive jaw defects, dental implants, or grafting of alveolar ridges.
• Treatment of soft tissue to prepare for dental procedures or dentures.

 DME, orthotic devices, and prosthetic appliances

• Bandages, pads, or diapers.
• 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.
• 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

 Experimental or Investigational therapies

• Drugs, therapies, and technologies:
• Before the long-term effect is known or proven; or
• That are not more effective than standard treatment.
• New procedures, services, supplies, and drugs that have not been reviewed and approved by GlobalHealth.

 General care or Hospital Services

• Treatment of any kind which is excessive or not Medically Necessary.
• Services received without an authorization when one is required. Complications arising from those services.
• Treatment of any kind received before your start date of coverage or after the time coverage ends, even if authorized.
• 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.
• Services, other than Hospital Services for behavioral health, for which you do not allow the release of information to GlobalHealth.
• Services for travel, insurance, licensing, employment, school, camp, sports, premarital, or pre-adoption purposes.
• Personal or comfort items.
• Services received while outside of the U.S. (50 states and District of Columbia).
• 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.
• Treatment of injuries or illnesses resulting from an attempt or commission of a felony, or as a result of being engaged in an illegal occupation.
• Elective enhancement procedures, services, supplies, or medications, including but not limited to:
• Anti-aging
• Athletic performance
• Cosmetic purposes
• Hair growth
• Sexual performance

• Separate charges for missed or canceled appointments, penalty or finance charges, maintenance and/or record-keeping, record copying, or Case Management services.
• 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.
• Custodial care, respite care, homemaker services, or domiciliary care.
• Treatment for injury resulting from extreme activities including, but not limited to:
• Base jumping
• Bungee jumping
• Bull riding
• Car racing
• Skydiving
• Motorcycle stunts
• Alternative drugs and/or treatments used in the place of standard therapy, to treat any condition or illness.
• Screening services requested solely by you, such as commercially advertised heart scans.

 Obstetrical and Infertility services

• Alternative programs for delivery such as home delivery and use of midwives and birthing centers.
• Elective abortions.
• Expenses related to surrogate parenthood.
• Home uterine monitoring.
• In vitro fertilization, artificial insemination, embryo transfers, reversal of voluntary sterilization, ovum transplant, gamete intrafallopian transfer (“GIFT”), zygote intrafallopian transfer (“ZIFT”), surrogate parenting, and donor semen expenses.

 Other coverage

• 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).
• Services that are provided as a result of Workers’ Compensation laws or similar laws.
• Treatment for which the cost is recoverable under any other coverage, including Workers’ Compensation, Occupational Disease law, or any state or government agency.

 Other Excluded Services

• Services resulting in whole or in part from an excluded condition, item, or service.

 Physical, occupational, and speech therapy

• Kinesiology, movement therapy, or biofeedback.
• Rolf technique.
• Massage therapy.
• Acupuncture/acupressure.
• Recreational therapy including, but not limited to:
• Animal-facilitated therapy
• Music therapy

 Prescription Drugs

• Non-preventive care drugs, dietary, formulas, foods, and products supplements available without a prescription (OTC).
• OTC drugs that are for the same purpose and have the same effect as Prescription Drugs, even if ordered by a doctor.
• Saline and medications for irrigation.
• Drugs prescribed for a non-FDA approved indication, dosage, or length of therapy.

 Repair and replacement

• Drugs, eyewear, devices, appliances, equipment, or other items that are lost, missing, sold, or stolen.
• Items that have been damaged or destroyed due to improper use or abuse.

 Transplants

• Artificial or non-human organ transplants.
• Transplants considered experimental, investigative, or unproven.

 Transportation/ lodging

• Routine, non-emergent ambulance transport unless preauthorized by GlobalHealth.
• Lodging, meals, and transportation costs.

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.
• Multiple pairs of glasses in lieu of bifocals or trifocals.

Weight Reduction Programs

• Gastric stapling, gastric balloon services, or any surgical treatment for obesity or weight-loss purposes.
• Commercial weight loss programs.