B. MEDICAL PLAN LIMITATIONS AND EXCLUSIONS
The benefits of this Plan are provided only for services and supplies that are Medically Necessary. These services are covered services and supplies that are consistent with the symptoms or diagnosis in the treatment of an Illness or Injury, are Medically Necessary and consistent with generally accepted professional standards, are not furnished primarily for the convenience of the patient, the Physician, or other provider, and are furnished at the most appropriate level which can be provided safely and effectively to the patient. Examples of services that are not Medically Necessary include hospitalization for diagnostic studies that could have been provided on an outpatient basis, hospitalization primarily for observation or evaluation, hospitalization to remove the patient from his or her customary work and/or home environment or for personal comfort.
The Plan reserves the right to determine if a service, supply, or hospitalization is Medically Necessary. The fact that a Physician or other provider has prescribed, ordered, recommended or approved a service, supply, or hospitalization does not, in itself, make it Medically Necessary.
The following charges are NOT Covered Charges/Expenses:
1. Excess of Reasonable and Customary.
Any portion of a charge which is in excess of the Reasonable and Customary charge for the treatment.
2. Not Medically Necessary.
Any charge for treatment that the Plan determines is not Medically Necessary. To determine this, the Plan may rely upon the advice of its medical review department and/or an independent medical reviewer and other medical experts. This provision shall not exclude any Covered Expense which specifically states that such treatment will be considered Medically Necessary.
3. Experimental or Not Generally Accepted Treatment.
This section modified by a Benefit Change
Experimental or Not Generally Accepted Treatment. Subject to the exceptions
described below, charges incurred for a treatment that is not generally accepted by the
medical profession, or is listed as Experimental, under Investigation, or limited to research
by the FDA, the American Medical Association (“AMA”), Diagnostic and Therapeutic
Technology Assessment (“DATTA”) or the Office of Medical Application of Research of
the National Institute of Health Office of Technology Association (“OMT”). If a treatment
has not been addressed by one of the organizations listed in the preceding sentence, the
Plan may determine if a treatment is appropriate based on the advice of its medical review
department and/or an independent medical reviewer and other medical experts.
Exceptions. Coverage for treatment described in this paragraph will not be denied if either
of the following exceptions apply:
- Certain FDA Approved Drugs Prescribed for Unapproved Purposes. The
coverage is for an FDA-approved drug that is used to treat a condition for which the
FDA has not approved the drug’s use, but only if the drug is prescribed for the
treatment of a life-threatening condition and the drug has been recognized for
treatment of that condition by the American Medical Association Drug Evaluations,
the American Hospital Formulary Service Drug Information or the United States
Pharmacopeia Dispensing Information, Volume I, “Drug Information for the Health
Care Professional.” “Life-threatening,” for this purpose, means either (or both)
diseases or conditions where the likelihood of death is high unless the course of the
disease is interrupted and diseases or conditions with potentially fatal outcomes,
where the end point of clinical intervention is survival.
- Certain Suspected Physical Causes of Autistic Symptoms. The coverage is
for alternative treatment for a condition suspected of playing a role in the
expression of symptoms of autism, including:
- vitamin supplementation therapy;
- oral secretin therapy;
- chelation;
- hyperbaric oxygen therapy;
- cranio-sacral therapy;
- fibroblast growth factor therapy;
- live cell and stem cell therapy;
- anti-fungal therapy;
- antibiotic therapy; and
- naltextrone therapy .
Covered charges allowed under this exception (ii) shall not exceed $3,000 for any
Calendar Year.
Any questions concerning the above changes may be directed to the Plan Office at (415) 263-3670.
4. Certain Eye Surgery.
Charges incurred for surgery to the eye to correct a retroactive error, such as radial keratotomy; charges incurred for the purchase or fitting of eye glasses or contact lens. However, charges incurred for a contact lens or eye glasses and frames required immediately following and as a result of cataract surgery will be a Covered Expense.
5. Cosmetic Charges.
Charges incurred in connection with treatment that is Cosmetic; other than:
- reconstructive surgery to restore tissue damaged by Injury or Illness, including surgery on one or both breasts to reestablish symmetry following a mastectomy; or
- treatment of a child from birth to correct a congenital disease or anomaly,
including an oral defect.
6. Elective Abortion.
Charges incurred for an elective abortion, except where the life or health of the mother is in danger if the procedure is not performed.
7. Custodial Care.
Charges incurred for Custodial Care.
8. No Legal Obligation to Pay.
Charges which a member is not legally obligated to pay for; or treatment which he or she obtains, or is entitled to obtain, under any Plan or program without charge, except Medicaid or Medi-Cal. This will include charges for treatment which is provided or paid for by the federal government at a Veteran's Administration facility for:
- an Injury or Illness related to the patient's military service; or
- the member or his or her Dependents, if retired from the armed services.
9. Act of War, Riot, or Civil Disorder.
Charges incurred as a result of an act of war, whether declared or not, or any related act; charges incurred as the result of participation in a riot or civil disorder;
10. Work-Related. Charges incurred as a result of:
- an Injury which arises out of or in the course of any employment with any other employer; or
- an Illness for which the member or Dependent
- is entitled to benefits under any workers’ compensation law or occupational disease law; or
- receives any settlement from a workers’ compensation or occupational disease carrier.
11. Third-Party Responsible.
Charges incurred for which a third party tortfeasor is responsible; however, benefits may be advanced from this Plan pending determination by way of court or administrative determination of third party liability or by way of settlement, whether or not the third party is responsible for payment of medical and Hospital costs.
12. Transportation.
Charges for transportation, except professional ambulance services.
13. Artificial Birth Methods.
Charges incurred in connection with:
- artificial insemination;
- in vitro fertilization; or
- in-vivo fertilization;
14. Personal Comfort Items.
Charges for personal comfort items B items used for an individual’s personal comfort, such as air purifiers, humidifiers, whirlpools, Jacuzzi or hot tub devices, exercise equipment, reclining chairs, bed boards, or other equipment not primarily medical in nature.
15. Certain Newborn Well-Baby Care.
Newborn well-baby care except for a “well-baby” Physician's Hospital visit or where included in a PPO Network Hospital contract.
16. Vitamins, Dietary Supplements, Weight-Control, Beauty Aids.
Charges for multiple and non-therapeutic vitamins, dietary supplements, weight-control items, and health and beauty aids are not Covered Expenses, nor is any drug which is not Medically Necessary for the care of treatment of an Illness or Injury.
17. Same Household.
Charges made by an individual who usually lives in the same household as the Participant or the Participant’s Dependent, or who is a member of the immediate family or the spouse’s immediate family.
18. Hearing Aids.
Charges for hearing aids.
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