Principal HMO Health Insurance Plan
The text presented in this web page is directly from the booklet provided by The Principal Life Insurance Company, which describes the major provisions of the HMO Group Health Insurance Policy issued to American Bank. It has been edited only insofar as necessary for it to be viewed on this website.
Topic Guide
HMO GROUP MEMBER SERVICES CONTRACT
INTRODUCTION
This HMO Group Member Services Contract and the Group Master Application, HMO Membership Handbook (Handbook), Schedules of Benefits, Group Enrollment Form, and applicable Supplemental Benefit Explanations (Riders), are the whole HMO Group Member Services Contract (Member Services Contract) between Principal Health Care of Florida, Inc. (hereafter referred to as "Health Plan") and the Subscriber and between the Health Plan and the Subscriber's Family Dependents as identified on the Group Enrollment Form. The Subscriber and Family Dependents are Members of the Health Plan. This Member Services Contract begins on the Effective Date or the Eligible Date as defined in the Group Master Application. This Member Services Contract continues, until it is replaced or terminated, as long as its conditions are met. By making payments or by having payments made on the Member's behalf, the Member accepts the provisions of this Member Services Contract.
The Health Plan is a health maintenance organization (HMO) licensed by the Florida Department of Insurance. The Health Plan is a wholly owned subsidiary of Principal Health Care, Inc., which is a member company of The Principal Financial Group.
The Health Plan arranges for its Member's health services and provides related administrative services. Members receive health care services from Participating Physicians and Participating Providers under contract with the Health Plan. Health care services obtained within the health maintenance network must have prior authorization by the Member's Primary Care Physician or designee, and/or the Health Plan.
ARTICLE 1 -GENERAL ITEMS AND DEFINITIONS
MEDICAL NECESSITY (MEDICALLY NECESSARY)
A. All services provided to Members must be Medically Necessary and covered by the Health Plan. The Health Plan retains the right to make all final determinations with regard to Medical Necessity. These determinations will be made by the Health Plan's Medical Director or designee.
B. The fact that a Participating Physician may prescribe, order, recommend or approve a service or supply does not in and of itself make the charge a Covered Service. The Health Plan will not cover a service or supply which is not Medically Necessary or which is not a Covered Service, even if it is not specifically listed or described under an exclusion or limitation.
A. Basic Requirement:
To obtain benefits provided by this Member Services Contract, the Member is subject to all terms, conditions, limitations and exclusions in this Member Services Contract, and to all the rules and regulations of the Health Plan. The Health Plan retains the right to make all final decisions with regard to Covered Services.B. Referrals and Authorizations:
Members must:(1) Receive medical care from the Member's Primary Care Physician of record; or
(2) Receive a referral from the Member's Primary Care Physician of record or designee with authority to make referrals prior to obtaining health services
and/or;
(3) Receive an authorization from the Health Plan when required prior to obtaining health services; and
(4) Participate in the Health Plan's Second Surgical Opinion Program, if required by the Health Plan.
Retroactive referrals are not covered. In the event of a Medical Emergency, these requirements will be waived by the Health Plan.
C. Participating Physicians and Providers.
The Health Plan reserves the right to make changes in its Participating Physician and Participating Provider network as is appropriate or necessary.
Payment to Providers.
Payment of benefits for Covered Services will be arranged by the Health Plan to be made directly to the Participating Physician or Participating Provider of the service. For Medical Emergency services, payment will be made by the Health Plan directly to the Participating Provider or may, at the Health Plan's discretion, be made to the Member.E. Copayments
Members are responsible for paying Copayments to Participating Physicians and Participating Providers at the time of service. Copayment amounts listed on the Schedule of Benefits incorporated into this Member Services Contract, must be paid regardless of the level of service a Member receives. The Schedule of Benefits states which payments apply to a Member's OutofPocket Maximum. Copayment amounts are not to exceed the Outof Pocket Maximum specified in the Schedule of Benefits. Members are still responsible for paying those copayments that do not apply to the Out-of-Pocket maximum.
F. OutofPocket Maximum.
The individual OutofPocket Maximum is a limit on the amount a Member will have to pay out of his or her pocket for specific Covered Services in a calendar year. Once a Member has reached the individual OutofPocket maximum, benefits for Covered Services are covered at 100% for the rest of that calendar year for the Member.The family OutofPocket Maximum is listed in the Schedule of Benefits, and is the dollar amount Members of the same family will have to pay outofpocket for specific Covered Services. No more than the individual OutofPocket Maximum will be applied for each Member. Once a family has reached the family OutofPocket maximum, benefits for Covered Services are covered at 100% for the rest of that calendar year for all family Members.
G. Medical Emergencies The Member must notify the Health Plan of all Medical Emergency services. The Health Plan will provide emergency care services inside or outside the designated Service Area, in the event of a Medical Emergency, Injury or unexpected Illness. The Health Plan must be notified within fortyeight (48) hours, or within a reasonable period as dictated by the circumstances, of all Medical Emergency services provided to a Member. Payment for treatment of Medical Emergencies outside the Service Area shall be limited to services required before the Member can, without medically harmful or injurious consequences, return to the Service Area for any additional necessary follow up treatment.
H. Maximum Lifetime Benefits. The maximum lifetime benefit payable for all Covered Services is listed on the Schedule of Benefits incorporated into this Member Services Contract.
MEMBER RESPONSIBILITY FOR PAYMENTS
A. Unauthorized Care.
Except for a Medical Emergency, a Member must pay for all care that was not provided or referred in advance by the Member's Primary Care Physician of record or designee, or authorized by the Health Plan. The Health Plan is not liable for, and will not pay for, services not provided by or approved by the Member's Primary Care Physician or the Health Plan.
B. Premium Payments.
This Member Services Contract and all certifications and determinations of eligibility for benefits under it are conditioned on the Health Plan's regular receipt of the Subscriber's Premium payments. The payments are made by individuals, or through the Subscriber's Employer or other group. Premium rates are specified in the Group Master Application.
Grace Period: This Member Services Contract has a thirtyone (31 ) day grace period. This provision means that if any required Premium is not paid on or before the date it is due, it may be paid during the following grace period. During the grace period, the Member Services Contract will stay in force. However, if any required Premium is not paid by the end of the grace period, benefits will cease on the Premium due date.
Copayments and OutofPocket Costs Maximum. Copayments are charges which the Member must pay. The Schedule of Benefits or Supplemental Benefit Explanation states, which payments apply to a Member's OutofPocket Maximum. These charges are in addition to the Premium payments and constitute the OutofPocket costs for covered services. OutofPocket costs shall not exceed 200 percent of the total annual premium. The OutofPocket maximum for individual and family OutofPocket costs is listed in the Schedule of Benefits.
Members should maintain accurate records of the Copayments made, as it is the Member's responsibility to determine when the OutofPocket Maximum is reached. Members are assured a predictable maximum in OutofPocket costs for Covered Services.
ARTICLE 2COVERED SERVICES
The following health care services are covered under this Member Services Contract, subject to the benefit limitations and Copayments defined in the Schedule of Benefits. Members must receive an authorization from their Primary Care Physician or designee, and/or the Health Plan, prior to receiving health care services. The Health Plan excludes any medical service(s), prescription drug, medicine, equipment, supply or procedure directly or indirectly related to a condition which is not Medically Necessary or a Covered Service.
PROFESSIONAL SERVICES
Care While Hospitalized.
During hospitalization, services of Physicians and ancillary medical personnel, surgical procedures, and consultation with and treatment by specialists are covered.
Ambulatory Care.
(1) Diagnosis and Treatment.
Physician services, including surgical procedures and consultation with and treatment by specialists, and services provided by other duly licensed medical professionals are covered.
(2) Preventive Health Service.
Preventive health services, including well baby care, periodic physical examinations and hearing evaluations are covered. Routine eye screening and evaluation (including determination of the need for refraction, but not including the actual cost of refraction) is covered. One annual gynecological examination, including a pap test, is covered.
(3) Dialysis services are covered.
Inpatient Hospital services, including but not limited to room and board; general nursing care services; use of equipment and supplies; use of operating room; recovery room, treatment room, and private room when Medically Necessary and prior authorization has been given by the Health Plan; intensive care and related Hospital services; internal prosthetics; medication; and anesthesia are covered. When available, and requested by the Member, the Health Plan covers the services of a certified registered nurse anesthetist licensed by the State of Florida.
Outpatient facility services, including but not limited to, Xray and laboratory and ambulatory surgery are covered.
XRAY, LABORATORY AND DIAGNOSTIC TESTS
Xray and laboratory tests, services and materials, including, but not limited to, diagnostic and therapeutic Xrays and isotopes, electrocardiograms, electroencephalograms, radiation therapy and chemotherapy are covered.
Administration of blood and administration of blood products are covered. Whole blood, blood products or packed cells are covered only if they have not been replaced by a donor or if they have not been replaced by an agency/organization without charge.
SHORTTERM PHYSICAL, SPEECH, OCCUPATIONAL, PULMONARY AND CARDIAC REHABILITATION THERAPY
Shortterm physical, speech, occupational, pulmonary and cardiac rehabilitation therapy are limited to treatment for conditions which in the judgement of a Participating Physician and the Medical Director or designee are subject to significant improvement of a Member's condition through relatively shortterm therapy (a period of up to sixty (60) days from the onset of therapy). However, if it is determined within the first two (2) weeks of therapy that the Member's condition will not significantly improve within the sixty (60) day period, benefits for therapy and/or treatment will be discontinued.
Members are entitled to receive Medically Necessary outpatient and/or inpatient rehabilitative services or therapies for conditions which, in the opinion of the Health Plan or Medical Director Or designee, the Member will respond significantly to shortterm therapy.
MEDICATIONS AND ALLERGY SERVICES
A. Medications.
Injectable medications used for therapeutic purposes are covered.
B. Immunizations.
Immunizations, except for travel, employment, school or any third party are covered.
C. Allergy Testing, Allergy Serum, and Administration of Injections.
Allergy testing, allergy serum and the administration of injections are covered.AMBULANCE SERVICE
Ambulance service for Medical Emergencies is covered. Benefits for transportation by air ambulance are reimbursed at the cost of ground ambulance transportation costs.
OBSTETRICAL CARE, NEWBORN CHILD CARE, FAMILY PLANNING, STERILIZATION AND INFERTILITY SERVICES
Obstetrical Care. Obstetrical care is covered, including the following services before and during confinement, and during the postpartum period: Hospital services (including delivery or birthing room); professional services (including operations and special procedures such as Caesarean Section); services of a midwife, nurse midwife, and birthing centers; anesthesia; injectables; Xrays and laboratory services are covered.
Newborn Child Care. Newborn children of the Subscriber, or Covered Family Member of the Subscriber, are covered from the moment of birth provided the newborn child is enrolled within thirtyone (31) days of the date of birth. Covered Services for newborn children includes coverage for Illness or Injury, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity, and transportation costs of the newborn child to and from the nearest appropriate facility. The facility will be staffed and equipped to treat the newborn child's condition, when such transportation is certified by the attending Physician as Medically Necessary to protect the health and safety of the newborn child.
Familv Planning. Sterilization and Infertilitv Services.
(1) Family Planning.
Family planning counseling, treatment and followup, information on birth control, insertion and removal of intrauterine devices, and measurement for contraceptive diaphragms are covered when listed in the Subscriber's Schedule of Benefits.
(2) Sterilization.
Male or female surgical sterilizations are covered when listed in the Subscriber's Schedule of Benefits.
(3) Infertility Services.
Diagnosis and surgical treatment of involuntary infertility and associated Xrays, laboratory procedures, and medication administration are covered, when listed in the Subscriber's Schedule of Benefits or Supplemental Benefit Explanation.ORGAN TRANSPLANTS
Organ transplants are covered when approved by Us, and if performed at a facility approved by Us. The following conditions apply:
- Organ and tissues covered for transplant include kidney, cornea, heart, liver and bone marrow, when determined Medically Necessary and specific criteria are met. Medically necessity will be determined by the Health Plan's Medical Director or designee. Live donor, professional and facility costs are covered if other sources of reimbursement are unavailable regardless of membership
- Organ preparation and transportation are covered.
Members approved for transplant will be directed to a selected facility approved for transplantation services at the discretion of the Medical Director. Coverage is available only if the pretransplant services, transplant procedure and postdischarge services are performed in the approved facility. Other transplants will be covered when approved by the Food and Drug Administration as nonexperimental and when they meet the definition of clinically accepted medical practice.
SKILLED NURSING FACILITY
Care in a Skilled Nursing Facility, only when in place of acute care hospitalization, is covered. Skilled Nursing Facility coverage includes medical supplies and equipment and drugs and biologicals ordinarily furnished by the Skilled Nursing Facility.
HOME HEALTH CARE
Home health care for diagnostic and therapeutic services is covered when:
* the services are ordered by a Physician and approved by the Primary Care Physician if appropriate under the benefit Plan;
* the services required are of a type which can only be performed by a licensed nurse, physical therapist, speech therapist, or occupational therapist;
* the services are a substitute or alternative to hospitalization;
* parttime intermittent visits are required;
* a treatment plan has been established and periodically reviewed by the ordering Physician;
* the agency rendering services is Medicare certified and licensed by the state of location; and
* the services are authorized by the Health Plan.
Participating Physician's home visits within the Service Area are covered.
PRIVATE DUTY NURSING
Special or private duty nursing is covered when determined Medically Necessary through Case Management.
Hospice services, rendered by a Statelicensed hospice, are covered. The Member must, in the judgement of a Physician, have a life expectancy of six (6) months or less.
HEALTH EDUCATION SERVICES
Health education services when provided in a Participating Physician's office or other Participating Provider setting are covered. Health education services include instructions on achieving and maintaining physical and mental health, and preventing Illness and Injury.
MEDICAL EMERGENCY SERVICES IN THE SERVICE AREA
Services for Medical Emergencies including Medical Emergency services in a Hospital outpatient setting, a Physician's office or other ambulatory setting.
A Medical Emergency is defined as: The sudden and acute onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably result in:
- Permanently placing the Member's health in jeopardy;
- Serious impairment to bodily function;
- Serious and permanent dysfunction to a body organ or part; or
- Other serious medical consequences.
Symptoms must occur suddenly and unexpectedly and must be sufficiently severe to cause a Member to seek medical assistance, regardless of the hour of day or night. Examples of Medical Emergencies are heart attacks, cerebrovascular accidents, poisoning, convulsions and severe bleeding. The Health Plan may determine that other similar acute conditions are or are not Medical Emergencies. Examples of routine care which do not qualify as Medical Emergencies are sprains, influenza, colds, ear infections and nausea. The determination of covered benefits for services rendered in an emergency room is based on the Health Plan's review of a Member's emergency room medical records, along with those relevant symptoms and circumstances which preceded the provision of care. The Member's Primary Care Physician of record or Health Plan must be notified following the onset of a Medical Emergency within fortyeight (48) hours or within a reasonable time period as dictated by the circumstances.
MEDICAL EMERGENCY SERVICES OUT OF THE SERVICE AREA
Unexpected and immediately required care needed as a result of accidental injury or acute Illness of such gravity that it is not medically feasible to bring the Member to the Primary Care Physician or a Participating Provider within the Service Area for treatment.
The Member may be transported from outside the Service Area to the Service Area for continued medical management of an emergency condition at the option of the Medical Director or designee. The Health Plan will only exercise this option when the Medical Director or designee determines that such action will not have a detrimental effect on the Member's medical condition.
The Health Plan must be notified of a Medical Emergency within fortyeight (48) hours following its onset or within a reasonable time period as dictated by the circumstance. Each case outside the Service Area will be reviewed individually to determine whether the problem constituted a Medical Emergency.
ORAL SURGICAL SERVICES
Oral surgical services are covered, limited to the functional restoration of structures other than teeth, i.e., treatment of trauma resulting in fracture or dislocation of jaw or laceration of mouth, tongue or gums.
PROSTHETIC DEVICES, CORRECTIVE MEDICAL APPLIANCES, AND DURABLE MEDICAL EQUIPMENT
Certain prosthetic devices are covered when listed in the Schedule of Benefits or Supplemental Benefit Explanation. These include external devices (such as artificial limbs, eyes and breast following a mastectomy) and internal devices (such as hip prosthesis and lens implant). External devices are limited to one each per Member per lifetime, except if a bilateral mastectomy is performed.
Crutches and other corrective medical appliances, such as orthopedic braces.
Durable medical equipment is covered if it:
(1) is listed in the Schedule of Benefits or Supplemental Benefit Explanation;
(2) is primarily and customarily used to serve a medical purpose;
(3) can withstand repeated use;
(4) is appropriate for use in a Member's home; and is on Our Durable Medical Equipment Reference List.
CORRECTIVE LENSES FOR CATARACTS
The first pair of eyeglasses, lenses or corrective lenses necessary following cataract surgery performed while a Member of the Health Plan.
RECONSTRUCTIVE SURGERY
Providing that the cause occurred while the Member was enrolled in the Health Plan, repair of disfigurement resulting from an Injury, reconstruction incidental to surgery, and surgery that substantially improves functioning of any malformed body part are covered.
ARTICLE 3EXCLUSIONS AND LIMITATIONS
The following services are excluded under this Member Services Contract unless otherwise noted as a limitation.
Any services, Hospital, professional or otherwise, which were not performed, arranged, authorized, and approved in advance by the Member's Primary Care Physician or designee, and/or the Health Plan are excluded. This exclusion shall not apply to Medical Emergencies. The Health Plan reserves the right to evaluate and determine coverage for care not directly provided by a Participating Physician or Participating Provider.
SERVICES NOT MEDICALLY NECESSARY AND NOT COVERED
The Health Plan excludes any medical service, prescription drug, medicine, equipment, supply or procedure directly or indirectly related to a condition which is not Medically Necessary, or which is not a Covered Service.
NONEMERGENCY FACILITY SERVICES
Services provided in an emergency facility for nonMedical Emergencies are excluded.
SERVICES OR SUPPLIES RELATED TO THE TREATMENT OF A PREEXISTING CONDITION
Services or supplies related to the treatment of a PreExisting Condition are excluded (unless waived in the Group Master Application) until the earlier of:
- The date ending ninety (90) consecutive days during which no confinement has existed or no treatment or service has been received for the PreExisting Condition; or
- The date that the Member has been covered under this Member Services Contract for atleast twelve(12) consecutive months; and then benefits will be payable only with respect to confinement occurring after that date or to treatment or service received after that date.
However, for Members covered on the Effective Date as stipulated in the Group Master Application, the PreExisting Condition restrictions will not apply to the first $2,000 (two thousand dollars) of Covered Services in the first twelve (12) months that this Member Services Contract is in force.
When coverage under this Member Services Contract replaces coverage under a prior Plan, continuous coverage under this Member Services Contract and/or under the prior plan may be applied to satisfy any required time period described in Article 3.4
PERSONAL OR CONVENIENCE ITEMS
Personal or convenience items such as special diets; inHospital television, telephone, private room unless Medically Necessary; and housekeeping, homemaker service, and room and board as part of home health services are excluded.
Ambulance transportation due to the absence of other transportation on the part of the Member is not covered. NonMedical Emergency ambulance services are also excluded. Benefits for transportation by air or sea ambulance are limited to ground ambulance transportation costs, except for Newborn Children.
NO LEGAL OBLIGATION TO PAY
Services are excluded for Injuries and Illnesses for which the Health Plan has no legal obligation to pay (e.g., free clinics, free government programs, courtordered care, expenses for which a voluntary contribution is requested) or for that portion of any charge which would not be made but for the availability of benefits from the Health Plan, or for workrelated Injuries and Illnesses. Services and supplies furnished under or as part of a study, grant, or research program are excluded.
THIRD PARTY LIABILITY
Services for which a third party has liability are excluded, including services covered by federal, state and other laws.
EYEGLASSES AND CORRECTIVE LENSES
Eyeglasses and corrective lenses are excluded except as necessary for the first pair of corrective lenses following cataract surgery performed while a Member of the Health Plan, unless otherwise provided in a Supplemental Benefit Explanation.
CUSTODIAL CARE
Custodial care, nursing home care, rest cures and domiciliary care, along with all related services, are excluded. Care is considered custodial when it is primarily for the purpose of meeting personal needs. For example, custodial care includes help in walking, getting in and out of bed, bathing, dressing, shopping, eating and preparing meals, performing general household services, taking medicine, or other home services furnished mainly to assist people in meeting personal, family or domestic needs to include extraordinary personal needs created by the Illness of a Family Dependent. Custodial care is excluded regardless of location or setting.
Physical examinations for employment, school, camp, sports, licensing, insurance, adoption or marriage, or other examinations ordered by a third party are excluded. Eye exams for refractive correction are excluded, unless otherwise provided in a Supplemental Benefit Explanation.
COSMETIC SERVICES AND SURGERY
Cosmetic services and surgery are excluded. Cosmetic surgery means surgery to change the texture or appearance of the skin or the relative size or position of any part of the body when such surgery is performed primarily for psychological purposes and is not needed to correct or substantially improve a bodily function. Removal of skin lesions is considered cosmetic unless lesions interfere with normal body functions or malignancy is suspected. Reduction mammoplasty is excluded.
PROSTHETIC DEVICES, DISPOSABLE ITEMS, AND DURABLE MEDICAL EQUIPMENT
The following prosthetic devices and services are excluded: dentures; hearing aids; contact lenses; non rigid appliances and supplies such as elastic stockings, garter belts, arch supports, corsets and corrective orthopedic shoes; orthotic devices; sunglasses; clothing; breast pumps; orthodontic braces; needles and syringes; contraceptive devices; items deemed to be experimental or research devices in the opinion of the Health Plan; devices designed exclusively to remedy sexual dysfunction except when authorized by a Participating Physician to repair the physical functioning of a body part as a result of a functional disorder or an accidental injury occurring during the period of membership under this Member Services Contract; repair, replacement, or routine periodic maintenance of prosthetic medical appliances; and all other devices deemed not to be Medically Necessary by the Health Plan are excluded.
Durable Medical Equipment that does not serve a medical purpose or cannot be used in a Member's home is excluded. Equipment that is generally not useful to a person in the absence of Illness, Injury or disease is excluded. Also excluded, are: deluxe equipment such as motor driven wheelchairs and beds, except when such deluxe features are necessary for the effective treatment of a Member's condition in order for the Member to operate the equipment himself/herself; items not primarily medical in nature or for the Member's comfort and convenience such as bedboards, bathtub lifts, overbed tables, adjustabed, telephone arms, air conditioners, air purifiers; replacement repair or routine periodic maintenance of purchased durable medical equipment; Physician's equipment such as stethoscope and sphygmomanometer; disposable supplies such as disposable sheaths, disposable electrodes, disposable bags and elastic stockings; exercise and hygienic equipment such as exercise cycle, Moore wheel, Bidet toilet seats and bath tubs seats; selfhelp devices (not primarily medical in nature) such as sauna baths and elevators; corrective orthopedic or orthotic shoes and arch supports; and research equipment or items deemed to be experimental by the Health Plan.
PHARMACEUTICAL SERVICES AND PRESCRIPTION DRUGS
Pharmaceutical services, prescription drugs or overthecounter medications incidental to outpatient care are excluded, unless otherwise provided in a Supplemental Benefit Explanation.
DENTAL AND ORAL SURGICAL SERVICES
Crowns, bridges, dentures, or other dental prosthetic devices, dental restorative care, periodontal care, or orthognathic surgery, including Hospital and professional services and supplies associated with such care are excluded. Services and supplies for treatment of Temporomandibular Joint Dysfunction (TMJ) are excluded, unless Medically Necessary and approved by the Health Plan or Medical Director or designee. Preventive dental services are excluded unless provided in a Supplemental Benefit Explanation.
EXPERIMENTAL PROCEDURES OR TREATMENTS
Any procedure or treatment that is deemed by the Health Plan to be experimental, or any procedure, medication or treatment that is used for a nonFDA approved indication.
ORGAN TRANSPLANTS
The following organ transplant services and conditions are excluded:
- The cost of any care arising from an organ donation by a Member when the recipient is not a Member; and
- Any transplant procedure that is performed in a facility that has not been designated by the Medical Director or designee as an approved transplant facility.
The determination of whether a transplant procedure is Medically Necessary will be made by the Health Plan's Medical Director or designee, based on specific criteria. Organ transplants not approved by the Food and Drug Administration or within the definition of clinically accepted medical practice, are excluded.
BLOOD
Whole blood, blood products or packed cells are excluded, if replaced by donor and if replaced by an agency/organization without charge. Blood storage is excluded.
MATERNITY/STERILIZATION/INFERTILITY
Prescription drugs, medicine, supplies or devices directly or indirectly related to birth control are excluded, unless otherwise provided in a Supplemental Benefit Explanation.
- Any medical service, prescription drugs, medicine, supplies or procedures directly or indirectly related to the following are excluded: child birth classes, reversal of voluntarily induced sterilization, services related to sex transformation, artificial insemination with donor semen, in vitro fertilization and embryo transport procedure, drug therapy for infertility, and home delivery for childbirth.
- Pergonal, Clomid, and other drugs meant to serve the same purpose as Pergonal and Clomid, are excluded.
- Sterilization and infertility services are excluded unless they are listed on the Subscriber's Schedule of Benefits.
- Maternity services provided outside the Service Area within three (3) weeks of the estimated date of delivery are excluded unless prior authorization has been given in writing by the Medical director or designee.
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
Mental health and substance abuse services are excluded, unless otherwise provided in a Supplemental Benefit Explanation.
Acupuncture, biofeedback, hypnotherapy, sleep therapy, weight reduction therapy, vocational therapy, marriage and sex counseling, behavior training, conduct disorders and related family counseling, and remedial education, including treatment of learning disabilities, attention deficit disorders or minimal brain dysfunction, are excluded. Therapy through behavior modification is excluded. Other therapy considered longterm (longterm therapy is defined as being more than sixty (60) days in duration from the onset of therapy) is excluded. Educational and other nonmedical treatments for mental retardation are excluded.
RADIAL KERATOTOMY AND EYE EXERCISES
Radial keratotomv and eve exercises are excluded.
The following hospice services are excluded:
Health care, visits, medical equipment or supplies that are not included in the Participating Physician's recommended plan of treatment;
- Services in the Member's home outside the Service Area;
- Financial and legal counseling;
- Any service for which the hospice does not customarily charge the Member, or his or her family; and
- Reimbursement for volunteer or spiritual counseling.
SURGICAL AND OTHER TREATMENT FOR OBESITY
Surgical procedures and associated care for the treatment of obesity, such as intestinal bypass surgery, stomach stapling, balloon dilation, wiring of the jaw, and procedures of similar nature, as well as the complications of such procedures, are excluded. Surgery or hospitalization for the purpose of weight reduction is excluded. Diet programs such as Optifast, NutriSystem and other similar diet programs are excluded.
ROUTINE FOOT CARE
Routine foot care is excluded. Routine foot care includes the removal or reduction of corns and calluses, clipping of the nails, and treatment of flat feet, fallen arches and chronic foot strain.
The Health Plan shall not be liable for any care of a condition to which a contributing cause was the commission of a felony or misdemeanor of which the Member is convicted or to which a contributing cause was the Member's engagement in an illegal activity. Services required due to accidents when the Member is convicted of driving while impaired (intoxicated or under the influence of drugs) are excluded.
FOOD OR FOOD SUPPLEMENTS
Food or food supplements (for example protein) are excluded. Nutritional counseling is excluded unless Medically Necessary and approved by the Health Plan.
GENETIC COUNSELING/GROWTH HORMONE THERAPY
Genetic counseling and genetic studies which are not needed for diagnosis or treatment of genetic abnormalities are excluded. Growth hormones which are not Medically Necessary, are excluded.
Travel other than ground ambulance travel for Medical Emergencies is excluded, regardless of whether it is prescribed by a Participating Physician or Participating Provider.
Immunizations for the purpose of travel or employment are excluded.
MILITARY SERVICE
Care for military serviceconnected conditions or disabilities to which the Member is legally entitled and for which facilities are reasonably available is excluded.
Charges incurred by Members by not keeping or canceling Participating Physician and Participating Provider appointments are excluded.
RETROACTIVE REFERRALS
Retroactive referrals are excluded.
AUDIOMETRIC SERVICES
Audiometric testing and expenses for hearing aids are excluded unless otherwise provided in the Schedule of Benefits.