General Exclusions
Except as specifically provided in this booklet,
no benefits will be provided for services, supplies or charges:
 Which are not medically necessary, as determined by Personal Choice, for the
diagnosis or treatment of illness or injury;
Which are experimental or investigative in nature;
Which were incurred prior to the covered person's effective date of coverage;
Which were or are incurred after the date of termination of the covered person's
coverage, except as provided in the general provisions of this booklet;
For any loss sustained or expenses incurred during military service while on active
duty, or as a result of enemy action or act of war, whether declared or
undeclared;
For which a covered person would have no legal obligation to pay;
Received from a dental or medical department maintained by or on behalf of a fund, a
mutual benefit association, labor union, trust, or similar person or group;
For any occupational illness or bodily injury
which occurs in the course of employment if benefits or compensation are
available, in whole or in part, under the provisions of the Workers'
Compensation Law or any similar Occupational Disease Law or Act.
This exclusion applies whether or not the
covered person claims the benefits or compensation;
To the extent benefits are provided by the Veterans Administration or by the
Department of Defense for members of the armed forces of any nation while on
active duty;
For injuries resulting from the maintenance or use of a motor vehicle if such treatment
or service is paid under a plan or policy of motor vehicle insurance, including
a certified self-insured plan, or payable in any manner under the Pennsylvania
Motor Vehicle Financial Responsibility Law;
Rendered by a member of the covered person's immediate family;
Performed by a professional provider enrolled in an education or training program when
such services are related to the education or training program and are provided
through a hospital or university;
For ambulance services except as specifically provided under this coverage;
For services and operations for cosmetic
purposes which are done to improve the appearance of any portion of the body,
and from which no improvement in physiologic function can be expected, except
as otherwise specifically provided in this booklet.
However, benefits are payable to correct a
condition resulting from an accident;
For telephone consultations, charges for failure to keep a scheduled visit, or
charges for completion of a claim form;
For music therapy;
For marriage counseling;
For custodial care, domiciliary care or rest cures;
For equipment costs related to services performed on high cost technological
equipment, as defined by Personal Choice, such as, but not limited to, computer
tomography (CT) scanners, magnetic resonance imagers (MRI) and linear
accelerators, unless the acquisition of such equipment by a professional
provider was approved through the Certificate of Need (CON) process and/or by
Personal Choice;
Directly related to the care, filling, removal or replacement of teeth, the treatment of
injuries to or diseases of the teeth, gums or structures directly supporting or
attached to the teeth, except as specifically stated under the coverage.
These include, but are not limited to,
apicoectomy (dental root resection), root canal treatments, soft tissue
impactions, alveolectomy, bone grafts or other procedures provided to augment
an atrophic mandible or maxilla in preparation of the mouth for dentures, and
treatment of periodontal disease unless otherwise indicated (you are eligible
for dental benefits under a separate Fund benefit; please refer to the section
titled "Dental Benefits");
For treatment of
Temporomandibular joint syndrome (TMJ), also known as
craniomandibular disorders (CMD), with intraoral devices or with any
non-surgical method to alter vertical dimension;
For palliative or cosmetic foot care including
flat foot condition, supportive devices for the foot, care of corns, bunions
(except by capsular or bone surgery), calluses, toe nails (except surgery for
ingrown nails), fallen arches, pes planus (flat feet), weak feet, chronic foot
strain, and symptomatic complaints of the feet;
For supportive devices of the foot (orthotics), except for podiatric appliances for
the prevention of complications associated with diabetes and for mechanical
supportive devices for treatment in conjunction with or following surgery;
For hearing aids or hearing examinations or tests for the prescription or fitting
of hearing aids;
For any treatment leading to or in connection with transsexual surgery except for
sickness or injury resulting from such surgery;
For assisted fertilization techniques such as, but not limited to, artificial
insemination, in-vitro fertilization, gamete intra-fallopian transfer (GIFT)
and zygote intra-fallopian transfer (ZIFT);
For treatment of sexual dysfunction not related to organic disease, except for
sexual dysfunction resulting from an injury;
For treatment of obesity, except for surgical treatment of morbid obesity when
weight is at least twice the ideal weight specified for frame, age, height, and
sex;
For personal hygiene and convenience items such
as, but not limited to, air conditioners, humidifiers, physical fitness or
exercise equipment, radio and television, beauty/barber shop services, guest
trays, wigs, chairlifts, stair glides, elevator, spa or health club
memberships, whirlpool, sauna, hot tub or equivalent device, whether or not
recommended by a provider;
For eyeglasses, lenses or contact lenses and the vision examination for prescribing
or fitting eyeglasses or contact lenses unless otherwise indicated (you are
eligible for benefits to cover routine vision expenses under a separate Fund
benefit; please refer to the section titled "Vision Care Plan" for more
information);
For correction of myopia or hyperopia by means of corneal microsurgery, such as
keratomileusis, keratophakia, and radial keratotomy and all related services;
For preventive services, except as specifically provided in this booklet;
For weight reduction and premarital blood tests;
Charges for unnecessary services or supplies, including tests and check-up exams, to
the extent that they are not needed for diagnosis of sickness or injury, or the
medical care of a diagnosed sickness or injury, except as specified under
Preventive care;
For acupuncture, except as provided under the
"Anesthesia" section of this booklet;
For travel, whether or not it has been
recommended by a professional provider or is required to receive treatment at
an out-of-area provider;
For immunizations required for employment purposes or for travel;
For care in a nursing home, home for the aged, convalescent home, school,
institution for retarded children or for custodial care in a skilled nursing
facility;
For counseling or consultation with a patient's relatives, or hospital charges for
a patient's relatives or guests, except as may be specifically provided in this
booklet or except as may be allowed under the sections titled "Transplant
Services" and "Bereavement Benefits" described in this booklet;
For medical supplies such as, but not limited to, thermometers, ovulation kits,
early pregnancy or home pregnancy kits, and home blood pressure machines;
For amino acid supplements, appetite suppressants or nutritional supplements unless
they are the sole source of nutrition for an individual who is unable to take
regular food due to metabolic or anatomic disorder.
Coverage does not include basic milk or soy
formulas for lactose intolerance, milk protein intolerance or other milk
allergy;
For inpatient private duty nursing services;
For any care that extends beyond traditional medical management for autistic
disease of childhood, pervasive development disorders, attention deficit disorder,
learning disabilities, behavioral problems, or mental retardation; or treatment
or care to effect environmental or social change;
For charges incurred for expenses in excess of benefit maximums as specified herein;
For any surgery performed for the reversal of a sterilization procedure;
For research studies;
For maintenance of chronic conditions, injuries or illness when response to
treatment has reached the maximum therapeutic level, no additional functional
improvement can be demonstrated or anticipated, and continuation of the service
will be of no therapeutic value to the covered person;
For cognitive therapy (cognitive therapy is a therapeutic approach designed to improve
cognitive functioning after central nervous system injury or trauma, including
therapy methods that retrain or alleviate problems caused by deficits in
attention, visual processing, language, memory, reasoning and problem solving
and utilizing tasks designed to reinforce or reestablish previously learned
patterns of behavior or to establish new compensatory mechanisms for the
impaired neurologic system);
For psychiatric care and the treatment of alcohol and drug abuse and dependency
(you are eligible for benefits to cover mental, nervous, drug and alcohol
treatment under a separate Fund benefit; please refer to the section titled
"Mental, Nervous, Drug &Alcohol Benefits" for more information);
For any other service or treatment, except as provided under the Personal
Choice Program.
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