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;
For drugs or medicines for which
the covered person has coverage under a free-standing prescription plan program
provided under the Fund (you are eligible for prescription drugs under a
separate Fund benefit; please refer to the section titled "Prescription Drug
Benefits" for more information);
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 prescription drugs, except for
insulin, insulin analogs and pharmacological agents for controlling blood sugar
levels (you are eligible for prescription drugs under a separate Fund benefit;
please refer to section titled "Prescription Drug Benefits" for more
information);
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. It includes therapy methods that retrain or alleviate problems caused by
deficits in attention, visual processing, language, memory, reasoning and
problem solving. It utilizes 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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