These exclusions and limitations are identical to the ones on the benefit summaries above.

This benefit summary provides a brief description of your health care plan benefits and is not a guarantee of payment. Please refer to your benefits booklet for a complete list of benefits and the limitations and exclusions that apply.

Mental Illness and Chemical Dependency Schedule

Prostate and Colorectal Cancer Screening

Covered services include medically necessary prostate and colorectal cancer screenings. Please refer to your benefits booklet for how cancer screenings are covered.

These Benefits Are Limited

• We provide transplant coverage only to those who have been covered by us, or another insurer with similar transplant coverage, for a total of at least 12 months (or since birth), providing there is no lapse between the two coverages. Benefits are based on the recipient’s eligibility, not the donor’s. Our payment for certain covered transplant services and supplies is limited to a lifetime maximum of $250,000 per enrollee.
• Inpatient rehabilitation care is limited to $15,000 per calendar year.
• Outpatient rehabilitation care is limited to $1,500 per calendar year.
• Neurodevelopmental therapy is limited to $1,500 per calendar year. Some plans have an age limit. Please refer to your benefits booklet for details.
• Home health care is limited to 130 visits per calendar year.
• Skilled nursing facility care is limited to 100 days per stay.
• Ground and air ambulance combined is limited to $5,000 per calendar year for non-emergencies.
• Temporomandibular joint disorder benefit is limited to $1,000 per calendar year and $5,000 per lifetime.
• Dental care is limited to the treatment of an accidental injury to natural teeth or fractured jaw and limited to $1,000 per calendar year. Diagnosis must be made within 6 months and treatment within 12 months of injury.
• Hospitalization for medically necessary dental care is limited to $1,000 per calendar year.
• Growth hormone benefit, when eligible according to the benefits booklet, is limited to $20,000 per calendar year.
• Acupuncture is limited to 12 treatments per calendar year.
• Spinal manipulation is limited to 10 treatments per calendar year.
• Preexisting conditions will not be covered during a waiting period after enrollment. You may receive credit from prior medical coverage. See your benefits booklet or employer for details.

These Pharmacy Benefits Are Not Covered

• Nonprescription medications, prescription medications with no proven therapeutic indication and prescription medications that are not medically necessary.
• Prescription medications for smoking cessation.
• Prescription medications for weight loss or treatment of obesity.
• Medications prescribed for cosmetic purposes and for treatment of hair loss or removal regardless of cause.
• Prescription medications for the treatment of impotence regardless of cause and for the treatment of infertility.

Emergency Care Guidelines

Covered services include the medical examination and ancillary tests required in determining the extent of an emergency medical condition. Examples include:

• Suspected heart attack
• Serious burn
• Loss of consciousness
• Poisoning
• Bleeding that does not stop
• Severe pain

These Services And Supplies Are Not Covered

• Expenses incurred before coverage begins or after coverage ends.
• Services provided by a member of your immediate family.
• Treatment not medically necessary (except as may be specificallyprovided).
• Eye exams, eye exercises, eyeglasses, routine foot care and hearing aids (except as specified in the benefits booklet).
• Self-help or training, instructional and physical exercise programs.
• Appliances or equipment primarily for comfort or convenience, custodial care and private duty nursing.
• Surgery or treatment (including any later complications) for obesity or weight control.
• Surgery to alter the refractive character of the eye.
• Orthopedic shoes.
• Cosmetic/reconstructive services, supplies and medications, including complications resulting from such services (except as specified in the benefits booklet).
• Orthognathic services.
• Services and supplies for family planning (except sterilization), artificial insemination, in vitro fertilization, diagnosis and treatment of infertility or surgery to correct voluntary sterilization.
• Dental exams and treatments (except as specified in the benefits booklet).
• Counseling or treatment in the absence of illness (except as specified in the benefits booklet).
• Experimental and investigational treatment, procedures, equipment, medications, devices and supplies.
• Third party liability, motor vehicle coverage and work-related conditions.
• Services and supplies to diagnosis or treat paraphilia.
• Services and supplies to diagnosis or treat gender identity disorders (including sex change procedures).
• Treatment of mental illness for which there is no effective cure.