In Detail... (cont'd)

INELIGIBLE MEDICAL EXPENSES

The Comprehensive PPO, Standard PPO, Safety Net PPO and POS options limit or exclude some medical treatments, services and supplies. The following list provides some examples of items that are not eligible for reimbursement; however, this list is not all-inclusive. If you do not find an expense listed under the Eligible Medical Expenses Section, call Blue Cross Blue Shield at 1-888-979-4514to determine if it is eligible under your medical plan option.

Ineligible treatments, services, and supplies include:

• The cost of acupuncture and acupressure treatment.
  
  
• The cost of ambulance service for non-emergencies or patient convenience.
  
  
• Expenses related to artificial organs - other than limbs, larynx, and eyes - including surgery and related expenses for any type of artificial organ transplant.
  
  
• The cost of caffeine or nicotine addiction, withdrawal, or dependence-related care, including prescription and nonprescription drugs.
  
  
• Charges above the usual, reasonable and customary (URC) limits.
  
  
• Charges for a sickness or injury due to war or any act of war, or incurred during military service.
  
  
• Charges for an injury incurred while committing a crime.
  
  
• Charges for services or supplies that are not medically necessary.
  
  
• Charges for services that are not ordered by a physician for the diagnosis, care, or treatment of an illness or injury, except preventive or well-child care.
  
  
• Charges that you are not legally required or obligated to pay, or charges that would not have been billed, such as for free immunizations provided at a local clinic or drugstore.
  
  
• The cost of comfort or convenience equipment or supplies, such as exercise and bathroom equipment, seat-lift chairs, air conditioners, humidifiers, dehumidifiers and purifiers, shoes or related corrective devices, spas, or computer "story boards" or "light talkers."
  
  
• Expenses related to cosmetic/reconstructive surgery, except if required:
  • Because of an accidental injury
  • To treat a condition that impairs the function of a body organ, including a congenital organ malformation of a child enrolled in the medical plan option
  • To reconstruct a breast after a mastectomy.
  
  
• Expenses related to courtordered treatment, unless certified as medically or psychologically necessary.
  
  
• Expenses related to custodial care or maintenance therapy, including care for conditions not typically responsive to treatment.
  
  
• The cost of dental services, except those described under eligible expenses. (This exclusion encompasses shortening or lengthening the maxilla or mandible for cosmetic purposes or correction of malocclusion.)
  
  
• Expenses related to educational programs for mental impairment or for developmental disorders such as cluttering and stuttering.
  
  
• Expenses related to experimental or investigational services or supplies. Any of the following criteria may be cause for classification as experimental or investigational:
  
  • Requiring federal or other governmental body approval, such as drugs and devices that do not have unrestricted market approval from the Food and Drug Administration (FDA) or final approval from any other governmental body for use in treatment of a specified condition. Any approval that is granted as an interim step in the regulatory process is not a substitute for final or unrestricted market approval
  • Insufficient or inconclusive scientific evidence in peer-reviewed medical literature to permit the claims administrator's evaluation of the therapeutic value of the service or supply
  • Inconclusive evidence that the service or supply has a beneficial effect on health outcomes
  • Evidence that the service or supply is not as beneficial as any established alternatives
  • Insufficient information or inconclusive scientific evidence that, when utilized in a noninvestigational setting, the service or supply has a beneficial effect on health outcomes and is as beneficial as any established alternatives.
  
  
• The cost of foot treatment for:
  
  • Weak, strained, flat, unstable or unbalanced feet, metatarsalgia, or bunions (except open-cutting operations)
  • Corns, calluses or toenails, except the removal of nail roots and necessary services prescribed by a physician (M.D. or D.O.) to treat metabolic or peripheral-vascular disease.
  
  
• The cost of homeopathic or related treatment.
  
  
• The cost of treating any illness or injury related to employment that is covered under workers' compensation or similar laws.
  
  
• Expenses related to infertility administration fees that are not medically necessary, such as egg and sperm costs and donor search fees.
  
  
• Charges for massage therapy
  
  
• The cost of care for the newborn child of an enrolled child, unless the newborn becomes an eligible dependent under Vought Benefits.
  
  
• The cost of over-the-counter medication or dietary supplements that do not require a prescription by law.
  
  
• Expenses related to penalties under the medical plan options for failure to comply with Blue Cross Blue Shield’s precertification procedures or for an out-of-network hospital stay.
  
  
• Expenses related to periodontal or periapical disease, or any condition other than a malignant tumor involving teeth, surrounding tissue or structure, except as described in eligible expenses. (if you select dental coverage, these expenses may be eligible under your dental plan option. Refer to the Dental chapter of this guide for more information.)
  
  
• Personal nonmedical expenses, such as telephone and television charges while in a hospital.
  
  
• Expenses related to physical, occupational or speech therapy for maintenance purposes, as determined by the claims administrator.
  
  
• Fees for physician assistant services, if not accepted medical practice in your state. To determine if the services of physician assistants are eligible in your state, call Blue Cross Blue Shield at 1-888-979-4514.
  
  
• Physician charges for duplicating records.
  
  
• The cost of radial keratotomy (RK), photo refractive keratectomy (PRK), astigmatic keratectomy (AK), LASIK, or other similar surgical procedures to improve or correct vision problems.
  
  
• Expenses related to the reversal of voluntary sterilization.
  
  
• The cost of services furnished by a hospital or facility operated by the U.S. government or any authorized agency of the U.S. government or furnished at the expense of such government or agency unless payment is legally required.
  
  
• The cost of services or supplies that any school system provides as required by law.
  
  
• The cost of services or supplies provided by any Vought Aircraft Medical Department.
  
  
• Charges related to services or treatment rendered by you, your spouse or your child, or by your parent, parent-in-law, brother, sister, brother-in-law or sister-in-law
  
  
• The cost of services received before coverage begins or after coverage ends.
  
  
• Expenses related to speech therapy to correct pre-speech deficiencies or to improve speech skills not fully developed, such as stuttering and developmental delay.
  
  
• Expenses related to transsexual surgery (sex-change operations), including counseling or therapy before or after the surgery
  
  
• Expenses related to weight reduction treatment, unless medically necessary.