In addition to the plan exclusions (not covered expenses) previously listed in the Covered Medical Expenses table on pages 2-11 to 2-34, the Plan will not provide benefits for any of the items listed in this section regardless of medical necessity or recommendation of a physician.
This list is intended to give you a general
description of expenses for services and supplies not covered by the Plan.
● Expenses exceeding the usual and customary charge for the geographic area in which services are rendered.
● Expenses not necessary for diagnosis of an illness or injury, except as specified under “Preventive Care.”
● Treatment not prescribed or recommended by a physician or other covered health care provider.
● Drugs, procedures, treatments, services,
supplies, and/or devices which are not medically necessary or are not provided according to Providence Health Plan’s policy.
● Services or supplies for which there is no legal obligation to pay or expenses which would not be made except for the availability of benefits under this Plan.
● Experimental and investigational drugs, treatments, devices, services, and/or supplies. ● Services furnished by or for the United States
Government or any other government, unless payment is legally required.
● Any injury or illness that is sustained by you or covered family member that arises out of, or as the result of, any work for wage or profit when coverage under any Workers’ Compensation Act or similar law is required for you or your covered family member. This exclusion also applies to injuries and illnesses that are the subject of a disputed claim settlement or claim disposition agreement under a Workers’ Compensation Act or similar law. This applies even if you waive your rights to those benefits or chose not to participate in them. This exclusion does not apply to covered persons who are exempt under any Workers’ Compensation Act or similar law.
● Services that are payable under any automobile
medical, personal injury protection (“PIP”), automobile no-fault, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance
makes benefits or services available to you whether or not you make application for such benefits or services. If such coverage is required by law and you lawfully fail to obtain it,
benefits will be deemed to have been payable to the extent of that requirement.
Any benefits or services provided under this plan that are subject to this exclusion are provided solely to assist you and such assistance does not waive the Plan’s right to reimbursement or subrogation as specified under Third-Party Liability, page 5-7. This exclusion also applies to services and supplies after you have received proceeds from a settlement as specified in the Benefits From Other Sources section, pages 5-7 to 5-10.
● Educational, vocational, or training services and supplies including, but not limited to, videos and books, educational programs to which drivers are referred by the judicial system and volunteer mutual support groups. .
● Expenses for missed appointments or telephone calls.
● Travel expenses of a physician or a covered person, except as approved by PHP and
specified in “Human Organ/Tissue Transplants” and “Obesity Related/Bariatric Surgery.” ● Services for immunizations or vaccinations
for employment, licensing, passports, travel purposes, and high risk occupations.
● Professional services, including diagnosis, treatment or prescribing other care, performed by a person who ordinarily resides in the covered person’s household or is related to the covered person, including self care and care of a spouse/Adult Benefit Recipient, parent, child, brother, sister, or in-law.
● Sanitarium, rest, or custodial care.
● Expenses eligible for consideration under any other plan of the employer.
● Treatment or services rendered outside the United States of America or its territories except for an accidental injury or a medical emergency.
● Dental services or treatment, except as a result of accidental injury.
● Hospitalization for dental services (except when approved by PHP to safeguard the health of the patient).
● Personal comfort or service items while confined in a hospital, such as, but not limited to, radio, television, telephone, and guest meals.
● Complications arising from any non-covered services, with the exception of bariatric surgery and emergency care.
“Surgical Services” on page 2-30.
● Human organ and tissue transplants, except as specified in Covered Medical Expenses.
● Expenses related to insertion or maintenance of an artificial heart.
● All services related to to and including a sex- change operation.
● Penile prosthetic implant.
● All services and supplies, including
prescriptions, for the diagnosis and treatment of sexual disorders or dysfunctions, regardless of gender or cause.
● Treatment of infertility (surgical or other) including fertility drugs.
● Reproductive sterilization including reversal, diaphragms, cervical sponges, spermicides, over the counter contraceptives.
● Services of homeopaths; faith healers; or lay, Direct Entry or Certified Professional midwives. ● Surgical procedures which alter the refractive
character of the eye, including, but not limited to laser eye surgery, radial keratotomy, myopic keratomelelusis and other surgical procedures of the refractive keratoplasty type, the purpose of which is to cure or reduce myopia, hyperopia or astigmatism.
● Routine vision exams and the fitting of eyeglasses or lenses orthoptics, vision therapy or supplies.
● Massage therapy or rolfing.
● Certified ambulance services and preauthorized air ambulance services are covered. However, care cars, other medical transportation vehicles and other non-emergency medical transportation services are not covered. ● Career or sex counseling.
● Expenses for education, counseling, job training or care for learning disorders or behavioral
in a facility that also provides medical and/or mental health treatment.
● Treatment, instructions, activities or drugs for weight reduction or control.
● Hearing aids or related supplies. ● Adoption expenses.
● Surrogacy expenses.
● Treatment of metatarsalgia or bunions, except for open cutting operations; corns, calluses or toe nails, except for removal of nail roots. ● Non-surgical treatment for or prevention of,
temporomandibular joint dysfunction (TMJ) and craniomandibular disorder and other conditions of the joint linking the jawbone and skull, and the muscles, nerves and other tissues related to that joint, except as specified under “TMJ Services.”
● Biofeedback. ● Hypnosis.
● Mental illness treatment for Autistic Disorder; Asperger’s Disorder; or Pervasive Developmental Disorder not otherwise specified coded with ICD-9 299., 299.00 or 299.01.
● Sleep studies and treatment of sleep disorders unless prior authorized by PHP as medically necessary.
● Wigs and artificial hair pieces except as stated in Other Equipment and Supplies.
● Non-prescription drugs or medicines.
● Equipment such as air conditioners, air purifiers, dehumidifiers, heating pads, hot water bottles, water beds, swimming pools, hot tubs, and any other clothing or equipment which could be used in the absence of an illness or injury. ● A service or supply for which a charge would
not have been made in the absence of insurance.
● A service or supply furnished in connection with or during a hospital stay of a person incurred
● before effective date of coverage, or ● after termination of coverage even if the
confinement began while the person was insured by the plan.
● Services and supplies received under the Washington or Oregon Death with Dignity Act. ● Ending of pregnancy unless consistent with
the Ethical and Religious Directives for Catholic Health Care Services Part 4 (fifth edition). Non- permitted:
● Abortion: the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus. ● Exclusions that apply to Mental Health and
Chemical Dependency Services:
● Services provided under a court order or as a condition of parole or probation or instead of incarceration which are not Medically Necessary;
● Personal growth services such as assertiveness training or consciousness raising;
● Services related to developmental disabilities, developmental delays or learning disabilities including, but not limited to, education Services. A learning disability is a condition where there is meaningful difference between a child’s current academic function and the level expected for a child that age. Educational Services include, but are not limited to, language and speech training, reading, and psychological and visual integration training as defined by the American Academy of Pediatrics Policy Statement - “Learning Disabilities, Dyslexia and Vision: A Subject Review”;
● School counseling and support services, home-based behavioral management, household management training, peer
support services, recreation, tutor and mentor services; independent living Services, therapeutic foster care, wraparound services; emergency aid for household items and expenses; services to improve economic stability, and interpretation services;
● Evaluation or treatment for education, professional training, employment investigations, and fitness for duty evaluations;
● Community Care Facilities that provide 24 hour non-medical residential care; ● Speech therapy, physical therapy and
occupational therapy services provided in connection with treatment of psychosocial speech delay, learning disorders, including mental retardation and motor skill
disorders, and educational speech delay including delayed language development; ● Counseling related to family, marriage, sex
and career including, but not limited to, counseling for adoption, custody, family planning or pregnancy, in the absence of a DSM-IV-TR diagnosis;
● Neurological services and tests including, but not limited to, EEGs; PET, CT and MRI imaging Services, and beam scans;
● Services related to the treatment of sexual disorders, dysfunctions or addiction; ● Vocational, pastoral or spiritual counseling; ● Dance, poetry, music or art therapy, except
as part of an approved treatment program; and
● Treatments that do not meet the national standards for Mental Health/Chemical Dependency professional practice. ● The following services are excluded from all
alternative care providers (Acupuncturist, Chiropractor, Naturopathic Physician): ● Alternative care services not stated as a
which are allowable when provided by naturopathic physician).
● Hypnotherapy, behavior training, sleep therapy and weight programs.
● Education programs, self-care or self-help programs or any self-help physical. ● Training or any related diagnostic testing. ● Massage therapy.
● Thermography.
● Therapeutic modalities and procedures that are considered by Providence Health Plan or their authorizing agent to be invasive. ● Emergency care and Urgent/Immediate care
services.
● Transportation costs including local ambulance charges.
● Any service or supply that is not permitted by state law with respect to the alternative care provider’s scope of practice.
● Services in excess of the benefit limits listed in the Covered Medical Expenses.
● Services provided while in the custody of any law enforcement authorities or incarcerated.
● Expenses related to any condition sustained by a covered member as a result of
engagement in an illegal occupation or the commission or attempted commission of an assault or other illegal act by the member, if such member is convicted of a crime on account of such illegal engagement or act. For purposes of this exclusion, “illegal” means any engagement or act that would constitute a felony or misdemeanor punishable by up to a year’s imprisonment under applicable law if such member is
covered services for a member for injuries resulting from an act of domestic violence or a medical condition (i.e., a physical or mental health condition).
NOTE: The Plan will not pay benefits for any condition, disability or expense sustained as a result of:
● intentional or accidental atomic explosion or other release of nuclear energy (whether in peace time or war time), ● participation in a riot or civil revolution,
● service as a member of the armed forces of any state or country,
● war or an act of war, whether declared or undeclared. This exclusion does not apply if the injury results from an act of domestic violence or a medical condition (whether physical or mental).