(Including complications of the following exclusions:)

1. ADDITIONAL FEES: No payment for charges made for failure to keep scheduled appointments or for completion of any required forms.
2. AMNIOCENTESIS/CHORIONIC VILLA SAMPLING: When used to determine the sex of the baby and when not Medically Necessary for a delivery date prior to age thirty-five (35).
3. BIOFEEDBACK: Covered only by individual review as accepted and proven for the diagnosis.
4. COSMETIC SURGERY (including laser surgery that is deemed cosmetic): No benefits will be paid for:
(a) that portion of breast surgery which involves the implanting or injecting of any substance into the body for restoring breast shape, except for charges which result from an Illness or Injury; or
(b) Cosmetic surgery, except for charges which: (i) result from an accident;
(ii) are the result of congenital birth defects.
5. COURT MANDATED TREATMENT: No payment will be made for treatments that are court mandated.
6. CUSTODIAL CARE: No benefits will be paid for services which are furnished mainly to assist a person in the activities of daily living. This includes any care that does not require day to day attention by medically trained persons including, but not limited to, bathing, feeding, homemaking, moving the patient, acting as a sitter or companion, training or help in personal hygiene, nutritional services such as "Meals on Wheels", or supervision in daily activities. This also includes transportation to and from treatment, and all other transportation.
7. DRUG AND ALCOHOL: Benefits will be provided for diagnosis or Treatment only as specified on your Schedule of Benefits. If your Plan has a prescription card provision, prescriptions must be submitted through your prescription card for coverage once a Covered Person has been on the Plan for thirty (30) days. Exceptions for prescription coverage may be made for eligible prescriptions not covered by your prescription card based on individual review. If this Plan is secondary for a Covered Person, you must submit your prescriptions to Phillips Administrative Service, Inc., for reimbursement of your Co-pay.
8. EQUIPMENT AND DEVICES: Benefits will not be paid for charges for equipment commonly used for nonmedical purposes, or marketed to the general public, or prescribed primarily for comfort, or intended to alter the physical environment. This includes appliances such as air conditioners, air purifiers, room humidifiers, heating and cooling pads, home blood pressure monitoring equipment, whirlpool baths, spas, saunas, heat lamps, tanning lights, pillows, and conveyances other than conventional wheelchairs. Also excluded are orthopedic shoes and shoe modifications. Mattresses and mattress pads are only covered when Medically Necessary to heal pressure sores. Exceptions may be made for heat lamps and tanning lights based on individual review.
9. GENETIC COUNSELING: No benefits will be paid for genetic counseling, genetic services, and related testing/procedures.
10. GOVERNMENT AGENCIES: Benefits will not be paid for charges incurred for Hospital confinement, services, Treatments, or supplies furnished by the United States or a foreign government agency for a disability related to military services, except for Federal Mandates which do not exclude self-insured plans.
11. HEARING AIDS AND EYE GLASSES: No benefits will be paid, unless specified on your Schedule of Benefits, for exams to determine the need, or for the fitting or purchase of:
(a) hearing aids; or
(b) eye glasses or contact lenses except as provided in connection with cataract surgery. The exception to this exclusion is: Medically Necessary hearing tests performed on children as a result of continual ear infections.
12. HOSPITAL WEEKEND ADMISSIONS: No benefits will be paid for the initial Friday, Saturday, and Sunday Room and Board charges incurred in connection with a Hospital confinement which begins on Friday, Saturday, or Sunday. Exceptions are made for emergency admissions or scheduled surgery within the twenty-four (24) hours immediately following admission to the Hospital.
13. INDUCEMENT OF PREGNANCY: No benefits will be paid for diagnosis or expenses related to reversal of sterilization, sex change, sex therapy, invitro fertilization, or artificial insemination, unless specified on your Schedule of Benefits.
14. INFERTILITY: No coverage for any charges related to fertility diagnosis, testing, Treatment, and drugs or their administration, unless specified on your Schedule of Benefits.
15. LASIK/LASEK SURGERY: No benefits will be paid for the diagnosis or Treatment of refractive errors, including but not limited to, LASIK/LASEK surgery.
16. LEGAL DUTY: Coverage is provided only for treatment for which the Covered Person has a legal duty to pay. This Plan will not create such a duty to pay. The exception to this is where Federal Law takes precedence.
17. LEARNING DISABILITIES: No benefits will be paid for charges incurred for special education classes or training for learning disorders.
18. LIMIT OF MEDICAL TREATMENT: Benefits will only be paid for charges by a Physician, Physician's Assistant, or Registered Nurse Practitioner who is present and consults with the Covered Person. Benefits will not be paid for charges for services of a Registered Nurse (R.N.), Licensed Practical Nurse (L.P.N.), or licensed physical therapist:
(a) who usually resides in the same household with the Covered Person;
(b) who is related by blood, marriage, or legal adoption to the Covered Person or to the Covered Person's spouse; or
(c) who is an Employee of the participating Employer.
(d) Physician's services are not covered if that Physician is related by blood, marriage, or legal adoption to the Covered Person.
19. LIPOSUCTION: There will be no benefits paid for liposuction or laser liposuction.
20. MARITAL AND FAMILY COUNSELING AND THERAPY: No benefits will be provided for charges incurred for marital or family counseling or therapy whether by an M.D., PhD., PsyD., M.S., M.S.W., or L.C.S.W., L.I.S.W., A.C.S.W., R.C.S.W., R.I.S.W., or C.I.S.W., unless specified on your Schedule of Benefits.
21. MASSAGE OR MASSAGE THERAPY: No benefits will be provided for charges incurred for massage or massage therapy, unless, provided by the treating physical therapist as part of an approved covered physical therapy program.
22. MENTAL AND NERVOUS: Benefits will be provided only as specified on your Schedule of Benefits for charges for diagnosis or treatment from an M.D., PhD., M.S., M.S.W., or L.C.S.W., A.C.S.W., R.C.S.W., R.I.S.W., or C.I.S.W., licensed by the state in which they are practicing. If other than an M.D., PhD., or PsyD., we must have a copy of the state license to cover. Other degrees considered by individual review. If your Plan has a prescription card provision, prescriptions must be submitted through your prescription card for coverage once a Covered Person has been on the Plan for thirty (30) days. Exceptions may be made for eligible prescriptions not covered by your prescription card based on individual review. If this Plan is secondary for a Covered Person, you must submit your prescriptions to Phillips Administrative Service, Inc., for reimbursement of your Co-pay.
23. NECESSARY, USUAL AND CUSTOMARY: Benefits are provided only for charges which are:
(1) Medically Necessary to the treatment of Illness or Injury;
(2) incurred on the advice of a Physician; and
(3) not more than those charges which are Usual and Customary for the services performed and the materials furnished, for the zip code area. Benefits will not be paid for any expenses for services or supplies which are:
(1) not provided in accordance with generally accepted professional medical standards; or
(2) incurred in connection with services and procedures including surgery or drugs which are considered experimental or research by nature as recognized by generally accepted medical standards and practices for the particular diagnosis as determined by the Third Party Administrator's Physician reviewers.
(3) submitted more than one (1) year from date of loss, unless the claimant was legally incapacitated. The Third Party Administrator may require, as part of the proof, authorization to obtain medical and non-medical information. (Medicare/Medicaid claims payable as mandated by current federal regulations as long as this plan is still in force at the time the claim and any required information is received.)
24. NON-OCCUPATIONAL COVERAGE: No benefits will be provided for losses which result from an Illness or Injury:
(1) which arises out of, or in the course of, employment with any Employer who is eligible to obtain coverage under Workers' Compensation or Occupational Disease Law;
(2) for which the Covered Person is eligible for benefits under any Workers' Compensation law or Occupational Disease Law; or
(3) for which the Covered Person is paid a Workers' Compensation benefit or Occupational Disease Law benefit.
25. NON-SURGICAL CARE OF SPINAL CONDITIONS: Benefits covered only as outlined on your Schedule of Benefits (including back, neck, spine, and vertebra). This applies to diagnosis, treatment, or maintenance by a Physician of:
(1) dislocation of vertebra, spine, back, or neck;
(2) musculoskeletal sprain or strain surrounding vertebra, spine, back, or neck;
(3) subluxation of vertebra; or
(4) misplaced vertebra. This limitation does not apply to diagnosis or Treatment requiring general anesthesia, surgery, or Hospital confinement or diagnostic testing (i.e. MRI's and CAT scans) when ordered by a Medical Doctor.


26. OBESITY AND NICOTINE ADDICTION: No benefits will be paid for expenses related to the diagnosis or Treatment of nicotine use or addiction, obesity, weight control, or diet, unless specified on your Schedule of Benefits.
27. ORAL SURGERY: No payment will be made for diagnosis or medical, surgical, or appliance Treatment for correction of any diagnosis other than Illness, accident, or Injury. Exceptions: Problems due to congenital disorders and removal of impacted teeth.
28. ORGAN TRANSPLANTS: No benefits will be paid for services related to whole organ transplants, except for cornea, heart, heart/lung, kidney, pancreas, or liver transplants for recipients who are Covered Persons. Exceptions may be made by medical review and clinical evidence, and may be based on overall general health, emotional well-being, recovery motivation, risk factor and projected prognosis of recovery as determined by the Third Party Administrator's Physician reviewers. All transplants must be precertified. Eligible transplants will include coverage for Medically Necessary services and supplies rendered in connection with a transplant, including pretransplant procedures such as donor costs for organ harvesting, post-operative care, and transplant-related chemotherapy for cancer. Donor costs include all costs incurred in connection with medical services required to remove the organ from the donor's body, preserving the organ, and transporting the organ to the site where the transplant is being performed. No payment will be made for the search of the organs. If the donor is covered under this Plan and the recipient is not, this Plan will not pay any benefits toward donor costs. (See your Schedule of Benefits to determine if your Plan's coverage for Organ Transplants is different. If different, coverage is based on the information on your Schedule of Benefits.)
29. ORTHOGNATHIC, PROGNATHIC OR MAXILLOFACIAL SURGERY: No benefits will be paid for services and supplies primarily for Treatment of and/or in connection with orthognathic, prognathic, and maxillofacial surgery except as follows:
(1) when Medically Necessary to repair an accidental Injury. Services must be provided within one (1) year after the accident;
(2) for removal of a malignancy, including reconstruction of the jaw within one (1) year after that surgery; or
(3) unless Medically Necessary as determined by individual review.
(4) to correct congenital birth defects, as defined by accepted medical practice, for Covered Persons who have been covered under this Plan from birth.
30. ORTHOTICS: No benefits paid including foot levelers and heel wedges. The exception to this exclusion is: functional biomechanical orthotics, knee straps, back stabilizers, and molded inserts for children's foot deformities. With preauthorization, approved routine maintenance covered no more than one (1) time in any twelve (12)-month period. Replacement, with preauthorization, one (1) every five (5) years with written documentation from Physician showing need for replacement. Coverage limited to the cost of the most efficient and economical service which can safely be provided to the patient as determined by the Third Party Administrators' Physician reviewers. Exceptions to the five (5)-year requirement may be made for replacements which are Medically Necessary for children who are growing.
31. OTHER: Benefits will not be paid for charges not listed under "Eligible Charges".
32. PHYSICIAN'S DIRECT CARE: Benefits will be paid only for Eligible Charges incurred by a Covered Person under the direct care of a Physician or under a Physician's supervision. Benefits will not be paid to a relative (by blood, marriage, or legal adoption).
33. PODIATRY: No payment for diagnosis, Treatment, or supplies for the feet, except for operations involving the exposure of bones, tendons, or ligaments, and surgical treatment of ingrown toenails, bunions, and plantar's warts. Exceptions may be made when Treatment is Medically Necessary (for instance, diabetes).
34. RADIAL KERATOTOMY: No benefits will be paid for surgical procedures for the diagnosis or Treatment of myopia, including, but not limited to, radial keratotomy.
35. REVERSAL OF STERILIZATION: No benefits will be paid for expenses related to reversal of sterilization.
36. RIOT-FELONY: No benefits will be paid for losses which are due to taking part in a riot or civil disturbance, or while committing, or attempting to commit, a felony.
37. ROOM AND BOARD: No benefits will be paid for Room and Board charges, incidental expenses, or travel expenses for family members of Inpatients.
38. ROUTINE PHYSICAL EXAMS: No benefits will be paid for health exams, tests, and immunizations (except as noted in Section entitled "Eligible Charges"), unless in connection with an Injury or Illness. Benefits for routine physical exams will be paid if this is an Eligible Charge listed on your Schedule of Benefits.
39. SELF-INFLICTED: No benefits will be paid for charges in connection with intentionally self-induced or self-inflicted Injury, except to the extent prevented by federal law from denying such claims. (See your Schedule of Benefits for any exceptions.)
40. SERVICES OR SUPPLIES: No benefits will be paid for services or supplies received by a Covered Person for which no charge would have been made in the absence of Medical Benefits for that Covered Person. (This includes services or supplies for which a Covered Person is not required to pay.)
41. SEXUALLY RELATED: No payment for services, supplies, Treatment, or medication related to sex transformations, reversal of transformations, sexual dysfunctions or inadequacies. (This includes diagnosis and any related lab charges.)
42. SNORING: No benefits payable for diagnosis or Treatment of snoring. Also, no benefits payable for devices or equipment to eliminate snoring.
43. STERILIZATION: No benefits will be paid for expenses related to sterilization procedures, except for those relating to tubal ligation or vasectomy. (See your Schedule of Benefits for any exceptions.)
44. SURROGATE MOTHERHOOD: No benefits will be paid for expenses incurred in connection with surrogate motherhood.
45. TMJ: No benefits will be paid for diagnosis, consultation, or Treatment of the temporomandibular joint (TMJ). (See your Schedule of Benefits for any exceptions.)
46. TRAVEL: No benefits will be paid for any travel, whether or not ordered by a Physician for medical reasons.
47. TREATMENT OF TEETH AND GUMS: No benefits will be paid for diagnosis or Treatment of teeth, gums, alveolar process, or supplies used in such Treatment, or for dental appliances. This exclusion does not apply to:
(a) Surgical Services, if performed on an Outpatient basis, for the removal of impacted teeth, including anesthesia charges and initial exam when in conjunction with removal of impacted teeth;
(b) setting of a jaw fractured or dislocated in an accident; or
(c) Major Medical Benefits for expenses incurred for Treatment of Accidental Injury to sound natural teeth, including the replacement of such teeth. Expenses must be incurred within twelve (12) months after such accident. (d) Outpatient Hospitalization and Anesthesia for Dental Services may be covered, based on individual review, for Covered Persons with complicating medical conditions. The actual dental services are not covered under your medical Plan. Examples include, but are not limited to: (i) mental handicaps;
(ii) physical disabilities;
(iii) a combination of medical conditions or disabilities which cannot be managed safely and efficiently in a dental office.
(iv) Extensive pediatric dental care which cannot be managed safely and efficiently in a dental office for eligible Dependents under age six (6) as determined by individual review. (Coverage for full-mouth restoration which cannot be managed safely and efficiently in a dental office for eligible Dependent children age six (6) and above will be based on individual review of age, mental status, and procedures to be performed.)
48. TREATMENT OUTSIDE OF THE UNITED STATES AND CANADA: No benefits will be paid for Treatment received outside of the United States or Canada except for an Illness or Injury which occurs while traveling outside of the country.
49. VISION THERAPY: No benefits will be paid for vision examinations, therapy, exercise, or training, unless Medically Necessary as determined by individual review.
50. VITAMINS: There will be no payment for vitamin or mineral supplements which do not legally require a Physician's written prescription for dispensing. Eligible charges may only be covered through your prescription card if your Plan has a prescription card provision. The exception to this is Medically Necessary vitamin or mineral injections done in a Physician's office or Hospital (each case will be individually reviewed for eligibility). If this Plan is your secondary coverage, eligible prescriptions must be submitted to Phillips Administrative Service, Inc., for reimbursement of your Co-pay.
51. WAR: No benefits will be paid for losses which are due to revolt, political conflict, war, or any act of war, whether declared or not.