The following is a list of services that are not covered under the Consumer Choice Plan:

• - Adoption expenses.
• - Autopsies.
• - Any service rendered by a close relative or someone sharing the same legal residence as the patient.
• - Breast pumps.
• - Blood or plasma when voluntary or when a refund or credit is made for those items. Fees incurred for voluntary blood donation or storage of blood products.
• - Care and services (to the extent allowed by law) furnished or payable under:
• - A plan or program operated by a national government or one of its agencies; or
• - A state cash sickness or similar law.
• - Care and supplies for which:
• - No charge is made, or there is no legal requirement to pay; or you or your dependent would not have to pay if you did not have this coverage.
• - Care or supplies furnished due to:
• - A war or act of war (declared or undeclared); or
• - Insurrection or riot.
• - Care which is:
• - Custodial;
• - To assist the patient in the activities of daily living; and
• - Not expected to improve the patient’s medical condition.
• - Charges above those considered reasonable and customary or usual and customary.
• - Charges for enteral feeding formulas.
• - Charges for equipment containing features of an aesthetic nature or features of a medical nature which are not required by the patient’s condition.
• - Charges for federal, state and/or local taxes.
• - Charges for home births.
• - Charges in excess of the lifetime maximum benefit ($2 million combined for all ACS medical plans).
• - Charges incurred by other than the diagnosed patient except as provided in the organ transplant benefit as specified under the plan.
• - Charges not included as covered expenses as listed beginning on page 26.
• - Charges related to services or supplies for common household use, such as exercise equipment; air conditioners, air filters, heaters, humidifiers and other equipment that adjusts or regulates the interior environment; computer equipment; water purifiers; mattresses and similar supplies, even if ordered by a physician.
• - Charges related to shipping and handling charges for any covered item.
• - Completion of any administrative forms.
• - Cosmetic, plastic surgery, reconstructive surgery or other services and supplies which improve, alter, or enhance appearance, whether or not for psychological or emotional reasons; except if:
• o Needed to improve the function of a part of the body that is malformed as a direct result of disease or a surgery performed to treat a disease or injury;
• o Needed to improve the function of a part of the body that is malformed as a result of a birth defect that interferes with normal function of the body or causes physical pain; or
• o In connection with breast reconstruction related to a mastectomy, as described on page 30.
• - Cost of any service connected with hospitalization when a participant remains in the hospital after hospitalization is no longer medically necessary.
• - Elective abortion, unless carrying the fetus to full term would seriously endanger the life of the mother. If complications arise after the performing of an abortion, any covered expenses incurred to treat those complications will be considered for benefits under the plan; the initial costs relating to the abortion will not be covered.
• - Examination or treatment ordered by a court in connection with legal proceedings.
• - Emergency room charges for services not considered Emergency Care as defined on page 152.
• - Expenses which relate to the pregnancy of a dependent child/child of domestic partner; however, expenses relating to complications of pregnancy or delivery will be covered.
• - Expenses which relate to treatment of nicotine addiction.
• - Eyeglasses (lenses and frames) and contact lenses, except after cataract surgery.
• - Foot care that is not medically necessary for treatment of a covered medical condition, including but not limited to care for corns, calluses, flat feet, fallen arches, weak feet, bunions, chronic foot strain, symptomatic complaints relating to the feet, toe nail trimming and supportive devices for feet.
• - Full body scans or EBCT (heart scans).
• - Gene therapy as a treatment for inherited or acquired disorders.
• - Immunizations for travel.
• - Injury or illness arising out of employment, whether or not you or your dependents are covered by worker’s compensation, similar state or federal laws or a work injury program.
• - Items purchased over the counter (with the exception of glucometers and blood pressure monitors when deemed medically necessary by a provider, which would be considered covered).
• - Keratotomy, LASIK or other eye surgery to correct refractive errors (near/far sightedness, astigmatism) or similar conditions of the eyes.
• - Liposuction.
• - Massage therapy not rendered by a physician.
• - Non-medical counseling services such as marriage and family therapy, behavioral therapy, sex therapy, hypnotherapy, assertiveness training, stress management and other forms of non-medical counseling.
• - Phototherapy devices related to seasonal affective disorder.
• - Preservation of tissue or cells.
• - Private duty nursing care while hospitalized.
• - Rehabilitation services primarily intended to improve the level of physical functioning for the purposes of enhanced job, athletic or recreational performance as determined by the plan administrator, including but not limited to work hardening program, back schools and programs of general physical conditioning.
• - Reversal of an elective sterilization procedure.
• - Routine physical examinations, routine vision exams, routine dental exams or other preventive services and supplies, except as specifically provided under the plan.
• - Services and costs related to surrogate parenting, unless the surrogate mother is covered by the Consumer Choice Plan.
• - Services and supplies which the claims administrator determines are not medically necessary;
• - Services or supplies considered experimental, investigational, or under clinical investigation (including drugs, biologicals, medications, devices, diagnoses and treatments). The determination of whether a service or supply is experimental, investigational or under clinical investigation shall be determined by guidelines established by the claims administrator with approval from the plan administrator.
• - Services or supplies rendered prior to the effective date or after the termination date of the participant’s coverage.
• - Services rendered by a clergy.
• - Services, surgery or supplies for obesity, weight reduction or dietary control, including but not limited to gastric bypass, lap-band and gastric plication.
• - Sex transformations/changes and any related procedures, services or supplies.
• - Speech therapy, unless it is to restore speech that was lost due to illness or injury. Excluded speech therapy includes that which is not restorative, including treatment:
• - Used to improve speech skills that have not been fully developed;
• - That can be considered custodial or educational; and
• - Intended to maintain speech communication.
• - Support hosiery, bandages, diapers, formula, toilets, shower or bath equipment, whirlpools, hot tubs and splinting of teeth.
• - Telephone consultations, charges for failure to keep a scheduled visit, charges for the copying of medical records, or charges for completion of a claim form.
• - Services related to Temporomandibular Joint Dysfunction.

Prescription drugs:

• - Drugs and medicines not approved by the U.S. Food and Drug Administration, vitamins, minerals and food supplements or nutritional supplements, formulas and therapies that are primarily intended for weight control, except for formulas necessary for treatment of phenylketonuria or other hereditary diseases may be covered.
• - Drugs, medicines or supplies used for performance, athletic performance or lifestyle enhancement, except to the extent coverage for such drugs or supplies is specifically provided.
• - Diet pills, Minoxidil and non-prescription drugs.
• - Retin-A/Avita and Differin after age 25 unless medically necessary.
• - Non-prescription contraceptive drugs or devices.
• - Cosmetic medications, including antiwrinkle medications, hair removal medications and hair growth stimulants.
• - Drugs taken or administered while confined to a hospital, rest home, extended convalescent facility, or other similar institution (charges for these drugs are covered as hospital expenses)
• - Growth hormones.
• - Over-the-counter drugs, whether or not prescribed or previously obtainable only with a prescription.
• - Refills of any prescriptions in excess of the number of refills specified by a doctor, or drugs dispensed more than one year following the date of the doctor’s prescription order.
• - Drugs labeled “Caution-limited by federal law to investigational use” or experimental drugs, even if a charge is made to the covered individual.
• - Non-federal legend drugs.
• - Non-systemic contraceptives, implants.
• - Mifeprex.
• - Immune/gamma globulins.
• - Immunosuppressants.
• - Yohimbine.
• - Fertility agents.
• - Smoking deterrents.
• - Dental fluoride products.
• - Anabolic steroids.
• - Vitamins (except for pre-natal vitamins prescribed by a doctor).
• - Drugs whose sole purpose is to promote or stimulate hair growth or for cosmetic purposes only.
• - Glucowatch product.
• - Inhaler spacers.
• - Ostomy supplies are excluded under the prescription drug benefit, but are covered as durable medical equipment under the medical benefit.
• - Biologicals, immunization agents or vaccines.
• - Charges for the administration or injection of any drug.
• - Medication for which the cost is recoverable under any workers’ compensation or occupational disease law or any state or governmental agency, or medication furnished by any other drug or medical service for which no charge is made to the member.
• - Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals.

Treatment of teeth:

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Questions about your employee benefits or other Human Resources issues? Contact the Workplace Solutions Center at (888) 471-2271.