The PPO Plans are designed to provide you and your family with comprehensive medical coverage. However, the plans do not pay for all services and supplies. Listed below are examples of services that are not covered under the plans and services that are limited. If a service is not specifically listed as covered, it is excluded. Contact the claims administrator if you have any questions about what is covered and not covered under the plans.

• - Acupuncture therapy, unless it is performed by a physician as a form of anesthesia in connection with surgery that is covered under this plan.
• - Amniocentesis, ultrasound, or any other procedures requested solely for sex determination of a fetus, unless medically necessary to determine the existence of a sex-linked genetic disorder.
• - Any service rendered by a close relative or someone sharing the same legal residence as the patient.
• - Any service rendered by a person who is not legally qualified to perform that service.
• - 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 are excluded as well.
• - 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 for a dependent of a dependent child/child of domestic partner.
• - Care or supplies furnished by a facility operated for or by the United States government (or its agency) or by a physician employed by that facility unless:
• ○ For emergency treatment when you or your dependent must pay for those services;
• ○ For non-service connected disabilities in a Veterans Administration hospital; or
• ○ Incurred by a United States military retiree (covered by this plan) and his/her covered dependents, while confined in a military medical facility.
• - 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.
• - Certain types of treatment for mental disorders, such as primal therapy, rolfing or psychodrama, megavitamin therapy, bioenergetic therapy, vision perception training, carbon dioxide therapy, recreational, sleep, musical, religious, and other mental health therapies determined by the claims administrator not to be effective for the treatment of such disorders.
• - 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.
• - 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:
• ○ 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;
• ○ 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
• ○ In connection with breast reconstruction related to a mastectomy, as described on page 57.
• - Charges above those considered reasonable and customary or usual and customary.
• - Charges for federal, state and/or local taxes.
• - 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 made by a physician for time on standby status if no actual service is performed.
• - Charges not included as covered expenses.
• - Charges related to pre-existing conditions, except as otherwise allowed under the plan.
• - Court ordered treatment for mental health conditions and/or health services, unless independently determined by the psychological case manager of the medical plan to be medically necessary.
• - Education or training of any type for the treatment of learning disabilities and attention deficit disorders, IQ testing except in connection with assessment or treatment of a speech, language or hearing disorder.
• - 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.
• - Emergency room charges for services not considered an emergency as defined on page 152.
• - Expenses which relate to the pregnancy of a dependent child/child of domestic partner; however, complications arising from the pregnancy or delivery will be covered.
• - Exercise for the eyes (orthoptics).
• - 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.
• - Human growth hormones, except for children with an absolute deficiency in growth hormone production who meet the appropriate guidelines determined by the plan administrator.
• - Injury or illness resulting from taking part in the commission of an assault or felony unless it is due to either a mental or physical medical condition.
• - 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.
• - In-vitro fertilization, artificial insemination and infertility treatment, and all related expenses.
• - Keratotomy, LASIK or other eye surgery to correct refractive errors (near/far sightedness, astigmatism) or similar conditions of the eyes.
• - Nerve stimulators.
• - 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.
• - Non-surgical treatment of Temporomandibular Joint Disorders (TMJD) and all other craniomandibular disorders.
• - Orthopedic shoes, trusses, corsets and similar items.
• - Over-the-counter disposable or consumable supplies.
• - Private duty nursing care while hospitalized.
• - Psychological testing when not medically necessary.
• - Purchase or rental of luxury medical equipment when standard equipment is appropriate for the patient’s condition (e.g., motorized wheelchairs or other vehicles, bionic or computerized artificial limbs).
• - 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, or services and supplies in excess of the coverage provided in the rehabilitation program.
• - Replacement of external prosthesis due to wear and tear, loss, theft or destruction.
• - Reports, evaluations, examinations or hospitalizations not required for health reasons.
• - Routine physical examinations, routine vision exams, routine dental exams or other preventive services and supplies, except as specifically provided under the plan.
• - Reversal of an elective sterilization procedure.
• - Self-administered services, except covered prescription drugs, allergy and insulin injections.
• - Services and costs relating to the biological mother of an adopted child, if the biological mother is not covered by the plan.
• - Services and costs related to surrogate parenting (including prenatal care and delivery), unless the surrogate mother is covered as an employee or spouse or domestic partner of an employee.
• - 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 or supplies for which a claim submission is 12 months or more after the date charges for such services were incurred.
• - Services or supplies for personal comfort or convenience (i.e. private room, television, telephone, guest trays, etc.).
• - Services or supplies where the patient is covered under another plan sponsored by the employer that covers that service, treatment or supply.
• - Services, surgery or supplies for obesity, weight reduction or dietary control, except when provided for treatment of morbid obesity. Morbid obesity is a condition in which an individual:
• ○ Is the greater of 100 pounds or two times over his/her normal weight (in accordance with the claims administrator’s standards);
• ○ Has been so for at least three (3) years, despite documented unsuccessful attempts to reduce under a physician monitored diet and exercise program; and
• ○ Over the age of 25.
• - Soft palate reconstruction (veloplasty) to correct speech impediments.
• - Sperm preservation.
• - 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.
• - Sex transformations/changes, gender identity disorders and any related procedures, services or supplies.
• - Support hosiery, bandages, diapers, formula, toilets, shower or bath equipment, whirlpools, hot tubs, splinting of teeth and other supplies, except those provided as part of a covered home health care service.
• - Thermograms, temperature gradient studies.
• - The cost of any service connected with hospitalization when a participant remains in the hospital after hospitalization is no longer medically necessary.
• - Wigs

Drugs or medicines:

• - Any quantity of drugs or medicines dispensed that exceeds a 30- or 90-day supply for retail or 90-day supply for mail order.
• - Drugs and medicines not approved by the U.S. Food and Drug Administration.
• - Vitamins, except for prenatal vitamins prescribed by a doctor, pediatric multi-vitamins with fluoride and iron, and certain other prescription vitamins that are considered medically necessary including the following Brand Name (and generic equivalents):
• ○ Rocaltrol and Calcijex (calcitriol), Vitamin D product
• ○ Zemplar (paricalcitol), Vitamin D product
• ○ Hectorol (doxercalciferol), Vitamin D product
• ○ Mephyton (phytonadione), Vitamin K
• ○ Cobal-1000, Nervidox S, and Tia-Doce S (cyanocobalamin), Vitamin B-12 injection
• ○ Folic acid 1 mg - available only as generic
• - Minerals and food supplements or nutritional supplements, formulas and therapies that are primarily intended for weight control.
• - Drugs labeled “Caution—limited by federal law to investigational use” or experimental drugs, even if a charge is made to the covered individual.
• - Vaccines or allergy serum unless administered at the Doctor’s office and otherwise covered by the plan.
• - Infertility drugs.
• - 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.
• - Injectable anabolic steroids and androgens.
• - Smoking cessation products such as nicotine patches, gum, or drugs only available with a prescription.
• - Topical fluoride products.
• - Anti-obesity pills.
• - Topical Vitamin A derivates such as Retin-A after age 26 unless medically necessary.
• - Prescription injectable contraceptives or contraceptive devices listed on the pharmacy benefit listing over the two hundred and fifty dollars ($250) calendar year limit.
• - Contraceptive drugs or devices dispensed by a pharmacy, except oral contraceptives, diaphragms, transdermal patches and vaginal rings.
• - 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).
• - Human growth hormones, except for children through age 18 with an absolute deficiency in growth hormone production who meet the appropriate guidelines determined by the pharmacy benefit manager Medco and who have received pre-authorization.
• - Over-the-counter and non-prescription drugs, whether or not prescribed or previously obtainable only with a prescription (excludes Prilosec OTC with a prescription).
• - Prescription drugs that may be provided without charge through local, state or federal programs.
• - Refills of any prescriptions in excess of the number of refills specified by a doctor.
• - Drugs dispensed more than one year following the date of the doctor’s prescription order.

Treatment of teeth:

• - Charges for removal of impacted wisdom teeth (or unerupted teeth).
• - Dental services or X-rays involving one or more teeth, the tissue or structure around them, the alveolar process or the gums.
• - Oral care and supplies which are used to change vertical dimension or closure.
• - Orthodontic treatment or any other non-surgical procedure, care or supply to correct a malocclusion of the teeth.
• - Non-surgical treatment of Temporomandibular Joint Disorders (TMJ).
• - Procedures involving the teeth, the area surrounding the teeth or the correction of malocclusion or orthognathous deformities.

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