We pay benefits only for Covered Services described in your Contract. Other sections of your Contract may also contain specific exclusions.

In addition to the specific exclusions listed elsewhere in this Contract, the following general exclusions apply:

• Services that must be Covered by a prior health plan as extended benefits.

• Services for which you would have no legal obligation to pay if you did not have your Contract or similar coverage.

• Services for which there is no charge.

• Services paid directly or indirectly by a local, state or federal government agency, except as otherwise provided by law.

• Services you require as a result of your commission or attempt to commit a felony, or your engagement in an illegal occupation.

• Services in excess of the limitations or maximums set forth in your Contract.

• Services or medications we determine are not Medically Necessary.

• Services or medications that we determine are Investigational, mainly for research purposes or Experimental in nature. However, to the extent required by law, we cover routine costs for patients who participate in cancer clinical trials.

• Services that are not provided in accordance with accepted professional medical standards in the United States.

• Services beyond those needed to restore your ability to perform Activities of Daily Living or to assist you in performing Activities of Daily Living (see Definitions), except as provided for in other sections of this Certificate.

• Acupuncture, acupressure or massage therapy; hypnotherapy, rolfing, homeopathic or naturopathic remedies.

• Electrical stimulation devices used externally. (This exclusion does not apply to bone growth stimulators or transcutaneous electrical nerve stimulation (TENS) devices for which you have received prior approval.  Note: we will not approve a TENS unit to treat headache, pelvic or deep abdominal pain, labor and vaginal delivery, dementia or jaw pain.)

• Automatic ambulatory home blood pressure monitoring or equipment.

• Biofeedback or other forms of self-care or self-help training.

• Bulk immunizations (those provided to a group of people, such as employees in an office setting), free-standing immunization clinics (except through a Home Health Agency or Visiting Nurse Association) or fluoride treatments performed in school.

• Whole blood, blood components, costs associated with the storage of blood, testing of blood the patient donates for his or her own use (even if the blood is used), transfusion Services for blood and blood components the patient donates for his or her own use in the absence of a covered surgical procedure. (This exclusion does not apply to blood derivatives and transfusion Services for whole blood, blood components and blood derivatives.)

• Care for which there is no therapeutic benefit or likelihood of improvement.

• Care, the duration of which is based upon a predetermined length of time rather than the condition of the patient, the results of treatment or the individual's medical progress.

• (Routine) circumcision.

• Clinical ecology, environmental medicine, Inpatient confinement for environmental change or similar treatment.

• Cognitive training or retraining and educational programs, including any program designed principally to improve academic performance, reading or writing skills, except for diabetes education or education provided through one of our Chronic Care Management programs.

• Screening colonoscopies except in patients over age 50 or patients with risk factors for colorectal disorders.

• Communication devices, communication augmentation devices and computer technology or accessories and other equipment, supplies or treatment intended primarily to enhance occupational, recreational or vocational activities, hobbies or academic performance.

• Consultations, except when they occur between Providers and the Providers attach a written report to the patient's medical record.

• Correction of near- or farsighted conditions or aphakia (where the lens of the eye is missing either congenitally or accidentally or has been surgically removed, as with cataracts) by means of corneal microsurgery or "laser Surgery," such as keratomileusis, keratophakia, and radial keratotomy and all related Services.

• Cosmetic procedures and supplies that are not Reconstructive.

• Custodial Care, Rest Cures.

• Dental Services and oral Surgery, unless specifically provided by your Contract; procedures designed primarily to prepare the mouth for dentures (including alveolar augmentation, bone grafting, frame implants and ramus mandibular stapling).

• Routine eye care (such as examinations), eye exercises or visual training.

• Eyeglasses or contact lenses unless you need them to replace the lens of an eye (and the lens was not replaced at the time of surgery).

• Education, educational evaluation or therapy or treatment of developmental delays, therapeutic boarding schools, Services that should be covered as part of an evaluation for or inclusion in a Child's Individualized Education Plan (IEP) or other educational program. (This exclusion does not apply to treatment of diabetes, such as medical nutrition therapy by approved Catamount Blue Preferred Providers, or Services through our Chronic Care Management programs.)

• Foot care or supplies that are palliative or Cosmetic in nature, including supportive devices and treatment for bunions (except capsular or bone Surgery), flat-foot conditions, subluxations of the foot, corns, callouses, toenails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet.  This exclusion does not apply to necessary foot care for treatment of diabetes.

• Hearing aids or examinations for the prescription or fitting of hearing aids.

• Home or automobile modifications or equipment like air conditioners, HEPA filters, humidifiers, stair glides, elevators, lifts, motorized scooters, furniture or "barrier-free" construction, even if prescribed by a Provider.

• Illnesses or injuries that are:
  • a result of an act of war (declared or undeclared); or
  • sustained in active military service (Note: upon receipt of written request, the Plan will suspend coverage for the military member and make a refund on a pro rata basis for subscription rates paid for the time period the member is in active military service).

• An Inpatient Stay determined not Medically Necessary while you are waiting for a different level of care, such as Skilled Nursing Facility or home care, whether or not it is available to you.

• Treatment for willfully uncooperative or intractable patients.

• Institutional or Custodial Care for the physically or mentally handicapped.

• Mandated treatment, including court-ordered treatment, unless such treatment is Medically Necessary, ordered by a Physician and Covered under your Contract.

• Neuromuscular stimulators, unless you have Prior Approval from us.

• Non-medical charges, such as:
  • taxes;
  • postage, shipping and handling charges;
  • a penalty for failure to keep a scheduled visit; or
  • fees for completion of a claim form.

• Nutritional counseling beyond three visits per calendar year. (This exclusion does not apply to nutritional counseling for the treatment of diabetes or as part of our Chronic Care Management programs.)

• Nutritional formulae or supplements, except for up to $2,500 per year for "medical foods" prescribed for the Medically Necessary treatment of an inherited metabolic disease or formulae and supplements administered through a feeding tube.

• Orthodontics, including orthodontics performed as adjunct to orthognathic surgery or in connection with accidental injury, unless otherwise mandated by law.

• Inpatient behavioral-based programs for pain management.

• Personal hygiene items.

• Personal service, comfort or convenience items.

• Photography Services, photographic supplies or film development supplies or Services (for example, external ocular photography or photography of moles to monitor changes).

• Physical fitness equipment, braces and devices intended primarily for use with sports or physical activities other than Activities of Daily Living (e.g. knee braces for skiing, running or hiking); weight loss or exercise programs;  health club or fitness center memberships. (This exclusion does not apply if you are actively participating in one of our Chronic Care Management programs, and the Services are offered through that Chronic Care Management program.)

• Pneumatic cervical traction devices.

• Prescription Drugs:
  • for treatment of infertility;
  • for treatment of sexual dysfunction;
  • for weight loss;
  • for refills beyond one year from the original Prescription date; and
  • brand-name Prescription Drugs when an exact generic is available.
    

• We also do not cover:
  • any drug considered to be Investigational;
  • vitamins, except those which, by law, require a prescription; and
  • drugs that do not require a prescription, except insulin, even if your doctor prescribes or recommends them.

• Specialized examinations required by your employer or for sports/recreational activities (e.g., driver certifications, pilot flight physicals, etc.)

• Support therapies, including pastoral counseling, assertiveness training, dream therapy, music or art therapy, recreational therapy, smoking cessation therapy, stress management, wilderness programs, adventure therapy and bright light therapy. (This exclusion does not apply if you are actively participating in one of our Chronic Care Management programs, and the Services are offered through that Chronic Care Management program.)

• Reversal of sterilization.

• Telephone consultations (between Provider and patient).

• Therapy Services provided as a part of chronic pain control, developmental, pulmonary or other form of rehabilitation, except:
  • treatment of diabetes by a Catatamount Blue Preferred Provider; or
  • Services for which you have prior written approval by the Plan.

• Travel (other than Ambulance transport), lodging and housing that is not integral to a Medically Necessary level of care, even if prescribed by a Physician.

• Evaluation and treatment leading to, or in connection with, artificial insemination (intravaginal, intracervical and intrauterine insemination), in vitro fertilization, embryo transplantation and gamete intrafallopian transfer (GIFT), infertility testing and drug therapy.

• Treatment leading to, or in connection with, transsexual Surgery.

• Treatment solely to establish or reestablish the capability to perform occupational, hobby, sport or leisure activities.

• Non-prescription treatment of obesity, except surgical treatment when:
  • your Physician determines that your Body Mass Index is over 40 (according to Table 1 in the "Methods for Voluntary Weight Loss and Control" booklet by the National Institute of Health Technology Assessment Conference Statement of March 1992); and
  • you have other medical conditions that could be significantly and adversely affected by this degree of obesity; or
  • you are actively participating in one of our Chronic Care Management programs, and the Services are offered through that Chronic Care Management program.

This exclusion does not apply to nutritional counseling benefits as explained on page .

• Work hardening programs and work-related illnesses or injuries (or those which you claim to be work-related, until otherwise finally adjudicated), provided such illnesses or injuries are covered by workers' compensation or should be so covered. (This provision shall not be deemed to require an individual, such as a sole proprietor or an owner partner, as a condition to obtaining coverage, to obtain workers' compensation if he or she is not under a legal obligation to be so covered.)

• Services and supplies not specifically described as Covered.

Provider Exclusions

Also, your Contract does not Cover Services or supplies prescribed or provided by a:

• Provider that we do not approve for the given service or that is not defined in our "Definitions" section as a Provider.

• Professional who provides Services as part of his or her education or training program.

• Member of your immediate family or yourself.

• Veterans Administration Facility treating a service-connected disability.

• Non-network Provider if we require use of a Network Provider as a condition for coverage under your Contract.

• Non-preferred Provider if we require use of a Preferred Provider as a condition for coverage under your Contract.