Services that exceed the eligible or allowable charges or the maximums allowed by the plan.

Physician’s fees for staff consultations required by Hospital rules and regulations.

Claims filed after 24 months from the date of service.

Services or supplies:

Received before the patient was covered by the plan.

That is not medically necessary, as determined by the claims administrator. In some cases, the utilization review organization will provide an opinion.

That you are entitled to under workers’ compensation or other laws.

Furnished by the local, state or federal government.

For which payment or benefits are available from the local, state or federal government (for example, Medicare), whether or not you receive that payment or benefit (except as otherwise provided by law).

For any illness or injury occurring on or after your coverage date as a result of war or an act of war.

That does not meet accepted standards of medical or dental practice, including, but not limited to, experimental services and supplies, and services primarily for research.

Received during an inpatient stay when the stay is related to behavior, social maladjustment, lack of discipline or other antisocial actions that are not specifically the result of mental illness.

You are not required to pay for or would have no legal obligation to pay for if you did not have this or similar coverage.

For human organ or tissue transplants other than those specified in the plan document.

For which benefits are duplicated because the spouse, parent and/or child are employees of the University and each is covered separately by the plan.

Custodial care services or education or training, or educational therapy, including treatment of learning disorders.

Home delivery of meals or homemaker services.

Routine physical examinations and immunizations, after the $300 wellness benefit has been provided.

Cosmetic surgery and related services and supplies, except correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors or diseases.

Charges for failure to keep a scheduled visit, completion of a claim form, telephone advice or physicians travel time.

Personal hygiene, comfort or convenience items such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones, commonly used for purposes other than medical reasons.

Special braces, splints, specialized equipment, appliances, ambulatory apparatus and battery or atomically controlled implants, unless specifically stated in the plan document.

Procurement or use of prosthetic devices, special appliances and surgical implants that are for cosmetic purposes, the comfort and convenience of the patient, or unrelated to the treatment of a disease or injury.

Blood derivatives not classified as drugs in the official formularies.

Blood or blood plasma for which the patient receives a refund or allowance, but only to the extent of the refund or allowance.

Charges after the first pair of eyeglasses, contact lenses or lenses used to treat cataracts.

Artificial eyes, and replacement of cataract lenses unless the prescription has changed.

Examinations for prescribing or fitting glasses or contact lenses or for determining the refractive state of the eye and any surgical treatment to correct refractive error except due to an accidental injury while covered by the plan.

Routine dental care.

Care and treatment of the teeth and gums unless required by an injury to natural teeth and for certain cutting procedures to the oral cavity.

Treatment provided to alter vertical dimension or treatment of temporomandibular joint dysfunction not caused by joint disease or physical trauma.

Treatment of flat foot conditions and the prescription of supportive devices for such conditions, and the treatment of subluxations of the foot.

Treatment of routine foot care except for diabetics.

Orthopedic shoes, except for diabetics, unless they are part of a leg brace and included in the orthopedist’s charges.

Maintenance care or maintenance occupational or physical therapy.

Maintenance speech therapy and speech therapy for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome), attention disorder, conceptual disability or mental retardation.

Occupational, speech, physical, chiropractic and naprapathy therapy/services in excess of 20 visits for the same diagnosis, unless approved in advance.

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

Diagnostic services:

As part of premarital examination.

For auditory problems.

For the determination of refractive errors of the eyes.

For surveys, case findings, research studies, screenings or similar procedures and studies, or tests which are investigational.

Hospital confinements primarily for observation or diagnostic studies which could have been performed on an outpatient basis.

Substance abuse treatment that is:

Court-ordered diagnostic evaluation,

Care in lieu of detention or correctional placement, or

Performed by other than a physician, registered clinical psychologist or licensed clinical professional counselor.

Services performed by a close relative or someone who has the same legal address as the patient.

Any service, treatment, drug or device that is considered experimental, educational or investigational; or is not recognized as generally accepted medical practice by the medical profession in the U.S. on the date the service or supply is rendered or received, as determined by the claims administrator.

Intentionally self-inflicted injury (unless due to mental illness), or an injury or illness resulting from participation in an assault or felony.

Charges for self-administered injectable medications, except insulin for diabetics and allergy injections.

Acupuncture.

Partial psychiatric hospitalization treatment unless approved in advance.

Expenses for infertility treatment other than those listed under What Is Covered or for covered treatments in excess of $50,000 per person in a lifetime.

Sterilization reversal.

Treatment or surgery to change gender or improve or restore sexual function.