The Medical Program, administered by CIGNA, does not cover the following expenses (except where indicated otherwise). The claims administrator makes a final determination as to whether an expense is excluded from coverage.

Charges incurred before your coverage effective date.

Services, treatments, and supplies that are not reasonably necessary for medical care or to treat an illness or injury, as determined by the claims administrator (except as specifically outlined under preventive care).

Medicine, supplies, or services that are not ordered by a properly licensed physician (or another properly licensed practitioner of the healing arts) who is acting within the scope of his or her license.

Testing or checkup procedures that are not necessary to diagnose or treat an illness or injury (except as specifically outlined under preventive care).

Educational or experimental treatments, procedures, devices, drugs, or medicines for which one or more of the following are true:

The service or supply is not approved for marketing by the Food and Drug Administration at the time the device, drug, or medicine is furnished;

The treatment method is not approved by the American Medical Association or the appropriate medical specialty society, or published in authoritative medical and scientific material; or

The treatment, procedure, device, or drug is the subject of ongoing trials to determine tolerated dose, toxicity, safety, or efficacy.

Routine physicals or mental health or substance abuse examinations and administrative documentation that are not required for health reasons but are required for (but not limited to):

Employment, insurance, school, or athletic exams;

Government licenses; or

Court-ordered, forensic, foreign travel, or custodial evaluations (except if the physical examination would have been performed as part of a routine exam and is within the scope of regular preventive care services covered under the Retiree Group Health Program).

Routine physical exams received under the CIGNA Open Access Plus option by out-of-network providers.

Vaccinations and inoculations for any purpose, including non-employment-related foreign travel (except as specifically outlined under preventive care).

Eyeglass lenses, frames, and contact lenses (except for the first pair of contact lenses or eyeglasses to treat keratoconus or post-cataract surgery).

Routine hearing aids or the fitting thereof.

Charges associated with the replacement of an external prosthetic appliance due to loss, theft, or destruction; or for any biomechanical external prosthetic appliance.

Tests and treatments that are directly related to the actual or attempted impregnation or fertilization that involves the covered individual as a surrogate, donor, or recipient, including (but not limited to):

Artificial insemination;

In vitro fertilization;

Infertility surgical treatment;

Gamete intrafallopian transfer (GIFT);

Zygote intrafallopian transfer (ZIFT); and

Depo-Provera when administered in the office of a provider who does not participate in the network (except as part of adjunctive therapy and palliative treatment of inoperable, recurrent, and metastatic endometrial or renal carcinoma).

Services or supplies that are related to penile prostheses, except appliances such as semirigid internal or erectoid vacuum external prosthetics used to correct a neurogenic bladder of organic etiology.

Services or supplies that are related to gender reassignment surgery, including hormonal therapy.

Services or supplies that are related to the reversal of voluntary sterilization.

Cosmetic surgery, unless:

While covered under the Medical Program, you are injured and your injury results in bodily damage that requires reconstructive surgery; or

It qualifies as reconstructive surgery following medically necessary surgery for the specific illness or injury; or

It is required to provide or restore a normal bodily function.

Services or supplies that are related to breast augmentation (except as outlined immediately above).

Nursing care and speech, occupational, or physical therapy provided by you, your spouse/domestic partner, or you or your spouse/domestic partner’s child, sibling, or parent.

Exercise and maintenance therapies designed to improve general physical condition, including (but not limited to) Phase III cardiac and pulmonary rehabilitation.

Outpatient rehabilitative therapy provided by a licensed physical, occupational, or speech therapist that is neither short-term nor restorative in nature, or that is in excess of the stated benefit level.

Routine outpatient treatment of a structural imbalance, distortion, or subluxation of the vertebrae (except for outpatient rehabilitative therapy, up to the maximum benefit level).

Routine chiropractic adjustments and manipulation, except for the treatment of a specific musculoskeletal disorder, up to the maximum benefit level.

Custodial care that helps with functions of daily living and personal needs.

Educational services or supplies, when the primary purpose is one of the following:

Training in the activities of daily living (except training that is directly related to an illness or injury that results in a loss of a previously demonstrated ability);

Scholastic instruction;

Vocational training;

Treatment of a learning disability; or

Prenatal instruction and exercise classes.

Educational services or supplies also include any service or supply that is designed to promote development beyond any level of function previously demonstrated.

Charges made by a provider, to the extent they result from scholastic, educational, or vocational training (as determined by the claims administrator).

Consumable medical supplies, except as noted in the “What Is an Expense That May Be a Covered Expense – Medical Program” section.

Non-medical services and supplies, such as:

Air conditioners;

Air filters or non-allergenic blankets; and

Modifications made to a home, property, or automobile (such as ramps, elevators, spas, air conditioners, and car hand controls).

Artificial aids, including (but not limited to) corrective orthotic devices and orthotic shoes (except if medically necessary), dentures, garter belts, corsets, and wigs.

Hygienic or self-help items, environmental control items, and institutional or athletic items.

Charges made by a physician for, or in connection with, a surgery that exceeds the following maximum (only applies if you or your spouse/domestic partner receives care from a non-participating provider): When two or more surgical procedures are performed at one time, the maximum amount covered is the amount that otherwise would be covered for the most expensive procedure, and one-half of the amount that would otherwise be covered for all surgical procedures.

Charges made by an assistant or co-surgeon in excess of 20% of the primary surgeon’s allowable charge. These charges apply only if you or your spouse/domestic partner receives care from a non-participating provider.

Any charge that is made for or in connection with tired, weak, or strained feet for which treatment consists of routine foot care, including (but not limited to) the removal of calluses and corns, or the trimming of nails (unless medically necessary for orthotics or corrective shoes).

Nutritional supplements provided in the home setting for a condition such as diabetes mellitus, anorexia, bulimia, and amino acid deficiency.

Transportation expenses via an air ambulance, unless medically necessary for the specific illness or injury (the claims administrator determines the medical necessity for an air ambulance).

Non-covered services and penalties associated with the failure to precertify a hospital admission.

Charges related to an injury or disease that is covered by Workers’ Compensation or similar law.

Charges for or in connection with an injury that arises out of or in the course of any employment for wage or profit.

Services and supplies you or your spouse/domestic partner receives:

By or from the U.S. government, or any other government unless payment of the charge is required by law; or

By any law or government plan under which you or your spouse/domestic partner is or could be covered.

Charges related to a sickness or injury due to a declared or undeclared act of war.

Charges in connection with injuries that result from acts of armed aggression by covered individuals who commit such acts while covered under the Program.

Court-ordered treatments, unless deemed medically necessary for the specific illness or injury.

Charges for you or your spouse/domestic partner that would in any way be paid or be entitled to payment by or through a public program (other than Medicaid).

Charges for which payment is unlawful where you or your spouse/domestic partner resides when the expense is incurred.

Charges that you or your spouse/domestic partner is not legally required to pay.

Charges that would not have been paid if you had no coverage.

Charges for late or missed appointments.

Charges related to the transfer of medical records.

Charges incurred as a result of an accident for which, in the opinion of the claims administrator, third-party liability exists.

Expenses under the mandatory part of any auto insurance policy written to comply with:

A “no-fault” insurance law; or

An uninsured motorist insurance law.

Elective medical care that is received outside the United States (only emergency care, as determined by the claims administrator, is covered).

Organ transplant travel services associated with cornea transplants, costs incurred due to travel within 60 miles of the home, laundry bills, telephone bills, alcohol and tobacco products, and transportation charges that exceed coach class rates. The Program does not pay benefits if you or your covered spouse/domestic partner is a donor.

Dental services, other than those listed under the “What Is an Expense That May Be a Covered Expense – Medical Program” section, or for oral surgery to remove impacted teeth, or to operate on gums or mouth as long as the operation is not performed for routine extractions or repairing of teeth.

Dental services rendered in a case of temporomandibular joint (TMJ) dysfunction syndrome that affects the jaw but not the teeth.

Charges in excess of the maximum reimbursable charges.

Charges that a third party is obligated to cover, such as under another plan or insurance policy, or a tort recovery or Workers’ Compensation recovery by you or your spouse/domestic partner.