Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace Detailed Table of Contents
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Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace   
How the Retiree Group Health Program Works
What Expense Is Excluded From Being a Covered Expense – Mental Health and Substance Abuse Program
The following mental health and substance abuse services are not covered. The claims administrator makes a final determination as to whether an expense is excluded from being a covered expense.
 | Services that extend beyond the period that is necessary to evaluate and diagnose mental retardation or autism.
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| Any mental health or substance abuse condition that, according to generally accepted professional standards, is not usually amenable to favorable modification.
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| Services that are within the scope of usual mental health and substance abuse practice, but are normally provided by a non-mental health or substance abuse clinician.
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| Any expense that you or your spouse/domestic partner incurs because of an accident and for which (in the claims administrator’s opinion) a third-party liability exists. The Mental Health and Substance Abuse Program pays benefits as otherwise payable under the Program. However, you or your spouse/domestic partner must first agree in writing to refund the lesser of:
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 | The amount actually paid for such expense by the Mental Health and Substance Abuse Program; or
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| An amount equal to the sum you or your spouse/domestic partner actually receives from the third party (or the insurance carrier of the third party) for such expense at the time that such third-party liability is determined and satisfied – whether by settlement, judgment, arbitration, or otherwise.
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| Any benefit that you or your spouse/domestic partner receives or that is payable under the mandatory part of any auto insurance policy written to comply with:
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| A “no-fault” insurance law; or
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| An uninsured motorist insurance law.
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| Any amount that is in excess of the amount that the provider has agreed to accept for the service.
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| Structured sexual therapy programs, or treatment for sexual offenders or perpetrators of sexual or physical violence.
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| Smoking or nicotine addiction treatment.
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| Treatment of chronic pain (other than by psychotherapy if it is determined such pain has a psychological origin).
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| Narcotic maintenance therapy in which an agonist, antagonist, or agonist/antagonist drug is used for chronic administration. Detoxification services related to such chronic drug maintenance use also are excluded from coverage.
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| Weight loss or personal growth treatments.
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| Rehabilitative treatment associated with permanent or temporary disability that results from an accident or injury (this applies to circumstances where such treatment is part of a comprehensive rehabilitation program).
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| Rehabilitative treatment that is associated with education, or hearing and/or vision impairment.
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| Charges made by any provider who is a member of a covered individual’s family.
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| Transportation services for non-emergency transportation between institutional care facilities, or to and from your residence.
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| Court-ordered treatment for a mental health and substance abuse condition that is not a covered service, as determined by the claims administrator.
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| Protective services ordered for a mental health and substance abuse condition that is not a covered service, as determined by the claims administrator.
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| Charges for which you or your spouse/domestic partner receives or is entitled to receive benefits by or through a public program other than Medicaid.
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| Charges to the extent that payment is unlawful where you reside.
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| Charges incurred in connection with an injury or disease covered by Workers’ Compensation or similar law.
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| Charges that you or your spouse/domestic partner is not legally required to pay.
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| Charges for late or missed appointments.
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| Charges you or your spouse/domestic partner incurs to transfer medical records.
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| Any charge you or your spouse/domestic partner incurs before your coverage effective date.
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| Any charge that is connected with a mental illness or injury due to a declared or undeclared act of war, including armed aggression.
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| Services not ordered by a properly licensed physician (or another properly licensed practitioner of the healing arts) acting within the scope of his or her license.
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| Provider charges, to the extent they result from a scholastic or vocational intervention, as determined by the claims administrator.
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| Any non-compliance penalties you or your spouse/domestic partner is required to pay because you or your spouse/domestic partner fails to follow precertification requirements.
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| Any charge for a non-covered service or penalty charge that you or your spouse/domestic partner is required to pay because you or your spouse/domestic partner fails to precertify a hospital admission.
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| Charges in excess of the maximum allowable limit.
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| Charges that a third party is obligated to cover, such as under another plan or insurance policy, tort recovery, or Workers’ Compensation recovery by you or your spouse/domestic partner. |
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