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.

Any mental health or substance abuse condition that, according to generally accepted professional standards, is not usually amenable to favorable modification.

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.

Any expense that you or your spouse 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 must first agree in writing to refund the lesser of:

The amount actually paid for such expense by the Mental Health and Substance Abuse Program; or

An amount equal to the sum you or your spouse 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.

Any benefit that you or your spouse receives or that is payable under the mandatory part of any auto insurance policy written to comply with:

A “no-fault” insurance law; or

An uninsured motorist insurance law.

Any amount that is in excess of the amount that the provider has agreed to accept for the service.

Structured sexual therapy programs, or treatment for sexual offenders or perpetrators of sexual or physical violence.

Smoking or nicotine addiction treatment.

Treatment of chronic pain (other than by psychotherapy if it is determined such pain has a psychological origin).

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.

Weight loss or personal growth treatments.

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).

Rehabilitative treatment that is associated with education, or hearing and/or vision impairment.

Charges made by any provider who is a member of a covered individual’s family.

Transportation services for non-emergency transportation between institutional care facilities, or to and from your residence.

Court-ordered treatment for a mental health and substance abuse condition that is not a covered service, as determined by the claims administrator.

Protective services ordered for a mental health and substance abuse condition that is not a covered service, as determined by the claims administrator.

Charges for which you or your spouse receives or is entitled to receive benefits by or through a public program other than Medicaid.

Charges to the extent that payment is unlawful where you reside.

Charges incurred in connection with an injury or disease covered by Workers’ Compensation or similar law.

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

Charges for late or missed appointments.

Charges you or your spouse incurs to transfer medical records.

Any charge you or your spouse incurs before your coverage effective date.

Any charge that is connected with a mental illness or injury due to a declared or undeclared act of war, including armed aggression.

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.

Provider charges, to the extent they result from a scholastic or vocational intervention, as determined by the claims administrator.

Any non-compliance penalties you or your spouse is required to pay because you or your spouse fails to follow precertification requirements.

Any charge for a non-covered service or penalty charge that you or your spouse is required to pay because you or your spouse fails to precertify a hospital admission.

Charges in excess of the maximum allowable limit.

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.