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<br />SB-A2
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<br />3.
<br />
<br />Custodial care or rest cures.
<br />
<br />4.
<br />
<br />Cosmetic procedures (except when Medically Necessary) and all Health
<br />Services related thereto, including, but not limited to, pharmaceutical
<br />regimes, nutritional procedures or treatments, plastic surgery,
<br />mammoplastic reconstruction and reconstructive surgery.
<br />
<br />5.
<br />
<br />In vitro fertilization, intra-fallopian transfer treatment, keratotomies,
<br />heart transplants, lung transplants, any invasive procedure intended
<br />primarily for treatment of morbid obesity, including gastric bypasses and
<br />JeJunal bypasses or experimental medical, surgical, or psychiatric
<br />procedures and pharmacological regimes and associated health services.
<br />
<br />6.
<br />
<br />Health Services not provided by or under the direction of a Participating
<br />Primary Care Physician or Psychiatric Primary Provider, except in
<br />Emergency situations (described in this section under C) or referral
<br />services authorized in writing in advance by Health Plan (described in
<br />this section under B. ).
<br />
<br />7.
<br />
<br />Hearing aids, eye glasses, contact lenses, or the fitting thereof.
<br />
<br />8.
<br />
<br />Such services as television, telephone, barber or beauty service, guest
<br />service and similar incidental services and supplies which are not
<br />Medically Necessary.
<br />
<br />9.
<br />
<br />Mental Health Services which are (a) rendered in connection with Mental
<br />Illnesses not classified in the International Classification of Diseases
<br />of the U.S. Department of Health and Human Services, (b) extended beyond
<br />the period necessary for evaluation and diagnosis of learning and
<br />behavioral disabilities or for mental retardation, or (c) for marriage
<br />counseling, when such services extend beyond the period necessary for
<br />short-term evaluation or crisis intervention, or (d) for Mental Illnepses
<br />which, according to generally accepted professional standards, are not
<br />usually amenable to favorable modification.
<br />
<br />10.
<br />
<br />The services of registered nurses and licensed practical nurses with the
<br />same legal residence as, or who are members of, a Covered Person's family
<br />including spouses, brothers, sisters, parents or children.
<br />
<br />11.
<br />
<br />Physical, psychiatric, or psychological examinations or testing, or
<br />vaccinations, immunizations, treatments, or testing not otherwise covered
<br />under this Contract, when such services are for purposes of obtaining or
<br />maintaining employment or insurance, or otherwise relating to employment
<br />or insurance, or relating to Judicial or administrative proceedings or
<br />orders, or which are conducted for purposes of medical research, or which
<br />are conducted to obtain or maintain a license of any type.
<br />
<br />12.
<br />
<br />Travel and transportation expenses, even though prescribed by a
<br />Participating Physician, except as provided for in this section under C.
<br />
<br />13.
<br />
<br />Outpatient services (including hospital emergency room services) and all
<br />associated expenses obtained during normal physician office hours, unless
<br />authorized in advance by the Health Plan or Health Plan's Psychiatric
<br />Primary Provider or unless necessary because of an Emergency, except as
<br />specified in this section under E.2. (b) of Benefits.
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