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Medicare Covered Services

Mental Health Services

Military Service Connected Injury/Illness Not Medically Necessary Nursery Care

Nursing Home, Skilled Nursing Facility, Extended Care, or Personal Care Facility Obesity Treatment or Weight Loss Therapies Pre-existing Conditions Refractive Eye Surgery Rehabilitation Services

Related Provider

Residential Treatment Facility Retainer Fees

Scope of License

Services Not Specifically Included as Benefits Sex Transformations

Sexual Dysfunction

Smoking Cessation Programs Speech Therapy

Not covered to the extent that charges for such services or supplies are paid or payable under Medicare, whether or not the participant has such Medicare coverage, whether or not Medicare benefits are claimed or received, or whether or not the participant has elected to obtain such Medicare coverage if eligible. Not covered when the primary diagnosis is substance abuse, alcohol abuse, drug abuse, or a combination of alcohol and drug abuse. Not covered, except in those cases where enforcement would be prohibited by law. Not covered. Hospital nursery care of a healthy newborn child is not covered, except for benefits provided under High Option for Children. Not covered.

Not covered, regardless of any claim of medical necessity, degree of obesity or clinical diagnosis. Not covered. Not covered. Not covered, unless otherwise specified in this Plan Document. Services rendered by a provider (physician or other provider) who is related to the participant by blood or marriage or who regularly resides in the participant’s household are not covered. Not covered.

Fees paid for the purpose of retaining the services of a health care provider are not covered. Services rendered by a physician or other provider not practicing within the scope of his license at the time and place service is rendered are not covered. Not covered.

Not covered.

Services for sexual function, sexual dysfunction, or inadequacies not related to organic disease are not covered. Not covered.

Not covered when services are provided for maintenance speech, delayed language development, articulation disorders, learning disabilities, attention disorders,


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