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Exclusions for HSA Choice and PPO

Summary Benefits Rates	Exclusions Important information Frequently Asked Questions (FAQs)
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Dependent Eligibility

Dependents are lawful spouse and unmarried children to age 19 (23 if enrolled as a full-time student at an accredited college, university or vocational school).

Out-of-Area Dependent Children Coverage

If your enrolled dependent child(ren) resides outside the service area, we will extend benefits for treatment of an illness or injury, and women's routine healthcare (or preventive healthcare if available in the plan) and maternity services, as if care were rendered by a participating physician or provider. Out-of-area dependents must access benefits within a 30-mile radius of their residence in order for the PPO benefit level to apply.

Limitations

Pre-existing conditions even if they worsen or reoccur. Note: Your plan’s six-month pre-existing exclusion period will be shortened one day for each day you had “creditable coverage” under another health plan, provided you do not have a 63-day lapse (or longer) in coverage immediately prior to your enrollment date in our plan, or, if earlier, the first day of the waiting period for such enrollment.
All medical and surgical admissions must be authorized by ODS.
Mental illness paid up to a $2,500 maximum in a 12-month period.
Alcohol treatment up to a $4,500 maximum in a 24-month period.
A 24-month exclusion period for transplants.
ODS will not pay benefits for covered expenses to the extent that you have any other coverage for those expenses.
Inpatient rehabilitation benefits are limited to 30 days per plan year; outpatient rehabilitation benefits are limited to 30 per plan year. Spinal/Vertebrae visits may be increased to 60 days with appropriate medical necessity and prior authorization before the initial 30 days has passed.
Transplant benefits are limited to an aggregate lifetime maximum benefit of $250,000.
Hospice benefits are limited to $20,000 for home care; 170 hours/3 months respite care.

Exclusions

Services provided by a member of the patient’s immediate family.
Services or supplies which are not medically necessary.
Services and supplies for reversal of sterilization or infertility.
Services and supplies for obesity, including complications arising out of such treatment.
Surgery to alter the refractive character of the eye.
Dental examinations and treatment, except as specifically listed.
Massage or massage therapy.
Services or supplies for the treatment of sexual dysfunction or inadequacy, or those related to sex change procedures.
Treatment of personality disorders.
Experimental or investigational treatment.
Services or supplies available in whole, or in part, under any city, county, state or federal law, except Medicaid.
Charges above those considered the maximum plan allowance.
Services or supplies for which an employer is required by law to provide benefits even if you choose not to accept those benefits.
Instruction programs, including, but not limited to, those to learn to self-administer drugs or nutrition, except as specifically provided for under the outpatient diabetic instruction benefit of this plan.
Appliances or equipment primarily for comfort, convenience, cosmetics, environmental control or education.
Cosmetic/reconstructive services and supplies.
Services and supplies associated with orthognathic surgery.
Drugs for treatment of mental illness.
Chemical dependency treatment, except for alcohol treatment.

This list is representative of the limitations and exclusions to this policy. It is not a complete list. For a complete list, see the individual policy or member handbook.