• SPD Table of Contents
  1. Important Contact Information
  2. Introduction
  3. Table of Contents
  4. Plan A Schedule of Benefits
  5. Plan B Schedule of Benefits
  6. Plan C Schedule of Benefits
  7. Plan 11 Schedule of Benefits
  8. Plan 11-C Schedule of Benefits
  9. Eligibility for Active Participants
  10. Eligibility for Retiree Coverage
  11. Insurance Coverage
  12. Weekly Loss of Time Benefit
  13. Medical Benefits
  14. Prescription Drug Program
  15. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  16. Members Assistance Program (MAP)
  17. Dental Benefit
  18. Vision Benefit
  19. Hearing Benefit
  20. Special Fund Program
  21. General Plan Exclusions and Limitations
  22. Other Limitations on Your Benefits
  23. Definitions
  24. Claim and Appeal Procedures
  25. General Plan Provisions
  26. Information About the Plan
  27. Board of Trustees

General Plan Exclusions and Limitations

No benefits are provided for any of the following:

1. Any charges for an abortion, except when the life of the mother would be endangered if the fetus were carried to term or when medical circumstances warrant an abortion.
2. Adoption expenses.
3. Any charge or portion of a charge that is determined to be in excess of the amount considered to be the allowable charge (as defined on page 74).
4. Alternative, complementary or non-standard treatments, such as acupressure, aversion therapy, hair analysis, herbal treatments, hippotherapy, holistic treatments, homeopathy, hypnosis, meditation, mind-body stress management, naprapathy, naturopathy, relaxation therapy, soft-tissue manipulative therapy or yoga.
5. Any treatment or service resulting from service in the armed forces, unless the person is legally required to pay such charge.
6. Claims filed later than the time frame allowed. For medical, dental and Special Fund claims, this means the calendar year following the year in which the claim was incurred.
7. Cosmetic surgery and treatment, except for:
   1. Treatment of injuries sustained in an accident, provided the treatment is received within five years or the accident (unless a delay is medically necessary); and
   2. Breast reconstruction following a mastectomy, including surgery and reconstruction of the non-affected breast in order to produce a symmetrical appearance, prosthesis and treatment of any physical complications of all stages of the mastectomy, including lymphedema.
8. Court-ordered treatment unless the treatment is medically necessary.
9. Treatment of injuries sustained while committing (or in the act of committing) a crime punishable as a Class X, 1 or 2 felony.
10. Custodial care, which shall include services and supplies, including room and board and other institutional services that are provided to a person, whether disabled or not, primarily to assist him/her in activities of daily living, except as specifically provided as hospice or home health care under the Major Medical Benefit. 11. The cost to repair or replace damaged, lost, missing or stolen equipment, prosthetics or medications.

12. Dental services and supplies rendered for treatment of the teeth, the gums (other than for tumors, or cysts that are not the result of infections to the teeth or gums) or other associated structures primarily in connection with the treatment or replacement of teeth, including treatment rendered in connection with mouth conditions due to periodontal or periapical disease, or involving any of the teeth, their surrounding tissue or structure, the alveolar process or the gingival tissue, unless the charges are for services rendered for the repair of accidental injury to sound natural teeth within twelve months of the accident, or are specified as payable under the Dental Benefit.
13. Drug testing for employment purposes or when court-ordered.
14. Unless specifically stated as covered, services or supplies provided for the purpose of education or training, regardless of the type or purpose of the education, the recommendation of the attending doctor or the qualifications of the individual providing the education.
15. Any treatment or service due to an illness that is covered by a Workers’ Compensation Act or other similar legislation, or due to any injury arising out of or in the course of employment for profit, except for treatment or services for asbestosis.
16. Environmental control devices such as air conditioners, humidifiers, dehumidifiers, or purifiers, even if recommended by a physician.
17. Any expenses for services or treatments that are experimental, investigative or inappropriate (as defined on page 75) based on medical circumstances and/or the advanced stage of a covered person’s illness or the likelihood that the service or treatment will measurably improve the covered person’s illness or medical condition.
18. Eyeglasses or eye examinations for the correction of vision or fitting of glasses, except as specifically provided under the Vision Benefit, or with respect to refractive surgery, when covered under the Major Medical Benefit.
19. Food, nutritional supplements or vitamins. Exceptions:
    1. The Plan will cover physician-prescribed enteral or parenteral nutrition administered in accordance with a treatment plan that has been approved and is being managed by the utilization review organization. Enteral/parenteral nutrition will only be covered when it is the primary source of nutrition for a patient who is unable to take oral nutrition as the result of sickness or accidental bodily injury.
    2. In certain cases, and when pre-approved by the utilization review organization, the Plan will also cover specialized infant formula for a child with an inborn error of metabolism. (Inborn errors of metabolism are specific rare inherited conditions, such as PKU, that can be diagnosed with standard diagnostic tests.) The Plan does not consider maldigestion or intolerance to lactose, gluten, fat, soy or protein to be an inborn error of metabolism. If the Plan’s criteria are met, coverage will be provided for up to 12 months at the out-of-network payment percentage.
20. Genetic testing, unless such testing is performed in connection with an actual treatment plan for a diagnosed illness, for certain prenatal testing as specified under the Major Medical Benefit, or unless covered under the Plan’s Preventive Benefit. Note that not all prenatal genetic testing is covered – see page 45 for more information. Carrier testing, pre-implantation testing of embryos, hereditary predisposition testing, prenatal tests to determine gender, and home testing kits are not covered.
21. Hearing aids or the fitting thereof, except as specifically provided under the Hearing Benefit.
22. Marijuana, whether or not prescribed by a doctor.
23. Marriage counseling, or family counseling that is not for direct treatment of an illness.
24. Any charge for services, treatments or supplies after the maximum benefit has been paid or maximum limitation has been reached for that type of treatment or service on behalf of that individual.
25. Any treatment, service or supply furnished by a person residing within the individual’s home, or who is a member of the individual’s immediate family (a spouse, child, stepchild, brother, stepbrother, sister, stepsister, parent, or stepparent of the individual or spouse).
26. An MRI in lieu of a mammogram because the patient has had cosmetic breast surgery.
27. Services provided by a non-covered provider based on the Plan’s definitions and coverage provisions. For example, the Plan does not cover skilled nursing facilities or residential treatment facilities that do not meet the Plan’s definitions of these facilities. In addition, the Plan does not cover the services or alternative medicine providers such as massage therapists, herbalists or naturopaths.
28. Expenses for services for which you would not be legally required to pay in the absence of coverage under this Plan or another insurance plan.
29. Any service, treatment or supply rendered when the individual was not eligible for benefits, including charges incurred before the individual’s effective date or after the individual’s coverage has terminated.
30. Treatment or services that are not medically necessary.
31. Any treatment, service or supply not prescribed by a physician for the treatment and diagnosis of an illness or injury, unless the service is specifically stated as covered.
32. Any treatment or service for organ transplants, except as specified under the Major Medical Benefit (page 47).
33. Physical or occupational therapy or other therapeutic services that are provided on a group (not one-onone) basis.
34. Residential treatment facility confinements in excess of 45 days for all related confinements.
35. Any routine or preventive charges incurred in the absence of a diagnosis, except as specifically provided under the Preventive Benefit or the Major Medical Benefit.
36. Any treatment or service to treat a self-inflicted injury or illness or any injury or illness resulting from a suicide or an attempted suicide, unless the injury or illness resulted from a medical condition (including both physical and mental health conditions).
37. Sex/gender change or reassignment surgical procedures and/or complications arising from such procedures, regardless of the reason the services are performed.
38. Any treatment for sexual dysfunction, including impotence or sex transferal, except for erectile dysfunction drugs as specified on page 53.
39. Shoes including orthopedic and corrective shoes, arch supports or shoe inserts.
40. Skilled nursing facility confinements in excess of 45 days for all related confinements.
41. Special home construction or modification to accommodate a disabled person or to facilitate the use of equipment, including but not limited to wheelchair ramps and stair lifts.
42. Speech therapy for developmental and psychosocial delays, learning and educational problems, attention disorders, behavioral problems, verbal apraxia, or stuttering or stammering unless due to a specific disease or injury.
43. Any treatment provided at a surgical center that is not in the Plan’s PPO network. (This does not apply when Medicare is primary and covers the facility.)
44. Surrogacy or surrogacy fees, or charges for donor or storage services.
45. Telemedicine charges except for one-on-one real-time consultations with covered providers for services that the Plan would have covered if the same services had been provided during a face-to-face consultation.
46. Transportation except as specifically provided under the Major Medical Benefit.
47. Any treatment or service that is compensated for or furnished by the United States government or any agency thereof, unless the person is legally required to pay such charge.
48. Vision therapy or orthoptics.
49. Any treatment or service resulting from war or any act of war, declared or undeclared.
50. Treatment for weight control or smoking cessation, except as specifically provided under the Preventive Benefit or the Major Medical Benefit.

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