Medical Expense Exclusion List

Program-Specific Exclusions

The Trust Critical Care Benefit will not cover services for the following areas. For avoidance of doubt, all other medical conditions not specifically stated as a Covered Condition on the Critical Care Benefit Program page are excluded.

• Any covered services through The Trust's Supplemental Mental Health Benefit plan
• Health insurance premiums
• Medication
• Group therapy outside of IOP or PHP services
• Psychological testing, including neuropsychological testing
• Medical services related to mental health diagnoses (e.g. lab testing, emergency room hospitalizations)
• Travel expenses related to mental health appointments
• Living expenses related to mental health appointments (e.g. sober living facilities)
• Marital and family therapy
• Abortion
• Preventive Care, Early Cancer Detection, Mammogram, Well Woman Exam, Smoking and Tobacco Use Counseling
• Chiropractic care
• Gender reassignment
• Allergy testing and/or treatment
• Treatment for TMK
• Treatment for Erectile Dysfunction

Standard Cigna Exclusions

• Care for health conditions that are required by state or local law to be treated in a public facility.
• Care required by state or federal law to be supplied by a public school system or school district.
• Care for military service disabilities treatable through governmental services if you are legally entitled to
  such treatment and facilities are reasonably available.
• Treatment of an Injury or Sickness which is due to war, declared, or undeclared.
• Charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan. For example, if Cigna determines that a provider or Pharmacy is or has waived, reduced, or forgiven any portion of its charges and/or any portion of Copayment, Deductible, and/or Coinsurance amounts) you are required to pay for a Covered Expense (as shown on The Schedule) without Cigna's express consent, then Cigna in its sole discretion shall have continued the right to deny the payment of benefits in connection with the Covered Expense, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the provider or Pharmacy represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payments) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a non-Participating Provider who has agreed to charge you or charged you at an In-Network benefits level or some other benefits level not otherwise applicable to the services received.
• Charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law.
• Assistance in the activities of daily living. including but not limited to eating. bathing, dressing or other
• Custodial Services or self care activities, homemaker services and services primarily for rest, domiciliary or convalescent care. For or in connection with experimental, investigational or unproven services
• Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug or Biologic therapies or devices that are determined by the utilization review Physician to be:
  • not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed
  • not demonstrated, through existing peer reviewed, evidence based, scientific literature to be safe and effective for treating or diagnosing the condition or Sickness for which its use is proposed:
  • the subject of review or approval by an Institutional Review Board for the proposed use except as
    provided in the "Clinical Trials" sections of this plan; or the subject of an ongoing phase I. Il or Ill clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the "ClinicalTrials" sections of this plan.
• In determining whether any such technologies, supplies. treatments, drug or Biologic therapies or devices are experimental, investigational and/or unproven, the utilization review Physician may rely on the clinical coverage policies maintained by Cigna or the Review Organization. Clinical coverage policies may incorporate, without limitation and as applicable, criteria relating to U.S. Food and Drug Administration approved labeling, the standard medical reference compendia and peer-reviewed evidence-based scientific literature or guidelines.
• Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self esteem.
• The following services are excluded from coverage regardless of clinical indications: acupressure: dance therapy, movement therapy applied kinesiology, rolfing, and extracorporal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.
• Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental X-rays, examinations, repairs, orthodontics, periodontics, casts. splints and services for dental malocclusion, for
  any condition. Charges made for services or supplies provided for or in connection with an accidental Injury to teeth are covered provided a continuous course of dental treatment is started within six months of an accident.
• Medical and surgical services, initial and repeat, intended for the treatment or control of obesity, except for treatment of clinically severe (morbid) obesity as shown in Covered Expenses. including: medical and
  surgical services to alter appearance or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity, and weight loss programs or treatments, whether prescribed or recommended by a Physician or under medical supervision.
• Unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations.
• Court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan.
• Any medications, drugs. services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation.
• Medical and Hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under this plan.
• Non-medical counseling and/or ancillary services including, but not limited to Custodial Services, educational services, vocational counseling, training and rehabilitation services, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, return to work services. work hardening programs
  and driver safely courses.
• Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical
  problem and when significant therapeutic improvement is not expected
• Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies. skin preparations and test strips. except as specified in the "Home Health Services" or "Breast Reconstruction and Breast Prostheses" sections of this plan
• Private Hospital rooms and/or private duty nursing except as provided under the Home Health Services provision.
• Personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs. complimentary meals. birth announcements. and other articles which are not for the specific treatment of an Injury or Sickness.
• Artificial aids including, but not limited to. corrective orthopedic shoes, arch supports, elastic stockings, garter belts. corsets, dentures and wigs.
• Aids or devices that assist with non-verbal communications, including but not limited to communication boards. pre-recorded speech devices, laptop computers, desktop computers. Personal Digital Assistants (PDAs] Braille typewriters, visual alert systems for the deaf and memory books
• Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post cataract surgery)
• Routine refractions, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.
• All non-injectable prescription drugs. unless Physician administration or oversight is required, injectable prescription drugs to the extent they do not require Physician supervision and are typically considered self-administered drugs. non-prescription drugs. and investigational and experimental drugs, except as provided in this plan.
• Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary.
•  Membership costs or fees associated with health clubs. weight loss programs and smoking cessation programs.
• Genetic screening or pre-implantations genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease
• Dental implants for any condition.
• Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review Physician's opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
• Blood administration for the purpose of general improvement in physical condition.
• Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks
• Cosmetics, dietary supplements and health and beauty aids.
• All nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism.
• For or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit.
• Charges for the delivery of medical and health-related services via telecommunications technologies, including telephone and internet, unless provided as specifically described under Covered Expenses
• Massage therapy.