In addition to any benefit limitations and/or exclusions described elsewhere in this Plan, we will not
provide coverage for any of the following:

Acupuncture/Hypnosis/Biofeedback. We will not provide coverage for any service or care related to acupuncture treatment and acupuncture therapy, hypnosis or biofeedback.

Blood Products. We will not provide coverage for blood donor services or for the cost of blood, blood plasma, other blood products, or blood processing or storage charges when they are available free of charge in the local area. When not free in the area, we will cover blood charges, even if you donate or store your own blood, if billed by a Facility, ambulatory surgery center or a certified blood bank.

Cosmetic Services. We will not provide coverage for services in connection with elective cosmetic surgery that is primarily intended to improve your appearance and is not Medically Necessary. Examples of the kinds of services that we often determine not to be Medically Necessary include breast enlargement, rhinoplasty and hair transplants.
We will, however provide coverage for services in connection with reconstructive surgery when such service is incident to or follows surgery resulting from trauma, infection, or other disease of the part of the body involved. We will also provide coverage for reconstructive surgery due to congenital disease or anomaly of a child covered under this Plan that has resulted in a functional physical defect. We will also provide coverage for services in connection with reconstructive surgery following a mastectomy.

Criminal Behavior. We will not provide coverage for any service or care related to the treatment of an
illness, accident or condition arising out of your participation in a felony. The illegal act will be determined
by the law of the state where the criminal behavior occurred. We will not pay for treatment mandated by a court as a condition of probation.

Custodial and Maintenance Care. We will not provide coverage for any service or care that is custodial
in nature, or any therapy that we determine is not expected to improve your condition. (Custodial Care and Maintenance Care are defined in Section 2.)

Dental Care. We will not provide coverage for any service or care (including anesthesia and inpatient
stays) for treatment of the teeth, gums, or structures supporting the teeth, or any form of dental surgery,
regardless of the reason that the service or care is necessary. For example, we will not provide coverage for x-rays, fillings, extractions, braces, prosthetics, extraction of impacted teeth, treatments for gum disease, therapy or other treatments related to dental TMJ disorder or dental oral surgery.

We will, however, provide coverage for medical treatment that is directly related to an injury or
accident involving the jaw or other bone structures adjoining the teeth, including mandibular repositioning to treat TMJ. In addition, we will provide benefits for service and care for treatment of sound natural teeth provided within 12 months of an accidental injury. We will also provide the benefits for service and care that is Medically Necessary for treatment due to a congenital (present at birth) disease or anomaly.

Developmental Delay. We will not provide coverage for any service or care related to the educational
treatment of behavioral disorders together with services for remedial education, including evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral training, and cognitive rehabilitation. This exclusion applies to services, treatment, or educational testing and training related to behavior (conduct) problems, learning disabilities, or developmental delays. Special education, including lessons in sign language, to instruct a participant whose ability to speak has been lost or impaired to function without that ability, is not covered.

Durable Medical Equipment; Prosthetic Devices; Medical Supplies. We will not provide coverage for
any service or care related to:

• (a) Disposable supplies (for examples, diapers, chux, sponges, syringes, incontinence pads, reagent strips, and bandages prescribed for one-time use outside of a provider site), except that this exclusion does not apply to diabetic supplies covered elsewhere in the Plan;
• (b) Wigs, hair prosthetics, or hair implants, except wigs necessitated as a result of chemotherapy or radiation therapy covered under the Plan up to a maximum of $800 benefit per Covered Person per lifetime;
• c) Custom-made shoes and arch supports; and
• (d) The purchase or rental of household fixtures, including elevators, escalators, ramps, seat lift chairs, stair glides, saunas, whirlpool baths, swimming pools, home tracking systems, exercise cycles, air or unit air conditioners, humidifiers, dehumidifiers, emergency alert equipment, handrails, heat appliances, improvements made to a house or place of business, and adjustments made to vehicles.

Experimental and Investigational Treatment. Unless otherwise required by law, we will not provide coverage for any service or care that consists of a treatment, procedure, drug, biological product, or medical device (collectively referred to as “Service”), an inpatient stay in connection with a Service, or treatment of a complication related to a Service if, in our judgment, the Service is Experimental or Investigational. See Section 10 for a description of your right to an external appeal of our determination that a Service is Experimental or Investigational.

“Experimental or Investigational” means that we determine the Service is:

• (a) Not of proven benefit for a particular diagnosis or for treatment of a particular condition;
• (b) Not generally recognized by the medical community, as reflected in published, peerreviewed medical literature, as effective or appropriate for a particular diagnosis or for treatment of a particular condition; or
• (c) Not of proven safety for a person with a particular diagnosis or a particular condition, i.e., is currently being evaluated in research studies to ascertain the safety and effectiveness of the treatment on the well being of a person with the particular diagnosis or in the particular condition.
  Governmental approval of a Service will be considered in determining whether the Service is Experimental or Investigational, but the fact that a Service has received governmental approval does not necessarily mean it is of proven benefit or appropriate or effective treatment for a particular diagnosis or condition.
• In determining whether a Service is Experimental or Investigational, we may, in our discretion, require that any or all of the following five criteria be met:
• (a) A Service that is a medical device, drug, or biological product must have received final approval of the United State Food and Drug Administration (FDA) to market for the particular diagnosis or for your particular condition. Any other approval granted as an interim step in the FDA regulatory process, e.g., an Investigational Device Exemption or an Investigational New Drug Exemption, is not sufficient. Once final FDA approval has been granted for a particular diagnosis or for your particular condition, use of the Service (medical device, drug, or biological product) for another diagnosis or condition may require that any or all of the five criteria be met.
• (b) Published, peer-reviewed medical literature must provide conclusive evidence that the Service has a definite, positive effect on health outcomes. The evidence must include reports of well-designed investigations that have been reproduced by nonaffiliates, authoritative sources with measurable results, backed up by the positive endorsements of
  national medical bodies or panels regarding scientific efficacy and rationale.
• (c) Published, peer-reviewed medical literature must provide demonstrated evidence that, over time, the Service leads to improvement in health outcomes, i.e., the beneficial effects of the Service outweigh any harmful effects.
• (d) Published, peer-reviewed, medical literature must provide proof that the Service is at least as effective in improving health outcomes as established services or technology, and established medical services or technology cannot be used due to medical reasons.
• (e) Published, peer-reviewed, medical literature must provide proof that improvement in health outcomes, as defined in paragraph (c) above, is possible in standard conditions of medical practice, outside of clinical investigatory settings.

  This exclusion shall not limit in any way benefits available for prescription drugs otherwise covered under this Plan which have been approved by the FDA for the treatment of certain types of cancer, when those drugs are prescribed for the treatment of a type of cancer for which they have not been approved by the FDA, so long as the drugs prescribed meet the requirements of Section 4303 (q) of the New York State Insurance Law.

Free Care. We will not provide coverage for any service or care that is furnished to you without charge or
that would have been furnished to you without charge if you were not covered under the Plan. This exclusion applies even if a charge for the service or care is billed. When service or care is furnished to you by your brother, sister, mother, father, son or daughter, or the spouse of any of them, we will presume that the service or care would have been furnished without charge.

Genetic Testing.We will generally not provide coverage for genetic testing or information; however,
certain genetic tests may be covered if prospectively reviewed and approved by the Plan’s case management consultant. Check with the case management consultant prior to testing to find out if it will be covered by the Plan.

Government Programs. We will not provide coverage for any service or care for which benefits are payable under Medicare or any other federal, state, or local government program, except when required by state or federal law. When you are eligible for Medicare, we will reduce our benefits by the amount Medicare would have paid for the services. Except as otherwise required by law, this reduction is made even if you fail to enroll in Medicare, you do not pay the charges for Medicare, or you receive services at a Facility that cannot bill Medicare. If this plan is secondary to Medicare due to the Medicare Eligibility of the participant, and the Provider does not accept Medicare reimbursement for services, the Plan will pay only what it would have paid if the Provider had accepted Medicare reimbursement.
However, this exclusion will not apply to you if one of the following applies:

• (a) Eligibility for Medicare by Reason of Age. You are entitled to benefits under Medicare by
  reason of your age, and the following conditions are met:
  1. The Employee is in “current employment status” (working actively and not retired); and
  2. The Employee’s employer maintains or participates in a group health plan that is required by law to have this Plan pay its benefits before Medicare.
• (b) Eligibility for Medicare by Reason of Disability Other Than End-stage Renal Disease.
  You are entitled to benefits under Medicare by reason of disability (other than end-stage renal disease); and the following conditions are met:
  1. The Employee is in “current employment status” (working actively and not retired); and
  2. The Employee’s employer maintains or participates in a large group health plan that is required by law to have this Plan pay its benefits before Medicare.
  3. Eligibility for Medicare by Reason of End-stage Renal Disease.
  4. You are entitled to benefits under Medicare by reason of end-stage renal disease, and there is a waiting
     period before Medicare coverage becomes effective. We will not reduce this Plan’s benefits, and we will provide benefits before Medicare pays, during the waiting period. We will also provide benefits before Medicare pays during the coordination period with Medicare. After the coordination period, Medicare will pay its benefits before we provide
     benefits under this Plan.

Late Claims. We will not provide coverage for any claim submitted more than 15 months after the service was rendered or the supply was furnished.

Military Service-Connected Conditions. We will not provide coverage for any service or care related to
any military service-connected disability or condition if the Veterans Administration (VA) has the responsibility to provide the service or care.

No-Fault Automobile Insurance. We will not provide coverage for any service or care for which benefits are recovered or recoverable under mandatory no-fault automobile insurance.

Non-Covered Service. We will not provide coverage for any service or care that is not specifically escribed in this Plan as a covered benefit or that is related to service or care not covered under this Plan, even when a provider considers the service or care to be Medically Necessary and appropriate. For example, we will not provide coverage for any service or care that is not primarily medical in nature, including, but not limited to the following: radio, telephone, television, air conditioner, humidifier, dehumidifier, air purifiers, beauty and barber services, commodes, exercise equipment, arch supports, foot orthotics, or orthotics used solely for sports.

Nutritional Therapy. We will not provide coverage for any service or care related to nutritional therapy,
unless we determine that it is Medically Necessary, or that it qualifies as diabetes self management education. We will not provide coverage for commercial weight loss programs or other programs with dietary supplements.

Podiatry and Routine Foot Care. Except as otherwise provided in the Plan, we will not cover routine care of the feet, including treatment of corns, calluses or toenails, unless the charges are for the removal of nail roots or are in conjunction with the treatment of a metabolic or peripheral vascular disease.

Prohibited Referral. We will not provide coverage for any pharmacy, clinical laboratory, radiation therapy, physical therapy, x-ray or imaging services that were provided pursuant to a referral prohibited by the New York Public Health Law.

Self-Help Diagnosis, Training and Treatment. We will not provide coverage for any service or care related to self-care diagnosis, training and treatment for recreational, vocational, employment or educational purposes.

Services Starting Before Coverage Begins. If you are receiving care on the day your coverage under this Plan begins, we will not provide coverage for any service or care you receive:

• (a) Prior to the first day of your coverage under this Plan; or
• (b) On or after the first day of your coverage under this Plan if that service or care is covered under any other health benefits contract, program or plan.

Sexual Dysfunction. We will not provide coverage for treatment of sexual dysfunction unless Medically
Necessary, as determined by the case management consultant.

Smoking Cessation Programs. We will not provide coverage for smoking cessation programs, including
but not limited to smoking deterrent patches, gums or devices.

Special Charges. We will not provide coverage for charges billed to you for telephone consultations,
missed appointments, new patient processing, interest, copies of provider records, or completion of claims forms. This exclusion applies to any late charges or extra day charges that you incur upon discharge from a Facility because you did not leave the Facility before the Facility’s discharge time. It also applies to additional fees charged by Professional Providers or Facilities because care is rendered after hours or on holidays.

Social Counseling and Therapy. We will not provide coverage for any service or care related to family,
marital, religious, sex or other social counseling or therapy except unless specifically provided under another section of this Plan.

Timothy’s Law Exclusions. Any benefits provided pursuant to “Timothy’s Law” will not apply to 1)
individuals who are incarcerated, confined or committed to a local correctional facility or prison, or a custodial facility for youth operated by the office of children and family services; 2) services provided solely because such services are ordered by a court; or 3) services determined to be cosmetic on the grounds that changing or improving an individual’s appearance is justified by the individual’s mental health needs.

Transsexual Surgery and Related Services.We will not provide coverage for any service or care related or leading up to transsexual surgery, including, but not limited to hospitalizations, hormone therapies, procedures, treatments or related services designed to alter the physical characteristics of your biologically determined gender to those of another gender, unless such surgery is determined to be Medically Necessary. Medical Necessity determinations are made by the Plan and are subject to retrospective denial and external review. Contact the case management consultant before assuming coverage.

Unlicensed Provider. We will not provide coverage for any service or care that is provided or prescribed
by an unlicensed provider or that is outside the scope of licensure of the duly-licensed provider rendering the service or care.

Vision and Hearing Examinations, Therapies and Supplies. Unless otherwise provided for in this Plan, we will not provide coverage for any service or care related to:

• (a) Routine eye or hearing examinations;
• (b) Eyeglasses, lenses, frames, contact lenses or hearing aids;
• (c) Vision or hearing therapy, vision training or orthoptics; or
• (d) Surgery or medical treatment to correct refractive errors, such as LASIK.

War. We will not provide coverage for any service or care which results from war or act of war (whether
declared or undeclared); participation in a felony, riot or insurrection; service in the Armed Forces or units
auxiliary thereto.

Weight Loss Services. We will not provide coverage for any service or care in connection with weight
reduction or dietary control, including, but not limited to gastric stapling, gastric by-pass, gastric bubble, or
other surgery or service, unless we determine that such care or service is Medically Necessary. Medically Necessity would include, but is not limited to cases of morbid obesity where weight is at least twice the ideal amount specified for frame, age, height, and gender in the most recent generally accepted life insurance tables, and where the patient has an underlying medical condition resulting from or affected by obesity. Medical Necessity determinations are subject to appeal and external review.

Workers’ Compensation. We will not provide coverage for any service or care for which benefits are provided under any State or Federal workers’ compensation or similar law.