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 and toenail maintenance. However, foot care services for diabetes, peripheral neuropathies and peripheral vascular disease are covered when Medically Necessary. • membership costs and fees associated with health clubs, weight loss programs or 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, storage or donation of blood or blood products, except for autologous donation in anticipation of scheduled services when medical management review determines 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. • health and beauty aids, cosmetics and dietary supplements. • all nutritional supplements, formulae, enteral feedings, supplies and specially formulated medical foods, whether prescribed or not 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 related to an Injury or Sickness payable under worker’s compensation or similar laws. • massage therapy. • products and supplies associated with the administration of medications that are available to be covered under the Prescription Drug Benefit. Such products and supplies include but are not limited to therapeutic Continuous Glucose Monitor (CGM) sensors and transmitters and insulin pods. • abortions, unless a Physician certifies in writing that the pregnancy would endanger the life of the mother, or the
expenses are incurred to treat medical complications due to abortion. • expenses incurred by a participant to the extent reimbursable under automobile insurance coverage. Coverage under this plan is secondary to automobile no- fault insurance or similar coverage. The coverage provided under this plan does not constitute “Qualified Health Coverage” under Michigan law and therefore does not replace Personal Injury Protection (PIP) coverage provided under an automobile insurance policy issued to a Michigan resident. This plan will cover expenses only not otherwise covered by the PIP coverage. General Limitations No payment will be made for expenses incurred for you or any one of your Dependents: • for charges by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected Injury or Sickness. • for any charges related to care provided through a public program, other than Medicaid. • for charges which would not have been made if the person did not have coverage. • to the extent that they are more than Maximum Reimbursable Charges. • to the extent of the exclusions imposed by any certification requirement shown in this plan. • for expenses for services, supplies, care, treatment, drugs or surgery that are not Medically Necessary. • for charges made by any Physician or Other Health Professional who is a member of your family or your Dependent's family. • for expenses incurred outside the United States other than expenses for Medically Necessary emergency or urgent care while temporarily traveling abroad.
HC-EXC582
01-25
Coordination of Benefits This section applies if you or any one of your Dependents is covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Coverage under this Plan plus another Plan will not guarantee 100% reimbursement.
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