These exclusions and limitations are identical to the ones on the benefit summaries above.

Exclusions

• Artificial heart, pancreas, or liver implants; bone marrow transplants except in the treatment of certain conditions (see Booklet for details)
• Certain treatments of mental disorders (e.g., biofeedback, sensitivity training, hypnosis, family or marital problems, behavior disorders, psychosexual dysfunction, learning disabilities, mental retardation)
• Cosmetic surgery; weight-loss treatment, including but not limited to surgical procedures and their reversals or revisions
• Counseling services, training or educational services, or services received to apply toward earning a degree
• Custodial care; Over-the-counter drugs and medicines
• Experimental or investigational treatments or procedures
• Genetic studies; non-prescription contraceptives; reversal of sterilization; resterilization; artificial insemination; and in vitro fertilization
• Massage therapy; music, art, dance, or recreation therapy
• Physical fitness exercise equipment and spa or club memberships
• Services covered by Workers Compensation, government-sponsored programs and other insurance (such as no-fault automobile insurance)
• Services determined by Us to be not Medically Necessary
• Services for TMJ dysfunction; dental care; jaw surgery for augmentation or reduction; services to increase vertical dimension/restore occlusion
• Services for which the Claimant has no legal obligation to pay
• Services provided before the coverage begins or after coverage ends
• Services provided for or in connection with a non-Covered Service, including complications resulting directly from non-Covered Services
• Services rendered by a member of the patient’s immediate family
• Services not licensed in Utah; Treatments or procedures outside generally accepted health care practice including holistic, homeopathic, ecological or environmental medicine; acupuncture
• Services not specifically listed in the Booklet as covered
• Services rendered by halfway houses, public or private schools
• Surgical correction of refractive errors of vision; eyeglasses, hearing aids or similar devices; routine foot care; corrective shoes and shoe accessories; personal convenience or hygiene items; special formulas, food supplements, or special diets
• Taxes, surcharges, tariffs, duties, assessments, or similar charges
• Services provided for or in connection with erectile dysfunction
• Telephone consultations, “missed” appointments, travel expenses, shipping, handling, postage, interest or finance charges
• Treatment caused by participation in illegal acts of violence; services provided as a result of a court order or other legal proceedings

Limitations

During the 9 months immediately following Your Enrollment Date, (or 18 months immediately following Your Effective Date if a Late Enrollee), NO BENEFITS will be provided for a Preexisting Condition (“PEC”). Your PEC limitation will be reduced by the aggregate periods of Creditable Coverage applicable to You as of Your Enrollment Date. A “Preexisting Condition” is a physical or mental condition (except pregnancy) for which medical advice, diagnosis, care or treatment was recommended or received within 6 months prior to the Enrollment Date. See Booklet for details regarding late enrollment and crediting of coverage.