Limitations & Exclusions 36. Organ, tissue and bone marrow transplants considered Experimental or Investigational Treatment; 37. Organ, tissue and bone marrow transplants treatment, including medical and Hospital Services for a Member who is a donor or prospective donor when the recipient of an organ, tissue or bone marrow transplant is not a Member. Covered Services for a non-member donor must be directly related to a covered transplant of a Member and are covered up to 12 months from the date of the transplant surgery; 38. Out-of-Network opinions, except as a Covered Benefit. Independent Medical Review of Denial of coverage by a Plan Provider for Experimental and Investigational Treatment is available; refer to the “Independent Medical Review” section; 39. OTC drugs, medications, and supplies are not a Covered Benefit, except as specified in this Membership Agreement and Evidence of Coverage & Disclosure Form; 40. Penile implants and services related to the implantation of penile prostheses, except as Medically Necessary to treat direct physical trauma, tumor, or physical disease to the circulatory system or the nerve supply; 41. Personal lodging, meals, travel expenses and all other non-medical expenses; 42. Personal or comfort items which are non-medical, environmental enhancements or environmental adaptations, modifications to dwellings, property or motor vehicles, adaptive equipment and training in operation and use of vehicles; 43. Physical exams, evaluations and reports including those for employment, insurance, licensing, school, sports, recreation, premarital purposes, or required for or by court proceedings, unless timing and scope coincide with covered periodic health appraisal exams; 44. Prescription drugs and accessories not Medically Necessary or in accordance with professionally recognized standards of care; non-prescription drugs or medications, including over the counter drugs; non-FDA Approved Drugs; Generic equivalents not approved as substitutable by the FDA; non-FDA approved Treatment Investigational New Drugs; National Cancer Institute Group C cancer drugs that are used for purposes other than those purposes approved by the FDA or the National Cancer Institute; 45. Reversal of voluntary sterilization or of voluntary induced infertility; 46. Routine foot care, including trimming of corns, calluses and nails, unless Medically Necessary; 47. Temporomandibular Joint (TMJ) Disorders Services that are not Medically Necessary. Intraoral appliances related to TMJ are limited to one (1) oral splint or appliance and are limited to an $800.00 maximum lifetime benefit. Intra-oral appliance and placement services which cost more than the lifetime limit of $800.00, for intra-oral positioning devices and related services, are not covered. 48. Transportation services unless Medically Necessary and authorized by the Medical Director or unless necessitated by an Emergency; Non-Emergency medical and psychiatric transport is covered when medically necessary. 49. Vision care except as specified as Covered Benefits; 50. Vocational Rehabilitation;
V A L L E Y H E A LT H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M 72
