• Care, services, diagnostic procedures, or operations for diagnostic purposes not related to an injury or sickness, except as provided for by the terms of the plan
• Care, services, diagnostic procedures, or operations that are
  
  • considered medical research;
  • investigative/experimental technology (unproven care, treatment, procedures, or operations);
  • not recognized by the U.S. medical profession as usual and/or common;
  • determined by DMBA not to be usual and/or common medical practice; or
  • illegal
• That a physician might prescribe, order, recommend, or approve services or medical equipment does not, of itself, make it an allowable expense, even though it is not specifically listed as an exclusion.
  
  Investigative/experimental technology means treatment, procedure, facility, equipment, drug, device, or supply that does not, as determined by DMBA, meet all of the following criteria:
  
  • The technology has final approval from all appropriate governmental regulatory bodies, if applicable. (Federal Drug Administration approval does not necessarily mean a service is not investigational/experimental.)
  • The technology is available in significant numbers outside the clinical trial or research setting.
  • The available research about the technology is substantial.
  For plan purposes, substantial means sufficient to allow DMBA to conclude the technology is
  
  • both medically necessary and appropriate for the covered person’s treatment,
  • safe and efficacious,
  • more likely than not to be beneficial to the covered person’s health, and
  • generally recognized as appropriate by the regional medical community as a whole.
  A service, care, treatment, or operation falling in these categories will continue to be excluded until the plan administrator determines that it meets all such criteria and specifically includes it as a covered service in the plan.

• Sterilization procedures, unless the covered individual meets DMBA’s current medical criteria
• Abortions, unless (i) the pregnancy is the result of rape or incest, (ii) the life or health of the mother would be in serious jeopardy, or (iii) the fetus has severe defects that will not allow it to survive beyond birth*
• Emergency contraception (e.g., levonorgestrel, ulipristal acetate), unless sought (1) as a result of rape or incest or (2) in anticipation of or following unprotected intercourse that if pregnancy were to result either (i) the life or health of the female would be in serious jeopardy if the fetus were carried to term or (ii) there is an increased risk that the fetus may have severe defects that will not allow it to survive beyond birth
• Care, services, diagnostic procedures, or operations in relation to the following infertility services: direct intraperitoneal insemination (DIPI), fallopian tubal sperm perfusion (FSP), intra-follicular insemination (IFI), and the GIFT procedure
• Donor eggs, sperm, or embryos (including services related to procurement of donor material) used in assisted reproductive technologies
• Cryopreservation (freezing), storage, and thawing of sperm, eggs, embryos, and ovarian and/or testicular tissue
• Reversal of sterilization procedures
• Planned home delivery for childbirth and all associated costs
• All pregnancy- and birth-related expenses (prenatal and postnatal) of an individual (including a covered individual) acting as a surrogate or gestational carrier**
• Services, drugs, or supplies to treat sexual dysfunction, erectile dysfunction, enhance sexual performance, or increase sexual desire, except the external erectile vacuum erection device under the durable medical equipment benefit

* Services related to an intrauterine fetal death or a miscarriage/spontaneous abortion occurring from natural causes are not subject to this exclusion.
** An infant born to a surrogate or gestational carrier is eligible for coverage from the date on which the infant became a dependent of the participant.

• General/multipurpose equipment or facilities, including related appurtenances, controls, accessories, or modifications thereof, including but not limited to buildings, motor vehicles, air conditioning, air filtration units, exercise equipment or machines, and vibrating chairs and beds; as well as certain medical equipment, including air filtration systems, dehumidifiers, hearing devices, humidifiers, nonprescription braces and orthotics, learning devices, spa and gym memberships, vision devices, and modifications associated with activities of daily living, homes, or vehicles
• Upgrade or replacement of medical equipment when the existing equipment is still functional, unless otherwise specified by the plan
• Replacement of a device when damage is due to the covered individual’s abuse or neglect
• Maintenance, repair, and upkeep of durable medical equipment

• Care, services, or supplies primarily for cosmetic purposes (whether or not for psychological or emotional reasons) to improve or change appearance or to correct a deformity without restoring a physical bodily function, except for injuries suffered while covered by the plan or as otherwise provided for by the terms of the plan
• Care, services, or supplies that are not medically necessary as defined by the plan*
• Care, services, or supplies for convenience, contentment, or other non-therapeutic purposes

* Covered individuals will receive benefits under this plan only for services that are determined to be medically necessary and not investigative/experimental technology. That a provider has prescribed, ordered, recommended, or approved services, or has informed the covered individual of its availability, does not in itself make it medically necessary or a covered expense. The plan administrator will make the final determination of whether any services are medically necessary or considered investigative/experimental technology. If a particular service is not medically necessary as defined by this plan and determined by the plan administrator, the plan will not pay for any charges related to such services, and any such charges will not be counted toward the out-of-pocket maximum. The charges will be outside the plan and will be the covered individual’s financial responsibility.

• Mental or emotional conditions without manifest psychiatric disorder as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or with non-specific symptoms
• Counseling, including but not limited to marriage and family counseling, recreational therapy, or other therapy*
• Services and materials in connection with surgical procedures undertaken to remedy a condition diagnosed as psychological
• Care and services for the abuse of or addiction to alcohol or drugs, except as provided for by the terms of the plan
• Care and services for learning disabilities or physical or mental developmental delay, including pervasive developmental disorders or cognitive dysfunctions, except as provided for by the terms of the plan
• Mental health services provided in a day treatment program or residential care facility, unless the individual receiving such services meets the requirements for the mental health alternative care benefit, as defined by DMBA, and as otherwise provided for by the terms of the plan
• Custodial and supportive care for covered individuals with mental illness

* Counseling for a covered individual’s diagnosed psychiatric disorder is not considered family or marriage therapy even with the family or spouse present.

• Services of any practitioner of the healing arts who
  
  • ordinarily resides in the same household with the covered individual, or
  • has legal responsibility for financial support and maintenance of the covered individual
• Gender reassignment surgery, including all associated procedures and services (medical, psychological, pharmaceutical, surgical, etc.) used to facilitate gender transition
• Charges over and above the allowable amount or reasonable and customary amount as determined by the plan administrator

• Education available to the general public without charge
• Educational evaluation and therapy, testing, consultation, rehabilitation, remedial education, services, supplies or treatment for developmental disabilities, communication disorders, or learning disabilities
• Educational treatment, including reading or math clinics or special schools for the intellectually disabled or behaviorally impaired individuals
• Therapy that is part of a special educational program

• Care, services, or supplies in connection with obesity, unless the covered individual meets DMBA’s current medical criteria

• Medications such as emergency contraceptives, dietary or nutritional products or supplements (including special diets for medical problems), herbal remedies, holistic or homeopathic treatments, products used to stimulate hair growth, medications whose use is for cosmetic purposes, over-the-counter (non-legend) products, vitamins (except prenatal vitamins and prescribed infant vitamins), weight-reduction aids, and non-formulary drugs, except to the extent specifically provided in the plan (including any requirements regarding preauthorization)