Bakery Drivers Local 734 | What Is Not Covered
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What Is Not Covered

What The Plan Does Not Cover

PLAN CONDITIONS, LIMITATIONS AND EXCLUSIONS

No payment will be made under any benefit provided under the Plan for loss sustained as a result of, or for charges incurred for, any of the services, supplies, charges, or types of treatment listed below. Notwithstanding the preceding, if a service, supply, or treatment is required to be provided pursuant to the preventive services mandate under the Affordable Care Act, then the Plan will provide coverage regardless of the exclusions stated below.

NO BENEFITS ARE PAYABLE FOR THE FOLLOWING:

  1. Charges incurred by a person who is not covered under the Plan at the time the charges are incurred.
  2. Charges incurred by a covered person for a particular type of treatment once the person has received Plan benefits totaling any applicable maximum benefit for that type of treatment during any stated period of time.
  3. Charges incurred for medical, dental, or vision benefits as well as hearing treatment provided to a covered person outside the United States of America, its Territories, and Canada after $250 in benefits have been paid for such treatment. The $250 limit does not apply to emergency room or hospitalization to treat an “emergency”.
  4. Any room and board charges incurred for any days of inpatient hospital care that are not pre-certified as medically necessary by Med-Care.
  5. Services or supplies related to the following that were not pre-certified (determined to be medically necessary and within the Plan’s coverage guidelines) by Med-Care:
    • ABA therapy
    • abortion
    • acupuncture
    • aqua therapy
    • chiropractic care
    • medical equipment
    • home health care
    • hospice care
    • hospital admissions
    • infertility services
    • massage therapy
    • nutrition counseling
    • obesity surgery
    • occupational therapy
    • physical therapy
    • podiatric (foot) surgery
    • skilled nursing facility confinements
    • sleep studies
    • speech therapy
    • surgeries
    • TMJ treatment (surgical)
  6. Services and supplies which are not recommended or approved by the attending doctor.
  7. Under the Comprehensive Medical Benefit, any amount in excess of the allowable charge.
  8. Charges incurred for routine or preventive care except as specifically stated in the “Covered Preventive Services” section.
  9. Services or supplies that are not medically necessary unless specifically set forth as a covered expense or covered medical expense.
  10. Services, supplies, treatments, or procedures that are not provided for the treatment or correction of, or in connection with, a specific non-occupational accidental bodily injury or sickness unless specifically identified as being covered under the Plan.
  11. Services provided to a covered person by an individual who ordinarily lives in your home or in the home of the covered person receiving the services, or who is your or your spouse’s close relative. A “close relative” means your spouse, or your or your spouse’s child, son-in-law, daughter-in-law, brother, brother-in-law, sister, sister-in-law, parent, father-in-law, or mother-in-law.
  12. Eye refractions, eyeglasses or contact lenses, including any charges made for follow-up treatment or for the fitting of any of these appliances, except as may be provided after cataract surgery or under the Vision Benefit.
  13. Services, supplies, or procedures that are experimental or investigative in nature, or any services, supplies, or procedures that are provided in connection with any treatment or procedure that is experimental or investigative. Exception: See No. 6 on page 15 for an exception to this exclusion.
  14. Services, treatments, programs, or surgical procedures provided in connection with an overweight condition or condition of obesity or morbid obesity, except as specified.
  15. Travel, whether or not recommended by a doctor, except as specifically provided in No. 38 on page 19.
  16. Any elective or non-emergency plastic or cosmetic surgery on the body except as specifically provided under No. 29 on page 18.
  17. Reversal or attempted reversal of vasectomies or other sterilization procedures.
  18. Vasectomies or other sterilization procedures for dependent children.
  19. Alternative, complementary, adjunctive or holistic therapies, such as naprapathy, naturopathy, herbal therapy, diet therapy, homeopathy or hypnosis; or treatment that is not the normal standard of medical care, including but not limited to acupressure, hypnotism, athletic training, aroma therapy, etc.
  20. Surgical or laser procedures performed to correct nearsightedness, farsightedness or astigmatism, including LASIK procedures.
  21. Services and supplies provided as a result of dental surgery, dental x-rays, or any other dental treatment, except as specifically provided under No. 7 on page 16 or as covered under the Dental Benefit.
  22. Treatment, therapy, or counseling for infertility, or artificial insemination or any related procedures, whether experimental or not, including but not limited to in vitro or in vivo fertilization, egg implantation, etc., or hormone therapy or any other direct attempt to induce or facilitate conception. (However, the Plan will cover the initial diagnostic testing to determine the cause of the infertility if pre-certified by Med-Care to be medically necessary and covered under the terms of the Plan.)
  23. Vitamins, nutritional supplements, food supplements or any other items of a like nature, whether or not prescribed by a physician, except for prescription prenatal vitamins.
  24. With respect to prescription drugs:
    • More than 72 doses per calendar year of on-demand erectile dysfunction drugs such as Viagra;
    • Proton-pump inhibitors (PPIs) such as Nexium, Prevacid and Prilosec, unless pre-certified by Med-Care; and
    • Non-sedating antihistamines (NSAHs) such as prescription Claritin and Allegra, unless pre-certified by Med-Care.
  25. Special education, regardless of the type or purpose of the education, the recommendation of the attending doctor or the qualifications of the individual providing the education, except for nutritional counseling as specified in the “Covered Medical Expenses” section.
  26. Education, training, or room and board while the person is confined in an institution which is primarily a school or other institution for training, a place of rest, or a place for the aged.
  27. Habilitative therapy, including behavioral, social or language therapy for children except as specifically provided for under the “Covered Medical Expenses section.” (The Plan does, however, cover habilitative speech therapy that is not educational in nature, not for a non-pervasive developmental delay, and pre-certified to be medically necessary, up to the maximum benefit limitations shown on the Schedule of Benefits.)
  28. Marriage counseling.
  29. Physical therapy, speech therapy, or any other type of therapy if either the prognosis or history of the person receiving the treatment or therapy does not indicate that there is a reasonable chance of improvement. This exclusion does not apply if the patient is in a hospice program.
  30. Custodial care except when included with other covered hospice services.
  31. Confinement or residency in a facility other than a hospital or covered residential treatment facility; or any confinement or residency for the purpose of rest or relaxation, custodial care, education, or transitional living (for example, a person recovering from an addiction or other emotional or behavioral disorder).
  32. Orthopedic shoes except for children under one year of age.
  33. Assistive listening devices other than wearable devices for the ear. This exclusion applies to amplifiers and FM systems.
  34. Any of the following items or items of a similar nature or purpose, regardless of intended use:
    • air conditioners
    • air purifiers
    • blankets or mattress covers
    • blood pressure instruments
    • chiropractic braces
    • commodes
    • communication devices (except following a laryngectomy)
    • dehumidifiers
    • devices/implants to simulate natural body contours (except for breast prostheses following mastectomy)
    • exercising equipment
    • health club memberships
    • humidifiers
    • heating units
    • orthopedic mattresses
    • pillows (including allergy-free pillows)
    • scales
    • stethoscopes
    • swimming pools
    • thermometers
    • stockings (except as stated in No. 13-g on page 17)
    • vibratory equipment
    • wigs (except as stated in No. 13-h on page 17)
    • whirlpools
  35. Transplant donor searches including testing of potential donors.
  36. Genetic testing unless included in the list of Covered Medical Expenses starting on page 15 or the list of covered preventive services starting on page 20, or unless the result of the test will directly impact the treatment being delivered to a patient who has a diagnosed medical condition. Prenatal genetic testing is excluded unless Med-Care determines the test to be medically necessary.
  37. Gene therapy drugs and products.
  38. Surrogacy or surrogate fees. This exclusion applies to, but is not limited to, charges in connection with: (a) the medical or other expenses of a surrogate who carries and delivers a child on behalf of a person covered under this Plan; or (b) a female employee’s or dependent’s carrying and delivering a child for someone else. Any child born of a covered person acting as a surrogate mother will not be considered a dependent of the surrogate mother or her spouse.
  39. Special home construction to accommodate a disabled person, such as ramps, elevators, or chair lifts. Exception: The Plan will cover the cost of a chair lift that meets the requirements described in No. 13-i on page 17.
  40. Repair or maintenance of prostheses, appliances, wheelchairs, or other medical equipment (even if the Plan covered the purchase of the equipment).
  41. Treatment of accidental bodily injury, sickness, or disease sustained while the person was performing any act of employment or doing anything pertaining to any occupation or employment for remuneration or profit for which benefits are payable in whole or in part under any workers’ compensation law, employer’s liability law, occupational diseases law or similar law. This exclusion applies to services designed to enable a person to perform an occupation, including but not related to work hardening or any other occupational training, exercise, or therapy regimen.
  42. Any hospitalization for any dental procedure unless pre-certified as medically necessary due to the person’s disability or medical condition.
  43. With respect to hospice services:
    • Services or supplies not provided as “core services” by the hospice providing the care; or charges made for services or supplies that are not listed as covered hospice expenses;
    • Bereavement counseling provided to a terminal person’s family after the patient’s death;
    • Administrative services, child care and/or housekeeping services, or transportation (except in emergency situations); or
    • Services or supplies that are rendered, provided, or supplied by family members.
  44. Treatment, care, services, supplies or procedures furnished by or payable under any plan or law of any government, federal or state, dominion or provincial, or any political subdivision of such.
  45. Treatment, care, services, supplies or procedures provided while a covered person is confined in a hospital owned or operated by a state, province, or political subdivision, or owned or operated by the United States Government or an agency of the United States Government. However, if charges are made by a Veterans Administration (VA) hospital which claims reimbursement for the “reasonable cost” of care furnished by the VA for a non-service-related disability, to the extent required by law, such charges will be considered covered medical expenses to the extent that they would have been considered covered medical expenses under the Plan had the VA not been involved.
  46. Treatment, care, services, supplies or procedures which are furnished, paid for, or otherwise provided due to past or present service of any individual in the armed forces of a government or for services provided or made available by any military facilities.
  47. Treatment of injury or sickness caused by war, or any act of war, whether or not war is declared; any act of international armed conflict; any conflict involving the armed forces of an international body; or insurrection.
  48. Services, supplies, treatment, or hospital confinements for which the person is not legally required to pay.
  49. Charges made that would not have been made if this Plan did not exist.
  50. The completing of claim forms (or any forms required to process a claim) by a doctor or other provider of medical services or supplies, or charges made for providing medical records.

This list is not an all-inclusive list of the Plan’s limitations and excluded services, supplies, and treatments. It is only representative of the types of services, supplies, and treatments, or the types of situations in which charges may be incurred, for which no payment is made. In general, benefits are payable under this Plan only for the direct treatment of non-occupational accidental injuries and sicknesses except when included in the list of covered preventive care services starting on page 20.