What is Not Covered?

The following services are excluded from your adultBasic coverage:

• Dental Care
• Vision Exams and Eyeglasses
• Hearing Exams and Hearing Aids
• Prescription Drugs (except for diabetic supplies and oral agents, and immunosuppressants)
• Services Provided by a Chiropractor
• Substance Abuse Diagnosis and Treatment (including hospitalization, detoxification and rehabilitation)
• Mental Health Diagnosis and Treatment (including hospitalization)
• Serious Mental Illness
• Durable Medical Equipment (DME) (except for diabetic supplies and orthotics for diabetics)

In addition, the following are excluded from your coverage:

1. Services or supplies which are:
   
   

   	A.		not provided by or referred by your primary care physician except in an emergency; or
   	B.		not medically necessary, as determined by your primary care physician and/or Keystone, for the diagnosis or treatment of illness, injury or restoration of physiological functions. This exclusion does not apply to routine and preventive covered services specifically provided under this contract;

    
   
2. The cost of services or supplies which are payable under Worker’s Compensation or employer’s liability laws or other legislation of similar purpose (or services for which you have no obligation to pay); 
   
   
3. Care related to military service disabilities and conditions which you are legally entitled to receive at government facilities which are not Keystone providers, and which are reasonably accessible to you; 
   
   
4. Care for conditions that federal, state or local law requires to be treated in a public facility; 
   
   
5. The cost of services covered under the Medicare program; 
   
   
6. The cost of hospital, medical or other health services resulting from accidental bodily injuries arising out of a motor vehicle accident, to the extent such costs are payable under any medical expense payment provision by whatever terminology used, including benefits mandated by law of any automobile insurance policy unless otherwise prohibited by applicable law; 
   
   
7. All dental services including but not limited to, treatment of teeth, extraction of teeth, treatment of dental abscesses or granuloma, treatment of gingival tissues (other than for tumors), dental examinations, treatment for temporomandibular joint syndrome or dysfunction, orthognathic surgery (to treat non-traumatic jaw deformity), dental implants and any other dental product or service unless specifically provided elsewhere under the contract and described in this handbook; 
   
   
8. Charges for broken appointments, services for which the cost is later recovered through legal action, compromise, or claim settlement, and charges for additional treatment necessitated by lack of patient cooperation or failure to follow a prescribed plan of treatment; 
   
   
9. Medical, surgical or any other health care procedures and treatments which are experimental or investigative; 
   
   
10. Physical examinations for non-preventive purposes, such as pre-marital examinations, physicals for college or travel, and examinations for insurance, licensing and employment; 
    
    
11. Cosmetic surgery, including cosmetic dental surgery. Cosmetic surgery is defined as any surgery done primarily to alter or improve the appearance of any portion of the body, and from which no significant improvement in physiological function could be reasonably expected.
    
    This exclusion includes surgical excision or reformation of any sagging skin on any part of the body, including but not limited to, the eyelids, face, neck, arms, abdomen, legs or buttocks; and services performed in connection with enlargement, reduction, implantation or change in appearance of a portion of the body, including but not limited to the ears, lips, chin, jaw, nose, or breasts (except reconstruction for post-mastectomy patients).
    
    This exclusion does not include those services performed when the patient is a member of Keystone and performed in order to restore bodily function or correct deformity resulting from a disease, recent trauma, or previous therapeutic process any of which occurs while such patient is a member of Keystone.
    
    This exclusion does not apply to otherwise covered services necessary to correct medically diagnosed congenital defects and birth abnormalities for a child within 31 days of birth; 
    
    
12. Rehabilitation therapy provided for: the ongoing outpatient treatment of chronic medical conditions that are not subject to significant improvement within 60 days; additional therapy beyond the plan’s day limit, if any; work hardening; evaluations not associated with short term rehabilitation therapy; or therapy for back pain in pregnancy without specific medical conditions; 
    
    
13. Any rehabilitation therapy service for: the maintenance of chronic conditions; injuries or illnesses when response to treatment has reached the maximum therapeutic level; or when no additional functional improvement can be demonstrated or anticipated and continuation of the service will be of no therapeutic value to the member; 
    
    
14. All procedures performed solely to eliminate the need for or reduce the prescription of corrective vision lenses including, but not limited to radial keratotomy and refractive keratoplasty; 
    
    
15. Services for treatment of mental retardation or other mental health services; 
    
    
16. Immunizations required for work or travel; 
    
    
17. Custodial and domiciliary care, residential care, protective and supportive care, including educational services, rest cures and convalescent care. This exclusion does not apply to educational services related to diabetic self-management training and evaluation; 
    
    
18. Weight reduction programs, including all diagnostic testing related to weight reduction programs, unless medically necessary. This exclusion does not apply to Keystone’s weight reduction program; 
    
    
19. Nutritional supplements, except when the member has no other source of nutritional intake due to a metabolic or anatomic disorder; 
    
    
20. Customized or motorized wheelchairs and other motor devices to assist or replace ambulatory functions; 
    
    
21. Personal or comfort items such as television, telephone, air conditioners, humidifiers, barber or beauty service, guest service and similar incidental services and supplies which are not medically necessary; 
    
    
22. Normal childbirth deliveries outside the service area within 30 days of the expected delivery date established by the provider in charge of the case; 
    
    
23. Any procedure or treatment designed to alter physical characteristics of the member to those of the opposite sex, and any other treatment or studies related to sex transformations; 
    
    
24. Treatment of bunions (except capsular or bone surgery), toenails (except surgery for ingrown nails), corns, calluses, fallen arches, flat feet, weak feet, chronic foot strain or symptomatic complaints of the feet or other routine podiatry care, unless associated with peripheral vascular disease and/or peripheral neuropathic disease, including but not limited to diabetes and deemed medically necessary by your primary care physician or Keystone; 
    
    
25. Services for the treatment of substance abuse; 
    
    
26. Marriage counseling; 
    
    
27. In vitro fertilization, embryo transplant, ovum retrieval including, but not limited to gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and any services required in connection with these procedures; 
    
    
28. Reproductive endocrinology and infertility treatments; 
    
    
29. Sterilization and reversal of sterilization and services required in connection with such procedures; 
    
    
30. Cranial prostheses including wigs and other devices intended to replace hair; 
    
    
31. Ambulance service, unless medically necessary; 
    
    
32. Services required by a member donor related to organ donation. Expenses for donors donating organs to member recipients are covered only as described in this handbook and provided under the contract. No payment will be made for human organs which are sold rather than donated; 
    
    
33. Charges for completion of any insurance form; 
    
    
34. Treatment for injuries sustained while committing a felony; or while intoxicated or under the influence of any narcotic not prescribed or authorized by your primary care physician; 
    
    
35. Injectable medications except those necessary for the immediate treatment of an injury or acute illness when provided or referred by your primary care physician and administered in the physician’s office; 
    
    
36. Outpatient prescription drugs and medications, and medications that may be dispensed without a doctor’s prescription; or contraceptive drugs and devices. This exclusion does not include insulin and oral agents used for the treatment of diabetes; 
    
    
37. Foot orthotic devices and the repair or replacement of external prosthetic devices, except as described in this handbook and provided under the contract. This exclusion does not apply to foot orthotic devices used for the treatment of diabetes; 
    
    
38. Hearing aids, or the fitting thereof or cochlear electromagnetic hearing devices or related services and routine hearing examinations; 
    
    
39. Any services, supplies or treatments not specifically listed in this handbook or provided under the contract as covered benefits, unless the unlisted benefit, service or supply is a basic health service required by the Pennsylvania Department of Health. Keystone reserves the right to specify providers of, or means of delivery of covered services, supplies or treatments under this plan, and to substitute such providers or sources where medically appropriate; 
    
    
40. Prescription drugs except for diabetic supplies and oral agents, and immunosuppressants related to organ transplant not approved by Keystone or prescribed drug amounts exceeding the quantity level limits as conveyed by the FDA or FutureScripts^® Pharmacy and Therapeutics Committee; 
    
    
41. The following outpatient services that are not performed by your primary care physician’s designated provider, when required under the plan, unless preapproved by Keystone:
    
    

    	A.		rehabilitation therapy services (other than speech therapy);
    	B.		certain podiatry services; and
    	C.		diagnostic radiology services;

     
    
    
42. Care for cognitive therapy; 
    
    
43. Inpatient care private duty nursing services; 
    
    
44. Medication furnished by any other medical service for which no charge is made to the member; 
    
    
45. Any charges for the administration of injectable insulin; and 
    
    
46. Genetic counseling and genetic studies except as otherwise stated in this handbook.