HEALTH SERVICES EXCLUSIONS

In addition to the access rule conditions noted above, the services and supplies listed in this section, are excluded from coverage and are not Covered Services and supplies under this Certificate:

Abortion

Abortion including any service or supply related to an elective abortion, is excluded from Coverage.

However, spontaneous abortions are not excluded nor are abortions performed when the life of the mother would be endangered if the fetus were carried to term.

Alcohol or Drug-Related Injuries

Alcohol or drug-related Injuries, when sustained as a result of being under the influence of alcohol, an illegal substance, or a narcotic not taken upon the advice of a Physician, are excluded from Coverage.

FHCA Small Group HMO_POS Contract (1_2015) 0315 56 Alternative Medical Treatments

Alternative medical treatments, including, but not limited to, the following are excluded from Coverage:

1. Self-care or self-help training;

2. Homeopathic medicine and counseling;

3. Ayurvedic medicine, such as lifestyle modifications and purification therapies;

4. Traditional Oriental medicine, including acupuncture;

5. Massage therapy;

6. Naturopathic medicine;

7. Environmental medicine, including the field of clinical ecology;

8. Chelation therapy;

9. Thermography;

10. Mind-body interactions such as meditation, imagery, yoga, dance, and art therapy;

11. Biofeedback services, except when considered Medically Necessary by the Health Plan and authorized in advance;

12. Prayer and mental healing;

13. Manual healing methods such as the Alexander technique, aromatherapy, Ayurvedic massage, craniosacral balancing, the Feldenkrais method, Hellerwork, polarity therapy, Reichian therapy, reflexology, rolfing, shiatsu, traditional Chinese massage, Trager therapy, trigger-point myotherapy, and biofield therapeutics;

14. Reiki, SHEN therapy, and therapeutic touch;

15. Bioelectromagnetic applications in medicine; and 16. Herbal therapies.

Ambulance Services Provided Without Transfer

Ambulance services provided without transfer to a Facility are not Covered.

Anesthesia Administration Services

Anesthesia services by an operating Physician or his or her partner or associate are not Covered. Refer to the Covered Services section of this Certificate for Covered anesthesia administration services.

Applied Behavior Analysis (ABA) Services

ABA services for any Condition are excluded from Coverage.

Arch Supports

Shoe inserts designed to effect conformational changes in the foot or foot alignment; orthopedic shoes; over-the-counter, custom-made or built-up shoes; cast shoes; sneakers; ready-made compression hose or support hose; or similar type devices/appliances, regardless of intended use, except for therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease are excluded from coverage.

Assisted Reproductive Therapy (Infertility)

Assisted reproductive therapy, including, but not limited to, associated services, supplies, and medications for In Vitro Fertilization (IVF); Gamete Intrafallopian Transfer (GIFT) procedures;

Zygote Intrafallopian Transfer (ZIFT) procedures; Artificial Insemination (Al); embryo transport;

surrogate parenting; donor semen and related costs, including collection and preparation; and infertility treatment medication, are excluded from Coverage.

Autopsy or Postmortem Examination Services

FHCA Small Group HMO_POS Contract (1_2015) 0315 57 Autopsy or postmortem examination services are excluded from Coverage, unless specifically requested by the Health Plan.

Blood Fees

Blood fees associated with the collection, storage, or donation of blood or blood products are excluded from Coverage except for autologous donation in anticipation of scheduled services where, in the Health Plan’s opinion, the likelihood of excess blood loss is such that transfusion is expected adjunct to surgery.

Bloodless Surgery

Bloodless surgery is excluded from Coverage, unless comparable outcomes, complication rates, and mortality rates are demonstrated through peer reviewed clinical studies when compared to standard surgical methods.

Breast Reduction Services

Breast reduction services are excluded from Coverage.

Charges, Expenses, or Costs Applied Toward Satisfaction of any Applicable Deductible, Coinsurance, or Copayment Amounts

Such charges, expenses or costs are the Covered Person’s responsibility and are not Covered by the Health Plan.

Charges, Expenses, or Costs in Excess of the Allowed Amount

Charges, expenses or costs in excess of the Health Plan’s Allowed Amount for Covered Services are excluded from Coverage.

Charges Incurred Outside of the United States

Charges incurred outside of the United States are excluded from Coverage, if the Insured traveled to such location to obtain medical services, Drugs, or supplies, or when such services, Drugs or supplies are illegal in the United States.

Complications of Non-Covered Services

Complications of non-Covered Services, including the diagnosis or treatment of any Condition, which arises as a complication of a non-Covered Service (e.g., Health Care Services to treat a complication of Cosmetic Surgery are not Covered).

Cosmetic Surgery

Plastic and Reconstructive Surgery and other services and supplies to improve the Insured’s appearance or self-perception (except as Covered under the Breast Cancer Treatment category in the Covered Services section of this Certificate), including, without limitation, procedures or supplies to correct hair loss or the appearance of skin wrinkling (e.g., Minoxidil, Rogaine, Retin-A), and hair implants/transplants, are excluded from Coverage.

Costs Incurred

Costs Incurred by the Insured related to the following, are excluded from Coverage:

1. Health Care Services resulting from accidental bodily Injuries arising out of a motor vehicle accident to the extent such services are payable under any medical expense provision of any automobile insurance policy or liability policy.

2. Telephone consultations, failure to keep a scheduled appointment, or completion of any form and/or medical information.

FHCA Small Group HMO_POS Contract (1_2015) 0315 58 Custodial Care

Custodial Care, including any service or supply of a custodial nature primarily intended to assist the Insured in the activities of daily living, is excluded from Coverage. This exclusion includes rest homes, home health aides (sitters), home parents, domestic maid services, Respite Care and provision of services which are for the sole purpose of allowing a family member or caregiver of a Covered Person to return to work.

Dental Services

All dental procedures, other than those described in the Covered Services section of this Certificate, are excluded from Coverage. This exclusion includes the following: extraction of teeth, restoration of teeth with fillings, crowns or other materials, bridges, cleaning of teeth, dental implants, dentures, dental implants, periodontal or endodontic procedures, orthodontic treatment, including palatal expansion devices, bruxism appliances and dental x-rays. Dental services related to the treatment of malocclusion or malposition of the teeth or jaws (orthognathic treatment), as well as temporomandibular joint (TMJ) syndrome or craniomandibular jaw disorders (CMJ) are also excluded. Non-dental treatments for these Conditions may be Covered if deemed Medically Necessary by the Health Plan. Additionally, dental services provided more than sixty-two (62) days after the date of an Accidental Dental Injury, regardless of whether or not the services could have been rendered within sixty-two (62) days, are excluded from Coverage.

This exclusion does not apply to dental services Covered under the Dental Services, Child Cleft Lip and Cleft Palate Treatment, and Pediatric Dental Services categories of the Covered Services section of this Certificate.

Durable Medical Equipment

Durable Medical Equipment (DME) items that are primarily for convenience and/or comfort; items available over-the-counter; wheelchair lifts or ramps; modifications to motor vehicles and or homes, such as wheelchair lifts or ramps; water therapy devices, such as Jacuzzis, swimming pools, whirlpools or hot tubs; exercise and massage equipment; air conditioners and purifiers; humidifiers;

water softeners and/or purifiers; pillows, mattresses or waterbeds; escalators; elevators; stair glides; emergency alert equipment; handrails and grab bars; heat appliances; dehumidifiers; and the replacement of equipment unless it is non-functional and not practically repairable, are excluded from Coverage.

Refer to the Covered Services section of this Certificate for Covered Durable Medical Equipment items.

Experimental and Investigational Treatment

Experimental and Investigational Treatment, as defined in the Definitions section of this Certificate, are excluded from Coverage. This exclusion does not include routine costs that would otherwise be Covered if the Insured were not enrolled in a clinical trial, as well as services except as otherwise Covered under the Bone Marrow Transplant provision of the Transplant Services category, both described in the Covered Services Section of this Certificate.

Failure to Follow Treatment

Further care for a Condition under treatment will not be covered if the Insured refuses to accept any treatment, procedure, or Facility transfer recommended by the Health Plan.

Food and Food Products

FHCA Small Group HMO_POS Contract (1_2015) 0315 59 Food and food products, including oral nutrition supplements, are excluded from Coverage with the exception of those listed as Covered Services under the Enteral/Parenteral and Oral Nutrition Therapy category of the Covered Services section of this Certificate.

Foot Care

Routine foot care, including any service or supply in connection with foot care in the absence of disease, is excluded from Coverage. This exclusion includes, but is not limited to, non-surgical treatment of bunions, flat feet, fallen arches, and chronic foot strain, toenail trimming, corns, or calluses. This exclusion does not apply to services otherwise Covered under the Diabetes Outpatient Self-Management category of the Covered Services section of this Certificate.

Hearing Aids

Hearing aids (external or implantable) and services related to the fitting or provision of hearing aids, including tinnitus maskers, batteries and cost of repair, are excluded from Coverage.

Home Health Care Services

The following Home Health Care services are excluded from Coverage:

1. Homemaker or domestic maid services;

2. Sitter or companion services;

3. Services rendered by an employee or operator of an adult congregate living facility, an adult foster home, an adult day care center, or a nursing home facility;

4. Custodial Care;

5. Food, housing, and home delivered meals; and

6. Services rendered in a Hospital, nursing home, or intermediate care Facility.

If the Insured’s Condition does not warrant the services being provided, or if the services are custodial in nature, the services will be denied. Any services that would not have been Covered had the Insured been confined in a Hospital are also excluded from Coverage.

Hospice Services

Covered Hospice services do not include bereavement counseling, pastoral counseling, financial or legal counseling, or Custodial Care. Refer to the Hospice Services category in the Covered Services section of this Certificate for information on Covered Hospice services.

Hospital Services

The following Hospital services are excluded when such services could have been provided without admitting you to the Hospital: 1) Room and board provided during the admission; 2) Physician visits provided while you were an Inpatient; 3) Occupational Therapy, Speech Therapy, Physical Therapy, and Cardiac Therapy; and 4) other services provided while you were an Inpatient.

In addition, expenses for the following and similar items are also excluded:

1. Gowns and slippers;

2. Shampoo, toothpaste, body lotions and hygiene packets;

3. Take-home Drugs;

4. Telephone and television;

5. Guest meals or gourmet menus; and 6. Admissions kits.

FHCA Small Group HMO_POS Contract (1_2015) 0315 60 Hypnotism or Hypnotic Anesthesia

Hypnotism and hypnotic anesthesia are excluded from Coverage.

Immunizations and Physical Examinations

Immunization and physical examinations, when required for travel, or when needed for school, employment, insurance or governmental licensing, are excluded from Coverage, except as such examinations are within the scope of, and coincide with, the periodic health assessment examination and/or state law requirements.

Infertility Treatment

Infertility services and supplies, including infertility testing, treatment of infertility and diagnostic procedures to determine or correct the cause or reason for infertility or inability to achieve conception, are excluded from Coverage. This exclusion includes medications (including, but not limited to, clomiphene citrate (Clomid)), artificial insemination, In Vitro Fertilization (IVF), ovum or embryo placement or transfer, gamete intra-fallopian tube transfer, cryogenic, or other preservation techniques used in such or similar procedures.

Injectables

Self-injectable medications are excluded from Coverage, except as specifically provided for on the plan’s Formulary.

Learning and Developmental Services

Testing, therapy or treatment for reading and learning disabilities are not Covered. Services or treatment for mental retardation or other mental services are not Covered, unless determined to be Medically Necessary.

Massage Therapy

Massage Therapy is not Covered under this Health Plan.

Mental Health Services and Supplies

The following mental health services are excluded from Coverage:

1. Services rendered in connection with a Condition not classified in current versions of