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Limitations and Exclusions
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Coverage under KPS
individual plans is limited to the diagnosis and therapeutic care or treatment of
disease, sickness or injury, or the preventive of disease, sickness or
injury, as described in the Contract. The following services are
specifically excluded from coverage. |
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Air conditioners, de-humidifiers, air purifiers
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Any
care, treatment or service received prior to your effective date of
coverage under this plan
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Any
care, treatment or service received after coverage under this
plan has ended
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Arch
supports, shoe orthotics, corrective shoes and elastic stockings
except as specifically provided under the Diabetic Education,
Equipment and Supplies benefit
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Artificial insemination, in vitro fertilization and gamete
intra-fallopian transplant (GIFT), including any direct or indirect
complications or after-effects other than pregnancy
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Expenses
incurred or services rendered if the illness or injury to you is caused, or alleged by
you to be caused, by
another party, to the extent that those benefits are available under
the terms of any other insurance coverage or source of payment,
including but not limited to:
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Vehicle medical, vehicle no-fault, personal injury protection
("PIP"), uninsured or underinsured motorist, or any similar
insurance contract
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Homeowner's, property or any other insurance policy, except
individual or group health care coverage
- An
agreement, judgment or settlement pursuant to which a third party
pays or agrees to pay for the costs of such services from assets
other than an insurance policy
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Biofeedback except in the case of urinary incontinence
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Cardiac
rehabilitation
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Charges
for non-covered services, and resulting complications,
including service not specifically described in this plan
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Conditions resulting from acts or war, whether declared or
undeclared
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Cosmetic
surgery, including treatment for complications of cosmetic surgery,
except as provided for under the Plastic and Reconstructive
Surgery benefit
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Developmental delay, speech delay or other learning disabilities
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Enuresis
training equipment
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Exercise
equipment and whirlpool baths
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Experimental and investigational procedures, as defined in this
plan
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Eye
glasses and contact lenses
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Hearing
aids, hearing devices such as cochlear implants, and hearing exams
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Hospitalization solely for diagnostic purposes
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Inpatient rehabilitation
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Maintenance, custodial or domiciliary care except as provided under
the Home Health and Hospice Care benefit
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Medical
services paid by the Veterans Administration or by state, local or
federal governmental programs
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Neurodevelopmental therapy
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Non-surgical treatment for deformities of the toes or feet,
including routine foot care, except when such care is directly
related to the treatment of diabetes
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Obesity
treatment, including, but not limited to, provider office visits, surgical weight loss
procedures, pre-surgical diagnostics and procedures, weight
reduction programs (such as Weight Watchers) and dietary control
programs
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Occupational illness services or services for any injury arising out
of, or in the course of, an activity pertaining to any trade,
business, employment (including self-employment) or occupation for
wage or profit, whether or not a proper and timely claim was filed
for such benefits under another plan or policy
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Orthoptics (eye exercise programs), pleoptics, visual analysis
therapy and/or training, and radial keratotomy
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Over-the-counter products (except insulin supplies for the treatment
of diabetes), including, but not limited to, contraceptive devices
or supplies, unless specifically listed as a benefit under this plan
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Personal
comfort items such a radios, telephones, televisions, etc.
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Pregnancy and maternity care, except for complications of pregnancy (except
for the Sound Harbor Elite plan)
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Prescription drugs except drugs dispensed at a hospital-based
emergency room or as provided under the Home Health and Hospice
Care benefit (excluded only in Sound Harbor Essential Five
and The Healthy Investor™ HSA plans)
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Private
duty nursing
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Reversal
of sterilization
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Self-help care of any form, including, but not limited to,
non-medical self-care, self-help training, marital or sexual
counseling
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Services, supplies
and drugs that are not Medically Necessary for the treatment of an
illness, injury or physical disability, even though the services are
not specifically listed as exclusions
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Services
and supplies for, or associated with, care or work on the teeth;
x-rays of the teeth and other dental procedures
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Services
for the treatment of complications arising from a non-covered service
or procedure, except for the complications of pregnancy
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Services
for which there is no charge to you
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Services
for which you are not legally required to pay
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Services
provided by a person who is related to you by blood or
marriage, or who resides in your home
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Sex
change or other sexual transformation procedures
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Speech,
occupational, educational, milieu, massage, and physical therapies
except as specifically included under the Home Health and Hospice
benefit or the Rehabilitation benefit
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Sterilization (excluded only in Sound Harbor Essential Five and
The Healthy Investor™ HSA plans)
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Treatment for abnormalities of the jaw, including malocclusion; jaw
augmentation or reduction surgery (orthognathic surgery); diagnosis
and treatment of temporomandibular joint (TMJ) disorders
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Treatment of chemical dependency disorders
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Treatment for sexual dysfunction including, but not limited to,
sterility, infertility, impotence or frigidity
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Treatment of sleep disorders, including studies, durable medical
equipment, such as C-pap machines, and surgeries
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Unnecessary duplicate diagnostic services for a single ongoing
illness; consultations for second surgical opinions are covered
under the Professional Services benefit
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Services
for elective care received in a foreign country
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Services
and supplies not specifically described in this plan
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Prescriptions not filled at a MedImpact participating pharmacy
except drugs dispensed at a hospital-based emergency room
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