Benefit Exclusion List

• Acupuncture/Homeopathic Alternative Medicine
• Advanced Oncology
• AIDS
• Allergy Maintenance Injections
• Chiropractic Services
• Cosmetic/Plastic Surgery
• Dialysis (Chronic) (Case by case approval only)
• Elective Vascular Surgery, including Intracranial
• Hearing Aids/Testing (By exception only)
• Home Health Care Services (Case by case approval only)
• Hospice Services
• Infertility Workups and Treatment
• Inpatient Behavioral Health Services
• Inpatient Rehabilitation Services
• Joint Replacements (Case by case approval only)
• Nutritional Services (Registered Dietitian)
• Obstetrics
• Organ Transplants
• Orthodontia
• Outpatient Rehabilitation Services (Case by case approval only)
• Procedures for Treatment of Obesity
• Prosthetic Appliances and Braces (Boots & crutches only, no prosthetic limbs)
• Skilled Nursing Care