Samaritan Select

Limitations and exclusions

• Surgeries and procedures
• Health related conditions, services, or supplies
• Drugs and medications
• Medical equipment and devices
• Mental health services
• Alternative types of treatment
• Other services, supplies, and treatments

This is only a summary of excluded (not reimbursable) services and supplies. Other limitations affecting benefits are described in your Plan document. Be sure to check this exclusions list before obtaining services. If you receive services that are on this list without the proper prior authorization, you may have to pay for that service yourself and it would not apply to your out-of-pocket limit.

This plan does not cover the following surgeries and procedures:

• Cosmetic or reconstructive surgery except as specified in the Covered Expenses section;
• Panniculectomy and abdominoplasty;
• Treatment for infertility, including artificial insemination, in vitro fertilization, or GIFT procedures;
• Surgery to reverse voluntary sterilization;
• Routine foot care such as treatment for corns and calluses, toenail conditions, hypertrophy or hyperplasia of the skin and nails unless the patient has diabetes, peripheral vascular disease, or recurrent infections;
• Surgical procedures that alter the refractive character of the eye, including but not limited to, radial keratotomy, myopic keratomileusis and other surgical procedures of the refractive keratoplasty type, the purpose of which is to cure or reduce myopia or astigmatism;
• Treatment to augment or reduce the upper or lower jaw, except when necessary due to an injury;
• Temporomandibular joint (TMJ) or myofascial pain treatment, advice, or appliances;
• Services for developmental or degenerative abnormalities of the jaw, malocclusion, dental implants, or improving placement of dentures;
• Transplants, except as specified in the Covered Expenses section; or
• Sex transformations.

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This plan does not cover the following health related conditions, services, or supplies:

• Myeloablative high dose chemotherapy, except when the related transplant is covered
• Massage, massage therapy, or myofascial release, even if it is part of a physical therapy program
• Treatment to modify tobacco use or promote general fitness
• Instructional or education programs, except diabetes self-management programs
• Services, supplies, testing or treatment for sterility, infertility, impotency, frigidity, or sexual inadequacy
• Custodial care, including routine nursing care and rest cures and hospitalization for environmental change

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This plan does not cover the following drugs and medications:

• Prescription drugs used primarily for weigh control or obesity, regardless of the diagnosis (including, but not limited to, amphetamines)
• Non-prescription drugs: Drugs which by law do not require a prescription order, except for insulin and certain over-the-counter drugs specifically covered by this Prescription Drug coverage
• Immunizations in anticipation of exposure through travel or work
• Vitamins except those which by law require a prescription order
• Drugs with no proven therapeutic indication
• Drugs used for other than medically necessary indications.
• The following miscellaneous drugs are specifically excluded:
  • Rogaine
  • Yohimbine
  • FluMist
• Drugs for which claims are submitted 12 months or more after the date of purchase
• Any drugs not specifically described as benefits under this Prescription Drug coverage
• Drugs or devices used for infertility
• Drugs or devices used for impotence (e.g. Viagra, MUSE, Yohimbine…etc.)
• Drugs or devices used for cosmetic reasons (e.g. Propecia, Renova…etc.)

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This plan does not cover the following medical equipment and devices:

• Eyeglasses or contact lenses, vision therapy, orthoptics and visual appliances (colored lenses, prisms and special glasses) for reading, learning or behavioral disabilities or dyslexia.
• Routine supplies and equipment mainly for comfort, convenience, cosmetic purposes, or environmental control. This includes appliances like air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat lamps, or tanning lights. It also includes personal items like telephones and televisions, and maintenance supplies or equipment commonly used for purposes other than medical care.

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This plan does not cover the following mental health services:

• Mental health treatment, advice, or counseling except as stated in the Covered Expenses section;
• Treatment for mental retardation, defined as below normal intellectual function with impaired learning, social adjustment, and maturation;
• Treatment of dementia (such as Alzheimer’s disease), including any organic psychotic manifestations;
• Treatment for personality disorders, dependency disorder, or behavioral, family, occupational, religious, or stress-related problems;
• Marital, career, or personal growth counseling;
• Mental or psychological evaluation for sexual dysfunction or inadequacy;
• Treatment for nicotine dependence (This may be available as a Wellness benefit. Contact SGS Wellness Program for details);
• Educational programs for drinking drivers, including court-ordered programs;
• Voluntary mutual support groups like Alcoholics Anonymous;
• Counseling in the absence of illness;
• Psychological testing that is not medically necessary; and
• Any mental health services unrelated to the treatment or diagnosis of a mental disorder.

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This plan does not cover the following alternative types of treatment:

• Acupuncture
• Chiropractic care
• Massage or massage therapy
• Naturopathic or homeopathic treatment
• Biofeedback
• Hypnosis

Any treatment or services provided by an alternative medicine provider are not covered under this plan

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Other services, supplies, and treatments this plan does not cover:

• Treatment that is not Medically Necessary for the treatment of an Illness or Injury.
• Experimental or unproven. A treatment, procedure, device, drug or medicine which either:
  • Cannot be lawfully marketed without U.S. Food and Drug Administration approval, and approval for marketing for the condition treated has not been given at the time the device, drug or medicine is furnished; or
  • Safety and effectiveness has not been proven by peer reviewed published well-designed controlled studies of sufficient statistical power; or
  • Does not improve measurable health outcomes; or
  • Does not compare favorably to existing treatments (effectiveness, cost, toxicity)
• Experimental or unproven shall also mean:
  • Any treatments, services, supplies or related expenses that are educational or provided primarily for research; or
  • Treatments, procedures, devices, drugs or medicines or other expenses relating to the transplant of non-human organs.
• Any charge over the Usual and Customary or Reasonable charge for services or supplies;
• Hospital, Skilled Nursing Facility or other facility services that began before the Covered Person’s coverage began, including services and supplies;
• Treatment incurred prior to enrollment and coverage under this Plan, or after coverage terminates. The only exception is that if this plan is replaced by a group health policy while you are hospitalized, Samaritan Choice Plans will continue paying covered hospital expenses until you are released or your benefits are exhausted, whichever occurs first;
• Any illness or injury resulting from an illegal activity or committing or attempting to commit a felony and any treatment received while incarcerated;
• Services or supplies otherwise available (such services or supplies will be covered if otherwise required by law):
  • Services or supplies for which the Covered Person could receive partial or complete payment had the Covered Person applied under any city, county, state or federal law;
  • Services or supplies the Covered Person could have received in a Hospital or program operated by a government agency or authority;
  • Services provided by an immediate family member, including parents, grandparents, spouse/domestic partner, siblings, children and grandchildren.
  • Services or supplies for which no charge is made, or for which no charge is normally made in the absence of insurance; and
  • Services or supplies for which the Covered Person is not charged or cannot be held liable because of an agreement between the provider rendering the service and another third-party payer that has already paid for the service.
  • Services or supplies with no charge, or which your employer would have paid for if you had applied;
• Charges that are the responsibility of a third party, such as worker’s compensation insurance, personal injury protection insurance, motor vehicle liability insurance, or uninsured or underinsured motorists;
• Charges for services or supplies if you are not willing to release medical information to Samaritan Choice Plans needs to determine eligibility for payment;
• Treatment of any condition caused by a war, armed invasion, or act of aggression, terrorism, or while serving in the armed forces;
• Work-related illness or injury;
• Charges for travel related expenses, telephone consultations, missed appointments, get acquainted visits, completion of claim forms or completion of reports requested by the Claims Administrator in order to process claims;
• Care designed mainly to help with daily activities such as walking, getting out of bed, bathing, dressing, eating, and preparing meals; or
• Services and supplies not specifically described as benefits under this Plan.

Click here to review the list of Limitations and Exclusions list for your vision plan.

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