Following is a listing of common non-covered services. For
a complete list of limitations and exclusions, refer to the
specific certificate of coverage.
All Plans Duplicate benefits provided under federal, state or local laws, regulations or programs except Medicaid; services involving cosmetic or reconstructive surgery (except as stated in the certificate); charges for personal items; convalescent or custodial care or rest cure; all keratotomy procedures; services related to temporomandibular joint dysfunction syndrome; blood or payments to donors of blood; any service or supply related to the medical management of obesity; services or supplies related to sex transformations; services related to the reversal of sterilization procedures; any medically-aided insemination procedure; charges for services by immediate relatives or by members of the household; acupuncture and admission for acupuncture; medically unnecessary services and admissions; services covered and payable under any medical expense payment provision of any automobile insurance policy; mental illness or substance use disorder services provided by a non-eligible provider; services, supplies or treatments not specifically listed as covered in the members certificate.