We do not cover Services and supplies which:

• Are not provided;
• Are provided without charge or for which You would not be required to pay if You did not have this coverage;
• Are received before the Effective Date of Coverage;
• Are not a Covered Service or relate to complications resulting from a Non-Covered Service;
• Are not furnished by a Qualified Practitioner or Qualified Treatment Facility;
• Are provided by or payable under any Health Benefit Plan or program established by a domestic or foreign government or political subdivision, unless such exclusion is prohibited by law;
• Are provided while You are confined in a Hospital or institution owned or operated by the United States Government or any of its agencies, except to the extent provided by 38 U. S. C. § 1729 as it relates to non-military Services provided at a Veterans Administration Hospital or facility;
• Are provided while You are in the custody of any law enforcement authorities or while incarcerated;
• Are self-administered or provided by a person who ordinarily resides in Your home or who is a member of Your immediate family (parent, spouse, sibling or child);
• Are provided for convenience, educational or vocational purposes including, but not limited to, videos and books, educational programs to which drivers are referred by the judicial system and volunteer mutual support groups;
• Are performed in association with a Service that is not covered under this Individual Contract;
• Are provided for any injury or illness that is sustained by any Member that arises out of, or as the result of, any work for wage or profit when coverage under any Workers' Compensation Act or similar law is required for the Member. This exclusion also applies to injuries and illnesses that are the subject of a disputed claim settlement under a Workers' Compensation Act or similar law. This exclusion does not apply to Members who are exempt under any Workers' Compensation Act or similar law;
• Are payable under any automobile medical, personal injury protection ("PIP"), automobile no-fault, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance makes benefits or Services available to You, whether or not You make application for such benefits or Services. Any benefits or Services provided under this Individual Contract that are subject to this exclusion are provided solely to assist You and such assistance does not waive;
• Are provided in an institution that specializes in treatment of developmental disabilities;
• Are provided for treatment or testing required by a third party or court of law which is not Medically Necessary;
• Are Experimental/Investigational;
• Have not been Prior Authorized as required in this Individual Contract;
• Are determined by Us not to be Medically Necessary for diagnosis and treatment of an injury or illness;
• Are received by a qualified Member under the Oregon Death with Dignity Act;
• Relate to any condition sustained by a Member as a result of engagement in an illegal occupation or the commission or attempted commission of an assault or other illegal act by the Member if such Member is convicted of a crime on account of such illegal engagement or act . For purposes of this exclusion, "illegal" means any engagement or act that would constitute a felony or misdemeanor punishable by up to a year's imprisonment under applicable law if such Member is convicted for the conduct. Nothing in this paragraph
• shall be construed to exclude Covered Services for a Member for injuries resulting from an act of domestic violence or medical condition (i.e. a physical or mental health condition); and
• Relate to a civil revolution or riot, duty as a Member of the armed forces of any state or country, or a war or act of war which is declared or undeclared.

• Conditions that are not responsive to therapeutic management after a diagnosis is made by a physician who has treated or examined the patient, except when the treatment or Services provided are effective in maintaining existing functionality or preventing a decline in functionality;
• Conditions for mental and nervous conditions not specified in the current edition of the DSM-IV;
• Services provided under a court order or as a condition of parole or probation or instead of incarceration which are not Medically Necessary;
• Personal growth Services such as assertiveness training or consciousness raising;
• Services related to developmental disabilities, developmental delays or learning disabilities including, but not limited to, education Services. A learning disability is a condition where there is meaningful difference between a child's current academic function and the level expected for a child that age. Educational Services include, but are not limited to, language and speech training, reading, and psychological and visual integration training as defined by the American Academy of Pediatrics Policy Statement - "Learning Disabilities, Dyslexia and Vision: A Subject Review;"
• School counseling and support Services, home-based behavioral management, household management training, peer support Services, recreation, tutor and mentor Services; independent living Services, therapeutic foster care, wraparound Services; emergency aid to household items and expenses; Services to improve economic stability, and interpretation Services;
• Evaluation or treatment for educations, professional training, employment investigations, and fitness for duty evaluations;
• Community care facilities that provide twenty-four (24) hour non-medical residential care;
• Speech therapy, physical therapy and occupational therapy Services provided in connection with treatment of psychosocial speech delay, learning disorders, including mental retardation and motor skill disorders, and educational speech delay including delayed language development
• Counseling related to family, marriage, sex and career including, but not limited to, counseling for adoption, custody, family planning or pregnancy, in the absence of a DSM-IV-TR diagnosis;
• Neurological Services and tests including, but not limited to EEGs; PET, CT and MRI imaging Services; and beam scans
• Services related to the treatment of sexual disorders, dysfunctions or addiction;
• Vocational, pastoral or spiritual counseling;
• Dance, poetry, music or art therapy, except as part of an approved treatment program; and
• Treatments that do not meet the national standards for Mental Health and Alcoholism Treatment professional practice.
• Services described in section 5.4 are excluded for the treatment of autism and Asperger's syndrome.

• The following Services if provided, ordered or approved by Non-Participating Providers: human organ/tissue transplants, chiropractic care , E-visits, and outpatient prescription drug;
• Services of licensed acupuncturists, a physician performing acupuncture Services, naturopathic physicians and chiropractic physicians; and
• Services of homeopaths; faith healers; or lay midwives.

• All Services related to sexual disorders or dysfunctions regardless of gender, including all Services related to a sex-change operation, including evaluation, surgery and follow-up Services;
• All Services for the treatment of infertility, including all Services related to surrogate parenting. For the purpose of this exclusion, infertility is defined as the inability to become pregnant after a year of unprotected intercourse or the inability to carry a pregnancy to term as evidenced by three (3) consecutive spontaneous abortions;
• Termination of pregnancy, unless there is a severe threat to the mother, or if the life of the fetus cannot be sustained;
• Sterilization (tubal ligation and vasectomy) Services;
• Reversal of voluntary sterilization;
• Condoms and other over-the-counter birth control products; and
• Home births and all related Services.

• Surgical procedures which alter the refractive character of the eye, including, but not limited to laser eye surgery, radial keratotomy, myopic keratomelelusis and other surgical procedures of the refractive keratoplasty type, the purpose of which is to cure or reduce myopia, hyperopia or astigmatism; and
• Orthoptics and vision training.

• Hearing aids, hearing therapies and/or devices, including all Services related to the examination and fitting of the hearing aids; and
• Hearing screenings and exams.

• Oral surgery (non-dental or dental) or other dental Services (all procedures involving the teeth; wisdom teeth; areas surrounding the teeth)
• Services to treat temporomandibular joint syndrome (TMJ); and
• Dentures and orthodontia.

• Routine foot care, such as removal of corns and calluses, except for Members with diabetes; and
• Services for insoles, arch supports, heel wedges, lifts and orthopedic shoes

• Charges that are in excess of the Usual, Customary and Reasonable (UCR) cost;
• Custodial Care;
• Transplants, except as described in the Summary of Benefits
• Services for Durable Medical Equipment (DME), Medical Supplies/Devices and Prosthetic Devices
• Charges for Services that are primarily and customarily used for a non-medical purpose or used for environmental control or enhancement (whether or not prescribed by a physician) including, but not limited to, air conditioners, air purifiers, vacuum cleaners, motorized transportation equipment, escalators, elevators, tanning beds, ramps, waterbeds, hypoallergenic mattresses, cervical pillows, swimming pools, whirlpools, spas, exercise equipment, gravity lumbar reduction chairs, home blood pressure kits, personal computers and related equipment or other similar items or equipment;
• Physical therapy and rehabilitation Services
• "Telephone visits" by a physician or "environment intervention" or "consultation" by telephone for which a charge is made to the patient. "Get acquainted" visits without physical assessment or diagnostic or therapeutic intervention provided and treatment sessions by computer Internet service;
• Missed appointments;
• Non-emergency medical transportation;
• Allergy shots and allergy serums
• All Services and supplies related to the treatment of obesity or morbid obesity;
• Services for dietary therapy including medically supervised formula weight-loss programs, unsupervised self-managed programs and over-the-counter weight loss formulas;
• Transportation or travel time, food, lodging accommodations and communication expenses
• Charges for health clubs or health spas, aerobic and strength conditioning, work-hardening programs, and all related material and products for these programs;
• Massage therapy;
• Light therapy for seasonal affective disorder, including equipment;
• Any vitamins, dietary supplements, and other non-prescription supplements;
• Services for genetic testing are excluded, except for Services to establish a diagnosis of a suspected congenital condition. Genetic testing is not covered for screening, to diagnose carrier states, or for informational purposes in the absence of disease;
• Services to modify the use of tobacco and nicotine, except when provided as Extra Values or Discounts (see Our Web site, www.providence.org/healthplans), where available;
• Services for Cosmetic Services including supplies and drugs, except as approved by Us
• Services, including routine physical examination, immunizations and vaccinations for insurance, employment, licensing purposes, or solely for the purpose of participating in camps, sports activities, recreation programs, college entrance or for the purpose of traveling or obtaining a passport for foreign travel;
• Non-sterile examination gloves;
• Sales taxes, handling fees and similar surcharges, as explained in the definition of UCR; and
• Air ambulance transportation for non-emergency situations unless approved by Us in advance.

• Drugs that are not provided in accordance with Our formulary-management program.
• Drugs used for weight loss or cosmetic purposes.
• Drugs or medications prescribed that do not relate directly to the treatment of a covered illness or injury.
• Over-the-Counter (OTC) drugs, medications, or vitamins that may be purchased without a Qualified Practitioner's written prescription and prescription drugs that are available in an OTC therapeutically similar form.
• Devices, appliances, supplies and durable medical equipment, even if a prescription is required for purchase.
• Drugs that do not have at least one (1) FDA-approved medication in a therapeutic amount.
• Drugs used in the treatment of fungal nail conditions.
• Drugs used in the treatment of the common cold.
• Experimental or investigational drugs or drugs used by a Member in a research study or in another similar investigational environment.
• Intrauterine devices (IUDs), diaphragms.
• Drugs or medications delivered, injected or administered to You by a physician or other provider or another trained person.
• Drugs prescribed by naturopathic physicians (N.D.).
• Drugs prescribed or recommended by chiropractic physicians.
• Amphetamines and amphetamine derivatives, except when used in the treatment of narcolepsy or hyperactivity in children and adults.
• Methadone for the treatment of chemical dependency. However, methadone for pain management is covered.
• Drugs used to treat all sexual dysfunctions or disorders, in either men or women, such as Viagra or drugs required for, or as a result of, sexual transformation
• Smoking cessation drug therapy, including nicotine replacement therapy.
• Drugs dispensed from pharmacies outside the United States, except for Urgent and Emergency Medical Conditions.
• Injectable medications
• Drugs or prescribed medications that are not Medically Necessary or are not provided according to Our medical policy.
• Drugs used for the treatment of fertility/infertility.
• Fluoride, for members over the age of ten (10) years old.
• Replacement of lost or stolen medications.
• Drugs to stimulate hair growth, including, but not limited to, Rogaine (i.e., topical minoxidil) or other similar drug preparations.
• Any drug, medicine, or device that does not have the United States Food and Drug Administration formal market approval through a New Drug Application, Pre-market Approval, or 510K.
• Drugs used in the treatment of drug induced fatigue, general fatigue and idiopathic hypersomnia.
• Drugs placed on prescription-only status by state or local law.
• Drugs that are not FDA approved or are designated as "less than effective" by the FDA (also known as a "DESI" drug).