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46. Drugs in quantities which exceed the limits established by the Plan. (See separate Prescription
Drug Benefit Plan booklet)
47. For Prescription Legend Drugs or Mail Service drugs. Prescription Drug coverage is provided by
a separate prescription drug vendor.
48. Care in self-care unit, apartment or similar Facility.
49. Charges for care or supplies furnished as a result of taking part in the commission of an assault or
felony or being engaged in an illegal occupation. This Exclusion does not apply if Your involvement
in the crime was solely the result of a medical or mental condition, or where You were the victim of
a crime, including domestic violence.
50. No Benefits are available for services that are not specifically described as Covered Services in
this Benefit Booklet. This exclusion applies even if Your Physician orders the service.
51. Service You get from Providers that are not licensed by law to provide Covered Services as defined
in this Booklet. Examples of non-covered providers include, but are not limited to, masseurs or
masseuses (massage therapists), and physical therapist technicians.
52. Educational services for remedial education including evaluation or treatment of learning
disabilities, minimal brain dysfunctions, learning disorders, behavioral training, and cognitive
rehabilitation. This includes educational services, treatment or testing and training related to
behavioral (conduct) problems, including but not limited to services for conditions related to autistic
disease of childhood (except to the same extent that the Plan provides for neurological disorders
and applied behavior analysis), hyperkinetic syndromes, including attention deficit disorder and
attention deficit hyperactivity disorder, learning disabilities, behavioral problems, and mental
retardation. Special education, including lessons in sign language to instruct a Member, whose
ability to speak have been lost or impaired, to function without that ability, is not covered.
75
Drug Benefit Plan booklet)
47. For Prescription Legend Drugs or Mail Service drugs. Prescription Drug coverage is provided by
a separate prescription drug vendor.
48. Care in self-care unit, apartment or similar Facility.
49. Charges for care or supplies furnished as a result of taking part in the commission of an assault or
felony or being engaged in an illegal occupation. This Exclusion does not apply if Your involvement
in the crime was solely the result of a medical or mental condition, or where You were the victim of
a crime, including domestic violence.
50. No Benefits are available for services that are not specifically described as Covered Services in
this Benefit Booklet. This exclusion applies even if Your Physician orders the service.
51. Service You get from Providers that are not licensed by law to provide Covered Services as defined
in this Booklet. Examples of non-covered providers include, but are not limited to, masseurs or
masseuses (massage therapists), and physical therapist technicians.
52. Educational services for remedial education including evaluation or treatment of learning
disabilities, minimal brain dysfunctions, learning disorders, behavioral training, and cognitive
rehabilitation. This includes educational services, treatment or testing and training related to
behavioral (conduct) problems, including but not limited to services for conditions related to autistic
disease of childhood (except to the same extent that the Plan provides for neurological disorders
and applied behavior analysis), hyperkinetic syndromes, including attention deficit disorder and
attention deficit hyperactivity disorder, learning disabilities, behavioral problems, and mental
retardation. Special education, including lessons in sign language to instruct a Member, whose
ability to speak have been lost or impaired, to function without that ability, is not covered.
75
