We do not cover the following:

• Services, drugs, or supplies you receive while you are not enrolled in this Plan
• Services, drugs, or supplies that are not medically necessary
• Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice
• Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants)
• Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest
• Services, drugs, or supplies related to sex transformations, sexual dysfunction or sexual inadequacy except for organic impotence as shown on pages 13, 34, 46, 66 and 74
• Services, drugs, or supplies for weight reduction/control or treatment of obesity except as shown under Surgical benefits, Section 5
• Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program
• Services, drugs and supplies for which no charge would be made if the covered individual had no health insurance coverage
• Computer “story boards,” “light talkers,” or other communication aids for communication-impaired individuals
• Services, drugs, or supplies you receive without charge while in active military service
• Services, drugs and supplies furnished by immediate relatives or household members, such as spouse, parent, child, brother, or sister by blood, marriage, or adoption
• Services and supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs and physical, speech and occupational therapy rendered by a qualified professional therapist on an outpatient basis are covered subject to plan limits
• Services, supplies and drugs not specifically listed as covered
• Services, supplies and drugs furnished or billed by someone other than a covered provider as defined on page 9
• Any portion of a provider's fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives (does not require the enrollee to pay) a deductible, copay or coinsurance, we will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived
• Charges which you or we have no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/or B (see pages 18 and 19), doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare (limiting charge) (see page 19), or State premium taxes however applied
• Biofeedback; non-medical self care or self help training, such as recreational, educational, or milieu therapy; or
• Charges that we determine to be in excess of the Plan allowance.

To print this entire FEHB Brochure or a section of this Brochure, click here.