Plan Limitations

This plan does not cover or provide benefits for the following:

  • Medical expenses that are covered or would be covered in the absence of Student Health Services coverage by any other valid and collectible insurance
  • Expenses incurred for a treatment, service, or supply that is not medically necessary, is not as effective as other treatment, or because you require a different or lesser level of care, as determined by Student Health Services in its sole discretion (even if prescribed, recommended, or approved by your attending physician or dentist).
  • Care received in and emergency that is not emergency care
  • Experimental or investigational services, including treatments, procedures, protocols, drugs, or devices as determined by Student Health Services in its sole discretion
  • Services of a physical or occupational therapist, except as referred through Student Health Services
  • Psychiatrist’s services outside the scope of Student Health Services, except as approved by Student Health Services
  • Refractions performed by an ophthalmologist, or vision care, except as referred through Student Health Services
  • Fitting of, or problems associated with, the elective use of contact lenses
  • Adult eye glasses, contact lenses, and hearing aids
  • Osteopathy
  • Health spa or similar facilities. Strengthening programs.
  • Acupuncture, holistic medicine, aroma therapy, massage, and massage therapy
  • Routine foot care when there is not a localized illness, injury, or symptom involving the foot. Medications filled away from campus without prior approval by Student Health provider.
  • Contraceptive medications, devices or methods that are not prescribed by a physician, and insertion of Norplant
  • Contraceptive devices, unless required to be covered in comprehensive guidelines supported by the Health Resources and Services Administration and approved by the Food and Drug Administration
  • Gardasil vaccine against human papillomavirus, if given before age 9 or after age 26
  • Services of the type ordinarily performed by a dentist, or an oral surgeon, except for services to repair an injury to a sound natural tooth
  • Vaccinations, immunizations, or medications required or recommended for travel. This exclusion does not apply to immunization that must be covered by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention for routine use in the United States (ACIP). Thus, for example, the following immunizations are not covered: Japanese Encephalitis, Polio (IPV) Adult Booster, Typhoid Oral Vaccine, Typhoid Vi Injectable and Yellow Fever.
  • Expenses incurred as a result of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a scheduled airline maintaining regular published schedules on a regularly established route
  • Expenses for injuries sustained as a result of a motor vehicle accident to the extent that benefits are payable under other valid and collectible insurance whether or not a claim is made for such benefits
  • Expenses covered by any automobile medical, personal injury protection, automobile no-fault, homeowner, commercial premises coverage, or similar contract of insurance when such contract or insurance is issued to or makes benefits available to you regardless of whether a claim is made
  • Expenses incurred for injury or sickness from declared or undeclared war of any act thereof
  • Expenses for artificial insemination, in vitro fertilization, or embryo transfer procedures, elective sterilization reversal, or elective abortion
  • Reversals of sterilization procedures such as vasectomies and tubal ligations
  • Infertility artificial reproduction procedures of any type, including but not limited to artificial insemination, in vitro fertilization and related techniques, gamete intrafallopian tube transfer (GIFT), ovum transfer and embryo transfer, procreative counseling, genetic counseling and genetic testing, cryopreservation of reproductive materials. Storage of reproductive materials, fertility tests, infertility treatment (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception, premarital examinations, impotence, organic or otherwise, reversal of sterilization procedures, sexual reassignment surgery;
  • Expenses incurred for transgender reassignment: complete hysterectomy, orchiectomy, penectomy, vaginoplasty, vaginectomy, clitoroplasty, labiaplasty, salpingo-oophorectomy, metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheseis, phalloplasty, Surgery to change specified secondary sex characteristics, specifically: thyroid chondroplasty (removal or reduction of the Adam’s apple); and bilateral mastectomy; and augmentation mammoplasty (including breast prosthesis). In addition to the surgeon fees, this exclusion applies to the services related to the surgery including: anesthesia, pathology, hospital and facility fees, and surgical center fees.
  • Expenses incurred for transgender treatments: reversal of genital surgery, sperm preservation in advance of hormone treatment, cryopreservation of fertilized embryos, voice modification surgery, facial feminization surgery, including but not limited to facial bone reduction, facial hair removal, and certain facial plastic reconstruction. Suction-assisted lipoplasty of the waist, voice therapy, hormone treatment on members under 18 years of age
  • Expenses for infants, other than routine well-newborn care in the first 48 to 96 hours, unless enrolled
  • Long-term/custodial nursing home care
  • Visiting nurse service except for those approved by or coordinated through Student Health Services
  • Ambulance services for trips to a physician’s office or clinic, a morgue or a funeral home.
  • Charges in excess of the reasonable and customary charge
  • Elective surgery or cosmetic surgery, except as medically necessary as a result of a birth defect, accidental injury or a malignant disease process or its treatment, or as a result of a mastectomy and in accordance with the reconstruction from mastectomy section.
  • Expenses incurred for custodial care, defined as services and supplies furnished to a person mainly to help him or her in the activities of daily life, including without limitation room and board and other institutional care, regardless of who prescribes, recommends or performs them
  • Intentionally self-inflicted injuries; or injuries or illnesses self-inflicted or sustained in the following circumstances: (a) Suicide or attempted suicide, (b) while engaged in any activity that constitutes a felony, (c) while performing any acts of violence of physical force that would not be performed by a reasonably prudent person in similar circumstances, or (d) caused by an intentional overdose of a legal prescription or over-the-counter drug or an illegal drug or other chemical substance. (Being under the influence of a chemical substance will not be considered to affect the person’s ability to form intent.) not resulting from a medical condition (including both physical and mental health conditions).
  • Outpatient care other than through Student Health Services, other than follow-up care after emergency room or hospital care for Students, Spouses, and Domestic Partners, and other than at Forest Park Pediatrics for covered children
  • Expenses incurred after the date Student Health Services coverage ends
  • Consultations, diagnostic studies, or medications not specifically authorized by Student Health Service physicians for students, spouses, and domestic partners, and by Forest Park Pediatrics for covered children
  • Genetic testing that does not meet preventive services criteria. Genetic testing for the sole purpose of determining the sex of a fetus. Genetic testing for non-Student Health Service covered persons.
  • Bariatric Surgery, except as identified under Bariatric. Not available for the Garren gastric bubble techniques relating to morbid obesity. This includes roux-enY(RNY), laparoscopic gastric bypass surgery or other gastric bypass surgery (surgical procedures that reduce stomach capacity and divert partially digested food from the duodenum to the jejunum, the section of the small intestine extending from the duodenum), or Gastroplasty, (surgical procedures that decrease the size of the stomach), or gastric banding procedures. Complications directly related to bariatric surgeries that result in an impatient stay or an extended inpatient stay for the bariatric surgery,
  • Inpatient hospital/physician services: oral surgery that is dental in origin; removal of impacted wisdom teeth, reversal of voluntary sterilization, radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, week strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratosis, surgical treatment of gynecomastia; treatment of hyperhidrosis, elective abortions; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectasia dermal veins.
  • Transplant, health services for organ and tissue transplants, except as identified under Transplantation Services. Mechanical or animal organ transplants, except services related to the implant or removal or a circulatory assist device (a device that supports the heart while the patient waits for a suitable donor heart to become available), and donor costs for organ or tissue transplantation to another person.
  • Wigs and artificial hair pieces or any drug-prescription or otherwise-used to treat baldness.
    This list is not meant to be exclusive or exhaustive. All claims submissions will be reviewed on a case-by-case basis and a determination will be made according to the terms of this document.

NOTE: Student Health Services will not pay for consultations, diagnostic studies, medications not specifically authorized by Health Service physicians, or for conditions that were under investigation or treatment at the time the student entered the university. Their latter situation will be dealt with on an individual basis, to help the student arrange for such tests and consultations as deemed necessary.