What the Medical Plans Do Not Cover

The following services and supplies are not covered by the SAIC self-insured medical plans:

• Treatment for the mouth, jaws and teeth when an injury or illness is dental in nature, including restorative dental and/or surgical treatment of the mouth or jaw, including but not limited to:
  • Non-accident related diagnosis and treatment of teeth and their supporting structures;
  • Treatment relating to or secondary to treatment of dental caries (cavities);
  • Extraction of a diseased or decayed tooth or for surgical removal or impacted teeth; and
  • Root canal therapy, periodontal surgery or X-rays and other diagnostic tests;
• Cosmetic surgery, unless required because of an accidental injury that takes place while the participant is covered by the plan, or the congenital malformation of a child born to the participant or his or her spouse or registered domestic partner while the participant has dependent coverage under the plan;
• Charges above the reasonable and customary limits as determined by the applicable Claims Administrator;
• Custodial care;
• Eye care exams and eyeglasses;
• Hearing aids;
• Orthopedic shoes or other devices to support the feet;
• Experimental, investigational or educational treatment or services as determined by the Claims Administrator;
• Treatment for accidents related to employment or an illness covered under Workers' Compensation or similar laws;
• Assistant surgeon services when the services of an assistant surgeon are not medically necessary for the surgical procedure;
• Treatment in a convalescent facility for drug addiction, chronic brain syndrome, alcoholism, senility, mental retardation and any other mental disorder;
• Skilled nursing care that does not require the education, training and technical skills of an R.N. or L.P.N. (such as transportation, meal preparation, charting of vital signs), any private duty nursing care given while the person is an inpatient in a hospital or other health care facility, care provided to help a person in the activities of daily life, such as bathing, feeding, personal grooming, dressing, getting in and out of bed or a chair, or toileting or care provided solely for skilled observation. Any service provided solely to administer oral medicines except where applicable law requires that such medicines be administered by a R.N. or L.P.N;
• Examinations to determine the need for, or adjustment of, hearing aids;
• Foot treatment for:
  • Weak, strained, flat, unstable or unbalanced feet; metatarsalgia; or bunions, except open cutting operations; and
  • Corns, calluses or toenails, except the removal of nail roots and medically necessary services prescribed by a doctor (M.D. or D.O.) in the treatment of metabolic or peripheral-vascular disease;
• Treatment resulting from an intentionally self-inflicted injury;
• Illness or injury due to an act of war (whether declared or undeclared) or an injury sustained while the participant is in military service for any country at war;
• Services, treatment, education testing or training related to learning disabilities or developmental delays;
• Care furnished mainly to provide a surrounding free from exposure that can worsen the participant's illness or injury;
• Treatments involving:
  • Bioenergetic therapy;
  • Carbon dioxide therapy;
  • Megavitamin therapy;
  • Primal therapy;
  • Psychodrama;
  • Rolfing; or
  • Vision perception training;
• Treatment of covered health care providers who specialize in the mental health care field and who receive treatment as part of their training in that field;
• Services of a resident doctor or intern rendered in that capacity;
• Education or special education or job training whether or not given in a facility that also provides medical or psychiatric treatment;
• Therapy, supplies or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis;
• Sex-change surgery or any treatment of gender identity disorders;
• Career, social adjustment, pastoral or financial counseling;
• Speech therapy except for loss of speech, or speech impairment or developmentally delayed speech due to a diagnosed disease, injury or congenital defect;
• Reversal of a sterilization procedure;
• Medical services performed or provided by a close relative;
• Services of "standby" surgeons;
• Services received before coverage begins or after coverage ends;
• Charges that participants are not legally required to pay or charges that would not have been made if the plans were not available;
• Charges above any maximum amounts shown;
• Convenience or personal care services, such as use of a telephone or television; and
• Medical expense not specifically described in the plans.