All benefits described in this booklet are subject to the following general exclusions. Benefits are not payable for:

1. Services or supplies obtained when the individual is not eligible.
2. Services or supplies determined not to be medically or dentally necessary. Medically or dentally necessary means that services or supplies (a) must be ordered through a physician or other qualified provider, (b) must be commonly and customarily recognized as appropriate in the treatment of the patients’ diagnosed injury or sickness as specified by authoritative medical or scientific literature and (c) must be the least costly of the alternative services or supplies which can be safely provided. Medical necessity does not include maintenance or supportive type treatment or services. Such services or supplies must not be educational or experimental in nature, or provided primarily for the purpose of medical or other research. The fact that services or supplies were furnished, prescribed or approved by a physician or other qualified provider does not in itself mean it was medically necessary. A medical service, supply or setting may be medically necessary in part only.
3. The portion of a charge for a service or supply in excess of the usual, customary and reasonable charge. Usual, customary and reasonable means the maximum amount the Plan will consider for reimbursement. The amount is determined by comparing the actual charge for the services or supplies with the prevailing charges usually made by the provider, when there is not health care coverage. This is not to exceed the prevailing charge in the same geographic area as the provider, for services of the same nature and duration, and performed by a person of similar training and experience, or for substantially equivalent supplies. The Trust or its medical consultants will determine the prevailing charge.
4. Any expense or charge for services or supplies which are considered experimental or investigational treatment, as determined by the Trust or its medical consultants. Experimental or investigational treatment means any services, including a treatment, procedure, facility, equipment, drug, drug usage, medical device, or supplies that, as determined by the Trust or its medical consultants, meets one or more of the following criteria:
   • A drug or device that cannot be lawfully marketed without the approval of the United States Food and Drug Administration, and has not been granted such approval on the date it is furnished.
   • A facility or provider who has not demonstrated proficiency in the service, based on experience, outcome, or volume of cases.
   • Reliable evidence shows the service is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety, or efficacy.
   • Reliable evidence shows the service is not as safe and effective for a particular medical condition, as compared to other generally available services, and that it poses a significant risk to the patient’s health or safety.

   Reliable evidence means only published reports and articles in authoritative medical and scientific literature, scientific results of the provider of care’s written protocols, or scientific data from another provider studying the same service.

5. Services or supplies obtained as a result of an injur y or illness which is covered under a workers’ compensation program or where a claim for such coverage has been made. However, where a contested claim for workers’ compensation is pending, benefits otherwise subject to this exclusion may be paid if you or your dependent observe the Plan’s requirements for advancement of benefits.
6. Services or supplies obtained as a result of an injury or illness which is, or appears to be, the responsibility of one or more third parties and for which payment is or may be made by a third party, or by one or more insurance companies whose insurance policies have become applicable. The term insurance includes, but is not limited to, automobile liability, automobile no-fault, uninsured or underinsured motorist, business or commercial liability, homeowner’s liability, umbrella liability, and medical payments or PIP coverages, regardless of whether such insurance is maintined by the injured person, by a third party, or by any other person or entity. However, where a third party claim is pending, benefits otherwise subject to this exclusion may be paid if you or your dependent observe the Plan’s requirements for advancement of benefits.
7. Services or supplies furnished by or for a federal, state or other governmental agency unless the Trust is required to pay by applicable law, or to the extent benefits are provided under any governmental program or law under which the individual is or could be covered. This exception does not apply to state plans under Medicaid or to any law or plan which states that its benefits are excess to those of any private insurance program or other nongovernmental program.
8. Services or supplies required for an injury or illness as a result of military service or an act of war.
9. Services or supplies for treating an injury or illness while legally confined in a penal institution, mental hospital or other government facility, for participation in criminal activities.
10. Charges for any services rendered by you, your spouse, or any member of your immediate family.
11. Services or supplies for which a claim is not submitted within one year (12 months) of the date the services or supplies are provided.

The term “services or supplies” as used in these General Exclusions includes prescription drugs.