The Mental Health and Chemical Dependency Services provided in this program are subject to the following exclusions. Benefits under this program are not payable for:

1. Services or supplies subject to the General Exclusions applicable to all benefits.
2. Treatment of detoxification in newborns (such treatment may be provided by the Trust’s medical plan).
3. Treatment of congenital and/or organic disorders, including, but not limited to, organic brain disease and Alzheimer’s disease.
4. Treatment of mental retardation, other than the initial diagnosis.
5. Treatment of obesity.
6. Court-ordered testing and treatment if not medically necessary.
7. Private hospital rooms and/or private duty nursing, unless determined to be a medically necessary service and authorized by .
8. Ancillary services such as vocational rehabilitation, behavioral training, sleep therapy and employment counseling, training or educational therapy for learning disabilities or other educational services.
9. All in-network outpatient, inpatient, and alternate care services in excess of those authorized by the Medical Director or his/her designee.
10. Broken appointments, except in cases where the participating provider is notified at least twenty-four (24) hours in advance that the appointment will not be kept, or in circumstances in which the eligible participant had no control over missing the appointment and could not notify the participating provider at least twenty-four (24) hours prior to the scheduled appointment. The eligible participant may be billed thirty dollars ($30.00) for the broken appointment. A broken appointment shall also count as one (1) session for the purpose of computing benefits.
11. All prescription or non-prescription drugs, except for drugs prescribed by a physician in connection with the eligible participant’s or dependent’s treatment as an inpatient at a hospital, or as a patient at an alternate care treatment facility.
12. Inpatient services, treatment, or supplies rendered without pre-admission certification from , except in the event of an emergency.
13. Damage to the facility of a participating provider or participating facility provider caused by the eligible participant or dependent. The actual cost of such damage may be billed directly to the participant or dependent.
14. Health care services, treatment or supplies determined to be experimental by the Medical Director in accordance with accepted mental health standards.
15. Health care services, treatment or supplies provided as a result of any Workers’ Compensation law or similar legislation or obtained through, or required by, any governmental agency or program, whether federal, state, or any subdivision thereof or caused by the conduct or omission of a third party for which the eligible participant or dependent has a claim for damages or relief, unless such eligible participant or dependent provides with an agreement to reimburse , which meets the requirements of the WTWT indemnity medical plan.
16. Health care services, treatment, or supplies for military service disabilities, for which treatment is reasonably available under governmental health care programs.
17. Health care services, treatment, or supplies which are primarily for rest, custodial, domiciliary or convalescent care.