What Is Not Covered

Care from a person who is a member of your family or your spouse/domestic partner's family;
Charges for the difference between a private and semi-private hospital room;
Correction of weak, unstable, or flat feet; arch supports; corrective shoes; shoe orthotics (except for custom-molded shoe inserts prescribed to treat a condition, disease or illness affecting the function of the foot); or treatment of corns, calluses, or chronic foot strain;
Cosmetic surgery treatment, except to repair damage from accident or injury; treat a functional birth defect; reconstruct a breast after mastectomy and/or reconstruction of the non-affected breast to produce a symmetrical appearance; or treat an infection or disease;
Custodial services, including custodial nursing care and group homes;
Donor expenses with regard to infertility treatment;
Educational therapy (except for members with a diagnosis of diabetes) and social or marital counseling;
Expenses for which you're not obligated to pay (for example, if a licensed provider or hospital waives an expense, the Plan will not pay any benefit to you or a licensed provider);
Expenses in excess of reasonable and customary (R&C) charges;
Expenses submitted later than December 31 of the year following the year in which services were provided;
Experimental, investigational, or unproven services, devices, or supplies (see the definition of "Experimental, Investigational, or Unproven Services" in "Defined Terms");
Hospital admissions and other services that began before the participant's effective date of coverage under the Expatriate Medical Plan;
Inpatient private duty nursing;
Non-medical charges for care in a nursing or convalescent home or long-term custodial care, even if prescribed by a licensed provider;
Non-prescription contraceptive devices, unless medically necessary (prescription oral contraceptives are covered under the Expatriate Medical Plan);
Non-surgical correction of temporomandibular joint (TMJ) syndrome, such as appliances or devices;
Nutritional support expenses including but not limited to:
regular grocery products (including over-the-counter infant formulas such as Similac, Nutramigen, and Enfamil) that meet the nutritional needs of the patient;
infant formula that is not specifically made to treat inborn errors of metabolism;
medical food products that:
are prescribed without a diagnosis requiring such food;
are used for convenience purposes;
have no proven therapeutic benefit without an underlying disease, condition, or disorder;
are used as a substitute for acceptable standard dietary interventions;
are used exclusively for nutritional supplementation; and
are required due to food allergies.
nutritional and electrolyte supplements, including infant formula, donor breast milk, nutritional supplements, dietary supplements, electrolyte supplements, diets for weight control or treatment of obesity (including liquid diets or food), food of any kind (diabetic, low fat, cholesterol), oral vitamins, and oral minerals.
Personal hospital services, such as television, telephone, etc.;
Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments if required solely for purposes of school, sports or camp, travel, career or employment, insurance, marriage, or adoption;
Refractive eye examinations for new lenses or the cost of eyeglasses or contacts. This does not apply to the first pair of contact lenses or the first pair of eyeglasses following either cataract surgery or a diagnosis of Keratoconus;
Refractive eye surgery including, but not limited to, Lasik or Radial Keratotomy;
Reproductive education and prevention classes;
Reversals of sterilization;
Routine dental care (please see the Expatriate Dental Plan section for information about services covered under the Expatriate Dental Plan);
Services, supplies, or treatment for weight loss, nutritional supplements, or dietary therapy;
Sickness or loss covered by workers' compensation laws or automobile insurance;
Sickness or loss that is later determined to be the legal responsibility of another person or company;
Treatments, services, or supplies that are not medically necessary or not approved by a licensed provider or services provided outside the scope of a provider's license;
Treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders, and paraphilias (sexual behavior that is considered deviant or abnormal);
Unbundled medical expenses — charges billed separately when considered by Cigna Global Health Benefits in its sole discretion to be part of a global procedure; and
A procedure or surgery to remove fatty tissue such as abdominoplasty, brachioplasty, mastopexy, thighplasty, or panniculectomy.