The following is a partial list of services or charges not covered by Interim Coverage. Check your Certificate/Policy for a full listing.

Expenses for the treatment of preexisting conditions, as defined in the preexisting conditions limitation provision; expenses incurred prior to the effective date of a covered person’s coverage or incurred after the expiration date, expenses to treat complications resulting from treatment, drugs, supplies, devices, procedures or conditions; expenses incurred for experimental or investigational services or treatment or unproven services or treatment; expenses for purposes determined by us to be educational; amounts in excess of the usual, reasonable and customary charges made for covered services or supplies; expenses you or your covered dependent are not required to pay, or which would not have been billed, if no insurance existed; expenses to the extent that they are paid or payable under another group insurance or medical prepayment plan; charges that are eligible for payment by Medicare or any other government program except Medicaid; expenses for care in government institutions unless you or your covered dependent are obligated to pay for such care; expenses for which benefits are paid or payable under workers’ compensation; medical expenses which are payable under any automobile insurance policy without regard to fault; expenses incurred by a covered person while on active duty in the armed forces; expenses resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection; expenses incurred while engaging in an illegal act or occupation or during the commission, or the attempted commission, of a felony or assault; expenses for the treatment of normal pregnancy or childbirth, except for complications of pregnancy; charges for a covered dependent who is a newborn child not yet discharged from the hospital, unless the charges are medically necessary to treat premature birth, congenital injury or sickness, or sickness or injury sustained during or after birth; expenses for voluntary termination of normal pregnancy, normal childbirth or elective cesarean section; expenses incurred for any drug, including birth control pills, implants, injections, supply, treatment device or procedure that prevents conception or childbirth; expenses for the diagnosis and treatment of infertility, including but not limited to any attempt to induce fertilization by any method, invitro fertilization, artificial insemination or similar procedures, whether the covered person is a donor, recipient or surrogate; expenses for sterilization or reversal of sterilization; expenses related to sex transformation or penile implants or sex dysfunction or inadequacies; expenses for physical exams or other services not needed for medical treatment, except as specifically covered; expenses for prophylactic treatment, including surgery or diagnostic testing, except as specifically covered; expenses for the treatment of alcoholism or alcohol abuse, chemical dependency, substance abuse or drug addiction; expenses incurred for loss sustained or contracted in consequence of the covered person being intoxicated or under the influence of any narcotic unless administered on the advice of a doctor. intoxication shall be established conclusively by a blood alcohol level of .10 or the legal limit in the state where the incident occurred, whichever is less; expenses incurred in connection with programs, treatment, or procedures for tobacco use cessation; expenses resulting from suicide or attempted suicide or intentionally self-inflicted injury, while sane or insane; expenses for dental treatment or care or orthodontia or other treatment involving the teeth or supporting structures; expenses of radial keratotomy or correction of refractive error, eye refractions, vision therapy, routine vision exams to assess the initial need for, or changes to prescription eyeglasses or contact lenses, the purchase, fitting or adjustment of eyeglasses or contact lenses, or treatment of cataracts; expenses for routine hearing exams to assess the need for or change to hearing aids, or the purchase, fittings or adjustments of hearing aids; expenses for cosmetic or reconstructive procedures, services or supplies except as specifically covered; expenses for breast reduction or augmentation or complications arising from these procedures; outpatient prescription or legend drugs, medications, vitamins, and mineral or food supplements, including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered by a doctor; expenses incurred in connection with any drug or other item used to treat hair loss; expenses incurred in the treatment of weak, strained, flat, unstable, or unbalanced feet, metatarsalgia, bunions, spurs, or the removal of corms, calluses or toenails, unless specifically for the treatment of a metabolic or peripheral vascular disease or for the prompt repair of an injury sustained while coverage is in force for the covered person; expenses incurred in the treatment of acne, or varicose veins; the expenses of weight loss programs or diets and transportation expenses.

Expenses for rest or recuperation cures or care in an extended care facility, convalescent nursing home, a facility providing rehabilitative treatment, skilled nursing facility, or home for the aged, whether or not part of a hospital; expenses for services or supplies for personal comfort or convenience, including homemaker services or supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to bathing, dressing, feeding, routine skin care, bladder care and administration of oral medications or eye drops; expenses for services or supplies furnished or provided by a member of your immediate family; expenses for diagnosis or treatment of a sleeping disorder; expenses incurred in the treatment of injury or sickness resulting from participation in skydiving, scuba diving, hang or ultra-light gliding, riding an all-terrain vehicle such as a dirt bike, snowmobile or go-cart, racing with a motorcycle, boat or any form of aircraft, any participation in sports for pay or profit, or participation in rodeo contests; expenses for the purchase of a noninvasive osteogenesis stimulator (bone stimulator); expenses for services or supplies of a common household use, such as exercise cycles, air or water purifiers, air conditioners, allergenic mattresses, and blood pressure kits; expenses during the first 6-months after the effective date of coverage for a covered person for a (a.) total or partial hysterectomy, unless it is medically necessary due to a diagnosis of carcinoma ; (b.) tonsillectomy; (c.) adenoidectomy; (d.) repair of deviated nasal septum or any type of surgery involving the sinus; (e.) myringotomy; (f.) tympanotomy; (g.) herniorraphy; or (h.) cholecystectomy; (subject to all other coverage provisions, including but not limited to, the pre-existing conditions exclusion); expenses for participating in interscholastic, intercollegiate or organized competitive sports; medical care, treatment, service or supplies received outside of the United States, Canada or its possessions; expenses for spinal manipulation or adjustment; expenses for private duty nursing services; expenses for the repair or maintenance of a wheelchair, hospital-type bed or similar durable mechanical equipment; expenses for orthotics, special shoes, spine and arch supports, heel wedges, sneakers or similar devices unless they are a permanent part of an orthopedic leg brace; expenses incurred in connection with the voluntary taking of a poison or inhaling gas; expenses incurred in connection with obesity treatment or weight reduction including all forms of intestinal and gastric bypass surgery, including the reversal of such surgery even if the covered person has other health conditions that might be helped by a reduction of obesity or weight; expenses for marital counseling or social counseling; expenses for acupuncture; expenses for a service or supply whose primary purpose is to provide a covered person with (1) training in the requirements of daily living; (2) instruction in scholastic skills such as reading and writing; (3) preparation for an occupation; (4) treatment of learning disabilities, developmental delays or dyslexia; or development beyond a point where function has been demonstrably restored; expenses for replacement of artificial limbs or eyes; expenses for removal of breast implants; or expenses that do not meet the definition of or are not specifically identified under the group policy as covered expenses.

With a Secure STM plan, you have access to discounted medical services through two national preferred provider organizations (PPOs). These network providers have agreed to negotiated prices for their services and supplies. While you have the flexibility to choose any health care provider, the discounts available through network providers for covered services will help to lower your out-of-pocket costs.

ACS—www.anci-care.com

A comprehensive network of 38,000 ancillary service providers. ACS represents providers of outpatient services, including lab and diagnostic testing, but it does not include physicians.

MultiPlan—www.multiplan.com

One of the nation’s largest networks, MultiPlan has more than 500,000 providers in 50 states, including physicians, and inpatient and outpatient facilities.

ACS and MultiPlan are not affiliated with Standard Security Life Insurance Company of New York, nor are they part of this insurance plan.

To search for a network health care provider or facility, please visit the websites listed above. At the time of service, simply present your identification card, which will include the network information needed for the provider to correctly process covered billed charges.