What the CAP Doesn't Cover
Unless exceptions to the following are specifically noted elsewhere in this Handbook, no benefits are provided for the following:
  • Services or supplies received from a provider or supplier who is not licensed, registered or certified under state law to the extent required to provide such service or supply, or if the service or supply provided is not within the scope of the provider's license, certificate or registration.
  • Services or supplies that are not Covered Health Services, which includes all services that are not Medically Necessary (see "Covered Health Services" and "Medically Necessary Services" in the Definitions section) or that are educational in nature, as determined by Anthem Blue Cross.
  • Charges in excess of the Customary and Reasonable Charges (see "Eligible Expenses" in the Definitions section and "How the CAP Works"), as determined by Anthem Blue Cross.
  • Services that are provided or a hospitalization that begins before coverage begins or after it ends, except as specifically noted elsewhere or unless the coverage began under another Company-sponsored medical plan.
  • Hospitalization that continues after coverage has ended and after you have recovered sufficiently to be discharged, unless you are certified as totally disabled as explained in "Extended Benefits When Coverage Ends" in the Health Care Participation section.
  • Hospitalization primarily for physical therapy or other rehabilitative care, unless approved by Anthem Blue Cross as a Medically Necessary Covered Health Service, except those benefits which would have been provided had the patient been treated on an outpatient basis. For example, charges for room and board during such a hospitalization are not covered.
  • Services in connection with the reversal of voluntary sterilization.
  • Services or supplies in connection with custodial care. Custodial care is defined as care provided primarily to assist an individual in meeting the activities of daily living including, but not limited to, walking, bathing, dressing, eating, preparation of special diets, changing catheters, and supervision over self-administration of medications not requiring constant attention of trained medical personnel. It is care that can be taught to a lay person who does not have any professional qualifications, skills or training.
  • Services or supplies which would not have been rendered or furnished if the Plan did not exist or services or supplies for which you would not have been required to pay.
  • Cosmetic procedures are excluded from coverage. Procedures that correct a congenital anomaly without improving or restoring physiologic function are considered cosmetic procedures. The fact that a covered person may suffer psychological consequences or socially avoidant behavior as a result of an injury, illness or congenital anomaly does not classify surgery or other procedures done to relieve such consequences or behavior as a reconstructive procedure.
  • Services or supplies furnished in connection with cosmetic surgery or surgery performed mainly to change appearance. This includes surgery performed to treat a mental, psychoneurotic, or personality disorder through a change in appearance. The following are not considered to be cosmetic surgery:
    • Surgery to correct the result of an accidental injury;
    • Surgery to treat a condition, including a birth defect, that impairs the function of a body organ; or
    • Surgery to reconstruct a breast after a mastectomy.
  • Services and supplies furnished in connection with surgical procedures for gender reassignment surgery, unless Medically Necessary as determined by Anthem Blue Cross.
  • Personal comfort and convenience items and services such as guest meals, television rental or barber services.
  • Reimbursement for meal expenses incurred in connection with the transplant or bariatric/transgender surgery travel benefit.
  • Medical or surgical treatment of excessive sweating (hyperhidrosis).
  • Dental and orthodontia services, including braces, bridges, and guards, or X-ray exams involving one or more teeth, the tissue or structure around them, the alveolar process, or the gums. This applies even if a condition requiring any of these services involves a part of the body other than the mouth, such as the treatment of Temporomandibular Joint Disorders (TMJD) or malocclusion involving joints or muscles by methods including, but not limited to, crowning, wiring or repositioning teeth.
This exclusion does not apply to services for treatment or removal of a malignancy; physicians' services or X-ray exams for treatment of accidental injury to natural teeth ("treatment" includes the replacement of those teeth), provided the participant is covered by the Plan, the accident occurred while covered, and the treatment is received within 12 months of the accident; or surgery on the maxilla or mandible that is Medically Necessary to correct TMJD or other medical disorders.
  • Maintenance chiropractic care. However, non-maintenance chiropractic services are Covered Health Services when approved and received as described under "Chiropractic Care."
  • Any services in connection with medical exams or tests not connected with the care and treatment of an actual illness, disease, or injury, except services that Anthem Blue Cross as Claims Administrator determines are standard preventive or well-care services, (such as annual physical examinations, mammograms and colonoscopies) and that are provided in accordance with Anthem Blue Cross' guidelines. Diagnostic procedures are covered for the prenatal diagnosis of genetic disorders of the fetus when authorized by a physician in the case of a high-risk pregnancy.
  • Services or supplies for or in connection with:
    • Exams to determine the need for (or changes of) eyeglasses or lenses of any type;
    • Eyeglasses or lenses of any type (except replacements for loss of the natural lens, or the initial pair of eyeglasses or contact lenses after eye surgery);
    • Eye surgery such as radial keratotomy or lasik surgery; or
    • Services for a surgical procedure to correct refraction errors of the eye, including any confinement, treatment, services or supplies given in connection with, or related to, the surgery.
  • Services or supplies furnished by the employer or a member of the participant's immediate family.
  • Services that do not meet the definition of Covered Health Services.
  • Any services or supplies that are considered to be "experimental" or "investigational," as determined solely by Anthem Blue Cross. Experimental procedures are defined as procedures that are mainly limited to laboratory and/or animal research. Investigational services include any treatment, therapy, procedure, drug, facility, equipment, device or supply that is not recognized in accordance with generally accepted professional medical standards as being safe and effective for use in the treatment of an illness, injury or condition. Investigational services also include those which require approval by the federal government or any agency thereof, or by any state governmental agency, prior to use, and where such approval has not been granted at the time the services were rendered.
  • Speech therapy that is not deemed to be a Medically Necessary Covered Health Service, as determined solely by Anthem Blue Cross, including but not limited to treatment received after the first 24 visits in a calendar year that is deemed by Anthem Blue Cross to be not Medically Necessary.
  • Physical and/or occupational therapy that is not deemed to be a Medically Necessary Covered Health Service, as determined solely by Anthem Blue Cross, including but not limited to treatment received after the first 24 visits in a calendar year that is deemed by Anthem Blue Cross to be not Medically Necessary. For purposes of counting the first 24 visits each calendar year, both physical therapy and occupational therapy visits will apply on a combined basis.
  • Massage therapy, if performed by a massage therapist, or any services performed by a massage therapist who is not also a physician or other approved health care provider (see the Definitions section). However, massage therapy performed by a physical therapist or chiropractor is covered, if deemed to be Medically Necessary by Anthem Blue Cross.
  • Screenings to determine the need for hearing correction; routine hearing tests; and hearing aids and exams to determine the need for hearing aids or the need to adjust them. This exclusion does not apply to cochlear implants for adults and children (age 2 or older) for the following diagnoses: (1) severe to profound bilateral sensorineural hearing loss and severely deficient speech discrimination; or (2) post-lingual deafness in an adult.
  • Any services or supplies for learning disabilities, behavioral problems, mental retardation, or hospitalization for environmental change, except for speech/occupational/physical therapy rendered in association with autistic spectrum disorder. Services and supplies in connection with mental, psychoneurotic, and personality disorders, or for abuse of or addiction to alcohol and drugs; however, such services and supplies are covered elsewhere under the Mental Health and Substance Abuse Program, administered by ValueOptions. This exclusion does not apply to services and supplies for medical detoxification.
  • Any services or supplies furnished in connection with foot care, unless they are determined to be Medically Necessary Covered Health Services and authorized by a physician.
  • Orthopedic shoes (except when joined to braces) or shoe inserts, such as orthotics, even if recommended by your physician.
  • Charges in excess of Customary and Reasonable or Eligible Expenses, as determined by Anthem Blue Cross, or in excess of any specified limitation.
  • Services or supplies that are not determined to be Covered Health Services, including any confinement or treatment given in connection with a service or supply that is not covered under the Plan.
  • Exercise programs, exercise monitoring, exercise equipment, health spa programs and outpatient dietary consultations.
  • Services or supplies primarily for weight reduction or treatment of obesity, unless they are determined to be Medically Necessary Covered Health Services and authorized by a physician. This exclusion will not apply to surgical treatment involving morbid obesity if:
    • surgical treatment of morbid obesity is necessary to treat another life-threatening condition involving morbid obesity; and
    • it has been documented that non-surgical treatments of the morbid obesity have failed, and
    • surgical treatment has been approved by Anthem Blue Cross.
  • Outpatient prescription drugs, unless dispensed as an infusion drug or injection that requires the expertise of trained medical personnel to dispense. (These may be covered by the separate Prescription Drug Plan, administered by Express Scripts.)
  • Mental health, alcohol or chemical dependency treatment. (These may be covered by the separate Mental Health and Substance Abuse Program, administered by ValueOptions.)
  • Heating pads and thermometers, and other over-the-counter products.
  • Devices and computers to assist in communication and speech.
  • Air purifiers, air conditioners and humidifiers.
  • Supplies for comfort, hygiene or beautification.
  • Services and supplies furnished in connection with injury or disease arising out of, or in the course of, any work for wage or profit (whether or not with the employer) if such injury or disease is covered by any Workers' Compensation law, occupational disease law or similar law. The Anthem Blue Cross Plan will provide services and supplies in connection with such injury or disease but will be entitled to reimbursement for them in accordance with rules set out in The Pacific Gas and Electric Company Health Care Plan for Retirees and Surviving Dependents Plan Document.
  • Treatment for conditions caused by war or aggression, declared or undeclared, or international armed conflict.
  • Services or supplies to the extent furnished by any law or government, unless required by law.
  • Benefits provided under the "Medicare" section of the Social Security Act.
  • Services and supplies for which coverage is available under any other Company-sponsored health plan or benefit program.
  • Alternative treatments such as acupressure, aromatherapy, hypnotism, rolfing and other forms of alternative treatment, as defined by the Office of Alternative Medicine of the National Institutes of Health.
  • Charges for failure to keep a scheduled appointment, transfer of medical records, and other similar charges for which no medical treatment or services have been provided.
  • Services that are educational in nature, unless specifically authorized by Anthem Blue Cross.
  • Except as otherwise provided herein for preventive and well-care exams and tests, any services in connection with routine physical exams or medical exams not connected with the primary purpose of the discovery of a medical condition, disease or illness leading to treatment, such as a pre-employment medical exam or a team sports exam.
  • Benefits provided under the extension of a benefits provision of other insurance policies, benefit plans, or health plan contracts.