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<br />)
<br />
<br />including hospital care frorn a non-participating Attending Physician or a non-participating Hospital, if
<br />elected by a member. In such circumstances, coverage is excluded for the entire episode of care, except
<br />when the admission was due to an emergency or with the prior written authorization of AvMed.
<br />
<br />12.28 Organ donor treatment and services. the Medical Services and Hospital Services for a donor or
<br />prospective donor who is an AvMed Member when the recipient of an organ transplant is not an AvMed
<br />Member. Coverage is provided for costs associated with the bone rnarrow donor-patients to the same
<br />extent as the insured recipient. The reasonable costs of searching for the bone marrow donor is limited
<br />to family members and the National Bone Marrow Donor Program. Post-transplant donor
<br />complications will not he covered.
<br />
<br />12.29 Over-the-counter medications, and prescription medications not otherwise covered including all
<br />contraceptives (medications and devices), hypodennic needles and syringes and Self-Administered
<br />Injectable Medications except insulin and insulin syringes for the treatment of diabetes as outlined in
<br />Section 10.06.
<br />
<br />12.30 Personal comfort items not Medically Necessary for proper medical care as Part of the therapeutic plan
<br />to treat or arrest the progression of an illness or injury. This Exclusion includes, but is not limited to:
<br />wigs (including partial hair pieces, weaves, and toupees), personal care kits, guest meals and
<br />accommodations, maid services, televisions/radios, telephone charges, photographs, complimentary
<br />meals, birth announcements, take horne supplies, travel expenses (other than Medically Necessary
<br />ambulance services that are provided for in Section 10.01), air conditioners, humidifiers, dehumidifiers,
<br />and air purifiers or filters.
<br />
<br />12.31 Physical examinations or tests, such as premarital blood tests or tests for continuing employrnent,
<br />education, licensing, or insurance or that are otheIVIise required by a third party.
<br />
<br />12.32 Private dnty nursing services.
<br />
<br />12.33 Rehahilitation programs. Alcohol or substance abuse rehabilitation, vocational rehabilitation,
<br />pulmonary rehabilitation, long term rehabilitation, or any other rehabilitation program.
<br />
<br />12.34 Removal of benign skin lesions and warts, moles, skin tags, lipomas, keloids, and scars, is not covered,
<br />even with a recommendation or prescription by a physician.
<br />
<br />12.35 Reversal of sterilization procedures.
<br />
<br />12.36 Sexual dysfunction. All rnedications, devices, and other forms of treatment related to a diagnosis of
<br />sexual dysfunction, regardless of etiology.
<br />
<br />12.37 Smoking cessation. Any service or supply to eliminate or reduce dependency on or addiction to
<br />tobacco, including but not limited to: nicotine withdrawal programs, facilities, and supplies (e.g.
<br />transderrnal patches, Nicorette gum).
<br />
<br />12.38 Speech therapy for delayed or abnormal speech pathology.
<br />
<br />12.39 Substance Abuse Treatment. Treatment for chronic alcoholism and chronic drug addiction, except
<br />those services offered as a basic health service. See Section 11.13.
<br />
<br />12.40 Surgically implanted devices and any associated external devices, except for cardiac pacemakers,
<br />intraocular lenses, cochlear implants, artificial joints, orthopedic hardware and vascular grafts. Dental
<br />appliances, other corrective lenses and hearing aids, including the professional fee for fitting them, are
<br />not covered.
<br />
<br />)
<br />
<br />.j
<br />
<br />)
<br />
<br />12.41 Temporomandibular Joint Dysfunction (TMJ). Services related to the diagnosis/treatment of TMJ
<br />except when Medically Necessary; all dental treatment for TMJ.
<br />
<br />33
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<br />A V -G I 00-2009
<br />MP-5319 (10/09)
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