State of Wisconsin Employees

Dental Exclusions

The plan doesn't cover the following services for dental and orthodontic services, in addition to all other exclusions:

Excess Medical Exclusions

This group health plan does not cover:

Any treatments, services, or supplies:
paid or payable by a Basic Plan; that would have been payable by the Standard Plan, in cases when enrolled in a Basic Plan or enrolled in Standard Plan II, or were denied by a Basic Plan for alcoholism, drug abuse, or nervous or mental disorders due to lack of referral, authorization, or certification; denied by a Basic Plan due to lack of referral, authorization, or certification, or any other reason unless specifically stated as covered in the policy; cosmetic surgery; medical exams, including eye and hearing exams, health assessments, procedures and associated services requested by a third party; educational/recreational therapy services; physical/exercise programs; preparation, fitting, or purchase of eyeglasses, contact lenses, or hearing aids; custodial or rest care; medical supplies and durable medical equipment for comfort, personal hygiene, or convenience; professional services not provided by a physician; housekeeping, shopping, or meal-preparation services; outpatient food, food supplements, or vitamins; room, board, services, and supplies furnished by a hospital if the participant is admitted on a Friday or Saturday, unless admission is medically necessary or on an emergency basis; motor vehicles and certain lifts; amounts that exceed our determination of a charge; amounts in excess of coordinated state mandate on nervous and mental care; reconstructive surgery; Retin-A, Minoxidil, Rogaine, or their equivalent in topical form, unless medically necessary.


Any treatments, services, or supplies connected with:
obesity, weight reduction, or dietetic control, except for morbid obesity and disease etiology; any illness or injury caused by engaging in an illegal occupation or commission of, or attempt to commit, a felony.


Any treatments, services, or supplies:
for any injury covered by Workers' Compensation or similar laws; furnished by the U.S. Veterans Administration, except when we're the primary payor; furnished by any federal, state, or local subdivision unless coverage is required by law; covered by Medicare; for any illness or injury caused by atomic or thermonuclear explosion or resulting radiation, or any type of military action; we determine as not medically necessary or appropriate; provided by immediate family members or by anyone else who lives with the participant; in connection with alcoholism, substance abuse, and nervous or mental disorders; provided to or received by a participant as a collateral in connection with any treatment of any person not covered under this policy; experimental or investigative in nature; not specifically covered under the policy; resulting or arising from complication of, or incidental to, any treatment, service, or supply not covered under the policy; for routine foot care, such as the removal of corns or calluses, and the non-operative partial removal of toenails; provided before the effective date of coverage, after coverage ends, or during any waiting periods; for health education, marriage counseling, holistic medicine, or other programs for complete personal fulfillment; used in educational or vocational training; for which proof of claims isn't provided to us; not related to an illness or injury, unless stated in the policy.

 

Treatments, services, or supplies for: or leading to, sex transformation surgery, and sex hormones related to such treatment; reversal of sterilization; artificial insemination, or fertilization methods and related professional or diagnostic services and medicines, including in vivo fertilization, in vitro fertilization, embryo transfer, gamete intra fallopian transfer (GIFT), and similar procedures; abortion procedures, unless stated in the policy.

AD&D Exclusions

This plan doesn't cover the following losses, in addition to the general exclusions:

Any loss due to: injuries received in any aircraft, except as a passenger in a commercial aircraft on a regularly-scheduled flight; sickness or disease; bacterial infections, unless due to accidental food poisoning; injury sustained while intoxicated or under the influence of any controlled substance unless prescribed by a physician; an intentionally self-inflected injury or sickness; suicide or attempted suicide; your participation in a riot or in the commission of a crime.