GENERAL EXCLUSIONS Exclusions, including complications from excluded items, are not considered covered benefits under this Plan and will not be considered for payment as determined by the Plan. The Plan does not pay for expenses Incurred for the following, unless otherwise stated below or as otherwise required to be covered by the No Surprises Act. The Plan does not apply exclusions to treatment listed in the Covered Medical Benefits section based upon the source of an Injury if the Plan has information that the Injury is due to a medical condition (including physical and mental health conditions and Emergencies) or domestic violence. 1. 3D Mammograms, unless covered elsewhere in this SPD. 2. Abdominoplasty. 3. Abortions: Unless a Physician states in writing that the mother’s life would be in danger if the fetus were carried to term, or unless the pregnancy is the result of incest or rape. 4. Acts of War: Injury or Illness caused or contributed to by international armed conflict, hostile acts of foreign enemies, invasion, or war or acts of war, whether declared or undeclared. 5. Acupuncture Treatment. 6. Alternative / Complementary Treatment. Refer to the Glossary of Terms for a definition of Alternative / Complementary Treatment. 7. Appointment Missed: An appointment the Covered Person did not attend. 8. Aquatic Therapy. 9. Assistance With Activities of Daily Living. 10. Assistant Surgeon, Co-Surgeons, or Surgical Team Services, unless determined to be Medically Necessary by the Plan. 11. Before Enrollment and After Termination: Services, supplies or treatment rendered before coverage begins or after coverage ends under this Plan. 12. Biofeedback Services. 13. Blood: Blood donor expenses. 14. Blood Pressure Cuffs / Monitors. 15. Breast Pumps, unless covered elsewhere in this SPD. 16. Cardiac Rehabilitation beyond Phase II, including self-regulated physical activity that the Covered Person performs to maintain health that is not considered to be a treatment program. 17. Claims received later than 12 months from the date of service. 18. Conditions listed in the most recent American Psychiatric Association Diagnostic and Statistical Manual (DSM) or the most recent revision of the International Classification of Diseases – Clinical Modification manual (ICD-CM) in the following categories: • Personality disorders; or • Behavior and impulse control disorders; or • “Z” codes. -91- 7670-00-413597