Common use of GENERAL EXCLUSIONS Clause in Contracts

GENERAL EXCLUSIONS. In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the Agreement, except as required by federal or state law. 2. Follow-up services or complications related to non-Covered Services, except as required by federal or state law. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to KFHPWA's medical director at X.X. Xxx 00000, Xxxxxxx, XX 00000-0000. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.

GENERAL EXCLUSIONS. ‌ In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the Agreement, except as required by federal or state law. 2. Follow-up services or complications related to non-Covered Services, except as required by federal or state law. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to KFHPWA's medical director at X.X. Xxx 00000, Xxxxxxx, XX 00000-0000. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.

GENERAL EXCLUSIONS. In addition to exclusions listed throughout the AgreementBenefits Booklet, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the AgreementBenefits Booklet, except as required by federal or state law. 2. Follow-up services or complications related to non-Covered Services, except as required by federal or state law. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to KFHPWA's medical director at X.X. Xxx 00000, Xxxxxxx, XX 00000-0000. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.

GENERAL EXCLUSIONS. In addition to exclusions listed throughout the AgreementBenefits Booklet, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the AgreementBenefits Booklet, except as required by federal or state law. 2. Follow-up services or complications related to non-Covered Services, except as required by federal or state law. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA Group Health consults with KFHPWAGroup Health’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA Group Health denial of coverage can be submitted to the Member Appeal Department, or to KFHPWAGroup Health's medical director at X.X. Xxx 00000, Xxxxxxx, XX 00000-0000. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.

GENERAL EXCLUSIONS. ‌ In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the Agreement, except as required by federal or state law. 2. Follow-up services or complications related to non-Covered Services, except as required by federal or state law. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives.. DRAFT 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to KFHPWA's KFHPWAs medical director at X.X. Xxx 00000, Xxxxxxx, XX 00000-0000. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.

GENERAL EXCLUSIONS. In addition to exclusions listed throughout the AgreementEOC, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the AgreementEOC, except as required by federal or state law. 2. FollowServices Related to a Non-up Covered Service: When a service is not covered, all services or complications related to the non- covered service (except for the specific exceptions described below) are also excluded from coverage. Members who have received a non-Covered Servicescovered service, except such as required by federal bariatric surgery, and develop an acute medical complication (such as band slippage, leak or state lawinfection) as a result, shall have coverage for Medically Necessary intervention to stabilize the acute medical complication. Coverage does not include complications that occur during or immediately following a non-covered service. Additional surgeries or other medical services in addition to Medically Necessary intervention to resolve acute medical complications resulting from non-covered services shall not be covered. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA KFHPWAO consults with KFHPWAKFHPWAO’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA KFHPWAO denial of coverage can be submitted to the Member Appeal Department, or to KFHPWAKFHPWAO's medical director at X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000WA 98124-00001593. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.

GENERAL EXCLUSIONS. In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the Agreement, except as required by federal or state law. 2. Follow-up services or complications related to non-Covered Services, except as required by federal or state law. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to KFHPWA's medical director at X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000WA 98124-00001593. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.

GENERAL EXCLUSIONS. ‌ In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the Agreement, except as required by federal or state law. 2. Follow-up services or complications related to non-Covered Services, except as required by federal or state law. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to KFHPWA's KFHPWAs medical director at X.X. Xxx 00000, Xxxxxxx, XX 00000-0000. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.

GENERAL EXCLUSIONS. ‌ In addition to exclusions listed throughout the Agreement, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the Agreement, except as required by federal or state law. 2. Follow-up services or complications related to non-Covered Services, except as required by federal or state law. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Member if the Member receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured.. DRAFT 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. 7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Member’s condition if any of the following statements apply to it at the time the service is or will be provided to the Member: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Member’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Member or Member’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Member’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to KFHPWA's medical director at X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000WA 98124-00001593. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations.. DRAFT 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non-Members. 13. Autopsy and associated expenses. 14. Job skills training for specific occupations or educational therapy. 15. Expenses for services and supplies incurred as a result of any work-related injury or illness. This includes individuals who are partners, proprietors or corporate officers who are not covered by a Workers’ Compensation Act or other similar law.