UTMB Multi-Share Plan Provider Network
Unless specifically stated otherwise, no benefits will be provided for or on account of the following items:
- Treatments, services, supplies and/or surgeries that are not medically necessary.
- Services received outside the Multi-Share Plan provider network.
- A sickness or bodily injury that is covered under Worker's Compensation or similar law.
- A sickness or bodily injury arising out of, or in the course of, any employment for wage, gain or profit.
- A sickness or bodily injury arising out of the commission of a crime or ordered by the court.
- Services provided to you, if they do not comply with the plan requirements:
- Service provided by a health care provider that is out-of-network (unless in an emergency situation and if it meets the defined emergency guidelines).
- Received in an emergency room, unless required because of emergency care.
- Any drug, biological product, device, medical treatment, or procedure which is experimental, or investigational or for research purposes.
- Treatment of nicotine habit or addition.
- Hearing aids, the fitting of aids or advice on their care.
- In-vitro fertilization; any medical or surgical treatment of infertility.
- Treatment of erectile dysfunction or injectable medications.
- Elective sterilization including, but not limited to tubal ligations and vasectomies and the reversal of elective sterilization.
- Cosmetic surgery, unless for reconstructive surgery and is subject to network constraints and plan limitations.
- Appliances or supplies for treatment of teeth, gums, or jaw.
- Custodial care and maintenance care including, but not limited to nursing homes and home health care.
- Inpatient mental health care services and treatment.
- Any treatment, including but not limited to surgical procedures for obesity.
- Services related to allergy testing or treatment.
- Alternative medicine, including but not limited to acupuncture, acupressure, reflexology, therapeutic massage, etc.
- Dialysis treatment and services.
- Any treatment or services relating to end-of-life palliative care including Hospice.
- All chiropractic services.
- Any human or artificial organ or tissue transplant.
- Speech treatment or services.
- Service and treatment related to intrauterine care, genetics testing and elective termination of pregnancy.
- Implants, injectable and insertables (as related to contraceptive management)
These limitation and exclusion apply even if a health care practitioner has performed or prescribed a medically appropriate procedure, treatment or supply. This does not prevent your health practitioner from providing or performing the procedure, treatment or supply; however, the procedure, treatment or supply will not be a covered expense.
Services and products excluded from 3-Share Plan coverage include, but are not limited to, the following:
- Services received outside the 3-Share Plan provider network
- Services received outside Galveston County (except Caremark network pharmacy services)
- Allergy tests or treatment
- Bariatric or other weight loss surgery
- Alternative or complementary care, such as acupuncture, acupressure, reflexology, therapeutic massage, etc.
- Cosmetic surgery or procedures
- Dental or orthodontic care, including treatment for temporomandibular joint dysfunction (TMJ)
- Dialysis treatment
- Durable medical equipment (DME)
- End-of-life palliative care, such as Hospice
- Erectile dysfunction treatment or injectable medication
- Glasses or contact lenses
- Hearing aids
- Home health care
- Infertility treatment or medication
- Inpatient mental health care
- Laser vision improvement surgery
- Neonatal care
- Nursing home care
- Physical, Occupational or Speech Therapy
- Experimental treatment or medication
This is not intended to be a complete list of excluded services. If you or your health care provider have questions regarding whether or not a service is covered, please call the 3-Share Plan Customer Service Line at (409) 766-4064.