UTMB Multi-Share Plan

Unless specifically stated otherwise, no benefits will be provided for or on account of the following items:

1. Treatments, services, supplies and/or surgeries that are not medically necessary.
2. Services received outside the Multi-Share Plan provider network.
3. A sickness or bodily injury that is covered under Worker's Compensation or similar law.
4. A sickness or bodily injury arising out of, or in the course of, any employment for wage, gain or profit.
5. A sickness or bodily injury arising out of the commission of a crime or ordered by the court.
6. Services provided to you, if they do not comply with the plan requirements:
   1. 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).
   2. Received in an emergency room, unless required because of emergency care.
   3. Any drug, biological product, device, medical treatment, or procedure which is experimental, or investigational or for research purposes.
   4. Treatment of nicotine habit or addition.
   5. Hearing aids, the fitting of aids or advice on their care.
   6. In-vitro fertilization; any medical or surgical treatment of infertility.
   7. Treatment of erectile dysfunction or injectable medications.
   8. Elective sterilization including, but not limited to tubal ligations and vasectomies and the reversal of elective sterilization.
   9. Cosmetic surgery, unless for reconstructive surgery and is subject to network constraints and plan limitations.
   10. Appliances or supplies for treatment of teeth, gums, or jaw.
   11. Custodial care and maintenance care including, but not limited to nursing homes and home health care.
   12. Inpatient mental health care services and treatment.
   13. Any treatment, including but not limited to surgical procedures for obesity.
   14. Services related to allergy testing or treatment.
   15. Alternative medicine, including but not limited to acupuncture, acupressure, reflexology, therapeutic massage, etc.
   16. Dialysis treatment and services.
   17. Any treatment or services relating to end-of-life palliative care including Hospice.
   18. All chiropractic services.
   19. Any human or artificial organ or tissue transplant.
   20. Speech treatment or services.
   21. Service and treatment related to intrauterine care, genetics testing and elective termination of pregnancy.
   22. 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.
• Chiropractic
• 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
• Implants
• Infertility treatment or medication
• Inpatient mental health care
• Laser vision improvement surgery
• Neonatal care
• Nursing home care
• Physical, Occupational or Speech Therapy
• Podiatry
• Prosthetics
• Transplants
• 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.