Refer to your CHC Healthcare Plan Agreement for a specific list. Each of the following Medical Services is usually an Excluded Coverage and a Denied Cost unless CHC provides you with prior written approval before the Medical Service is performed. ✓  Any Medical Service not shown or checked in the Table on your CHC Healthcare Plan. ✓  Any Pre-Existing Medical Condition not disclosed on Addendum A of your CHC Healthcare Plan. ✓  Any Prescription Medication being taken not disclosed on Addendum A of your CHC Healthcare Plan. ✓  Any Elective Medical Service including vasectomy, pregnancy and maternity ✓  Any Medical Service or combination of Medical Services that exceeds or will exceed: (a) $250, (b) 130% of the Medicare reimbursement amount, (c) the respective Medical Services and Prescription Medications Medical Benefit Amount, (d) or in CHC’s sole opinion, exceeds the usual and customary frequency or cost for such Medical Service ✓  Any Medical Service whereby the same or similar Medical Service was performed at an interval or frequency deemed by CHC to be excessive or too frequent ✓  Any Medical Service cost that exceeds the usual and customary cost for such Medical Service ✓  Any Medical Claim or collection of Medical Claims that exceed the Medical Services or Prescription Medications Plan Benefit Amount ✓  Any Medical Claim not timely submitted to CHC for Reimbursement ✓  Any Medical Service whereby a Medical Claim was denied by an insurance company or is not an accepted Medicare reimbursement ✓  Any non-life threatening, or Routine Medical Service received in Hospital ER or a Free-Standing ER instead of by a PCP or at an Urgent Care Facility ✓  Any Medical Service for substance abuse, physical abuse and mental health treatments including any habit or addiction treatments, counseling or services ✓  Any Medical Service whereby the Medical Provider’s diagnosis found no specific medical condition or there is no supporting documentation from a Medical Provider to justify the need for the Medical Service ✓  Any medical bill that was paid or should have been paid by any third-party, including, but not limited to: Stop-Loss insurance, other insurance policies, employer, state or federal programs or plan