Noncovered Services

The following is a partial list of treatments, services, supplies and expenses that HIRSP does not cover:

• Cosmetic treatments
  
• Eyeglasses
  
• Hearing aids
  
• Routine dental care
  
• Health care services performed by members of your immediate family or anyone else living with you
  
• Any services covered by any other policy of healthcare insurance
  
• Custodial care
  
• Infertility, impotence and sterilization services or drugs
• Charges for procedures or services that are determined as not medically necessary and appropriate
• Expenses incurred for procedures or services that are of questionable medical value, experimental or investigative (except drugs for the treatment of HIV infection)

For more specific information about services that HIRSP does not cover, refer to the HIRSP policy or contact HIRSP Customer Service.

Grievance and Appeal Rights
HIRSP has a grievance and appeal process if you disagree with a HIRSP decision, such as:

• Denial or termination of coverage
• Denial or reduction of claim payment
• Denial of an application for a reduction of HIRSP premium, deductible or drug out-of-pocket maximum
• Denial of prior approval

For more information about grievance and appeal rights, you may refer to the HIRSP policy received upon HIRSP's approval of coverage or contact HIRSP Customer Service.