Limitations and exclusions

For group policies

2022 benefit year

All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in your certificate. The following list is not exhaustive and may vary based on your policy. For a complete listing, see your member certificate.

  • Court-ordered drug testing unless Medically Necessary
  • Cytotoxic testing and sublingual antigens associated to allergy testing
  • Hair analysis (unless lead or arsenic poisoning is suspected)
  • Preimplantation genetic testing of embryos and gametes
  • Convenience items for a Member or a Member’s family, unless stated otherwise in this policy
  • Infertility drugs, including, but not limited to, those administered by a medical provider
  • Outpatient prescription drugs, except those prescriptions otherwise covered under this policy
  • Oral nutrition: oral nutrition is not considered a medical item. We do not cover nutritional support that is taken orally (i.e., by mouth), unless mandated by state law or covered under our medical policy for a specific condition. Examples include, but are not limited to, over-the-counter nutritional supplements, infant formula, and donor breast milk.
  • Replacement of an item if the item is lost, stolen, unusable or nonfunctioning because of misuse, abuse, or neglect 
  • Sexual dysfunction devices and supplies, including but not limited to medications and injections
  • Autopsy
  • Consultation, treatment, or procedures for Assisted Reproductive Technology (ART)
  • Charges directly related to a non-covered service, such as hospitalization charges, except when a complication results from the non-covered service that could not be reasonably expected and the complication requires medically necessary treatment. The treatment of the complication must be a covered benefit.
  • Consultation for, or procedures connected to in vitro fertilization, embryo transplantation, and/or any other assistive reproductive  technique (e.g., GIFT, ZIFT)
  • Cosmetic services, including cosmetic surgery
  • Experimental or investigational services, treatments, or procedures, and any related complications as determined by us, unless coverage is required by state or federal law
  • Non-medical services provided in a Hospital or medical setting, not otherwise listed as covered in this certificate
  • Items that can be purchased over the counter and considered to be for comfort, convenience and/or personal hygiene, examples include, but are not limited to: seasonal affective disorder light units, disposable undergarments, wigs and modification to a Member’s home such as ramps, grab bars, stair lifts and bench/chair lifts.
  • Podiatry services or routine foot care provided when there is no localized illness, injury, or symptoms. These include, but are not limited to 1) the examination, treatment, or removal of all or part of corns, calluses, hypertrophy or hyperplasia of the skin or subcutaneous tissues of the feet; the cutting, trimming, or other non-operative partial removal of toenails; or 3) any treatment or services in connection with any of these.
  • Obesity-related services, including any weight loss method, surgical treatment or hospitalization for the treatment of obesity, unless specifically covered under this certificate
  • Reversal of voluntary sterilization and related procedures
  • Services, treatment, and supplies provided to a Member while the Member is held or detained in custody of law enforcement officials, or imprisoned in a local, state, or federal penal or correctional institution
  • Services and supplies furnished by a government plan, hospital, or institution the law requires you to pay 
  • Services, treatment, and supplies provided in connection with any illness or injury caused by: a Member engaging in an illegal occupation or b) a Member committing or attempting to commit, a felony. (Note that this exclusion does not apply to the treatment of injuries that result from an act of domestic violence, if that treatment would otherwise be covered). 
  • Services provided by Members of the subscriber’s immediate family or any person living with the subscriber
  • Services or supplies associated to a denied prior authorization
  • Services or supplies associated to a denied admission
  • Services or supplies not medically necessary, not recommended or approved by a provider, or not provided within the scope of the provider’s license
  • Services or items provided as a result of war or any act of war, insurrection, riot or terrorism
  • Services or supplies provided for an injury sustained while erforming military service
  • Services or supplies for which a Member receives or is entitled to receive any benefits, settlement, award, or damages, or following any claim under, any Workers’ Compensation Act, employer’s liability insurance plan, or similar law or act. “Entitled” means the Member is actually insured under Workers’ Compensation.
  • Surrogacy services, for a non-Member
  • Sexual dysfunction treatment and services including, but not limited to surgery
  • Sterilization procedures for men
  • Sterilization procedures for women and patient education and counseling related to contraception for all women with reproductive capacity. (Although these are technically excluded from your group’s health plan insurance coverage, we will pay for them as preventive services, as required by federal regulations)
  • Take home drugs and supplies unless a written prescription is obtained and filled at a network pharmacy
  • Acupuncture
  • Chelation therapy for atherosclerosis
  • Coma stimulation programs
  • Alternative medicine, not otherwise listed in the policy
  • Low level light therapy
  • Massage therapy
  • Prolotherapy
  • Swim or pool therapy, unless prior authorization is obtained
  • Administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics 
  • Court-ordered care, unless medically necessary and otherwise covered under this certificate
  • Educational services, except for diabetic self-management classes
  • Internet consultations, including all related charges and costs, except as defined by our medical policy
  • Missed appointment charges
  • Telephone consultation charges between providers
  • Charges or costs exceeding a benefit maximum or maximum allowable fee, where applicable
  • Expenses incurred before the supply or service is actually provided unless prior authorized by us


2021 benefit year

All benefits are subject to limitations and exclusions as described in your Member Certificate and Schedule of Benefits. The following list is not exhaustive. For a complete listing refer to the Member Certificate and Schedule of Benefits.

 Non-covered Infertility services

  • Consultation for, or procedures in connection with, in vitro fertilization, embryo transplantation, and/or any other assistive reproductive technique (e.g. GIFT, ZIFT).
  • Reversal of voluntary sterilization and related procedures.
  • All charges or costs relating to donor sperm.
  • Services related to surrogacy.

 
Non-covered maternity services

  • Elective abortions.
  • Home or intended out of hospital deliveries.
  • Amniocentesis or CVS (Chorionic Villi Sampling) performed exclusively for sex determination.
  • Birthing classes.
  • Treatment, services, or supplies for a third party or nonmember traditional surrogate or gestational carrier.
  • Collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility.

 
Non-covered outpatient physical, speech and occupational therapy

  • Long term and maintenance therapy.

 
Non-covered transplant services

  • Transplants and all related expenses, not outlined as covered procedures in the Member Certificate.
  • Services and supplies in connection with covered transplants unless prior authorized by the Medical Affairs Division.
  • Any experimental or investigational transplant or any other transplant-like technology not listed in the Member Certificate. Any resulting complications from these and any services and supplies related to such experimental or investigational transplantation or complications, including, but not limited to: high dose chemotherapy, radiation therapy or immunosuppressive drugs.
  • Transplants involving non-human or artificial organs.

 
General exclusions and limitations

  • Acupuncture, dry needling, and prolotherapy.
  • Autopsy.
  • Chelation therapy for atherosclerosis.
  • Coma Stimulation programs.
  • Court-ordered care, unless medically necessary and otherwise covered under this plan.
  • Cytotoxic testing and sublingual antigens in conjunction with allergy testing.
  • Dental or dental-related services, treatments, or procedures not specifically covered under the “Dental Services” subsection of this policy.
  • Dental implants. 
  • Orthognathic surgery, except for the treatment of TMD when prior authorized by our Medical Affairs Division.
  • Services required for administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics.
  • Experimental or investigational services, treatments or procedures, and any related complications as determined by our Medical Affairs Division, unless coverage is required by state or federal law.
  • Services provided by members of the subscriber’s immediate family or any person residing with the subscriber.
  • Holistic medicine and any other form of alternative medicine.
  • Lyme disease vaccination.
  • Massage therapy.
  • Oral surgery, unless specifically covered under the policy.
  • Swim or pool therapy, unless prior authorization is obtained.
  • Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay.
  • Items or services required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while performing military service.
  • Podiatry services or routine foot care rendered in the absence of localized illness, injury, or symptoms in connection with, but not limited to: (a) the examination, treatment or removal of all or part of corns, calluses, hypertrophy or hyperplasia of the skin or subcutaneous tissues of the feet; (b) the cutting, trimming or other non-operative partial removal of toenails; (c) the treatment of flexible flat feet; or (d) for any treatment or services in connection with any of these.
  • Any services to the extent a member receives or is entitled to receive any benefits, settlement, award or damages for any reason of, or following any claim under, any Workers’ Compensation Act, employer’s liability insurance plan or similar law or act. 
  • Treatment, services, and supplies provided in connection with any illness or injury caused by: (a) a member’s engaging in an illegal occupation or (b) a member’s commission of, or an attempt to commit, a felony.
  • Treatment, services, and supplies provided to a member while the member is held or detained in custody of law enforcement officials, or imprisoned in a local, state or federal penal or correctional institution.
  • Hair analysis (unless lead or arsenic poisoning is suspected).
  • Obesity-related services, including any weight loss method, unless specifically covered under the policy.
  • All services or supplies provided in conjunction with the treatment of sexual dysfunction or sexual transformation, including, but not limited to, medications, surgical treatment, and injections.
  • Any hospital service or medical care not listed in the policy.
  • Outpatient prescription drugs, except those prescriptions otherwise covered under the policy.
  • Services and supplies rendered outside the scope of the provider’s license.
  • An expense incurred before the supply or service is actually provided unless prior approval is received.
  • Services or supplies for, or in connection with a non-covered procedure or service, including complications, regardless of when a non-covered procedure or service is or was performed, a denied authorization or a denied admission.
  • Services provided in conjunction with the diagnosis and treatment of infertility, unless specifically covered under the policy.
  • Treatment, services or supplies for a non-member traditional surrogate or gestational carrier.
  • All charges or costs exceeding a benefit maximum or maximum allowable fee where applicable.
  • Collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility including for surrogacy or gestational carriers.
  • Oral nutrition.
  • Educational services, except for diabetic self-management classes.
  • Cosmetic services, including cosmetic surgery.
  • Replacement of an item if the item is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect.
  • No coverage is available for missed appointment charges, or telephone consultation charges by or between providers.
  • Low-Level Light Therapy.
  • In-home behavioral health therapy services provided for the convenience of the member.
  • Laser treatment for Port Wine Stain (PWS) lesions, except on the face.
  • Items of convenience for a member or a member’s family.
  • Travel immunizations.