Limitations and exclusions

This list is based on the limitations and exclusions included in the commercial certificates filed in the benefit year listed. All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in your Policy and Benefit Summary (“Policy”).

2024 benefit year

The following list is not exhaustive and may vary based on your Policy. For a complete listing refer to your Policy.

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
Drugs provided or administered by a physician or other provider, except those drugs that meet the definition of Professionally Administered Drugs. Coverage for Professionally Administered Drugs described under Professionally Administered Prescription Drugs. Coverage for prescription drugs is as described in Outpatient Prescription Drugs or otherwise described as a specific benefit 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 non-functioning because of misuse, abuse, or neglect
Sexual dysfunction supplies, including but not limited to medications and injections
Autopsy
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. treatment, for Assisted Reproductive Technology (ART)
Cosmetic services, and procedures including cosmetic surgery 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 Policy
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
Medical and surgical treatment of excessive sweating (hyperhidrosis)
Podiatry services or routine foot care rendered 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; 2. the cutting, trimming, or other non-operative partial removal of toenails; or 3. for any treatment or services in connection with any of these
Bariatric surgery, including initial procedures, surgical revisions and subsequent procedures.
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) a Member’s 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)
Removal of blemishes on skin surfaces and scars (excluding scar revisions) primary for cosmetic purposes, unless otherwise covered in the Surgical Services section.
Repair of a pierced body part and surgical repair of bald spots or loss of hair.
Repairs to teeth, including any other dental procedures or treatment, whether the dental treatment is needed because of a primary dental problem or as a manifestation of a medical treatment or condition.
Surgical correction of male breast enlargement primarily for cosmetic purposes.
Hair transplants.
Treatment for superficial veins, also referred to as telangiectasia, thread, reticular or spider veins.
Orthognathic surgery for cosmetic purposes. Experimental or investigational services, treatments,
Hearing aids (including internal, external or implantable hearing aids or devices) and other devices to improve hearing and their related fittings except as specifically stated in this Policy. Additionally, hearing aids that are available over-the-counter. Cochlear implants and their related fittings are covered as surgical services under office visits or hospital.

2023 benefit year

The following list is not exhaustive and may vary based on your Policy. For a complete listing refer to your Policy.

Court-ordered drug testing unless Medically Necessary.
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
Drugs provided or administered by a physician or other provider, except those drugs that meet the definition of Professionally Administered Drugs
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 supplies, including but not limited to medications and injections
An insured person being intoxicated, as defined by applicable state law in the state where the illness occurred or under the influence of illegal narcotics or non-prescribed controlled substances unless administered or prescribed by Physician
Autopsy
Consultation, treatment, or procedures for Assisted Reproductive Technology (ART).
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 • n fertility-related services or procedures not otherwise covered by this policy. This includes, but is not limited to the collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility. Hospital or medical service not listed in this Policy
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
Medical and surgical treatment of excessive sweating (hyperhidrosis)
Non-emergent 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.
Podiatry services or routine foot care rendered 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; 2. the cutting, trimming, or other non-operative partial removal of toenails; or 3. for 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 policy
Reversal of voluntary sterilization and related procedures
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) a Member’s 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 a 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 performing 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
Take home drugs and supplies unless a written prescription is obtained and filled at a network pharmacy
Travel immunizations
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 Policy
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

This notice was last updated June 2023.