Limitations and exclusions

This list is based on the limitations and exclusions included in the commercial certificates filed in the benefit year listed.

2022 benefit year

All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in your Policy and Benefit Summary (“Policy”).

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
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
Infertility-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

2021 benefit year

General limitations & exclusions

All benefits are subject to limitations and exclusions as described in your schedule of benefits and in your policy and benefit summary (“policy”). The following list is not exhaustive and may vary based on your policy. For a complete listing refer to your policy.

Medical

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 connected to the treatment of infertility, including but not limited to those administered in a physician’s office
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, overthe-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
Autopsy
Charges or costs relating to donor sperm
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
Infertility-related services and procedures
Infertility-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. It also applies to the use of non-Member Traditional Surrogates or Gestational Carriers, who are not covered under 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
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
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

Non-Medical

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
Hospital or medical service not listed in this Policy
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)
Services provided by Members of the subscriber’s immediate family or any person living with the subscriber
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
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