Limitations and exclusions

For group policies

2024 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
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 for the purpose of Assisted Reproductive Technology (ART)
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 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 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
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, excepts 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.

2023 benefit year

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