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Limitations and exclusions

These lists are 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 certificate. The following list is not exhaustive and may vary based on your policy. For a complete listing, refer to your certificate. 

2022 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
  • 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, 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
  • 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, or 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
  • 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.

2021 benefit year

All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in either your policy and benefit Summary (“policy”) if you have individual coverage or your group member certificate (“certificate”) if you have coverage through your employer. The following list is not exhaustive and may vary based on your policy or certificate. For a complete list, see your member policy or certificate.

  • 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, 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
  • 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
  • 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
* Indicates language that will likely vary in your Policy or Certificate.
  • 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

* Indicates language that will likely vary in your Policy or Certificate.
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