Limitations & Exclusions

Medical

These medical plans don’t cover all health care expenses and include limitations and exclusions. Please refer to your plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates, essential health benefits, or the plan design or rider(s) purchased.

• All medical and hospital services not specifically covered in, or that are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage ends
• Cosmetic surgery
• Custodial care
• Dental care and dental X-rays for individuals age 19 and older*
• Donor egg retrieval
• Experimental and investigational procedures (except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial)
• Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for individuals age 19 and older or cosmetic purposes
• Hearing aids
• Home births
• Immunizations for travel or work
• Implantable drugs and certain injectable drugs, including injectable infertility drugs
• Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents
• Non-emergency care when traveling outside the U.S.
• Non-medically necessary services or supplies
• Office visits to an ophthalmologist, optometrist or optician related to the fitting of prescription contact lenses
• Orthotics
• Over-the-counter medications and supplies
• Radial keratotomy or related procedures
• Reversal of sterilization
• Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling
• Special or private duty nursing
• Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens, and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions

Pediatric dental*

These medical plans don’t cover all pediatric dental care expenses and include limitations and exclusions. Please refer to your plan documents to see which services we cover. The following is a partial list of services and supplies that we generally don’t cover. However, your plan documents may have exceptions to this list. We base these documents on state laws, essential health benefits, or the plan design or rider(s) you buy.

• All pediatric dental services not specifically covered in, or that your plan documents limit or exclude, including costs of services before coverage begins and after coverage ends
• Instructions for diet, plaque control and oral hygiene
• Dental services or supplies that you may primarily use to change, improve or enhance appearance
• Dental implants
• Experimental or investigational drugs, devices, treatments or procedures
• Services not necessary for the diagnosis, care or treatment of a condition
• Orthodontic treatment that isn’t medically necessary for a severe or handicapping condition
• Replacement of lost or stolen appliances
• Services and supplies provided where there is no evidence of pathology, dysfunction or disease