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General Limitations and Exclusions for Most Plans
We want to help you understand what is covered by your health plan and answer your questions. This list will give you a general idea of what isn't covered—what is excluded—but if you want to know about a specific service, it's best to call us or refer to your member materials.
What Does Calendar Year Mean?
Unless otherwise noted on your materials, benefits are calculated on a calendar year basis—regardless of when you enrolled. Out-of-pocket maximums, limitations, and deductibles start over every year on January 1.
What Are Excess Charges?
Charges from doctors or facilities that exceed our allowed amount for covered services are called excess charges. You are responsible to pay for excess charges from nonparticipating providers and facilities. These charges do not apply to your out-of-pocket maximum.
Are Services Related to Noncovered Services Also Excluded?
If you get a noncovered service at the same time as a covered service (such as a covered operation), only charges relating to the covered service will be considered for payment. Charges related to the noncovered service may not be paid.
These Services are Not Covered
Unless otherwise noted in your Member Payment Summary, the following services are not covered:
- Abortions, selected types of
- Acupuncture and acupressure
- Administrative services/charges, for nonmedical purposes
- Allergy tests, treatment, and services, selected types of
- Anesthesia, selected types of
- Attention-Deficit and Hyperactivity Disorder (ADHD)
- Bariatric surgery
- Biofeedback and neurofeedback
- Birthing centers and home childbirth
- Cancer therapy, selected types of
- Chiropractic services
- Complementary and Alternative Medicine (CAM)
- Certain complications from a noncovered service
- Certain durable medical equipment
- Certain behavioral health/chemical dependency services
- Claims after one year
- Custodial care
- Debarred providers
- Dental anesthesia
- Duplication of coverage
- Exercise equipment and fitness training
- Experimental or investigational treatments and services
- Eye surgery, refractive
- Food supplements
- Gene therapy
- Habilitation therapy services (large employer plans only)
- Hearing aids, selected types of
- Home health aides
- Illegal activities, selected types of
- Immunizations, selected types of
- Infertility treatment
- Methadone therapy
- Non covered service in conjunction with a covered service
- Pain management services, selected types of
- Pervasive developmental disorder
- Prescription drugs, injectable drugs, and specialty medications, selected types of
- Reconstructive, corrective, and cosmetic services, selected types of
- Rehabilitation therapy services, selected types of
- Related provider services
- Respite care
- Robot-assisted surgery
- Services that are not medically necessary
- Sex reassignment surgery
- Sexual dysfunction
- Telephone and e-mail consultations
- Temporomandibular Joint (TMJ) disorder and orthognathic (Individual plans only)
- Terrorism or nuclear release
- Travel-related expenses
- War, related services
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