General Limitations and Exclusions 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.
• 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
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| 2023 Group Insurance Plans
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