Limitations and Exclusions

Please Note

All benefits are subject to limitations and exclusions as described in your Member Certificate and Summary of Benefits.

The following list is not exhaustive. For a complete listing refer to the Member Certificate and Summary of Benefits or contact the Customer Care Center.

TMD

Non-surgical treatment of tempormandibular disorders (TMD) is limited to $1,250 per member per contract year.

Non-Covered Infertility Services

• Reversal of voluntary sterilization and related procedures.
• All charges or costs relating to donor sperm.

Non-Covered Maternity Services

• Elective abortions.
• Home or intended out of hospital deliveries.
• Amniocentesis or CVS (Chorionic Villi Sampling) performed exclusively for sex determination.
• Birthing classes.
• Treatment, services, or supplies for a third party or nonmember traditional surrogate or gestational carrier.

Outpatient Physical, Speech and Occupational Therapy Non-Covered Services

• Long term and maintenance therapy.

Non-Covered Transplant Services

• Transplants and all related expenses, not outlined as covered procedures in the Member Certificate.
• Services and supplies in connection with covered transplants unless prior authorized by the Medical Affairs Division.
• Retransplantation.
• Any experimental or investigational transplant, or any other transplant-like technology not listed in the Member Certificate. Any resulting complications from these, and any services and supplies related to such experimental or investigational transplantation or complications, including, but not limited to: high dose chemotherapy, radiation therapy or immunosuppressive drugs.
• Transplants involving non-human or artificial organs.

General Exclusions and Limitations

• Acupuncture, dry needling and prolotherapy.
• Autopsy.
• Chelation therapy for atherosclerosis, except as prior authorized by our Medical Affairs Division.
• Coma Stimulation programs.
• Court ordered care, unless medically necessary and otherwise covered under the certificate.
• Cytotoxic testing and sublingual antigens in conjunction with allergy testing.
• Services required for administrative examinations such as, employment, licensing, insurance, adoption, or participation in athletics.
• Experimental or investigational services, treatments or procedures, and any related complications as determined by Dean's Medical Affairs Division, unless coverage is required by state or federal law.
• Services provided by members of the subscriber's immediate family or any person residing with the subscriber.
• Holistic medicine and any other form of alternative medicine.
• Massage therapy.
• Swim or pool therapy, unless Prior Authorization is obtained.
• Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay.
• Items or services required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while performing military service.
• Podiatry services or routine foot care rendered in the absence of localized illness, injury, or symptoms in connection with, but not limited to:
  • 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;
  • for any treatment or services in connection with any of these.
• Any services to the extent a member receives or is entitled to receive any benefits, settlement, award or damages for any reason of, 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.
• Treatment, services, and supplies provided in connection with any illness or injury caused by:
  • a member's engaging in an illegal occupation or
  • a member's commission of, or an attempt to commit, a felony.
• Treatment, services, 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.
• Hair analysis (unless lead or arsenic poisoning is suspected).
• Any hospital service or medical care not listed in the Member Certificate.
• Services and supplies rendered outside the scope of the provider's license.
• An expense incurred before the supply or service is actually provided, unless Prior Authorization is obtained.
• Services or supplies for, or in connection with, a non-covered procedure or service, including complications; a denied referral or Prior Authorization; or a denied admission.
• Obesity-related services, including any weight loss method, unless specifically covered under the Certificate.
• Services or supplies not medically necessary, not recommended or approved by a provider, or not provided within the scope of the provider's license.
• All charges or costs exceeding a benefit maximum or maximum allowable fee where applicable.
• Collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility.
• All services or supplies provided in conjunction with the treatment of sexual dysfunction or sexual transformation, including, but not limited to, medications, surgical treatment and injections.
• Cosmetic or plastic surgery.
• Refractive eye surgery and radial keratotomy. Astigmatic Keratotomy is covered when Prior Authorization is obtained.
• Ambulance service that is not an emergency transportation, including nonemergency air transportation, unless Prior Authorization is obtained.
• Educational services except for diabetic self-management classes.
• Items of convenience.