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Exclusions Summary
It’s important to know what’s not covered through your plan. Note that no benefits are provided for the following, except where state mandates apply:
For all Health Access Plans:
- Charges incurred due to a pre-existing condition until you have been continuously insured for 12 months
- Illness or injury caused by war, commission of a felony, attempted suicide, influence of an illegal substance or level of substance, or a hazardous activity
- Routine hearing care, routine vision care, vision therapy, surgery to correct vision, routine foot care, or foot orthotics
- Cosmetic services including chemical peels, plastic surgery and medications
- Charges by a health care practitioner or medical provider who is an immediate family member
- Custodial care, home health care or hospice care
- Charges reimbursable by Medicare, Workers’ Compensation or automobile insurance carriers
- Hormone stimulation treatment to promote or delay growth
- Routine dental care, unless you choose the dental insurance option
- Treatment for TMJ or CMJ and certain jaw/tooth disorders
- Charges for educational testing or training, vocational or work hardening programs, transitional living, or services provided through a school system
- Diagnosis and treatment of infertility
- Maternity, pregnancy (except for complications of pregnancy), routine newborn care, surrogate pregnancy and routine nursery charges
- Storage of umbilical cord stem cells or other blood components in the absence of sickness or injury
- Genetic testing, counseling and services
- Durable or personal medical equipment
- Services provided by a chiropractor
- Charges for sex transformation, treatment of sexual dysfunction or inadequacy, or to restore or enhance sexual performance or desire
- Charges incurred for drugs obtained outside of the United States
- Over-the-counter products
- Contraceptive drugs or devices
- Drugs not approved by the FDA
- The difference in cost between a generic and brand name drug when the generic is available
- Treatment of “quality of life” or “lifestyle” concerns, including, but not limited to: smoking cessation; obesity; hair loss; sexual function, dysfunction, inadequacy, or desire; or cognitive enhancement
- Treatment used to improve memory or to slow the normal process of aging
- Behavior modification or behavioral problems, except for diabetes self-management training and education
- Prophylactic treatment
- Telemedicine (including but not limited to treatment rendered through the use of interactive audio, video, or other electronic media)
- Experimental or investigational services
- Charges for any amount in excess of any benefit maximum
- Charges for homeopathic medicines or non-medical items
- Treatment of behavioral health (mental/nervous disorders) and substance abuse
- Charges for adjustments or subluxation treatment
- Charges for non-covered services and associated complications
- Charges for take-home drugs dispensed at an institution (other than a pharmacy)
Pre-Existing Conditions
A pre-existing condition is an illness or injury and related complications for which, during the 12-month period immediately prior to the effective date of your health insurance coverage:
- You sought, received or were recommended medical advice, consultation, diagnosis, care or treatment
- Prescription drugs were prescribed
- Symptoms were produced
- Diagnosis was possible
Benefits are not paid for charges incurred due to a pre-existing condition until you have been continuously insured under the plan for 12 months. After the 12-month period, benefits are paid for a pre-existing condition, unless the condition is specifically excluded from coverage.
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