Surgery or related services for cosmetic purposes to improve appearance, but not to restore bodily function or correct deformity resulting from disease, trauma, or congenital or developmental anomalies.
Private duty nursing.
Personal care services and domiciliary care services not stated herein.
Cosmetic Services (including drugs and injectables)
Nonreplaceable fees for blood and blood products.
Unless otherwise specified in covered services, dental work or treament which includes hospital or professional care in connection with:
- The operation or treament for the fitting or wearing of dentures.
- Orthodontic care or malocclusion.
- Operations on or for treatment of or to the teeth or supporting tissues of the teeth, except for removal of tumors and cysts or treatment of injury to natural teeth due to an accident if the treatment is received within 6 months of the accident
- Dental implants
Experimental services.
Immunizations related to foreign travel.
Insulin pumps.
The purchase, examination, or fitting of hearing aids and supplies, and tinnitus maskers, unless included as covered benefit. |
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Arch support, orthotic devices, in-shoe supports, orthopedic shoes, elastic supports, or exams for their prescription or fitting, unless these services are determined to be medically necessary. Inpatient admissions primarily for physical therapy, unless authorized by the plan.Treatment of sexual dysfunction not related to organic disease.
Services to reverse a voluntary sterilization procedure
In vitro fertilization, ovum transplants and gamete intrafallopian tube transfer, zygote intrafallopian transfer, or cryogenic or other preservation techniques used in these or similar procedures.
Practitioner, hospital, or clinical services related to radial keratotomy, myopic keratomileusis, and surgery which involves corneal tissue for the purpose of altering, modifying, or correcting myopia, hyperopia, or stigmatic error.
Nonmedical ancillary services such as vocational rehabilitation, employment counseling, or educational therapy.Services that are not medically necessary.Medical expenses for a pre-existing condition are not covered (full postponement rule) for the first 12 months after the member's effective date. Lookback period for determining a pre-existing condition (conditions for which diagnosis, care or treatment was recommended or received) is 6 months prior to the effective date. The pre-existing condition limitation period will be reduced by the number of days of prior creditable coverage the member has as of the effective date, unless the individual has a creditable coverage HIPAA certificate indicating 18 months of creditable coverage, in which case no pre-existing condition limitation will apply.
Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regiments 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.
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