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Home  Exclusions and Limitations
Exclusions and Limitations |
This is a delegate listing of major exclusions and limitations.
A more detailed listing can also be found out easily in the Combined
Evidence of Coverage and Disclosure Form/Certificate.
Exclusions and Limitations Common to All Medical Plans:
Any amounts in excess of the maximum amounts as stated
in the Combined Evidence of Coverage and Disclosure Form/Certificate.
- Services or supplies determined by Anthem blue cross are not necessary to be determined medically.
- Services received before your effective date.
- Services received after your coverage ends.
Any conditions for which benefits are recovered easily or can be recovered
either by adjudication, settlement or otherwise, under any workers' reward,
employer's liability law or occupational disease law, even if you do not
declare them.
- Services for which you are not legally forced to pay for or services which has no charge and is made to you in the absence of insurance coverage.
- Services that are not listed exclusively in the Combined Evidence of Coverage and Disclosure Form/Certificate as covered services.
- Professional services established from a person who lives in the member's home or who is related to the member either by blood, marriage or adoption.
- Optometric services and eye exercises that are squeezed of orthoptics, eyeglasses, contact lenses and eye refractions, except as stated in the Combined Evidence of Coverage and Disclosure Form/Certificate specifically.
- Eye surgeries that are accepted solely for the rationale of correcting refractive defects such as near-sightedness (myopia), astigmatism and far-sightedness (presbyopia).
Hearing aids
Services that are being used for weight reduction or other treatments
that are being used for obesity primarily occupy abundant weight reduction
as the major method of treatment, except medically treatment of morbid
obesity with Anthem blue cross former authorization.Sterilization reversal
and other services for infertility except as specifically stated in
the Combined Evidence of Coverage and Disclosure Form/Certificate. Any
amounts in excess of the lifetime maximum for infertility services.Procedures
for amending each and every characteristics of the body to those of
the opposite sex. This may even include any medical, surgical or psychiatric
treatment or studies related to sex changes.
Every dental services, together with diagnostic, preventative, x-rays,
dentures, bridges, crowns, caps, orthodontic services, braces and other
orthodontic appliances and supplies, dental implants and related procedures,
except as specifically stated in the Combined Evidence of Coverage and
Disclosure Form/Certificate.Cosmetic surgery or some other services
are performed for varying normal structures of the body for the sake
of perking up appearance.
Custom physical examinations for insurance, employment license or school.
Treatment of mental or nervous disorders or psychological testing except as specifically stated under the benefits section of the Combined Evidence of Coverage and Disclosure Form/Certificate.
Custodial care.
Services which are tentative in nature.
Educational services, except as specifically provided or set by Anthem blue cross.
Nutritional counseling as specifically provided or arranged by Anthem blue cross exceptionally.
Services offered by a local, state or federal government agency, except
when payment is expressly required by federal or state law.Conditions
caused by an act of war or the unintended release of nuclear energy
when government funds are accessible for treatment of illness or injury
take place from such release of nuclear energy.Inpatient room along
with board charges in connection with a hospital stay principally for
diagnostic tests on an outpatient basis which could have been achieved
safely.If not your physician determines that oral contraceptive drugs
contraceptive devices are not medically apt.Consultations are provided
by telephone or facsimile machines.
Health club memberships.
Services for which you are entitled to receive Medicare benefits, whether or not they are actually paid.
Charges in excess of the limited fee schedule and reasonable and customary amounts determined by Anthem blue cross.
Suppose the plan is deemed medically necessary to prevent complications
of phenylketonuria (PKU) food supplements for formulas and special food
products that are prescribed by a physician in consultation with a metabolic
disease specialist.
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