This article covers various medical services, treatments, and items that are not covered or have limitations under the health insurance plan.
Medical Service | Limitations and Exclusions |
|---|---|
Abortion | Not covered, unless documented to be medically necessary to preserve the life or physical health of the mother. |
Acupuncture/Biofeedback | Not covered |
Allowable charge | Charges exceeding the allowable charge are not covered. |
Assistant at surgery | Not covered, unless services are medically necessary and rendered by a physician, physician assistant, or first nurse assistant. |
Cardiac Rehabilitation – Outpatient | Not covered unless determined to be medically necessary by BCBSMS. |
Canceled or missed appointments | Not covered |
Charity Hospital, Public Mental Institution, Public Health Institution, Sanatorium | Services for which the participant has no legal obligation to pay or for which no charge would be made if the participant had no health insurance coverage are not covered. |
Chelation Therapy | Not covered, except for treatment of acute heavy metal poisoning. |
Coding | Charges resulting from inappropriate coding, as determined by BCBSMS, are not covered. |
Convalescent, custodial, or domiciliary care | Not covered, including companions and sitters. |
Copayments, coinsurance, deductibles | Not covered |
Cosmetic services | Not covered, except for correction of defects incurred by a participant while covered under the Plan through traumatic injury or disease requiring surgery. |
Counseling | Sex therapy and marriage or family counseling are not covered. |
Coverage effective dates | Services or supplies provided before coverage becomes effective or after coverage ends are not covered. |
Dental services | Not covered, except when services are provided due to an accidental injury to sound natural teeth occurring while the participant is covered by the Plan, or as a direct result of a disease covered by the Plan. |
Dental services (hospital or ambulatory surgical facility services and anesthesia) | Hospital services and supplies for covered dental care and treatment, and covered dental or oral surgery are not covered unless an inpatient hospital stay is medically necessary by Acentra. Outpatient hospital, ambulatory surgical facility, or anesthesia services are not covered unless determined medically necessary by BCBSMS. |
Diabetic Self-Management Education and Support | Outpatient Diabetic Self-Management Education and Support is not covered, except as approved by Acentra. |
Dietary/Nutritional supplements, breast milk | Not covered |
Educational training | Educational training is not covered unless otherwise specified in this Plan Document or covered under Wellness/Preventive Services. |
Equipment | Equipment that has a nontherapeutic use (i.e., humidifiers, air conditioners or filters, whirlpools, wigs, vacuum cleaners, fitness supplies, etc.) is not covered. |
Experimental/Investigational | Experimental/investigational treatments, procedures, facilities, equipment, and supplies are not covered, as determined by BCBSMS or Acentra. |
Eye examinations | Routine eye examinations (except as provided through well-child care), eyeglasses, or contact lenses or fittings for them are not covered. |
Foot care | Palliative or cosmetic foot care is not covered. |
Gene manipulation therapy | Not covered |
Genetic testing or counseling | Not covered unless provided under Wellness/Preventive Services and when determined medically necessary by BCBSMS. |
Government agency | Services or supplies provided by the U.S. or other government agencies, at no charge to the patient, are not covered. |
Hair loss | Services and supplies for the treatment of hair loss are not covered. |
Hearing examinations and hearing aids | Routine hearing examinations are not covered except for newborn screening. Hearing Aids are not covered. |
Holistic therapies | Not covered |
Hypnosis | Not covered |
Infertility treatment, artificial insemination, intrauterine insemination, in vitro fertilization, or reversal of sterilization | Not covered |
Luxury, deluxe, or convenience items | Not covered |
Massage therapy | Not covered |
Maternity benefits | Charges or expenses related to the pregnancy of a dependent, other than the spouse, are not covered unless otherwise specified in this Plan Document. |
Medical records | Fees for medical records and claim filing are not covered. |
Medical Prescription Drug Benefits | Not covered, unless included in the Medical Prescription Drug Formulary or determined medically necessary. These Medical Prescription Drugs include but are not limited to: those where an equivalent product is available over the counter; where Prior Authorization is required in order for benefits to be provided and Prior Authorization is not obtained; those for which benefits are sought by the participant when the participant has failed to comply with the Plan's Medical Policy requirements with regard to Prescription Drugs and/or Medical Prescription Drugs; or those not provided in the appropriate place of service. See other limitations and exclusions related to the Prescription Drug Program specified in this Plan Document. |
Medicare covered services | Not covered to the extent that charges for such services or supplies are paid or payable under Medicare, whether or not the participant has such Medicare coverage, whether or not Medicare benefits are claimed or received, or whether or not the participant has elected to obtain such Medicare coverage, if eligible. |
Military Service connected injury/illness | Not covered, except in cases where enforcement would be prohibited by law. |
Nursing home, extended care, or personal care facility | Not covered |
Obesity treatment or weight loss therapies, prescriptions | Not covered, regardless of any claim of medical necessity, degree of obesity or clinical diagnosis, unless otherwise specified in this Plan Document or covered under wellness/preventive services. Nutritional and behavioral counseling services are covered when performed by a network provider. |
Prescription Digital Therapeutics | Software programs or applications intended to prevent, manage, or treat a medical disorder or disease are not covered. |
Pulmonary rehabilitation | Not covered unless determined to be medically necessary by BCBMS. |
Refractive eye surgery | Not covered |
Rehabilitation services | Not covered, unless otherwise specified in this Plan Document. |
Related provider | Services rendered by a provider (physician or other provider) who is related to the participant by blood or marriage or who regularly resides in the participant's household are not covered. |
Retainer fees | Fees paid for the purpose of retaining the services of a health care provider are not covered. |
Scope of license | Services rendered by a physician or other provider not practicing within the scope of his license at the time and place service is rendered are not covered. |
Services not specifically included as benefits | Not covered |
Services deemed not medically necessary | Not covered |
Sex transformations | Not covered, Puberty-blocking drugs are not covered |
Smoking cessation programs | Not covered, unless specified as a Wellness/Preventive Service for Adults. |
Speech therapy | Not covered when services are provided for maintenance speech, articulation disorders, learning disabilities, attention disorders, psychosocial speech delay, behavioral problems, conceptual handicap, intellectual disability, stammering or stuttering. |
Telehealth visit | Telehealth visits must be a "real-time" consultation and do not include the use of audio-only telephone, email, or fax. These services must be provided by a network provider or approved vendor. |
Telephone consultations | Not covered |
Therapy services | Primal therapy, rolfing, psychodrama, megavitamin therapy, bioenergetic therapy, aromatherapy, colonic irrigation, reflexology, vision perception training, carbon dioxide therapy, and related therapies are not covered. |
Third party liability | Services related to an injury or illness that occurs due to the wrongful act or omission of another party for which that party or some other party makes settlement or is legally responsible is not covered. However, if the participant is unable to recover from the responsible party, benefits of this Plan will be provided. |
Travel expenses such as transportation, meals, and lodging | Not covered, except as provided under transplant benefits. |
Visual or orthoptic training | Not covered |
War | Services rendered for diseases contracted or injuries sustained as a result of war, declared or undeclared, or any act of war are not covered. |
Workers' compensation/employer liability law | Services related to any injury or illness arising out of or in the course of employment entitling the participant to benefits under any workers' compensation or employer liability law are not covered. |
Category | Not Covered Items |
|---|---|
Muscle Enhancements | Anabolic steroids |
Weight Loss | Anorectics |
Anti-Aging | Anti-wrinkle agents |
Infertility | Infertility medications |
Non-Proven Treatments | Medications not proven effective, investigative drugs, off-label FDA use, drugs considered not medically necessary |
Immunizations | Immunizations except as provided through the Vaccine Program |
Pregnancy Termination | Medications for termination (abortifacients) |
Hair Loss | Medications for alopecia |
Administration Fees | Charges for drug administration or injection except through the Vaccine Program |
Exclusion List | Medications listed on a Drug Exclusion List |
Compound Medications | Compounds exceeding $200 unless PBM approved |
Supplements and Nutrients | Dietary/nutritional supplements, minerals (except specific iron supplements) |
FDA Approval | Non-FDA approved medications, drugs on the market for less than 6 months and/or have not been approved by the PBM |
Free Government Drugs | Drugs supplied at no cost by local, state, and federal government entities |
Pigmentation Treatments | Pigmenting/depigmenting agents |
Cosmetic Uses | Drugs for cosmetic purposes |
Device Exclusions | Therapeutic devices, appliances, including needles, syringes, support garments, and other nonmedicinal substances* |
OTC Alternatives | Prescription drugs with OTC equivalents |
Vision Products | Vision Enhancement Agents, such as prescription ophthalmic products |
Vitamins | Vitamins except for prenatals and folic acid for certain women |
Fluoride | Fluoride supplements except for young children |
Hemantics | Blood building supplements |
Breast Milk | Breast milk |
Similar Nature Drugs | Certain drugs that are considered similar in nature to currently available medications |
Workers' Compensation Drugs | Drugs paid by workers’ compensation coverage |
Scope of License | Drugs prescribed by a provider not acting within the scope of his license |
Refill Limits | Refills in excess of the number specified by the provider or any refills dispensed more than one year after the date of provider’s original prescription |
Excess Dosage | More than the recommended daily dosage |
Non-Legend Drugs | Non-legend drugs other than those listed as covered |