Plan Exclusions and Limitations
The plan does not pay benefits for any of the following services, treatments, items or supplies, except as specifically provided for under Covered Services, Supplies and Equipment. Exclusions are not covered even if they are prescribed by a physician or if they are the only available treatment for the diagnosed condition. Some services may be medically necessary but not covered by the plan.
A. Alternative treatments
- Kinesiology (movement therapy).
- Rolf technique (Rolfing).
- Art therapy, music therapy, dance therapy, equine therapy; and other forms of alternative treatment as defined by the National Center for Complementary and Integrative Health of the National Institutes of Health.
- Dental expenses that are covered under the dental plan.
C. Devices, appliances, prosthetics and supplies
- Devices that attach to a building (walls, ceilings, floors, etc.).
- Medical devices covered under pharmacy benefits are not covered, with the exception of diabetic testing supplies, ostomy supplies and products required by ACA.
- Over-the-counter disposable medical supplies such as bandages, tape, gauze pads, alcohol, iodine, peroxide, saline, etc.
- Devices, appliances, prosthetics and/or supplies, over-the-counter or otherwise, that are not primarily medical in nature and/or not considered medically necessary by the plan. Examples include, but are not limited to: braces, compression garments, room humidifiers, air purifiers, pulse oximeters, blood pressure cuffs, exercise equipment, swimming pools, Jacuzzi pumps, saunas, hot tubs, automobiles or adaptive equipment for automobiles, sun lamps, augmentative communication devices, patient lifts, adaptive bathroom and self-care equipment, assistive devices, and cold/cryotherapy devices.
- Equipment that exceeds lifetime or maximum benefits (e.g., one walker per lifetime, one breast pump per pregnancy, one CPAP every five years).
- Mattresses not specifically designed for the prevention or treatment of skin breakdown or healing, or any other bedding purchased for any other reason.
- Lost, stolen or damaged (e.g., mold, insect, etc.) equipment or devices.
- Any device not FDA approved for general use or sale in the United States.
- Breast pumps provided by non-network suppliers/providers.
- Any covered items or services not used exclusively by the member or a covered dependent.
- Products marketed with 510(k) clearance (FDA cleared).
- Prescription scar treatments.
- Off-label use of drugs (use of a drug for the treatment of conditions that are not indicated on the drug’s label).
- Over-the-counter drugs and vitamins (e.g., cough and cold drugs) except as required by ACA under pharmacy benefits.
- Drugs under investigation in approved clinical trials.
- Lost, stolen or damaged drugs.
- Any drug not FDA approved for general use or sale in the United States.
- Impotency drugs, unless following prostatectomy surgery.
E. Experimental/investigation services
- Any treatment, appliance/device, drug or procedure, including any particular aspect of a treatment, deemed or considered experimental or investigation by the plan.
- Items and services provided solely to satisfy data collection and analysis needs, including any service(s) not necessary for routine care such as specialized lab tests or drugs.
F. Personal care, comfort or convenience
- Items which are furnished primarily for personal comfort or convenience and/or are not primarily medical in nature.
- Includes but is not limited to exercise equipment, air purifiers, air conditioners, humidifiers, spas, elevators, telephones, tablets, computers, software applications, watches, televisions, cervical pillows, protective clothing or shoes, and supplies for hygiene or beautification.
- Exercise programs/fees/classes.
- Weight management/loss programs such as Weight Watchers, Jenny Craig, Diet Center, Zone diet or similar programs including any over-the-counter food or nutritional supplements (e.g., amino acid supplements, Optifast liquid protein meals, NutriSystem pre-packaged foods, Medifast foods or phytotherapy).
- Appetite suppressants.
G. Procedures and treatments
- Treatment of alopecia.
- Cosmetic or elective surgical procedures, treatments or drugs not necessary as the result of an accident with continuous coverage from the date of the accident to the date of corrective surgery.
- Complications from any such procedure not originally covered by HealthChoice.
- Breast reconstruction or implants not covered under the Women’s Health and Cancer Rights Act of 1998 and/or the Oklahoma Breast Cancer Patient Protection Act of 1998.
- Custodial care.
- Dyslexia testing.
- Electromyography without needle.
- Any routine hygienic foot/hand care, including trimming nails, and any other service rendered in the absence of localized illness, injury or symptoms involving the feet or hands.
- Home dialysis training.
- Home uterine monitoring.
- Marriage counseling.
- Medical services or treatments not generally accepted as the standard of care by the medical community.
- Weight-loss (bariatric) surgery that involves any of the following:
- Band and band revisions.
- Sleeve, bypass or duodenal switch performed outside of a network MSBSA-QIP certified comprehensive center for excellence.
- Revisions or complications to/from any procedure not originally covered by HealthChoice.
- Tobacco cessation counseling outside preventive service benefit coverage.
- Venipuncture by a physician when also billing for lab charges.
- Preoperative or postoperative care generally rendered by the operating surgeon, unless the surgeon itemizes his charges and the total amount charged is no more than the total allowable amounts for the surgery.
- Services provided in a school or daycare setting.
- Manipulative and physical therapy for palliative care (treatment for only the relief of pain), elective care (care designed to relieve recurring subjective symptoms), or prolonged care (treatment that does not move toward resolution as documented in the evaluation or re-evaluation goals).
- Any confinement, medical care or treatment not recommended by a duly qualified practitioner.
- Medical and/or mental health treatment of any kind, including hospital care, medications and medical care or medical equipment, which is excessive or where medical necessity has not been proven.
- Ultraviolet treatment – actinotherapy in the home (tanning beds).
- Cord blood banking, collection and storage.
- Speech therapy for learning disabilities or birth defects.
- Services supplied by a provider who is a relative by blood or marriage of the patient or one who normally lives with the patient.
I. Reproduction/sexual health
- Infertility treatment, including artificial insemination, embryo transplant, in vitro fertilization, surrogate parenting, ovum transplant, donor semen, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and reversal voluntary sterilization.
- Sex transformation surgeries.
- Treatment for sexual dysfunction including implants of any nature except following a prostatectomy subject to state law.
- Surrogate mother expenses for non-covered participants.
J. Services provided under another plan or program
- Injury or sickness which is covered under an Extended Benefits provision of previous health coverage, until such time as such individual has exhausted all extended benefits available thereunder.
- Expenses to the extent the insured person is reimbursed or is entitled to reimbursement, or is in any way indemnified for such expenses by or through any public program, state or federal, or any such program of medical benefits sponsored and paid for by the federal government or any agency or subdivision thereof.
- Bodily injury or illness arising out of or in the course of any employment not specifically excluded by 85A O.S. 2013 § 2 of the Workers’ Compensation Code.
- Any services required by state or federal law to be supplied by a public school system or school district.
K. Vision and hearing
- Eye examinations for the fitting of corrective lenses or any charges related to such examinations, orthoptics, visual training for any diagnosis other than mild strabismus, eyeglasses, except for the first lens(es) used as a prosthetic replacement after the removal of the natural lens, other corrective lenses, or radial keratomy or LASIK (exceptions may apply to eye exams, refer to Preventive Services).
- Hearing aids and examinations for fitting or prescription.
- Batteries for hearing aids.
L. Other exclusions
- Charges for missed or cancelled appointments, mileage, penalties, finance charges, separate charges for maintenance, record keeping or case management services.
- Fees or retainers paid to concierge medicine providers.
- Claims submitted later than 365 days from the date of service.
- Medical care and supplies for which no charge is made or no payment would be requested if the insured individual did not have this coverage.
- Expenses incurred prior to the effective date of an individual’s coverage, or for expenses incurred during a period of confinement which had its inception prior to the effective date of an individual’s coverage.
- Hospitalization or other medical treatment furnished to the insured or dependent that begins after coverage has terminated.
- Complications from any non-covered or excluded treatments, items or procedures.
- Illness, injury or death as a result of committing or attempting to commit an assault or felony, including participation in a riot or insurrection as an aggressor.
- Intentionally self-inflicted injuries or illness, except when the injury (a) resulted from being the victim of an act of domestic violence or (b) resulted from a documented medical condition (including both physical and mental health conditions) that is covered under the health plan.
- Amounts billed for medical and surgical services and supplies in excess of the fee schedule for such services and supplies.
- Wrongful act or negligence of another when an employee or dependent has released the responsible party, unless subrogation has been waived or reduced in writing in an individual case, solely at EGID’s option, and only for good cause.
- Travel cost related to organ transplants.
- Charges for injuries resulting from war or act of war (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer.