• Provider Not Recognized by Plan
Exclude services, supplies, or devices if they are not prescribed, performed, or directed by a provider or facility not defined by us as such, or not licensed to do so.
• Reversal of Sterilization
Exclude reversal of elective sterilization.
• Services from Relatives or Members of Immediate Family
Exclude services (applies to medical and pharmacy services) performed by a provider who is a family member by birth, marriage, or adoption, or by the provider to self.
• Services Related to Surrogacy
Exclude services related to surrogacy.
• Sexual Dysfunction
Exclude drugs and devices used for the treatment of sexual dysfunction.
Exclude services related to sexual transformations.
• Smoking Cessation Programs
Exclude smoking cessation programs that are not affiliated with WellPoint.
• Standby Physician Charges
Exclude all standby physician service charges.
• Unlisted Services
Exclude services not explicitly listed as covered.
• Vein Surgery
Exclude treatments of all varicose and spider vein surgeries for cosmetic purposes.
• Vision Services
Exclude the following:
• Vision Correction Surgery (e.g. Lasik, radial keratotomy, etc.) to correct refractive error, including near sightedness, far sightedness, and/or astigmatism;
• Orthoptics and vision therapy/training; and
• Prescription and non-prescription eyewear.
Exclusion does not apply to medical and surgical services for the treatment of injuries and diseases affecting the eye (examples include eye exams for diabetics, eyewear/contacts and related services to replace human lenses following surgery or injury, etc.).