Provider Not Recognized by Plan

images  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

images  Exclude reversal of elective sterilization.

Services from Relatives or Members of Immediate Family

images  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

images  Exclude services related to surrogacy.

Sexual Dysfunction

images  Exclude drugs and devices used for the treatment of sexual dysfunction.

images  Exclude services related to sexual transformations.

Smoking Cessation Programs

images  Exclude smoking cessation programs that are not affiliated with WellPoint.

Standby Physician Charges

images  Exclude all standby physician service charges.

Unlisted Services

images  Exclude services not explicitly listed as covered.

Vein Surgery

images  Exclude treatments of all varicose and spider vein surgeries for cosmetic purposes.

Vision Services

images  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.

images  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.).



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