Radial keratotomy; and surgery, services, evaluations or supplies for the surgical correction of near sightedness and/or astigmatism or any other correction of vision due to a refractive problem X X Y
Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision) or visual training X X Y
Vision-medical benefits for low vision aids, eyeglasses, contact lenses for prescription or fitting and follow-up care thereof, except that covered expenses will include the purchase of the first pair of eyeglasses, lenses, frames or contact lenses that follows cataract surgery or loss of lens due to eye disease for aphakia or aniridia X X Y
War Not Covered by most planse
Any disease or injury resulting from a war, declared or not, or any military duty or any release of nuclear energy. Also excluded are charges for services directly related to military service provided or available from the Veterans’ Administration or military medical facilities as required by law X X Y
Services resulting from war X Y Y

a Approximately 25 percent of customers will accept these exclusions as listed. About 50 percent of customers will add exclusions to the list, while the other 25 percent will remove some exclusions. Those customers who add or remove exclusions typically only make changes to a small number of services. This list of exclusions is typical for both self-funded plans as well as traditionally insured plans. Self-funded plans, however, tend to customize this list more than fully insured plans.

b This table reflects exclusions for CIGNA’s Typical Small Group Employer Plan.

c This table reflects exclusions for Anthem/Blue Standard Coverage/Typical small group and individual plans.

d Never events are errors in medical care that are clearly identifiable, preventable, and serious in their consequences, such as surgery performed on a wrong body part, and specific conditions that are acquired during your hospital stay, such as severe bed sores.

e Respondents sometimes answered on the gray category line when specific wording choices did not match their own.

f Elective abortions are not a benefit in the individual plan products; maternity care is not a typical benefit in individual plans.

g Exception: Benefits are provided for actively employed partners and small business owners not covered under a Workers’ Compensation Act or similar law, if elected by the group and additional premium is paid. Services or supplies for injuries or diseases related to you or your dependent’s job to the extent you or your dependent is required to be covered by a workers’ compensation law.

h Coordination of benefits provided.

i Except expenses for administration and processing of blood and blood products (except blood factors) covered as part of inpatient and outpatient services.

j Except as otherwise specified for services covered under “reconstructive surgery.”

k Does not apply to hospice.

l This exclusion does not apply to services covered under “hospice care.”

m Except as specifically allowable under Oral and maxillofacial surgery.

n Exclusion does not apply to: anesthesia and associated facility charges as a result of age and/or disability criteria; dental accidents—treatment, sought within 12 months, of an injury to natural teeth and when a treatment plan submitted for prior approval. Injuries resulted from biting and/or chewing are not considered a dental accident; radiation—dental services to prepare the mouth for radiation therapy to treat head and/or neck cancer.

o Other oral surgical services are covered, including treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; orthognathic surgery that is required because of a medical condition or injury which prevents normal function of the joint or bone and is deemed medically necessary to attain functional capacity of the affected part; oral/surgical correction of accident-related injuries; treatment of lesions, removal of tumors and biopsies; incision and drainage of infection of soft tissue not including teeth-related cysts or abscesses.

p Structures supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.

q This exclusion does not apply to accidental injury to sound and natural teeth.

r Structures directly supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.

s This exclusion does not apply to coverage for medication management.

t A Service is experimental or investigational if the health plan, in consultation with the medical group, determines that: generally accepted medical standards do not recognize it as safe and effective for treating the condition in question (even if it has been authorized by law for use in testing or other studies on human patients); it requires government approval that has not been obtained when Service is to be provided; it cannot be legally performed or marketed in the United States without FDA approval; it is the subject of a current new drug or device application on file with the FDA; it is provided as part of a research trial; (see specific section for clinical trials); it is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity, or efficacy as among its objectives; it is subject to approval or review of an IRB or other body that approves or reviews research; it is provided pursuant to informed consent documents that describe the services as experimental or investigational, or indicate that the services are being evaluated for their safety, toxicity or efficacy; or the prevailing opinion among experts is that use of the services should be substantially confined to research settings or further research is necessary to determine the safety, toxicity, or efficacy of the service.

u Covered subject to terms and conditions of the contract. For example, there may be network limitations, medical policy limitations, cost-sharing requirements, dollar caps, visit limits, etc.

v Except when medically necessary.

w Cochlear implants are not necessarily included in the exclusion. Cover routine hearing screenings as a part of preventive care.

x Except when provided as a procedure during a covered therapy.

y A condition in which an individual has a BMI of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment.

z Insurer may outline drugs that should be reviewed based on employer selection: drugs used in the treatment of infertility, sexual dysfunction, weight control, smoking cessation, and growth hormone.

aa For 2011, for example: Alabama, Arizona, Idaho, Illinois, Kentucky, Louisiana, Mississippi, Missouri, Montana, North Dakota, Oklahoma, South Carolina, South Dakota, and Wyoming.

bb A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care.

cc Nursing services in a home or hospice setting are covered as a part of home health care benefits and hospice benefits.

dd Certain services are exempted, including those preventive services specifically covered under preventive care (adult and child), preventive screenings specifically listed in the plan brochure; and certain routine services associated with covered clinical trials.

ee The plan might choose alternative wording for this exclusion: in situations where you receive monetary compensation to act as a surrogate, health plan will seek reimbursement of all charges for covered services you receive that are associated with conception, pregnancy and/or delivery of the child. A surrogate arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the child.

ff Exclusion does not apply to medial and surgical services for the treatment of injuries and diseases affecting the eye (e.g., eye exams for diabetics, eyewear/contacts and related services to replace lenses following surgery or injury, etc.).



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