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Exclusions
MEDICAL PLANS
No benefits are provided for the following (see separate exclusions
for Outpatient Prescription Drug Plan shown below): |
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Charges
incurred due to a pre-existing condition until you have been
continuously insured for nine months.
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Sickness
or injury caused by war, participation in a felony, attempted
suicide, or a hazardous activity for which compensation is received.
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Routine
hearing care, routine vision care, vision therapy, surgery to
correct vision, routine foot care, or foot orthotics.
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Cosmetic
services including chemical peels, plastic surgery, and medications.
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Charges
by a health care practitioner or medical provider who is an
immediate family member. Immediate family members are you, your
spouse, your children, brothers, sisters, parents, their spouses,
and anyone with whom legal guardianship has been established.
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Custodial care.
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Charges reimbursable by Medicare, Workers' Compensation, or
automobile insurance carriers.
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Growth
hormone stimulation treatment to promote or delay growth.
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Routine
dental care.
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Services
provided through a school system.
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Diagnosis
and treatment of infertility.
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Pregnancy,
maternity, and other expenses related to surrogate pregnancy (except
as specifically provided in Assurant Comprehensive and Assurant
Catastrophic plans).
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Storage
of umbilical cord stem cells or other blood components in the
absence of sickness or injury.
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Generic
testing, counseling and services.
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Charges
for sex transformation, treatment of sexual dysfunction or
inadequacy, or to restore or enhance sexual performance or desire.
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Over-the-counter
products.
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Outpatient
prescription drugs (except as specifically provided in Assurant
Comprehensive plan and when purchased as an option with the Assurant
Catastrophic plan).
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Treatment
of "quality of life" or "lifestyle" concerns,
including, but not limited to: smoking cessation, obesity, hair
loss, or cognitive enhancement.
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Cranial
orthotic devices, except following cranial surgery.
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Experimental
or investigational services.
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Charges
in excess of the lifetime maximum or any other benefit maximum.
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Charges
for non-medical items.
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Charges
related to health care practitioner assisted suicide.
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Treatment
of substance abuse, including related prescription drugs.
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| OUTPATIENT
PRESCRIPTION DRUG PLAN |
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Charges
for any amount in excess of any calendar year maximum
benefit.
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Charges
for any supplies, or drugs to treat, impact or influence controlling
the covered person’s weight; or charges
related to obesity.
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Charges
for supplies or drugs used for growth hormone
therapy, including growth hormone medication and its derivatives or
other drugs.
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Charges
for supplies or drugs related to the following conditions,
regardless of underlying causes: sex transformation; gender
dysphoric disorder; gender reassignment; treatment of sexual
function, dysfunction or inadequacy; treatment to enhance, restore
or improve sexual energy, performance or desire.
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Charges
for infertility diagnosis and treatment for males
or females including, but not limited to, drugs and medications
regardless of intended use.
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Charges
for drugs that have not been fully approved by the FDA for marketing
in the United States.
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Charges
for any over-the-counter products or medications.
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Charges
for prescription products, drugs or medications in the following
categories, whether or not prescribed by a health care practitioner:
=== Dietary or nutritional substances or dietary supplements
=== Nutraceuticals
=== Tube feeding formulas and infant formulas
=== Medical foods
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Charges
for drugs dispensed at or by a health care practitioner’s office,
clinic, hospital or other non-pharmacy setting for take home by the
covered person; amounts above the contracted rate for participating
pharmacy reimbursement.
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Charges
for any ancillary charge or any difference between the cost of the
prescription order at a nonparticipating pharmacy and the
contracted rate that would have been paid for the same prescription
order had a participating pharmacy been used.
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Charges
for any drug used for cosmetic services; drugs used to treat
onychomycosis (nail fungus); botulinum
toxin and its derivatives.
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Charges
for drugs prescribed for dental services, or
unit-dose drugs; drugs used in the treatment of chronic fatigue or
related syndromes or conditions; drugs containing nicotine or its
derivatives.
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Charges
for DDAVP (desmopressin acetate) or other drugs
used in the treatment of nocturnal enuresis (bedwetting) for a
covered person under the age of 8.
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Charges
for drugs used to treat, impact or influence quality of life or
lifestyle concerns including, but not limited
to: smoking deterrence or cessation; athletic performance; body
conditioning, strengthening, or energy; prevention or treatment of
hair loss; prevention or treatment of excessive hair growth or
abnormal hair patterns.
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Charges
for drugs used to treat, impact or influence: skin coloring or
pigmentation; social phobias; slowing the
normal processes of aging; memory improvement or cognitive
enhancement; daytime drowsiness; overactive bladder; dry mouth;
excessive salivation; or hyperhidrosis (excessive sweating).
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Charges
for drugs used for inpatient or outpatient treatment
of behavioral health or substance abuse.
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Drug
charges incurred outside of the United States; charges for drugs
obtained from pharmacy provider sources outside the United States,
except for covered charges that are received for an emergency
medical condition.
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Charges
for Retin-A (tretinoin) and other drugs used in the treatment or
prevention of acne, rosacea or related
conditions for a covered person age 30 or older.
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Important
Information About This
Page |
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This is a brief summary of exclusions and
limitations; it is
not a contract or certificate of coverage. The complete terms of coverage
are determined by the carrier's contract. While we have accurately
represented the information in this Benefit Summary as of the time it was
published, should any discrepancies exist between this Benefit Summary and
the carrier's contract, the carrier's contract shall prevail. Please refer
to the carrier's contract for a complete statement of benefits including
waiting periods, limitations and exclusions. |
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