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Exclusions & Limitations
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The noncovered services and supplies under Asuris Northwest Health's
standard individual medical plans include, but are not limited to: |
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Acupuncture for smoking cessation.
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Addiction to or abuse of drugs, alcohol, or any other chemical
substance, whether legal or illegal, except for injuries sustained
as a consequence of being intoxicated or under the influence of
narcotics.
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Benefits
covered by government programs.
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Charges
for services or supplies that are above the allowed amount, except
as required by law for emergencies.
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Charges
that in the absence of the contract there would be no obligation to
pay.
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Cosmetic
surgery and supplies (including drugs) and the treatment of any
direct or indirect complications or such surgery, except: 1) when
related to an illness or injury; 2) for congenital anomalies; 3) for
reconstructive breast surgery following mastectomies to the extent
required under federal and state law as follows: a) reconstruction
of the diseased breast; b) reconstruction of the nondiseased breast
to produce a symmetrical appearance; and c) prostheses and physical
complications of all stages of a mastectomy, including lymphedemas.
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Custodial care.
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Dentistry, dental x-rays, or hospitalization for dentistry.
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Dyslexia
treatment.
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Hospitalization for conditions for which the member is not usually
hospitalized, such as common colds, minor
cuts or bruises, removal or small tumors and similar minor
conditions.
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Injuries
sustained while practicing for or competing in professional or
semiprofessional athletics contest.
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Investigational services or supplies.
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In-vitro
fertilization, artificial insemination, embryo transfer, or other
artificial means of conception, including any expenses for fertility
drugs.
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Marital
counseling; family counseling, except for Mental Disorders.
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Maternity/complications of pregnancy (excluded on
Asuris HSA Healthplan, Asuris Core Plan and Clarity 50 plans
only).
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Neurodevelopmental therapy.
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Over-the-counter contraceptive supplies and devices.
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Physical
or psychiatric exams to obtain or continue employment, licensure,
legal proceedings, insurance, school admission, sports activities, or for purposes of
medical research.
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Prescription drugs, except as provided to an inpatient (excluded
on Asuris
HSA Healthplan, Asuris Core Plan and Clarity 50 plans only).
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Preventive care, except for routine mammography, prostate, and
colorectal cancer
screening services (excluded on Clarity 50 plan only).
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Private
duty nursing or hourly nursing charges.
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Routine
hearing
exams, hearing aids.
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Routine
newborn care (excluded on Asuris HSA Healthplan, Asuris Core Plan
and Clarity 50 plans
only).
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Services
and supplies for which benefits are or would have been payable to a
member eligible and enrolled under Medicare, regardless of whether
the member actually enrolled.
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Services
or supplies covered by auto insurance, personal injury protection
insurance, homeowner insurance, or commercial premises coverage.
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Services
or supplies not medically necessary* for illness, injury, or
physical disability.
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Services
provided by a family member (spouse, parent or child).
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Smoking
cessation.
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Sterilization.
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Surgery
(including reversals), treatment, programs, or supplies that are
intended to result in weight reduction, regardless of diagnosis.
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Surgery
or treatment for sexual
dysfunction/impotence or transsexualism.
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Treatment and any appliances used in connection with malocclusions,
jaw abnormalities, Temporomandibular Joint (TMJ) Disorders, and
myofascial pain syndrome.
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Treatment from any condition caused by or resulting from active
participation in the armed forces in a war or insurrection.
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Treatment of any condition that the Secretary of Veterans Affairs
determines to have been incurred in, or aggravated during,
performance of service in the uniformed services of the United
States.
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Vision
exams and hardware (excluded on
Asuris HSA Healthplan, Asuris HSA Healthplan Comprehensive, Asuris
Core Plan and
Clarity 50 plans only).
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Visits
or consultations that are not in person, including but not limited
to any telephone, Internet, or other electronic communication
(except tele-medicine in remote locations, as approved by Asuris
Northwest Health), whether initiated by the member of the member's
provider.
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Visual
analysis, therapy, training, or orthoptics.
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*Medically
Necessary: Health care services or supplies that a physician or
other health care provider exercising prudent clinical judgment,
would provide to you for the purpose of preventing, evaluating,
diagnosing, or treating an illness, injury, disease or its symptoms
that are: In accordance with generally accepted standards of medical
practice; clinically appropriate, in terms of type, frequency,
extent, site and duration, and considered effective for your
illness, injury or disease; and not primarily for the convenience of
you, or your physician or other health care provider, and not more
costly than an alternative service or sequence of services, or
supply at least as likely to produce equivalent therapeutic or
diagnostic results as to the diagnosis or treatment of your illness,
injury or disease. For these purposes, "generally accepted standards
of medical practice" means standards that are based on credible
scientific evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community, Physician
Specialty Society recommendations and the views of the physicians
practicing in relevant clinical areas and other relevant factors. |
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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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