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General
Limitations and Exclusions
All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in your Policy and
Benefit Summary (“Policy”). The following list is not exhaustive and may vary based on your Policy. For a complete listing
refer to your Member Policy.
Medical
• Cytotoxic testing and sublingual antigens in conjunction with allergy testing.
• Hair analysis (unless lead or arsenic poisoning is suspected).
• Preimplantation genetic testing of embryos and gametes.
• Convenience items for a Member or a Member’s family, unless otherwise specified in this policy.
• Drugs provided in conjunction with the treatment of infertility, including but not limited to those administered in a
physician’s office.
• Outpatient prescription drugs, except those prescriptions otherwise covered under this Policy.
• Oral Nutrition: Oral nutrition is not considered a medical item. We do not cover nutritional support that is taken
orally (i.e., by mouth), unless mandated by state law or covered under Our medical policy for a specific condition.
Examples include, but are not limited to, over-the-counter nutritional supplements, infant formula, and donor
breast milk.
• Replacement of an item if the item is lost, stolen, or unusable/nonfunctioning because of misuse, abuse,
or neglect.
• Sexual dysfunction and sexual transformation supplies, including but not limited to medications and injections.
• Autopsy.
• Charges or costs relating to donor sperm.
• Consultation for, or procedures in connection with, in vitro fertilization, embryo transplantation, and/or any other
assistive reproductive technique (e.g. GIFT, ZIFT).
• Cosmetic services, including cosmetic surgery. Experimental or investigational services, treatments, or
procedures, and any related complications as determined by Our Medical Affairs division, unless coverage is
required by state or federal law.
• Infertility-related services and procedures.
• Infertility-related services or procedures not otherwise covered by this policy, including but not limited to the
collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility,
including for surrogacy or Gestational Carriers.
• Laser treatment for Port Wine Stain (PWS) lesions, except on the face and neck.
• Podiatry services or routine foot care rendered in the absence of localized illness, injury, or symptoms in
connection with, but not limited to: (a) the examination, treatment, or removal of all or part of corns, calluses,
hypertrophy or hyperplasia of the skin or subcutaneous tissues of the feet; (b) the cutting, trimming, or other
non-operative partial removal of toenails; or (c) for any treatment or services in connection with any of these.
• Obesity-related services, including any weight loss method, unless specifically covered under this Policy.
• Reversal of voluntary sterilization and related procedures.
• Services related to surrogacy.
• Sexual dysfunction and sexual transformation treatment and services including but not limited to
surgical treatment.