Health Access Insurance Exclusions Summary
It’s important to know what’s not covered through your plan.
Note that no benefits are provided for the following, except where state mandates apply:
For all Health Access Plans:
Charges incurred due to a pre-existing condition until you have been continuously insured for 12 months
Illness or injury caused by war, commission of a felony, attempted suicide, influence of an
illegal substance or level of substance, or a hazardous activity
Routine hearing care, routine vision care, vision therapy, surgery to correct vision, routine foot care, or foot orthotics
Cosmetic services including chemical peels, plastic surgery and medications
Charges by a health care practitioner or medical provider who is an immediate family member
Custodial care, home health care or hospice care
Charges reimbursable by Medicare, Workers’ Compensation or automobile insurance carriers
Hormone stimulation treatment to promote or delay growth
Routine dental care, unless you choose the dental insurance option
Treatment for TMJ or CMJ and certain jaw/tooth disorders
Charges for educational testing or training, vocational or work hardening programs, transitional living, or services provided through a school system
Diagnosis and treatment of infertility
Maternity, pregnancy (except for complications of pregnancy), routine newborn care, surrogate pregnancy and routine nursery charges
Storage of umbilical cord stem cells or other blood components in the absence of sickness or injury
Genetic testing, counseling and services
Durable or personal medical equipment
Services provided by a chiropractor
Charges for sex transformation, treatment of sexual dysfunction or inadequacy, or to restore or enhance sexual performance or desire
Charges incurred for drugs obtained outside of the United States
Over-the-counter products
Contraceptive drugs or devices
Drugs not approved by the FDA
The difference in cost between a generic and brand name drug when the generic is available
Treatment of “quality of life” or “lifestyle” concerns, including, but not limited to: smoking cessation; obesity; hair loss; sexual function, dysfunction, inadequacy, or desire; or cognitive enhancement
Treatment used to improve memory or to slow the normal process of aging
Behavior modification or behavioral problems, except for diabetes self-management training and education
Prophylactic treatment
Telemedicine (including but not limited to treatment rendered through the use of interactive audio, video, or other electronic media)
Experimental or investigational services
Charges for any amount in excess of any benefit maximum
Charges for homeopathic medicines or non-medical items
Treatment of behavioral health (mental/nervous disorders) and substance abuse
Charges for adjustments or subluxation treatment
Charges for non-covered services and associated complications
Charges for take-home drugs dispensed at an institution (other than a pharmacy)
Pre-Existing Conditions
A pre-existing condition is an illness or injury and related complications for which, during the 12-month period immediately prior to the effective date of your health insurance coverage:
You sought, received or were recommended medical advice, consultation, diagnosis, care or treatment
Prescription drugs were prescribed
Symptoms were produced
Diagnosis was possible
Benefits are not paid for charges incurred due to a pre-existing condition until you have been continuously insured under the plan for 12 months. After the 12-month period, benefits are paid for a pre-existing condition, unless the condition is specifically excluded from coverage.
This is a summary of information. State specific exclusions apply. For a complete listing of benefits, exclusions and limitations ,please refer to the certificate of insurance. In the event there are discrepancies with the information in this outline, the terms and conditions of the coverage documents will govern.