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Exclusions
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The services listed below are not covered:

  1. Services that do not meet the Basic Health definition of "Medical Necessity" for the diagnosis, treatment, or prevention of injury or illness, or to improve the functioning of a malformed body member, even though such services are not specifically listed as exclusions.
  2. Services not provided, ordered, or authorized by the member's health plan or its contracting providers, except in an emergency.
  3. Services received before the member's effective date of coverage.
  4. Custodial or domiciliary care, or rest cures for which facilities of an acute care general hospital are not medically required. Custodial care is care that does not require the regular services of trained medical or allied health care professionals and that is designed primarily to assist in activities of daily living. Custodial care includes, but is not limited to, help in walking, getting in and out of bed, bathing, dressing, preparation and feeding of special diets, and supervision of medications which are ordinarily self-administered.
  5. Hospital charges for personal comfort items; or a private room unless authorized by the member's health plan; or services such as telephones, televisions, and guest trays.
  6. Medical equipment & supplies not specifically listed in this “Schedule of Benefits” except while the member is in the hospital (including, but not limited to, hospital beds, wheelchairs, and walk aids).
  7. Emergency facility services for nonemergency conditions.
  8. Charges for missed appointments or for failure to provide timely notice for cancellation of appointments; charges for completing or copying forms or records.
  9. Sleep studies, except the initial sleep study authorized by the contracted health plan. Only one sleep study per member per calendar year is covered.
  10. Transportation except as specified under "Organ transplants" and "Emergency care."
  11. Immunizations, except as covered under preventive care. Immunizations for the purpose of travel, employment, or required because of where you reside are not covered.
  12. Implants, except: cardiac devices, artificial joints, intraocular lenses (limited to the first intraocular lens following cataract surgery), and implants as defined in the "Plastic and reconstructive services" benefit.
  13. Sex change operations.
  14. Investigation of or treatment for infertility or impotence.
  15. Reversal of sterilization.
  16. Artificial insemination.
  17. In-vitro fertilization.
  18. Eyeglasses; contact lenses (except the first intraocular lens following cataract surgery); routine eye examinations, including eye refraction, except when provided as part of a routine examination under "Preventive care."
  19. Hearing aids.
  20. Orthopedic shoes and routine foot care.
  21. Speech and recreation therapy.
  22. Dental services, including orthodontic appliances, and services for temporomandibular joint problems, except for repair necessitated by accidental injury to sound natural teeth or jaw, provided that such repair begins within ninety (90) days of the accidental injury or as soon thereafter as is medically feasible, and provided the member is eligible for covered services at the time that services are provided.
  23. Medical services, drugs, supplies, or surgery directly related to the treatment of obesity, including morbid obesity (such as, but not limited to gastroplasty, gastric stapling, or intestinal bypass).
  24. Weight loss programs.
  25. Cosmetic surgery, including treatment for complications of cosmetic surgery, except as otherwise provided in the "Schedule of Benefits."
  26. Medical services received from or paid for by the Veterans Administration or by state or local government, except where in conflict with Washington State or federal law or regulation; or the portion of expenses for medical services payable under the terms of any insurance policy that provides payment toward the member's medical expenses without a determination of liability to the extent that payment would result in double recovery.
  27. Conditions resulting from acts of war (declared or not).
  28. Direct complications arising from excluded services.
  29. Replacement of lost or stolen medications.
  30. Evaluation and treatment of learning disabilities, including dyslexia.
  31. Any service or supply not specifically listed as a covered service unless medically necessary, prescribed by a contracting provider and authorized in advance by the health plan.