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Plan Exclusions

Exclusions are an item or risk not covered by a plan. They are used to protect the plan from adverse selection. Plan benefits are excluded for items such as self-inflicted injury, war, drug and alcohol or accidents that occurred while committing a crime.

Below are important exclusions from the coverage:

  • Workers’ Compensation Injuries
  • Cosmetic Surgery Procedures
  • Bariatric/Gastric Surgery
  • Sex Transformation/Change Surgery

The Extended Inpatient and Outpatient Benefit provision has additional exclusions:

  • The Extended Inpatient and Outpatient Benefit provision is effective 90 days after the effective date of the member;
  • Maternity inpatient and outpatient services are effective 10 months after the effective date
  • Any hospital confinement that began on or before the effective date is excluded from plan coverage
  • Outpatient Drugs, Kidney Dialysis, Chemo Therapy, and All Other Infusion Therapy is excluded from coverage under Inpatient and Outpatient Provision
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