Exclusions and Limitations:
Every health plan has certain exclusions or limitations. The majority are general in nature and will usually affect all health plans. To assist you in determining what kind of exclusions and limitations you can expect with your Anthem Blue Cross plan, we will cover the most common exclusions below.
Before and After Coverage - You will typically see a notice that the plan will not provide coverage for any services that are received before the coverage date begins. This means that if you purchase a plan on March 15, and the coverage date is April 1 st, any services that you receive during this time would not be covered. Any services that you receive after the coverage expires will not be covered as well.
Non-Medically Necessary - This is a clause that prevents payments for claims that are not "medically necessary." It may include services or supplies and Anthem Blue Cross will determine what is and what is not "medically necessary."
Maximum Benefits - Once you reach your plan’s maximum benefit level, any services you receive after this point will not be covered. The majority of the plans offered by Anthem Blue Cross have very high maximum levels, such as $5,000,000. This allows most people to enjoy coverage throughout their entire life.
Services Received by Relatives - Any professional services that you receive from a provider that lives in your home, is related to you, whether through adoption, blood or marriage will not be covered by Anthem Blue Cross plans.
Certain Eye Surgeries - Certain eye surgeries that are performed to correct near-sightedness, far-sightedness or astigmatism will not be covered by your plan. If there is another reason for the surgery, other than sight correction, the procedure may be covered.
Hearing and Vision Services - Unless a plan specifically covers these areas, the majority of health plans from Anthem Blue Cross do not offer coverage for hearing aids or for optometric services such as orthoptics, contact lenses, glasses or eye refractions. You can find whether or not your plan provides coverage for these items in the Combined Evidence of Coverage and the Disclosure Form/Certificate.
Sex Change Operations - An operation that is performed for the sole purpose of changing ones gender will not be covered.
Reversal of Sterilizations and Infertility Treatments - These procedures will not be covered, unless it is specifically stated otherwise in your plan.
Weight Reduction Services - procedures that are performed to correct or treat obesity that have weight reduction as the primary purpose will not be covered. If a procedure is deemed "medically necessary" to treat morbid obesity, Anthem Blue Cross may authorize the procedure. You will need to wait for this authorization before coverage will go into effect.
Routine Physicals - If you require a routine physical for insurance purposes, school, licensing or for employment purposes, this exam will not be covered by your insurance.
Cosmetic Surgery - If a surgery is performed with the intent to improve physical appearance, it will not be covered. Examples of this would include a rhinoplasty, if the structure of your nose is otherwise perfect. However, if you needed a rhinoplasty procedure to breath properly, it could be covered. You would need to check with your representative for more information.
These are just a few of the common exclusions you will run into with your plan. It is important to carefully read all of your documentation so that you will completely understand what is and is not covered by your health plan.
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