Arizona Medical Insurance > BlueCross BlueShield of Arizona > Policy Exclusions
Exclusions and Limitations – Examples of Services and Supplies Not Covered
The following is a partial list of conditions and services that are limited or excluded. Expenses for services that exceed benefit limitations are not covered. Detailed
information about benefits, limitations and exclusions is in the contract booklet and is available prior to enrollment upon request. Pre-existing condition waiting
periods apply to BlueClassic and all BluePreferred plans.
- Abortions except as stated in the contract
- Activity therapy
- Acupuncture
- Alternative medicine, non-traditional or alternative medical therapies, including but
not limited to naturopathic and homeopathic medicine, diet therapies, nutritional
or lifestyle therapies, aromatherapy
- Biofeedback and/or hypnotherapy
- Cognitive and vocational therapy
- Complications of body piercing/tattooing
- Complications of noncovered benefits
- Cosmetic or aesthetic surgery and services, except for breast reconstruction
following a medically necessary mastectomy in ccordance with state and/or
federal law
- Costs paid by other organizations - costs/services customarily paid for by an
employer, the government, biotechnical, pharmaceutical or medical device industry
sources or other individuals or organizations including, but not limited to worksite
or ergonomic evaluations
- Counseling or behavioral medication services except as stated in the contract.
- Court-ordered services – testing, treatment or therapy except as stated in the
contract
- Custodial care, except for limited hospice benefits
- Dental/orthodontic services or supplies
- Dietary/nutritional supplements – all dietary, caloric and nutritional supplements,
including, for example, specialized formulas for infants, children or adults or other
special foods or diets, even if prescribed by a physician or other eligible provider
except as stated in the contract
- Environmental medicine
- Fees other than for medically appropriate in-person, direct patient treatment, tests,
services, medications, supplies or equipment
- Fertility or infertility treatment, medications or procedures
- Foot care
- Genetic/chromosome testing and screening
- Government services – services available under a governmental health program
- Growth hormone(s) – except as determined medically necessary by BCBSAZ to
treat diagnostically proven growth hormone deficiency. Growth hormone(s) to treat
Idiopathic Short Stature (ISS) is expressly excluded
- Hearing services or devices, except as stated in the contract
- Investigational treatments, procedures, equipment, medications, devices or
supplies, as determined by BCBSAZ and only as required by Arizona law
- Inpatient treatment for substance abuse, except for detoxification (BluePreferred only)
- Lodging and meals, except as stated in the contract
- Manipulation of the spine under anesthesia
- Massage therapy except as stated in the contract
- Medications dispensed in a physician’s/provider’s office – prescription medications
and over-the-counter medications, including pharmaceutical manufacturer’s
samples, dispensed to the patient in a physician’s/provider’s office by any mode of
administration
- Medications for off-label, unlabeled or orphan medications (orphan medications
are used for diagnosis, treatment or prevention of a rare disease or condition)
unless otherwise specified by BCBSAZ medical or prescription medication
coverage guidelines. This does not include medications used for the treatment
of cancer
- Nonmedically necessary services as determined by BCBSAZ. BCBSAZ may
not be able to determine medical necessity until after services are rendered
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- Normal maternity services (except on BlueSelect HMO)
- Normal maternity services when delivery occurs prior to completion of the
12-month waiting period (BlueSelect Only)
- Over-the-counter medications – any medication, device, equipment or supply
(except for certain diabetic supplies and inhaler spacers, as described in the
pharmacy benefit) that is lawfully obtainable without a prescription
- Personal comfort items
- Screening tests, except as stated in the contract
- Services from family member(s) – services that are provided by an eligible provider
who is a member of your immediate family
- Services for which you have no legal obligation to pay
- Services without a prescription, when a prescription is required
- Services of ineligible providers
- Services not requiring licensed professional
- Services or supplies delivered prior to the coverage effective date or after
coverage termination date
- Services or supplies related to or associated with a noncovered service or supply
- Sexual dysfunction – evaluation and/or testing, diagnosis, treatment (surgical or
nonsurgical), or medication or devices for sexual dysfunction, regardless of the
cause of the condition, including trauma
- Smoking cessation programs, medications, aids or devices
- Strength training, cardiovascular endurance training, fitness/strengthening
programs and/or other services primarily designed to improve or increase fitness
- Telephonic or electronic consultations
- Therapy services except as stated in the contract
- Training and education, except for certain diabetes and asthma training or training
related to BCBSAZ-established disease management program(s)
- Transplants (organ, tissue, bone marrow/peripheral stem cell rescue procedures)
not approved by BCBSAZ; nor high-dose chemotherapy, radiation administered or
other related services administered in conjunction with a noncovered transplant
- Transport services or travel expenses, except as stated in the contract
- Transsexual treatment or surgery, and/or any related services
- Treatment for behavioral or mental health conditions at non-acute facilities
(e.g., residential, skilled nursing)
- Vision therapy, radial keratotomy, all types of refractive keratoplasties,
eyeglasses and contact lenses and the vision examination for prescribing
and fitting of the same
- Vitamins – except for certain vitamins, as determined by BCBSAZ, when a
prescription is written by a physician
- Waivered conditions
- Weight loss/gain therapy or treatment except as stated in the contract
- When a provider is also the covered person, services rendered by that provider for
him/herself are excluded from coverage
- Workers’ Compensation – services for an illness or injury covered by Workers’
Compensation or similar benefits, unless you are exempt from such coverage or
have made a statutory opt-out election
- AN 11-MONTH WAITING PERIOD FOR PRE-EXISTING CONDITIONS
APPLIES. A pre-existing condition is defined as a condition, regardless of the
cause of the condition, for which medical advice, diagnosis, care or treatment was
recommended or received during the 12 months before your effective date.
Services for pre-existing conditions are not covered until 11 consecutive months
after the contract effective date.
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Important Note
This is only a brief summary of benefits and exclusions. Please refer to the specific provisions found within the contract booklet for detailed information about benefits,
limitations and exclusions. If the benefits listed in this summary differ from those stated in the contract booklet, the terms of the contract booklet apply. There is no
guarantee of continued benefits outlined in summary or the contract booklet. The contract may be amended, and benefits may be added, deleted or changed by
BCBSAZ upon 31 days’ notice to the contract holder. |
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