Arizona Medical Insurance > HealthNet of Arizona > Plan Exlcusions & Limitations

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EXCLUSIONS AND LIMITATIONS

The exclusions and limitations presented in this Benefit Overview are not comprehensive. For a full list of exclusions and limitations see the Evidence of Coverage for HMO Plans or Policy for PPO Plans.

Exclusions and limitations include but are not limited to:

HMO Plans: Hospital and professional services for a normal delivery are covered only for expectant members who have been enrolled for 21 consecutive months when delivery occurs. Hospital and professional services for members who have been enrolled less than 21 consecutive months are limited to prenatal care, after 12 months of enrollment, and complications of pregnancy, as defi ned in the Evidence of Coverage.

With the exception of emergency care and direct access benefits, all services and items must be provided or arranged by your primary care physician.  Selected services require authorization by Health Net of Arizona, Inc.

PPO Plans: Eligible expenses for covered services delivered by non-contracted providers and facilities will be an amount determined by Health Net based on a percentage of the Health Net fee schedule, which is generally comparable to eligible expenses for covered services delivered by contracted providers and facilities. This amount may be adjusted by Health Net from time to time and at any time.

Precertification is required for certain services. Failure to obtain precertifi cation will result in a reduction in benefi ts. For a comprehensive list of services requiring precertifi cation see the Policy. Services that must be precertifi ed include, but are not limited to: Hospital inpatient admissions (non-emergency, including acute, subacute or rehabilitation), hospital observation stays (less than 24 hours), mental health and substance abuse inpatient admissions, skilled nursing inpatient facility admissions, transplants/transplant services, select outpatient procedures, select rehabilitative programs and therapies, select durable medical equipment, home health care services (including home infusion therapy), non-emergent ambulance and transportation services, prosthetics, oncology services, podiatry services, sleep studies, oxygen and related breathing equipment, epidural steroid injections, magnetic resonance imaging (MRI), computerized axial tomography (CAT), positron emission tomography (PET) scans, magnetic resonance angiography (MRA), self-injectable medications (except insulin), select in-offi ce pharmacy injectables.

Coverage for maternity services is limited to complications of pregnancy.

HMO and PPO Plans: The following services and/or procedures are either limited in coverage or excluded from coverage under these health plans. These services include, but are not limited to: comfort/convenience items, hearing aids, cosmetic surgery, court ordered care, custodial care, experimental/investigational procedures and drugs, gender alterations, infertility services, inpatient mental health services, long-term
rehabilitative services, obesity, paternity testing, radial keratotomy, substance abuse treatment programs, mail order prescriptions, employment counseling, exercise programs, fraudulent services, missed appointments, temporomandibular joint disorder, vocational programs. For a complete list, refer to either the Evidence of Coverage for HMO Plans or Policy for PPO Plans.

In- and out-of-network benefits are subject to deductible, then a percentage of eligible medical expenses.

All drugs covered by your outpatient prescription benefit are placed in one of four tiers on the Preferred Drug List (PDL). The lower the tier, the lower your copayment. The Health Net PDL is a listing of covered medications. Some drugs on the PDL may require prior authorization from Health Net. Prescriptions are limited to a 31-day supply. Other quantity limitations may apply.

Skilled nursing coverage is limited to 60 days per calendar year.

Expenses you incur for the following cannot be used to satisfy the out-of-pocket maximum: failure to follow prior authorization/precertification guidelines, mental illness, substance abuse, infertility, use of emergency room for non-emergent care, prescription drugs, copayments, limitations, exclusions. Check your Evidence of Coverage or Policy.

Pre-existing Condition Limitation (PPO Plans Only): Expenses for conditions for which a member received any medical advice, diagnosis, care or treatment during the 6 month period immediately preceding the member’s effective date of coverage will be excluded from coverage the first 12 months of enrollment.

High-Deductible PPO Plans: Preventive health care services are defined as routine physical, pap smear, mammography and PSA screenings. For a complete list see Policy.