Small Group Medical Plans Limitations & Exclusions

The primary limitations and exclusions for each of the plans are described below. Please take a few moments to review this information. This list is a representative overview only. A comprehensive list and more details of each plan’s limitations and exclusions can be found in the plan-specific Certificate of Coverage.

Limitations & Exclusions for the Premier Flex 500, 1000, 2000, 1000, 2500, and Saver 1000 Plans; the Flex Advantage 1000, 2000, 2500 and Saver 2000 Plans; and the HSA-Compatible Plans A, B and C.

• Any amounts in excess of maximum amounts of covered expenses.
• Services not specifically listed in the plan as covered services.
• Services or supplies that are not medically necessary as determined by UniCare.
• Services or supplies that UniCare considers to be experimental or investigative.
• Services received before the effective date of coverage or during an inpatient stay that began before that effective date of coverage.
• Services received after coverage ends.
• Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if you do not claim those benefits.
• Services for the diagnosis or treatment of any employment related accidental injury or illness.
• Conditions caused by or contributed by (a) an act of war; (b) the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e) services received for any condition caused by an insured person’s commission of, or attempt to commit, a felony or to which a contributing cause was the insured person being engaged in an illegal activity; (f) an insured person, age 19 or older, being intoxicated or under the influence of illegal narcotics or nonprescribed controlled substances unless administered on the advice of a physician.
• Any services provided by a local, state or federal government agency except when payment under the plan is expressly required by federal or state law.
• Professional services received or supplies purchased from yourself, a person who lives in the insured person’s home or who is related to the insured person by blood, marriage or adoption, or the insured employee’s employer.
• Inpatient or outpatient services of a private duty nurse.
• Inpatient room and board charges in connection with a hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
• Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
• Treatment of drug, alcohol, or other substance addiction or abuse.
• Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically stated under dental care in the comprehensive benefits section of the plan, including dental services for temporomandibular joint dysfunction.
• Orthodontic services, braces and other orthodontic appliances including orthodontic services for temporomandibular joint dysfunction.
• Dental implants:Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
• Hearing aids.
• Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in the plan.
• An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
• Outpatient speech therapy.
• Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in the plan. This includes, but is not limited to, items dispensed by a physician.
• Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or to medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.
• Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.
• Treatment of sexual dysfunction, impotence and/or inadequacy.
• All services related to the evaluation or treatment of fertility and/or infertility.
• Cryopreservation of sperm or eggs.
• All contraceptive services and supplies, including, but not limited to, all related consultations, examinations, evaluations, medications, medical, laboratory, devices or surgical procedures.
• Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
• Services primarily for weight reduction or treatment of obesity, or any care which involves weight reduction as a main method for treatment, except as specifically stated under morbid obesity in the comprehensive benefits section of the plan.
• Charges by a provider for telephone consultations.
• Items which are furnished primarily for your personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, etc.).
• Educational services, except for diabetes self-management and as specifically provided or arranged by UniCare.
• Nutritional counseling or food supplements.
• Any services received on or within nine months after the eligibility date of coverage if they are related to a preexisting condition (15 months after the effective date for a late enrollee).
• Durable medical equipment not specifically listed as covered services in the comprehensive benefits or infusion therapy sections of the plan. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment; treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings.
• All infusion therapy together with any associated supplies, drugs or professional services are excluded, except as specifically provided under the benefit for infusion therapy described in the plan.
• All foreign country provider charges are excluded under the plan, except as specifically stated under treatment received from foreign country providers under the benefits section of the plan.
• Growth hormone treatment.
• Routine foot care, including the cutting or removal of corns or calluses, the trimming of nails, routine hygienic care and any service rendered in the absence of localized illness, injury or symptoms involving the feet.
• Charges for which we are unable to determine our liability because you or an insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or, (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
• Charges for the services of a standby physician.
• Charges for animal to human organ transplants.
• Claims received after 15 months from the date service was rendered.

Additional Limitations & Exclusions for the UniCare Premier Flex Saver 1000 and Flex Advantage Saver 2000 Plans

• All services related to sterilization.
• Acupuncture/acupressure treatment.
• Services for durable medical equipment.