These exclusions apply to the medical plans only (including unlimited spinal manipulations and vision) and do not apply to the wellness programs, dental options and EAP.

Waiting Periods 

No benefits are provided for treatment relating to a transplant until the member has been covered under this or a prior Asuris plan with the same group for six consecutive months. There is a waiting period that must be met prior to benefits being available for pre-existing conditions: groups with 2-50 eligible employees have a nine-month pre-existing condition waiting period and groups with 51 or more eligible employees have a three-month pre-existing condition waiting period. Members may receive credit from prior medical coverage.

Outside the Service Area

Outside the states of Washington, Oregon, Idaho, and Utah, all covered services will be provided at the Category 1 payment and copay levels on the above plans and providers can balance bill members above our allowed payment. Through arrangements with our affiliates in Washington, Oregon, Idaho, and Utah, members can access all their levels of providers and payment in those states as if in the home service area.

General Medical Exclusions

Coverage is not provided for any of the following, including direct complications or consequences that arise from:

• Cosmetic/Reconstructive Services and Supplies except for reconstruction for functional injury and disease, to treat a congenital anomaly, and for breast reconstruction following a medically necessary mastectomy to the extent required by law
• Counseling in the absence of illness
• Custodial Care: Non-skilled care and helping with activities of daily living
• Dental Examinations and Treatments
• Fees, Taxes, Interest: Charges for shipping and handling, postage, interest, or finance charges that a provider might bill
• Government Programs: Benefits that are covered, or would be covered in the absence of this plan, by any federal, state or governmental program
• Infertility except to the extent covered services are required to diagnose such condition
• Investigational Services: Treatment or procedures (health interventions) and services, supplies, and accommodations provided in connection with investigational treatments or procedures
• Medications without a Prescription Order
• Military Service Related Conditions: The treatment of any condition caused by or arising out of a member’s active participation in a war or insurrection or conditions incurred in or aggravated during performance in the Uniformed Services
• Motor Vehicle Coverage and Other Insurance Liability
• Non-Direct Patient Care including appointments scheduled and not kept, charges for preparing medical reports, itemized bills or claim forms, and visits or consultations that are not in person, including telephone consultations and email exchanges
• Non-Duplication of Medicare: Services and supplies to the extent payable under Medicare, when by law, the plan would not be primary to Medicare had the member properly enrolled in Medicare when first eligible regardless of whether or not the member actually enrolled
• Obesity or Weight Reduction/Control: Medical treatment, medication, surgical treatment (including reversals), programs, or supplies that are intended to result in or relate to weight reduction, regardless of diagnosis
• Orthognathic Surgery except for congenital conditions, temporomandibular joint disorder, injury, and sleep apnea
• Personal Comfort Items: Items that are primarily for comfort, convenience, cosmetics, environmental control, or education
• Physical Exercise Programs and Equipment including hot tubs or membership fees at spas, health clubs, or other facilities, even if the program, equipment, or membership is recommended by the member’s provider
• Private Duty Nursing including ongoing shift care in the home
• Riots, Rebellion and Illegal Acts: Services and supplies for treatment of an illness, injury, or condition caused by a member’s voluntary participation in a riot, invasion, or aggression, insurrection, or rebellion, sustained by a member while committing an illegal act or felony
• Routine Foot Care including treatment of corns and calluses and trimming of nails
• Routine Hearing Care: Routine hearing examinations, programs, or treatment for hearing loss including hearing aids (externally worn or surgically implanted) and the surgery and services necessary to implant them, except for cochlear implants
• Self-Help, Self-Care, Training, or Instructional Programs including childbirth classes, diet and weight monitoring services and instruction programs, including those to learn how to stop smoking and programs that teach a person how to use durable medical equipment or how to care for a family member
• Services and Supplies Provided by a Member of Your Family
• Services and Supplies that are not Medically Necessary
• Services to Alter Refractive Character of the Eye
• Sexual Reassignment Treatment and Surgery: Treatment, surgery, and counseling services for sexual reassignment
• Sexual Dysfunction: Regardless of cause, except for counseling provided by covered, licensed mental health practitioners
• Third-Party Liability: Services and supplies for treatment of illness or injury for which a third party is or may be responsible
• Tobacco Addiction Treatment including supportive items for addiction to tobacco, tobacco products, or nicotine substitutes, including prescription medications
• Travel and Transportation Expenses other than covered ambulance services
• Work-related conditions except for subscribers who are owners, partners, or corporate officers and are exempt from state or federal workers’ compensation law

This is a brief summary of benefits; it is not a certificate of coverage. All benefits must be medically necessary. For full coverage provisions, refer to the contract.