These exclusions apply to the medical plans only and do not apply to the wellness programs.

Preventive Care

Preventive services and immunizations are covered according to guidelines set forth by the United States Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA).

Waiting Periods

No benefits are provided for treatment relating to a transplant until the member has been covered under this or a prior plan for six consecutive months. There is a waiting period that must be met prior to benefits being available for pre-existing conditions; groups with 1-50 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. Pre-existing condition waiting periods do not apply to Members up to age 19.

Outside the Service Area

Through arrangements with our affiliates in Washington, Oregon, Idaho and Utah, members can access all levels of providers and payment in those states as if in the home service area. Outside those four states, members have the security of knowing they can access providers across the country. Through the Asuris Preferred Network, members receive Category 1 coverage with thousands of providers nationwide, discounted services, balanced-billing protection, and nationwide provider search capability. When you're an Asuris Northwest Health member, you take your benefits with you.

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; except sales taxes for durable medical equipment and mobility enhancing equipment.
• 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
• 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; applies even if the program, equipment, or membership is recommended by the member’s provider
• Private Duty Nursing including ongoing shift care in the home
• Riot, 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, armed invasion or aggression, insurrection, or rebellion or 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
• 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.