Exclusions
Aetna
BCBS
Doctors
Generations
Healthsource
Optimum Choice
Partners
Coventry/Principal
Qualchoice
Wellness
WellPath
United
Injury or sickness for which other coverage is available
Workers Compensation
x
x
x
  
x
x
x
x
x
x
x
x
Military
x
x
x
x
  
x
x
x
x
x
x
x
Medicare
x
x
x
x
x
x
  
x
x
x
x
x
Any health care benefits plan / Coordination of benefits
x
x
x
x
x
x
x
x
Employer's liability
x
x
x
x
x
x
x
x
Occupational Disease Law
x
x
x
x
x
x
x
x
                         
Provider Limitations
                        
No relative/household member
x
x
x
x
x
x
x
x
x
Care which provider would otherwise not request payment
x
x
x
x
x
x
x
x
x
Out-of-network provider or facility not coordinated/ referred by PCP, unless in an emergency or other situation authorized in member certificate
x
x
x
x
x
x
x
x
x
x
x
Care by unlicensed individual
x
x
x
x
x
x
x
Services or articles which are not within the scope or licensure or certificate of the provider
x
x
x
x
Services provided in government hospitals/entity
x
x
x
x
x
x
x
x
Services and supplies furnished under or as part of a study, grant, or research program
x
x
x
x
x
Conditions that federal, state, or local law requires to be treated in a public facility
x
x
x
x
x
x
x
x
x
Second opinion (unless required by plan)
x
Self-referred services
  
x
x
      
x
x
  
x
x
  
                         
Non-medical services or items
Personal comfort, hygiene or convenience items/ not uniquely germane to treatment of disease
x
x
x
x
x
x
x
x
x
x
x
x
Items not medical in nature such as whirlpools, saunas, air mattresses, and elevators.
x
x
x
x
x
x
x
x
Maintenance, custodial care, rest homes or rest cures
x
x
x
x
x
x
x
x
x
x
x
x
Care or supplies in health resorts, spas, sanitariums, tuberculosis hospitals, or infirmaries at camps
x
x
x
Broken/missed appts.
  
x
x
x
    
x
x
x
x
x
x
Completion of forms/transfer of medical records
  
x
x
x
        
x
x
x
NA 1
Telephone consultations
x
x
x
x
NA 1
Medical information required by PCP
  
x
                    
Provider appearances at hearings and court proceedings.
x
x
x
x
Supplies, medication, and equipment provided by a hospital during a member's stay for which precertification was not obtained.
x
x
x
x
NA 1
                         
Injury or sickness resulting from:
War/military/civil insurrection
x
x
x
x
x
x
x
x
x
Commission of a felony/criminal activity
x
x
x
x
x
x
x
Being engaged in an illegal occupation
    x  
x
      
x
  
x
    
Court-ordered examinations & care
x
x
x
x
x
x
x
x
x
x
x
x
Self-infliction
    x  
x
              
Major disaster or epidemic affecting facilities or pesonnel
 x
x
x
Services required due to accidents when the member is convicted of driving while intoxicated or under the influence or drugs (except when prescribed and taken under the direction of a physician)
x
                         
Authorization/Coverage constraints
Hospital care beyond that which is pre-certified (before or after)
x
x
x
x
x
x
Care before or after date upon which benefits are effective
x
x
x
x
x
x
x
x
x
All services not specifically covered under terms of EOC
x
x
x
x
x
x
x
x
Non-covered services provided or requested by the member's personal physician.
x
x
x
x
x
x
x
Services for which member is not legally obligated to pay
x
x
x
x
x
x
x
x
x
x
Services, supplies, or treatment in excess of the benefit year or lifetime maximum as shown in the summary of benefits.
x
x
x
x
x
x
Services related to complications or side effects resulting from non-covered services or treatment
x
x
x
x
x
x
x
Care needed as a result of member acting 'against medical advice'
x
x
x
x
Covered health services that cannot be provided due to any law, regulation, or agency action.
x
x
x
x
Services not generally provided in the Plan service area unless it is generally accepted medical practice to refer patients outside the service area for such services.
x
Health interventions that do not meet the Health Plan's "Coverage Criteria."
x
x
x
Services received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group.
x
x
x
x*
                         
Miscellaneous
                        
Treatment of sexual dysfunction not related to organic disease
x
x
x
x
x
x
x
Sex changes and all related services and supplies
x
x
x
x
x
x
x
x
x
x
x
Tests or services not related to specific injury or symptoms
x
x
x
x
Autopsy
    
x
      
x
    
x
    
Hair analysis testing
            
x
x
  
x
  
x
Services required by a third party
x
x
x
x
x
Premarital laboratory work required by any state or local law
x
x
x
x
x
x
Treatment for sexual offenders or perpetrators of sexual or physical violence.
x
x
x**
Wigs
x
x
x
x

1. United HealthCare prohibits providers from charging members for these services.

*If it was not required by a third party (which would be non-covered) and there was a fee charged.

**If a court-ordered service, it is not covered, unless ordered by a PCP and approved by the plan as medically necessary. Also see #1 under miscellaneous.

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