Appendix F

General Exclusions

This table presents a sampling of general exclusions, beginning with a set of what was presented as typical of industry-wide practices,1 followed by a Federal Employees Health Benefits (FEHB) program fee-for-service product,2 and then exclusions among CIGNA typical small group employer plan,3 UnitedHealthcare small group plans,4 Wellpoint Anthem Blue Standard small business plan5 (see Appendix E for more detail on the latter), and the Medicare program.6,7 The FEHB program develops a short list of general exclusions for both its fee-for-service and managed care plans (see, for example, Chapter 5, Box 5-2), which individual insurers can expand upon.

1 Personal communication, Charles Bevilacqua, Kaiser Permanente; the list of industry-wide practices are not necessarily specific to Kaiser but identified across many insurers as typical.

2 These are specific to Blue Cross and Blue Shield (BCBS) fee-for-service benefit plan under the FEHBP program (http://www.fepblue.org/benefitplans/2011-sbp/bcbs-2011-RI71-005.pdf).

3 Personal communication, Rosemary Lester, CIGNA Product, September 9, 2011.

4 Personal communication, Sam Ho, UnitedHealthcare, September 13, 2011.

5 Personal communication, Ruth Raskas, WellPoint, September 9, 2011.

6 CMS (Centers for Medicare and Medicaid Services) Medicare benefit policy manual: Chapter 16—general exclusions from coverage (http://www.cms.gov/manuals/Downloads/bp102c16.pdf).

7 Responses were compiled exactly as submitted, explaining any variance in style (e.g., X = excluded; X for Cigna = explicitly excluded or otherwise not a covered benefit; Y = excluded; N = not excluded).



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Appendix F General Exclusions This table presents a sampling of general exclusions, beginning with a set of what was presented as typical of industry-wide practices,1 followed by a Federal Employees Health Benefits (FEHB) program fee-for-service product,2 and then exclusions among CIGNA typical small group employer plan,3 UnitedHealthcare small group plans,4 Wellpoint Anthem Blue Standard small business plan5 (see Appendix E for more detail on the latter), and the Medicare program.6,7 The FEHB program develops a short list of general exclusions for both its fee-for-service and managed care plans (see, for example, Chapter 5, Box 5-2), which individual insurers can expand upon. 1 Personal communication, Charles Bevilacqua, Kaiser Permanente; the list of industry-wide practices are not necessarily specific to Kaiser but identified across many insurers as typical. 2 These are specific to Blue Cross and Blue Shield (BCBS) fee-for-service benefit plan under the FEHBP program (http://www.fepblue.org/ benefitplans/2011-sbp/bcbs-2011-RI71-005.pdf). 3 Personal communication, Rosemary Lester, CIGNA Product, September 9, 2011. 4 Personal communication, Sam Ho, UnitedHealthcare, September 13, 2011. 5 Personal communication, Ruth Raskas, WellPoint, September 9, 2011. 6 CMS (Centers for Medicare and Medicaid Services) Medicare benefit policy manual: Chapter 16—general exclusions from coverage (http:// www.cms.gov/manuals/Downloads/bp102c16.pdf). 7 Responses were compiled exactly as submitted, explaining any variance in style ( e.g., X = excluded; X for Cigna = explicitly excluded or otherwise not a covered benefit; Y = excluded; N = not excluded). 209

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TABLE F-1 General Exclusions of Health Plans 210 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare General Exclusions Service, drugs, or supplies you receive while you are not enrolled in this plan X X X Y Not Covered Services, drugs, or supplies not required according to accepted standards of X X Y Not Covered medical, dental, or psychiatric practice in the United States Services, drugs, or supplies billed by Preferred and Member facilities X X N Not addressed for inpatient care related to specific medical errors and hospital-acquired in contracts conditions known as never eventsd Services not specifically/explicitly listed as covered X X Y Not Covered All services, drugs, or supplies related to the non-covered service are X X Y Not Covered excluded from coverage, except services we would otherwise cover to treat complications of the non-covered service Services, drugs, or supplies not required to prevent, diagnose, or treat a X X Y Not Covered medical condition Services for conditions that a plan physician determines are not responsive to X X Y Not Covered therapeutic treatment Services or supplies for which no charge would be made if the covered X X Y Not Covered individual had no health insurance coverage Services related to and required as a result of services which are not covered N Not addressed Y under Medicare in contracts Medical Necessity Not Coverede Services deemed not medically necessary X Y Services, drugs, or supplies that are not medically necessary X X Y Services not reasonable and necessary X N, eligible Y expense Abortion f Services, drugs, or supplies related to abortions, except when the life of the X Y Varies across mother would be endangered if the fetus were carried to term, or when the plans pregnancy is the result of an act of rape or incest Active Military Service Services, drugs, or supplies you receive without charge while in active military X X Y Not Covered service

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TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Automobile, No Fault, Any Liability Insurance or Workers’ Compensation Not Covered by most planse Care for any condition or injury recognized or allowed as a compensable loss X X Y through any Workers’ Compensation, occupational disease or similar lawg Services reimbursable under automobile, no fault, any liability insurance X Nh Y workers’ compensation Blood The cost of whole red blood or red blood cells when they are donated or X Y Not Covered replaced or billedi by some plans Charges for Administrative Services Exclude services, supplies, or devices if they are not prescribed, performed, or X Y Not Covered directed by a provider or facility not defined by us as such, or not licensed to do so Clinical Trials Research costs (costs related to conducting a clinical trial such as research X Not a Y Not Covered physician and nurse time, analysis of results, and clinical tests performed only Benefit for research purposes) unless mandated Extra care costs related to taking part in a clinical trial such as additional Not a Y Not Covered tests that a patient might may need as part of the trial, but not as part of the Benefit patient’s routine care unless mandated Cosmetic Services Not Coverede Cosmetic servicesj X X Y Services, drugs, or supplies you receive for cosmetic purposes X X Y Cosmetic surgery or other procedures performed solely for beautification or to X Y improve appearance Surgical treatments of gynecomastia (male breast reduction) for cosmetic X Y purposes Cosmetic surgery X Y Y Counseling Religious, personal growth counseling or marriage counseling including X X Y, except Not Covered services and treatment related to religious, personal growth counseling or DSM by most plans marriage counseling, unless the primary patient has a DSM IV diagnosis diagnosis also Excluded 211 continued

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TABLE F-1 Continued 212 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Crime Treatment of injuries sustained while committing a crime X (X in Y Not Covered plans for by most plans individuals) Custodial Care Not Coverede Custodial care X X Y Y Custodial care (such as feeding, dressing, bathing, transferring, and activities X Y of daily living)k Custodial care means assistance with activities of daily living (e.g., walking, X X Y getting in and out of bed, bathing, dressing, feeding, toileting, and taking medicine), or care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses or certificates or the presence of a supervising licensed nursel Dental/Oral Services Dental services Not Covered with some variation across plans for surgical extraction of impacted teeth and for TMJ treatment and appliancese Any dental or oral surgical procedures or drugs involving orthodontic care, X X Y the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or continued use of denturesm Orthodontic care for malposition of the bones of the jaw or for X X Y temporomandibular joint (TMJ) syndrome Dental procedures and appliances to correct disorders of the X X Y, except temporomandibular (jaw) joint (also known as TMD or TMJ disorders) surgery is covered Routine dental services, including topical and oral fluoride preparations, from X Y standard medical and pharmacy benefits except where mandated (does not apply to products with embedded dental coverage)n

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TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Teeth extractions, surgical removal of impacted teeth, and other oral surgical X Y services (not to include pharmacy services) for care of the teeth or of the bones and gums directly supporting the teeth. These services are dental and nature and not covered under medicalo Extractions, treatment of cavities, care of the gums or structures directly X X Y supporting the teethp,q Treatment of periodontal abscess, removal of impacted teeth, orthodontia X X Y (including braces), false teeth, or any other dental services or supplies, except as otherwise covered under the plan Items and services in connection with the care, treatment, filling, removal, or X Y Y replacement of teeth, or structures supporting the teethr Any dental procedures involving orthodontic care, inlays, gold or platinum X Y fillings, bridges, crowns, pin/post reduction, dental implants, surgical periodontal procedures, or the preparation of the mouth for the fitting or continued use of dentures Educational Services; Self-Training; Vocational Services Not Coverede Self-care or self-help training X Not a Benefit Y unless mandated Educational services, self management/help training services, and vocational Not a Benefit Y services except where mandated for diabetes and asthma, or where explicitly unless covered by another benefit mandated Any educational services and programs or therapies for behavioral/conduct Not a Benefit Y problemss unless mandated Coverage does not include services other than self management of a medical X Not a Benefit Y condition as determined by the Health Plan to be primarily educational in unless nature mandated Equipment Equipment that basically serves comfort or convenience functions or is X X Y Not Covered primarily for the convenience of a person caring for you or your dependent, i.e., exercycle or other physical fitness equipment, elevators, hoyer lifts, shower/bath bench. Air conditioners, air purifiers and filters, batteries and charges, dehumidifiers, humidifiers, air cleaners and dust collection devices 213 continued

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TABLE F-1 Continued 214 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Experimental/Investigational Procedures Not Coverede Experimental or investigational servicest X X Y Experimental or investigational procedures, treatments, drugs, or devices X X Y Services related to complications resulting or arising from excluded services X N except where mandated or where DOI agreements have been made to cover Services deemed to be experimental or investigational unless specifically X Y covered (e.g., Clinical Cancer Trials) Fees Not Coverede Expenses in excess of usual, customary and reasonable fees X X N, eligible expense Free care (no charge items) X X Y Food and Dietary Supplements Benefits for food or food supplements, except formulas and/or food products Not a Benefit Y Not Covered that are prescribed, ordered or supervised by a physician and medically unless necessary as defined by medical policy mandated Nutritional supplements and formulae needed for the treatment of inborn X Not a Benefit Y Coveredu errors of metabolism unless mandated Foot Care Foot carev X N See below Y Routine or palliative foot care (comfort or cosmetic) unless medically X Y Not Covered necessary Shoe inserts, orthotics (except for care of the diabetic foot), and orthopedic X X N, we Not Covered shoes (except when an orthopedic shoe is joined to a brace) cover one by most plans pair foot orthotics Furniture Furniture (other than medically necessary durable medical equipment) such as X X Y Not Covered commercial beds, mattresses, chairs

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TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Government Programs Xe Not Covered by most plans except as required by mandatee Treatment where payment is made by any local, state, or federal government X X N (except Medicaid), or for which payment would be made if the Participant had applied for such benefits. Services that can be provided through a government program for which you as a member of the community are eligible for participation. Such programs include, but are not limited to, school speech and reading programs Items and services furnished, paid for or authorized by governmental X N Y entities—Federal, state, or local governments Health Club Memberships Xe Not Covered by most planse Health club memberships from core medical benefit X Y Membership costs or fees associated with health clubs, weight loss programs X X Y Hearing Aids and Routine Hearing Tests Generally Not Covered by plans unless mandatede Hearing aidsw X Y Hearing aids, hearing devices and related examinations and services X X Y Hearing aids and auditory implants Y Y Hypnotherapy Hypnotherapy (hypnosis) X X Y Not Covered Infertility Services See Reproductive Services See Reproductive Services Legal Liability Not Coverede Charges which the enrollee or Plan has no legal obligation to pay, such X X Y as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/or B, doctor's charges exceeding the amount specified by the HHS when benefits are payable under Medicare, or State premium taxes however applied 215 continued

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TABLE F-1 Continued 216 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Services for which the member has no liability to pay in the absence of this X Y plan’s coverage. This includes, but is not limited to: government programs; incarceration; workers compensation; and free clinics No legal obligation to pay for or provide services X N Y Location Coverede,u Services, other than Emergency Services, received outside the United States X X Y whether or not the services are available in the United States Services not provided within the United States Y Y Massage Therapy Massage therapyx X X Y Not Covered by most plans Medical Reports Completion of specific medical reports, including those not directly related X X Y Not Covered to treatment of the Participant, e.g., employment or insurance physicals, and reports prepared in connection with litigation Medical Supplies Criteria for coverage varies across planse Disposable supplies for home use X X Y Obesity/Weight Loss Services Services, drugs, or supplies for the treatment of obesity, weight reduction, or X X Y Generally Not dietary control, except for office visits and diagnostic tests for the treatment Covered by of morbid obesityy; gastric restrictive procedures, gastric malabsorptive plans unless procedures, and combination restrictive and malabsorptive procedures mandated Nutritional counseling when billed by a covered provider such as a physician, X X Y Coveredu as part nurse, nurse practitioner, licensed certified nurse, nurse practitioner, licensed of Preventative certified nurse midwife, dietician or nutritionist, who bills independently for services for non- nutritional counseling services grandfathered plans after 9/23/2010 if services are rendered by a covered provider. Otherwise, Not Covered for most plans

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TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Commercial weight loss programs from core medical benefit X Y Not Covered Weight reduction programs: fees and charges relating to fitness programs, X X Y Not Covered weight loss, or weight control programs Gastric bypass and bariatric surgery except where mandated Not a Y Generally Not Benefit Covered by unless plans unless Mandated mandated Outpatient Prescription Drugsz Compounded products unless the drug is listed on our drug formulary or one X X Y Compound of the ingredients requires a prescription by law Coveredu only if one of ingredients requires a prescription Drugs prescribed for cosmetic purposes X X Y Not Covered Drugs that shorten the duration of the common cold X N Coveredu if a prescription is required Drugs used to enhance athletic performance X X Y Not Covered Drugs which are available over the counter and prescriptions for which drug X X Y Not Covered strength may be realized by the over the counter product by most plans Experimental or investigational drugs X X Y Not Covered If a service is not covered, any drugs or supplies needed in connection with X X Y Not Covered that service are not covered Prescription drugs for which there is an over the counter drug equivalent X X Y Not Covered Replacement of lost, damaged or stolen drugs X X N Not Covered by most plans Special packaging (packaging of prescription medications may be limited to X N Not applicable standard packaging) Drugs and supplies needed solely for travel X X N Not Covered by most plans Personal Care Items Not Coverede Personal comfort items X Y Y Personal comfort items such as beauty and barber services, radio, television, X X Y or telephone 217 continued

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TABLE F-1 Continued 218 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Personal comfort items such as those that are furnished primarily for your X X Y personal comfort or convenience, including those services and supplies not directly related to medical care, such as guest’s meals and accommodations, hospital admission kit, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, over the counter convenience items and take-home supplies Providers/Facilities Services, drugs, or supplies you receive from a provider or facility barred or X Y Not applicable suspended from the FEHB Program Services or supplies furnished by immediate relatives or household members, X X Y Not Covered such as spouse, parents, children, brothers or sisters by blood, marriage or by most plans adoption Services (applies to medical and pharmacy services) performed by a provider X Y Not Covered who is a family member by birth, marriage, or adoption, or by the provider by most plans to self Services rendered by a provider who is a close relative or member of your X X Y Not Covered household. Close relative means wife or husband, parent, child, brother or by most plans sister, by blood, marriage or adoption Charges imposed by immediate relatives of the patient or members of the X Y Not Covered Y patient’s households by most plans Services or supplies furnished or billed by a noncovered facility, except that X Y, except Not Covered medically necessary prescription drugs; oxygen; and physical, speech and speech and occupational therapy rendered by a qualified professional therapist on an occupational outpatient basis are covered subject to plan limits therapy Excluded in most cases Services, drugs, or supplies you receive from noncovered providers except in X Y, except Not Covered medically underserved areasaa we do not allow in underserved areas either Services you receive from a provider that are outside the scope of the X X Y Not Covered provider's licensure or certification Services/service charges of standby physicians X X Y Not Covered by some plans Care by non-plan providers except for authorized referrals or emergenciesbb Y Not Covered under certain plan types

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TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Care by non-plan providers except for authorized referrals, emergencies and X Y Not Covered out of area urgent care under certain plan types Private duty nursing X Y Not Covered by some plans Private duty nursing provided in an inpatient setting (acute care or skilled X Y Not Covered nursing facility)cc by some plans Private duty nursing as a registered bed patient unless a plan physician X X Y Not Covered determines medical necessity by some plans Private duty nursing in home or long term facility X X Y Not Covered by some plans Services, supplies, or devices if they are not prescribed, performed, or directed X Y Not Covered by a provider or facility not defined by us as such, or not licensed to do so Inpatient hospital or SNF services not delivered directly or under arrangement N Not addressed Y by the provider in contracts Care in halfway house X Y Not Covered Private room unless medically necessary or if a semi-private room is not X X Y Generally Not available Covered Recreational Therapy/Activities Not Coverede Recreational or educational therapy and any related diagnostic testing, except X X Y as provided by a hospital during a covered inpatient stay Recreational, diversional and play activities X X Y Reproductive Services Fetal reduction surgery X Y Generally not addressed in contracts The reversal of voluntary/elective sterilization X X Y Not Covered Infertility services when the infertility is caused by or related to voluntary X X Y Not Covered sterilization by most plans except as required by mandate 219 continued

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TABLE F-1 Continued 220 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare All assisted reproductive technologies (ART) and the associated diagnostic X Y Not Covered testing and Rx treatments to support ART (e.g., artificial insemination, in-vitro by most plans fertilization, ZIFT [zygote intrafallopian transfer], GIFT [gamete intrafallopian except as transfer]) required by mandate In vitro fertilization services X Y Not Covered by most plans except as required by mandate Infertility services related to advanced reproductive technologies including X X Y Not Covered but not limited to in vitro fertilization (IVF); gamete intrafallopian transfer by most plans (GIFT); zygote intrafallopian transfer (ZIFT) and variations of these except as procedures required by mandate Donor charges and services X X Y Not Covered by most plans except as required by mandate Cryopreservation of donor sperm and eggs X X Y Not Covered by most plans except as required by mandate Any experimental, investigational or unproven infertility procedures or X X Y Not Covered therapies Routine Services Not Covered under some grandfathered planse Routine services and appliances Unable to N Y determine definition of category, therefore no comment

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TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Routine services, such as periodic physical examinations; screening X N examinations; immunizations; and services or tests not related to a specific diagnosis, illness, injury, set of symptoms, or maternity caredd Sexual Transformations/Dysfunction/Inadequacy Sexual reassignment surgery X X Y Not Covered Services related to sexual transformations X Y Not Covered Services, drugs, or supplies related to sex transformations X Y Not Covered Services, drugs, or supplies related to sex transformations, sexual dysfunction, X X Y See above and or sexual inadequacy (except for surgical placement of penile prostheses to below treat erectile dysfunction) Drugs and devices used for the treatment of sexual dysfunction X Y Not Covered by some plans Shift Differentials Professional charges for shift differentials X X Y Not addressed in contract Smoking Cessation Smoking cessation programs X Y, Programs not affiliated with WellPoint Not Covered in most plans Surrogacy Services provided to an individual not covered under the plan are Not Coverede Surrogate parenting X Y Services related to surrogacy X Y Services related to conception, pregnancy or delivery in connection with a X X Y surrogate arrangement. A surrogate arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the childee 221 continued

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TABLE F-1 Continued 222 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Testing Testing for ability, aptitude, intelligence or interest X X Y Not Covered by some plans Third-party Requests or Requirements Physical examinations and other services, and related reports and paperwork, X X Y Generally Not in connection with third-party requests or requirements, such as those for: Covered with employment, participation in employee programs, insurance, disability, some nuances licensing, or on court order or for parole or probation across plans Topical Hyperbaric Oxygen Therapy (THBO) Topical Hyperbaric Oxygen Therapy (THBO) X Not a N Not addressed Benefit in contract Travel or Transportation Travel or transportation (other than a state licensed professional ambulance X X Y Generally not service) expenses even though prescribed by a physician, except as noted addressed in under transplants contract Treatment of Dementia, Amnesia, or Mental Retardation Treatment of dementia, amnesia or mental retardation, except for treatment of X Y, no mental Not Covered psychological symptoms related to these conditions covered by some plans unless optional is purchased Vein Surgery Treatments of all varicose and spider vein surgeries for cosmetic purposes X Y Not Covered Vision Services Vision services generally Not Covered with some nuances across planse Eye glasses and contact lenses for individuals at least 18 years of age. X Y, excluded any age Vision correction surgery (e.g., Lasik, radial keratotomy) to correct refractive X Y error, including near sightedness, far sightedness, and/or astigmatism; orthoptics and vision therapy/training; prescription and non-prescription eyewearff

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TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Radial keratotomy; and surgery, services, evaluations or supplies for the X X Y surgical correction of near sightedness and/or astigmatism or any other correction of vision due to a refractive problem Orthoptics (a technique of eye exercises designed to correct the visual axes of X X Y eyes not properly coordinated for binocular vision) or visual training Vision-medical benefits for low vision aids, eyeglasses, contact lenses for X X Y prescription or fitting and follow-up care thereof, except that covered expenses will include the purchase of the first pair of eyeglasses, lenses, frames or contact lenses that follows cataract surgery or loss of lens due to eye disease for aphakia or aniridia War Not Covered by most planse Any disease or injury resulting from a war, declared or not, or any military X X Y duty or any release of nuclear energy. Also excluded are charges for services directly related to military service provided or available from the Veterans’ Administration or military medical facilities as required by law Services resulting from war X Y Y a Approximately 25 percent of customers will accept these exclusions as listed. About 50 percent of customers will add exclusions to the list, while the other 25 percent will remove some exclusions. Those customers who add or remove exclusions typically only make changes to a small number of services. This list of exclusions is typical for both self-funded plans as well as traditionally insured plans. Self-funded plans, however, tend to customize this list more than fully insured plans. b This table reflects exclusions for CIGNA’s Typical Small Group Employer Plan. c This table reflects exclusions for Anthem/Blue Standard Coverage/Typical small group and individual plans. d Never events are errors in medical care that are clearly identifiable, preventable, and serious in their consequences, such as surgery performed on a wrong body part, and specific conditions that are acquired during your hospital stay, such as severe bed sores. e Respondents sometimes answered on the gray category line when specific wording choices did not match their own. f Elective abortions are not a benefit in the individual plan products; maternity care is not a typical benefit in individual plans. g Exception: Benefits are provided for actively employed partners and small business owners not covered under a Workers’ Compensation Act or similar law, if elected by the group and additional premium is paid. Services or supplies for injuries or diseases related to you or your dependent’s job to the extent you or your dependent is required to be covered by a workers’ compensation law. h Coordination of benefits provided. i Except expenses for administration and processing of blood and blood products (except blood factors) covered as part of inpatient and outpatient services. j Except as otherwise specified for services covered under “reconstructive surgery.” k Does not apply to hospice. l This exclusion does not apply to services covered under “hospice care.” m Except as specifically allowable under Oral and maxillofacial surgery. n Exclusion does not apply to: anesthesia and associated facility charges as a result of age and/or disability criteria; dental accidents—treatment, sought within 12 months, of an injury to natural teeth and when a treatment plan submitted for prior approval. Injuries resulted from biting and/or chewing are not considered a dental accident; radiation—dental services to prepare the mouth for radiation therapy to treat head and/or neck cancer. 223 continued

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TABLE F-1 Continued 224 o Other oral surgical services are covered, including treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; orthognathic surgery that is required because of a medical condition or injury which prevents normal function of the joint or bone and is deemed medically necessary to attain functional capacity of the affected part; oral/surgical cor - rection of accident-related injuries; treatment of lesions, removal of tumors and biopsies; incision and drainage of infection of soft tissue not including teeth-related cysts or abscesses. p Structures supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. q This exclusion does not apply to accidental injury to sound and natural teeth. r Structures directly supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. s This exclusion does not apply to coverage for medication management. t A Service is experimental or investigational if the health plan, in consultation with the medical group, determines that: generally accepted medical standards do not recognize it as safe and effective for treating the condition in question (even if it has been authorized by law for use in testing or other studies on human patients); it requires government approval that has not been obtained when Service is to be provided; it cannot be legally performed or marketed in the United States without FDA approval; it is the subject of a current new drug or device application on file with the FDA; it is provided as part of a research trial; (see specific section for clinical trials); it is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity, or efficacy as among its objectives; it is subject to approval or review of an IRB or other body that approves or reviews research; it is provided pursuant to informed consent documents that describe the services as experimental or investigational, or indicate that the services are being evaluated for their safety, toxicity or efficacy; or the prevailing opinion among experts is that use of the services should be substantially confined to research settings or further research is necessary to determine the safety, toxicity, or efficacy of the service. u Covered subject to terms and conditions of the contract. For example, there may be network limitations, medical policy limitations, cost-sharing requirements, dollar caps, visit limits, etc. v Except when medically necessary. w Cochlear implants are not necessarily included in the exclusion. Cover routine hearing screenings as a part of preventive care. x Except when provided as a procedure during a covered therapy. y A condition in which an individual has a BMI of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment. z Insurer may outline drugs that should be reviewed based on employer selection: drugs used in the treatment of infertility, sexual dysfunction, weight control, smoking cessation, and growth hormone. aa For 2011, for example: Alabama, Arizona, Idaho, Illinois, Kentucky, Louisiana, Mississippi, Missouri, Montana, North Dakota, Oklahoma, South Carolina, South Dakota, and Wyoming. bb A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. cc Nursing services in a home or hospice setting are covered as a part of home health care benefits and hospice benefits. dd Certain services are exempted, including those preventive services specifically covered under preventive care (adult and child), preventive screenings specifically listed in the plan brochure; and certain routine services associated with covered clinical trials. ee The plan might choose alternative wording for this exclusion: in situations where you receive monetary compensation to act as a surrogate, health plan will seek reimbursement of all charges for covered services you receive that are associated with conception, pregnancy and/or delivery of the child. A surrogate arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the child. ff Exclusion does not apply to medial and surgical services for the treatment of injuries and diseases affecting the eye (e.g., eye exams for diabetics, eyewear/contacts and related services to replace lenses following surgery or injury, etc.).