What do the guidelines define as not eligible for sharing?
Medical bills related to the following conditions are not
eligible for sharing:
• Treatment that is in violation of the Statement of Beliefs and Ethics including illness or injury arising from grossly negligent acts, use of illegal drugs, abuse of alcohol or any illegal activity, whether or not an arrest is made, charges are filed, or a conviction
results;
• Treatment related to current use of illegal drugs;
• Residential drug/alcohol treatment;
• Procedures or surgery that is not medically necessary;
• Prophylactic (treatment intended to prevent disease) and preventive surgery without personal history of diagnosis and a doctor’s recommendation;
• Inpatient rehab;
• Inpatient and Outpatient drug/alcohol rehabilitation;
• Inpatient mental health services;
• Nutrition services;
• Alternative or naturopathic treatment;
• Experimental treatment;
• Genetic testing not required for treatment of an existing condition;
• Hearing aids;
• Non-prescription (over-the-counter) drugs and medical supplies/equipment;
• Fertility/infertility treatment;
• Direct Primary Care costs;
• Medical marijuana;
• Routine or preventive care not listed in the “Preventative
Screening” or “Wellness” sections, above;
• Sleep studies not related to a specific disease or
disorder;
• Treatment related to genetic defects, hereditary
diseases, or congenital conditions present before membership;
• Weight management treatment or procedures;
• Dental or Vision services not related to a medical injury or illness;
• Orthotics;
• Transportation to appointments;
• Cosmetic, Transgender, or voluntary treatment or surgery;
• Psychotropic medication;
• Birth control;
• Vaccinations and / or immunizations;
• Treatment for members aged 65 or older that is not Medicare-eligible.
• Treatments, procedures, medications that are not FDA and CMS approved.
See the Guidelines for complete details.