Oregon Medical Insurance > HealthNet of Oregon > Exclusions

All the following benefits, accommodations, care, services, equipment, medications or supplies are expressly excluded or limited from coverage:

• Any care deemed not Medically Necessary.
• Services or supplies exceeding benefits maximums.
• Treatment of illness or injury for which a third party is responsible.
• Experimental or investigational procedures.
• Non-authorized emergency services as required by Plan contract.
• Expenses for any condition or complication caused by any procedure, treatment, service, drug, device, product or supply excluded from coverage.
• Private room; private duty nurses.
• Temporomandibular joint (TMJ) related services and Orthognathic (jaw) surgery.
• Custodial Care; respite care.
• Vision services or supplies (except as outlined in your policy).
• Corrective appliances and artificial aids, braces, disposable or non-prescription or over-the-counter supplies.
• Cosmetic surgery.
• Reduction or augmentation mammoplasty, except as provided in your policy.
• Medical or psychological reports or physical examinations required primarily for your protection and convenience or for third parties.
• Immunizations and inoculations.
• Public facility care; military service disabilities.
• Infertility services and supplies.
• Reversal of voluntary, surgically induced infertility (sterilization).
• Diagnosis, treatment and rehabilitation services for obesity and eating disorders.
• All organ and tissue transplants or autologous stem cell rescue not explicitly listed as covered.
• Personal comfort items.
• Learning disorders, psychosocial problems, speech delay, conceptual handicap and developmental delay or dyslexia.
• Speech generating devices.
• Rehabilitation, speech and hearing therapy; chiropractic manipulations.
• Medications, surgical treatment or hospitalization for treatment of impotency, penile implants, services, devices, prosthetics or aids related to treatment for any types of sexual dysfunction, congenital or acquired; sperm storage or banking.
• Genetic engineering.
• Non-medical self-help training.
• Bone bank and eye bank charges.
• Counseling or training in connection with family, sexual, marital, or occupational issues.
• Orthoptics, pleoptics (visual therapy and/or training), visual analysis.
• Services for which you would not be liable in the absence of our coverage.
• Occupational illnesses or injuries that are covered by Workers’ Compensation or any other employer liability law.
• Court-ordered care, unless determined to be Medically Necessary and Prior Authorized.
• Outpatient prescription or other drugs and medications, including but not limited to insulin and oral chemotherapy drugs. Prescriptions relating to an inpatient/outpatient confinement filled at a hospital pharmacy prior to discharge for use at home (take- home medications) except for prescriptions for a 24-hour supply or less, following an emergency room visit.
• Diagnosis, treatment and rehabilitation services for injuries sustained while practicing for or competing in a professional or semi-professional athletic contest.
• Pain Management Programs.
• Biofeedback.
• Hair analysis.
• Services or supplies for any illness, injury or condition caused in whole or in part by or related to your use of a motor vehicle when tests show you had a blood alcohol level in excess of that permitted to legally operate a motor vehicle under the laws of the state in which the accident occurred.
• Extraction and storage of autologous blood and derivatives.
• Routine foot care.
• Growth hormone therapy.
• Family planning, counseling, and assessment for birth control and birth control devices.
• Preventive and routine examination, services, testing and supplies are excluded for all Members except limited women’s health services and except as specifically provided for Members to age 18 in the Preventive Care Value Benefits Supplemental Benefit Schedule if endorsed to your Agreement and except as provided in the IFP Value Plans or as otherwise specified by agreement.
• Circumcisions.
• Drug detoxification; Chemical Dependency except alcohol treatment.
• Known congenital defect or disease unless continually covered with us from birth.
• Alternative Care: All services must be provided by a ASHN preferred provider. Services include chiropractic, naturopathic, acupuncture and massage therapy if endorsed to your Agreement.
• Autologous blood.
• Services of a nutritionist, except for diabetes management and inborn errors of metabolism.

Exclusion periods

• Services related to an organ transplant, including evaluation, will be
  covered after a 24-month exclusion period has been satisfied.

Services for the following specified conditions will be covered after a 12-month exclusion period has been satisfied.

• Allergies & their symptoms, including asthma
• Elective procedures that we determine can be reasonably postponed until the end of the exclusion period.
• Mental disorders.

Services for a pre-existing condition will be covered after a 6-month exclusion period has been satisfied. Pregnancy is subject to the pre-existing conditions.

Upon our receipt of a certificate of Creditable Coverage, the exclusion periods will be reduced by the length of Creditable Coverage under other Health Benefit Plans provided the following conditions are met:

• Creditable Coverage must either remain in effect on the effective date of coverage or was terminated no more than 63 days prior to the effective date, and
• Except for services for a pre-existing condition, the excluded service must have been covered under the other Health Benefit Plan.
• The exclusion periods do not apply to a newborn or newly adopted child.