Oregon Medical Insurance > Kaiser Permanente of Oregon > Plan Exclusions

General Exclusions - The following are not covered:

• Services not approved by a Kaiser Permanente physician (except for qualifying emergency and urgent care services)
• Conditions covered by workers’ compensation or that are the employer’s responsibility
• Financial responsibility for services and supplies that an employer is required by law to provide
• Conditions that a government agency, except Medicaid, is required by law to provide
• Dental services
• Experimental or investigational services
• Acupuncture
• Designated blood donations including procurement and storage of cord blood, unless exception criteria is met
• Sexual reassignment surgery
• Routine foot-care services
• Physical exams and mental health services or testing required to participate in employee programs, to obtain or maintain employment, insurance, or governmental licensing or on a court order or required for parole or probation
• Cognitive rehabilitation programs
• Long-term rehabilitation, long-term physical occupational therapy, long-term speech and language services
• Drugs for infertility diagnosis and treatment
• Outpatient supplies
• Services to induce pregnancy, such as in-vitro fertilization, ovum transplants, and gamete and zygote intrafallopian transfers (artificial insemination is, however, a covered service)
• Cost of donor semen and donor eggs
• Reversal of voluntary, surgically induced infertility
• Transplant services, except prescribed heart, lung, heart-lung, liver, cornea, bone marrow, stem cell, pancreas, pancreas after kidney, small bowel, small bowel-liver, kidney, and simultaneous kidney-pancreas transplants
• Nonhuman and artificial organs and their implantation
• Educational or clinical programs for weight control and food supplements
• Vision therapy (orthoptics or eye exercises)
• Internally implanted insulin pumps, artificial hearts, and artificial larynx
• Custodial care or care in an intermediate care facility
• Cosmetic services and supplies
• Radial keratotomy, photorefractive keratectomy, and refractive surgery including evaluations for the procedures
• Hearing aids
• Eyeglasses and contact lenses
• Low-vision aids
• Durable medical equipment, corrective appliances, and artificial aids
• Hypnotherapy and related services
• Drugs used in the treatment of sexual dysfunction
• Drugs not approved by the FDA, unless the Health Resources Commission finds that the drug is recognized in independent medical or pharmaceutical journals as effective for that use
• Drugs that are necessary or related to an excluded service
• Any packaging other than the dispensing pharmacy’s standard packaging
• Drugs used for surgery related to weight management
• Over-the-counter drugs
• Prescriptions extemporaneously compounded
• Genetic testing
• Services provided or arranged by criminal justice institutions for members confined therein, unless care would be covered as an emergency service
• Mental health services for mental retardation, after diagnosis
• Mental health services for the following conditions if the treating physician determines the condition is not responsive to therapeutic management: chronic psychosis, care for inorganic psychosis and intractable personality disorders
• Services and treatment provided for obesity or weight control, including bariatric or gastric bypass surgery
• Medical services for temporomandibular joint disorders
• Mental health services on court order or as a condition of parole or probation; unless determined by Medical Group to be Medically Necessary and appropriate
• Psychological testing on court order, or testing for ability, aptitude, intelligence or interest
• Mental health treatment in a residential or day treatment facility
• The following chemical dependency services are excluded: care in a treatment facility not approved or arranged by a Medical Group Physician; continuation in a course of counseling for patients who are disruptive or physically abusive; methadone maintenance, except when prescribed by a Medical Group Physician
• Drugs not included in the drug formulary, unless a nonformulary drug is medically necessary and has been specifically prescribed and authorized through the nonformulary process
• Non-preferred generic and therapeutic equivalents as determined by the Regional Formulary and Therapeutics Committee
• Replacement of drugs and accessories due to loss, damage and/or carelessness
• High-cost drugs and drugs that require special handling such as refrigeration, professional administration, or professional observation, cannot be provided through mail order.

General Limitations:

• Members must be enrolled continuously for 24 months before these transplants are covered:  cornea, lung, heart-lung, liver (for alcoholic cirrhosis), bone marrow (for certain conditions), pancreas, pancreas after kidney, simultaneous kidney-pancreas, small bowel, small bowel-liver, or stem cell. Members will be given credit for prior coverage if the transplant was covered under the prior creditable coverage.