Anthem Traditional PPO Plans - Indiana

Not all Anthem individual health policies contain the same exclusions, and these exclusions can change as Anthem updates their contracts.  The following exclusions were gathered from a currently popular Anthem plan, but should be interpreted as providing only a general representation of what Anthem does not cover under its individual policies for Indiana residents:

• Which Anthem determines are not medically necessary;
• Received from an individual or entity that is not a provider, as defined in the health insurance contract;
• Which are experimental/investigative or related to such, whether incurred prior to, in connection with, or subsequent to the experimental/investigative service or supply, as determined by Anthem;
• For any condition, disease, defect, ailment, or injury arising out of and in the course of employment if benefits are available under any Worker's Compensation Act or other similar law.  This exclusion applies if you receive the benefits in whole or inn part.  This exclusion also applies whether or not you claim the benefits or compensation.  It also applies whether or not you recover from any third party;
• To the extent that they are provided as benefits by any governmental unit, unless otherwise required by law or regulation;
• For illness or injury that occurs as a result of any act of war, declared or undeclared, while serving in the armed forces;
• For a condition resulting from direct participation in a riot, civil disobedience, nuclear explosion, or nuclear accident;
• For any pre-existing condition for the time period specified in the Schedule of Benefits, subject to the Credit for Prior Coverage provision of the contract;
• For court ordered testing or care unless medically necessary and authorized by your network provider;
• For which you have no legal obligation to pay in the absence of this or like coverage;
• Received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust or similar person or group;
• Received from, referred, or prescribed by a member of your immediate family, including your spouse, child, brother, sister, parent, or self;
• For completion of claim forms or charges for medical records or reports unless otherwise required by law;
• For missed or canceled appointments;
• For mileage costs or other travel expenses, except as authorized by Anthem;
• For which benefits are payable under Medicare part A and/or Medicare Part B or would have been payable if a member had applied for Part A and/or Part B, except, as specified elsewhere in the contract or as otherwise prohibited by federal law;
• Charges in excess of the maximum allowable amount;
• Incurred prior to your coverage effective date;
• Incurred after the termination date of the coverage except as specified elsewhere in the contract;
• For cosmetic treatment intended primarily to improve appearance but not to restore body function or correct deformity from disease, trauma, birth or growth defects or prior therapeutic processes;
• Services which are solely performed to preserve the present level of function or prevent regression of functions for an illness, injury or condition which is resolved or stable;
• For custodial care, domiciliary or convalescent care;
• For foot care only to improve comfort or appearance including, but not limited to care for flat feet, subluxations, corns, bunions (except capsular and bone surgery), calluses, and toenails;
• For any treatment of teeth, gums or tooth related service except as otherwise specified as coved in the contract;
• Related to weight loss or treatment of obesity;
• For sex transformation surgery and related services, or the reversal thereof;
• For marital counseling;
• For eyeglasses or contact lenses.  This exclusion does not apply for initial prosthetic lenses or sclera shells following intra-ocular surgery, or for soft contact lenses due to a medical condition;
• For hearing examinations, hearing aids or examinations for prescribing or fitting them;
• For services or supplies primarily for educational, vocational, or training purposes, expect as otherwise specified in the contract;
• For reversal of sterilization;
• For artificial insemination; fertilization (such as in vitro or GIFT) or procedures and testing related to fertilization; infertility drugs and related services following the diagnosis of infertility;
• For or related to developmental delays, learning disabilities, hyperkinetic syndromes, or mental retardation except the following are covered:  (1) treatment of pervasive developmental disorders (including Asperger's syndrome and autism), as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association; when services are provided as prescribed by the insured's physician; and (2) Prescription Drugs for treating learning disabilities, hyperkinetic syndromes and mental retardation.  Any other exclusion or limitation in the contract with item (1) above will not apply.
• For personal hygiene and convenience items;
• For care received in an emergency room which is not emergency care, except as specified in the contract;
• For expenses incurred at a health spa or similar facility;
• For self-help training and other forms of non-medical self care, except as otherwise provided in the contract;
• For examinations relating to research screenings;
• For stand-by charges of a physician;
• Physical exams and immunizations required for enrollment in any insurance program, as a condition of employment, for licensing, or for other purposes;
• Eye examinations and service related to radial keratotomy or keratomileusis or excimer laser photo refractive keratectomy;
• Related to any mechanical equipment, device, or organ.  However, this exclusion does not apply to a left ventricular assist device when used as a bridge to a heart transplant.
• For private duty nursing service rendered in a hospital or skilled nursing facility;
• For private duty nursing services except when provided through the home care services benefit under the contract;
• Services and supplies related to sex transformation or male or female sexual or erectile dysfunctions or inadequacies regardless of origin or cause.  This exclusion includes sexual therapy and counseling.  This exclusion also includes penile prostheses or implants and vascular or artificial reconstruction, prescription drugs, and all other procedure and equipment developed for or used in the treatment of impotency, and all related diagnostic testing.
• For services, supplies and other care provided for elective abortions accomplished by any means, as defined by applicable law;
• For maternity services, except as under the maternity options for Blue Access Plan 2.  Anthem will cover complications of pregnancy as stated in the contract.
• Drugs in quantities which exceed the limits established by the plan.