Anthem Lumenos Health 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 recently issued Anthem Lumenos policy, but should be interpreted as providing only a general representation of what Anthem does not cover under its individual Lumenos policies for Indiana residents:

1. Which We determine are not Medically Necessary or do not meet Our Medical Policy, clinical coverage guidelines, or benefit policy guidelines;
2. Received from an individual or entity that is not a Provider, as defined in this Contract or recognized by Us;
3. 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 Us;
4. 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.  If Worker’s Compensation Act benefits are not available to you, then this Exclusion does not apply.  This exclusion applies if you receive the benefits in whole or in 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;
5. To the extent that they are provided as benefits by any governmental unit, unless otherwise required by law or regulation;
6. For illness or injury that occurs as a result of any act of war, declared or undeclared, while serving in the armed forces;
7. For care required while incarcerated in a federal, state or local penal institution or required while in custody of federal, state or local law enforcement authorities, including work release programs, unless otherwise required by law or regulation;
8. For a condition resulting from direct participation in a riot, civil disobedience, nuclear explosion, or nuclear accident;
9. For any Pre-Existing Condition for the time period specified in the Schedule of Benefits, subject to the Credit for Prior Coverage provision of this Contract.  This Exclusion is not applicable to newborns, adopted children or children placed for adoption who are enrolled under this Contract within 31 days of the date of birth or placement for adoption; However, the Pre-Existing Condition waiting period is applicable to a newborn child, an adopted child or a child placed for adoption when the Subscriber is the newborn child or the child being adopted even if the Contract is effective within the first 31 days of birth, adoption or placement for adoption;
10. For court ordered testing or care unless Medically Necessary
11. For which you have no legal obligation to pay in the absence of this or like coverage;
12. 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;
13. Received from, referred, or prescribed by a member of your immediate family, including your spouse, child, brother, sister, parent, or self;
14. For completion of claim forms or charges for medical records or reports unless otherwise required by law;
15. For missed or canceled appointments;
16. For mileage costs or other travel expenses, except as authorized by Us;
17. For which benefits are payable under Medicare Parts A, B and/or D, or would have been payable if a Member had applied for Parts A and/or B, except, as specified elsewhere in this Contract or as otherwise prohibited by federal law, as addressed in the section titled “Medicare” in General Provisions.  For the purposes of the calculation of benefits, if the Member has not enrolled in Medicare Part B, We will calculate benefits as if the Member had enrolled;
18. Charges in excess of the Maximum Allowable Amount;
19. Incurred prior to your Effective Date;
20. Incurred after the termination date of this coverage except as specified elsewhere in this Contract;
21. For any procedures, services, equipment or supplies provided in connection with cosmetic services. Cosmetic services are primarily intended to preserve, change or improve your appearance or are furnished for psychiatric or psychological reasons.  No benefits are available for surgery or treatments to change the texture or appearance of your skin or to change the size, shape or appearance of facial or body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts).  Complications directly related to cosmetic services treatment or surgery, as determined by Us, are not covered.  This exclusion applies even if the original cosmetic services treatment or surgery was performed while the Member was covered by another carrier prior to coverage under this Contract.  Directly related means that the treatment or surgery occurred as a direct result of the cosmetic services treatment or surgery and would not have taken place in the absence of the cosmetic services treatment or surgery.  This exclusion does not apply to conditions including but not limited to: myocardial infarction; pulmonary embolism; thrombophlebitis; and exacerbation of co-morbid conditions.
22. 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;
23. For Custodial Care, domiciliary or convalescent care, whether or not recommended or performed by a professional;
24. For membership, administrative, or access fees charged by Physicians or other Providers. Examples of administrative fees include, but are not limited to, fees charged for educational brochures or calling a patient to provide their test results;
25. 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 except when Medically Necessary including but not limited to, foot care for diagnosis of diabetes or for impaired circulation to the lower extremities;
26. For any treatment of teeth, gums or tooth related service except as otherwise specified as covered in this Contract;
27. For bariatric surgery, regardless of the purpose it is proposed or performed. This includes but is not limited to Roux-en-Y (RNY), Laparoscopic gastric bypass surgery or other gastric bypass surgery (surgical procedures that reduce stomach capacity and divert partially digested food from the duodenum to the jejunum (the section of the small intestine extending from the duodenum), or Gastroplasty (surgical procedures that decrease the size of the stomach), or gastric banding procedures. Complications directly related to bariatric surgery that result in an Inpatient stay or an extended Inpatient stay for the bariatric surgery, as determined by Us, are not covered. This exclusion applies when the bariatric surgery was not a Covered Service under this Plan or any previous Anthem plan, and it applies if the surgery was performed while the Member was covered by a previous carrier prior to coverage under this Contract. Directly related means that the Inpatient stay or extended Inpatient stay occurred as a direct result of the bariatric procedure and would not have taken place in the absence of the bariatric procedure. This exclusion does not apply to conditions including but not limited to: myocardial infarction; excessive nausea/vomiting; pneumonia; and exacerbation of co-morbid medical conditions during the procedure or in the immediate post operative time frame.
28. For weight loss programs except as specifically listed as covered in this Contract. Weight loss programs not approved by Us, including but not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) or fasting programs are not covered.
29. For sex transformation surgery and related services, or the reversal thereof;
30. For marital counseling;
31. For prescription, fitting, or purchase of eyeglasses or contact lenses except as otherwise specifically stated as a Covered Service. 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;
32. For hearing examinations, hearing aids or examinations for prescribing or fitting them;
33. For services or supplies primarily for educational, vocational, or training purposes, except as otherwise specified herein;
34. For reversal of sterilization;
35. 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;
36. Any new FDA Approved Drug Product or Technology (including but not limited to medications, medical supplies, or devices) available in the marketplace for dispensing by the appropriate source for the product or technology, including but not limited to Pharmacies, for the first six months after the product or technology received FDA New Drug Approval or other applicable FDA approval. The Plan may at its sole discretion, waive this exclusion in whole or in part for a specific New FDA Approved Drug Product or Technology;
37. For personal hygiene, environmental control, or convenience items including but not limited to: air conditioners, humidifiers, physical fitness equipment; personal comfort and convenience items during an Inpatient stay, including but not limited to daily television rental, telephone services, cots or visitor’s meals; charges for failure to keep a scheduled visit; for non-medical self-care except as otherwise stated; purchase of rental of supplies for common household use, such as exercise cycles, air purifiers, central or unit air conditioners, water purifiers, allergenic pillows or mattresses or waterbeds, treadmill or special exercise testing or equipment solely to evaluate exercise competency or assist in an exercise program; for a health spa or similar facility;
38. For telephone consultations or consultations via electronic mail or internet/web site, except as required by law, or authorized by Anthem;
39. For care received in an emergency room which is not Emergency Care, except as specified in this Contract;
40. For expenses incurred at a health spa or similar facility;
41. For self-help training and other forms of non-medical self care, except as otherwise provided herein;
42. For examinations relating to research screenings;
43. For stand-by charges of a Physician;
44. Physical exams and immunizations required for enrollment in any insurance program, as a condition of employment, for licensing, or for other purposes;
45. For eye surgery to correct errors of refraction, such as near-sightedness, including with limitation, radial keratotomy or keratomileusis or excimer laser photo refractive keratectomy;
46. For routine eye exams and eyeglasses;
47. Related to artificial and/or mechanical hearts or ventricular and/or atrial assist devices related to a heart condition or for subsequent services and supplies for a heart condition as long as any of the above devices remain in place. This Exclusion includes services for implantation, removal and complications. This Exclusion does not apply for left ventricular assist devices (LVAD) when used as a bridge to a heart transplant;
48. For Private Duty Nursing Services rendered in a Hospital or Skilled Nursing Facility.
49. For Private Duty Nursing Services except when provided through the Home Care Services benefit.
50. 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 procedures and equipment developed for or used in the treatment of impotency, and all related diagnostic testing.
51. For services, supplies and other care provided for elective abortions accomplished by any means, as defined by applicable law;
52. For (services or supplies related to) alternative or complementary medicine. Services in this category include, but are not limited to, acupuncture, holistic medicine, homeopathy, hypnosis, aroma therapy, massage therapy, reike therapy, herbal, vitamin or dietary products or therapies, naturopathy, thermograph, orthomolecular therapy, contact reflex analysis, bioenergial synchronization technique (BEST) and iridology-study of the iris;
53. For contraceptive devices except as specifically stated within this Contract.
54. Reconstruction services except as specifically stated in the Covered Services section of this Contract, or as required by law;
55. Sclerotherapy for the treatment of varicose veins of the lower extremities including ultrasonic guidance for needle and/or catheter placement and subsequent sequential ultrasound studies to assess the results of ongoing treatment of varicose veins of the lower extremities with sclerotherapy;
56. Treatment of telangiectatic dermal veins (spider veins) by any method;
57. For Drugs, devices, products, or supplies with over the counter equivalents;
58. Complications directly related to a service or treatment that is a non Covered Service under this Contract because it was determined by Us to be Experimental/Investigational or non Medically Necessary. Directly related means that the service or treatment occurred as a direct result of the Experimental/Investigational or non Medically Necessary service and would not have taken place in the absence of the Experimental/Investigational or non Medically Necessary service.
59. For care received in an emergency room which is not Emergency Care, except as specified in this Contract. This includes, but is not limited to suture removal in an emergency room.
60. For maternity services, except We will cover Complications of Pregnancy as stated.
61. Drugs in quantities which exceed the limits established by the Plan.

Non-Covered Prescription Benefits

• Fertility drugs;
• Drugs for treatment of sexual or erectile dysfunctions or inadequacies, regardless of origin or cause;
• Drugs, devices and products, or Prescription Legend Drugs with over the counter equivalents and any drugs, devices or products that are therapeutically comparable to an over the counter drug, device or product;
• Off label use, except as otherwise prohibited by law or as approved by Us or APM;
• Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order;
• Charges for the administration of any drug;
• Drugs consumed at the time and place where dispensed or where the Prescription Order is issued, including but not limited to samples provided by a Physician. This does not apply to drugs used in conjunction with a Diagnostic Service, with Chemotherapy performed in the office; or drugs eligible for coverage under the Medical Supplies benefit; they are Covered Services;
• Any drug which is primarily for weight loss;
• Drugs not requiring a prescription by federal law (including drugs requiring a prescription by state law, but not by federal law), except for injectable insulin;
• Drugs in quantities which exceed the limits established by the Plan, or which exceed any age limits established by Us;
• Any drug which is primarily for cosmetic purposes (including, but not limited to, preserving, changing or improving your appearance, such as changing the appearance or texture of your skin);
• Any new FDA Approved Drug Product or Technology (including but not limited to medications, medical supplies, or devices) available in the marketplace for dispensing by the appropriate source for the product or technology, including but not limited to Pharmacies, for the first six months after the product or technology received FDA New Drug Approval or other applicable FDA approval. The Plan may at its sole discretion, waive this exclusion in whole or in part for a specific New FDA Approved Drug Product or Technology;
• Contraceptive devices are payable as medical supplies based on where the service is performed or the item is obtained. If such items are over the counter drugs, devices or products, they are not Covered Services;
• Oral immunizations, and biologicals, although they are federal legend drugs, are payable as medical supplies based on where the service is performed or the item is obtained;
• Human growth hormones.