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Coverage Exclusions
Following is an outline of the limitations and exclusions for the Humana One Individual Health Plan. This outline is intended for convenient reference. Consult the policy for a complete list of limitations and exclusions.
Unless stated otherwise no benefits are payable for expenses arising from:
- Services not medically necessary or which are experimental, investigational or for research purposes.
- Services not authorized or prescribed by a health care practitioner or for which no charge is made.
- Services while confined in a hospital or other facility owned or operated by the United States government, provided by a person who ordinarily resides in the covered person’s home or who is a family member, or that are performed in association with a service that is not covered under the policy.
- Charges in excess of the maximum allowable fee or which exceed any policy benefit maximum.
- Expenses incurred before the effective date or after the date coverage terminated.
- Cosmetic procedures and any related complications except as stated in the policy.
- Custodial or maintenance care. Any drug, medicine or device which is not FDA approved.
- Contraceptives other than oral, including implant systems and devices regardless of the purpose for which prescribed.
- Medications, drugs or hormones to stimulate growth.
- Legend drugs not recommended or deemed necessary by a health care practitioner or drugs prescribed for a non-covered injury or sickness
- Drugs prescribed for intended use other than for indications approved by the FDA or recognized off-label indications through peer-reviewed medical literature, experimental or investigational use drugs.
- Over the counter drugs (except insulin) or drugs available in prescription strength without a prescription.
- Drugs used in treatment of nail fungus.
- Prescription refills exceeding the number specified by the health care practitioner or dispensed more than one year from the date of the original order.
- Vitamins, dietary products and any other nonprescription supplements.
- Infertility services.
- Pregnancy and well-baby expenses.
- Elective medical or surgical procedures; abortion; gender change or sexual dysfunction.
- Vision therapy; all types of refractive keratoplasties or any other procedures, treatments or devices for refractive correction; eyeglasses; contact lenses; hearing aids; dental exams.
- Hearing and eye exams; routine physical examinations for occupation, employment, school, travel, purchase of insurance or premarital tests.
- Services received in an emergency room unless required because of emergency care.
- Dental services (except for dental injury), appliances or supplies.
- War or any act of war, whether declared or not; commission or attempt to commit a civil or criminal battery or felony.
- Standby physician or assistant surgeon, unless medically necessary; private duty nursing; communication or travel time; lodging or transportation, except as stated in the policy.
- Obesity except for morbid obesity.
- Nicotine habit or addiction; educational or vocation therapy, services and schools; light treatment for Seasonal Affective Disorder (S.A.D.); alternative medicine; marital counseling; genetic testing, counseling or services; sleep therapy or services rendered in a premenstrual syndrome clinic or holistic medicine clinic.
- Foot care services.
- Charges for non-medical purposes or used for environmental control or enhancement (whether or not prescribed by a health care practitioner).
- Health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; personal computers and related or similar equipment; communication devices other than due to surgical removal of the larynx or permanent lack of function of the larynx.
- Hair prosthesis, hair transplants or implants and wigs.
- Temporomandibular joint disorder, craniomaxillary disorder, craniomandibular disorders, and any treatment for jaw, joint or head and neck neuromuscular disorder.
- Injury or sickness arising out of or in the course of any occupation, employment or activity for compensation, profit or gain, whether or not benefits are available under Workers’ Compensation. This exclusion does not apply to a covered person qualifying as a sole proprietor, officer or partner under state law, and such benefits are not covered under any Workers’ Compensation plan, provided the covered person is not covered under a Workers’ Compensation plan, except for certain professions or activities as outlined in the policy.
- Inpatient services when in an observation status or when the stay is due to behavioral, social maladjustment, lack of discipline or other antisocial actions not a result of a mental disorder.
- Attempted suicide or intentionally self-inflicted injury, whether sane or insane.
- Charges covered by other medical payments insurance.
- Organ transplants not approved based on established criteria or investigational, experimental or for research purposes.
- Charges incurred for a hospital stay beginning on a Friday or Saturday unless due to emergency care or surgery is performed on the day admitted
Indiana Only
- Contraceptives other than oral, including implant systems and services regardless of the purpose for which prescribed.