Services Not Covered

Under Network Blue New England, no benefits are provided for:

  • Ambulance services unless necessitated by an emergency or medical necessity or authorized in advance by the plan for transfer from one facility to another
  • Any claim submitted more than one year from the date the service was rendered
  • Blood and blood products
  • Care for military service-connected disabilities for which the member is legally entitled to treatment or services
  • Charges in excess of the plan maximum amount or other limit
  • Commercial diet plans or weight loss programs
  • Cosmetic procedures, except when medically necessary
  • Cost for any services for which the member is entitled to treatment at government expense or under Workers’ Compensation or occupational disability laws
  • Court-ordered examinations and services (unless deemed medically necessary by the plan)
  • Custodial or domiciling care to assist a member in the activities of daily living or provide room and board, training in personal hygiene, and other forms of self-care; personal care in the home except when medically necessary as part of a treatment plan for a medical condition
  • Dental services, including periodontal, restorative, orthodontic services, and dentures
  • Educational services (including problems of school performance) or testing for developmental, educational, or behavioral problems except as medically necessary under an early intervention program
  • Equipment for environmental control or general household use, such as air filters, air conditioners, air purifiers, liquidizers, bath seats, bed pans, dehumidifiers, elevators, heating pads, hot water bottles, and humidifiers
  • Eyeglasses, contact lenses, and fittings. This exclusion does not apply to eyeglasses and contact lenses that are required due to cataract surgery, covered corneal transplants, and keratoconus
  • Hearing aids
  • Infertility services for members who are not medically infertile
  • Missed appointments
  • Non-prescription smoking cessation aids
  • Non-covered services even if precertification was mistakenly given
  • Non-durable medical equipment, unless used as part of the treatment at a medical facility or as part of approved home health care services
  • Orthotics
  • Osteopathic manipulation, electrolysis, routine foot care, biofeedback, pain management programs, massage therapy, and acupuncture
  • Personal comfort or convenience items for rest or custodial care
  • Physical examinations for insurance, licensing, or employment
  • Private duty nursing
  • Private room unless medically necessary
  • Refractive eye surgery
  • Reversal or attempted reversal of voluntary sterilization (including procedures necessary for conception following voluntary sterilization)
  • Sensory integrative praxis test; testing for central auditory processing
  • Services incurred prior to the effective date of coverage
  • Services incurred after termination of coverage under the plan
  • Services for any person who is not covered under the plan when the services are rendered
  • Services for which no charges would have been made in the absence of coverage under this plan
  • Services or supplies from anyone related to you by blood, marriage, or adoption, or who ordinarily lives with you
  • Services not within the scope of the physician’s, provider’s, or hospital’s licensure
  • Services that require precertification, where the precertification was not obtained or the precertification guidance was not followed
  • Services that are not medically necessary
  • Services that are considered experimental
  • Services that are considered obsolete and no longer medically justified
  • Services at a residential treatment center
  • Surrogate pregnancy (any form of surrogacy)
  • Non-dental medical care services only to diagnose and treat temporomandibular joint dysfunction
  • The part of the charge for a service or supply in excess of the usual, customary, and reasonable (UCR) charge
  • Transsexual surgery, including related procedures and treatments and reversal of such procedures
  • Weight loss programs or charges for weight reduction except when extreme obesity adversely affects another medical condition and treatment is medically necessary as determined by the Plan

For a comprehensive list of services and conditions not covered by Network Blue New England, please refer to the description for Network Blue New England available from the Benefits Section of Human Resources.