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-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
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 Human Resources.