Expenses Not Covered
The following medical expenses are not covered under the Plan.
  • Health services and supplies that do not meet the definition of a covered health service. (See "Medical Plan Definitions.") Covered health services are those health services including services, supplies or pharmaceutical products, which UnitedHealthcare determines to be all of the following:
  • Health services related to a non-covered health service: When a service is not a covered health service, all services related to that non-covered health service are also excluded. This exclusion does not apply to services the Plan would otherwise determine to be covered health services if they are to treat complications that arise from the non-covered health service.
For the purpose of this exclusion, a "complication" is an unexpected or unanticipated condition that is superimposed on an existing disease and that affects or modifies the prognosis of the original disease or condition. Examples of a "complication" are bleeding or infections, following a cosmetic procedure, that require hospitalization.
  • Health services provided in a foreign country, unless required as emergency health services.
  • Services and supplies that are not necessary for the diagnosis, care or treatment of the disease or injury involved.
  • Experimental or investigational services or unproven services, unless the Plan has agreed to cover them as defined in "Medical Plan Definitions." This exclusion applies even if experimental or investigational services or unproven services, treatments, devices or pharmacological regimens are the only available treatment options for your condition.
  • Items and services provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient.
  • A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.
  • Items and services provided by the research sponsors free of charge for any covered member enrolled in the trial.
  • Services or supplies that are experimental, investigational or unproven (However, this exclusion will not apply to services or supplies [other than drugs] received in connection with a disease if UnitedHealthcare determines that the disease is expected to cause death within one year in the absence of effective treatment, and the service or supply is effective or shows promise of being effective for that disease. This exclusion will not apply to drugs that have been designated as an investigational new drug or are being studied at the Phase III level in a national clinical trial by the National Cancer Institute, if UnitedHealthcare determines that the drug is effective or shows promise of being effective for the disease.) If you are not a participant in a qualifying clinical trial and have a sickness or condition that is likely to cause death within one year of the request for the treatment, UnitedHealthcare may at its discretion, consider an otherwise experimental or investigational service to be a covered health service for that sickness or condition. Prior to such consideration, UnitedHealthcare must determine that, although unproven, the service has significant potential as an effective treatment for that sickness or condition.
  • Services, treatment, educational testing or training related to learning disabilities or developmental delays except for speech therapy services.
  • Care furnished mainly to provide a surrounding free from exposure that can worsen the member's disease or injury
  • Treatment of covered healthcare providers who specialize in the mental healthcare field and who receive treatment as part of their training in that field
  • Services of a resident physician or intern rendered in that capacity
  • Expenses above the eligible expense fee limits set by UnitedHealthcare
  • Hospital or other facility expenses for custodial care
  • Services and supplies furnished, paid for or for which benefits are provided or required because of a person's past or present service in the armed forces
  • Services and supplies furnished, paid for or for which benefits are provided or required under any law of a government (This does not include a plan established by a government for its own employees or their dependents, or Medicaid.)
  • Charges for eye refractions or vision examinations
  • Charges for eyeglasses or contact lenses to correct refractive errors
  • Eye surgery to eliminate refractive errors (such as radial keratotomy or LASIK)
  • Services or supplies for education, special education or job training, whether or not given in a facility that also provides medical or psychiatric treatment
  • Charges for plastic surgery, reconstructive surgery, cosmetic surgery, liposuction or other services and supplies which improve, alter or enhance appearance, whether or not for psychological or emotional reasons. This exclusion will NOT apply if the service or supply is needed:
    • To improve the function of a body part (other than a tooth) that is malformed as a result of a severe birth defect or as a direct result of disease or surgery performed to treat a disease or injury
    • To repair an injury as long as surgery is performed in the calendar year of the accident which causes the injury or in the next calendar year
    • For breast reduction surgery in which UHC determines is requested to treat a physiologic functional impairment or for coverage required by the Women's Health and Cancer Rights Act of 1998
    • For medically necessary treatments for gender dysphoria
  • Charges for therapy, supplies or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis
  • Charges for cosmetic procedures for gender dysphoria including:
    • Abdominoplasty
    • Blepharoplasty
    • Breast enlargement, including augmentation mammoplasty and breast implants
    • Body contouring, such as lipoplasty
    • Brow lift
    • Calf implants
    • Cheek, chin, and nose implants
    • Injection of fillers or neurotoxins
    • Face lift, forehead lift, or neck tightening
    • Facial bone remodeling for facial feminizations
    • Hair removal
    • Hair transplantation
    • Lip augmentation
    • Lip reduction
    • Liposuction
    • Mastopexy
    • Pectoral implants for chest masculinization
    • Rhinoplasty
    • Skin resurfacing
    • Thyroid cartilage reduction; reduction thyroid chondroplasty; trachea shave (removal or reduction of the Adam's Apple)
    • Voice modification surgery, including voice lessons and voice therapy.
  • The following fertility treatment-related services:
    • Cryopreservation and other forms of preservation of reproductive materials except as described under Fertility.
    • Long-term storage (greater than one year) of reproductive materials such as sperm, eggs, embryos, ovarian tissue and testicular tissue .
    • Donor services and non-medical costs of oocyte or sperm donation such as donor agency fees.
    • Embryo or oocyte accumulation defined as a fresh oocyte retrieval prior to the depletion of previously banked frozen embryos or oocytes.
    • Ovulation predictor kits.
  • The following services related to gestational carrier or surrogate:
    • Fees for the use of a gestational carrier or surrogate.
    • Insemination costs of surrogate or transfer embryo to gestational carrier.
    • Pregnancy services for a gestational carrier or surrogate who is not a covered person.
  • Voluntary sterilization.
  • The reversal of voluntary sterilization.
  • Health care services and related expenses for surgical, non-surgical or drug-induced pregnancy termination. This exclusion does not apply to treatment of a molar pregnancy, ectopic pregnancy, or missed abortion (commonly known as a miscarriage).
  • Artificial reproductive treatments done for non-genetic disorder sex selection or eugenic (selective breeding) purposes.
  • Fertility treatment with voluntary sterilization currently in place (vasectomy, bilateral tubal ligation).
  • Fertility treatment following unsuccessful reversal of voluntary sterilization.
  • Fertility treatment following the reversal of voluntary sterilization (tubal reversal/reanastomosis; vasectomy reversal/vasovasostomy or vasoepididymostomy).
  • Nutritional counseling for the following: obesity/weight loss, conditions which have not been shown to be nutritionally related, including but not limited to chronic fatigue syndrome and hyperactivity.
  • Charges for food of any kind, infant formula, standard milk-based formula, and donor breast milk. This exclusion does not apply to enteral formula and other modified food products for which Benefits are provided as described under Enteral Nutrition
  • Charges for marriage, family, child, career, social adjustment, pastoral or financial counseling without a medical diagnosis
  • Charges for acupuncture, acupressure, aromatherapy, hypnotism, massage therapy, rolfing and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health
  • Services provided by a close relative or anyone who resides in the patient's home (Close relatives include the patient's spouse, and any child, sibling or parent of the employee or spouse.)
  • Travel and transportation costs associated with an organ transplant, as well as the expenses incurred by an organ donor whether or not the person is covered by the Plan, except as described under "Travel and Lodging Assistance Program."
  • Health services for transplants involving animal organs.
  • Charges for treatment of an injury or illness due to an act of war (declared or undeclared) or contracted while on duty with any military service for any country
  • Charges for treatment of obesity, unless the patient meets specific medical criteria as described under
  • Charges for Loop gastric bypass; Gastroplasty - "stomach stapling"; Duodenal switch operation; Biliopancreatic bypass; Lap-Band; Mini-gastric bypass.
  • Non-surgical treatment of obesity, including morbid obesity.
  • Surgical treatment of obesity unless there is a diagnosis of morbid obesity as described under "Obesity Surgery."
  • Charges for insulin syringes, lancets, insulin pen injectors and diabetic test strips (These expenses are covered under the prescription drug plan.)
  • Services provided for comfort or convenience such as televisions, telephones, air conditioners, air purifiers, humidifiers, dehumidifiers, beauty or barbershop services or home remodeling to accommodate a health need.
  • Prescribed or non-prescribed medical supplies. Examples of supplies that are not covered include, but are not limited to:
    • Compression stockings.
    • Ace bandages.
    • Gauze and dressings.
This exclusion does not apply to:
    • Diabetic supplies for which benefits are provided.
    • Ostomy supplies for which benefits are provided.
    • Urinary catheters for which benefits are provided.
  • Dental services. This exclusion will not apply to anesthesia and associated hospital and facility charges that are not covered under the dental plan and are provided when, in the opinion of the treating dentist, any of the following criteria apply:
    • The related procedure involves extracting six or more teeth in various quadrants
    • Use of local anesthesia is considered ineffective because of acute infection, anatomic variation, or allergy
    • The procedure involves multiple extractions or restorations for a child under age four
    • There is a concurrent hazardous medical condition
    • The procedure is intended to address extensive oral-facial and/or dental trauma and would be ineffective or compromised if performed using local anesthesia
The benefits described here are covered only for anesthesia and related hospital and facility charges that are not covered by the dental insurance carrier.
  • Prescription drugs and over-the-counter medications or supplies (These expenses may be covered under the prescription drug plan.)
  • Self-administered or self-infused medications. This exclusion does not apply to medications which, due to their characteristics, (as determined by UnitedHealthcare), must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an outpatient setting. This exclusion does not apply to hemophilia treatment centers contracted to dispense hemophilia factor medications directly to covered members for self-infusion.
  • Routine foot care
  • Orthotic appliances and devices, except when both of the following are met:
    • The appliance or device is prescribed by a physician for a medical purpose
    • It is custom manufactured or custom fitted to an individual covered member
Examples of excluded orthotic appliances and devices include but are not limited to cranial bands or any braces that can be obtained without a physician's order (This exclusion does not include diabetic footwear which may be covered for an individual with diabetic foot disease.)
  • Non-powered exoskeleton devices are excluded. Intracellular micronutrient testing is excluded.
  • Cranial molding helmets and cranial banding are excluded except when used to avoid the need for surgery, and/or to facilitate a successful surgical outcome.
  • Health services for organ and tissue transplants except as identified under "Organ Transplant Benefits", unless UnitedHealthcare determines the transplant to be appropriate according to UnitedHealthcare's transplant guidelines
  • Growth hormone therapy
  • Domiciliary care
  • Liposuction
  • Custodial care
  • Respite care
  • Rest cures
  • Psychosurgery
  • Wigs
  • Treatment of benign gynecomastia (abnormal breast enlargement in males)
  • Medical and surgical treatment for snoring, except when provided as part of treatment for documented obstructive sleep apnea
  • Appliances for snoring
  • Personal trainer
  • Naturalist
  • Holistic or homeopathic care
  • Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments that are otherwise covered when:
    • Required solely for purposes of career, education, sports or camp, travel employment insurance, marriage or adoption (This exclusion does not include vaccines that are required by Stryker. If these vaccinations are required by your position the vaccinations are covered at 100%.)
    • Related to judicial or administrative proceedings or orders
    • Conducted for purposes of medical research
    • Required to obtain or maintain a license of any type (This exclusion does not include vaccines that are required by Stryker. If these vaccinations are required by your position the vaccinations are covered at 100%.)
  • Health services received after the date your coverage under the Plan ends, including health services for medical conditions arising before the date your coverage under the Plan ends
  • In the event that a provider waives copayments, coinsurance and/or the annual deductible for a particular health service (No benefits are provided for the health service for which the copayments, coinsurance and/or annual deductible are waived.)
  • Charges in excess of any specified limitation
  • Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), if the services are considered to be dental in nature, including oral appliances
  • Any charges for missed appointments, room or facility reservations, completion of claim forms or record processing
  • Any charges higher than the actual charge (The actual charge is defined as the provider's lowest routine charge for the service, supply or equipment.)
  • Any charge for services, supplies or equipment advertised by the provider as free
  • Any charges by a provider sanctioned under a federal program for reason of fraud, abuse or medical competency
  • Any charges prohibited by federal anti-kickback or self-referral statutes
  • Outpatient rehabilitation services, spinal treatment or supplies including, but not limited to, spinal manipulations by a chiropractor or other doctor, for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or reoccurring
  • Spinal treatment, including chiropractic and osteopathic manipulative treatment, to treat an illness such as asthma or allergies
  • Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from an injury, stroke, congenital anomaly or developmental delay
  • Devices and computers to assist in communication and speech except for dedicated speech generating devices and tracheo-esophageal voice devices for which benefits are provided
  • Habilitative services for maintenance/preventive treatment
  • Any expenses you incur pursuing a claims appeal that you file.
  • Certain new pharmaceutical products and/or new dosage forms until the date as determined by UnitedHealthcare or their designee, but no later than December 31st of the following calendar year.
This exclusion does not apply if you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment). If you have a life-threatening sickness or condition, under such circumstances, benefits may be available for the new pharmaceutical product to the extent provided under the Plan.