General Policy Exclusions

The following are not covered:

  • Services not approved by a Kaiser Permanente physician (except for qualifying emergency and urgent care services)
  • Conditions covered by workers’ compensation or that are the employer’s responsibility
  • Financial responsibility for services and supplies that an employer is required by law to provide
  • Conditions that a government agency, except Medicaid, is required by law to provide
  • Dental services
  • Experimental or investigational services
  • Acupuncture
  • Designated blood donations including procurement and storage of cord blood, unless exception criteria is met
  • Sexual reassignment surgery
  • Routine foot-care services
  • Physical exams and mental health services or testing required to participate in employee programs, to obtain or maintain employment, insurance, or governmental licensing or on a court order or required for parole or probation
  • Cognitive rehabilitation programs
  • Long-term rehabilitation, long-term physical occupational therapy, long-term speech and language services
  • Drugs for infertility diagnosis and treatment
  • Outpatient supplies
  • Services to induce pregnancy, such as in-vitro fertilization, ovum transplants, and gamete and zygote intrafallopian transfers (artificial insemination is, however, a covered service)
  • Cost of donor semen and donor eggs
  • Reversal of voluntary, surgically induced infertility
  • Transplant services, except prescribed heart, lung, heart-lung, liver, cornea, bone marrow, stem cell, pancreas, pancreas after kidney, small bowel, small bowel-liver, kidney, and simultaneous kidney-pancreas transplants
  • Nonhuman and artificial organs and their implantation
  • Educational or clinical programs for weight control and food supplements
  • Vision therapy (orthoptics or eye exercises)
  • Internally implanted insulin pumps, artificial hearts, and artificial larynx
  • Custodial care or care in an intermediate care facility
  • Cosmetic services and supplies
  • Radial keratotomy, photorefractive keratectomy, and refractive surgery including evaluations for the procedures
  • Hearing aids
  • Eyeglasses and contact lenses
  • Low-vision aids
  • Durable medical equipment, corrective appliances, and artificial aids
  • Hypnotherapy and related services
  • Drugs used in the treatment of sexual dysfunction
  • Drugs not approved by the FDA, unless the Health Resources Commission finds that the drug is recognized in independent medical or pharmaceutical journals as effective for that use
  • Drugs that are necessary or related to an excluded service
  • Any packaging other than the dispensing pharmacy’s standard packaging
  • Drugs used for surgery related to weight management
  • Over-the-counter drugs
  • Prescriptions extemporaneously compounded
  • Genetic testing
  • Services provided or arranged by criminal justice institutions for members confined therein, unless care would be covered as an emergency service
  • Mental health services for mental retardation, after diagnosis
  • Mental health services for the following conditions if the treating physician determines the condition is not responsive to therapeutic management: chronic psychosis, care for inorganic psychosis and intractable personality disorders
  • Services and treatment provided for obesity or weight control, including bariatric or gastric bypass surgery
  • Medical services for temporomandibular joint disorders
  • Mental health services on court order or as a condition of parole or probation; unless determined by Medical Group to be Medically Necessary and appropriate
  • Psychological testing on court order, or testing for ability, aptitude, intelligence or interest
  • Mental health treatment in a residential or day treatment facility
  • The following chemical dependency services are excluded: care in a treatment facility not approved or arranged by a Medical Group Physician; continuation in a course of counseling for patients who are disruptive or physically abusive; methadone maintenance, except when prescribed by a Medical Group Physician
  • Drugs not included in the drug formulary, unless a nonformulary drug is medically necessary and has been specifically prescribed and authorized through the nonformulary process
  • Non-preferred generic and therapeutic equivalents as determined by the Regional Formulary and Therapeutics Committee
  • Replacement of drugs and accessories due to loss, damage and/or carelessness
  • High-cost drugs and drugs that require special handling such as refrigeration, professional administration, or professional observation, cannot be provided through mail order.

General Limitations:

  • Members must be enrolled continuously for 24 months before these transplants are covered:  cornea, lung, heart-lung, liver (for alcoholic cirrhosis), bone marrow (for certain conditions), pancreas, pancreas after kidney, simultaneous kidney-pancreas, small bowel, small bowel-liver, or stem cell. Members will be given credit for prior coverage if the transplant was covered under the prior creditable coverage.