Any service not Medically Necessary for the diagnosis, treatment or prevention of injury or illness, even if it is not specifically listed as an exclusion (except for specific services offered through the Preventive Care Medical Benefit); services requiring Prior Authorization for which Prior Authorization is not obtained; care in a setting when another setting of care is more cost-effective or appropriate for the treatment; services in excess of the maximum number of units or days specified in the Policy; services, devices or medications prescribed by or performed by a practitioner without appropriate licensure or training; services that are experimental, investigational, or unproven; charges for failure to keep a scheduled visit, for the copying of medical records or for the completion of a Claim or administrative forms; services or supplies primarily for personal convenience or comfort, including but not limited to phones, televisions, guest services, deluxe or suite hospital room, air conditioners, diapers or hygiene items; private duty nursing; respite care, except as expressly covered by the Policy; and transportation, except ambulance services to the nearest appropriate facility, if medically necessary and other forms of transportation would likely endanger your health (emergent air ambulance services are reviewed retrospectively).

Amounts for services provided by In-Network Providers in excess of the Allowed Amount, although In-Network Providers are not permitted to bill the Member for the amount in excess of the Allowed Amount. For Out-of-Network Providers, unless provided for otherwise under the No Surprises Act, amounts charged in excess of the Usual, Customary and Reasonable (UCR) rate are not covered and the Member may be billed by the Provider for the amount in excess of UCR.

Services received before your effective date of coverage or after the coverage termination date; services related to complications arising from non-covered services, including those services that would not have been covered by the St. Luke’s Health Plan at the time the complication arose; services received outside the United States, except for services that qualify as Emergency Services or Urgent Care, in which case the Member may qualify to be repaid only under specific circumstances; services resulting from participation in declared or undeclared acts of terrorism, war, military service, participation in a riot or civil disobedience; services that are the result of any injury or illness incurred by you while you are participating in the commission of a felony, unless the injury or illness is the result of domestic violence or a physical or mental health condition; services related to injuries incurred while under the influence of a controlled substance and/or alcohol; and autopsies.

Amounts for which the covered person has no obligation to pay, including (but not limited to) any charges by a facility owned or operated by the United States or any state or local government unless you are legally obligated to pay (excluding: (i) covered expenses rendered by a medical facility owned or operated by the United States Veteran’s Administration when the services are provided to you for a non-service related illness or injury, and (ii) covered expenses rendered by a United States military medical facility to you and you are not on active military duty); services for which you receive compensation or reimbursement through another contractual arrangement or Medical Benefit, other than employer-based disability payments, such as (but not limited to) surrogate pregnancy; services for any condition, illness or injury that arises from or during the course of work for wages or profit that is covered by state insurance workers’ compensation and federal act or similar law; services or supplies payable under a contract or insurance for uninsured or underinsured (UIM) coverage, motor vehicle, motor vehicle no-fault, or personal injury protection (PIP) coverage, commercial premises or homeowner’s medical premise coverage or other similar type of contract or insurance; services or supplies received without charge from a medical department maintained by an employer, a mutual benefit association, labor union, trustee or similar group; treatment furnished without charge or paid directly or indirectly by any government or for which a government prohibits payment of benefits; services provided by a Family Member (spouse, parent or child); services provided by clergy; and services provided in a school setting (such as early learning and K-12).

Physical examinations, reports or related services or supplies for the purpose of obtaining or maintaining employment, insurance, or licenses or permits of any kind, school admission, school sports clearances, immigration, foreign travel, medical research, camps, or government licensure, or other reasons not related to medical needs; and court ordered examinations or treatment of any kind, except when Medically Necessary.

Care provided by phone, fax, e-mail, Internet or Telemedicine, except as expressly covered under the Policy; follow-up phone calls from Provider for test results, referrals, prescription refills or reminders that occur within seven (7) days of an in-person office visit; and calls to nurse line or to obtain educational material.

Dental, oral surgery or orthodontic related services (unless accident-related or otherwise specifically covered by St. Luke’s Health Plan); care of the teeth or dental structures; tooth damage due to biting or chewing; dental X-rays; extractions of teeth, impacted or otherwise (except as covered under St. Luke’s Health Plan); orthodontia treatment, appliances, or services; procedures in preparation for dental implants, except as covered under the Dental Trauma Medical Benefits; services to correct malposition of teeth; treatments for Temporomandibular Joint Dysfunction (TMJ); or dentures or related services.

Biofeedback equipment; equipment or supplies whose primary purpose is preventing illness or injury; exercise equipment; items not manufactured exclusively for the direct therapeutic treatment of an illness or injured patient; items used outside the home primarily for sports/recreational activities; oral appliances, except to treat obstructive sleep apnea; over-the-counter items (except Medically Necessary crutches, walkers, standard wheelchairs, diabetic supplies and ostomy supplies are covered); personal comfort items including but not limited to air conditioners, lumbar rolls, heating pads, diapers or personal hygiene items; phototherapy devices related to seasonal affective disorder; supportive equipment/environmental adaptive items including, but not limited to, handrails, chair lifts, ramps, shower chairs, commodes, car lifts, elevators, and modifications made to the patient’s home, place of work, or vehicle; standard car seats or strollers; push chairs; air filtration/purifier systems or supplies; water purifiers; allergenic mattresses; orthopedic or other special chairs; pillows; bed-wetting training equipment; corrective shoes; whirlpool baths; vaporizers; room humidifiers; hot tubs or other types of tubs; home UV or other light units (light boxes or specialized lamps or bulbs); home blood testing equipment and supplies (except diabetic equipment and supplies, and home anticoagulation meters); and repair or replacement of items not used in accordance with manufacturer’s instructions or recommendations or items lost or stolen.

Maternity care and services: The $0 copay for maternity care applies to all professional (physician) charges for both routine office visits and delivery. This also includes routine postpartum office visits. Maternity and newborn-related facility charges are not covered by the $0 copay.

If you purchase St. Luke’s Health Plan on the Your Health Idaho exchange:

If you purchase St. Luke’s Health Plan off exchange:

When provided through home health benefits, custodial care; housekeeping or meal services; maintenance care; and shift or hourly care services; when provided through hospice care, custodial care or maintenance care, except palliative care to the terminally ill patient subject to the stated limits; financial or legal counseling services; housekeeping or meal services; services by you or your family or volunteers; services not specifically listed as covered hospice services under St. Luke’s Health Plan; supportive equipment such as handrails or ramps; room and board while you reside in a skilled nursing facility, adult family home, or assisted living facility; and transportation.

Behavioral health: The $0 copay for behavioral health applies to all professional (physician) charges for both outpatient and inpatient mental health care services. Facility charges for mental health services are not covered by the $0 copay.

Family counseling: Marriage and couples counseling; family therapy, in the absence of an approved mental health diagnosis; nontraditional, alternative therapies that are not based on American Psychiatric and American Psychological Association acceptable techniques and theories; sensitivity training; and treatment for sexual dysfunctions and paraphilic disorders.

Substance disorders: Alcoholics Anonymous or other similar Chemical Dependency programs or support groups; care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior; court-ordered or other assessments to determine the medical necessity of court-ordered treatments; court-ordered treatments or treatments related to deferral of prosecution, deferral of sentencing or suspended sentencing or treatments ordered as a condition of retaining driving rights, when no medical necessity exists; custodial care, including housing that is not integral to a Medically Necessary level of care, such as care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior or to achieve family respite; emergency patrol services; housing for individuals in a Partial Hospital Program or Intensive Outpatient Program; information or referral services; information schools; long-term or custodial care; nonsubstance related disorders; therapeutic group homes, residential community homes, therapeutic schools, adventure-based and/or wilderness programs or other similar programs; and treatment without ongoing concurrent review to ensure that treatment is being provided in the least restrictive setting required.

Learning disabilities: Learning disabilities and related services, educational testing or associated training; special education for the developmentally disabled; day habilitation services designed to provide training, structured activities and specialized assistance to adults, chore services to assist with basic needs, vocational and custodial services; vocational rehabilitation, work hardening or training programs regardless of diagnosis or symptoms that may be present, or for non-Medically Necessary education.

Provider support: Providers accompanying children or family members to health care appointments that are not part of the direct provision of Applied Behavior Analysis (ABA) services; ABA services by more than one program manager for each child/family (program development, treatment planning, supervision); training of therapy assistants and family members (as distinct from supervision); parent/provider training or classes, except for one-on-one or one-on-two direct training of the parents of one identified patient; and services provided in a home school, or public/private school environment that are part of a child’s schooling as distinct from specific ABA treatment services (e.g., acting as the “Teacher’s Aide,” or helping a child with homework).

Any medication not included in the St. Luke’s Health Plan formulary; any over-the-counter products, except as expressly covered by the Policy; anorectics (any drug used for the purpose of weight loss); any prescription refilled in excess of the number specified by the physician, or any refill dispensed after one year from the physician’s original order; diagnostic tests; medications labeled “Caution: Limited by federal law to investigational use” or that are otherwise Experimental or Investigational; medications used for cosmetic purposes, including but not limited to medications such as Botox, Minoxidil (Rogaine), Tretinoin (Retin A, covered through age 25); FDA Approved High Dollar Non-Essential Medications (new drug formulations and derivatives of similar agents already marketed, or combinations of agents that provide no additional clinical benefit to the currently available medications); high dollar kits and non-FDA approved patches; fluoride, except as required under the Patient Protection and Affordable Care Act; immunological agents, biological sera, blood or blood plasma; impotency medications, including but not limited to Viagra; infertility medications; medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed medical facility, rest home, sanitarium, extended care facility, convalescent medical facility, nursing home, or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals; non-legend medications other than insulin and certain over-the-counter medications required under the Patient Protection and Affordable Care Act or as otherwise determined to be Medically Necessary; non-systemic contraceptives and implants, such as diaphragms, IUDs, cervical caps which would be covered through the Medical Benefits; or condoms which are over the counter; nutritional supplements; prescriptions which an eligible individual is entitled to receive without charge from any Workers’ Compensation laws; therapeutic devices or appliances, including support garments and other non-medical substances, regardless of intended use, except those listed above; and vitamins, singly or in combination, except prenatal and federal legend vitamins to treat covered medical conditions, or as required by the Patient Protection and Affordable Care Act (PPACA); certain narcotic analgesics or other addictive or potentially addictive medications that St. Luke’s Health Plan determines not to cover; medications prescribed in quantities, dosages, or usages that are outside the usual standard of care for the medication in question or for the practitioner prescribing the drug; serum for allergies not administered in a Provider’s office; prescriptions dispensed in a Provider’s office unless expressly approved by St. Luke’s Health Plan; compounded medications; botanical or herbal medicines; FDA-approved medications, medications or other items for non- approved indications, except when an FDA-approved drug has been proven clinically effective to treat such indication and is supported in peer-reviewed scientific medical literature; and vitamin B-12 injections except to treat Vitamin B-12 deficiency.

Services, supplies or surgery to repair, modify or reshape a functioning body structure for improvement of the patient’s appearance or self-esteem (except for gender affirming surgery), including reduction of adipose tissue, abdominoplasty/panniculectomy and liposuction; dermabrasion, chemical peels or skin procedures to improve appearance or to remove scars or tattoos; athletic training, bodybuilding, fitness training or related expenses; gym memberships (unless expressly set forth in the Policy); prescription or non-prescription diets, nutritional and/or food supplements, vitamins, minerals or other dietary formulas or supplements, including weight loss shakes, unless expressly covered by the Policy; exercise programs and equipment; complications resulting from bariatric surgery performed internationally; and complications arising from bariatric surgery performed at non-ASMBS centers; services provided by a spa, health club or fitness center, except covered Medically Necessary services provided within the scope of the Provider’s license; and routine foot care, except as covered by St. Luke’s Health Plan if you have peripheral vascular disease or diabetes.

Services that are considered cosmetic (including but not limited to) abdominoplasty, blepharoplasty, breast augmentation, calf implants, cheek/malar implants, chin augmentation (reshaping or enhancing the size of the chin), collagen injections, cryothyroid approximations (voice modification surgery), electrolysis (hair removal), face-lift, facial bone reduction, forehead lift, hair transplantation, laryngoplasty (reshaping of laryngeal framework/voice modification surgery), lip reductions/enhancement (decreasing/increase lip size), liposuction, mastopexy (breast lift), neck tightening, pectoral implants, reduction thyroid chondroplasty (trachea shave), and rhinoplasty.

Animal-to-human transplants; artificial or mechanical devices designed to permanently replace human organs; complications arising from the donation procedure if the donor is not a Plan Member; donor expenses for you if you donate an organ or bone marrow, however, complications arising from the donation would be covered as any other illness to the extent they are not covered under the recipient’s health plan; and transplants considered experimental and investigational.

Investigational items, services, tests, or devices that are the object of the clinical trial; interventions, services, tests, or devices provided by the trial sponsor without charge; data collection or record keeping costs that would not be required absent the clinical trial; any activity or service (e.g., imaging, lab tests, biopsies) necessary only to satisfy the data collection needs of the trial; services or interventions clearly not consistent with widely accepted and established standards of care; and interventions associated with treatment for conditions not covered by St. Luke’s Health Plan.

Non-prescription sunglasses or safety glasses; radial keratotomy, Lasik or any other refractive surgery; orthoptics; pleoptics; vision therapy; visual analysis therapy or training related to muscular imbalance of the eye; optometric therapy; services or supplies received principally for cosmetic purposes other than contact lenses selected in place of eyeglasses; adult vision care including routine eye exams and hardware; additional vision hardware services including, but not limited to, scratch resistant coating, tinting, and the like; and specialized intraocular lenses associated with cataract surgery that correct vision disorders, such as Multifocal and Toric intraocular lenses.

These exclusions were last updated October 1, 2022.