Asuris Northwest Health - Online Application

• Acupuncture for smoking cessation.
• Addiction to or abuse of drugs, alcohol, or any other chemical substance, whether legal or illegal, except for injuries sustained as a consequence of being intoxicated or under the influence of narcotics.
• Benefits covered by government programs.
• Charges for services or supplies that are above the allowed amount, except as required by law for emergencies.
• Charges that in the absence of the contract there would be no obligation to pay.
• Cosmetic surgery and supplies (including drugs) and the treatment of any direct or indirect complications of such surgery, except: 1) when related to an illness or injury; 2) for congenital anomalies; 3) for reconstructive breast surgery following mastectomies to the extent required under federal and state law as follows: a) reconstruction of the diseased breast; b) reconstruction of the nondiseased breast to produce a symmetrical appearance; and c) prostheses and physical complications of all stages of a mastectomy, including lymphedemas.
• Custodial care.
• Dentistry, dental x-rays, or hospitalization for dentistry.
• Dyslexia treatment.
• Hospitalization for conditions for which the member is not usually hospitalized, such as common colds, minor cuts or bruises, removal of small tumors and similar minor conditions.
• Injuries sustained while practicing for or competing in professional or semiprofessional athletics contest.
• Investigational services or supplies.
• In-vitro fertilization, artificial insemination, embryo transfer, or other artificial means of conception, including any expenses for fertility drugs.
• Marital counseling; family counseling, except for Mental Disorders.
• Maternity/complications of pregnancy (excluded on PPO Catastrophic, HSA-Qualified Preferred Catastrophic, Asuris HSA Healthplan, and Asuris ClaritySM 50 plans only).
• Neurodevelopmental therapy.
• Occupational injury or disease (excluded on PPO Comprehensive, PPO Catastrophic, and HSA-Qualified Preferred Catastrophic plans only).
• Over-the-counter contraceptive supplies and devices.
  
• Physical or psychiatric exams to obtain or continue employment, licensure, legal proceedings, insurance, school admission, sports activities, or for purposes of medical research.
• Prescription drugs, except as provided to an inpatient (excluded on PPO Catastrophic, HSA-Qualified Preferred Catastrophic, Asuris HSA Healthplan, and Asuris Clarity 50 plans only).
• Preventive care, except for mammography services and prostate cancer screening (excluded on PPO Catastrophic and Asuris Clarity 50 plans only).
• Private duty nursing or hourly nursing charges.
  
• Routine hearing exams, hearing aids.
  
• Routine newborn care (excluded on PPO Catastrophic, HSA-Qualified Preferred Catastrophic, Asuris HSA Healthplan, and Asuris Clarity 50 plans only).
• Services and supplies for which benefits are or would have been payable to a member eligible and enrolled under Medicare, regardless of whether the member actually enrolled.
• Services or supplies covered by auto insurance, personal injury protection insurance, homeowner insurance, or commercial premises coverage.
• Services or supplies not medically necessary* for illness, injury, or physical disability.
• Services provided by a family member (spouse, parent, or child).
• Smoking cessation (excluded on HSA-Qualified Preferred Catastrophic, Asuris HSA Healthplan, Asuris HSA Healthplan Comprehensive, and Asuris Clarity plans onlyy).
• Sterilization.
• Surgery (including reversals), treatment, programs, or supplies that are intended to result in weight reduction, regardless of diagnosis.
• Surgery or treatment for sexual dysfunction/impotence or transsexualism.
• Treatment and any appliances used in connection with malocclusions, jaw abnormalities, Temporomandibular Joint Disorders, and myofascial pain syndrome.
• Treatment of any condition caused by or resulting from active participation in the armed forces in a war or insurrection.
• Treatment of any condition that the Secretary of Veterans Affairs determines to have been incurred in, or aggravated during, performance of service in the uniformed services of the United States.
• Vision exams and hardware (excluded on PPO Catastrophic, HSA-Qualified Preferred Catastrophic, Asuris HSA Healthplan, Asuris HSA Healthplan Comprehensive, and Asuris Clarity 50 plans only).
• Visits or consultations that are not in person, including but not limited to any telephone, Internet, or other electronic communication (except tele-medicine in remote locations, as approved by the Company), whether initiated by the member or the member’s provider.
• Visual analysis, therapy, training, or orthoptics.

*Medically Necessary: Health care services or supplies that a physician or other health care provider exercising prudent clinical judgment, would provide to you for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that are: In accordance with generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your illness, injury or disease; and not primarily for the convenience of you, or your physician or other health care provider, and not more costly than an alternative service or sequence of services, or supply at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your illness, injury or disease. For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of the physicians practicing in relevant clinical areas and other relevant factors.