Drug Benefit Exclusions
All health insurance plan have a drug formulary, or list of covered medications. Obviously, drugs not on that list are excluded, but the exclusions may include services and miscellaneous fees related to drug benefits.
Many excluded drug benefits are in the cosmetic or nontraditional category. Drugs used for purely cosmetic purposes (like hair-growth stimulants and supplements for clear skin or strong nails) are usually not covered. Ditto for nontraditional drugs, like food supplements and experimental medications, and drugs that are used to abort a pregnancy.
There are also some nonmedication exclusions in this category. For example, many workers stand in one position for hours, which can cause damage to the back and legs and result in more serious complications like deep-vein thrombosis. But insurance usually doesn't cover supportive garments and back braces.
Most of these exclusions happen in both fee-for-service and managed-care plans, but there are differences.
Exclusions by Plan
Fee-for-service plans, or indemnity insurance, reimburse a set percentage of your health expenses and give you the freedom to select providers and hospitals. With this freedom often comes a higher monthly premium. Also, this type of insurance focuses more on the sick patient than on preventative care. Because of this, preventative care, such as annual physicals and "well" baby checkups, is often excluded.
HMOs and PPOs are the most popular types of managed-care plans. These plans are restrictive in terms of freedom of choice, but they're also usually much cheaper than other insurance plans.
Managed-care plans have more of a focus on preventative care, so physicals and the like are not excluded. Cosmetic surgery, experimental drugs and alternative medicine, however, are usually excluded.
Check out the links below to learn more about health insurance exclusions.
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More Great Links
- Solve Your Problems.com: Health Insurance Exclusions. http://www.solveyourproblem.com/insurance/health_insurance_exclusions_not_covered.shtml
- NAIC: State's Insurance Department Web Sites. http://www.naic.org/state_web_map.htm
- MMC: Insurance Basics, Exclusions in Coverage. http://mmc.healthinsurance.com/hi/web/basics/individual/Exclusions.aspx
- Quotit.net: What's Not Covered? http://www.quotit.net/resources/terms_health2.htm#covered
- FreeAdvice.com: Exclusions and Limitations. http://insurance.freeadvice.com/insurance_help.php/108_119_127.htm
- U.S. Department of Labor: Pre-Existing Condition Exclusion. http://www.dol.gov/elaws/ebsa/health/glossary.htm?wd=Preexisting_Condition_Exclusion
- CDC: FASTATS, Home Health Care. http://www.cdc.gov/nchs/fastats/homehealthcare.htm