ELIGIBILE ITEMS |
LOMN REQUIRED |
INELIGIBLE ITEMS |
Services Not Covered by Insurance Obstetrical Care Syntonic Phototherapy Fertility Enhancement and Treatments (surrogate or gestational carrier expenses) Nursing Pillows or Covers Egg and Embryo Storage Fees Dentures (for cosmetic reasons) Temporary Continuation of Coverage (TCC) Premiums (if you have a health care FSA) Medicated Lip Product (for cold sore/fever blister) Private Hospital Room Chinese Herbal Practioner and Herbal Treatments (for general health) Dependent Care (for healthy child) Finance Charges Deductibles Gynecologist Goggles (prescription) Flavoring Added to Medication Cold and Hot Packs (for non-medical use) Gambling Treatment Lip Balm (SPF 15 or higher) Homeopathic Care and Medicines Well Baby, Well Child Care Erectile Dysfunction Treatment Stem Cell Harvesting or Storage (for medical reasons) Pregnancy Termination Medicated Lip Product (lip balm lower than SPF 15) Crystalens Massage Therapy (for medical condition) Fertility Enhancement and Treatments (ovulation kit) Pre-Paid Payments Illegal Operations, Illegal Treatments Long Term Care Services Specialized Medical Equipment or Services Medical Information Storage Plan Glucose Monitoring Device Sinus Medication Lactation Consultant Funeral Expenses Minerals, Mineral Supplement (for medical condition) Medical Services (payment for treatment of medical condition) Ovulation Monitor Electrolysis (hair removal for medical condition) Transportation (for medical care) Drugs (over-the-counter) Paternity Testing Sales Tax Chiropractor Marijuana Laxatives Condoms Mediscope Dental Emergency Kit Train Fare (primarily for medical care) Dermabrasion (for cosmetic reasons) Contact Lens Service Agreement and Warranty Mentally Challenged, Special Home Abdominoplasty (for medical condition) Alcoholism, Drug Addiction Treatment Patterning Exercises Hand sanitizer Varicose Veins Treatment (for medical condition) Trips (for general health) Breast Reduction (for medical condition) Shampoos and Soaps Medical Alert Bracelet, Necklace Allergy Products (used even without allergies) Fuel, Gasoline for Medical Care Petroleum Jelly Teething, Toothache Remedies Food Neurologist Oxygen Vaporizer, Humidifier Meals (for inpatient care) Anti-Itch Migraine Relief (over-the-counter) Blepharoplasty (for cosmetic reasons) Out-of-Network Provider Topical Steroids Health Club or Gym Membership Fees (for medical condition) Sensory Items Safety Glasses (Prescription) Prenatal Vitamins Automobile Modifications (cost of operating the car) Umbilical Cord Blood (harvesting/storage for medical condition) OTC (over-the-counter) Organ Recipient Expenses (paid by the donor) COBRA Premiums (if you have a health care FSA) Dance Lessons (for medical condition) Umbilical Cord Blood (harvesting/storage for non-medical reasons) Hospice Care/Palliative Care Pregnancy Tests Wellness Scan Arthritis Care Bariatric Surgery (for cosmetic reasons) Late Payment Fee Denture Adhesive Fitness Program (for general health) Lead Paint Removal (for medical condition) Ambulance Service Medicine and Drugs, Over-the-Counter (OTC) Orthodontia Acne (over-the-counter item) Television for Visually or Hearing Impaired (cost to modify TV or buy new) Dental Treatment (non-cosmetic) Transplant Breast Implants or Removal (for medical condition) Contraceptives Swimming Lessons (for medical condition) Weight Loss Drugs, Medicines (over-the-counter for medical condition) Humidifier (for medical care) Copayment (copay) Herbs and Herbal Supplement (for general health) Physician Fees, Pre-Paid Nursing Supplies Radial Keratotomy Baby Health Monitor Life Coach Body Scan Car Modification (cost of operating the car) Decongestant Warranty Eye Care (for eye drops) Insect Bite Cream, Ointment Nasal Strips Veneers (for cosmetic reasons) Joint Supplement (for medical condition) Psychologist Mileage (primarily for medical care) Dental Treatment (over-the-counter flouride) Stop-Smoking Program PET Scan Liquid Adhesive Bandage for Small Cuts Wig (styling or cleaning products) Invisalign Orthodontics Exercise Equipment, Exercise Program (for medical condition) Pre-Existing Condition Legal Fees (for surrogate mother) Medicare Parts A, B and D (if you have an HSA) Dental Treatment (tooth bonding) Chiropody Personal Trainer Fees (for medical condition) First Aid Kit Suppositories Disabled Dependent Medical Care Calcium (for medical condition) Retin-A (for medical condition) Home Health Care Durable Medical Equipment (DME) Toothbrushes Fiber Supplement (for general health) GIFT (Gamete intrafallopian transfer) Ultrasound Exercise Equipment, Exercise Program (for general health) Marriage Counseling Medical Records Fertility Enhancement and Treatments (fees for preserving) Pedometer Retin-A (for effects of aging) Psychiatric Services and Care Crutches Organ Donor/Recipient Expenses (paid by recipient) Long Term Disability (LTD) Insurance Premiums (if you have a health care FSA) Cord Blood (harvesting/storage for non-medical reasons) Veneers (non-cosmetic) Hydrotherapy Foot Care (non-medicated) Sunscreen (lower than SPF 15) Personal Protective Equipment (PPE) Companion Animal Whirlpool Baths Hypnosis Surgery (for cosmetic reasons) Tanning Salon Visits or Equipment (for cosmetic reasons/appearance) Rhinoplasty (for cosmetic reasons) Osteopath Egg Recipient Fees Nursing Home (medical care, meals and lodging) Occupational Therapy Fluoride Rinse, Pills and Toothpaste Therapy (marriage/family for non-medical reasons) Sleep Deprivation Treatment Newborn Nursing Care Birthing Classes (not related to the actual childbirth) Toiletries (Personal Hygiene) Counseling (for medical condition) Drug Addiction Treatment Toll Fees (primarily for medical care) Naturopathic Care, Naturopathic Healers (for medical condition) Topical Analgesics (Muscles and Arthritis) Mask (personal protective equipment) Psychoanalysis Contact Lenses and Supplies (over-the-counter products) Special Computer Program for the Blind Immunizations Propecia (for medical condition) Legal Fees (for divorce) Inclinator Adoption Medical Expenses (for tax qualified dependents) Lap Band Surgery (for obesity treatment) Sperm Storage (for non-medical reasons) Maternity Charges Prescription Drug Discount Program Lip Balm (SPF lower than 15) Sunburn Cream, Ointment Nutritional Supplement (for medical condition) Insulin Diagnostic Tests and Procedures Probiotics (for medical condition) Medicine, Prescription (for cosmetic reasons) Sunglasses (no vision correction) Cervical Pillow Bio-identical Hormone Replacement Therapy (used as an enhancement) Alternative Medicine, Alternative Healers (for medical condition) Bio-identical Hormone Replacement Therapy (for medical condition) Bandages, Band-Aids Sterilization Procedure or Reversal Blood Donor Fee Diet Food Premiums (for Medicare supplement policies) Stem Cell Harvesting or Storage (for non-medical reasons) Waterpik Digestive Aids (for medical condition) Orthopedic Shoes Over-the-Counter (OTC) Drugs and Medicines Lessons (non-medical) Acne (routine skin care) Vitamin (for general health) Hyperbaric Oxygen Therapy Eye Exams, Eyeglasses, Eye Surgery, Eye Care Somnoplasty Fiber Supplement (for medical condition) DNA Collection and Storage (for paternity testing) Glucosamine and Glucosamine Chondroitin Digestive Aids (over-the-counter) Doctor Fees Injection Snore Plasty Long Term Disability (LTD) Insurance Premiums (if you have an HSA) Therapy (for medical condition) Rolfing, Structural Integration Telephone for Hearing Impaired (cost of phone in hospital/treatment center) Transportation (non-medical) Antihistamines Retention Fees Contact Lenses and Supplies (for cosmetic reasons) Homeopathic Care and Medicines (for general health) Naturopathic Healers Laboratory Fees Clinic Sexual Dysfunction Corneal Molding Breathalyzer Post-tax non-employer paid medical insurance premiums Chairs, Reclining Bedside Commode, Toilet (for medical reasons) Special Food Pregnancy Charges Paid Monthly per Contract COBRA Premiums (If you have an HSA) Obstetrical Care (prepaid expenses for the birth) Investigational Surgery Personal Items Asthma Equipment and Treatment (over-the-counter products) CPR Gastric Bypass Surgery Including Excess Skin Removal (for obesity treatment) Throat Lozenges Automated External Defibrillator (AED) Speech Therapy Denture Cleanser Student Health Fee (cost of medical care) Cold and Hot Packs (for medical purposes) Body Restoration Technique Sexual Counseling Sharps Container Air Fare (primarily for medical care) Ultrasound, Pre-Natal (non-medical request by patient) Lamaze Classes (not related to the actual childbirth) Lodging and Trips (for general health) Babysitting, Child and Dependent Care (for healthy child) Dance Lessons (non-medical) Maternity Clothes Motion Sickness Founder’s Fees Shipping and Handling Holistic, Homeopathic Professional (for medical condition) Health Screenings Prescription Drugs, Medicines Fever Reducing Medication Walker Allergy Treatment Products (required for medical condition) Analgesics (painkillers), Antipyretics (fever reducers) Bracanalysis Testing Phone Consultation with Doctor Car Rental (primarily for medical care) Naturopathic Care, Naturopathic Healers (for general health) UVR treatments Nasal Aspirator Headache Medicine Ear Care and Ear Wax Removal Products Foot Care (over-the-counter) Operation (for cosmetic reasons) Dyslexia Treatment Support Hose Acupuncture Non-Prescription Drugs, Medicines Tanning Salon Visits or Equipment (for medical condition) Circumcision Home Improvements Subway Fare (primarily for medical care) Automobile Modifications (for medical condition) Colon Therapy, Colon Hydrotherapy, Colonics Convalescent Home (custodial care) Educational Classes (for medical condition) Artificial Reproductive Technologies (active attempt to conceive) Tuition (for special school/camp/program) Kenalog injections (for medical condition) Ophthalmologist Monitor Cold Sore and Fever Blister Treatments (lip balm SPF lower than 15) Collagen Injections (for medical condition) Crania-Sacral Therapy Legal Fees (for guardian/estate) Purifier Electrolysis (hair removal for cosmetic reasons) Experimental Drugs Club Dues and Fees (for medical condition) Schools, Special Thermography Kenalog Injections (for cosmetic reasons) Co-Insurance Breast Reconstruction Surgery Diabetic Equipment and Supplies Nutritional Supplement (for general health) Peak Flow Meter Artificial Insemination (active attempt to conceive) Telephone Consultation Fee Vasectomy, Vasectomy Reversal Wart Removal Treatment Egg and Sperm Donor Fees Compression Socks, Stockings Laetrile Thermacare Heat Wraps Specialty Clothing & Shoes Pastoral Counseling X-Ray Baby Formula Tummy Tuck NSAIDS (over-the-counter) Fluoride product (over-the-counter) Dentures (non-cosmetic) Thermometer Digestive Aids (for general health) Tubal Ligation, Tubal Ligation Reversal Taxes on Medical Services and Products Medicated Lip Product (lip balm SPF 15 or higher) Alternative Medicine, Alternative Healers (for general health) Blood Pressure Monitor Pillows for Lumbar and Cervical Support Lactation Aids and Supplies Flu Shot Maternity Aids Morning-After Contraception Pill Household Help Acupressure Autopsy Artificial Eye, Limb, Teeth Varicose Veins Treatment (for cosmetic reasons) HDHP, High-deductible health plan (premiums) Bleaching or Whitening Teeth Cosmetic Treatment (for medical condition) Back Brace Telephone for Hearing Impaired (fees for enhancing/repairing a phone) Alopecia Treatment Menstrual Pain Reliever Eye Exams, Eyeglasses, Eye Surgery, Eye Care (for repairs) Forms Completion Baldness Treatment (for cosmetic reasons) Arch and Insole Support Norplant insertion or removal Smoking Cessation Program and Medication Acne (services) Electronic Cigarettes Hormone Replacement Therapy (HRT) (used as an enhancement) Diaper Rash Creams Lice Treatment and Removal (fees paid to specialist) Medicine, Prescription Drugs (prescription) Fertility Enhancement and Treatments Home Diagnostic Kits, Tests, Devices Psychotherapist Legal Fees (for fertility treatment) Restylane Injections (for cosmetic reasons) Weight Loss Programs (for medical condition) Speech Therapy (dvds, videos, software) Language Classes Continuous Positive Airway Pressure (CPAP) Diathermy Vision Correction Wig (for medical condition) Medicare Parts A, B and D (if you have a health care FSA) Lap Band Surgery (for medical condition) Guide Dog Abdominoplasty (for cosmetic reasons) Tutoring Physical Exam for Caregiver Medical Services (virtual office visits) Cough Suppressants Penile Implants Behavioral Modification Programs Christian Science Practitioners Surrogate Mother Fees (for search of surrogate) Birth Control (over-the-counter) Club Dues and Fees (for general health/non-medical) Handicap, Disability Placards and License Plates Home modifications (with Capital Expense Form) Aspirin Kenesio Tape Counseling (marriage/family for non-medical reasons) Swimming Lessons (non-medical) Premiums (if you have an HSA) Christian Science Treatments (for general health) Liposuction (for medical condition) Liposuction (for cosmetic reasons) Breast Reduction (for cosmetic reasons) Contact Lenses and Supplies (for vision correction) Learning Disabilities Medical Monitoring, Testing Devices Pregnancy Items Anti-Diarrhea Dental Maintenance Organization (DMO) Fees (if you have an HSA) Baldness Treatment (for medical condition) Expenses that have been reimbursed previously under or could be reimbursed under another medical plan Dermatology (for cosmetic reasons) Holistic, Homeopathic Professional (for general health) Bus Fare (primarily for medical care) Surrogate Mother Fees (for medical expenses for the surrogate) Pediculicide/Lice Treatment Physical exam Insurance Premiums (for Medicare supplement policies) Transportation (for nurse or companion) Trips (to receive medical care) Birth Control (prescription) Genetic Testing Legal Fees (to authorize treatment) Prosthesis Nicotine Gum and Patches Work Related Physical Examination for the Employee Over-the-Counter (OTC) Supplies Lessons (for medical condition) Blepharoplasty (for medical condition) Doula Fees Denturist Concierge Medicine Half Way House Expenses not incurred during the coverage period Gastric Bypass Surgery Including Excess Skin Removal (for cosmetic reasons) Medical Services (phone consultation) Hair Removal or Transplant (for cosmetic reasons) Drug Overdose Treatment Diapers, Diaper Service Hospital Services Bariatric Surgery Birthing Classes (related to childbirth) Nutritionist (for general well-being) Antibiotics, topical Breastfeeding Supplies Transportation Cost of Disabled Individual Commuting To and From Work Educational Classes (non-medical/general well-being) Insurance Premiums (if you have a health care FSA) nor pre-tax employer-sponsored medical insurance premiums Seeing-eye Dog, Service Animal Surgery (for medical care) Autoette (wheelchair) Dependent Care (for disabled person) Adaptive Equipment Calcium (for general health) Preventive Care Services Excess Skin Removal Medical Newsletter Appearance Improvement Dermatology (for medical condition) Stem Cell Injections Controlled Substances Orthotics Heart Rate Monitors Scale, food or weight Bariatric Surgery (for obesity treatment) Vitamin (for medical condition) Lodging and Trips (to receive medical care) Childbirth Classes/Lamaze (related to childbirth) Nursing services provided at home Sperm Storage (for medical reasons) Occlusal Guard Collagen Injections (for cosmetic reasons) Dehumidifier First Aid Supplies Sunglasses (with prescription) Capital Expense (cost of installing equipment in home) Elevator Skin Tag Removal (for medical condition) Sitz Bath Braille Books and Magazines Fitness Program (for medical condition) Herbs and Herbal Supplement (for medical condition) Substance Abuse Treatment Rogaine (for cosmetic reasons) Sanitizing wipes Gastric Bypass Surgery Including Excess Skin Removal (for medical condition) Wheelchair, Walker Pill Cutters, Pill Box, Pill Sorters and Pill Organizers Hormone Replacement Therapy (HRT) (for medical condition) Feminine Hygiene Products Particulate Respirator Mask Hemorrhoid Treatment Parking Fees (primarily for medical care) Breast Pump Purchase or Rental Pulse Oximeter Childbirth Assisted Living Facility Childbirth Classes/Lamaze (not related to the actual childbirth) Cold Sore and Fever Blister Treatments (lip balm SPF 15 or higher) Medical Care Outside U.S. Joint Supplement (for general health) Pregnancy and Delivery Charges HMO, Health Maintenance Organization (premiums) Supplement (for medical condition) Anti-Gas Long Term Care Insurance Premiums (if you have a health care FSA) Human Guide Dietary Supplement (for medical condition) Eye Care, Eyeglasses (warranties) Medical Services (monthly/annual fee) Hearing Aids and Batteries Heating Pads Medicine and Drugs from Other Countries (purchased and consumed in another country) Dehydration Treatment Personal Trainer Fees (for general health) Propecia (for cosmetic reasons) Organ Donor Expenses (paid by donor) Ostomy, Colostomy Supplies Micro-Dermabrasion (for cosmetic reasons) Tattoo Removal (for cosmetic reasons) Botox Injections (for medical condition) Car Modification (specially designed car to hold a wheelchair) Long Term Care Insurance Premiums (if you have an HSA) Blood Sugar Test Kits and Strips Student Health Fee (fees/premium for program) Midwife Dental, cosmetic Respite Care Drugs (controlled substances) Alternative Healers Television for Visually or Hearing Impaired (cost of TV in hospital/treatment center) Transportation (to attend Alcoholics Anonymous) Gauze Pads Dietician Premiums (if you have a health care FSA) Anti-Fungal Life Alert Emergency Medical Alert System Orthokeratology Chemical Peel (for cosmetic reasons) Missed Appointment Fees LASIK, Laser Eye Surgery Infertility Treatments Lumbar Support Anesthesiology Fluoride Device and Treatment (In home or Office) Reflexology Cold Medicines First Aid Drugs and Medicines Urinalysis Botox Injections (for cosmetic reasons) Chelation Therapy Medical Conference (admission and transportation) Pain Relievers (Over-the-counter) Meals (for a companion) Anti-Embolism Socks, Stockings Rogaine (for medical condition) Automobile Modifications (specially designed car to hold a wheelchair) Eye Exams, Eyeglasses, Eye Surgery, Eye Care (not needed for vision correction) Progesterone, Testosterone Hormones (for cosmetic reasons) Ear Plugs Minerals, Mineral Supplement (for general health) Face Lift (for cosmetic reasons) Usual, Customary and Reasonable (UCR), Charges Above Expectorant Taxi Fare (primarily for medical care) Braces, Orthodontia Phototherapy Smoking Cessation Program and Medication (over-the-counter) Swimming Pool (for medical condition) Allergy Medicine Physical Therapy Probiotics (for general health) Ultrasound, Pre-Natal (to monitor growth/condition) Inversion Table Legal Fees (for adoption) Temporary Continuation of Coverage (TCC) Premiums (if you have an HSA) Lap Band Surgery (for cosmetic reasons) Vaccinations Nebulizer Skin Tag Removal (for cosmetic reasons) Spermicide Crown, dental Veterinary Fees (for guide dog/animal) Epsom Salts Progesterone, Testosterone Hormones (for medical condition) Mattress Weight Loss Drugs, Medicines (prescribed) Air Conditioner, Air Filter, Air Purifier Psychotherapy Cosmetic Treatment (for non-medical reasons) Vision Discount Programs Experimental Medical Services Preventative Care Screenings Birthing Coach Reasonable & Customary (R&C) Antacids, Acid Reducers Blood Storage In Vitro Fertilization Asthma Equipment and Treatment Neti Pot Carpal Tunnel Wrist Supports, Braces Oncologist Tri-Care Premiums (if you have an HSA) Rehabilitation Center (meals and lodging) Convalescent Home (medical care, meals & lodging) Natural Lens Replacement Optometrist Glucose Tabs Corneal Ring Segments Sunscreen (SPF 15 or higher) Diarrhea Medicine Nutritionist (for medical condition) Post Mastectomy Clothing Adoption Medical Expenses (incurred by birth mother, associated with birth) Adoption Medical Expenses (incurred before adoption negotiations) Swimming Pool (for recreation) Breast Augmentation (for cosmetic reasons) Impotence Chinese Herbal Practitioner Medicine and Drugs from Other Countries (purchased in another country for use in U.S.) Tri-Care Premiums (if you have a health care FSA) Weight Loss Programs (for general health) Screening Tests Operation (for medical care) Car Modification (for medical condition) Surrogate Mother Fees (for medical expenses, if member is surrogate) Dental Treatment (oral hygiene & supplies) Ear, Body Piercing Dental Maintenance Organization (DMO) Fees (if you have a health care FSA) Cord Blood (harvesting/storage for medical condition) OSHA Handling Fees for Bio-Hazards Waste Disposal. Breast Implants or Removal (for cosmetic reasons) Lice Treatment and Removal (over-the-counter) Hair Removal or Transplant (for medical condition) Reading Glasses Nasal Sprays, Nasal Solutions Cold Sore and Fever Blister Treatments (over-the-counter) Insurance Premiums (if you have an HSA) Rehabilitation Center (custodial care for permanent residence) Cholesterol Testing Lamaze Classes (related to childbirth) Boutique, Concierge, Practice Fees Incontinence Products Health Club or Gym Membership Fees (for general health/non-medical) Mastectomy-Related Expenses Supplement (for general health) Dietary Supplement (for general health) Lead Paint Correction (repaint affected area) Massage Therapy (for general health) Kinesiology Defibrillator Mouth Guard