Exclusions and Limitations
Exclusions
The following section provides you with information on what services and supplies Kaiser Permanente
will not pay for regardless of whether the service is medically necessary or not.
The services and supplies listed below are excluded from coverage. These exclusions apply to all
services and supplies that would otherwise be covered the plan. When a service or supply is excluded,
all services and supplies related to that excluded service or supply are also excluded, even if they would
otherwise be covered under this plan.
(1) Services that are not medically necessary.
(2) Services performed or prescribed under the direction of a person who is not a health care
practitioner.
(3) Services that are beyond the scope of practice of the health care practitioner performing the service.
(4) Services to the extent they are covered by any government unit, except for veterans in Veterans'
Administration or armed forces facilities for services received for which the recipient is liable.
(5) Services for which a Covered Person is not legally, or as a customary practice, required to pay in the
absence of a health benefit plan.
(6) The purchase, examination, or fitting of eyeglasses or contact lenses, except for aphakic patients and
soft or rigid gas permeable lenses or sclera shells intended for the use in the treatment of a disease or
injury.
(7) Personal care services and domiciliary care services.
(8) Services rendered by a health care practitioner who is a Covered Person's spouse, mother, father,
daughter, son, brother or sister.
(9) Experimental services.
(10) Practitioner, hospital, or clinical services related to radial keratotomy, myopic keratomileusis, and
surgery which involves corneal tissue for the purpose of altering, modifying, or correcting myopia,
hyperopia, or stigmatic error.
(11) In vitro fertilization, ovum transplants and gamete intrafallopian tube transfer, zygote intrafallopian
transfer, or cryogenic or other preservation techniques used in these or similar procedures.
(12) Services to reverse a voluntary sterilization procedure.
(13) Services for sterilization or reverse sterilization for a dependent minor.
(14) Medical or surgical treatment for obesity, unless otherwise specified in the "Covered Services"
section of this EOC.
(15) Medical or surgical treatment for reducing or controlling weight, unless otherwise specified in the
"Covered Services" section of this EOC.
(16) Services incurred before the effective date of coverage for a Covered person.
(17) Services incurred after a Covered Person's termination of coverage, except as provided in the
Extension of benefits provision of this EOC.