HSA Washington: Health Savings Accounts in Washington

Asuris Northwest Health - Online Application

Medical Plan Limitations and Exclusions

A pre-existing condition is a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period before the effective date of coverage and terminates nine months following the effective date of coverage.

Medical limitations and exclusions	Asuris Emerge Core	Asuris Emerge Plus	Asuris Emerge HSA Plans
Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery	Excluded	$2,500 per lifetime maximum benefit	Excluded
Chemical Dependency Treatment	Excluded	Excluded	Excluded
Cosmetic/Reconstructive Services and Supplies	Excluded	Excluded	Excluded
Counseling in the Absence of Illness	Excluded	Excluded	Excluded
Custodial Care	Excluded	Excluded	Excluded
Fees, Taxes, Interest	Excluded	Excluded	Excluded
Government Programs	Excluded	Excluded	Excluded
Hospitalization for Dentistry	Excluded	Excluded	Excluded
Infertility Treatment	Excluded	Excluded	Excluded
Investigational Services	Excluded	Excluded	Excluded
Medications without a Prescription Order	Excluded	Excluded	Excluded
Military Service Related Conditions	Excluded	Excluded	Excluded
Motor Vehicle Coverage and Other Insurance Liability	Excluded	Excluded	Excluded
Neurodevelopmental Therapy Services	Excluded	Excluded	Excluded
Non-Direct Patient Care	Excluded	Excluded	Excluded
Nutritional Counseling (except as provided for diabetic education)	Excluded	Excluded	Excluded
Obesity or Weight Reduction/Control	Excluded	Excluded	Excluded
Orthognathic Surgery (except for congenital conditions, injury, and sleep apnea)	Excluded	Excluded	Excluded
Orthotics (except diabetic orthotics)	Excluded	$500 per-calendar-year maximum benefit	Excluded
Personal Comfort Items	Excluded	Excluded	Excluded
Physical Exercise Programs and Equipment	Excluded	Excluded	Excluded
Private Duty Nursing	Excluded	Excluded	Excluded
Riot, Rebellion and Illegal Acts	Excluded	Excluded	Excluded
Routine Foot Care	Excluded	Excluded	Excluded
Routine Hearing Exams	Excluded	Excluded	Excluded
Self-Help, Self-Care, Training or Instructional Programs	Excluded	Excluded	Excluded
Services and Supplies Provided by a Member of Your Family	Excluded	Excluded	Excluded
Services and Supplies That Are Not Medically Necessary	Excluded	Excluded	Excluded
Services to Alter Refractive Character of the Eye	Excluded	Excluded	Excluded
Sexual Reassignment Treatment and Surgery	Excluded	Excluded	Excluded
Sexual Dysfunction	Excluded	Excluded	Excluded
Temporomandibular Joint (TMJ) Disorder Treatment	Excluded	Excluded	Excluded
Third-Party Liability	Excluded	Excluded	Excluded
Tobacco Addiction Treatment	Excluded	Excluded	Excluded
Travel and Transportation Expenses (other than covered ambulance services)	Excluded	Excluded	Excluded
Routine Vision Exam and Hardware	Excluded	Combined $150 per calendar year maximum; not subject to deductible or coinsurance maximum	Excluded
Work-Related Conditions	Excluded	Excluded	Excluded
This chart does not contain all limitations and exclusions. Please refer to your policy for a complete list of benefits and the limitations and exclusions that apply
Asuris Emerge Dental
Limitations and exclusions Exclusions applicable to both Dental Option 1 and Dental Option 2 except where noted.
Additional procedures to construct new crown under existing partial denture framework Application of desensitizing medicaments Application of desensitizing resin for cervical and/ or root surface Behavior management, for Dental Option 1 only Bleaching of teeth Broken retainers Collection of cultures and specimens Connector bar or stress breaker Diagnostic casts or study models Duplicate x-rays, for Dental Option 1 only Endodontic endosseous implants, for Dental Option 1 only Exfoliative cytology sample collection or brush biopsy, for Dental Option 1 only Experimental or investigational services: experimental or investigational services as determined by Asuris dental policy, for Dental Option 1 only Fees, Taxes, Interest Gold foil restorations, for Dental Option 1 only Hospitalizations for dentistry House/extended care facility calls Implant maintenance procedures, including: removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis Incision and drainage of abscess extraoral soft tissue, complicated or non-complicated Indirect pulp capping Interim partial or complete dentures Labial veneers Local anesthesia, sterilization, and supplies billed as separate charges (these procedures are considered inclusive of billed procedures) Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue per tooth, for Dental Option 1 only Lost or stolen items Maxillofacial prosthetic procedures Military service related conditions: Any condition resulting from military service in the armed forces of any country or any act of war (declared or undeclared) Modification of removable prosthesis following implant surgery Nitrous oxide, for Dental Option 1 only		Occlusal analysis and adjustments Occlusal guards, for Dental Option 1 only Oral hygiene instructions Oral/facial photographic images Orthodontic services, including craniomandibular orthopedic treatment: procedures for tooth movement, regardless of purpose, correction of malocclusion, preventive orthodontic procedures, and other orthodontic treatment Pediatric dentures, for Dental Option 1 only Pin retention in addition to restoration Precision attachments Prescription drugs, including take home prescription drugs, pre-medications, or supplies Provisional splinting, for Dental Option 1 only Pulp vitality tests Radical resection of maxilla or mandible Radiographic/surgical implant index Removal of nonodontogenic cyst, tumor, or lesion Replacement of lost, stolen, or broken dental appliances Services and supplies provided by a family member: services and supplies provided to a member by an immediate family member Services and supplies that are not Medically necessary: Services and supplies that are not medically necessary for the treatment of an illness, injury or physical disability Services performed in a laboratory, for Dental Option 1 only Surgical procedures for isolation of a tooth with rubber dam Surgical stent, for Dental Option 1 only Therapeutic drug injections Third Party Coverage: Services and supplies for treatment of illness or injury for which a third party is responsible [e.g. automobile medical, personal injury protection (PIP), automobile no-fault, homeowner, commercial premises coverage or similar coverage Tobacco ornutritional counseling for the control and prevention of oral disease Tooth transplantation, for Dental Option 1 only Travel and transportation expenses Treatment of complications (post surgical); unusual circumstances Treatment of simple or compound fractures of the mandible Treatment of Temporomandibular Joint Dysfunction Unspecified implant procedures