Medicare Advantage plan EOC exclusions

Adaptive equipment

May be covered under the member's over-the-counter allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart

Ambulance mileage

Mileage for ambulance transport beyond nearest facility or to/from facility preferred by member and/or family

May be covered under the member's worldwide assistance program. See Chapter 4, Section 2.1, Medical Benefits Chart

Assistive listening devices

Including but not limited to telephone amplifiers and alerting devices

Not covered under any condition

Athletic clothes and shoes

Not covered under any condition

Bathroom safety devices

Including but not limited to lifts, raised toilet seats, bidet toilet seats, transfer benches, grab bars, and parallel bars

May be covered under the member's over-the-counter allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart

Beds

Including but not limited to oscillating mattresses, bed baths (home type), bed boards, lifters (elevator), lounges (power or manual

Not covered under any condition

Blood glucose analyzers

Reflectance colorimeter

Not covered under any condition

Chair portion of chair lift system

Not covered under any condition

Chiropractic care

Maintenance care, x-ray, labs, and any other service performed within the office

Routine chiropractic services covered under the member's plan*** are described in Chapter 4, Section 2.1, Medical Benefits Chart

Companion and concierge care

Not covered under any condition

Continuous glucose monitoring (CGM) devices

Covered: Medicare-approved devices only. Priority Health will determine if the member meets medically-necessary criteria.

Cosmetic surgery or procedures

Covered after an accidental injury, or to improve a malformed part of the body. Covered for all stages of reconstruction for a breast after mastectomy, as well as for the unaffected breast to product a symmetrical appearance.

Counseling services

Including but not limited to geriatric day care programs, individual psychophysiological therapy including biofeedback, marriage counseling, pastoral counseling

Not covered under any condition

Cruise ship services

Medicare may cover medically necessary health care services received by the member on a cruise ship in the following situations:

• The doctor is allowed under certain laws to provide medical services on the cruise ship
• The ship is in a U.S. port or no more than 6 hours away from the U.S. port when services are received, regardless of whether it's an emergency.

Medicare doesn't cover health care services received when the ship is more than 6 hours away from a U.S. port.

Custodial care

 See Chapter 12, Definitions of important words for custodial care

Not covered under any condition

Dental services, non-routine, Medicare covered

Inpatient or outpatient dental care required to treat illness or injury may be covered as inpatient or outpatient care. Priority Health will determine if the member meets the medically necessary Medicare criteria

Dental services, routine, not Medicare covered**

Outpatient facility and professional dental expenses for routine dental services

Routine dental services covered under the medical plan are described in Chapter 4, Section 2.1, Medical Benefits chart. If the member purchased the Enhanced Dental and Vision package, which is an optional supplemental benefit for an extra premium, additional dental services are covered, see Chapter 4, Section 2.2 of the Evidence of Coverage for details

Drugs, Part B

Non-chemotherapy drugs and biologicals used for conditions not approved by Food and Drug Administration (FDA), such as biomedical hormones, and not covered under Medicare

Not covered under any condition

Drugs, Part D

Part D drugs purchased from or obtained while in another country, including those obtained on a cruise ship. These are considered non-FDA approved.

Not covered under any condition. Self-administered drugs may be covered when provided in an outpatient setting such as an outpatient hospital, ER room or physician office. See also Chapter 4, Section 2.1, Medical Benefits Chart and Chapter 12, Definitions and important words.

Emergency communications systems

Includes personal emergency response systems (PERS), medical alert devices, in-home telephone alert systems

May be covered under the member's plan. See Chapter 4, Section 2.1, Medical Benefits Chart.

Experimental or investigational medical and surgical procedures, equipment and medications

Experimental procedures and items are those determined by our plan and Original Medicare to not be generally accepted by the medical community

May be covered by Original Medicare under a Medicare-approved clinical research study or by our plan. See Chapter 3, Section 5 for more information on clinical research studies.

FDA exclusions

Services not approved by the federal Food & Drug Administration

Not covered under any condition

Fees charged by immediate family/household members

Not covered under any condition

Fitness equipment rentals

Not covered under any condition

Foot care, routine

Some limited coverage provided according to Medicare guidelines (e.g., if member has diabetes).PriorityMedicare D-SNP includes routine foot care, outside of original Medicare guidelines.

Full-time nursing care in-home

Not covered under any condition

Gender reassignment

Surgery and gender reassignment hormones

Covered if determined by Priority Health to meet medical necessity criteria

Hearing services, routine, not covered by Medicare

Hearing aid exams, hearing aids and hearing aid evaluations including the fitting and checking of hearing aids

Routine hearing services covered under the member's plan are described in Chapter 4, Section 2.1, Medical Benefits Chart. 

Homemaker services

Includes household assistance, light housekeeping or light meal preparation

May be covered under the member's Companion Care benefit, if plan includes this benefit**. See Chapter 4, Section 2.1, Medical Benefits Chart

Homeopathic services

Not covered under any condition

Immunizations (when covered under Part D)

Immunizations covered under Part D benefits, including but not limited to Shingrix, and tetanus (when not used to treat an injury or illness)

Members should be directed to their pharmacy for Part D immunizations. Plan will not reimburse if dispensed in a doctor's office.

Incontinence pads/supplies

May be covered under the member's over-the-counter allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart

Knee walker

May be covered under OTC depending on the member's plan

Lab tests

Not medically necessary under Medicare coverage criteria

May be covered under the Personalized Health Risk Assessment benefit on PriorityMedicare Thrive and PriorityMedicare Thrive Plus. See Chapter 4, Section 2.1 for details.

All other plans - routine: Not covered under any condition when ordered solely as part of an annual physical exam and not to diagnose a medical condition

Lift chair

The lifting mechanism of a lift chair only

The lifting mechanism may be covered if determined by Priority Health to meet medically necessary criteria. Chair/recliner portion is not covered under any condition.

Long-term care

Not covered under any condition

Massage therapy

Not covered under any condition, when performed by a massage therapist

Meals delivered to the home

Not covered under any condition

Naturopathic services 

Not covered under any condition

Orthopedic shoes or supportive devices for the feet

Shoes that are part of a leg brace and are included in the cost of the brace. Orthopedic or therapeutic shoes for people with diabetic foot disease. May also be covered under your over-the-counter allowance. See Chapter 4, Section 2.1, Medical Benefits Chart.*

Personal in-room items

Not covered under any condition at a hospital or skilled nursing facility, including but not limited to a telephone or television

Physical exams and other services required by third parties

Exams/services for purposes such as obtaining or maintaining employment, participation in employee programs, insurance or licensing, sports participation, on court order, or when required for parole or probation

Not covered under any condition

Private-duty nurses

Not covered under any condition

Private room

Not covered when semi-private rooms are available

Precluded Providers

Services from providers who appear on the CMS Preclusion List. See Chapter 12, Definitions of important words, for CMS Preclusion list.

Not covered under any condition.

Pre-operative testing

Including but not limited to lab tests, X-rays, EKGs, EEGs, and cardiac monitoring, when performed strictly for pre-operative clearance when no underlying medical condition exists for testing

Not covered under any condition

Residential treatment

Not covered under any condition when the main purpose is to remove the member from his/her environment to prevent the re-occurrence of a condition such as but not limited to eating disorders, alcohol addiction, etc.

Reversal of sterilization

Not covered under any condition

Smart devices

Including smart phones, tablets, personal computers, etc. and the cost of applications

Not covered under any condition

Sporting good merchandise

Camping gear, rackets/paddles, hiking/fishing poles and golf clubs

 Not covered under any condition

Structural modifications

Including but not limited to ramps, doorways, elevators and stairway elevators

Not covered under any condition

Support hose

May be covered under the member's over-the-counter (OTC) allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart

Surgical leggings

May be covered under the member's over-the-counter (OTC) allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart

Temporomandibular joint syndrome (TMJ) treatment

Not covered on Individual MAPD and DSNP plans. May be covered on some Employer Group plans. See Chapter 4, Section 2.1, Medical Benefits Chart in Evidence of Coverage.

Transportation

Including commercial or private air transport, car, taxi, bus, gurney van and wheelchair van, even if it is the only way to travel to a network provider

May be covered by a member's Companion Care benefit depending on plan. See Chapter 4, Section 2.1, Medical Benefits Chart.

Also may be covered as part of the Transportation benefit if the member has a DSNP plan.

 VA services

Services provided to veterans in Veterans Affairs (VA) facilities

Not covered under any condition

Vision services, routine, not covered by Medicare

Eye exams, eyewear, refraction, retinal imaging, and fitting of eyewear

Routine vision services covered under the member's plan are described in Chapter 4, Section 2.1, Medical Benefits Chart. If the member has purchased the enhanced dental and vision package, which is an enhanced optional benefit for an extra premium, additional vision services are covered. See Chapter 4, Section 2.2 for details. 

Vision services, routine, not covered by Medicare**

Refractive surgical procedures laser astigmatism correction, radial keratotomy and keratoplasty to treat refractive defects, LASIK or LASEK surgery, keratophakia and keratomileusis, nonconventional intraocular lenses (IOLs) following cataract surgery (for example, a presbyopia-correcting IOL)

Not covered under any condition

War related

Items or services needed whether due to or related to injuries caused by war or an act of war

Not covered under any condition

Weight loss treatment

Including but not limited to medications, self-help groups, non-Medicare covered weight loss programs, meal programs and dietary supplements

Nutrition support services may be covered on PriorityMedicare Thrive and PriorityMedicare Thrive Plus. See Chapter 4, Section 2.1 for more details.
Not covered under any condition on all other plans.

Wigs

Not covered under any condition