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Arc Stop Loss Proposal Exclusions & Limitations

By accepting and signing an Arc Stop Loss Proposal, all signing parties agree that the following limitations and exclusions shall be explicitly incorporated into all formal and informal documents and communications that are intended for the purpose of providing detailed coverage and benefits information, including, but not limited to, the Plan Document, Summary Plan Description (SPD), Summary of Benefits and Coverage (SBC), and relevant plan onboarding materials.

Furthermore, these exclusions and limitations must be enforced through TPA operations, including, but not limited to, utilization management, claims operations, payment integrity, and other processes. These care, supplies, treatments, and/or services may be covered by the Plan, should a group choose to cover them. However, they will not be reimbursable under the Plan’s stop loss policy:

General Limitations & Exclusions

  • Administrative costs (including charges for completing claim forms and breaking appointments)
  • Care, supplies, treatment, and/or services incurred because of war or any act of war
  • Care, supplies, treatment, and/or services received outside of the US, unless in an emergency
  • Care which is paid, may be paid, or could be provided at government expense, unless participant is legally obligated to pay
  • Care that is not medically necessary, and complications from care that is not medically necessary
  • Cosmetic services, supplies or prescription drugs unless from an accident, covered illness, or congenital anomaly causing a functional defect found at birth
  • Custodial care that does not restore health
  • Dental care (including routine care, cavities, braces, gum diseases, and/or dentures), except emergency repair due to injury and medically-necessary oral surgical procedures
  • Durable medical equipment, medical devices, and medical supplies that are available over the counter (including glucometers) and/or not medically necessary (including, but not limited to, comfort / convenience items or any similar device), including hearing aids
  • Experimental or investigational care, supplies, treatment, and/or services
  • Long-term care (including charges related to bathing, dressing, eating, toileting, transferring, and continence)
  • Complications from non-covered services and drugs
  • Non-prescription drugs
  • Occupational injuries and/or sicknesses
  • Services, supplies, and/or treatment of plan participants incurred during confinement in prison, jail, or other penal institutions
  • Services or treatments that exceed plan limits or maximum allowable charges
  • Subrogation, reimbursement, and/or third-party responsibility
  • Treatment for injuries or illness resulting from hazardous pursuits, hobbies or activities or from illegal acts
  • Treatment for injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or malpractice on the part of any caregiver, institution, or provider
  • Vision care (including routine eye exams)

Medical Exclusions:

  • Alternative medicine (including acupuncture, holistic, homeopathic, or naturopathic services, and thermography)
  • Biofeedback
  • Cosmetic surgery and related services, supplies, or complications (including medically unnecessary circumcision); unless required for reconstructive purposes due to accidental injury, congenital anomaly, or as otherwise mandated by law
  • Education or training programs
  • Gender-affirming care (including hormone therapy, surgical procedures, and related follow-up care
  • Gene and cellular therapies and associated services and supplies (including products or treatments that introduce, replace, or otherwise modify genetic material within human cells; cell therapies or adoptive cell transfers; and associated services and supplies) such as CAR-T therapy
  • Hair pieces
  • Fertility-related services and infertility treatment (including fertility evaluation and testing and surrogacy, unless the surrogate is a participant, in which case the preventive care and/or pregnancy expenses may be covered in accordance with the plan provisions)
  • Medical supplies, unless medically necessary
  • Non-surgical, not medically-necessary cosmetic treatments (including routine foot care, hyperthidrosis, and/or non-medically necessary dermatological care)
  • Nutritional supplements, except as required by ACA preventive care guidelines
  • Obesity treatments (including bariatric surgery, treatments for complications caused by uncovered weight-loss surgery), except obesity screening and counseling that may be covered under the Preventive Care benefit
  • Oral surgery or dental treatments
  • Orthopedic shoes, except for diabetics
  • Penile implants
  • Routine patient costs for participation in an approved clinical trial
  • Sexual dysfunction
  • Sterilization and tubal ligation reversal
  • Travel vaccines

Pharmacy Exclusions:

  • Acne control
  • Allergy services and products (including allergenic extracts / biological miscellaneous and allergy sera)
  • Anabolic steroids
  • Anti-aging products
  • Any drug or medicine that is consumed or administered at the place where it is dispensed
  • Blood and blood plasma/blood products
  • Certain prescription drug products for which there are therapeutically equivalent alternatives available
  • Charges for drugs which may be properly received without charge under local, State or Federal programs
  • Charges for the administration of a covered drug
  • Complementary / homeopathic / alternative / herbal medications
  • Cosmetic drugs
  • Drugs or medicine that is to be taken by a participant, in whole or in part, while confined in an institution
  • Drugs prescribed, dispensed, or intended for use during an inpatient stay
  • Experimental or investigational use drugs
  • Fertility drugs
  • Gender-affirming care (including hormone therapy)
  • Gene and cellular therapies and associated services and supplies (see Medical Exclusions above)
  • Growth hormones
  • Hair growth or hair reduction agents (including Rogaine)
  • Immunologicals
  • Impotency drugs
  • Injectables, including Imitrex injections
  • Legend drugs (including Class V, diabetic supplies, diagnostics, legend drugs with over-the-counter equivalents, prenatal vitamins, and vitamins)
  • Medications for which prior authorization is required, but not obtained (including all specialty medications)
  • Non-prescription drug or medicine
  • Nutritional supplements, except as Medically Necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia, and homocystinuria food protein allergies, food protein-induced enterocolitis syndrome, eosinophilic disorders and short-bowel syndrome, as administered under the direction of a Physician
  • Ostomy supplies
  • Over-the-counter drugs, except to the extent required by the FFCRA
  • Prescriptions necessitated due to an occupational activity or event occurring as a result of an activity for wage or profit which an eligible person is entitled to receive without charge under any workers' compensation or similar law
  • Sexual dysfunction
  • Smoking deterrents
  • Tuberculin/allergy syringes
  • Weight-loss drugs (including anorexiants and GLP-1s prescribed for any condition other than type 2 diabetes)
  • X-ray / diagnostic agents