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TMJ and CMD, Contraceptives, and Sexual Dysfunction

UPDATED: February 24, 2015

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What follows is a breakdown of specific exclusions from coverage found in a typical individual health insurance policy.

(Typical wording*):

Limitations, Exclusions and Non-Waiver (cont.)

B. Exclusions (cont.) [In addition to other general Policy exclusions from coverage, the Policy does not provide coverage for any of the following, all of which are specifically excluded]:

32. Temporomandibular Joint Disorder (TMJ) or Craniomandibular Disorder (CMD);

33. contraceptives, oral or otherwise, whether medication or device, regardless of intended use;

34. Prescription Drugs that are dispensed by a Provider, Hospital or other state-licensed facility;

35. immunization agents, biological or allergy sera, hematinics, blood or blood products administered on an Outpatient basis;

36. products used for cosmetic purposes or indications;

37. level one controlled substances;

38. Prescription Drugs used to treat or cure hair loss or baldness;

39. anabolic steroids or growth hormones;

40. Appetite suppressants, including but not limited to, anorectics or any other drugs used for the purpose of weight control;

41. Fertility medications;

42. Compounded prescription Drugs;

43. Drugs or medications prescribed for the treatment of sexual or erectile dysfuntions;

44. Flouride products;

TMJ/CMD: Under the policy above, any treatment for TMJ (temporomandibular joint disorder) or CMD (craniomandibular disorder) and any of the expenses related thereto are excluded from coverage. In other words, the expenses for TMJ disorder and CMD disorder are out-of-pocket. However, not all insurance policies have specific exclusion clauses. Some will cover a certain dollar amount.

Contraceptives: This health insurance policy does not cover any form of contraceptives, regardless of their intended use.

In order to be subject to consideration for coverage, prescription drugs must be dispensed by pharmacists on an outpatient basis under orders by a provider who is acting within the scope of his or her license to treat an injury or sickness. If your health care provider dispenses the drug, its cost is not eligible for coverage under the policy.

Allergy shots administered on an outpatient basis, which most are, are excluded from coverage.

Consistent with the exclusion of the expenses of cosmetic surgery, so too are the expenses for products used for cosmetics purposes.

*Wording may vary from contract to contract and from state to state.

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