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Exclusions
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Exclusions
Q. Are there expenses not covered by the Plan?
A. Although the Plan covers many types of treatments and services, it
does not cover all of them. Exclusions shall be interpreted and applied
consistently with Clinical Policy Bulletins published by Aetna. These bulletins
can be accessed on the Aetna NavigatorTM Web site and the Aetna Web site at
www.aetna.com.
See page 19 for more information.
No benefits are payable under the Plan (POS II
"A" and "B") for any charge incurred for:
- Any claim submitted past the claim-filing deadline.
- Any expense incurred before you or your family members became covered under this option (except children less than 31 days old).
- Any expense not recommended and approved by a physician
acting within the scope of his or her license.
- Any expenses that exceed reasonable and customary
limits.
- Bariatric surgery expenses for the treatment of morbid obesity in excess of the $25,000 lifetime maximum.
- Chelation therapy.
- Chiropractic services for therapeutic purposes in excess of $1,000 per person per year and any maintenance chiropractic care.
- Concierge or annual fees. Any portion not related to medical care (such as a private waiting room, same-day appointments, extended time with physician) is excluded.
- Confinement in a facility that is primarily a school, place of rest,
or nursing home.
- Cosmetic surgical procedures, treatments or hospital confinements.
- Custodial care
or maintenance care, even if ordered by a physician.
- Dental charges except as specifically provided for on page
40.
- Drugs or vitamins that are available over the counter, even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol)
- Elective abortions
- Experimental or investigational
drugs or treatments for a particular diagnosis, other than treatments of last resort.
- Foot orthotics and other supportive devices for feet with the exception of some types of foot braces, even if prescribed by a physician.
- Immunizations/vaccinations obtained outside of a physician's office or hospital, except for the shingles vaccine.
- In-hospital expenses for non-medical items, such as a telephone or television
set.
- In-vitro fertilization, embryo transferal, GIFT (Gamete Intra-Fallopian Transfer),
ZIFT (Zygote Intra-Fallopian Transfer), artificial insemination or other similar or related
procedures, including follow-up testing, to bypass infertility in order to
produce pregnancy.
- Laser-assisted in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and other similar or related procedures to improve visual acuity. Revision or repeated treatment of surgery is not covered.
- Nurse's aides.
- Nutritional programs, weight programs, and related
food supplements, except for physician expenses and lab costs for
treatment of morbid obesity, and for nutritional counseling
performed by a licensed nutritionist for anorexia nervosa and
bulimia nervosa, consistent with Aetna's Clinical Policy
Bulletins, when supervised and billed by a doctor.
- Nutritional supplements, even if prescribed by a
physician, except for treatment of phenylketonuria (PKU).
- Outpatient physical or occupational treatment necessary due to delayed development.
- Outpatient prescription drugs in excess of the
allowed supply (34 days for retail and 90 days for mail order) per
fill or refill.
- Outpatient speech therapy outpatient treatment necessary due to delayed speech development or treatment that is educational rather than restorative in nature.
- Periodic physical examinations paid for by the company.
- Private-duty nursing, except as defined in the Covered Expenses section.
- Private room rate above the hospital's most common semiprivate room rate, except where total isolation is medically required
and documented in writing by the physician.
- Routine eye examinations, eyeglasses, contact lenses, and
orthoptics.
- Self-treatment.
- Training, education or behavior modification for Autism Spectrum Disorder
- Treatment not specifically covered or meeting the Plan's requirements for
medical necessity
for the care or treatment of a particular disease, injury, or pregnancy.
- Treatment of injuries received or illnesses contracted
while on military assignment and covered by a government medical plan.
- Treatment of occupational illnesses or injuries sustained
in situations covered by workers' compensation or a similar law.
- Transportation or travel expenses other than emergency transportation
service by professional ambulance.
- Voluntary sterilization reversal procedures
(including any services for infertility related to voluntary
sterilization and its reversal).
- Wigs or hairpieces for androgenic alopecia (male pattern baldness).
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