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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 17 for more information.
No benefits are payable under the Plan for any charge incurred for:
- Any claim submitted past the claim-filing deadline.
- Any expense incurred before you or your dependents became covered
under this option (except dependent children less than 31 days old).
- Any expense after the Plan has paid the lifetime maximum benefit of
$6,000,000.
- Any expense not recommended and approved by a physician
acting within the scope of his or her license.
- Any expense incurred during the period of pre-existing exclusion.
- Any expenses above reasonable and customary limits.
- Bariatric surgery expenses for the treatment of
morbid obesity in excess of the $25,000
lifetime maximum within the Plan $6,000,000 lifetime maximum.
- Chelation therapy.
- Chemical dependency inpatient treatment after the fourth treatment for an individual.
- Chiropractic services for therapeutic purposes in excess of $1,000 per person per year and any maintenance chiropractic care.
- 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 37.
- Drugs or vitamins that are available over the counter, even if prescribed by a physician.
- Experimental or investigational
drugs or treatments for a particular diagnosis, other than treatments of last resort.
- Foot orthotics and other supportive devices for feet, even if prescribed by a physician.
- 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.
- Non-therapeutic abortions.
- 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.
- Nutritional supplements, even if prescribed by a physician,
except for treatment of phenylketonuria (PKU).
- Outpatient or network inpatient mental health or chemical
dependency treatment not pre-certified by Magellan Health Services.
- Outpatient prescription drugs in excess of the allowed supply (34 days for retail and 90 days for mail order) per fill or refill.
- 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.
- Laser-assisted in situ keratomileusis (LASIK), photorefractive
keratectomy (PRK), and other similar or related procedures to improve visual
acuity.
- Routine eye examinations, eyeglasses, contact lenses, and
orthoptics.
- Self-treatment.
- Speech therapy outpatient treatment necessary due to delayed
speech development or treatment that is educational rather than restorative in
nature.
- Voluntary sterilization reversal procedures
(including any services for infertility related to voluntary
sterilization and its reversal).
- 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, unless:
- Pre-approved by the Administrator-Benefits;
- In conjunction with Aetna's National Medical Excellence® Program or
Partners in Health Centers of Excellence; or
- Moving from a non-POS II to a POS II facility following an emergency admission.
- Wigs or hairpieces for androgenic alopecia (male pattern baldness).
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