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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.
In addition, if you are enrolled in Medicare Part D there are no benefits
for outpatient prescription drugs under the Plan.
No benefits are payable under the Plan for any charge incurred for:
Services
- Care not related to and for diagnosis or treatment of injury or sickness.
- Care received in a government hospital, if the patient would not
have to pay if not covered by the Plan.
- Cosmetic surgery, except necessary expenses in connection with treatment of an accidental
injury.
- Custodial care
which primarily helps people meet personal needs and daily living
activities, whether given in or out of a hospital,
skilled-nursing facility,
nursing home or similar facility.
- Dental treatments, except as noted on page
29.
- Experimental or investigational
procedures or other procedures not proven by
long-term clinical studies (see Key Terms on page
52).
- Home-health care not approved by Medicare.
- Hospice care not approved by Medicare.
- In-home skilled-nursing care
not approved in advance by Aetna.
- Mental health condition that does not constitute the definition of a
mental health condition
(see Key Terms on page
53).
- Nurse's aides.
- Private-duty nursing care in a hospital or extended-care facility.
- Routine screening colonoscopies.
- Routine eye examinations.
- Routine hearing examinations.
- Routine physical examinations and related diagnostic lab and
radiology.
- Self-Treatment
- Skilled-nursing services and skilled rehabilitation services
provided in a skilled-nursing facility not approved by Medicare.
- Treatment for temporomandibular joint dysfunction (TMJ) not approved by Medicare.
- Treatment for which a covered person is not legally required to pay.
- Treatment of conditions for which benefits are provided by worker's
compensation or similar laws.
- Treatment of corns, calluses or toenails unless the procedure involves removing a nail
root or treating a metabolic or peripheral-vascular disease.
- Treatment of weak, strained or flat feet or any metatarsalgia or bunion unless the charges involve a cutting procedure.
- Vaccinations, inoculations or preventive shots or any charges for examination
for checkup purposes, other than those specifically noted on page
29
or covered by Medicare Part B.
Supplies
- Dental prosthetic appliances or the fitting of such appliances, except
as required on account of accidental bodily injury to physical organs.
- Eyeglasses.
- Hearing aids.
- Nutritional supplements, even if prescribed by a physician, except for the
treatment of phenylketonuria (PKU).
- Non-prescription drugs, vitamins, or medicines that can be purchased over the counter even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol).
- Orthopedic shoes, foot orthotics and other supportive devices for the feet
not approved by Medicare.
- Outpatient prescription drugs
purchased in excess of the allowed supply (34-day supply for retail
pharmacies and 90-day supply for mail order) per prescription or refill.
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