Exclusions

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 website at www.aetna.com. See Basic Plan features for more information.

The Plan does not cover the following services and supplies:

General exclusions

• Any services or supplies that are not medically necessary, as determined by Aetna.
• Any procedure, treatment or other type of coverage prohibited under federal, state, local or other applicable law
• Charges for missed appointments, and/or completion of claim forms.  
• Care for conditions that, by state or local law, must be treated in a public facility.
• Court-ordered services and services required by court order as a condition of parole or probation, unless medically necessary and provided by participating providers upon referral from your PCP.
• Expenses that are the legal responsibility of Medicare or a third party payer.
• Experimental and investigational services and procedures; ineffective surgical, medical, psychiatric, or dental treatments or procedures; research studies, or other experimental or investigational health care procedures or pharmacological regimes, as determined by Aetna, unless approved by Aetna in advance. This exclusion will not apply to drugs:
• that have been granted treatment investigational new drug (IND) or Group c/treatment IND status,
• that are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute, or
• that Aetna has determined, based upon scientific evidence, demonstrate effectiveness or show promise of being effective for the condition.
• Refer to the Key Terms section for a definition of experimental or investigational.
• Health services, including those related to pregnancy that are provided before your coverage is effective or after your coverage has been terminated.
• Treatment in a federal, state or governmental facility, including care and treatment provided in a nonparticipating hospital owned or operated by any federal, state or other governmental entity, except to the extent required by applicable laws.
• Treatment of illnesses, injuries or disabilities related to military service for which you are entitled to receive treatment at government facilities that are reasonably available to you.
• Treatment of injuries sustained while committing a felony.
• Treatment of sickness or injury covered by a worker’s compensation act or occupational disease law, or by United States Longshoreman’s and Harbor Worker’s Compensation Act.
• Services not covered by the Plan, even when your PCP has issued a referral for those services.
• Services or supplies covered by any automobile insurance policy, up to the policy’s amount of coverage limitation.
• Services provided by your close relative (your spouse, child, brother, sister, or the parent of you or your spouse) for which, in the absence of coverage, no charge would be made.
• Services required by a third party, including (but not limited to) physical examinations, diagnostic services and immunizations in connection with:
• ·obtaining or continuing employment,
• ·obtaining or maintaining any license issued by a municipality, state or federal government,
• securing insurance coverage,
• travel, and
• school admissions or attendance, including examinations required to participate in athletics, unless the service is considered to be part of an appropriate schedule of wellness services.
• Services and supplies that are not medically necessary.
• Services you are not legally obligated to pay for in the absence of this coverage.

Physicians and other health professionals

• Any program or service performed in a nonconventional setting, even if the services are performed by a licensed provider, including: spas/resorts, outdoor learning or leadership programs; wilderness, camp, or ranch programs; academic, vocational, or recreational settings.
• Any service in connection with, or required by, a procedure or benefit not covered by the Plan.
• Services primarily of an educational nature or in an educational setting, including but not limited to services for developmental reading disorders, developmental arithmetic disorders, developmental language disorders or developmental articulation disorders.

Hospital and other facility care

• Ambulance services, when used for non-emergency transportation.
• Cosmetic surgery or surgical procedures primarily for the purpose of changing the appearance of any part of the body to improve appearance or self-esteem. However, the Plan covers the following:
• reconstructive surgery to correct the results of an injury.
• surgery to treat congenital defects (such as cleft lip and cleft palate) to restore normal bodily function.
• surgery to reconstruct a breast after a mastectomy that was done to treat a condition, or as a continuation of a staged reconstructive procedure.
• Inpatient care for serious mental illness which is not provided in a hospital or mental health treatment facility.
• Outpatient supplies, including (but not limited to) outpatient medical consumable or disposable supplies such as syringes, incontinence pads, elastic stockings and reagent strips, (except as described under Prescription Drugs).
• Personal comfort or convenience items, including services and supplies that are not directly related to medical care, such as guest meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, take-home supplies, and other similar items and services.
• Private duty nursing care, unless preauthorized.
• Radial keratotomy, including related procedures designed to surgically correct refractive errors.
• Surgical operations, procedures or treatment of obesity, except when approved in advance by Aetna. Bariatric surgery is excluded in all events and will not be pre-authorized

Specific conditions

• Acupuncture and acupuncture therapy, except when performed by a participating physician as a form of anesthesia in connection with covered surgery.
• Biofeedback, except as specifically approved by Aetna.
• Blood, blood plasma, or other blood derivatives or substitutes.
• Breast augmentation and otoplasties, including treatment of gynecomastia.
• Care furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the condition or injury.
• Contact Lens Fitting.
• Custodial care and rest cures.
• Dental care and treatment, including (but not limited to):
  • care, filling, removal or replacement of teeth,
  • dental services related to the gums,
  • apicoectomy (dental root resection),
  • ·orthodontics,
  • root canal treatment,
  • soft tissue impactions,
  • alveolectomy,
  • augmentation and vestibuloplasty treatment of periodontal disease,
  • prosthetic restoration of dental implants, and
  • dental implants.
• Elective abortions.
• Hair analysis.
• Hearing aids. Even though this Plan does not provide coverage for hearing aids, if you are considering the purchase of hearing aids, you may be able to lower your out-of-pocket expenses through the Amplifon Hearing Health Care (formerly HearPo) Discount Program or the Hearing Care Solutions Discount Program. These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of-pocket expenses could be lower. To find a participating hearing discount center location, you can visit www.aetna.com or call Amplifon Hearing Health Care (formerly HearPo) at 1-877-301-0840 or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.
• Home births.
• Home uterine activity monitoring.
• Household equipment, including (but not limited to) the purchase or rental of exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypo-allergenic pillows, mattresses or waterbeds, is not covered. Improvements to your home or place of work, including (but not limited to) ramps, elevators, handrails, stair glides and swimming pools, are not covered.
• Hypnotherapy, except when approved in advance by Aetna.
• Incidental charges.
• Implantable drugs.
• Maintenance, replacement, or repair for continuously rented Durable Medical Equipment (DME), frequently serviced DME, or oxygen equipment are not covered as a separate expense under the Plan.
• Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision).
• Orthotics (except for diabetes).  If for diabetes, the orthotic must be coordinated by the PCP. Contact Aetna Member services for preauthorization.
• Recreational, educational and sleep therapy, including any related diagnostic testing.
• Religious, marital and sex counseling, including related services and treatment.
• Reversal of voluntary sterilizations, including related follow-up care and treatment of complications of such procedures.
• Routine hand and foot care services, including routine reduction of nails, calluses and corns.
• Routine hearing exam.
• Special education, including lessons in sign language to instruct a plan participant whose ability to speak has been lost or impaired to function without that ability.
• Special medical reports, including those not directly related to the medical treatment of a plan participant (such as employment or insurance physicals) and reports prepared in connection with litigation.
• Specific injectable drugs, including:
  • experimental drugs or medications, or drugs or medications that have not been proven safe and effective for a specific condition or approved for a mode of treatment by the FDA and the National Institutes of Health,
  • ·needles, syringes and other injectable aids (except as described under Prescription Drugs),
  • drugs related to treatments not covered by the Plan, and
  • performance-enhancing steroids.
• Specific non-standard allergy services and supplies, including (but not limited to):
  • cytotoxicity testing (Bryan’s Test),
  • treatment of non-specific candida sensitivity, and
  • urine auto injections.
• Therapy or rehabilitation, including (but not limited to):
  • primal therapy
  • chelation therapy
  • rolfing
  • psychodrama
  • megavitamin therapy
  • purging
  • bioenergetic therapy
  • ·vision perception training
  • carbon dioxide therapy
  • Thermograms and thermography.
• Treatment, including therapy, supplies and counseling, for sexual dysfunctions or inadequacies that do not have a physiological or organic basis.
• Treatment of temporomandibular joint (TMJ) syndrome, with the exception of diagnostic and surgical treatment, including (but not limited to):
• treatment performed by placing a prosthesis directly on the teeth,
• non-surgical medical and dental services, and
• therapeutic services related to TMJ.

• Weight reduction programs and dietary supplements.