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 even when medical provider has recommended/prescribed the services.
• 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 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