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.
No benefits are payable under the Plan (EMMP 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 expenses that exceed reasonable and customary limits.
- 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 are excluded by the Plan
Physicians and other health professionals
- Any expense not recommended and approved by a physician acting within the scope of his or her license.
- 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.
- Experimental or investigational drugs or treatments for a particular diagnosis.
- Periodic physical examinations paid for by the company.
- Treatment not specifically covered or meeting the Plan's requirements for medically necessary for the care or treatment of a particular disease, injury, or pregnancy, even when medical provider has recommended/prescribed the services
Hospital and other facility care
- Cosmetic surgical procedures, treatments or hospital stays, except for those that are primarily for the purpose of restoring a bodily function or surgery, which is medically necessary.
- Custodial care or maintenance care, even if ordered by a physician.
- In-hospital expenses for non-medical items, such as a telephone or television set.
- Private-duty nursing, except as defined in the Covered expenses section.
- Private room rate above the hospital's most common semiprivate room rate, except when medically necessary.
- Stay in a facility that is primarily a school, place of rest, or nursing home.
- 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.
- Dental charges except as specifically provided in the Covered Expenses section.
- Drugs or vitamins that are available over the counter, even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol).
- 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.
- Non-therapeutic or elective abortions.
- Foot orthotics and other supportive devices for feet with the exception of some types of foot braces, even if prescribed by a physician.
- 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.
- 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 or dietician, consistent with Aetna's Clinical Policy Bulletins.
- Nutritional supplements, even if prescribed by a physician, except for treatment of phenylketonuria (PKU).
- Outpatient prescription drugs in excess of the allowed supply (34 days for retail and 90 days for home delivery) per fill or refill.
- Routine eye examinations, eyeglasses, contact lenses, and orthoptics.
- Some prescription medications including injections, billed by and provided in an outpatient hospital or Doctor's office, are not covered under Aetna, but may be covered under the prescription drug program administered through Express Scripts.
- Wigs or hairpieces for androgenic alopecia (male pattern baldness).
- 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, transportation costs to travel to a COE/IOE, if the distance is over 100 miles, and for Organ, Tissue, and Bone Marrow Transplants.
- Voluntary sterilization reversal procedures (including any services for infertility related to voluntary sterilization and its reversal).