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Exclusions for the ExxonMobil Medical Plan – Aetna POS II A and POS II B options

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 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:

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
  • Any claim submitted past the claim-filing deadline.
  • Includes those court-ordered services and supplies, or those required as a condition of parole, probation, release or as a result of any legal proceeding
  • Payment for a portion of the charge that Medicare or another party is responsible for as the primary payer.
  • Experimental or investigational drugs, devices, treatments or procedures unless otherwise covered under clinical trial therapies (experimental or investigational) or covered under clinical trials (routine patient costs). See the Eligible health services under your plan – Other services section.
  • 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.
  • Any service in connection with, or required by, a procedure or benefit not covered by the Plan.
  • 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 you are not legally obligated to pay for in the absence of this coverage.
  • 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.
  • 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.
  • 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.

Physicians and other health professionals

  • Any expense not recommended and approved by a physician acting within the scope of their license.

Hospital and other facility care

  • Any program or services performed in an experimental or investigational setting, per Aetna´s Clinical policy bulletins.
  • Ambulance services, when used for non-emergency transportation.
  • Any outpatient disposable supply or device (except as described under Prescriptions Drugs) including, but not limited to: Sheaths, Bags, Elastic garments, Support hose, Bandages, Bedpans, Syringes, Blood or urine testing supplies, Other home test kits, Splints, Neck braces, Compresses, Other devices not intended for reuse by another patient.
  • Private room rate above the hospital’s most common semiprivate room rate, except when medically necessary.
  • Care, services or supplies provided in:
    • Rest homes
    • Assisted living facilities
    • Similar institutions serving as a persons’ main residence or providing mainly custodial or rest care
    • Health resorts
    • Spas or sanitariums
    • Infirmaries at schools, colleges, or camps

Specific conditions

  • Any services and supplies related to births that take place in the home or in any other place not licensed to perform deliveries, including Home uterine activity monitoring.
  • Bariatric surgery expenses for the treatment of morbid obesity in excess of the $25,000 lifetime maximum.
  • Biofeedback, except as specifically approved by Aetna.

Blood, blood plasma, synthetic blood, blood derivatives or substitutes

  • Chiropractic services for therapeutic purposes in excess of 20 visits or $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.
  • Non-therapeutic or elective abortions.
  • Hair analysis
  • Prosthetic devices:
    • Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet, unless required for the treatment of or to prevent complications of diabetes, or if the orthopedic shoe is an integral part of a covered leg brace
    • Trusses, corsets, and other support items
    • Repair and replacement due to loss, misuse, abuse or theft
  • Laser-assisted in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and other similar or related procedures to improve visual acuity.
  • 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). 
  • 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.
  • 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.
  • Outpatient prescription drugs in excess of the allowed supply (34 days for retail and 90 days for home delivery) per fill or refill.
  • Radial keratotomy, including related procedures designed to surgically correct refractive errors.
  • Recreational, educational and sleep therapy, including any related diagnostic testing.
  • Religious, marital and sex counseling, including related services and treatment.
  • Reversal of voluntary sterilizations.
  • Routine hand and foot care services, including routine reduction of nails, calluses and corns.
  • 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, contact lens fitting, and orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision).
  • Self-treatment.
  • 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.
  • Treatment, including therapy, supplies and counseling, for sexual dysfunctions or inadequacies.
  • 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.
  • Wigs or hairpieces for androgenic alopecia (male pattern baldness).
  • Treatment of occupational illnesses or injuries sustained in situations covered by workers’ compensation or a similar law.
  • Transportation or travel expenses except for:
    • emergency transportation service by professional ambulance
    • transportation costs to travel to a COE/IOQ/IOE:
      • if the distance is over 100 miles,
      • and for Organ, Tissue, and Bone Marrow Transplants.

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