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.  
• Any claim submitted past the claim-filing deadline.
• 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.
• 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:
  • oobtaining or continuing employment,
  • oobtaining 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
• Any expenses that exceed reasonable and customary limits.
• 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.
• 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 his or her license.

Hospital and other facility care

• Ambulance services, when used for non-emergency transportation.Any program or services performed in an experimental or investigational setting, per Aetna´s Clinical policy bulletins.
• 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
• 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).

Specific conditions

• Applied Behavior Analysis (ABA) for Autism spectrum disorder 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.
• 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.
• Chiropractic services for therapeutic purposes in excess of 20 visits 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.
• Fertility benefits provided by Progyny.
• 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. 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).
• 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 or Life Mart 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.
• 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.
• 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.
• Routine eye examinations, eyeglasses, contact lenses, and orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision).
• Routine hearing exam.
• 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,
  • oneedles, 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
• rolfing
• psychodrama
• megavitamin therapy
• purging
• bioenergetic therapy
• ovision perception training
• carbon dioxide therapy
• Thermograms and thermography.
• Treatment, including therapy, supplies and counseling, for sexual dysfunctions or inadequacies.
• Jaw joint disorder treatment (TMJ) performed by prosthesis placed directly on the teeth, surgical and non-surgical medical and dental services, and diagnostic or therapeutics services related to TMJ
• Weight reduction programs and dietary supplements.
• 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/IOE:
• if the distance is over 100 miles,
• and for Organ, Tissue, and Bone Marrow Transplants.

Concurrent Care Claims, Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive notice if Aetna makes an adverse benefit determination.

Adverse benefit determinations are decisions Aetna makes that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service.

Adverse benefit determinations can be made for one or more of the following reasons:

• The individual is not eligible to participate in the Plan, or
• Aetna determines that a benefit or service is not covered by the Plan because:
• it is not included in the list of covered benefits,
• it is specifically excluded,
• a Plan limitation has been reached, or
• it is not medically necessary.