Q. Are there expenses not covered by the Plan?
A. Although the Plan covers many types of treatments and services, it does not cover all. In addition, if you are enrolled in Medicare Part D there are no benefits for outpatient prescription drugs under the Plan.
No benefits are payable under the Plan for any charge incurred for:
- Care not related to and for diagnosis or treatment of injury or sickness.
- Care received in a government hospital, if the patient would not have to pay if not covered by the Plan.
- Cosmetic surgery, except necessary expenses in connection with treatment of an accidental injury.
- Custodial care which primarily helps people meet personal needs and daily living activities, whether given in or out of a hospital, skilled-nursing facility, nursing home or similar facility.
- Dental treatments, except as noted under Covered expenses.
- Experimental or investigational procedures or other procedures not proven by long-term clinical studies (see Key terms).
- Home-health care not approved by Medicare.
- Hospice care not approved by Medicare.
- In-home private duty nursing care not approved in advance by Aetna.
- Mental health condition that does not constitute the definition of a mental health condition (see Key terms).
- Nurse's aides.
- Private-duty nursing care in a hospital or extended-care facility.
- Routine screening colonoscopies.
- Routine eye examinations.
- Routine hearing examinations.
- Routine physical examinations and related diagnostic lab and radiology.
- Skilled-nursing services and skilled rehabilitation services provided in a skilled-nursing facility not approved by Medicare.
- Treatment for temporomandibular joint dysfunction (TMJ) not approved by Medicare.
- Treatment for which a covered person is not legally required to pay.
- Treatment of conditions for which benefits are provided by worker's compensation or similar laws.
- Treatment of corns, calluses or toenails unless the procedure involves removing a nail root or treating a metabolic or peripheral-vascular disease.
- Treatment of weak, strained or flat feet or any metatarsalgia or bunion unless the charges involve a cutting procedure.
- Vaccinations, inoculations or preventive shots or any charges for examination for checkup purposes, other than those specifically noted under Covered expenses or covered by Medicare Part B.
- Dental prosthetic appliances or the fitting of such appliances, except as required on account of accidental bodily injury to physical organs.
- 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 Ampifon Hearing Health Care 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 and search Find a Doctor, Facility or Pharmacy and then select Hearing Discount Locations. To compare costs, please call Ampifon at 1-888-HEARING (1-888-432-7464) or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.
- Nutritional supplements, even if prescribed by a physician, except for the treatment of phenylketonuria (PKU).
- Non-prescription drugs, vitamins, or medicines that can be purchased over the counter even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol).
- Orthopedic shoes, foot orthotics and other supportive devices for the feet not approved by Medicare.
- Outpatient prescription drugs purchased in excess of the allowed supply (34-day supply for retail pharmacies and 90-day supply for home delivery) per prescription or refill.