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Exclusions

Exclusions for the Retiree Medical Plan - POS II A and B options

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 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 ( 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 expense not recommended and approved by a physician acting within the scope of his or her license.
  • Any expenses that exceed reasonable and customary limits.
  • 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.
  • Confinement in a facility that is primarily a school, place of rest, or nursing home.
  • Cosmetic surgical procedures, treatments or hospital confinements, 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.
  • Dental charges except as specifically provided for in Specific coverage 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.
  • Elective abortions
  • Experimental or investigational drugs or treatments for a particular diagnosis.
  • Foot orthotics and other supportive devices for feet with the exception of some types of foot braces, even if prescribed by a physician.
  • In-hospital expenses for non-medical items, such as a telephone or television set.
  • Fertility services, treatments, and prescriptions.
  • Maintenance, replacement, or repair for continuously rented DME, frequently serviced DME, or oxygen equipment are not covered as a separate expense under the Plan.
  • 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 physical or occupational treatment necessary due to delayed development.
  • Outpatient prescription drugs in excess of the allowed supply (34 days for retail and 90 days for home delivery) per fill or refill.
  • Outpatient speech therapy treatment necessary due to delayed speech development or treatment that is educational rather than restorative in nature.
  • Periodic physical examinations paid for by the company.
  • 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.
  • 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.
  • 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.
  • Routine eye examinations, eyeglasses, contact lenses, and orthoptics.
  • Self-treatment.
  • Treatment not specifically covered or meeting the Plan's requirements for medical necessity for the care or treatment of a particular disease, injury, or pregnancy, . even when medical provider has recommended/prescribed the services.
  • 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).
  • Wigs or hairpieces for androgenic alopecia (male pattern baldness).
  • Charges for missed appointments, and/or completion of claim forms are excluded by the Plan. 

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