The following are not Covered Benefits except as described in the Covered Benefits section of this Contract or by amendment(s) attached to this Contract:
Ambulance services, for routine transportation to receive outpatient or inpatient services. Applied Behavior Analysis and similar programs unless specifically described in this Contract. Behavioral health services that are not primarily aimed at treatment of illness, injury, restoration
of physiological functions or that do not have a physiological or organic basis. Biofeedback, except as precertified by Aetna.
Blood and blood plasma, including but not limited to, provision of blood, blood plasma, blood derivatives, synthetic blood or blood products other than blood derived clotting factors, the collection or storage of blood plasma, the cost of receiving the services of professional blood donors, apheresis or plasmapheresis. Only administration, processing of blood, processing fees, and fees related to autologous blood donations are covered.
Care for conditions that state or local laws require to be treated in a public facility, including but not limited to, mental illness commitments.
Care furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the disease or injury.
Certain Transplant Occurrence-related services or supplies including: treatment furnished to a donor when the Transplant recipient is not a Member; services and supplies not obtained from an IOE, including the harvesting or storage of organs without the expectation of immediate transplantation for an existing illness; harvesting and/or storage of bone marrow, tissue or stem cells without the expectation of transplantation within 12 months for an existing illness;
outpatient Prescription Drugs not expressly related to an outpatient Transplant Occurrence; and home infusion therapy.
Charges for Transplant expenses incurred within the first twelve month of continuous coverage under this Contract. This limitation may be reduced by the number of months of prior
Transplant coverage the Member has on the Effective Date of Coverage under this Contract, if the Member has at least 12 months of such prior Transplant coverage.
This limitation will not apply for a child during the first 12 months of life otherwise eligible for coverage under the Plan.
Clinical trial therapies
- Services and supplies related to data collection and record-keeping that is solely needed due to the clinical trial (i.e. protocol-induced costs)
promising experimental and investigational interventions for terminal illnesses in certain clinical trials in accordance with Aetna’s claim policies).
Cornea (Corneal Graft with Amniotic Membrane) or Cartilage (autologous chondrocyte or autologous osteochondral mosaicplasty) Transplants unless authorized by Aetna.
Contraception, except as specifically described in the Covered Benefit section including, but not limited to, over-the-counter contraceptive supplies such as condoms, contraceptive foams, jellies and ointments.
Cosmetic Surgery, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery. This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty, except when determined to be Medically Necessary by an Aetna Medical Director, is not covered. This exclusion does not apply to surgery to correct the results of injuries causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily
functions, including but not limited to, cleft lip and cleft palate.
Court ordered services, or those required by court order as a condition of parole or probation. Custodial Care.
Dental services except as specifically covered in the Covered Benefitssection, including but not limited to, services related to the care, filling, removal or replacement of teeth and treatment of injuries to or diseases of the teeth, dental services related to the gums, apicoectomy (dental root resection), orthodontics, root canal treatment, soft tissue impactions, bony impacted teeth, alveolectomy, augmentation and vestibuloplasty treatment of periodontal disease, false teeth, prosthetic restoration of dental implants, and dental implants. This exclusion does not include removal of bony impacted teeth, bone fractures, removal of tumors, and orthodontogenic cysts. Educational services and treatment of behavioral disorders, together with services for remedial
education including evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral training, and cognitive rehabilitation. This includes services, treatment or educational testing and training related to behavioral (conduct) problems, learning disabilities, or developmental delays. Special education, including lessons in sign language to instruct a Member, whose ability to speak has been lost or impaired, to function without that ability, are not covered.
Experimental or Investigational Procedures, or ineffective surgical, medical, psychiatric, or dental treatments or procedures, research studies, or other experimental or investigational health care procedures or pharmacological regimes as determined by Aetna, unless precertified by Aetna. This exclusion will not apply with respect to drugs:
- That have been granted treatment investigational new drug (IND) or Group c/treatment IND status;
- That are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute; or
- Aetna has determined that available scientific evidence demonstrates that the drug is effective or the drug shows promise of being effective for the disease.
• E-Visits – Non-Contracted Providers.
Any services that are given by providers that are not contracted with Aetna as e- visitproviders. Any services that are not provided during an internet-based consult or via telephone.
Foot Orthotics.
Habilitation Therapy Services -- Physical, Occupational and Speech Therapy, unless specifically described in theCovered Benefits section, this exclusion includes:
Therapies to treat delays in development and/or chronic conditions. Examples of non- covered diagnoses that are considered both developmental and/or chronic in nature are:
- Pervasive developmental disorders
- Down syndrome
This exclusion does not apply to physical therapy, occupational therapy or speech therapy provided for the treatment of Autism Spectrum Disorder.
Any service unless provided in accordance with a specific treatment plan Services you get from a home health care agency.
Services not given by a physician (or under the direct supervision of a physician),physical, occupational or speech therapist.
Services for the treatment of delays in development, including speech development, unless as a result of a gross anatomical defect present at birth.
Hair analysis.
Hearing aids. Related services and supplies, except as specifically described in this Contract Home births.
Home Health Care. Unless specifiedin Covered Benefits section: - Services or supplies that are not a part of the home health care plan;
- Services of a person who usually lives with you, or who is a member of your, or your spouse’s or your domestic partner’s family;
- Services for infusion therapy; - Transportation;
- Services or supplies provided to a minor or dependent adult when a family member or caregiver is not present; and
- Services that are custodial care. - Services for applied behavior analysis. Home uterine activity monitoring.
Household equipment, including but not limited to, the purchase or rental of exercise cycles, water purifiers, hypo-allergenic pillows, mattresses or waterbeds, whirlpool or swimming pools, exercise and massage equipment, central or unit air conditioners, air purifiers, humidifiers, dehumidifiers, escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a Member’s house or place of business, and adjustments made to vehicles.
Hypnotherapy, except when precertified by Aetna. Implantable drugs.
Infertility.Any services, treatments, procedures or supplies that are designed to enhance fertility or the likelihood of conception, such as:
- Drugs, and drugs related to the treatment of non-covered benefits.
- Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH agonists.
- Reversal of voluntary sterilization including related procedures, services and supplies. - The purchase of donor sperm and any charges for the storage of sperm.
- All charges associated with surrogacy for you or the surrogate. A surrogate is a female carrying her own genetically related child where the child is conceived with the
intention of turning the child over to be raised by others, including the biological father. - Home ovulation prediction kits or home pregnancy tests.
- Medication that is Experimental or Investigational in relation to infertility. - The purchase of donor embryos, donor oocytes, or donor sperm.
- Charges associated with cryopreservation or storage of cryopreserved eggs and embryos (e.g., office, hospital, ultrasounds, laboratory tests, etc.), including thawing charges.
- All charges associated with the care of the donor in a donor egg cycle. This includes, but is not limited to, any payments to the donor, donor screening fees, fees for lab tests, and any charges associated with care of the donor required for donor egg retrievals or transfers.
- All charges associated with the use of a gestational carrier for the female acting as the gestational carrier. A gestational carrier is a female carrying an embryo to which she is not genetically related.
- Comprehensive infertility services ART services.
- Any charges associated with obtaining sperm for ART services.
- Ovulation induction with menotropins, Intrauterine insemination and any related services, products or procedures.
- In vitro fertilization (IVF), Zygote intrafallopian transfer (ZIFT), Gamete intra- fallopian transfer (GIFT), Cryopreserved embryo transfers and any related services, products or procedures (such as Intracytoplasmic sperm injection (ICSI) or ovum microsurgery).
• Mental health treatment.
Mental health services for the following categories (or equivalent terms as listed in the most recent version of the International Classification of Diseases (ICD)):
- Dementias and amnesias without behavioral disturbances
- Tobacco use disorders - Specific disorders of sleep
- Antisocial or dissocial personality disorder - Pathological gambling, kleptomania, pyromania
- Specific delays in development (learning disorders, academic underachievement) - Intellectual disability
- Wilderness Treatment Programs or any such related or similar programs, school and/or education services.
Military service related diseases, disabilities or injuries for which the Member is legally entitled to receive treatment at government facilities and which facilities are reasonably available to the Member.
Missed appointment charges.
Non-Medically Necessary services, including but not limited to, those services and supplies: - Which are not Medically Necessary, as determined by Aetna, for the diagnosis and
treatment of illness, injury, restoration of physiological functions, or covered preventive services;
- That do not require the technical skills of a medical, mental health or a dental professional; - Furnished mainly for the personal comfort or convenience of the Member, or any person
who cares for the Member, or any person who is part of the Member’s family, or any Provider;
- Furnished solely because the Member is an inpatient on any day in which the Member’s disease or injury could safely and adequately be diagnosed or treated while not confined; - Furnished solely because of the setting if the service or supply could safely and adequately be
furnished in a Physician’s or a dentist’s office or other less costly setting.
Nursing and aide services provided outside of the home(such as in conjunction with school, vacation, work or recreational activities).
- Outpatient infusion therapy services, other than as specifically described in the Covered Benefits section, including:
- Enteral nutrition
- Blood transfusions and blood products - Dialysis
Outpatient Prescription contraceptive drugs and devices services, other than as specifically described in the Covered Benefits section, including:
- Oral drugs that are brand-name Prescription Drugs and biosimilar Prescription Drugs.
- Injectable drugs that are brand-name Prescription Drugs and biosimilar Prescription Drugs.
- Vaginal rings that are generic Prescription Drugs, brand-name Prescription Drugs and biosimilar Prescription Drugs.
- Transdermal contraceptive patches that are generic Prescription Drugs, brand-name Prescription Drugs and biosimilar Prescription Drugs.
- Female contraceptive devices that are brand-name devices.
- FDA-approved female brand-name and biosimilar emergency contraceptives and brand-name over-the-counter (OTC) emergency contraceptives.
- Other FDA-approved female and male brand-name over-the-counter (OTC) contraceptives. Outpatient supplies, including but not limited to, medical consumable or disposable supplies such
as syringes, incontinence pads, elastic stockings, and reagent strips.
Payment for that portion of the benefit for which Medicare or another party is the primary payer. Personal comfort or convenience items, including those services and supplies 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 like items and services.
Prescription or non-Prescription Drugs and medicines, except as provided on an inpatient basis. Private Duty Nursing (See the Home Health Benefits section regarding coverage of nursing
services).
Recreational, educational, and sleep therapy, including any related diagnostic testing. Religious, marital and sex counseling, including services and treatment related to religious
counseling, marital/relationship counseling, and sex therapy.
Reversal of voluntary sterilizations, including related follow-up care and treatment of complications of such procedures.
Routine foot/hand care, including routine reduction of nails, calluses and corns.
Services for which a Member is not legally obligated to pay in the absence of this coverage. Services for the treatment of sexual dysfunctions or inadequacies, including therapy, supplies, or
counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis.
Services, including those related to pregnancy, rendered before the effective date or after the termination of the Member’s coverage, unless coverage is continued under the Continuation and Conversion section of this Contract.
Services performed by a relative of a Member for which, in the absence of any health benefits coverage, no charge would be made.
Services required by third parties, including but not limited to, physical examinations, diagnostic services and immunizations in connection with obtaining or continuing employment, obtaining or maintaining any license issued by a municipality, state, or federal government, securing insurance coverage, travel, school admissions or attendance, including examinations required to participate
in athletics, except when such examinations are considered to be part of an appropriate schedule of wellness services.
Services which are not a Covered Benefit under this Contract, even when a prior Referral has been issued by a PCP.
Short-Term Rehabilitation Services -- Outpatient Cognitive Rehabilitation, Physical, Occupational and Speech Therapy
Services for the treatment of delays in development, including speech development, unless as a result of a gross anatomical defect present at birth.
Except for physical therapy, occupational therapy or speech therapy provided for the treatment of Autism Spectrum Disorder, Therapies to treat delays in development and/or chronic conditions. Examples of non-covered diagnoses that are considered both developmental and/or chronic in nature are:
- Down syndrome - Cerebral palsy
- Any service unless provided in accordance with a specific treatment plan - Services you get from a home health care agency.
- Services provided by a physician,or treatment covered as part of the spinal manipulation benefit. This applies whether or not benefits have been paid under the spinal manipulation section.
- Services not given by a physician (or under the direct supervision of a physician),physical,occupational or speech therapist.
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Specific non-standard allergy services and supplies, including but not limited to, skin titration (wrinkle method), cytotoxicity testing (Bryan's Test), treatment of non-specific candida sensitivity, and urine autoinjections.
Specific injectable drugs, including:
- Experimental drugs or medications, or drugs or medications that have not been proven safe and effective for a specific disease or approved for a mode of treatment by the Food and Drug Administration (FDA) and the National Institutes of Health (NIH);
- Needles, syringes and other injectable aids;
- Drugs related to the treatment of non-coveredservices; and
- Drugs related to the treatment of Infertility, contraception, and performance enhancing steroids.
Special medical reports, including those not directly related to treatment of the Member, e.g., employment or insurance physicals, and reports prepared in connection with litigation. • Substance Abuse Treatment
Except as provided in the Covered Benefitssection, alcoholism or drug abuse rehabilitation treatment on an inpatient or outpatient basis
• Telemedicine
Any services that are given by providers that are not contracted with Aetna as telemedicineproviders. Any services that are provided other than during an internet-
Tobacco Use: Any treatment, drug, service or supply to stop or reduce smoking or the use of other tobacco products or to treat or reduce nicotine addiction, dependence or cravings, including counseling, hypnosis and other therapies, medications, nicotine patches and gum except as specifically described in this Contract.
Therapy or rehabilitation, including but not limited to, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetic therapy, vision perception training, and carbon dioxide.
Thermograms and thermography.
Treatment in a federal, state, or governmental entity, including care and treatment provided in a non-participating Hospital owned or operated by any federal, state or other governmental entity, except to the extent required by applicable laws.
Treatment of mental retardation, defects, and deficiencies. This exclusion does not apply to mental health services or to medical treatment of mentally retarded Members in accordance with the benefits provided in the Covered Benefits section of this Contract.
Treatment of occupational injuries and occupational diseases, including those injuries that arise out of (or in the course of) any work for pay or profit, or in any way results from a disease or injury which does. If a Member is covered under a Workers' Compensation law or similar law, and submits proof that the Member is not covered for a particular disease or injury under such law, that disease or injury will be considered "non-occupational" regardless of cause.
Treatment of spinal disorder, including care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or dislocation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of, or related to, distortion, misalignment, or dislocation of or in the vertebral column. Unauthorized services, including any service obtained by or on behalf of a Member without a
Referral issued by the Member’sPCP or precertified by Aetna. This exclusion does not apply in a Medical Emergency, in an Urgent Care situation, or when it is a direct access benefit. Unauthorized services obtained by the Member that require precertification by Aetna including
but not limited to Hospital admissions and outpatient surgery. Participating Providers are responsible for obtaining precertification of Covered Benefits from Aetna.
Vision: Vision-related services and supplies, except as described in the Covered Benefits section.
In addition, the plan does not cover:
- Special supplies such as non-Prescription sunglasses;
- Vision service or supply which does not meet professionally accepted standards; - Special vision procedures, such as orthoptics or vision training;
- Eye exams during your stayin a Hospital or other facility for health care; - Eye exams for contact lenses or their fitting;
- Eyeglasses or duplicate or spare eyeglasses or lenses or frames; - Replacement of lenses or frames that are lost or stolen or broken; - Acuity tests;
- Eye Surgery for the correction of vision, including radial keratotomy, LASIK and similar