Not every health care service or supply is covered by the plan. Even if prescribed, recommended, or approved by your Physician or Dental Provider it may not be covered. The plan covers only those services and supplies that are Medically Necessary and included in the Covered Benefits section. Charges made for the following are not covered except to the extent listed under the Covered Benefits
section or by amendment attached to this Certificate. In addition, some services are specifically limited or excluded. This section describes expenses that are not covered or subject to special limitations.
These Prescription Drug exclusions are in addition to the exclusions listed under your medical coverage. The plan does not cover the following expenses:
Administration or injection of any drug.
HO SG2015COC 01 67 SG Off Exchange All drugs or medications in a therapeutic drugclass if one of the drugs in that Therapeutic
DrugClass is not a Prescription Drug, unless Medically Necessary.
Any prescriptions drugs obtained at a Non-Participating Pharmacy except for those
Prescription Drugs obtained from a Non-Participating Pharmacy are limited to those obtained in connection with Emergency Care and out-of-area Urgent Care services.
Allergy sera and extracts.
Any non-emergency charges incurred outside of the United States if you traveled to such location to obtain Prescription Drugs, or supplies, even if otherwise covered under this Certificate. This also includes Prescription Drugs or supplies if:
- Such prescription drug or supplies are unavailable or illegal in the United States; or
- The purchase of such Prescription Drugs or supplies outside the United States is considered illegal.
Any drugs or medications, services and supplies that are not Medically Necessary, as determined by Aetna for the diagnosis, care or treatment of the illness or injury involved. This applies even if they are prescribed, recommended or approved by your Physician..
Any Prescription Drug or supply used for the treatment of sexual dysfunction/ enhancement in any form. Any Prescription Drug in any form that is in a similar or identical class; has a similar or identical mode of action; or exhibits similar or identical outcomes.
Brand-name Prescription Drugs and devices when a Generic Prescription Drug or device equivalent, Biosimilar Prescription Drug or Generic Prescription Drug or device alternative is available, unless otherwise covered by medical exception.
Biological sera, blood, blood plasma, blood products or substitutes or any other blood products.
Contraceptives, except as specifically described in the Covered Benefits section including, but not limited to, over the counter contraceptive supplies such as condoms, contraceptive foams, jellies and ointments.
Cosmetic drugs, medications or preparations used for cosmetic purposes or to promote hair growth, including but not limited to:
- Health and beauty aids;
- Chemical peels;
- Dermabrasion;
- Treatments;
- Bleaching;
- Creams;
- Ointments or other treatments or supplies, to remove tattoos, scars or to alter the appearance or texture of the skin.
Drugs given by, or while the person is an inpatient in, any healthcare facility; or for any drugs provided on an outpatient basis in any such institution to the extent benefits are payable for it.
Drugs given or entirely consumed at the time and place it is prescribed or dispensed.
Drugs or medications that include the same active ingredient or a modified version of an active ingredient and:
- Is therapeutically equivalent or therapeutically alternative to a covered Prescription Drug
(unless medical exception is approved), or
- Is therapeutically equivalent or therapeutically alternative to an over-the-counter (OTC) product (unless medical exception is approved).
Drugs recently approved by the U.S. Food and Drug Administration (FDA), but which have not yet been reviewed by Aetna’s Pharmacy and Therapeutic Committee.
Drugs, services and supplies given in connection with treatment of an occupational injury or occupational illness.
Drugs used primarily for the treatment of infertility, or for or related to artificial insemination, in vitro fertilization, or embryo transfer procedures, except as described in the Covered Benefits
section.
Drugs used for the purpose of weight gain or reduction, including but not limited to:
- Stimulants;
- Preparations;
- Foods or diet supplements;
- Dietary regimens and supplements;
- Food or food supplements;
- Appetite suppressants; and
- Other medications.
Drugs used for the treatment of obesity.
Durable medical equipment, monitors and other equipment except as described in the Covered Benefitssection.
Experimental or investigational drugs or devices, except as described in the Covered Benefits
section.
This exclusion will not apply with respect to drugs that:
- Have been granted treatment investigational new drug (IND); or Group c/treatment IND status; or
- Are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute; and
- Aetna determines, based on available scientific evidence, are effective or show promise of being effective for the illness.
Food items: Except as described in the Covered Benefitssection, any food item, including infant formulas, nutritional supplements, vitamins, medical foods and other nutritional items, even if it is the sole source of nutrition. . This limitation will not apply to formulas and special modified food products as specifically stated in this Certificate.
HO SG2015COC 01 69 SG Off Exchange Genetics: Any treatment, device, drug, or supply to alter the body’s genes, genetic make-up, or
the expression of the body’s genes except for the correction of congenital birth defects.
Immunization or immunological agents except as described in the Covered Benefitssection.
Implantable drugs and associated devices, except for injectable generic contraceptives and as described in the Covered Benefits section.
Injectables or infused drugs, except for injectable generic contraceptives and as described in the
Covered Benefitssection.
- Any charges for the administration of an infused or injected Prescription Drug or injectable insulin and other infused or injected drugs covered by Aetna;
- Certain injectable agents such as injectable contrasts/dyes used for imaging (e.g., MRI, CT, Bone Scans), except insulin;
- Needles and syringes except diabetic needles and syringes, or for a covered drug; and
- Injectable drugs if an alternative oral drug is available.
Prescription Drugs for which there is an over-the-counter (OTC) product which has the same active ingredient even if a Prescription is written, unless Medically Necessary.
Prescription Drugs, medications, injectables or supplies given through a third party vendor contract with the employer.
Prescription drugs unless the drug is included on the Preferred Drug Guide (Formulary) or a medical exception is granted.
Prescription orders filled prior to the effective date or after the termination date of coverage under this Certificate.
Prophylactic drugs for travel.
Refills over the amount specified by the Prescription order. Before recognizing charges, Aetna may require a new Prescription or proof as to need, if a Prescription or refill appears excessive under accepted medical practice standards.
Refills dispensed more than one year from the date the latest Prescription order was written, or as otherwise allowed by applicable law of the jurisdiction in which the drug is dispensed.
Replacement of lost or stolen Prescriptions.
Strength and performance: Drugs or preparations, devices and supplies to enhance strength, physical condition, endurance or physical performance, including performance enhancing steroids.
Sex change: Any treatment, drug or supply related to changing sex or sexual characteristics, including but not limited to hormones and hormone therapy.
Supplies, devices or equipment of any type, except as specifically provided in the Covered Benefits section.
Test agents except diabetic test agents.
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 described in the Covered Benefitssection.