Limitations & Exclusions

Medical

These medical plans do not cover all health care expenses and include exclusions and limitations. You should refer to your plan documents to determine which health care services are covered and to what extent.

The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s). Services and supplies that are generally not covered include, but are not limited to:

• All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates
• Cosmetic surgery
• Custodial care
• Donor egg retrieval
• Infertility services and other related reproductive services unless specifically listed as covered in your plan documents
• Weight control services including surgical procedures for the treatment of obesity, medical treatment, and weight control/loss programs
• Experimental and investigational procedures, (except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial)
• Charges in connection with pregnancy care other than for pregnancy complications
• Immunizations for travel or work
• Implantable drugs and certain injectable drugs including injectable infertility drugs
• Orthotics
• Over-the-counter medications and supplies
• Radial keratotomy or related procedures
• Reversal of sterilization
• Services, supplies or counseling related to the treatment of sexual dysfunction
• Special or private duty nursing
• Therapy or rehabilitation other than those listed as covered in the plan documents

Dental

Listed below are some of the charges and services for which our dental plans do not provide coverage. For a complete list of exclusions and limitations, refer to plan documents.

• Dental services or supplies that are primarily used to alter, improve or enhance appearance (negotiated rates for cosmetic procedures are available when a participating dentist is accessed)
• Experimental services, supplies or procedures
• Treatment of any jaw joint disorder, such as temporomandibular joint disorder
• Replacement of lost or stolen appliances and certain damaged appliances
• Services that Aetna defines as not necessary for the diagnosis, care or treatment of a condition involved
• All other limitations and exclusion our plan documents

Pre-Existing Conditions
For Applicants 19 and older: During the first 12* months following your effective date of coverage, no coverage will be provided for the treatment of a pre-existing condition unless you have prior creditable coverage.

A pre-existing condition is an illness, disease, physical condition, or injury for which medical advice, or treatment was recommended or received and/or the use of prescription drugs of any kind within six months preceding the effective date of coverage. Services or supplies for the treatment of a pre-existing condition are not covered for the first 12 months after the member’s effective date. If the member had continuous prior creditable coverage within the 63** days immediately preceding the signature on the application and meets certain other requirements, then the pre-existing condition exclusion of 12* months may not apply.