Limitations and 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 n Custodial care n Donor egg retrieval n 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 n Immunizations for travel or work n Implantable drugs and certain injectable drugs including injectable infertility drugs
Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents
Medical expenses for a pre-existing condition are not covered for the first 12 months after the member's effective date. Look back period for determining a pre-existing condition (conditions for which diagnosis, care or treatment was recommended or received) is six (6) months prior to the effective date of coverage. If the applicant had prior creditable coverage within 63 days immediately before the signature on the enrollment form, then the pre-existing conditions exclusion of the plan will be waived.
Non-medically necessary services or supplies n Orthotics n Over-the-counter medications and supplies n Radial keratotomy or related procedures n Reversal of sterilization n Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling
Special or private duty nursing
Therapy or rehabilitation other than those listed as covered in the plan documents
For Virginia only:
Mental health services for PPO Plans not covered except for severe biologically based mental or nervous disorders.
Chemical dependency and substance abuse not covered except for severe biologically based mental or nervous disorders.
Dental
Listed below are some of the charges and services for which these 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 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 exclusions in your plan documents
10-day right to review
Do not cancel your current insurance until you are notified that you have been accepted for coverage. We'll review your enrollment form to determine if you meet underwriting requirements. If you're denied, you'll be notified by mail. If you're approved, you'll be sent an Aetna Advantage Plan contract and ID card.
If, after reviewing the contract, you find that you're not satisfied for any reason, simply return the contract to us within 10 days. We will refund any premium you've paid (including any contract fees or other charges) less the cost of any services paid on behalf of you or any covered dependent.
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