Although the Aetna Group Medical Plan Option covers most types of medical, hospital and surgical expenses, there are some expenses that are not covered. Aetna Group Medical Plan Option exclusions include, but are not limited to:
y Injuries arising from any employment or occupation;
y Illnesses covered by workers’ compensation;
y Treatment, supplies, or services that are not medically necessary in terms of generally accepted medical standards or are in excess of reasonable and customary rates;
y Routine eye or hearing exams, eye refractions, eyeglasses, contact lenses, hearing aids, or any type of appliance or fittings used to improve sight or hearing, except as specifically stated under covered expenses;
y Cosmetic or reconstructive procedures and any related services or supplies that alter appearance but do not restore or improve impaired physical function;
Exceptions are:
Repair of defects resulting from an accident that occurred while covered under the Aetna Group Medical Plan Option;
Replacement of diseased tissue surgically removed while covered under the Aetna Group Medical Plan Option; and
Treatment of a birth defect in a child who has been continuously covered under the Aetna Group Medical Plan Option since birth.
y Treatment of the teeth or supporting tissues of the teeth, including impacted teeth, except as provided under covered expenses.
y Operations or treatment in connection with the fitting or wearing of dentures or orthodontic devices.
y Treatment of injury or illness due to war whether declared or undeclared.
y Expenses that occur outside the United States or Canada unless:
You or your dependent is a resident of one or the other; and
The charges are incurred while traveling on business, pleasure, or for educational purposes.
y Investigational services.
y Treatment, supplies, or services that are deemed to be experimental in terms of generally accepted medical standards.
y Various services that are determined to be essentially maintenance care.
y Various services that are determined to be essentially custodial care.
y Treatment or surgery to change gender or to improve or restore sexual function.
y Services or expenses for or related to Assisted Reproduction Technology (ART) which is any process of taking human eggs or sperm, or both, and putting them into a medium or the body to try to cause reproduction. Examples of ART are in vitro fertilization and gamete intrafallopian tube transfer.
y Routine pediatric care except as described under the preventive care benefits.
y The replacement of artificial limbs or eyes.
y Services performed by relatives. Charges for services performed by you or your spouse or you or your spouse’s parent, sister, brother, or child are not covered.
y Services or supplies for which you are not required to pay.
y Education or training.
y Food supplements.
y Equipment or supplies made or used for exercise or physical fitness (e.g., whirlpool baths, air conditioners, humidifiers, etc.), that have therapeutic and nontherapeutic uses.
y Usual and normal home medical supplies, first aid, personal comfort, or beautification items.
y Any surgical procedure performed for the purpose of correcting vision for:
Myopia (nearsightedness);
Hyperopia (farsightedness) and expenses related to such procedures; or
Astigmatism.
y Charges resulting from preexisting conditions (illnesses or injuries) for which medical advice, diagnosis, or treatment was recommended or received within a six-month period prior to the enrollment date or the eligibility waiting period (whichever comes first).
y Expenses incurred after the date coverage ceases for you or a dependent.
y Charges for the testing and storage of blood and blood plasma for future use.
y Treatment of weight loss when another underlying severe medical condition is not present; outpatient prescriptions are NOT covered even when there is an underlying medical condition.
y Hyperalimentation or total parenteral nutrition, except as provided under covered expenses.
y Blood testing for allergies, unless:
Direct skin testing is impossible or inconclusive; or
A history of severe anaphylactic allergy exists. The following organ and/or tissue transplant benefits will NOT be paid for:
y Artificial or nonhuman transplants;
y Charges that are paid under other provisions of the Aetna Group Medical Plan Option;
y Charges for transportation, lodging, and necessary living expenses if a participating center is not used;
y The costs for and associated with organ, bone marrow, or stem cell donations, except as allowed under the Lowe’s contract with Aetna. (Please call Aetna at 1-877-212-8811 for more information);
y The costs for and associated with autologous bone marrow or stem cell harvesting and storage, if not followed by subsequent transplant within six months;
y Bone marrow or stem cell transplants when the human leukocyte antigen (HLA) is not an identical five out of six allogeneic match between the donor and the recipient;
y Immunizations for travel or work; or
y Reversal of sterilization.
All forms of nontraditional care (also called alternative care) such as acupressure/acupuncture, biofeedback, herbal therapy, homeopathy, naturopathy, massage therapy, nutrition counseling, personal fitness training, tai chi, vitamin therapy, yoga, etc., even when performed or supervised by a licensed physician or other covered provider.
Expense for prescription drugs, including select specialty medications. (However, outpatient drugs are provided for Copay 500 and Copay 750 participants through Express Scripts.)