Logo_pebb
General Medical Exclusions for 2008
Print_pagePrint this page

Aetna Public Employees Plan

Aetna Public Employees Plan covers only the services and conditions specifically identified in this Certificate of Coverage. Unless a service or condition fits into one of the specific benefit definitions, it is not covered. If you have questions, call Member Services at 1-800-222-9205.

Here are some examples of common services and conditions that are not covered. Many others are also not covered—these are examples only, not a complete list. These examples are called exclusions, meaning these services are not covered, even if medically necessary.

  1. Acupuncture, except as described under "Acupuncture."
  2. Air ambulance, if ground ambulance would serve the same purpose.
  3. Carotid Intima Thickness Testing.
  4. Circumcision, unless determined medically necessary for a medical condition.
  5. Complications directly arising from services that are not covered.
  6. Conditions caused by or arising from acts of war.
  7. Cosmetic services or supplies, including drugs, pharmaceuticals, removal of excess tissue, and similar procedures. However, Aetna Public Employees Plan does cover:
    • Reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury.
    • Reconstructive surgery of a congenital anomaly (such as cleft lip or palate).
  8. Court-ordered care, unless determined by Aetna Public Employees Plan to be medically necessary and otherwise covered.
  9. Custodial care.
  10. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services listed under "Dental Services."
  11. Dietary or food supplements, including:
    • Herbal supplements, dietary supplements, medicinal foods, and homeopathic drugs.
    • Infant or adult dietary formulas, except for treatment of congenital metabolic disorders such as phenylketonuria (PKU) detected by newborn screening, when specialized formulas have been established as effective for treatment.
    • Minerals.
    • Prescription or over-the-counter vitamins (except prenatal vitamins during pregnancy).
  12. Dietary programs designed for weight control or weight loss.
  13. Drugs or medicines not covered by Washington State Rx Services as described in "Your Prescription Drug Benefit" section.
  14. Educational programs, except those listed under "Diabetes Education" and "Tobacco Cessation Program."
  15. Electron Beam Tomography (EBT), self-referred or prescribed by a provider.
  16. Equipment not primarily intended to improve a medical condition or injury, including but not limited to:
    • Air conditioners or air purifying systems.
    • Arch supports.
    • Communication aids.
    • Elevators.
    • Exercise equipment.
    • Massage devices.
    • Overbed tables.
    • Sanitary supplies.
    • Telephone alert systems.
    • Vision aids.
    • Whirlpools, portable whirlpool pumps, or sauna baths.
  17. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals.
  18. Experimental or investigational services, supplies, or drugs, except for clinical trials consistent with Medicare coverage criteria.
  19. Extracorporeal Shockwave Therapy (low-energy shock waves focused on a source of pain such as soft tissue).
  20. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy, photokeratectomy, or LASIK surgery.
  21. Foot care: Cutting of toenails; non-surgical care for diagnosed corns and calluses; or any other routine foot care (unless you are diabetic).
  22. Genetic testing done solely to select a medication to treat a new diagnosis.
  23. Genetic testing or counseling for family planning, or any other genetic testing or counseling, except as described under "Genetic Counseling and Testing."
  24. Home health care except as provided under "Home Health Care." For example, Aetna Public Employees Plan does not cover the following:
    • Any services or supplies not included in the home health care treatment plan or not specifically mentioned under the "Home Health Care" section.
    • Dietary assistance.
    • Expenses related to normal activities of living such as food, clothing, household supplies, Meals on Wheels, or similar services.
    • Homemaker, chore worker, or housekeeping services.
    • Custodial care.
    • Nonclinical social services.
    • Separate charges for records, reports, or transportation.
    • Services by family members or volunteer workers.
    • Services that are not medically necessary.
  25. Hospice care except as provided under "Hospice Care (Including Respite Care)." For example, the following are not covered:
    • Any services or supplies not included in the hospice care plan, or not specifically mentioned under the "Hospice Care" section.
    • Expenses related to normal activities of living such as food, clothing, household supplies, Meals on Wheels, or similar services.
    • Homemaker, chore worker, or housekeeping services (except as provided by home health aides as part of the hospice program).
    • Legal or financial counseling.
    • Separate charges for records, reports, or transportation.
    • Services by family members or volunteer workers.
    • Services provided while the member is receiving home health care benefits.
    • Services to other than the terminally ill member including bereavement, pastoral, or spiritual counseling.
  26. Hospital inpatient charges such as admissions solely for diagnostic procedures that could be performed on an outpatient basis.
  27. Immunizations, except as described under "Preventive Care." Immunizations for the purpose of travel or employment, or required because of where you reside, or any other reasons not listed, are not covered.
  28. In vitro fertilization and all related services and supplies, including all procedures involving selection of embryo for implantation.
  29. Learning disabilities treatment after diagnosis, except as described under "Physical, Occupational, Speech, and Neurodevelopmental Therapy," or when treatment is part of a mental health disorder and covered under "Mental Health."
  30. Magnetic Resonance Imaging—Upright MRIs (uMRI), also known as "positional," "weight-bearing" (partial or full), or "axial loading."
  31. Maintenance therapy.
  32. Manipulations of the spine or extremities, except as described under "Spinal and Extremity Manipulations."
  33. Massage therapy, unless services meet the criteria in "Massage Therapy."
  34. Medicare-covered services or supplies delivered under a private contract with a provider who does not offer services through Medicare, when Medicare is the patient's primary coverage.
  35. Mental health:
    • Inpatient programs not solely for treatment of chemical dependency or a mental health condition that requires inpatient care treatment (examples include, but are not limited to schools, wilderness programs, and behavioral programs for adolescents).
    • Marital, family, or other counseling or training services, except when provided to treat an individual member's neuropsychiatric, mental, or personality disorder.
  36. Missed appointments.
  37. Organ donor coverage for anyone who is not an Aetna Public Employees Plan member, or costs of locating a donor (such as tissue typing of family members), except as described under "Organ Transplants."
  38. Orthognathic surgery, or surgery to straighten or correct the jaw, except that Aetna Public Employees Plan does cover surgery to treat a congenital anomaly such as cleft lip or palate.
  39. Orthoptic therapy (eye training) or vision services, except as described under "Vision Care (Routine)."
  40. Orthotics (except for diabetics; see "Durable Medical Equipment, Supplies, and Prostheses").
  41. Other insurance coverage—Services or supplies are not covered if benefits are available under any automobile medical, automobile no-fault, personal injury protection, commercial liability, commercial premises medical, homeowner's policy, or other similar type of insurance or contract, if it covers medical treatment of injuries. (When we say "available," we mean that you could get services paid under another policy by making a claim.) However, Aetna Public Employees Plan may advance payments to you (except for workers' compensation claims, which are not covered; see exclusion #61) with the expectation that Aetna Public Employees Plan will be reimbursed from any settlement.
  42. Panniculectomy or removal of excess skin due to weight loss.
  43. Physical exam—Any additional portion of a physical exam beyond what Aetna Public Employees Plan covers under the preventive care benefit, even if required for employment, travel, immigration, licensing, or insurance and related reports.
  44. Provider administrative fees—Any charges for completing forms or copying records, except for records requested by Aetna Public Employees Plan to perform retrospective utilization review.
  45. Recreation therapy.
  46. Replacement of lost or stolen durable medical equipment.
  47. Replacement of lost or stolen medications or medications confiscated or seized by Customs or other authorities.
  48. Reproductive failure or sterility testing or treatment, including drugs, pharmaceuticals, artificial insemination, and any other type of testing or treatment.
  49. Residential treatment programs that are not solely for chemical dependency treatment or a mental health condition requiring inpatient care treatment (such as schools, wilderness programs, and behavioral programs for teenagers).
  50. Reversal of voluntary sterilization (vasectomy or tubal ligation).
  51. Services provided by non-network providers, except for emergency care.
  52. Services provided by an Aetna network provider or obtained without following Aetna's standard precertification requirements.
  53. Services or supplies:
    • That are not medically necessary, as determined by the plan, for the diagnosis and treatment of illness, injury, or restoration of physiological functions, and are not covered as preventive care. This applies even if services are prescribed, recommended or approved by your provider.
    • For which no charge is made, or for which a charge would not have been made if you had no health care coverage.
    • Provided by a family member or any household member.
    • Provided by a resident physician or intern acting in that capacity.
    • That are solely for comfort (except as described in "Hospice Care").
    • For which you are not obligated to pay.
  54. Sexual dysfunction or disorder diagnosis, counseling or treatment (except for penile prostheses, as stated under "Durable Medical Equipment, Supplies, and Prostheses").
  55. Sexual reassignment surgery, services, counseling, or supplies.
  56. Skilled nursing facility services or confinement:
    • For treatment of mental health conditions or mental retardation.
    • When primary use of the facility is as a place of residence.
    • When treatment is primarily custodial.
  57. Temporomandibular joint (TMJ) disorder treatment, except as described under "Temporomandibular Joint (TMJ) Treatment."
  58. Tobacco cessation services, supplies, or medications, except as described under "Tobacco Cessation Program."
  59. Transportation by "cabulance" or other nonemergency service.
  60. Weight control, weight loss, and obesity treatment:
    • Non-surgical: Any program, drugs, services, or supplies for weight control, weight loss, or obesity treatment. Exercise programs (formal or informal), exercise equipment, or travel expenses associated with non-surgical or surgical services are not covered. Such treatment is not covered even if prescribed by a provider.
    • Surgical: Any bariatric surgery procedure, any other surgery for obesity or morbid obesity, and any related medical services, drugs, or supplies, except if approved through case management as described under "Obesity Surgery." Removal of excess skin is not covered.
  61. Wilderness training programs.
  62. Workers' compensation—Aetna Public Employees Plan does not cover services or supplies if benefits are available under any workers' compensation or other similar type of program, insurance, or contract. (When we say "available," we mean that you could get services paid for by a workers' compensation or similar program by making a claim.)

If you have questions about whether a certain service or supply is covered, call Aetna Public Employees Plan at 1 800 222 9205.

Managed-Care Plans

The following services and supplies are excluded from all PEBB-sponsored managed-care plans. Plan-specific exceptions are noted. For further explanation of any exclusion, refer to the plan's certificate of coverage.

  1. Services not provided by a plan-designated provider or obtained in accordance with the plan's standard referral and authorization requirements, except for emergency care or as covered under coordination of benefits provisions.
  2. Non-participating providers are not covered inside or outside of the service area except for: emergencies; as specifically provided in the student eligibility section; or when otherwise specifically provided.
  3. Experimental or investigational services, supplies, and drugs.
  4. That additional portion of a physical exam beyond a routine physical that is specifically required for the purpose of employment, travel, immigration, licensing, or insurance and related reports.
  5. Services or supplies for which no charge is made, or for which a charge would not have been made if the enrollee had no health care coverage or for which the enrollee is not liable; services provided by a family member.
  6. Drugs and medicines not prescribed by a plan-designated provider, except for emergency treatment.
  7. Cosmetic services or supplies except: to restore function, for reconstructive surgery of a congenital anomaly, or reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury.
  8. Skilled nursing facility confinement or residential mental health treatment programs for mental health conditions, mental retardation, or for care which is primarily domiciliary, convalescent, or custodial in nature.
  9. Conditions caused by or arising from acts of war.
  10. Dental care including: orthognathic surgery (except for congenital anomalies), myofascial pain dysfunction (MPD), and dental implants.
  11. Sexual reassignment surgery, services, and supplies.
  12. Reversal of voluntary sterilization.
  13. Testing and treatment of infertility and sterility, including but not limited to artificial insemination and in vitro fertilization.
  14. Services and supplies provided solely for the comfort of the enrollee, except palliative care provided under the “Hospice Care” benefit.
  15. Coverage for an organ donor, unless the recipient is an enrollee of the plan.
  16. Weight control, obesity treatment, and treatment for morbid obesity, including any medical services, drugs, supplies, or any bariatric surgery (such as gastroplasty, gastric banding, or intestinal bypass), regardless of co-morbidities, complications of obesity, or any other medical condition. Exception: The surgical exclusion noted above does not apply to Group Health Cooperative or Kaiser Permanente preauthorized, medically necessary bariatric surgery for treatment of adult morbid obesity as shown in each plan's certificate of coverage and Bariatric Management criteria.
  17. Evaluation and treatment of learning disabilities, including dyslexia, except as provided for neurodevelopmental therapies.
  18. Orthoptic therapy (eye training); vision services, except as specified for vision care. Surgery to improve the refractive character of the cornea including any direct complications.
  19. Orthotics, except foot care appliances for prevention of complications associated with diabetes, which are covered.
  20. Routine foot care.
  21. Services for which an enrollee has a contractual right to recover cost under homeowner's or other no-fault coverage, to the extent that it can be determined that the enrollee received double recovery for such services.
  22. Any medical services or supplies not specifically listed as covered.
  23. Direct complications arising from excluded services.
  24. Pharmaceutical treatment of impotence or sexual dysfunction.
  25. When Medicare coverage is primary, charges for services or supplies provided to enrollees through a “private contract” agreement with a physician or practitioner who does not provide services through the Medicare program.
  26. Replacement of lost or stolen medications.
  27. Recreation therapy.

Uniform Medical Plan

UMP covers only the services and conditions specifically identified in this Certificate of Coverage. Unless a service or condition fits into one of the specific benefit definitions, it is not covered. If you have questions, call Customer Service at 1-800-762-6004.

Here are some examples of common services and conditions that are not covered. Many others are also not covered—these are examples only, not a complete list. These examples are called "exclusions": these services are not covered, even if medically necessary.

  1. Acupuncture, except as described under "Acupuncture."
  2. Air ambulance, if ground ambulance would serve the same purpose (see also exclusion 62).
  3. Carotid Intima Media Thickness testing.
  4. Circumcision, unless determined medically necessary for a medical condition.
  5. Complications directly arising from services that are not covered.
  6. Conditions caused by or arising from acts of war.
  7. Cosmetic services or supplies, including drugs, pharmaceuticals, removal of excess tissue and similar procedures. However, UMP does cover:
    • Reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury.
    • Reconstructive surgery of a congenital anomaly (such as cleft lip or palate).
  8. Court-ordered care, unless determined by UMP to be medically necessary and otherwise covered.
  9. Custodial care; see in "Definitions" section.
  10. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services listed under "Dental Services."
  11. Dietary or food supplements, including:
    • Herbal supplements, dietary supplements, medicinal foods, and homeopathic drugs.
    • Infant or adult dietary formulas, except for treatment of congenital metabolic disorders detected by newborn screening such as phenylketonuria (PKU) when specialized formulas have been established as effective for treatment.
    • Minerals.
    • Prescription or over-the-counter vitamins (except prenatal vitamins during pregnancy).
  12. Dietary programs designed for weight control or weight loss.
  13. Drugs or medicines not covered by UMP as described in the "How the UMP Prescription Drug Benefit Works" section.
  14. Educational programs, except those listed under "Diabetes Education," "Nutritional Therapy," and "Tobacco Cessation Program."
  15. Electron Beam Tomography (EBT), self-referred or prescribed by a provider.
  16. Equipment not primarily intended to improve a medical condition or injury, including but not limited to:
    • Air conditioners or air purifying systems.
    • Arch supports.
    • Exercise equipment.
    • Sanitary supplies.
  17. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals.
  18. Experimental or investigational services, supplies, or drugs, except for clinical trials consistent with Medicare coverage criteria.
  19. Extracorporeal Shockwave Therapy; low-energy shock waves focused on a source of pain (soft tissue).
  20. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy, photokeratectomy, or LASIK surgery.
  21. Foot care: Cutting of toenails; non-surgical care for diagnosed corns and calluses; or any other routine foot care (unless you are diabetic).
  22. Genetic testing done solely to select a medication to treat a new diagnosis.
  23. Genetic testing or counseling for family planning, or any other genetic testing or counseling, except as described under "Genetic Testing."
  24. Home health care except as described under "Home Health Care (Including Respite Care)." For example, UMP does not cover the following home health services:
    • Any services or supplies not included in the home health care treatment plan or not specifically mentioned under "Home Health Care (Including Respite Care)."
    • Unless preauthorized:
      • Daily visits.
      • Visits exceeding two hours per day.
      • Visits continuing for more than three weeks.
      • 24-hour or full-time care in the home.
    • Dietary assistance.
    • Expenses for normal activities of living such as food, clothing, household supplies, Meals on Wheels, or similar services.
    • Homemaker, chore worker, or housekeeping services.
    • Custodial care.
    • Nonclinical social services.
    • Psychiatric care.
    • Separate charges for records, reports, or transportation.
    • Services by family members or volunteer workers.
    • Services that are not medically necessary.
  25. Hospice care except as provided under "Hospice Care." For example, the following are not covered:
    • Any services or supplies not included in the hospice care plan, not specifically mentioned under "Hospice Care," or provided in excess of the specified limits.
    • Expenses for normal necessities of living such as food, clothing, household supplies, Meals on Wheels, or similar services.
    • Homemaker, chore worker, or housekeeping services (except as provided by home health aides as part of the hospice program).
    • Legal or financial counseling.
    • Separate charges for records, reports, or transportation.
    • Services by family members or volunteer workers.
    • Services provided while the enrollee is receiving home health care benefits.
    • Services to other than the terminally ill enrollee including bereavement, pastoral, or spiritual counseling.
  26. Hospital inpatient charges such as:
    • Admissions solely for diagnostic procedures that could be performed on an outpatient basis.
    • Beds "reserved" while the patient is being treated in a special-care unit or is on leave from the hospital.
    • High-cost services and devices that do not meet the medical necessity criteria of "the level of service, supply, or intervention recommended for this condition is cost-effective compared to alternative interventions, including no intervention." See additional information under "Hospital Services."
    • Personal items (television, special diets not medically necessary to treat the covered condition, or convenience items).
    • Private room charges, unless medically necessary and preauthorized by UMP.
  27. Immunizations, except as described under "Preventive Care." Immunizations for the purpose of travel or employment, or required because of where you reside, are not covered.
  28. In vitro fertilization and all related services and supplies, including all procedures involving selection of embryo for implantation.
  29. Learning disabilities treatment after diagnosis, except as described under "Physical, Occupational, Speech, and Neurodevelopmental Therapy," or when treatment is part of a mental health disorder and covered under the "Mental Health" benefit.
  30. Magnetic Resonance Imaging—Using upright MRIs (uMRI): Also known as "positional," "weight-bearing" (partial or full), or "axial loading."
  31. Maintenance therapy (see in "Definitions" section).
  32. Manipulations of the spine or extremities, except as described under "Spinal and Extremity Manipulations."
  33. Massage therapy, unless services meet the criteria in "Massage Therapy." Also, services from massage therapists who are not UMP network providers, and services not preauthorized that are longer than one hour per session, are not covered.
  34. Medicare-covered services or supplies delivered under a "private contract" with a provider who does not offer services through Medicare, when Medicare is the patient's primary coverage.
  35. Mental health:
    • Inpatient programs not solely for treatment of chemical dependency or a mental health condition that requires inpatient care treatment (examples include, but are not limited to: schools, wilderness programs, and behavioral programs for adolescents).
    • Marital, family, or other counseling or training services, except when provided to treat neuropsychiatric, mental, or personality disorders (covered services are described under "Mental Health").
    • Services from non-PhD psychologists (unless the provider is employed by and delivers services within a licensed community mental health agency, and that agency bills for the services).
  36. Missed appointments.
  37. Non-approved provider types—Services delivered by types of providers not listed as approved under "Approved Provider Types," or by providers delivering services outside of the scope of their licenses, are not covered.
  38. Non-network provider charges that are above the UMP allowed amount, even when the provider is paid at the out-of-area rate, except when the enrollee has been admitted to the hospital as a result of an emergency room visit and the annual out-of-pocket limit has been met.
  39. Organ donor coverage for anyone who is not a UMP enrollee, or costs of locating a donor (such as tissue typing of family members), except as described under "Organ Transplants."
  40. Organ transplant expenses not preauthorized by UMP.
  41. Orthognathic surgery, or surgery to straighten or correct the jaw, except that UMP does cover surgery to treat a congenital anomaly (such as cleft lip or palate).
  42. Orthoptic therapy (eye training) or vision services, except as described under "Vision Care (Routine)."
  43. Orthotics (except for diabetics; see "Durable Medical Equipment, Supplies, and Prostheses").
  44. Other insurance coverage—Services or supplies are not covered if benefits are available under any automobile medical, automobile no-fault, personal injury protection, commercial liability, commercial premises medical, homeowner's policy, or other similar type of insurance or contract, if it covers medical treatment of injuries. (When we say "available," we mean that you could get services paid under another policy by making a claim.) However, UMP may advance payments to you with the expectation that UMP will be reimbursed from any settlement—except for workers' compensation claims, which are not covered (see exclusion 65).
  45. Panniculectomy or removal of excess skin due to weight loss.
  46. Physical exam—Any additional portion of a physical exam beyond what UMP covers under "Preventive Care," even if required for employment, travel, immigration, licensing, or insurance and related reports.
  47. Prescription drug charges over the UMP allowed amount, regardless of where purchased.
  48. Provider administrative fees—Any charges for completing forms or copying records, except for records requested by UMP to perform retrospective utilization review.
  49. Recreation therapy.
  50. Registered counselors of any type.
  51. Replacement of lost or stolen durable medical equipment.
  52. Replacement of lost or stolen medications or medications confiscated or seized by Customs or other authorities.
  53. Reproductive failure or sterility testing or treatment, including drugs, pharmaceuticals, artificial insemination, and any other type of testing or treatment.
  54. Residential treatment programs that are not solely for chemical dependency treatment or a mental health condition requiring inpatient care treatment (such as schools, wilderness programs, and behavioral programs for teenagers).
  55. Reversal of voluntary sterilization (vasectomy or tubal ligation).
  56. Services or supplies:
    • For which no charge is made, or for which a charge would not have been made if you had no health care coverage.
    • Provided by a family member.
    • That are solely for comfort (except as described in "Hospice Care").
    • For which you are not obligated to pay.
  57. Sexual dysfunction or disorder diagnosis, counseling, or treatment (except for penile prostheses, as stated under "Durable Medical Equipment, Supplies, and Services").
  58. Sexual reassignment surgery, services, counseling, or supplies.
  59. Skilled nursing facility services or confinement:
    • For treatment of mental health conditions or mental retardation.
    • When primary use of the facility is as a place of residence.
    • When treatment is primarily custodial (see "Custodial Care" in "Definitions" section).
  60. Temporomandibular joint (TMJ) disorder treatment, except as described under "Temporomandibular Joint (TMJ) Treatment."
  61. Tobacco cessation services, supplies, or medications, except as described under "Tobacco Cessation Program."
  62. Transportation by "cabulance" or other nonemergency service.
  63. Weight control, weight loss, and obesity treatment as follows:
    • Non-surgical: Any program, drugs, services, or supplies for weight control, weight loss, or obesity treatment. UMP does not cover exercise programs (formal or informal), exercise equipment, or travel expenses associated with non-surgical or surgical services. UMP will not cover such treatment even if prescribed by a provider.
    • Surgical: Any bariatric surgery procedure, any other surgery for obesity or morbid obesity, and any related medical services, drugs, or supplies. unless approved through case management as described under "Obesity Surgery." Removal of excess skin is not covered.
  64. Wilderness training programs.
  65. Workers' compensation—UMP does not cover services or supplies if benefits are available under any workers' compensation or other similar type of program, insurance, or contract. (When we say "available," we mean that you could get services paid for under another policy by making a claim.)

If you have questions about whether a certain service or supply is covered, call UMP at 1-800-762-6004 (or 425-670-3000 in the Seattle area).