IQVIA Benefits Handbook
BENEFITS NOT COVERED BY THE MEDICAL PLAN
While the Medical Plan covers a wide variety of medically necessary services, there are some expenses that are not covered. Some of these are listed below.
Exclusions that apply to many services are listed in this section and in "Benefits Covered by the Medical Plan." In addition, the plan does not cover charges for services, supplies, drugs for the following:
  • Care for health conditions that are required by state or local law to be treated in a public facility.
  • Care required by state or federal law to be supplied by a public school system or school district.
  • Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available.
  • Treatment of an illness or injury which is due to war, declared or undeclared.
  • Charges for which you are not obligated to pay or for which you are not billed or would not have been billed except that you were covered under your Medical Plan.
  • Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other custodial services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.
  • Any services and supplies for or in connection with experimental, investigational or unproven services. Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance abuse or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by Aetna's or Kaiser's, as applicable, medical director to be:
    • Not demonstrated, through existing peer-reviewed, evidence-based scientific literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.
    • Not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed for the proposed use.
    • The subject of review or approval by an Institutional Review Board for the proposed use, except as provided in the "Clinical Trials" section of "Other Services."
    • The subject of an ongoing phase I, II or III clinical trial, except as provided in the "Clinical Trials" section of "Other Services."
    • Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one's appearance.
  • Abdominoplasty, panniculectomy, redundant skin surgery, removal of skin tags, acupressure, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
  • Non-surgical treatment of TMJ disorder.
  • Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental X-rays, examinations, repairs, orthodontics, periodontics, casts, splints and services for dental malocclusion, for any condition. However, charges made for services or supplies provided for or in connection with an accidental injury to sound natural teeth are covered provided a continuous course of dental treatment is started within six months of the accident. Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support and are functional in the arch.
  • Unless otherwise covered as a basic benefit, reports, evaluations, physical examinations, or hospitalization not required for health reasons, including but not limited to employment, insurance or government licenses, and court ordered, forensic or custodial evaluations.
  • Court ordered treatment or hospitalization, unless such treatment is being sought by a participating physician or otherwise covered under "Benefits Covered by the Medical Plan."
  • Infertility drugs, in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage.
  • Reversal of male and female voluntary sterilization procedures.
  • Any services, supplies, medications or drugs for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmia and premature ejaculation.
  • Medical and hospital care and costs for the infant child of a dependent, unless this infant child is otherwise eligible under the Medical Plan.
  • Non-medical counseling or ancillary services, including, but not limited to custodial services, education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return-to-work services, work hardening programs, driving safety and services, training, educational therapy or other non-medical ancillary services.
  • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including, but not limited to routine, long-term or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
  • Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the "Inpatient Hospital Services," "Outpatient Facility Services" or "Home Health Services" sections of "Benefits Covered by the Medical Plan."
  • Private hospital rooms and/or private duty nursing except as provided in the Home Health Services section of "Benefits Covered by the Medical Plan."
  • Personal or comfort items such as personal care kits provided on admission to a hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements and other articles which are not for the specific treatment of illness or injury.
  • Artificial aids, including but not limited to corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, dentures and wigs.
  • Aids or devices that assist with non-verbal communications, including, but not limited to communication boards, pre-recorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
  • Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post cataract surgery).
  • Routine refraction, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.
  • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, non-prescription drugs and investigational and experimental drugs, except as provided in "Benefits Covered by the Medical Plan."
  • Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary.
  • Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs.
  • Genetic screening or pre-implantation genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically-linked inheritable disease.
  • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in Aetna's or Kaiser's medical director's opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Blood administration for the purpose of general improvement in physical condition.
  • Cost of biologicals that are medications for the purpose of travel or to protect against occupational hazards and risks. Travel immunizations are covered.
  • Cosmetics, dietary supplements and health and beauty aids.
  • Nutritional supplements and formulas are excluded, except for infant formula needed for the treatment of inborn errors of metabolism.
  • Expenses incurred for medical treatment by a person age 65 or older, who was covered under the Medical Plan as a retiree, or his/her dependents, when payment is denied by the Medicare plan because treatment was not received from an in-network provider. Note that retiree medical coverage ends when the participant reaches age 65. There is no retiree medical coverage for terminated or retired employees age 65 or older.
  • Expenses incurred for medical treatment when payment is denied by the primary plan because treatment was not received from an in-network provider of the primary plan.
  • Services for or in connection with an injury or illness arising out of, or in the course of, any employment for wage or profit.
  • Telephone, e-mail & Internet consultations.
  • Massage therapy.
This list is subject to change at any time.