AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

Not included are charges for:
• Any ear or hearing exam to diagnose or treat an Illness or Injury;
• Drugs or medicines;
• Any hearing care service or supply which is a Covered Expense in whole or in part under any other
part of this Plan or under any other plan of group benefits provided through your Employer;
• Any hearing care service or supply for which a benefit is provided under any workers' compensation
law or any other law of like purpose, whether benefits are payable as to all or only part of the charges;
• Any hearing care service or supply which does not meet professionally accepted standards;
• Any service or supply received while the person is not a Covered Individual;
• Any exams given while the Covered Individual is confined in a Hospital or other facility for medical
care;
• Any exam required by an employer as a condition of employment, or which an employer is required to
provide under a labor agreement or is required by any law of a government, or
• Any service or supply furnished by a Non-Preferred Care Provider.
HOSPICE CARE EXPENSES
Charges made for the following furnished to a Covered Individual for Hospice Care when given as a part
of a Hospice Care program are included as Covered Medical Expenses.
FACILITY EXPENSES
The charges made in its own behalf by a:
• Hospice Facility;
• Hospital; or
• Convalescent Facility.
Which are for:
INPATIENT CARE
Room and Board and other services and supplies furnished to a Covered Individual while a full-time
Inpatient for: pain control and other acute and chronic symptom management.
• Not included is any charge for daily room and board in a private room over the Private Room Limit.
OUTPATIENT CARE
Services and supplies furnished to a Covered Individual while not confined as a full-time Inpatient.
OTHER EXPENSES FOR OUTPATIENT CARE
Charges made by a Hospice Care Agency for:
• Part-time or intermittent nursing care by an R.N. or L.P.N. for up to eight hours in any one day.
• Medical social services under the direction of a Physician. These include:
o Assessment of the Covered Individual’s:
� Social, emotional, and medical needs; and
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