Common use of Cosmetic Surgery Clause in Contracts

Cosmetic Surgery. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reason unrelated to care for gender dysphoria and Medically Necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses is not Covered, unless Medically Necessary due to diabetes or Coverage for Diabetes Education must be: • medically necessary, or • due to a significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Cosmetic Surgery. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reason reasons unrelated to care for gender dysphoria and Medically Necessary medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses calluses, is not Covered, unless Medically Necessary due to diabetes or Coverage for Diabetes Education must be: • medically necessary, or • due to a other significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary peripheral neuropathies. Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Cosmetic Surgery. Surgery or other services done only to make the member: look beautiful; to Improve appearance; or to change or reshape normal parts or tissues of the body. This does not apply to reconstructive surgery the member might need to: get back the use of a body part; have for breast reconstruction after a mastectomy; correct or repair a deformity caused by birth defects, abnormal development, Injury or illness In order to Improve function, symptomatology or create a normal appearance. Cosmetic Surgery surgery does not become reconstructive because of psychological or psychiatric reasons. Custodial Care or Rest Cures. Room and board charges for a hospital stay mostly for a change of scene or to make the member feel good. Services given by a rest home, a home for the aged, or any place like that Dental Services or Supplies. Dentures, bridges, crowns, caps, or dental prostheses, dental implants, dental serv!ces, tooth extraction, or treatment to the teeth or gums. Cosmetic dental surgery or other dental services for beauty purposes. Diabetic Supplies. Prescription and nOll1lrescriptlon diabetic supplies except as specified as covered In b~ ' Eye Exe.rcises or Services and Supplies for Conrectlng II'lSion. Optometry services, eye exercises, and orthoptiCS, except for eye exams to find out if the member's vision needs to be corrected. Eyeglasses or contact lenses are not covered. Contact lens filling is not Coveredcovered. Examples of Cosmetic Eye Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne for Refractive Defects. Any eye surgery just for correcting vision (including cryotherapylike nearsightedness and/or astigmatism), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), . Contact lenses and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reason unrelated to care for gender dysphoria and Medically Necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial eyeglasses needed after this surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically NecessaryFood or Dietary Supplements. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental care and dental X-rays are not CoveredNutritional and/or dietary supplements, except as provided specified as covered in the Benefits SectionEOCor as required by law. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses is not Covered, unless Medically Necessary due to diabetes or Coverage for Diabetes Education must be: • medically necessary, or • due to a significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These includeThis exclusion includes, but are Is not limited to, those nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not require either a written prescription or dispensing by a licensed pharmacist ~ealth ClUb Membership. Health club memberships, exercise equipment, charges from a physical fitness Instructor or personal trainer, or any other charges for activities, equipment, or facilities used for developing or maintaining physical fitness, even If ordered by a doctor. This exclusion also applies to health spas. Immunizations. Immunizations needed to travel outside the USA. Infertility Treatment Any infertility treatment including artificial insemination or in vitro fertilization & sperm bank. Ufestyle Programs. Programs to help member change how one lives, like fitness clubs, or dieting programs. This does not apply to cardiac rehabilitation programs approved by the medical group. Mental or nervous disorders. Academic or educational testing, counseling. Remedying an applianceacademic or education problem, deviceexcept as stated as covered in the EOC. Non-Prescription Drugs. NOll1lrescription, object over.thEH:ounter drugs or service medicines. Orthopedic shoes and shoe inserts. This exclusion does not apply to orthopedic footwear used as an integral part of a brace, shoe inserts that is are custom molded to the patient or therapeutic shoes and Inserts designed to treat foot complications due to diabetes, as specifically stated In the EOC. Outpatient Drugs. Outpatient prescription drugs or medications including insulin. Personal Care and Supplies. Services for comfort and ease and is not primarily medical in naturepersonal care, such as: help in walking, shower bathing, dressing, feeding, or tub stools/chairspreparing food. Any supplies for comfort, seatshygiene or beauty purposes. Private Contracts. Services or supplies provided pursuant to a private contract between the member and a provider, bath grab barsfor which reimbursement under the Medicare program is prohibited, shower headsas specified in Section 1B02 (42 U.S.C.13S5a) ofTIUe XVIIIofthe Social Security Act Routine Exams. Routine physical or psychological exams or tests asked for by a job or other group, hot tubs/Jacuzzis, vaporizers, accessories such as basketsa school, trayscamp, seat or shades for wheelchairssports program. Scalp hair prostheses. Scalp hair prostheses, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits)including wigs or any form of hair replacement Sexual Problems. Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair or replacement Treatment of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices any sexual problems unless due to lossa medical problem, neglectphysical defect, misuse, abuse, or disease. Sterilization Reversal. Surgery done to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has reverse a functional wheelchair, regardless of the original purchaser of the wheelchairsterilization.

Cosmetic Surgery. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reason unrelated to care for gender dysphoria and Medically Necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered.  Dental care and dental X-rays are not Covered, except as provided in the Benefits SectionSection and as provided for under the Unique Services Reimbursement Program for the Active Plan.  Dental implants are not CoveredCovered except as provided for under the Unique Services Reimbursement Program for the Active Plan.  Malocclusion treatment, if part of routine dental care and orthodontics, is not CoveredCovered except as provided for under the Unique Services Reimbursement Program for the Active Plan.  Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses calluses, is not Covered, unless Medically Necessary due to diabetes or Coverage for Diabetes Education must be: • medically necessary, or • due to a other significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary peripheral neuropathies.  Durable Medical Equipment  Upgraded or deluxe Durable Medical Equipment is not Covered.  Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits).  Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered.  Repair and Replacement  Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered.  Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered.  Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Cosmetic Surgery. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reason unrelated to care for gender dysphoria and Medically Necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newbornsNecessary. newborns stay, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered.  Dental care and dental X-rays are not Covered, except as provided in the Benefits Section.  Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered.  Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses is not Covered, unless other significant peripheral neuropathies. Medically Necessary due to diabetes or Coverage for Diabetes Education must be: • medically necessary, or • due to a significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary  Durable Medical Equipment  Upgraded or deluxe Durable Medical Equipment is not Covered.  Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits).  Duplicate Durable Medical Equipment items (i.e., i.e. for home and office) are not Covered.  Repair and Replacement  Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered.  Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered.  Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.