Common use of Cosmetic Surgery Clause in Contracts

Cosmetic Surgery. Cosmetic Surgery is not Cov red. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar (except for truncal veins), and nasal rhinoplasty. revision, microphlebectomy, sclerotherapy Circumcisions, performed other than for newborns Necessary. stay, are not Covered unless Medically e Ref r to Refer to Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatments, devices, Orthotics, and Prescription Drugs/Medications 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 Services  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 a pliances 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. Diabetes Services 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 other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment,

Cosmetic Surgery. Cosmetic Surgery is not Cov redCovered. 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. revision, microphlebectomy, sclerotherapy Circumcisions, Necessary. performed other than for newborns Necessary. staynewborns, are not Covered unless Medically e Ref r to Refer to Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatments, devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for extended warranties and premiums for other insurance coverage Costs Cost for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Servic s Refer to  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 a pliances 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. Diabetes Services Routine Rout ne 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 other significant peripheral eripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment,

Cosmetic Surgery. Cosmetic Surgery is not Cov red. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar (except for truncal veins), and nasal rhinoplasty. revision, microphlebectomy, sclerotherapy Circumcisions, performed other than for newborns Necessary. stay, are not Covered unless Medically e Ref r to Refer to Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatments, devices, Orthotics, and Prescription Drugs/Medications 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 Services (over age 19)  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 a pliances 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. Diabetes Services 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 other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment,

Cosmetic Surgery. Cosmetic Surgery is not Cov redCovered. 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. revision, microphlebectomy, sclerotherapy Circumcisions, performed other than for newborns Necessary. staynewborns, are not Covered unless Medically e Ref r to Necessary. Refer to Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatments, devices, Orthotics, and Prescription Drugs/Medications 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 Services Refer to  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 a pliances 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. Diabetes Services 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 other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment,, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids  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 Cov redCovered. 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. revision, microphlebectomy, sclerotherapy Circumcisions, performed other than for newborns Necessary. staynewborns, are not Covered unless Medically e Ref r to Necessary. Refer to Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatments, devices, Orthotics, and Prescription Drugs/Medications 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. Refer to Dental Services  ➢ 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 a pliances 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. Diabetes Services 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 other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment,, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids ➢ 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 Cov red. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar (except for truncal veins), and nasal rhinoplasty. revision, microphlebectomy, sclerotherapy Circumcisions, performed other than for newborns Necessary. stay, are not Covered unless Medically e Ref r Refer to Refer to Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatments, devices, Orthotics, and Prescription Drugs/Medications 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 Services  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 a pliances 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. Diabetes Services 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 other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment,

Cosmetic Surgery. Cosmetic Surgery is not Cov red. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar (except for truncal veins), and nasal rhinoplasty. revision, microphlebectomy, sclerotherapy Circumcisions, performed other than for newborns Necessary. stay, are not Covered unless Medically e Ref r Refer to Refer to Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic treatments, devices, Orthotics, and Prescription Drugs/Medications 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 Services  ⮚ 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 a pliances 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. Diabetes Services 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 other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment,