Common use of Dialysis Benefits Clause in Contracts

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: • Renal dialysis; • Hemodialysis; • Peritoneal dialysis; and • Self-management training for home dialysis. Benefits do not include: • Comfort, convenience, or luxury equipment; or • Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: • Mobility devices, such as wheelchairs; • Peak flow meter for the self-management of asthma; • Glucose monitor for the self-management of diabetes; • Apnea monitors for the management of newborn apnea; • Home prothrombin monitor for specific conditions; • Oxygen and respiratory equipment; • Disposable medical supplies used with DME and respiratory equipment; • Required dialysis equipment and medical supplies; • Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; • DME rental fees, up to the purchase price; and • Breast pumps. Benefits do not include: • Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; • Exercise equipment; • Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; • Self-help or educational devices; • Speech or language assistance devices, except as specifically listed; • Wigs; • Adult eyewear; • Video-assisted visual aids for diabetics; • Generators; • Any other equipment not primarily medical in nature; or • Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: • Shoes only when permanently attached to orthotic devices; • Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; • Knee braces for post-operative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; • Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Orthotic devices intended to provide additional support for recreational or sports activities; • Orthopedic shoes and other supportive devices for the feet, except as listed; • Backup or alternate items; or • Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: • Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; • Artificial limbs and eyes; • Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; • Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; • Supplies necessary for the operation of prostheses; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Speech or language assistance devices, except as listed; • Dental implants; • Backup or alternate items; or • Repair or replacement due to loss or misuse.

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: • Renal dialysis; • Hemodialysis; • Peritoneal dialysis; and • Self-management training for home dialysis. Benefits do not include: • Comfort, convenience, or luxury equipment; or • Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: • Mobility devices, such as wheelchairs; • Peak flow meter monitor for the self-management of asthma; • Glucose monitor for the self-management of diabetes; • Apnea monitors for the management of newborn apnea; • Home prothrombin monitor for specific conditions; • Oxygen and respiratory equipment; • Disposable medical supplies used with DME and respiratory equipment; • Required dialysis equipment and medical supplies; • Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; • DME rental fees, up to the purchase price; and • Breast pumps. Benefits do not include: • Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; • Exercise equipment; • Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; • Self-help or educational devices; • Speech or language assistance devices, except as specifically listed; • Wigs; • Adult eyewear; • Video-assisted visual aids for diabetics; • Generators; • Any other equipment not primarily medical in nature; or • Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: • Shoes only when permanently attached to orthotic devices; • Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; • Knee braces for post-operative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; • Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Orthotic devices intended to provide additional support for recreational or sports activities; • Orthopedic shoes and other supportive devices for the feet, except as listed; • Backup or alternate items; or • Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: • Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; • Artificial limbs and eyes; • Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; • Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; • Supplies necessary for the operation of prostheses; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Speech or language assistance devices, except as listed; • Dental implants; • Backup or alternate items; or • Repair or replacement due to loss or misuse.

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: •  Renal dialysis; •  Hemodialysis; •  Peritoneal dialysis; and •  Self-management training for home dialysis. Benefits do not include: •  Comfort, convenience, or luxury equipment; or •  Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: •  Mobility devices, such as wheelchairs; •  Peak flow meter monitor for the self-management of asthma; •  Glucose monitor for the self-management of diabetes; •  Apnea monitors for the management of newborn apnea; •  Home prothrombin monitor for specific conditions; •  Oxygen and respiratory equipment; •  Disposable medical supplies used with DME and respiratory equipment; •  Required dialysis equipment and medical supplies; •  Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; •  DME rental fees, up to the purchase price; and •  Breast pumps. Benefits do not include: •  Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; •  Exercise equipment; •  Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; •  Self-help or educational devices; •  Speech or language assistance devices, except as specifically listed; •  Wigs; •  Adult eyewear; •  Video-assisted visual aids for diabetics; •  Generators; •  Any other equipment not primarily medical in nature; or •  Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: •  Shoes only when permanently attached to orthotic devices; •  Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; •  Knee braces for post-operative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; •  Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; •  Device fitting and adjustment; •  Device replacement at the end of its expected lifespan; and •  Repair due to normal wear and tear. Benefits do not include: •  Orthotic devices intended to provide additional support for recreational or sports activities; •  Orthopedic shoes and other supportive devices for the feet, except as listed; •  Backup or alternate items; or •  Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: •  Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; •  Artificial limbs and eyes; •  Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; •  Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; •  Supplies necessary for the operation of prostheses; •  Device fitting and adjustment; •  Device replacement at the end of its expected lifespan; and •  Repair due to normal wear and tear. Benefits do not include: •  Speech or language assistance devices, except as listed; •  Dental implants; •  Backup or alternate items; or •  Repair or replacement due to loss or misuse.

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: • Renal dialysis; • Hemodialysis; • Peritoneal dialysis; and • Self-management training for home dialysis. Benefits do not include: • Comfort, convenience, or luxury equipment; or • Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: • Mobility devices, such as wheelchairs; • Peak flow meter for the self-management of asthma; • Glucose monitor for the self-management of diabetes; • Apnea monitors for the management of newborn apnea; • Home prothrombin monitor for specific conditions; • Oxygen and respiratory equipment; • Disposable medical supplies used with DME and respiratory equipment; • Required dialysis equipment and medical supplies; • Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; • DME rental fees, up to the purchase price; and • Breast pumps. Benefits do not include: • Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; • Exercise equipment; • Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; • Self-help or educational devices; • Speech or language assistance devices, except as specifically listed; • Wigs; • Adult eyewear; • Video-assisted visual aids for diabetics; • Generators; • Any other equipment not primarily medical in nature; or • Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: • Shoes only when permanently attached to orthotic devices; • Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; • Knee braces for post-operative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; • Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Orthotic devices intended to provide additional support for recreational or sports activities; • Orthopedic shoes and other supportive devices for the feet, except as listed; • Backup or alternate items; or • Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: • Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; • Artificial limbs and eyes; • Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; • Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; • Supplies necessary for the operation of prostheses; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Speech or language assistance devices, except as listed; • Dental implants; • Backup or alternate items; or • Repair or replacement due to loss or misuse.

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: •  Renal dialysis; •  Hemodialysis; •  Peritoneal dialysis; and •  Self-management training for home dialysis. Benefits do not include: •  Comfort, convenience, or luxury equipment; or •  Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: •  Mobility devices, such as wheelchairs; •  Peak flow meter monitor for the self-management of asthma; •  Glucose monitor for the self-management of diabetes; •  Apnea monitors for the management of newborn apnea; •  Home prothrombin monitor for specific conditions; •  Oxygen and respiratory equipment; •  Disposable medical supplies used with DME and respiratory equipment; •  Required dialysis equipment and medical supplies; •  Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; •  DME rental fees, up to the purchase price; and •  Breast pumps. Benefits do not include: •  Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; •  Exercise equipment; •  Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; •  Self-help or educational devices; •  Speech or language assistance devices, except as specifically listed; •  Wigs; •  Adult eyewear; •  Video-assisted visual aids for diabetics; •  Generators; •  Any other equipment not primarily medical in nature; or •  Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: •  Shoes only when permanently attached to orthotic devices; •  Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; •  Knee braces for post-operative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; •  Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; •  Device fitting and adjustment; •  Device replacement at the end of its expected lifespan; and •  Repair due to normal wear and tear. Benefits do not include: •  Orthotic devices intended to provide additional support for recreational or sports activities; •  Orthopedic shoes and other supportive devices for the feet, except as listed; •  Backup or alternate items; or •  Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: •  Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; •  Artificial limbs and eyes; •  Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; •  Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; •  Supplies necessary for the operation of prostheses; •  Device fitting and adjustment; •  Device replacement at the end of its expected lifespan; and •  Repair due to normal wear and tear. Benefits do not include: •  Speech or language assistance devices, except as listed; •  Dental implants; •  Backup or alternate items; or •  Repair or replacement due to loss or misuse.

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: • Renal dialysis; • Hemodialysis; • Peritoneal dialysis; and • Self-management training for home dialysis. Benefits do not include: • Comfort, convenience, or luxury equipment; or • Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: • Mobility devices, such as wheelchairs; • Peak flow meter for the self-management of asthma; • Glucose monitor including continuous blood glucose monitor, and all related necessary supplies for the self-management of diabetes; • Apnea monitors for the management of newborn apnea; • Home prothrombin monitor for specific conditions; • Oxygen and respiratory equipment; • Disposable medical supplies used with DME and respiratory equipment; • Required dialysis equipment and medical supplies; • Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; • DME rental fees, up to the purchase price; and • Breast pumps. Benefits do not include: • Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; • Exercise equipment; • Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; • Self-help or educational devices; • Speech or language assistance devices, except as specifically listed; • Wigs; • Adult eyewear; • Video-assisted visual aids for diabetics; • Generators; • Any other equipment not primarily medical in nature; or • Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Self-applied continuous blood glucose monitors are also covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: • Shoes only when permanently attached to orthotic devices; • Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; • Knee braces for post-operative postoperative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; • Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Orthotic devices intended to provide additional support for recreational or sports activities; • Orthopedic shoes and other supportive devices for the feet, except as listed; • Backup or alternate items; or • Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: • Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; • Artificial limbs and eyes; • Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; • Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; • Supplies necessary for the operation of prostheses; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Speech or language assistance devices, except as listed; • Dental implants; • Backup or alternate items; or • Repair or replacement due to loss or misuse.

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: • Renal dialysis; • Hemodialysis; • Peritoneal dialysis; and • Self-management training for home dialysis. Benefits do not include: • Comfort, convenience, or luxury equipment; or • Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: • Mobility devices, such as wheelchairs; • Peak flow meter monitor for the self-management of asthma; • Glucose monitor for the self-management of diabetes; • Apnea monitors for the management of newborn apnea; • Home prothrombin monitor for specific conditions; • Oxygen and respiratory equipment; • Disposable medical supplies used with DME and respiratory equipment; • Required dialysis equipment and medical supplies; • Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; • DME rental fees, up to the purchase price; and • Breast pumps. Benefits do not include: • Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; • Exercise equipment; • Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; • Self-help or educational devices; • Speech or language assistance devices, except as specifically listed; • Wigs; • Adult eyewear; • Video-assisted visual aids for diabetics; • Generators; • Any other equipment not primarily medical in nature; or • Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: • Shoes only when permanently attached to orthotic devices; • Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; • Knee braces for post-operative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; • Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Orthotic devices intended to provide additional support for recreational or sports activities; • Orthopedic shoes and other supportive devices for the feet, except as listed; • Backup or alternate items; or • Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: • Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; • Artificial limbs and eyes; • Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; • Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; • Supplies necessary for the operation of prostheses; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Speech or language assistance devices, except as listed; • Dental implants; • Backup or alternate items; or • Repair or replacement due to loss or misuse.

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: • Renal dialysis; • Hemodialysis; • Peritoneal dialysis; and • Self-management training for home dialysis. Benefits do not include: • Comfort, convenience, or luxury equipment; or • Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: • Mobility devices, such as wheelchairs; • Peak flow meter monitor for the self-management of asthma; • Glucose monitor for the self-management of diabetes; • Apnea monitors for the management of newborn apnea; • Home prothrombin monitor for specific conditions; • Oxygen and respiratory equipment; • Disposable medical supplies used with DME and respiratory equipment; • Required dialysis equipment and medical supplies; • Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; • DME rental fees, up to the purchase price; and • Breast pumps. Benefits do not include: • Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; • Exercise equipment; • Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; • Self-help or educational devices; • Speech or language assistance devices, except as specifically listed; • Wigs; • Adult eyewear; • Video-assisted visual aids for diabetics; • Generators; • Any other equipment not primarily medical in nature; or • Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: • Shoes only when permanently attached to orthotic devices; • Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; • Knee braces for post-operative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; • Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Orthotic devices intended to provide additional support for recreational or sports activities; • Orthopedic shoes and other supportive devices for the feet, except as listed; • Backup or alternate items; or • Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: • Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; • Artificial limbs and eyes; • Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; • Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; • Supplies necessary for the operation of prostheses; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Speech or language assistance devices, except as listed; • Dental implants; • Backup or alternate items; or • Repair or replacement due to loss or misuse.

Dialysis Benefits. Benefits are available for dialysis services at a freestanding dialysis center, in the Outpatient Department of a Hospital, in a physician office setting, or in your home. Benefits include: • Renal dialysis; • Hemodialysis; • Peritoneal dialysis; and • Self-management training for home dialysis. Benefits do not include: • Comfort, convenience, or luxury equipment; or • Non-medical items, such as generators or accessories to make home dialysis equipment portable. Durable medical equipment Benefits are available for durable medical equipment (DME) and supplies needed to operate the equipment. DME is intended for repeated use to treat an illness or injury, to improve the function of movable body parts, or to prevent further deterioration of your medical condition. Items such as orthotics and prosthetics are only covered when necessary for Activities of Daily Living. Benefits include: • Mobility devices, such as wheelchairs; • Peak flow meter monitor for the self-management of asthma; • Glucose monitor for the self-management of diabetes; • Apnea monitors for the management of newborn apnea; • Home prothrombin monitor for specific conditions; • Oxygen and respiratory equipment; • Disposable medical supplies used with DME and respiratory equipment; • Required dialysis equipment and medical supplies; • Medical supplies that support and maintain gastrointestinal, bladder, or bowel function, such as ostomy supplies; • DME rental fees, up to the purchase price; and • Breast pumps. Benefits do not include: • Environmental control and hygienic equipment, such as air conditioners, humidifiers, dehumidifiers, or air purifiers; • Exercise equipment; • Routine maintenance, repair, or replacement of DME due to loss or misuse, except when authorized; • Self-help or educational devices; • Speech or language assistance devices, except as specifically listed; • Wigs; • Adult eyewear; • Video-assisted visual aids for diabetics; • Generators; • Any other equipment not primarily medical in nature; or • Backup or alternate equipment. Asthma inhalers and inhaler spacers are covered under the Prescription Drug Benefits Rider, if your Employer selected it as an optional Benefit. See the Diabetes care services section for more information about devices, equipment, and supplies for the management and treatment of diabetes. Orthotic equipment and devices Benefits are available for orthotic equipment and devices you need to perform Activities of Daily Living. Orthotics are orthopedic devices used to support, align, prevent, or correct deformities or to improve the function of movable body parts. Benefits include: • Shoes only when permanently attached to orthotic devices; • Special footwear required for foot disfigurement caused by disease, disorder, accident, or developmental disability; • Knee braces for post-operative rehabilitation following ligament surgery, instability due to injury, and to reduce pain and instability for patients with osteoarthritis; • Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist and used to treat mechanical problems of the foot, ankle, or leg by preventing abnormal motion and positioning when improvement has not occurred with a trial of strapping or an over-the-counter stabilizing device; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Orthotic devices intended to provide additional support for recreational or sports activities; • Orthopedic shoes and other supportive devices for the feet, except as listed; • Backup or alternate items; or • Repair or replacement due to loss or misuse. Prosthetic equipment and devices Benefits are available for prosthetic appliances and devices used to replace a part of your body that is missing or does not function, and related supplies. Benefits include: • Tracheoesophageal voice prosthesis (e.g. Xxxx-Xxxxxx device) and artificial larynx for speech after a laryngectomy; • Artificial limbs and eyes; • Internally-implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if surgery to implant the device is covered; • Contact lenses to treat eye conditions such as keratoconus or keratitis sicca, aniridia, or to treat aphakia following cataract surgery when no intraocular lens has been implanted; • Supplies necessary for the operation of prostheses; • Device fitting and adjustment; • Device replacement at the end of its expected lifespan; and • Repair due to normal wear and tear. Benefits do not include: • Speech or language assistance devices, except as listed; • Dental implants; • Backup or alternate items; or • Repair or replacement due to loss or misuse.