Common use of Eyeglasses and Contact Lenses Clause in Contracts

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels are Not Covered. • LDAA Local Delivery of Antimicrobial Agents used for Periodontal Procedures are Not Covered.

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ our Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ Covered. • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and at any stage in a serious illness, and it can be provided together with curative treatmentstreatment. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs Oral and Injections Injectable when provided by a practitioner/provider • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ Covered • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels are Not Covered. • LDAA Local Delivery of Antimicrobial Agents used for Periodontal Procedures are Not Covered.

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care healthcare procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or‌‌ • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type test means an analysis of medical test that identifies changes in human DNA, RNA, chromosomes, genesproteins, or proteinsmetabolites, if the analysis detects genotypes, mutations, or chromosomal changes. However, a genetic test does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Accordingly, a test to determine whether an individual has a BRCA1 or BRCA2 variant is a genetic test. Similarly, a test to determine whether an individual has a genetic variant associated with hereditary nonpolyposis colorectal cancer is a genetic test. However, an HIV test, complete blood count, cholesterol test, liver function test, or test for the presence of alcohol or drugs is not a genetic test. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Coverage‌‌‌‌‌ Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ our Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels are Not Covered. • LDAA Local Delivery of Antimicrobial Agents used for Periodontal Procedures are Not Covered.

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care healthcare procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or‌‌ • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type test means an analysis of medical test that identifies changes in human DNA, RNA, chromosomes, genesproteins, or proteinsmetabolites, if the analysis detects genotypes, mutations, or chromosomal changes. However, a genetic test does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Accordingly, a test to determine whether an individual has BRCA1 or BRCA2 variant is a genetic test. Similarly, a test to determine whether an individual has a genetic variant associated with hereditary nonpolyposis colorectal cancer is a genetic test. However, an HIV test, complete blood count, cholesterol test, liver function test, or test for the presence of alcohol or drugs is not a genetic test. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Coverage‌‌‌‌‌ Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ our Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. o Compounding kits are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximumspocket Maximum. • Herbal or alternative medicine and holistic supplements are not Covered. Covered.‌ • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ Covered • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels and non-FDA approved hormone pellets are Not Covered. • LDAA Local Delivery of Antimicrobial Agents (LDAA) used for Periodontal Procedures are Not Covered. Reconstructive Surgery for Cosmetic Purposes Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, micro phlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy.

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ our Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ Covered. • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may are not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ Covered • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels are Not Covered. • LDAA Local Delivery of Antimicrobial Agents used for Periodontal Procedures are Not Covered.

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care healthcare procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels are Not Covered. • LDAA Local Delivery of Antimicrobial Agents used for Periodontal Procedures are Not Covered.or

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care healthcare procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type test means an analysis of medical test that identifies changes in human DNA, RNA, chromosomes, genesproteins, or proteinsmetabolites, if the analysis detects genotypes, mutations, or chromosomal changes. However, a genetic test does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Accordingly, a test to determine whether an individual has BRCA1 or BRCA2 variant is a genetic test. Similarly, a test to determine whether an individual has a genetic variant associated with hereditary nonpolyposis colorectal cancer is a genetic test. However, an HIV test, complete blood count, cholesterol test, liver function test, or test for the presence of alcohol or drugs is not a genetic test. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ our Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-Hair loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-hair loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ Covered. • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs Oral and Injections Injectable when provided by a practitioner/provider • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Palliative Care Palliative care may be appropriate at any age and at any stage in a serious illness, and it can be provided together with curative treatment. Palliative care is not Covered under this plan. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. Covered • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. o Compounding kits are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ Covered • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels and non-FDA approved hormone pellets are Not Covered. • LDAA Local Delivery of Antimicrobial Agents (LDAA) used for Periodontal Procedures are Not Covered.. Reconstructive Surgery for Cosmetic Purposes Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery 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. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Voice Training is not Covered. • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network (outside of the 5-county area) If you fail to obtain Prior Authorization for services received Out-of-network (outside of the 5- county area) that require Prior Authorization, those services are not Covered. However, Members are not liable when an In-network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered:

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care healthcare procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ our Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-Hair loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-hair loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ Covered. • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs Oral and Injections Injectable when provided by a practitioner/provider • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Palliative Care Palliative care may be appropriate at any age and at any stage in a serious illness, and it can be provided together with curative treatment. Palliative care is not Covered under this plan. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. Covered • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ Covered • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels are Not Covered. • LDAA Local Delivery of Antimicrobial Agents used for Periodontal Procedures are Not Covered.

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care healthcare procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or‌‌‌‌ • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A is a type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ our‌‌‌‌‌ Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ Covered. • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services Services‌‌‌‌ • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and at any stage in a serious illness, and it can be provided together with curative treatmentstreatment. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs Oral and Injections Injectable when provided by a practitioner/provider • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications Medications‌ • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. o Compounding kits are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ Covered‌‌‌ • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels and non-FDA approved hormone pellets are Not Covered. • LDAA Local Delivery of Antimicrobial Agents (LDAA) used for Periodontal Procedures are Not Covered. Reconstructive Surgery for Cosmetic Purposes Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery 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. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Voice Training is not Covered. • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered.‌‌‌‌‌‌‌ Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered.

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care healthcare procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels are Not Covered. • LDAA Local Delivery of Antimicrobial Agents used for Periodontal Procedures are Not Covered.or

Eyeglasses and Contact Lenses. Routine vision care and Eye Refractions for determining prescriptions for corrective lenses are not Covered, except as identified in the Benefits Section. Corrective eyeglasses or sunglasses, frames, lens prescriptions, contact lenses or the fitting thereof, are not Covered except as identified in the Benefits Section. Eye refractive procedures including radial keratotomy, laser procedures, and other techniques are not Covered. Visual training is not Covered. Eye movement therapy is not Covered. Exercise Equipment, Personal Trainers Exercise equipment, videos, and personal trainers are not Covered. Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices Experimental or Investigational drugs, diagnostic genetic testing, medicines, treatments, procedures, or devices are not Covered. Experimental or Investigational medical, surgical, diagnostic genetic testing, other health care procedures or treatments, including drugs. As used in this Agreement, “Experimental” or “Investigational” as related to drugs, devices, medical treatments or procedures means: • The drug or device cannot be lawfully marketed without approval of the FDA and approval for marketing has not been given at the time the drug or device is furnished; or • Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or • Reliable evidence shows that the consensus of opinion among experts regarding the drug, medicine, and/or device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with the standard means of treatment or diagnosis; or‌‌‌ or • Except as required by state law, the drug or device is used for a purpose that is not approved by the FDA; or • Testing is Covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient and if approved by the FDA. Routine genetic testing is not Covered; or • For the purposes of this section, “reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature listed in state law; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure; or • As used in this section, “Experimental” or “Investigational” does not mean cancer chemotherapy or other types of therapy that are the subjects of on-going phase IV clinical trials. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy involving the musculoskeletal system is not Covered. Foot Care 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. Genetic Testing Genetic testing A type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of developing or passing on a genetic disorder if that person has a known family history or classic symptoms of a disorder. Genetic testing is not covered when the test is performed primarily for the medical management of other family members. Additional expenses for banking of genetic material is not covered. Genetic Inborn Errors of Metabolism Coverage Genetic Inborn Errors of Metabolism Coverage does not include the following items: • Food substitutes for lactose intolerance or other carbohydrate intolerances, including soy foods or elemental formulas or other Over-the-counter (OTC) digestive aids are not Covered, unless listed as a Covered Over-the-counter (OTC) medication on our‌‌‌‌ Formulary. • Ordinary food that might be part of an exclusionary diet are not Covered. • Food substitutes that do not qualify as Special Medical Foods for the treatment of IEM are not Covered. • Special Medical Foods for conditions that are not present at birth are not Covered. • Dietary supplements and items for conditions including, but not limited to, Diabetes Mellitus, Hypertension, Hyperlipidemia, Obesity, Autism Spectrum Disorder, Celiac Disease and Allergies to food products are not Covered. Hair-loss (or baldness) Hair-loss or baldness treatments, medications, supplies and devices, including wigs, and special brushes are not Covered regardless of the medical cause of the hair-loss or baldness. Home Health Care Services/Home Intravenous Services and Supplies Private duty nursing is not Covered. Custodial Care needs that can be performed by non-licensed medical personnel to meet the normal activities of daily living do not qualify for Home Health Care Services and are not Covered. Examples of Custodial Care that are not Covered include, but are not limited to, bathing, feeding, preparing meals, or performing housekeeping tasks. Hospital Services Acute Medical Detoxification in a Residential Treatment Center is not Covered. Rehabilitation is not Covered as part of acute medical detoxification. Mental Health and Alcohol and Substance Use Disorder Mental Health • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. • Psychological testing when not Medically Necessary is not Covered. • Residential Treatment Centers are not Covered, unless for the treatment of Alcoholism and/or Substance Use Disorder • Special education, school testing or evaluations, educational counseling, therapy or care for learning deficiencies or disciplinary problems are not Covered. This applies whether or not associated with manifest mental illness or other disturbances except as Covered under the Family, Infant and Toddler Program. Refer to the Benefits Section. • Court ordered evaluation or treatment, or treatment that is a condition of parole or probation or in lieu of sentencing, such as psychiatric evaluation or therapy is not Covered.‌‌‌ • Alcohol and/or Substance Use Disorder services are not considered mental health benefits. Alcoholism Services and Substance Use Disorder Services • Treatment in a halfway house is not Covered. • Codependency treatment is not Covered. • Bereavement, pastoral/spiritual and sexual counseling are not Covered. Nutritional Support and Supplements Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings is not Covered. Palliative Care Palliative care may be appropriate at any age and any stage in serious illness, and it can be provided together with curative treatments. Palliative care is not Covered under this plan. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained may not be Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications prescribed for off-label or unproven indications when a Medical Necessity has not been established are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. • Prescription Drugs/Medications used in conjunction with In-vitro fertilization and artificial insemination are not Covered. • Oral or injectable medications used to promote pregnancy are not Covered. • Over-the-counter (OTC) medications and drugs are not Covered. Refer to our Formulary for a list of Covered Over-the-counter (OTC) medications as determined by our Pharmacy and Therapeutics Committee. • Prescription Drugs, Medications or Devices used for the treatment of sexual dysfunction are not Covered. • Prescription Drugs/Medications for the purpose of weight reduction or control, except for Medically Necessary treatment for morbid obesity, are not Covered. • Prescription Drugs/Medications used for cosmetic purposes are not Covered. • Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are not Covered. o Infant formula is not Covered under any circumstance • Compounded Prescription Drugs/Medications are not Covered. o Bulk powders are not Covered. • Discount Cards or prescription Drug Savings Cards do not apply to Deductible or Out of Pocket Maximum. • Brand name drugs dispensed when a generic equivalent is available will not count towards Deductible or Out of Pocket Maximums. • Herbal or alternative medicine and holistic supplements are not Covered. • Vaccinations, drugs and immunizations for the primary intent of medical research or non- Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, or functional capacity examinations related to employment are not Covered‌ • Immunizations for the purpose of foreign travel, flight and or passports are not Covered. • Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including “all-natural” pills, creams, lotions and gels are Not Covered. • LDAA Local Delivery of Antimicrobial Agents used for Periodontal Procedures are Not Covered.or