Common use of Prosthetics Clause in Contracts

Prosthetics. 100% of eligible charges after the deductible. Not covered. Hearing aids for members under age 19 for hearing loss that is not correctable by other covered procedures. Coverage limited to one hearing aid per ear every 3 years. 100% of eligible charges after the deductible. Not covered. Wigs for hair loss resulting from alopecia areata are limited to one wig per calendar year. 100% of eligible charges after the deductible. Not covered. • Special dietary treatment for phenylketonuria (PKU) is covered when recommended by a physician, physician assistant or advanced practice registered nurse. • Limited coverage for amino-acid based elemental formulas that are consumed orally and treat cystic fibrosis or certain other metabolic and malabsorption errors. • Enteral feedings when they are prescribed by a physician, physician assistant or advanced practice registered nurse and are required to sustain life. 100% of eligible charges after the deductible. Not covered. Diabetic supplies Coverage includes over-the-counter diabetic supplies, glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 100% of eligible charges after the deductible. Not covered. PIC covers equipment and services ordered by a physician, physician assistant or advanced practice registered nurse and provided by DME/prosthetic/orthotic vendors. For verification of eligible equipment and supplies, contact PIC Customer Service at the address and phone number shown on the inside cover of this contract. If you are over age 18, contact lenses and their related fittings are not eligible for coverage unless they are prescribed as medically necessary for the treatment of keratoconus. Members must pay for lens replacement. Amino-acid based elemental formulas are covered only when 1) they are consumed orally, 2) are ordered by a physician, physician assistant, or advanced practice registered nurse for a person who is five years or younger, 3) are medically necessary, and 4) treat the following metabolic and other malabsorption conditions that have been diagnosed by a specialist:

Prosthetics. 10080% of eligible charges after the deductible. Not covered. Hearing aids for members under age 19 for hearing loss that is not correctable by other covered procedures. Coverage limited to one hearing aid per ear every 3 years. 10080% of eligible charges after the deductible. Not covered. Wigs for hair loss resulting from alopecia areata are limited to one wig per calendar year. 10080% of eligible charges after the deductible. Not covered. • Special dietary treatment for phenylketonuria (PKU) is covered when recommended by a physician, physician assistant or advanced practice registered nurse. • Limited coverage for amino-acid based elemental formulas that are consumed orally and treat cystic fibrosis or certain other metabolic and malabsorption errors. • Enteral feedings when they are prescribed by a physician, physician assistant or advanced practice registered nurse and are required to sustain life. 10080% of eligible charges after the deductible. Not covered. Diabetic supplies Coverage includes over-the-counter diabetic supplies, glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 10080% of eligible charges after the deductible. Not covered. PIC covers equipment and services ordered by a physician, physician assistant or advanced practice registered nurse and provided by DME/prosthetic/orthotic vendors. For verification of eligible equipment and supplies, contact PIC Customer Service at the address and phone number shown on the inside cover of this contract. If you are over age 18, contact lenses and their related fittings are not eligible for coverage unless they are prescribed as medically necessary for the treatment of keratoconus. Members must pay for lens replacement. Amino-acid based elemental formulas are covered only when 1) they are consumed orally, 2) are ordered by a physician, physician assistant, or advanced practice registered nurse for a person who is five years or younger, 3) are medically necessary, and 4) treat the following metabolic and other malabsorption conditions that have been diagnosed by a specialist:

Prosthetics. 10070% of eligible charges after the deductible. Not covered. Hearing aids for members under age 19 for hearing loss that is not correctable by other covered procedures. Coverage limited to one hearing aid per ear every 3 years. 10070% of eligible charges after the deductible. Not covered. Wigs for hair loss resulting from alopecia areata are limited to one wig per calendar year. 10070% of eligible charges after the deductible. Not covered. • Special dietary treatment for phenylketonuria (PKU) is covered when recommended by a physician, physician assistant or advanced practice registered nurse. • Limited coverage for amino-acid based elemental formulas that are consumed orally and treat cystic fibrosis or certain other metabolic and malabsorption errors. • Enteral feedings when they are prescribed by a physician, physician assistant or advanced practice registered nurse and are required to sustain life. 10070% of eligible charges after the deductible. Not covered. Diabetic supplies Coverage includes over-the-counter diabetic supplies, glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 10070% of eligible charges after the deductible. Not covered. PIC covers equipment and services ordered by a physician, physician assistant or advanced practice registered nurse and provided by DME/prosthetic/orthotic vendors. For verification of eligible equipment and supplies, contact PIC Customer Service at the address and phone number shown on the inside cover of this contract. If you are over age 18, contact lenses and their related fittings are not eligible for coverage unless they are prescribed as medically necessary for the treatment of keratoconus. Members must pay for lens replacement. Amino-acid based elemental formulas are covered only when 1) they are consumed orally, 2) are ordered by a physician, physician assistant, or advanced practice registered nurse r for a person who is five years or younger, 3) are medically necessary, and 4) treat the following metabolic and other malabsorption conditions that have been diagnosed by a specialist:

Prosthetics. 10075% of eligible charges after the deductible. Not covered. Hearing aids for members under age 19 for hearing loss that is not correctable by other covered procedures. Coverage limited to one hearing aid per ear every 3 years. 10075% of eligible charges after the deductible. Not covered. Wigs for hair loss resulting from alopecia areata are limited to one wig per calendar year. 10075% of eligible charges after the deductible. Not covered. • Special dietary treatment for phenylketonuria (PKU) is covered when recommended by a physician, physician assistant or advanced practice registered nurse. • Limited coverage for amino-acid based elemental formulas that are consumed orally and treat cystic fibrosis or certain other metabolic and malabsorption errors. • Enteral feedings when they are prescribed by a physician, physician assistant or advanced practice registered nurse and are required to sustain life. 10075% of eligible charges after the deductible. Not covered. Diabetic supplies Coverage includes over-the-counter diabetic supplies, glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 10075% of eligible charges after the deductible. Not covered. PIC covers equipment and services ordered by a physician, physician assistant or advanced practice registered nurse and provided by DME/prosthetic/orthotic vendors. For verification of eligible equipment and supplies, contact PIC Customer Service at the address and phone number shown on the inside cover of this contract. If you are over age 18, contact lenses and their related fittings are not eligible for coverage unless they are prescribed as medically necessary for the treatment of keratoconus. Members must pay for lens replacement. Amino-acid based elemental formulas are covered only when 1) they are consumed orally, 2) are ordered by a physician, physician assistant, or advanced practice registered nurse for a person who is five years or younger, 3) are medically necessary, and 4) treat the following metabolic and other malabsorption conditions that have been diagnosed by a specialist: