Page 30 - QCS.19 SPD - PPO

Benefits do not include any device, appliance, Orthotics, Orthotic braces, including needed changes to shoes to fit
braces. Braces that stabilize an injured body part and braces to treat curvature of the spine are a Covered Health
Care Service.

· Any device, appliance, pump, machine, stimulator, or monitor that is fully implanted into the body.
Implantable devices are a Covered Health Care Service for which Benefits are available under the
applicable medical/surgical Covered Health Care Service categories in this Plan.

· Diagnostic or monitoring equipment purchased for home use, unless otherwise described as a Covered
Health Care Service.

· Powered exoskeleton devices.
We will decide if the equipment should be purchased or rented.

Benefits are available for repairs and replacement, except as described in Section 6: Exclusions:
Benefits for ostomy supplies are limited to the following:

· Pouches, face plates and belts;
· Irrigation sleeves, bags and catheters; and

· Skin barriers.
Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive
remover, or other items not listed above.

Emergency Health Care Services

Services that are required to stabilize or begin treatment in an Emergency. Emergency Health Care Services
must be received on an outpatient basis at a Hospital or Alternate Facility. Emergency Health Care Services are
available 24 hours per day, seven days per week. If you require Emergency Health Care Services, go to the
nearest emergency room or call 911 for help.
Benefits include the facility charge, supplies and all professional services required to stabilize your condition
and/or begin treatment. This includes placement in an observation bed to monitor your condition (rather than
being admitted to a Hospital for an Inpatient Stay).
Benefits are not available for services to treat a condition that does not meet the definition of an Emergency.

Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care
Services, you must obtain prior authorization within one business day or on the same day of admission if
reasonably possible.

Gender Dysphoria

Benefits for the treatment of gender dysphoria provided by or under the direction of a Physician:
For the purpose of this Benefit "gender dysphoria" is a disorder characterized by the specific diagnostic criteria
classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
Hearing Aids

Hearing Aids required for the correction of a Hearing Impairment and charges for related fitting and testing. The
Hearing Aid must be purchased due to a written recommendation by a Physician.

Covered Health Care Services are limited to a single purchase, including repair/replacement, every 36 months.
If more than one hearing aid can meet your functional needs, Benefits are available only for the hearing aid that
meets the minimum specifications for your needs.

Benefits for bone anchored hearing aids (BAHA) are a Covered Health Care Service for which Benefits are
provided under the applicable medical/surgical benefit categories in the Summary Plan Description. They are only
available if you have either of the following:

Page 25 Section 5- Additional Coverage Details
PPO - 2017