Page 36 - QCS.19 SPD - PPO

· Whether the pump should be purchased or rented (and the duration of any rental).
Examples of preventive medical care are:

Physician office services:
· Routine physical examinations;

· Well baby and well child care;
· Immunizations and;

· Hearing screening.

Lab, X-ray or other preventive tests:
· Cervical cancer screening;

· Prostate cancer screening; and
· Bone mineral density tests.

Prosthetic Devices
External prosthetic devices that replace a limb or a body part, limited to:

· Artificial arms, legs, feet and hands;

· Artificial face, eyes, ears and noses;
· Speech aid prosthetics and trachea-esophageal voice prosthetics; and

· Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998. Benefits include
mastectomy bras. Benefits for lymphedema stockings for the arm are provided as described under
Durable Medical Equipment (DME), Orthotics, Supplies and Ostomy Supplies.

Benefits are provided only for external prosthetic devices and do not include any device that is fully implanted into
the body other than breast prostheses. Internal prosthetics are a Covered Health Care Service for which Benefits
are available under the applicable medical/surgical Covered Health Care Service categories in this Summary Plan
Description.

If more than one prosthetic device can meet your functional needs, Benefits are available only for the prosthetic
device that meets the minimum specifications for your needs. If you purchase a prosthetic device that exceeds
these minimum specifications, we will pay only the amount that we would have paid for the prosthetic that meets
the minimum specifications, and you will be responsible for paying any difference in cost.
The prosthetic device must be ordered or provided by, or under the direction of a Physician.
Benefits are available for repairs and replacement, except that:

· There are no Benefits for repairs due to misuse, malicious damage or gross neglect; and

· There are no Benefits for replacement due to misuse, malicious damage, and gross neglect or for lost or
stolen prosthetic devices.
Reconstructive Procedures

Reconstructive procedures when the primary purpose of the procedure is either of the following:

· Treatment of a medical condition, or
· Improvement or restoration of physiologic function.

Reconstructive procedures include surgery or other procedures which are related to an Injury, Sickness or
Congenital Anomaly. The primary result of the procedure is not a changed or improved physical appearance.

Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital Anomaly
without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that you may

Page 31 Section 5- Additional Coverage Details
PPO - 2017