Common use of Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic Clause in Contracts

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. MEDICAL SUPPLIES means those consumable supplies that are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits.

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: •  can withstand repeated use; •  is primarily and customarily used to serve a medical purpose; •  is not useful to a person in the absence of an illness or injury; and •  is for use in the home. MEDICAL SUPPLIES means those consumable supplies that are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits. Outpatient/In Your Home We will cover the following durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices subject to our guidelines. Durable Medical Equipment A durable medical equipment (DME) item may be classified as a rental item or a purchased item. A DME rental item is billed on a monthly basis for a specific period of months, after which time the item is considered paid up to our allowance. Our allowance for a rental DME item will never exceed our allowance for a DME purchased item. Preauthorization is recommended for certain rental and purchased items. Repairs and supplies to rental equipment are included in our rental allowance. Preauthorization is recommended for replacement and repairs of purchased durable medical equipment. We will cover the following durable medical equipment subject to our guidelines:  wheelchairs, hospital beds, and other durable medical equipment used only for medical treatment; and  replacement of purchased equipment which is needed due to a change in your medical condition (replacement of covered durable medical equipment will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty, and cannot be repaired). Medical Supplies We will cover the following medical supplies subject to our guidelines:  essential accessories such as hoses, tubes and mouthpieces for use with medically necessary durable medical equipment (these accessories are included as part of the rental allowance for rented equipment);  catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and  respiratory therapy equipment solutions. Medical supplies provided during an office visit are included in our office visit allowance. Prosthetic Devices This agreement provides coverage per Rhode Island General Law. We will cover the following prosthetic devices subject to our guidelines:  prosthetic appliances such as artificial limbs, breasts, larynxes and eyes, including the replacement or adjustment of these appliances (replacement of a covered device will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired);  devices, accessories, batteries and supplies necessary for attachment to and operation of prosthetic devices;  orthopedic braces (except corrective shoes and orthotic devices used in connection with footwear); and  Initial and subsequent prosthetic devices following a mastectomy and following an order of a physician or surgeon. This agreement provides benefits for mastectomy-related prosthetics in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Laws 27-20-29 et seq. See Section 3.34 - Surgery Services - Mastectomy.

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. MEDICAL SUPPLIES means those consumable supplies that which are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits. Outpatient/In Your Home We will cover the following durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices subject to our guidelines. Durable Medical Equipment A durable medical equipment (DME) item may be classified as a rental item or a purchased item. A DME rental item is billed on a monthly basis for a specific period of months, after which time the item is considered paid up to our allowance. Our allowance for a rental DME item will never exceed our allowance for a DME purchased item. Preauthorization is recommended for certain rental and purchased items. Repairs and supplies to rental equipment are included in our rental allowance. Preauthorization is recommended for replacement and repairs of purchased durable medical equipment. We will cover the following durable medical equipment subject to our guidelines: • Wheelchairs, hospital beds, and other durable medical equipment used only for medical treatment; • Replacement of purchased equipment which is needed due to a change in your medical condition (replacement of covered durable medical equipment will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty, and cannot be repaired). Medical Supplies We will cover the following medical supplies subject to our guidelines: • Essential accessories such as hoses, tubes and mouthpieces for use with medically necessary durable medical equipment (these accessories are included as part of the rental allowance for rented equipment); • Catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and • Respiratory therapy equipment solutions. Medical supplies provided during an office visit are included in our office visit allowance. Prosthetic Devices This agreement provides coverage per Rhode Island General Law. We will cover the following prosthetic devices subject to our guidelines: • Prosthetic appliances such as artificial limbs, breasts, larynxes and eyes, including the replacement or adjustment of these appliances (replacement of a covered device will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired); • Devices, accessories, batteries and supplies necessary for attachment to and operation of prosthetic devices; • Orthopedic braces (except corrective shoes and orthotic devices used in connection with footwear); and • Initial and subsequent prosthetic devices following a mastectomy and following an order of a physician or surgeon. This agreement provides benefits for mastectomy-related prosthetics in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Laws 27-20-29 et seq. See Section 3.34 - Surgery Services - Mastectomy.

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. MEDICAL SUPPLIES means those consumable supplies that are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits. Outpatient/In Your Home We will cover the following durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices subject to our guidelines. Durable Medical Equipment A durable medical equipment (DME) item may be classified as a rental item or a purchased item. A DME rental item is billed on a monthly basis for a specific period of months, after which time the item is considered paid up to our allowance. Our allowance for a rental DME item will never exceed our allowance for a DME purchased item. Preauthorization is recommended for certain rental and purchased items. Repairs and supplies to rental equipment are included in our rental allowance. Preauthorization is recommended for replacement and repairs of purchased durable medical equipment. We will cover the following durable medical equipment subject to our guidelines: • wheelchairs, hospital beds, and other durable medical equipment used only for medical treatment; and • replacement of purchased equipment which is needed due to a change in your medical condition (replacement of covered durable medical equipment will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty, and cannot be repaired). Medical Supplies We will cover the following medical supplies subject to our guidelines: • essential accessories such as hoses, tubes and mouthpieces for use with medically necessary durable medical equipment (these accessories are included as part of the rental allowance for rented equipment); • catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and • respiratory therapy equipment solutions. Medical supplies provided during an office visit are included in our office visit allowance. Prosthetic Devices This agreement provides coverage per Rhode Island General Law. We will cover the following prosthetic devices subject to our guidelines: • prosthetic appliances such as artificial limbs, breasts, larynxes and eyes, including the replacement or adjustment of these appliances (replacement of a covered device will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired); • devices, accessories, batteries and supplies necessary for attachment to and operation of prosthetic devices; • orthopedic braces (except corrective shoes and orthotic devices used in connection with footwear); and • Initial and subsequent prosthetic devices following a mastectomy and following an order of a physician or surgeon. This agreement provides benefits for mastectomy-related prosthetics in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Laws 27-20-29 et seq. See Section 3.34 - Surgery Services - Mastectomy.

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: •  can withstand repeated use; •  is primarily and customarily used to serve a medical purpose; •  is not useful to a person in the absence of an illness or injury; and •  is for use in the home. MEDICAL SUPPLIES means those consumable supplies that are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits.

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: •  can withstand repeated use; •  is primarily and customarily used to serve a medical purpose; •  is not useful to a person in the absence of an illness or injury; and •  is for use in the home. MEDICAL SUPPLIES means those consumable supplies that which are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, diabetic equipment/supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits. Outpatient/In Your Home We will cover the following durable medical equipment, medical supplies, diabetic equipment/supplies, enteral formula or food, and prosthetic devices subject to our guidelines. Durable Medical Equipment A durable medical equipment (DME) item may be classified as a rental item or a purchased item. A DME rental item is billed on a monthly basis for a specific period of months, after which time the item is considered paid up to our allowance. Our allowance for a rental DME item will never exceed our allowance for a DME purchased item. Preauthorization is recommended for certain rental and purchased items. Repairs and supplies to rental equipment are included in our rental allowance. Preauthorization is recommended for replacement and repairs of purchased durable medical equipment. We will cover the following durable medical equipment subject to our guidelines:  Wheelchairs, hospital beds, and other durable medical equipment used only for medical treatment;  Replacement of purchased equipment which is needed due to a change in your medical condition (replacement of covered durable medical equipment will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty, and cannot be repaired). Medical Supplies We will cover the following medical supplies subject to our guidelines:  Essential accessories such as hoses, tubes and mouthpieces for use with medically necessary durable medical equipment (these accessories are included as part of the rental allowance for rented equipment);  Catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and  Respiratory therapy equipment solutions. Medical supplies provided during an office visit are included in our office visit allowance. Diabetic Equipment/Supplies In accordance with Rhode Island General Law §27-20-30, this agreement provides coverage for the following medically necessary diabetic equipment and supplies, subject to medical necessity review:  therapeutic/molded shoes for the prevention of amputation are covered for the treatment of diabetes; our allowance for molded shoes includes the initial inserts. Additional medically necessary inserts for custom-molded shoes are covered; and  blood glucose monitors, blood glucose monitors for the legally blind, external insulin infusion pumps and appurtenances thereto, insulin infusion devices and injection aids for the treatment of insulin treated diabetes, non-insulin treated diabetes and gestational diabetes; and  test strips for glucose monitors and/or visual reading, cartridges for the legally blind, and infusion sets for external insulin pumps for the treatment of insulin treated diabetes, non-insulin treated diabetes, and gestational diabetes. Covered diabetic equipment and supplies bought at a licensed medical supply provider are subject to the benefit limits as shown in the Summary of Medical Benefits. Some diabetic equipment and supplies can be bought at a network pharmacy. When bought at a network pharmacy, the covered diabetic equipment and supplies are subject to the benefit limits shown in the Summary of Pharmacy Benefits. Prosthetic Devices This agreement provides coverage per Rhode Island General Law. We will cover the following prosthetic devices subject to our guidelines:  Prosthetic appliances such as artificial limbs, breasts, larynxes and eyes, including the replacement or adjustment of these appliances (replacement of a covered device will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired);  Devices, accessories, batteries and supplies necessary for attachment to and operation of prosthetic devices;  Orthopedic braces (except corrective shoes and orthotic devices used in connection with footwear); and  Initial and subsequent prosthetic devices following a mastectomy and following an order of a physician or surgeon. This agreement provides benefits for mastectomy-related prosthetics in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Laws 27-20-29 et seq. See Section 3.35 - Surgery Services - Mastectomy.

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: •  can withstand repeated use; •  is primarily and customarily used to serve a medical purpose; •  is not useful to a person in the absence of an illness or injury; and •  is for use in the home. MEDICAL SUPPLIES means those consumable supplies that are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits. Outpatient /In Your Home We will cover the following durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices subject to our guidelines. Durable Medical Equipment A durable medical equipment (DME) item may be classified as a rental item or a purchased item. A DME rental item is billed on a monthly basis for a specific period of months, after which time the item is considered paid up to our allowance. Our allowance for a rental DME item will never exceed our allowance for a DME purchased item. Preauthorization is recommended for certain rental and purchased items. Repairs and supplies to rental equipment are included in our rental allowance. Preauthorization is recommended for replacement and repairs of purchased durable medical equipment. We will cover the following durable medical equipment subject to our guidelines:  wheelchairs, hospital beds, and other durable medical equipment used only for medical treatment; and  replacement of purchased equipment which is needed due to a change in your medical condition (replacement of covered durable medical equipment will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty, and cannot be repaired). Medical Supplies We will cover the following medical supplies subject to our guidelines:  essential accessories such as hoses, tubes and mouthpieces for use with medically necessary durable medical equipment (these accessories are included as part of the rental allowance for rented equipment);  catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and  respiratory therapy equipment solutions. Medical supplies provided during an office visit are included in our office visit allowance. Prosthetic Devices This agreement provides coverage per Rhode Island General Law. We will cover the following prosthetic devices subject to our guidelines:  prosthetic appliances such as artificial limbs, breasts, larynxes and eyes, including the replacement or adjustment of these appliances (replacement of a covered device will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired);  devices, accessories, batteries and supplies necessary for attachment to and operation of prosthetic devices;  orthopedic braces (except corrective shoes and orthotic devices used in connection with footwear); and  Initial and subsequent prosthetic devices following a mastectomy and following an order of a physician or surgeon. This agreement provides benefits for mastectomy-related prosthetics in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Laws 27-20-29 et seq. See Section 3.34 - Surgery Services - Mastectomy.

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan agreement to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: •  can withstand repeated use; •  is primarily and customarily used to serve a medical purpose; •  is not useful to a person in the absence of an illness or injury; and •  is for use in the home. MEDICAL SUPPLIES means those consumable supplies that which are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits. Outpatient/In Your Home We will cover the following durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices subject to our guidelines. Durable Medical Equipment A durable medical equipment (DME) item may be classified as a rental item or a purchased item. A DME rental item is billed on a monthly basis for a specific period of months, after which time the item is considered paid up to our allowance. Our allowance for a rental DME item will never exceed our allowance for a DME purchased item. Preauthorization is recommended for certain rental and purchased items. Repairs and supplies to rental equipment are included in our rental allowance. Preauthorization is recommended for replacement and repairs of purchased durable medical equipment. We will cover the following durable medical equipment subject to our guidelines:  Wheelchairs, hospital beds, and other durable medical equipment used only for medical treatment;  Replacement of purchased equipment which is needed due to a change in your medical condition (replacement of covered durable medical equipment will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty, and cannot be repaired). Medical Supplies We will cover the following medical supplies subject to our guidelines:  Essential accessories such as hoses, tubes and mouthpieces for use with medically necessary durable medical equipment (these accessories are included as part of the rental allowance for rented equipment);  Catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings;  Respiratory therapy equipment solutions. Medical supplies provided during an office visit are included in our office visit allowance. Prosthetic Devices This agreement provides coverage per Rhode Island General Law. We will cover the following prosthetic devices subject to our guidelines:  Prosthetic appliances such as artificial limbs, breasts, larynxes and eyes, including the replacement or adjustment of these appliances (replacement of a covered device will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired);  Devices, accessories, batteries and supplies necessary for attachment to and operation of prosthetic devices;  Orthopedic braces (except corrective shoes and orthotic devices used in connection with footwear); and  Initial and subsequent prosthetic devices following a mastectomy and following an order of a physician or surgeon. This agreement provides benefits for mastectomy-related prosthetics in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Laws 27-20-29 et seq. See Section 3.35 Surgery Services - Mastectomy.

Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic. Devices We cover medically necessary durable medical equipment, medical supplies, and prosthetic devices that meet the minimum specifications. The provider must meet eligibility and credentialing requirements as defined by the plan to be eligible for reimbursement. DURABLE MEDICAL EQUIPMENT is equipment (and supplies necessary for the effective use of equipment) which: •  can withstand repeated use; •  is primarily and customarily used to serve a medical purpose; •  is not useful to a person in the absence of an illness or injury; and •  is for use in the home. MEDICAL SUPPLIES means those consumable supplies that which are disposable and not intended for re-use. Medical supplies require an order by a physician and are essential for the care or treatment of an illness, injury, or congenital defect. PROSTHETIC DEVICES means devices (other than dental) which replace or substitute all or a part of an internal body part (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body part necessary to alleviate functional loss or impairment due to an illness, injury or congenital defect. Inpatient Inpatient medically necessary durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices you receive as an inpatient, when provided and billed for by the hospital where you are an inpatient, are covered as a hospital service. See Section 8.0 for the definition of hospital services. When you are prescribed a medically necessary prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the benefit limits for Medical Equipment, Medical Supplies, and Prosthetic Devices - Outpatient will apply, as shown in the Summary of Medical Benefits. Outpatient/In Your Home We will cover the following durable medical equipment, medical supplies, enteral formula or food, and prosthetic devices subject to our guidelines. Durable Medical Equipment A durable medical equipment (DME) item may be classified as a rental item or a purchased item. A DME rental item is billed on a monthly basis for a specific period of months, after which time the item is considered paid up to our allowance. Our allowance for a rental DME item will never exceed our allowance for a DME purchased item. Preauthorization is recommended for certain rental and purchased items. Repairs and supplies to rental equipment are included in our rental allowance. Preauthorization is recommended for replacement and repairs of purchased durable medical equipment. We will cover the following durable medical equipment subject to our guidelines:  Wheelchairs, hospital beds, and other durable medical equipment used only for medical treatment;  Replacement of purchased equipment which is needed due to a change in your medical condition (replacement of covered durable medical equipment will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty, and cannot be repaired). Medical Supplies We will cover the following medical supplies subject to our guidelines:  Essential accessories such as hoses, tubes and mouthpieces for use with medically necessary durable medical equipment (these accessories are included as part of the rental allowance for rented equipment);  Catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and  Respiratory therapy equipment solutions. Medical supplies provided during an office visit are included in our office visit allowance. Prosthetic Devices This agreement provides coverage per Rhode Island General Law. We will cover the following prosthetic devices subject to our guidelines:  Prosthetic appliances such as artificial limbs, breasts, larynxes and eyes, including the replacement or adjustment of these appliances (replacement of a covered device will be allowed only if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired);  Devices, accessories, batteries and supplies necessary for attachment to and operation of prosthetic devices;  Orthopedic braces (except corrective shoes and orthotic devices used in connection with footwear); and  Initial and subsequent prosthetic devices following a mastectomy and following an order of a physician or surgeon. This agreement provides benefits for mastectomy-related prosthetics in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Laws 27-20-29 et seq. See Section 3.35 Surgery Services - Mastectomy.