Common use of Homemaker Services Clause in Contracts

Homemaker Services. The following costs and Services for infertility consultation services, in vitro fertilization or artificial insemination: - The cost of equipment and of collection, storage and processing of sperm or eggs. - In vitro fertilization that does not meet state law requirements. - Artificial insemination and in vitro fertilization that do not meet Health Plan and Medical Group requirements and criteria. - Services related to conception by artificial means other than artificial insemination or in vitro fertilization, such as ovum transplants, gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT), including prescription drugs related to such Services and donor sperm and donor eggs used for such Services. - Services to reverse voluntary, surgically-induced infertility. - Stand-alone ovulation induction Services. • Non FDA-approved drugs and devices. • Certain exams and Services. Certain Services and related reports/paperwork, in connection with third party requests, such as those for: employment, participation in employee programs, sports, camp, insurance, disability, licensing, or on court-order or for parole or probation. Physical examinations that are authorized and deemed medically necessary by a ▇▇▇▇▇▇ Permanente physician and are coincidentally needed by a third party are covered according to the member’s benefits. • Long term physical therapy, occupational therapy, speech therapy; maintenance therapies; routine vision services; services provided by family or household members; duplicate services provided by another therapy or available through schools and/or government programs. • Services not generally and customarily available in the Hawaii service area. • Services and supplies not medically necessary. A service or item is medically necessary (in accord with medically necessary state law definitions and criteria) only if, 1) recommended by the treating ▇▇▇▇▇▇ Permanente physician or treating ▇▇▇▇▇▇ Permanente licensed health care practitioner, 2) is approved by ▇▇▇▇▇▇ Permanente’s medical director or designee, and 3) is for the purpose of treating a medical condition, is the most appropriate delivery or level of service (considering potential benefits and ▇▇▇▇▇ to the patient), and known to be effective in improving health outcomes. Effectiveness is determined first by scientific evidence, then by professional standards of care, then by expert opinion. Coverage is limited to the services which are cost effective and adequately meet the medical needs of the member. • All Services, drugs, injections, equipment, supplies and prosthetics related to treatment of sexual dysfunction, except evaluations and health care practitioners’ services for treatment of sexual dysfunction. • Personal comfort items, such as telephone, television, and take-home medical supplies, during covered skilled nursing care. • Take home supplies for home use, such as bandages, gauze, tape, antiseptics, ace type bandages, drug and ostomy supplies, catheters and tubing. • The following costs and Services for transplants: - Non-human and artificial organs and their transplantation. - Bone marrow transplants associated with high-dose chemotherapy for the treatment of solid tissue tumors, except for germ cell tumors and neuroblastoma in children. • Services for injuries or illness caused or alleged to be caused by third parties or in motor vehicle accidents. • Transportation (other than covered ambulance services), lodging, and living expenses. SAMPLE • Travel immunizations. • Services for which coverage has been exhausted, Services not listed as covered, or excluded Services. Benefits and Services are subject to the following limitations: • Services may be curtailed because of major disaster, epidemic, or other circumstances beyond ▇▇▇▇▇▇ Permanente's control such as a labor dispute or a natural disaster. • Coverage is not provided for treatment of conditions for which a member has refused recommended treatment for personal reasons when ▇▇▇▇▇▇ Permanente physicians believe no professionally acceptable alternative treatment exists. Coverage will cease at the point the member stops following the recommended treatment. • Ambulance services are those services which: 1) use of any other means of transport, regardless of availability of such other means, would result in death or serious impairment of the member’s health, and 2) is for the purpose of transporting the member to receive medically necessary acute care. In addition, air ambulance must be for the purpose of transporting the member to the nearest medical facility designated by Health Plan for receipt of medically necessary acute care, and the member’s condition must require the services of an air ambulance for safe transport. • Autism services are limited to: 1) diagnosis and treatment of autism, and 2) applied behavioral analysis services. Treatment for autism will be provided in accord with an approved treatment plan. The following are excluded from coverage: 1) services provided by family or household members, and 2) autism services that duplicate services provided by another therapy or available through schools and/or government programs. • Coverage of blood and blood processing includes (regardless of replacement, units and processing of units) whole blood, red cell products, cryoprecipitates, platelets, plasma, and fresh frozen plasma. Rh immune globulin is provided subject to the cost share for skilled-administered prescription drugs. Coverage of blood and blood processing also includes collection, processing, and storage of autologous blood when prescribed by a ▇▇▇▇▇▇ Permanente physician for a scheduled surgery whether or not the units are used. • Chemical dependency services include coverage in a specialized alcohol or chemical dependence treatment unit or facility approved by ▇▇▇▇▇▇ Permanente Medical Group. Specialized alcohol or chemical dependence treatment services include day treatment or partial hospitalization services and non-hospital residential services. All covered chemical dependency services will be provided under an approved individualized treatment plan. Your coverage includes treatment for conditions listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association that meet the standards of medical necessity. • Members are covered for contraceptive drugs and devices (to prevent unwanted pregnancies) only when all of the following criteria are met: 1) prescribed by a licensed Prescriber, 2) the drug is one for which a prescription is required by law, and 3) obtained at pharmacies in the Service Area that are operated by Kaiser Foundation Hospital or ▇▇▇▇▇▇ Foundation Health Plan, Inc. • When applicable, the deductible is the amount that members must pay for certain services before Health Plan will cover those services. Services that are subject to the deductible are noted in the “You Pay” column of this benefit summary (for example, if “after deductible” is noted in the “You Pay” column after the copayment, then members or family units must meet the deductible before the noted copayment will be effective). This deductible is separate from any other benefit-specific deductible that may be described herein. For example if prescription drugs are subject to a drug deductible, payments toward that drug deductible do not count toward this medical deductible. Payments toward this medical deductible do not count toward any other benefit-specific deductible (such as a drug deductible). Services that are subject to this medical deductible are: 1) outpatient surgery or procedures provided in an ambulatory surgery center (ASC) or other hospital-based setting, 2) hospital inpatient care, 3) specialty laboratory services, 4) specialty imaging services, 5) skilled nursing care, and 6) emergency services (when noted). • Up to a 30-consecutive-day supply of diabetes supplies is provided (as described under the prescribed drugs section) if all of the following criteria are met: 1) prescribed by a licensed Prescriber, 2) on the Health Plan formulary and used in accordance with formulary criteria, guidelines, or restrictions, and 3) obtained at pharmacies in the Service Area that are operated by Kaiser Foundation Hospital, ▇▇▇▇▇▇ Foundation Health Plan, Inc. or a pharmacy we designate. • Prescribed drugs that require skilled administration by medical personnel must meet all of the following: 1) prescribed by a ▇▇▇▇▇▇ Permanente licensed prescriber, 2) on the Health Plan formulary and used in accordance with formulary guidelines or restrictions, and 3) prescription is required by law. SAMPLE • Durable medical equipment (such as oxygen dispensing equipment and oxygen, diabetes equipment, home phototherapy equipment for newborns, and breast feeding pump) must be prescribed by a ▇▇▇▇▇▇ Permanente or ▇▇▇▇▇▇ Permanente-designated physician, preauthorized in writing by ▇▇▇▇▇▇ Permanente, and obtained from sources designated by ▇▇▇▇▇▇ Permanente on either a purchase or rental basis, as determined by ▇▇▇▇▇▇ Permanente. Durable medical equipment is that equipment and supplies necessary to operate the equipment which: 1) is intended for repeated use, 2) is primarily and customarily used to serve a medical purpose, 3) is appropriate for use in the home, 4) is generally not useful to a person in the absence of illness or injury, 5) was in general use on March 1 of the year immediately preceding the year in which this Service Agreement became effective or was last renewed, 6) is not excluded from coverage from Medicare, and if covered by Medicare, meets the coverage definitions, criteria and guidelines established by Medicare at the time the diabetes equipment is prescribed, and 7) is on ▇▇▇▇▇▇ Permanente’s formulary and used in accordance with formulary criteria, guidelines, or restrictions. Repair, replacement and adjustment of durable medical equipment, other than due to misuse or loss, is included in coverage. Diabetes equipment is limited to glucose meters and external insulin pumps, and the supplies necessary to operate them. Coverage of breast feeding pump includes any equipment that is required for pump functionality. If rented or loaned from ▇▇▇▇▇▇ Permanente, the member must return any durable medical equipment items to ▇▇▇▇▇▇ Permanente or its designee or pay ▇▇▇▇▇▇ Permanente or its designee the fair market price for the equipment when it is no longer prescribed by a ▇▇▇▇▇▇ Permanente physician or used by the member. Coverage is limited to the standard item of durable medical equipment in accord with Medicare guidelines that adequately meets the medical needs of the member. Convenience and luxury items and features are not covered. The following are excluded from coverage: 1) comfort and convenience equipment, and devices not medical in nature such as sauna baths and elevators, 2) disposable supplies for home use such as bandages, gauze, tape, antiseptics, and ace type bandages, 3) exercise and hygiene equipment, 4) electronic monitors of the function of the heart or lungs, 5) devices to perform medical tests on blood or other body substances or excretions, 6) dental appliances or devices, 7) repair, adjustment or replacement due to misuse or loss, 8) experimental or research equipment, 9) durable medical equipment related to sexual dysfunction, and 10) modifications to a home or car. • Emergency services are covered for initial emergency treatment only. Member (or member’s family) must notify Health Plan within 48 hours if admitted to a non-▇▇▇▇▇▇ Permanente facility. Emergency Services are those medically necessary services available through the emergency department to medically screen, examine and Stabilize the patient for Emergency Medical Conditions. An Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity that meet the prudent layperson standard and the absence of immediate medical attention will result in serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or place the health of the individual in serious jeopardy. Examples of an Emergency Medical Condition include chest pain or other heart attack signs, poisoning, loss of consciousness, convulsions or seizures, broken back or neck, heavy bleeding, sudden weakness on one side, severe pain, breathing problems, drug overdose, severe allergic reaction, severe ▇▇▇▇▇, and broken bones. Examples on non-emergencies are colds, flu, earaches, sore throats, and using the emergency room for convenience or during normal office hours for medical conditions that can be treated in a medical office. Continuing or follow-up treatment for Emergency Medical Conditions at a non-▇▇▇▇▇▇ Permanente facility is not covered. • When applicable, essential health benefits are provided to the extent required by law and include ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services to the extent required by HHS and EHB-benchmark plan. Pediatric oral care services are covered under this Service Agreement only if a separate Dental Rider is attached (covered services are described within any applicable Dental Rider). A complete list of essential health benefits is available through Member Services. Essential health benefits are provided upon payment of the copayments listed under the appropriate benefit sections (e.g. – office visits subject to office visit copay, inpatient care subject to hospital inpatient care copay, etc.). • External prosthetic devices and braces (including speech generating devices and voice synthesizers) must be prescribed by a ▇▇▇▇▇▇ Permanente physician, preauthorized in writing by ▇▇▇▇▇▇ Permanente, and obtained from sources designated by ▇▇▇▇▇▇ Permanente. External prosthetic devices must meet all of the following criteria: 1) are affixed to the body externally, 2) are required to replace all or part of any body organ or replace all or part of the function of a permanently inoperative or malfunctioning body organ, 3) were in general use on March 1 of the year immediately preceding the year in which this Service Agreement became effective or was last renewed, and 4) are not excluded from coverage from Medicare, and if covered by Medicare, meet the coverage definitions criteria and guidelines established by Medicare at the time the prosthetic is prescribed. Fitting and adjustment of these devices, including repairs and replacement other than due to misuse or loss, is included in coverage. Covered braces are those rigid and semi-rigid devices which: 1) are required to support a weak or deformed body member, or 2) are required to restrict or eliminate motion in a diseased or injured part of the body, and 3) are not excluded from coverage from Medicare, and if covered by Medicare, meet the coverage definitions, criteria and guidelines established by Medicare at the time the brace is prescribed. The following items are not covered as external prosthetics, but may be covered under another benefit category: 1) pacemakers and other surgically implanted internal prosthetic devices (these are covered under implanted internal prosthetic devices and aids), 2) hearing aids (these are covered under the hearing aid benefit), and 3) corrective lenses and eyeglasses (these are covered under any applicable pediatric vision care service and may also be covered if an Optical Rider is attached). The following items are excluded from coverage: 1) dental prostheses, devices and appliances, 2) non-rigid appliances such as elastic stockings, garter belts, arch supports, non-rigid corsets and similar devices, 3) orthopedic aids such as corrective shoes and shoe inserts, 4) replacement of lost prosthetic devices, 5) repairs, adjustments or replacements due to misuse or loss, 6) experimental or research devices and appliances, 7) external prosthetic devices related to sexual dysfunction, 8) supplies, whether or not related to external prosthetic devices or braces, 9) external prosthetics for comfort and/or convenience, or which are not medical in nature, and 10) disposable s

Homemaker Services. The following costs and Services for infertility consultation services, in vitro fertilization or artificial insemination: - The cost of equipment and of collection, storage and processing of sperm or eggs. - In vitro fertilization that does not meet state law requirements. - Artificial insemination and in vitro fertilization that do not meet Health Plan and Medical Group requirements and criteria. - Services related to conception by artificial means other than artificial insemination or in vitro fertilization, such as ovum transplants, gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT), including prescription drugs related to such Services and donor sperm and donor eggs used for such Services. - Services to reverse voluntary, surgically-induced infertility. - Stand-alone ovulation induction Services. • Non FDA-approved drugs and devices. • Certain exams and Services. Certain Services and related reports/paperwork, in connection with third party requests, such as those for: employment, participation in employee programs, sports, camp, insurance, disability, licensing, or on court-order or for parole or probation. Physical examinations that are authorized and deemed medically necessary by a ▇▇▇▇▇▇ Permanente physician and are coincidentally needed by a third party are covered according to the member’s benefits. • Long term physical therapy, occupational therapy, speech therapy; maintenance therapies; routine vision services; services provided by family or household members; duplicate services provided by another therapy or available through schools and/or government programs. • Services not generally and customarily available in the Hawaii service area. • Services and supplies not medically necessary. A service or item is medically necessary (in accord with medically necessary state law definitions and criteria) only if, 1) recommended by the treating ▇▇▇▇▇▇ Permanente physician or treating ▇▇▇▇▇▇ Permanente licensed health care practitioner, 2) is approved by ▇▇▇▇▇▇ Permanente’s medical director or designee, and 3) is for the purpose of treating a medical condition, is the most appropriate delivery or level of service (considering potential benefits and ▇▇▇▇▇ to the patient), and known to be effective in improving health outcomes. Effectiveness is determined first by scientific evidence, then by professional standards of care, then by expert opinion. Coverage is limited to the services which are cost effective and adequately meet the medical needs of the member. • All Services, drugs, injections, equipment, supplies and prosthetics related to treatment of sexual dysfunction, except evaluations and health care practitioners’ services for treatment of sexual dysfunction. • Personal comfort items, such as telephone, television, and take-home medical supplies, during covered skilled nursing care. • Take home supplies for home use, such as bandages, gauze, tape, antiseptics, ace type bandages, drug and ostomy supplies, catheters and tubing. • The following costs and Services for transplants: - Non-human and artificial organs and their transplantation. - Bone marrow transplants associated with high-dose chemotherapy for the treatment of solid tissue tumors, except for germ cell tumors and neuroblastoma in children. • Services for injuries or illness caused or alleged to be caused by third parties or in motor vehicle accidents. • Transportation (other than covered ambulance services), lodging, and living expenses. SAMPLE • Travel immunizations. • Services for which coverage has been exhausted, Services not listed as covered, or excluded Services. Benefits and Services are subject to the following limitations: • Services may be curtailed because of major disaster, epidemic, or other circumstances beyond ▇▇▇▇▇▇ Permanente's control such as a labor dispute or a natural disaster. • Coverage is not provided for treatment of conditions for which a member has refused recommended treatment for personal reasons when ▇▇▇▇▇▇ Permanente physicians believe no professionally acceptable alternative treatment exists. Coverage will cease at the point the member stops following the recommended treatment. • Ambulance services are those services which: 1) use of any other means of transport, regardless of availability of such other means, would result in death or serious impairment of the member’s health, and 2) is for the purpose of transporting the member to receive medically necessary acute care. In addition, air ambulance must be for the purpose of transporting the member to the nearest medical facility designated by Health Plan for receipt of medically necessary acute care, and the member’s condition must require the services of an air ambulance for safe transport. • Autism services are limited to: 1) diagnosis and treatment of autism, and 2) applied behavioral analysis services. Treatment for autism will be provided in accord with an approved treatment plan. The following are excluded from coverage: 1) services provided by family or household members, and 2) autism services that duplicate services provided by another therapy or available through schools and/or government programs. • Coverage of blood and blood processing includes (regardless of replacement, units and processing of units) whole blood, red cell products, cryoprecipitates, platelets, plasma, and fresh frozen plasma. Rh immune globulin is provided subject to the cost share for skilled-administered prescription drugs. Coverage of blood and blood processing also includes collection, processing, and storage of autologous blood when prescribed by a ▇▇▇▇▇▇ Permanente physician for a scheduled surgery whether or not the units are used. • Chemical dependency services include coverage in a specialized alcohol or chemical dependence treatment unit or facility approved by ▇▇▇▇▇▇ Permanente Medical Group. Specialized alcohol or chemical dependence treatment services include day treatment or partial hospitalization services and non-hospital residential services. All covered chemical dependency services will be provided under an approved individualized treatment plan. Your coverage includes treatment for conditions listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association that meet the standards of medical necessity. • Members are covered for contraceptive drugs and devices (to prevent unwanted pregnancies) only when all of the following criteria are met: 1) prescribed by a licensed Prescriber, 2) the drug is one for which a prescription is required by law, and 3) obtained at pharmacies in the Service Area that are operated by Kaiser Foundation Hospital or ▇▇▇▇▇▇ Foundation Health Plan, Inc. • When applicable, the deductible is the amount that members must pay for certain services before Health Plan will cover those services. Services that are subject to the deductible are noted in the “You Pay” column of this benefit summary (for example, if “after deductible” is noted in the “You Pay” column after the copayment, then members or family units must meet the deductible before the noted copayment will be effective). This deductible is separate from any other benefit-specific deductible that may be described herein. For example if prescription drugs are subject to a drug deductible, payments toward that drug deductible do not count toward this medical deductible. Payments toward this medical deductible do not count toward any other benefit-specific deductible (such as a drug deductible). Services that are subject to this medical deductible are: 1) outpatient surgery or procedures provided in an ambulatory surgery center (ASC) or other hospital-based setting, 2) hospital inpatient care, 3) specialty laboratory services, 4) specialty imaging services, 5) skilled nursing care, and 6) emergency services (when noted). • Up to a 30-consecutive-day supply of diabetes supplies is provided (as described under the prescribed drugs section) if all of the following criteria are met: 1) prescribed by a licensed Prescriber, 2) on the Health Plan formulary and used in accordance with formulary criteria, guidelines, or restrictions, and 3) obtained at pharmacies in the Service Area that are operated by Kaiser Foundation Hospital, ▇▇▇▇▇▇ Kaiser Foundation Health Plan, Inc. or a pharmacy we designate. • Prescribed drugs that require skilled administration by medical personnel must meet all of the following: 1) prescribed by a ▇▇▇▇▇▇ Permanente licensed prescriber, 2) on the Health Plan formulary and used in accordance with formulary guidelines or restrictions, and 3) prescription is required by law. SAMPLE • Durable medical equipment (such as oxygen dispensing equipment and oxygen, diabetes equipment, home phototherapy equipment for newborns, and breast feeding pump) must be prescribed by a ▇▇▇▇▇▇ Permanente or ▇▇▇▇▇▇ Permanente-designated physician, preauthorized in writing by ▇▇▇▇▇▇ Permanente, and obtained from sources designated by ▇▇▇▇▇▇ Permanente on either a purchase or rental basis, as determined by ▇▇▇▇▇▇ Permanente. Durable medical equipment is that equipment and supplies necessary to operate the equipment which: 1) is intended for repeated use, 2) is primarily and customarily used to serve a medical purpose, 3) is appropriate for use in the home, 4) is generally not useful to a person in the absence of illness or injury, 5) was in general use on March 1 of the year immediately preceding the year in which this Service Agreement became effective or was last renewed, 6) is not excluded from coverage from Medicare, and if covered by Medicare, meets the coverage definitions, criteria and guidelines established by Medicare at the time the diabetes equipment is prescribed, and 7) is on ▇▇▇▇▇▇ Permanente’s formulary and used in accordance with formulary criteria, guidelines, or restrictions. Repair, replacement and adjustment of durable medical equipment, other than due to misuse or loss, is included in coverage. Diabetes equipment is limited to glucose meters and external insulin pumps, and the supplies necessary to operate them. Coverage of breast feeding pump includes any equipment that is required for pump functionality. If rented or loaned from ▇▇▇▇▇▇ Permanente, the member must return any durable medical equipment items to ▇▇▇▇▇▇ Permanente or its designee or pay ▇▇▇▇▇▇ Permanente or its designee the fair market price for the equipment when it is no longer prescribed by a ▇▇▇▇▇▇ Permanente physician or used by the member. Coverage is limited to the standard item of durable medical equipment in accord with Medicare guidelines that adequately meets the medical needs of the member. Convenience and luxury items and features are not covered. The following are excluded from coverage: 1) comfort and convenience equipment, and devices not medical in nature such as sauna baths and elevators, 2) disposable supplies for home use such as bandages, gauze, tape, antiseptics, and ace type bandages, 3) exercise and hygiene equipment, 4) electronic monitors of the function of the heart or lungs, 5) devices to perform medical tests on blood or other body substances or excretions, 6) dental appliances or devices, 7) repair, adjustment or replacement due to misuse or loss, 8) experimental or research equipment, 9) durable medical equipment related to sexual dysfunction, and 10) modifications to a home or car. • Emergency services are covered for initial emergency treatment only. Member (or member’s family) must notify Health Plan within 48 hours if admitted to a non-▇▇▇▇▇▇ Permanente facility. Emergency Services are those medically necessary services available through the emergency department to medically screen, examine and Stabilize the patient for Emergency Medical Conditions. An Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity that meet the prudent layperson standard and the absence of immediate medical attention will result in serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or place the health of the individual in serious jeopardy. Examples of an Emergency Medical Condition include chest pain or other heart attack signs, poisoning, loss of consciousness, convulsions or seizures, broken back or neck, heavy bleeding, sudden weakness on one side, severe pain, breathing problems, drug overdose, severe allergic reaction, severe ▇▇▇▇▇, and broken bones. Examples on non-emergencies are colds, flu, earaches, sore throats, and using the emergency room for convenience or during normal office hours for medical conditions that can be treated in a medical office. Continuing or follow-up treatment for Emergency Medical Conditions at a non-▇▇▇▇▇▇ Permanente facility is not covered. • When applicable, essential health benefits are provided to the extent required by law and include ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services to the extent required by HHS and EHB-benchmark plan. Pediatric oral care services are covered under this Service Agreement only if a separate Dental Rider is attached (covered services are described within any applicable Dental Rider). A complete list of essential health benefits is available through Member Services. Essential health benefits are provided upon payment of the copayments listed under the appropriate benefit sections (e.g. – office visits subject to office visit copay, inpatient care subject to hospital inpatient care copay, etc.). • External prosthetic devices and braces (including speech generating devices and voice synthesizers) must be prescribed by a ▇▇▇▇▇▇ Permanente physician, preauthorized in writing by ▇▇▇▇▇▇ Permanente, and obtained from sources designated by ▇▇▇▇▇▇ Permanente. External prosthetic devices must meet all of the following criteria: 1) are affixed to the body externally, 2) are required to replace all or part of any body organ or replace all or part of the function of a permanently inoperative or malfunctioning body organ, 3) were in general use on March 1 of the year immediately preceding the year in which this Service Agreement became effective or was last renewed, and 4) are not excluded from coverage from Medicare, and if covered by Medicare, meet the coverage definitions criteria and guidelines established by Medicare at the time the prosthetic is prescribed. Fitting and adjustment of these devices, including repairs and replacement other than due to misuse or loss, is included in coverage. Covered braces are those rigid and semi-rigid devices which: 1) are required to support a weak or deformed body member, or 2) are required to restrict or eliminate motion in a diseased or injured part of the body, and 3) are not excluded from coverage from Medicare, and if covered by Medicare, meet the coverage definitions, criteria and guidelines established by Medicare at the time the brace is prescribed. The following items are not covered as external prosthetics, but may be covered under another benefit category: 1) pacemakers and other surgically implanted internal prosthetic devices (these are covered under implanted internal prosthetic devices and aids), 2) hearing aids (these are covered under the hearing aid benefit), and 3) corrective lenses and eyeglasses (these are covered under any applicable pediatric vision care service and may also be covered if an Optical Rider is attached). The following items are excluded from coverage: 1) dental prostheses, devices and appliances, 2) non-rigid appliances such as elastic stockings, garter belts, arch supports, non-rigid corsets and similar devices, 3) orthopedic aids such as corrective shoes and shoe inserts, 4) replacement of lost prosthetic devices, 5) repairs, adjustments or replacements due to misuse or loss, 6) experimental or research devices and appliances, 7) external prosthetic devices related to sexual dysfunction, 8) supplies, whether or not related to external prosthetic devices or braces, 9) external prosthetics for comfort and/or convenience, or which are not medical in nature, and 10) disposable s