Common use of Housekeeping Clause in Contracts

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, vision therapy, or vision services Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered Donor non-medical expenses Charges incurred as a donor of an organ CHIP DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child). SUPPLIES COVERED EXCLUDED COMMENTS / MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia.

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, training and vision therapy, or vision services therapy Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP Donor non-medical expenses Charges incurred as a donor of an organ when the recipient is not covered under this health plan CHIP & CHIP PERINATAL PROGRAM DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child)but are a benefit for CHIP Perinate Newborns. SUPPLIES COVERED EXCLUDED COMMENTS / COMMENTS/MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan plan. Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia.

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, training and vision therapy, or vision services therapy Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP Donor non-medical expenses Charges incurred as a donor of an organ when the recipient is not covered under this health plan CHIP & CHIP PERINATAL PROGRAM DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child)but are a benefit for CHIP Perinate Newborns. SUPPLIES COVERED EXCLUDED COMMENTS / COMMENTS/MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan plan. Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia. Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include: • Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: • For members who could be sustained on an age-appropriate diet. • Traditionally used for infant feeding • In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) • For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care provided by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Insulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets, Wound Care X Eligible for coverage when used during covered home care for wound care. Irrigation Sets, Urinary X Eligible for coverage for individual with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Eligible for individuals with diabetes. Med Ejector X Needles and Syringes/Diabetic See Diabetic Supplies Needles and Syringes/IV and Central Line See IV Therapy and Dressing Supplies/Central Line. Needles and Syringes/Other X Eligible for coverage if a covered IM or SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Saline, Normal X Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. Xxxxx Sleeve X Xxxxx Socks X Suction Catheters X Syringes See Needles/Syringes. Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External Catheter & Supplies X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan Urinary, Indwelling Catheter & Supplies X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When determined to be medically necessary. Urostomy supplies See Ostomy Supplies. Subject: Attachment B-3 - STAR Value-added Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-3, Value-added Services. Revision 1.1 June 30, 2006 Contract amendment did not revise Attachment B-3, Value-added Services. Revision 1.2 September 1, 2006 Revised the Physical Health Value-added Services to include Home Visits to New Mothers. Revised the certification provision by changing the start date for the 12-month provision of services.

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, training and vision therapy, or vision services therapy Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP Donor non-medical expenses Charges incurred as a donor of an organ when the recipient is not covered under this health plan CHIP DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child). SUPPLIES COVERED EXCLUDED COMMENTS / COMMENTS/MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia. Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include: • Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: • For members who could be sustained on an age-appropriate diet. • Traditionally used for infant feeding • In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) • For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care provided by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Insulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets, Wound Care X Eligible for coverage when used during covered home care for wound care. Irrigation Sets, Urinary X Eligible for coverage for individual with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Eligible for individuals with diabetes. Med Ejector X Needles and Syringes/Diabetic See Diabetic Supplies Needles and Syringes/IV and Central Line See IV Therapy and Dressing Supplies/Central Line. Needles and Syringes/Other X Eligible for coverage if a covered IM or SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Saline, Normal X Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. Xxxxx Sleeve X Xxxxx Socks X Suction Catheters X Syringes See Needles/Syringes. Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External Catheter & Supplies X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan Urinary, Indwelling Catheter & Supplies X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When determined to be medically necessary. Urostomy supplies See Ostomy Supplies. Subject: Attachment B-2.1 - STAR + PLUS Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services. Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. This is the initial version of Attachment B-2.1, STAR+PLUS Covered Services, which lists the Acute Care Services and the Community Based Long Term Care Services. Revision 1.2 September 1, 2006 Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services. Revision 1.3 September 1, 2006 Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services. Revision 1.5 January 1, 2007 Revised Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient and outpatient mental health services for adults.

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, training and vision therapy, or vision services therapy Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP Donor non-medical expenses Charges incurred as a donor of an organ when the recipient is not covered under this health plan CHIP DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child). SUPPLIES COVERED EXCLUDED COMMENTS / COMMENTS/MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia. Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include: • Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: • For members who could be sustained on an age-appropriate diet. • Traditionally used for infant feeding • In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) • For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care provided by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Insulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets, Wound Care X Eligible for coverage when used during covered home care for wound care. Irrigation Sets, Urinary X Eligible for coverage for individual with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Eligible for individuals with diabetes. Med Ejector X Needles and Syringes/Diabetic See Diabetic Supplies Needles and Syringes/IV and Central Line See IV Therapy and Dressing Supplies/Central Line. Needles and Syringes/Other X Eligible for coverage if a covered IM or SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Saline, Normal X Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. Xxxxx Sleeve X Xxxxx Socks X Suction Catheters X Syringes See Needles/Syringes. Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External Catheter & Supplies X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan Urinary, Indwelling Catheter & Supplies X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When determined to be medically necessary. Urostomy supplies See Ostomy Supplies. Subject: Attachment B-2.1 - STAR + PLUS Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services. Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. This is the initial version of Attachment B-2.1, STAR+PLUS Covered Services, which lists the Acute Care Services and the Community Based Long Term Care Services. Revision 1.2 September 1, 2006 Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services. Revision 1.3 September 1, 2006 Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services. Revision 1.5 January 1, 2007 Revised Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient and outpatient mental health services for adults.

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, vision therapy, or vision services Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered Donor non-medical expenses Charges incurred as a donor of an organ CHIP DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child). SUPPLIES COVERED EXCLUDED COMMENTS / MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia. Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include: • Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: • For members who could be sustained on an age-appropriate diet. • Traditionally used for infant feeding • In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) • For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care provided by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Insulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets, Wound Care X Eligible for coverage when used during covered home care for wound care. Irrigation Sets, Urinary X Eligible for coverage for individual with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Eligible for individuals with diabetes. Med Ejector X Needles and Syringes/Diabetic See Diabetic Supplies Needles and Syringes/IV and Central Line See IV Therapy and Dressing Supplies/Central Line. Needles and Syringes/Other X Eligible for coverage if a covered IM or SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Saline, Normal X Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. Xxxxx Sleeve X Xxxxx Socks X Suction Catheters X Syringes See Needles/Syringes. Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External Catheter & Supplies X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan Urinary, Indwelling Catheter & Supplies X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When determined to be medically necessary. Urostomy supplies See Ostomy Supplies. Subject: Attachment B-2.2 - STAR+PLUS Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a September 1, 2011 Initial version of Attachment B-2.2, “STAR+PLUS Covered Services.” 1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions 2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision. 3 Brief description of the changes to the document made in the revision. STAR+PLUS Covered Services Acute Care Services The following is a non-exhaustive, high-level listing of Acute Care Covered Services included under the Medicaid STAR+PLUS Program. STAR+PLUS MCOs are responsible for providing a benefit package to Members that includes all Medically Necessary services covered under the traditional, fee-for-service Medicaid programs except for Non-capitated Services. Non-capitated Services are listed in Attachment B-1, RFP Section 8.2.2.8. Non-capitated Services are not included in the STAR+PLUS MCOs’ Capitation Rates; however, STAR+PLUS MCOs must coordinate care for Members for these Non-capitated Services so that Members have access to a full range of Medically Necessary Medicaid services, both capitated and non-capitated. STAR+PLUS MCOs may also elect to include Value-added Services in their benefit packages, if approved by HHSC (see Attachment B-2.2). STAR+PLUS Program benefits are subject to the same benefit limits and exclusions that apply to the traditional, fee-for-service Medicaid programs, with the following exception. Adult STAR+PLUS Members are not subject to the 30-day spell-of-illness limitation that applies to traditional, fee-for-service Medicaid coverage. Adult STAR+PLUS Members are generally limited to three (3) prescriptions per month. However, STAR+PLUS MCOs must provide unlimited prescriptions to Members who are qualified for and enrolled in the 1915(c) STAR+PLUS Waiver Program. For a complete listing of the limitations and exclusions that apply to each Medicaid benefit category, STAR+PLUS MCOs should refer to the current Texas Medicaid Provider Procedures Manual and the bi-monthly Texas Medicaid Bulletin. (These documents can be accessed online at: xxxx://xxx.xxxx.xxx.) The services listed in this Attachment are subject to modification based changes in Federal and State laws, regulations, and policies. Services included under the MCO capitation payment • Ambulance services • Audiology services, including hearing aids, for adults and children • Behavioral Health Services*, including: o Inpatient mental health services for Adults and Children o Outpatient mental health services for Adults and Children o Psychiatry services o Counseling services for adults (21 years of age and over) o Substance use disorder treatment services, including o Outpatient services, including: Assessment Detoxification services Counseling treatment Medication assisted therapy o Residential services, including Detoxification services Substance use disorder treatment (including room and board) *These services are not subject to the quantitative treatment limitations that apply under traditional, fee-for-service Medicaid coverage. The services may be subject to the MCO’s non-quantitative treatment limitations, provided such limitations comply with the requirements of the Mental Health Parity and Addiction Equity Act of 2008. • Birthing services provided by a physician or Advanced Practice Nurse in a licensed birthing center • Birthing services provided by a licensed birthing center • Cancer screening, diagnostic, and treatment services • Chiropractic services • Dialysis • Durable medical equipment and supplies • Early Childhood Intervention (ECI) services • Emergency Services • Family planning services • Home health care services • Hospital services, inpatient and outpatient • Laboratory • Mastectomy, breast reconstruction, and related follow-up procedures, including: o outpatient services provided at an outpatient hospital and ambulatory health care center as clinically appropriate; and physician and professional services provided in an office, inpatient, or outpatient setting for: o all stages of reconstruction on the breast(s) on which medically necessary mastectomy procedure(s) have been performed; o surgery and reconstruction on the other breast to produce symmetrical appearance; o treatment of physical complications from the mastectomy and treatment of lymphedemas; and o prophylactic mastectomy to prevent the development of breast cancer. o external breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed. • Medical checkups and Comprehensive Care Program (CCP) Services for children (birth through age 20) through the Texas Health Steps Program • Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps medical checkup for children six (6) months through 35 months of age. • Optometry, glasses, and contact lenses, if medically necessary • Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals • Drugs and biologicals provided in an inpatient setting • Podiatry • Prenatal care • Primary care services • Preventive services including an annual adult well check for patients 21 years of age and over • Radiology, imaging, and X-rays • Specialty physician services • Therapies – physical, occupational and speech • Transplantation of organs and tissues • Vision

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, training and vision therapy, or vision services therapy Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP Donor non-medical expenses Charges incurred as a donor of an organ when the recipient is not covered under this health plan CHIP DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child). SUPPLIES COVERED EXCLUDED COMMENTS / COMMENTS/MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia. Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include: • Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: • For members who could be sustained on an age-appropriate diet. • Traditionally used for infant feeding • In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) • For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care provided by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Insulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets, Wound Care X Eligible for coverage when used during covered home care for wound care. Irrigation Sets, Urinary X Eligible for coverage for individual with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy.

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, vision therapy, or vision services Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered Donor non-medical expenses Charges incurred as a donor of an organ CHIP DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child), with the exception of a limited set of disposable medical supplies, published at xxxx://xxx.xxxxxxxxxxxx.xxx/formulary/limited-hhs.shtml, when they are obtained from an authorized pharmacy provider. SUPPLIES COVERED EXCLUDED COMMENTS / MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia.

Housekeeping. Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities Services or supplies received from a nurse, which do not require the skill and training of a nurse Vision training, vision therapy, or vision services Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered Donor non-medical expenses Charges incurred as a donor of an organ CHIP DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members (Unborn Child). SUPPLIES COVERED EXCLUDED COMMENTS / MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia. Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include: • Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: • For members who could be sustained on an age-appropriate diet. • Traditionally used for infant feeding • In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) • For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care provided by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Insulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets,Wound Care X Eligible for coverage when used during covered home care forwound care. Irrigation Sets, Urinary X Eligible for coverage for individual with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Eligible for individuals with diabetes. Med Ejector X Needles and Syringes/Diabetic See Diabetic Supplies Needles and Syringes/IV and Central Line See IV Therapy and Dressing Supplies/Central Line. Needles and Syringes/Other X Eligible for coverage if a covered IM or SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant.Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Saline, Normal X Eligible for coverage:a) when used to dilute medications for nebulizer treatments;b) as part of covered home care for wound care;c) for indwelling urinary catheter irrigation. Xxxxx Sleeve X Xxxxx Socks X Suction Catheters X Syringes See Needles/Syringes. Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External Catheter & Supplies X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan Urinary, Indwelling Catheter & Supplies X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When determined to be medically necessary. Urostomy supplies See Ostomy Supplies. Subject: Attachment B-2.2 - STAR+PLUS Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a September 1, 2011 Initial version of Attachment B-2.2, “STAR+PLUS Covered Services.” Revision 2.1 March 1, 2012 Attachment B-2.2 is modified to reinstate the waiver of the three prescription limit for adults language and to add the waiver of the $200,000 individual annual limit on inpatient services. STAR+PLUS Covered Services is modified to clarify the requirements regarding services provided in free-standing psychiatric hospitals and chemical dependency treatment facilities in lieu of the acute care hospital setting. Services included under the HMO capitation payment is modified to clarify the requirements for "Prenatal care services rendered in a birthing center."