Common use of Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are Covered Clause in Contracts

Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are Covered. o Orthotic Appliances Prior Auth Required Orthotic Appliances include braces and other external devices used to correct a body function including clubfoot deformity. Orthotic Appliances must be Medically Necessary and require Prior Authorization. Orthotic Appliances are subject to the following limitations: o Foot Orthotics or shoe appliances are not Covered, except for our Members with diabetic neuropathy or other significant neuropathy. Custom fabricated knee-ankle- foot orthoses (KAFO) and ankle-foot orthoses (AFO) are Covered for our Members in accordance with nationally recognized guidelines. Refer to Orthotic Appliances are limited to a Calendar Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  Prosthetic Devices Prosthetic Devices are artificial devices, which replace or augment a missing or impaired part of the body. The purchase, fitting and necessary adjustments of Prosthetic Devices and supplies that replace all or pa t of the function of a permanently inoperative or Prior Auth Required malfunctioning body part are Covered when they replace a limb or other part of the body, after accidental or surgical removal and/or when the body’s growth necessitates replacement. Authorization. Prosthetic Devices must be Medically Necessary and require Prior Examples of Prosthetic Devices include, but are not limited to: o breast prostheses when required because of mastectomy and prophylactic mastectomy o artificial limbs o prosthetic eye o prosthodontic appliances o penile prosthesis o joint replacements o heart pacemakers o tracheostomy tubes and cochlear implants Refer to Prosthetic Devices are limited to a Calendar Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  Repair and Devices Replacement of Durable Medical

Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are Covered. o Orthotic Appliances Prior Auth Required Orthotic Appliances include braces and other external devices used to correct a body function including clubfoot deformity. Orthotic Appliances must be Medically Necessary and require Prior Authorization. Orthotic Appliances are subject to the following limitations: o Foot Orthotics or shoe appliances are not Covered, except for our Members with diabetic neuropathy or other significant neuropathy. Custom fabricated knee-ankle- foot orthoses (KAFO) and ankle-foot orthoses (AFO) are Covered for our Members in accordance with nationally recognized guidelines. Refer to Orthotic Appliances are limited to a Calendar Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  • Prosthetic Devices Prosthetic Devices are artificial devices, which replace or augment a missing or impaired part of the body. The purchase, fitting and necessary adjustments of Prosthetic Devices and supplies that replace all or pa t of the function of a permanently inoperative or Prior Auth Required malfunctioning body part are Covered when they replace a limb or other part of the body, after accidental or surgical removal and/or when the body’s growth necessitates replacement. Authorization. Prosthetic Devices must be Medically Necessary and require Prior Examples of Prosthetic Devices include, but are not limited to: o breast prostheses when required because of mastectomy and prophylactic mastectomy o artificial limbs o prosthetic eye o prosthodontic appliances o penile prosthesis o joint replacements o heart pacemakers o tracheostomy tubes and cochlear implants Refer to Prosthetic Devices are limited to a Calendar Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  • Repair and Devices Replacement of Durable MedicalDevices

Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are Covered. o  Orthotic Appliances Prior Auth Required Orthotic Appliances include braces and other external devices used to correct a body function including clubfoot deformity. Orthotic Appliances must be Medically Necessary and require Prior Authorization. Orthotic Appliances are subject to the following limitations: o Foot Orthotics or shoe appliances are not Covered, except for our Members with diabetic neuropathy or other significant neuropathy. Custom fabricated knee-ankle- foot orthoses (KAFO) and ankle-foot orthoses (AFO) are Covered for our Members in accordance with nationally recognized guidelines. Refer to Orthotic Appliances are limited to a Calendar Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  Prosthetic Devices Prosthetic Devices are artificial devices, which replace or augment a missing or impaired part of the body. The purchase, fitting and necessary adjustments of Prosthetic Devices and supplies that replace all or pa t of the function of a permanently inoperative or Prior Auth Required malfunctioning body part are Covered when they replace a limb or other part of the body, after accidental or surgical removal and/or when the body’s growth necessitates replacement. Authorization. Prosthetic Devices must be Medically Necessary and require Prior Examples of Prosthetic Devices include, but are not limited to: o breast prostheses when required because of mastectomy and prophylactic mastectomy o artificial limbs o prosthetic eye o prosthodontic appliances o penile prosthesis o joint replacements o heart pacemakers o tracheostomy tubes and cochlear implants Refer to Prosthetic Devices are limited to a Calendar Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  Repair and Devices Replacement of Durable Medical

Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are Covered. o Orthotic Appliances Prior Auth Required Orthotic Appliances include braces and other external devices used to correct a body function including clubfoot deformity. Orthotic Appliances must be Medically Necessary and require Prior Authorization. Orthotic Appliances are subject to the following limitations: o Foot Orthotics or shoe appliances are not Covered, except for our Members with diabetic neuropathy or other significant neuropathy. Custom fabricated knee-ankle- foot orthoses (KAFO) and ankle-foot orthoses (AFO) are Covered for our Members in accordance with nationally recognized guidelines. Refer to Orthotic Appliances are limited to a Calendar Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  • Prosthetic Devices Prosthetic Devices are artificial devices, which replace or augment a missing or impaired part of the body. The purchase, fitting and necessary adjustments of Prosthetic Devices and supplies that replace all or pa t of the function of a permanently inoperative or Prior Auth Required malfunctioning body part are Covered when they replace a limb or other part of the body, after accidental or surgical removal and/or when the body’s growth necessitates replacement. Authorization. Prosthetic Devices must be Medically Necessary and require Prior Examples of Prosthetic Devices include, but are not limited to: o breast prostheses when required because of mastectomy and prophylactic mastectomy o artificial limbs o prosthetic eye o prosthodontic appliances o penile prosthesis o joint replacements o heart pacemakers o tracheostomy tubes and cochlear implants Refer to Prosthetic Devices are limited to a Calendar Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  • Repair and Devices Replacement of Durable Medical

Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are Covered. o Orthotic Appliances Prior Auth Required  Orthotic Appliances Orthotic Appliances include braces and other external devices used to correct a body function including clubfoot deformity. Orthotic Appliances must be Medically Necessary and require Prior Authorization. Orthotic Appliances are subject to the following limitations: o Foot Orthotics or shoe appliances are not Covered, except for our Members with diabetic neuropathy or other significant neuropathy. Custom fabricated knee-ankle- foot orthoses (KAFO) and ankle-foot orthoses (AFO) are Covered for our Members in accordance with nationally recognized guidelines. Refer to  Orthotic Appliances are limited to a Calendar Contract Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  Prosthetic Devices Prosthetic Devices are artificial devices, which replace or augment a missing or impaired part of the body. The purchase, fitting and necessary adjustments of Prosthetic Devices and supplies that replace all or pa t part of the function of a permanently inoperative or Prior Auth Required inoperative or malfunctioning body part are Covered when they replace a limb or other part of the body, after accidental or surgical removal and/or when the body’s growth necessitates replacement. Authorization. Prosthetic Devices must be Medically Necessary and require Prior Authorization. Examples of Prosthetic Devices include, but are not limited to: o breast prostheses when required because of mastectomy and prophylactic mastectomy o artificial limbs o prosthetic eye o prosthodontic appliances o penile prosthesis o joint replacements o heart pacemakers o tracheostomy tubes and cochlear implants Refer to  Prosthetic Devices are limited to a Calendar Contract Year maximum. Refer to your Summary of Benefits and Coverage for this maximum.  Repair and Devices Replacement of Durable MedicalMedical Equipment, Prosthetics and Orthotic Devices Prior Auth o Repair and replacement of Durable Medical Equipment, Prosthetics and Orthotic Required Devices requires Prior Authorization.