Common use of Hearing Services Clause in Contracts

Hearing Services. Covered Services include: • Routine hearing screenings (see “Preventive Care” later in this section) • Hearing exams to determine the need for hearing correction (see “Preventive Care” later in this section) • Services related to the ear or hearing, such as outpatient care to treat an ear infection and outpatient Prescription Drugs, supplies and supplements (see “Office Visits” later in this section and the section titled WHAT IS COVERED – PRESCRIPTION DRUGS) • Cochlear implants (see “Durable Medical Equipment and Medical Devices, Special Footwear, Orthotics, Prosthetics and Medical and Surgical Supplies” earlier in this section) • Hearing aids and hearing tests to determine their efficacy and hearing tests to determine an appropriate hearing aid. Home Care Services Precertification is required for Home Care Services (see the section titled GETTING APPROVAL FOR BENEFITS for details). Benefits are available for Covered Services performed by a Home Health Care Agency or other professional Provider in Your home. To be eligible for benefits, You must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis. Services must be prescribed by a Physician and the services must be so inherently complex that they can be safely and effectively performed only by qualified, technical, or professional health staff. Covered Services include but are not limited to: • A registered nurse • A medical social service worker • Diagnostic services • Nutritional guidance • Training of the patient and/or family/caregiver • A health aide who is employed by, or under arrangement with, a Home Health Agency or Visiting Nurse Association. A health aide is covered only if You are also receiving the services of a registered nurse or licensed therapist employed by the same organization and the registered nurse is supervising the services • A licensed therapist for Physical Therapy, Occupational Therapy, speech or respiratory therapy • Necessary medical supplies provided by the Home Health Agency or Visiting Nurse Association • Private Duty Nursing when Medically Necessary and approved by Xxxxx Limitations: • Up to 100 visits per Calendar Year. • The ordering Physician must be treating the illness or injury necessitating the Home Health Care and renew the order for these services once every thirty (30) days. • Providers in California must be a California licensed Home Health Agency or Visiting Nurse Association. • We will not cover personal comfort items. Hospice Care Precertification is required for Hospice Care (see the section titled GETTING APPROVAL FOR BENEFITS for details). The services and supplies listed below are Covered Services when given by a Hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms, but is not meant to cure a terminal illness. Covered Services include: • Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care. An interdisciplinary team includes, but is not limited to, the enrollee and the patient's family, a physician and surgeon, a registered nurse, a social worker, a volunteer, and a spiritual caregiver. • Short-term inpatient Hospital care when needed in periods of crisis. • Short-term inpatient Hospital care as respite care. Inpatient respite care is limited to a maximum of five (5) consecutive days per admission. • Skilled nursing services, which shall be available on a 24-hour on-call basis, home health aide services and homemaker services given by or under the supervision of a registered nurse. • Social services and counseling services provided by a licensed social worker. • Nutritional support such as intravenous feeding and feeding tubes or hyperalimentation • Physical Therapy, Occupational Therapy, speech therapy and respiratory therapy given by a licensedtherapist. • Pharmaceuticals, medical equipment and supplies needed for the palliative care of Your condition, including oxygen, related respiratory therapy supplies and incontinence supplies. • Bereavement (grief) services for the Member and the Member’s direct family members. Your Physician and Hospice medical director must certify that You are terminally ill and likely have less than twelve (12) months to live. Your Physician must agree to care by the Hospice and must be consulted in the development of Your care plan. The Hospice must keep a written care plan on file and provide it to Us upon request. Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy given as palliative care are available to the Member in Hospice. These additional Covered Services will be covered under other sections of this document. Limitations: The following services, supplies or care are not covered: • Services or supplies for personal comfort or convenience, including homemaker services that are not under the supervision of a registered nurse • Food services, meals, formulas and supplements other than listed above or for dietary counseling even if the food, meal, formula or supplement is the sole source of nutrition • Services not directly related to the medical care of the Member, including estate planning, drafting of xxxxx, funeral counseling or arrangement or other legal services • Services provided by volunteers Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services Please see “Transplant Services” later in this part. Infertility Covered services include: Treatment for infertility, meaning procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer. Services for In vitro fertilization are not covered. An In-Network Physician determines the appropriate number of drug-induced ovulation attempts for the GIFT treatment cycle. Infusion Therapy Please see “Therapy Services” later in this part. Inpatient Facility Services Precertification is required for all inpatient Facility admissions and stays. Precertification is NOT required for emergency and inpatient Hospital stays for the delivery of a child or mastectomy surgery, including the length of Hospital stays associated with mastectomy and/or breast reconstruction surgery for breast. For emergency admissions, You, Your authorized representative or Physician must tell Us within forty-eight (48) hours of the admission or as soon as possible within a reasonable period of time (see the section titled GETTING APPROVAL FOR BENEFITS fordetails).

Hearing Services. Covered Services include: • Routine hearing screenings (see “Preventive Care” later in this section) • Hearing exams to determine the need for hearing correction (see “Preventive Care” later in this section) • Services related to the ear or hearing, such as outpatient care to treat an ear infection and outpatient Prescription Drugs, supplies and supplements (see “Office Visits” later in this section and the section titled WHAT IS COVERED – PRESCRIPTION DRUGS) • Cochlear implants (see “Durable Medical Equipment and Medical Devices, Special Footwear, Orthotics, Prosthetics and Medical and Surgical Supplies” earlier in this section) • Hearing aids and hearing tests to determine their efficacy and hearing tests to determine an appropriate hearing aid. Home Care Services Precertification is required for Home Care Services (see the section titled GETTING APPROVAL FOR BENEFITS for details). Benefits are available for Covered Services performed by a Home Health Care Agency or other professional Provider in Your home. To be eligible for benefits, You must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis. Services must be prescribed by a Physician and the services must be so inherently complex that they can be safely and effectively performed only by qualified, technical, or professional health staff. Covered Services include but are not limited to: • A registered nurse • A medical social service worker • Diagnostic services • Nutritional guidance • Training of the patient and/or family/caregiver • A health aide who is employed by, or under arrangement with, a Home Health Agency or Visiting Nurse Association. A health aide is covered only if You are also receiving the services of a registered nurse or licensed therapist employed by the same organization and the registered nurse is supervising the services • A licensed therapist for Physical Therapy, Occupational Therapy, speech or respiratory therapy • Necessary medical supplies provided by the Home Health Agency or Visiting Nurse Association • Private Duty Nursing when Medically Necessary and approved by Xxxxx Limitations: • Up to 100 visits per Calendar Year. • The ordering Physician must be treating the illness or injury necessitating the Home Health Care and renew the order for these services once every thirty (30) days. • Providers in California must be a California licensed Home Health Agency or Visiting Nurse Association. • We will not cover personal comfort items. Hospice Care Precertification is required for Hospice Care (see the section titled GETTING APPROVAL FOR BENEFITS for details). The services and supplies listed below are Covered Services when given by a Hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms, but is not meant to cure a terminal illness. Covered Services include: • Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care. An interdisciplinary team includes, but is not limited to, the enrollee and the patient's family, a physician and surgeon, a registered nurse, a social worker, a volunteer, and a spiritual caregiver. • Short-term inpatient Hospital care when needed in periods of crisis. • Short-term inpatient Hospital care as respite care. Inpatient respite care is limited to a maximum of five (5) consecutive days per admission. • Skilled nursing services, which shall be available on a 24-hour on-call basis, home health aide services and homemaker services given by or under the supervision of a registered nurse. • Social services and counseling services provided by a licensed social worker. • Nutritional support such as intravenous feeding and feeding tubes or hyperalimentation • Physical Therapy, Occupational Therapy, speech therapy and respiratory therapy given by a licensedtherapist. • Pharmaceuticals, medical equipment and supplies needed for the palliative care of Your condition, including oxygen, related respiratory therapy supplies and incontinence supplies. • Bereavement (grief) services for the Member and the Member’s direct family members. Your Physician and Hospice medical director must certify that You are terminally ill and likely have less than twelve (12) months to live. Your Physician must agree to care by the Hospice and must be consulted in the development of Your care plan. The Hospice must keep a written care plan on file and provide it to Us upon request. Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy given as palliative care are available to the Member in Hospice. These additional Covered Services will be covered under other sections of this document. Limitations: The following services, supplies or care are not covered: • Services or supplies for personal comfort or convenience, including homemaker services that are not under the supervision of a registered nurse • Food services, meals, formulas and supplements other than listed above or for dietary counseling even if the food, meal, formula or supplement is the sole source of nutrition • Services not directly related to the medical care of the Member, including estate planning, drafting of xxxxx, funeral counseling or arrangement or other legal services • Services provided by volunteers Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services Please see “Transplant Services” later in this part. Infertility Covered services include: Treatment for infertility, meaning procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer. Services for In vitro fertilization are not covered. An In-Network Physician determines the appropriate number of drug-induced ovulation attempts for the GIFT treatment cycle. Infusion Therapy Please see “Therapy Services” later in this part. Inpatient Facility Services Precertification is required for all inpatient Facility admissions and stays. Precertification is NOT required for emergency and inpatient Hospital stays for the delivery of a child or mastectomy surgery, including the length of Hospital stays associated with mastectomy and/or breast reconstruction surgery for breast. For emergency admissions, You, Your authorized representative or Physician must tell Us within forty-eight (48) hours of the admission or as soon as possible within a reasonable period of time (see the section titled GETTING APPROVAL FOR BENEFITS fordetails).

Hearing Services. Covered Services include: • Routine hearing screenings (see “Preventive Care” later in this section) • Hearing exams to determine the need for hearing correction (see “Preventive Care” later in this section) • Services related to the ear or hearing, such as outpatient care to treat an ear infection and outpatient Prescription Drugs, supplies and supplements (see “Office Visits” later in this section and the section titled WHAT IS COVERED – PRESCRIPTION DRUGS) • Cochlear implants (see “Durable Medical Equipment and Medical Devices, Special Footwear, Orthotics, Prosthetics and Medical and Surgical Supplies” earlier in this section) • Hearing aids and hearing tests to determine their efficacy and hearing tests to determine an appropriate hearing aid. Home Care Services Precertification is required for Home Care Services (see the section titled GETTING APPROVAL FOR BENEFITS for details). Benefits are available for Covered Services performed by a Home Health Care Agency or other professional Provider in Your home. To be eligible for benefits, You must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis. Services must be prescribed by a Physician and the services must be so inherently complex that they can be safely and effectively performed only by qualified, technical, or professional health staff. Covered Services include but are not limited to: • A registered nurse • A medical social service worker • Diagnostic services • Nutritional guidance • Training of the patient and/or family/caregiver • A health aide who is employed by, or under arrangement with, a Home Health Agency or Visiting Nurse Association. A health aide is covered only if You are also receiving the services of a registered nurse or licensed therapist employed by the same organization and the registered nurse is supervising the services • A licensed therapist for Physical Therapy, Occupational Therapy, speech or respiratory therapy • Necessary medical supplies provided by the Home Health Agency or Visiting Nurse Association • Private Duty Nursing when Medically Necessary and approved by Xxxxx Limitations: • Up to 100 visits per Calendar Year. • The ordering Physician must be treating the illness or injury necessitating the Home Health Care and renew the order for these services once every thirty (30) days. • Providers in California must be a California licensed Home Health Agency or Visiting Nurse Association. • We will not cover personal comfort items. Hospice Care Precertification is required for Hospice Care (see the section titled GETTING APPROVAL FOR BENEFITS for details). The services and supplies listed below are Covered Services when given by a Hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms, but is not meant to cure a terminal illness. Covered Services include: • Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care. An interdisciplinary team includes, but is not limited to, the enrollee and the patient's family, a physician and surgeon, a registered nurse, a social worker, a volunteer, and a spiritual caregiver. • Short-term inpatient Hospital care when needed in periods of crisis. • Short-term inpatient Hospital care as respite care. Inpatient respite care is limited to a maximum of five (5) consecutive days per admission. • Skilled nursing services, which shall be available on a 24-hour on-call basis, home health aide services and homemaker services given by or under the supervision of a registered nurse. • Social services and counseling services provided by a licensed social worker. • Nutritional support such as intravenous feeding and feeding tubes or hyperalimentation • Physical Therapy, Occupational Therapy, speech therapy and respiratory therapy given by a licensedtherapist. • Pharmaceuticals, medical equipment and supplies needed for the palliative care of Your condition, including oxygen, related respiratory therapy supplies and incontinence supplies. • Bereavement (grief) services for the Member and the Member’s direct family members. Your Physician and Hospice medical director must certify that You are terminally ill and likely have less than twelve (12) months to live. Your Physician must agree to care by the Hospice and must be consulted in the development of Your care plan. The Hospice must keep a written care plan on file and provide it to Us upon request. Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy given as palliative care are available to the Member in Hospice. These additional Covered Services will be covered under other sections of this document. Limitations: The following services, supplies or care are not covered: • Services or supplies for personal comfort or convenience, including homemaker services that are not under the supervision of a registered nurse • Food services, meals, formulas and supplements other than listed above or for dietary counseling even if the food, meal, formula or supplement is the sole source of nutrition • Services not directly related to the medical care of the Member, including estate planning, drafting of xxxxx, funeral counseling or arrangement or other legal services • Services provided by volunteers Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services Please see “Transplant Services” later in this part. Infertility Covered services include: Treatment for infertility, meaning procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer. Services for In vitro fertilization are not covered. An In-Network Physician determines the appropriate number of drug-induced ovulation attempts for the GIFT treatment cycle. Infusion Therapy Please see “Therapy Services” later in this part. Inpatient Facility Services Precertification is required for all inpatient Facility admissions and stays. Precertification is NOT required for emergency and inpatient Hospital stays for the delivery of a child or mastectomy surgery, including the length of Hospital stays associated with mastectomy and/or breast reconstruction surgery for breast. For emergency admissions, You, Your authorized representative or Physician must tell Us within forty-eight (48) hours of the admission or as soon as possible within a reasonable period of time (see the section titled GETTING APPROVAL FOR BENEFITS fordetails).

Hearing Services. Covered Services include: • Routine Hearing Exams We cover hearing screenings (see “Preventive Care” later in this section) • Hearing exams tests to determine the need for hearing correction correction, when ordered by a Plan Provider. Refer to Preventive Health Care Services for coverage of newborn hearing screenings. Hearing Aids A hearing aid is defined as a device that is of a design and circuitry to optimize audibility and listening skills in the environment commonly experienced by children, and is non-disposable. Children up until the end of the month they turn age 19 We cover one hearing aid for each hearing-impaired ear every thirty-six (see “Preventive Care” later in this section36) • Services related to months. See the ear or hearingbenefit-specific exclusions immediately below for additional information. Benefit-Specific Exclusions: Except as listed above for hearing aids for children, such as outpatient care to treat an ear infection and outpatient Prescription Drugs, supplies and supplements (see “Office Visits” later in this section and the section titled WHAT IS COVERED – PRESCRIPTION DRUGS) • Cochlear implants (see “Durable Medical Equipment and Medical Devices, Special Footwear, Orthotics, Prosthetics and Medical and Surgical Supplies” earlier in this section) • following exclusions apply: 1. Hearing aids and hearing tests to determine their efficacy and hearing or tests to determine an appropriate hearing aidaid and its efficacy; except as specifically provided in this section, or as provided under a Hearing Services Rider, if applicable. 2. Replacement parts and batteries. 3. Replacement of lost or broken hearing aids. 4. Comfort, convenience or luxury equipment or features. We cover the following home health care Services, only if you are substantially confined to your home, and only if a Plan Physician determines that it is feasible to maintain effective supervision and control of your care in your home: 1. Skilled nursing care; 2. Home Care health aide Services; and 3. Medical social Services. Home health Services Precertification is required for Home Care are Medically Necessary health Services (see the section titled GETTING APPROVAL FOR BENEFITS for details). Benefits are available for Covered Services performed by a Home Health Care Agency or other professional Provider in Your home. To be eligible for benefits, You must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis. Services must be prescribed by a Physician and the services must be so inherently complex that they can be safely and effectively performed only provided in your home by qualifiedhealth care personnel and are directed by a Plan Provider. They include visits by registered nurses, technical, practical nurses or professional home health staff. Covered Services include but are not limited to: • A registered nurse • A medical social service worker • Diagnostic services • Nutritional guidance • Training of aides who work under the patient and/or family/caregiver • A health aide who is employed by, supervision or under arrangement with, a Home Health Agency or Visiting Nurse Association. A health aide is covered only if You are also receiving the services direction of a registered nurse or licensed therapist employed medical doctor. We also cover any other outpatient Services, as described in this section that have been authorized by the same organization and the registered nurse is supervising the services • A licensed therapist for Physical Therapy, Occupational Therapy, speech or respiratory therapy • Necessary medical supplies provided by the Home Health Agency or Visiting Nurse Association • Private Duty Nursing when your Plan Physician as Medically Necessary and approved by Xxxxx Limitations: • Up to 100 visits per Calendar Yearappropriately rendered in a home setting. • The ordering Physician must be treating the illness or injury necessitating the Home Health Care and renew Visits Following Mastectomy or Removal of Testicle We cover the order cost of inpatient hospitalization Services for these services once every thirty a minimum of forty-eight (3048) dayshours following a mastectomy. • Providers in California must be A Member may request a California licensed Home Health Agency or Visiting Nurse Association. • We will not cover personal comfort items. Hospice Care Precertification is required for Hospice Care (see the section titled GETTING APPROVAL FOR BENEFITS for details). The services and supplies listed below are Covered Services when given by shorter length of stay following a Hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms, but is not meant to cure a terminal illness. Covered Services include: • Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care. An interdisciplinary team includes, but is not limited to, the enrollee and the patient's family, a physician and surgeon, a registered nurse, a social worker, a volunteer, and a spiritual caregiver. • Short-term inpatient Hospital care when needed in periods of crisis. • Short-term inpatient Hospital care as respite care. Inpatient respite care is limited to a maximum of five (5) consecutive days per admission. • Skilled nursing services, which shall be available on a 24-hour on-call basis, home health aide services and homemaker services given by or under the supervision of a registered nurse. • Social services and counseling services provided by a licensed social worker. • Nutritional support such as intravenous feeding and feeding tubes or hyperalimentation • Physical Therapy, Occupational Therapy, speech therapy and respiratory therapy given by a licensedtherapist. • Pharmaceuticals, medical equipment and supplies needed for the palliative care of Your condition, including oxygen, related respiratory therapy supplies and incontinence supplies. • Bereavement (grief) services for mastectomy if the Member and decides, in consultation with the Member’s direct family membersattending physician that less time is needed for recovery. Your Physician and Hospice medical director must certify that You are terminally ill and likely have For a Member who remains in the hospital for at least forty-eight (48) hours following mastectomy, we cover the cost of a home visit if prescribed by the attending physician. For Members undergoing a mastectomy or removal of a testicle on an outpatient basis, as well as Members who receive less than twelve (12) months to live. Your Physician must agree to care by the Hospice and must be consulted in the development of Your care plan. The Hospice must keep a written care plan on file and provide it to Us upon request. Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy given as palliative care are available to the Member in Hospice. These additional Covered Services will be covered under other sections of this document. Limitations: The following services, supplies or care are not covered: • Services or supplies for personal comfort or convenience, including homemaker services that are not under the supervision of a registered nurse • Food services, meals, formulas and supplements other than listed above or for dietary counseling even if the food, meal, formula or supplement is the sole source of nutrition • Services not directly related to the medical care of the Member, including estate planning, drafting of xxxxx, funeral counseling or arrangement or other legal services • Services provided by volunteers Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services Please see “Transplant Services” later in this part. Infertility Covered services include: Treatment for infertility, meaning procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer. Services for In vitro fertilization are not covered. An In-Network Physician determines the appropriate number of drug-induced ovulation attempts for the GIFT treatment cycle. Infusion Therapy Please see “Therapy Services” later in this part. Inpatient Facility Services Precertification is required for all inpatient Facility admissions and stays. Precertification is NOT required for emergency and inpatient Hospital stays for the delivery of a child or mastectomy surgery, including the length of Hospital stays associated with mastectomy and/or breast reconstruction surgery for breast. For emergency admissions, You, Your authorized representative or Physician must tell Us within forty-eight (48) hours of inpatient hospitalization following the admission surgery, we cover the following: 1. One home visit scheduled to occur within twenty-four (24) hours following his or as soon as possible within a reasonable period her discharge from the hospital or outpatient facility; and 2. One additional home visit, when prescribed by the patient’s attending physician. Additional limitations may be stated in the Summary of time (see Services and Cost Shares. See the section titled GETTING APPROVAL FOR BENEFITS fordetails).benefit-specific limitations and exclusions immediately below for additional information. Benefit-Specific Limitations: Benefit-Specific Exclusions:

Hearing Services. Covered Services include: • Routine hearing screenings (see “Preventive Care” later in this section) • Hearing exams to determine the need for hearing correction (see “Preventive Care” later in this section) • Services related to the ear or hearing, such as outpatient care to treat an ear infection and outpatient Prescription Drugs, supplies and supplements (see “Office Visits” later in this section and the section titled WHAT IS COVERED – PRESCRIPTION DRUGS) • Cochlear implants (see “Durable Medical Equipment and Medical Devices, Special Footwear, Orthotics, Prosthetics and Medical and Surgical Supplies” earlier in this section) • Hearing aids and hearing tests to determine their efficacy and hearing tests to determine an appropriate hearing aid. Home Care Services Precertification is required for Home Care Services (see the section titled GETTING APPROVAL FOR BENEFITS for details). Benefits are available for Covered Services performed by a Home Health Care Agency or other professional Provider in Your home. To be eligible for benefits, You must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis. Services must be prescribed by a Physician and the services must be so inherently complex that they can be safely and effectively performed only by qualified, technical, or professional health staff. Covered Services include but are not limited to: • A registered nurse • A medical social service worker • Diagnostic services • Nutritional guidance • Training of the patient and/or family/caregiver • A health aide who is employed by, or under arrangement with, a Home Health Agency or Visiting Nurse Association. A health aide is covered only if You are also receiving the services of a registered nurse or licensed therapist employed by the same organization and the registered nurse is supervising the services • A licensed therapist for Physical Therapy, Occupational Therapy, speech or respiratory therapy • Necessary medical supplies provided by the Home Health Agency or Visiting Nurse Association • Private Duty Nursing when Medically Necessary and approved by Xxxxx Limitations: • Up to 100 visits per Calendar Year. • The ordering Physician must be treating the illness or injury necessitating the Home Health Care and renew the order for these services once every thirty (30) days. • Providers in California must be a California licensed Home Health Agency or Visiting Nurse Association. • We will not cover personal comfort items. Hospice Care Precertification is required for Hospice Care (see the section titled GETTING APPROVAL FOR BENEFITS for details). The services and supplies listed below are Covered Services when given by a Hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms, but is not meant to cure a terminal illness. Covered Services include: • Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care. An interdisciplinary team includes, but is not limited to, the enrollee and the patient's family, a physician and surgeon, a registered nurse, a social worker, a volunteer, and a spiritual caregiver. • Short-term inpatient Hospital care when needed in periods of crisis. • Short-term inpatient Hospital care as respite care. Inpatient respite care is limited to a maximum of five (5) consecutive days per admission. • Skilled nursing services, which shall be available on a 24-hour on-call basis, home health aide services and homemaker services given by or under the supervision of a registered nurse. • Social services and counseling services provided by a licensed social worker. • Nutritional support such as intravenous feeding and feeding tubes or hyperalimentation • Physical Therapy, Occupational Therapy, speech therapy and respiratory therapy given by a licensedtherapist. • Pharmaceuticals, medical equipment and supplies needed for the palliative care of Your condition, including oxygen, related respiratory therapy supplies and incontinence supplies. • Bereavement (grief) services for the Member and the Member’s direct family members. Your Physician and Hospice medical director must certify that You are terminally ill and likely have less than twelve (12) months to live. Your Physician must agree to care by the Hospice and must be consulted in the development of Your care plan. The Hospice must keep a written care plan on file and provide it to Us upon request. Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy given as palliative care are available to the Member in Hospice. These additional Covered Services will be covered under other sections of this document. Limitations: The following services, supplies or care are not covered: • Services or supplies for personal comfort or convenience, including homemaker services that are not under the supervision of a registered nurse • Food services, meals, formulas and supplements other than listed above or for dietary counseling even if the food, meal, formula or supplement is the sole source of nutrition • Services not directly related to the medical care of the Member, including estate planning, drafting of xxxxx, funeral counseling or arrangement or other legal services • Services provided by volunteers Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services Please see “Transplant Services” later in this part. Infertility Covered services include: Treatment for infertility, meaning procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer. Services for In vitro fertilization are not covered. An In-Network Physician determines the appropriate number of drug-induced ovulation attempts for the GIFT treatment cycle. Infusion Therapy Please see “Therapy Services” later in this part. Inpatient Facility Services Precertification is required for all inpatient Facility admissions and stays. Precertification is NOT required for emergency and inpatient Hospital stays for the delivery of a child or mastectomy surgery, including the length of Hospital stays associated with mastectomy and/or breast reconstruction surgery for breast. For emergency admissions, You, Your authorized representative or Physician must tell Us within forty-eight (48) hours of the admission or as soon as possible within a reasonable period of time (see the section titled GETTING APPROVAL FOR BENEFITS fordetails).

Hearing Services. Covered Services include: • Routine hearing screenings (see “Preventive Care” later in this sectionpart) • Hearing exams to determine the need for hearing correction (see “Preventive Care” later in this sectionpart) • Services related to the ear or hearing, such as outpatient care to treat an ear infection and outpatient Prescription Drugs, supplies and supplements (see “Office Visits” later in this section part and the section titled part WHAT IS COVERED – PRESCRIPTION DRUGS) • Cochlear implants (see “Durable Medical Equipment and Medical Devices, Special Footwear, Orthotics, Prosthetics and Medical and Surgical Supplies” earlier in this sectionpart) • Hearing aids and hearing tests to determine their efficacy and hearing tests to determine an appropriate hearing aid. Home Care Services Precertification is required for Home Care Services (see the section titled part called GETTING APPROVAL FOR BENEFITS for details). Benefits are available for Covered Services performed by a Home Health Care Agency or other professional Provider in Your home. To be eligible for benefits, You must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis. Services must be prescribed by a Physician and the services must be so inherently complex that they can be safely and effectively performed only by qualified, technical, or professional health staff. Covered Services include but are not limited to: • A registered nurse • A medical social service worker • Diagnostic services • Nutritional guidance • Training of the patient and/or family/caregiver • A health aide who is employed by, or under arrangement with, a Home Health Agency or Visiting Nurse Association. A health aide is covered only if You are also receiving the services of a registered nurse or licensed therapist employed by the same organization and the registered nurse is supervising the services • A licensed therapist for Physical Therapy, Occupational Therapy, speech or respiratory therapy • Necessary medical supplies provided by the Home Health Agency or Visiting Nurse Association • Private Duty Nursing when Medically Necessary and approved by Xxxxx Limitations: • Up to 100 visits per Calendar Year. • The ordering Physician must be treating the illness or injury necessitating the Home Health Care and renew the order for these services once every thirty (30) days. • Providers in California must be a California licensed Home Health Agency or Visiting Nurse Association. • We will not cover personal comfort items. Hospice Care Precertification is required for Hospice Care (see the section titled part called GETTING APPROVAL FOR BENEFITS for details). The services and supplies listed below are Covered Services when given by a Hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms, but is not meant to cure a terminal illness. Covered Services include: • Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care. An interdisciplinary team includes, but is not limited to, the enrollee and the patient's family, a physician and surgeon, a registered nurse, a social worker, a volunteer, and a spiritual caregiver. • Short-term inpatient Hospital care when needed in periods of crisis. • Short-term inpatient Hospital care as respite care. Inpatient respite care is limited to a maximum of five (5) consecutive days per admission. • Skilled nursing services, which shall be available on a 24-hour on-call basis, home health aide services and homemaker services given by or under the supervision of a registered nurse. • Social services and counseling services provided by a licensed social worker. • Nutritional support such as intravenous feeding and feeding tubes or hyperalimentation • Physical Therapy, Occupational Therapy, speech therapy and respiratory therapy given by a licensedtherapistlicensed therapist. • Pharmaceuticals, medical equipment and supplies needed for the palliative care of Your condition, including oxygen, related respiratory therapy supplies and incontinence supplies. • Bereavement Xxxxxxxxxxx (grief) services for the Member member and the Membermember’s direct family members. Your Physician and Hospice medical director must certify that You are terminally ill and likely have less than twelve (12) months to live. Your Physician must agree to care by the Hospice and must be consulted in the development of Your care plan. The Hospice must keep a written care plan on file and provide it to Us upon request. Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy given as palliative care are available to the Member in Hospice. These additional Covered Services will be covered under other sections of this document. Limitations: The following services, supplies or care are not covered: • Services or supplies for personal comfort or convenience, including homemaker services that are not under the supervision of a registered nurse • Food services, meals, formulas and supplements other than listed above or for dietary counseling even if the food, meal, formula or supplement is the sole source of nutrition • Services not directly related to the medical care of the Member, including estate planning, drafting of xxxxx, funeral counseling or arrangement or other legal services • Services provided by volunteers Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services Please see “Transplant Services” later in this part. Infertility Covered services include: Treatment for infertility, meaning procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery, and gamete intrafallopian transfer. Services for In vitro fertilization are not covered. An In-Network Physician determines the appropriate number of drug-induced ovulation attempts for the GIFT treatment cycle. Infusion Therapy Please see “Therapy Services” later in this part. Inpatient Facility Services Precertification is required for all inpatient Facility admissions and stays. Precertification is NOT required for emergency and inpatient Hospital stays for the delivery of a child or mastectomy surgery, including the length of Hospital stays associated with mastectomy and/or breast reconstruction surgery for breast. For emergency admissions, You, Your authorized representative or Physician must tell Us within forty-eight (48) hours of the admission or as soon as possible within a reasonable period of time (see the section titled GETTING APPROVAL FOR BENEFITS fordetails).twelve