64 21. Custodial Care Custodial Care, convalescent care or rest cures. This Exclusion does not apply to Hospice services. 22. Delivery Charges Charges for delivery of Prescription Drugs. 23. Dental Devices for Snoring Oral appliances for snoring. 24. Dental Treatment Dental treatment, except as listed below. Excluded treatment includes but is not limited to preventive care and fluoride treatments; dental X- rays, supplies, appliances and all associated costs; and diagnosis and treatment for the teeth, jaw or gums such as: • Removing, restoring, or replacing teeth; • Medical care or surgery for dental problems (unless listed as a Covered Service in this Booklet); • Services to help dental clinical outcomes. Dental treatment for injuries that are a result of biting or chewing is also excluded. This Exclusion does not apply to services that the Plan must cover by law. 25. Drugs Contrary to Approved Medical and Professional Standards Drugs given to you or prescribed in a way that is against approved medical and professional standards of practice. 26. Drugs Over Quantity or Age Limits Drugs which are over any quantity or age limits set by the Plan. 27. Drugs Over the Quantity Prescribed or Refills After One Year Drugs in amounts over the quantity prescribed, or for any refill given more than one year after the date of the original Prescription Order. 28. Drugs That Do Not Need a Prescription Drugs that do not need a prescription by federal law (including Drugs that need a prescription by state law, but not by federal law), except for injectable insulin or other Drugs provided in the Preventive Care paragraph of the "What’s Covered" section. 29. Drugs Prescribed by Providers Lacking Qualifications/Certifications Prescription Drugs prescribed by a Provider that does not have the necessary qualifications and including certifications as determined by the Plan. 30. Educational Services Services, supplies or room and board for teaching, vocational, or self-training purposes. This includes, but is not limited to boarding schools and/or the room and board and educational components of a residential program where the primary focus of the program is educational in nature rather than treatment based. 31. Emergency Room Services for non-Emergency Care Services provided in an emergency room for conditions that do not meet the definition of Emergency. This includes, but is not limited to suture removal in an emergency room. For non-emergency care please use the closest Participating Urgent Care Center or your Primary Care Physician. 32. Experimental or Investigational Services Services or supplies that are found to be Experimental / Investigational. This also applies to services related to Experimental / Investigational services, whether you get them before, during, or after you get the Experimental / Investigational service or supply. The fact that a service or supply is the only available treatment will not make it Covered Service if the Plan concludes it is Experimental / Investigational. Details on the criteria the Plan uses to determine if a Service is Experimental or Investigational is outlined below. 33. Eyeglasses and Contact Lenses Eyeglasses and contact lenses to correct your eyesight unless listed as covered in this Booklet. This Exclusion does not apply to lenses needed after a covered eye surgery. 34. Eye Exercises Orthoptics and vision therapy. 35. Eye Surgery Eye surgery to fix errors of refraction, such as near-sightedness. This includes, but is not limited to, LASIK, radial keratotomy or keratomileusis, and excimer laser refractive keratectomy.

2025 Retiree Indemnity Plan Booklet - Page 65 2025 Retiree Indemnity Plan Booklet Page 64 Page 66