69 50) Medical Equipment, Devices and Supplies a) Replacement or repair of purchased or rental equipment because of misuse, abuse, or loss/theft. b) Surgical supports, corsets, or articles of clothing unless needed to recover from surgery or injury. c) Non - Medically Necessary enhancements to Standard: equipment and devices. d) Supplies, equipment and appliances , including wigs that include comfort, luxury, or convenience items or features that exceed what is Medically Necessary in your situation. Reimbursement will be based on the Maximum Allow ed Amount for a standard item that is a Covered Service, serves the same purpose, and is Medically Necessary. Any expense, including items you purchase with features that exceed what is Medically Necessary, will be limited to the Maximum Allowed Amount for the standard item, and the additional costs will be your responsibility. e) Disposable supplies for use in the home such as bandages, gauze, tape, antiseptics, dressings, ace - type bandages, and any other supplies, dressings, appliances or devices that are not specifically listed as covered in the “What's Covered” section. 51) Medicare For which benefits are payable under Medicare Parts A and/or B or would have been payable if you had applied for Parts A and/or B, except as required by federal law, as described in the section titled "Medicare" in “General Provisions.” If you do not enroll in Medicare Parts A and/or B when you are eligible, and Medicare would be primary (e.g., for Members in retiree plans or COBRA Members entitled to Medicare) , we will calculate benefits as if you had enrolled . Please refer to Medicare.gov for more details on when you should enroll. 52) Missed or Cancelled Appointments Charges for missed or cancelled appointments. 53) New Prescription Drugs, Indications, and/or Dosage Forms New Prescription Drugs, new indications and/or new dosage forms will not be covered until the date they are reviewed and determined to be eligible for coverage by our Pharmacy and Therapeutics (P&T) Process. 54) Non - approved Drugs Drugs not approved by the FDA. 55) Non - Approved Facility Services from a Provider that does not meet the definition of Facility. 56) Non - Medically Necessary Services Services we conclude are not Medically Necessary. This includes services that do not meet our medical policy, clinical coverage, or benefit policy guidel i nes . 57) Nutritional or Dietary Supplements Nutritional and/or dietary supplements, except as described in this Booklet or that must be covered by law. This Exclusion includes, but is not limited to, nutritional formulas and dietary supplements that you can buy over - the - counter and those you can get without a written Prescription or from a licensed pharmacist. 58) Off label use Off label use, unless the Plan approves it, or when: (1) The Drug is recognized for treatment of the indication in at least one (1) Standard: reference compendium; (2) The Drug is recommended for that particular type of cancer and found to be safe and effective in formal clinical studies, the results of which have been published in a peer reviewed professional medical journal published in the U nited States or Great Britain. 59) Oral Surgery Extraction of teeth, surgery for impacted teeth and other oral surgeries for to treat the teeth or bones and gums directly supporting the teeth, except as listed in this Booklet. 60) Personal Care and Convenience a) Items for personal comfort, convenience, protection, cleanliness such as air conditioners, humidifiers, water purifiers, sports helmets, raised toilet seats, and shower chairs, b) First aid supplies and other items kept in the home for general use (bandages, cotton - tipped applicators, thermometers, petroleum jelly, tape, non - sterile gloves, heating pads), c) Home workout or therapy equipment, including treadmills and home gyms, d) Pools, whirlpools, spas, or hydrotherapy equipment,