47 • One pair of glasses or contact lenses used after surgical removal of the lens(es) of the eyes; • Breast prosthesis (whether internal or external) and surgical bras after a mastectomy, as required by the Women’s Health and Cancer Rights Act. This includes coverage for custom fabricated breast prostheses and one (1) additional breast prosthesis per brea st affected by the mastectomy. • Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. • Restoration prosthesis (composite facial prosthesis) • Wigs needed after cancer treatment, limited to the maximum shown in the Schedule of Benefits. • Benefits are also available for cochlear implants. Prosthetic Limbs & Orthotic Custom Fabricated Brace or Support Prosthetic limbs (artificial leg or arm) and a Medically Necessary orthotic c ustom fabricated brace or support designed as a component of a prosthetic limb, including repairs or replacements, will be covered if: • Determined by your Physician to be Medically Necessary to restore or maintain your ability to perform activities of daily living or essential job related activities; and • Not solely for comfort or convenience. Coverage for Prosthetic limbs and orthotic devices under this provision m ust be equal to the coverage that is provided for the same device, repair, or replacement under the federal Medicare program. Reimbursement must be equal to the reimbursement that is provided for the same device, repair, or replacement under the federal M edicare reimbursement schedule, unless a different reimbursement rate is negotiated. Prosthetic limbs and Orthotic c ustom fabricated braces or supports designed as components for a prosthetic limb are covered the same as any other Medically Necessary items and services and will be subject to the same annual Deductible, Coinsurance, Copayment as other Covered Services under your Plan. Medical and Surgical Supplies Your Plan includes coverage for medical and surgical supplies that serve only a medical purpose, are used once, and are purchased (not rented). Covered supplies include syringes, needles, surgical dressings, splints, and other similar items that serve onl y a medical purpose. Covered Services do not include items often stocked in the home for general use like Band - Aids, thermometers, and petroleum jelly. Medical food that is Medically Necessary and prescribed by a Physician for the treatment of an inherited metabolic disease is covered. Medical foods mean a formula that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered enterally under the direction of a Physician. Blood and Blood Products Your Plan also includes coverage for the administration of blood products. Emergency Care Services