54. Prescription Medications that are administered or dispensed as take-home drugs as part of treatment while in the Hospital or at a medical facility (including claims billed on a claim form from a long-term care facility, assisted living facility, or Skilled Nursing Facility) and that require a Physician’s Prescription. Coverage does not include paper (script) claims obtained at a retail pharmacy, which are covered under the Prescription benefit. 55. Preventive / Routine Care as listed under the Schedule of Benefits. The Plan pays benefits for Preventive Care services provided on an Outpatient basis at a Physician’s office, an Alternate Facility, or a Hospital that encompass medical services that have been demonstrated by clinical evidence to be safe and effective in either the early detection of disease or in the prevention of disease, have been proven to have a beneficial effect on health outcomes, and include the following as required under applicable law: • Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force; • Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; • With respect to infants, Children, and adolescents, evidence-informed Preventive Care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and • Additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. • Well-women Preventive Care visit(s) for women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care. The well-women visit should, where appropriate, include the following additional preventive services listed in the Health Resources and Services Administrations guidelines, as well as others referenced in the Affordable Care Act: ➢ Screening for gestational diabetes; ➢ Human papillomavirus (HPV) DNA testing; ➢ Counseling for sexually transmitted infections; ➢ Counseling and screening for human immune-deficiency virus; ➢ Screening and counseling for interpersonal and domestic violence; and ➢ Breast cancer genetic test counseling (BRCA) for women at high risk. Please visit the following links for additional information: https://www.healthcare.gov/preventive-care-benefits/ https://www.healthcare.gov/preventive-care-children/ https://www.healthcare.gov/preventive-care-women/ 56. Private Duty Nursing Services only covered when provided through the home care services benefit when Outpatient care is required and Medically Necessary 24 hours per day. Coverage does not include Inpatient private duty nursing services. 57. Prosthetic Devices. The initial purchase, fitting, repair and replacement of fitted prosthetic devices (artificial body parts, including limbs, eyes and larynx) that replace body parts. Benefits may be payable for subsequent repairs or replacement only if required: • Due to the growth or development of a Dependent Child; or • When necessary because of a change in the Covered Person’s physical condition; or • Because of deterioration caused from normal wear and tear. The repair or replacement must also be recommended by the attending Physician. In all cases, repairs or replacement due to abuse or misuse, as determined by the Plan, are not covered and replacement is subject to prior approval by the Plan. -64- 7670-00-413597