ii Clinical Trials...........................................................................................................................................40 Congenital Heart Disease (CHD) Surgeries............................................................................................42 Dental Services - Accident Only..............................................................................................................42 Diabetes Services ...................................................................................................................................43 Durable Medical Equipment (DME), Orthotics and Supplies ..................................................................43 Emergency Health Care Services - Outpatient .......................................................................................44 Enteral Nutrition ......................................................................................................................................45 Gender Dysphoria...................................................................................................................................45 Habilitative Services................................................................................................................................45 Home Health Care ..................................................................................................................................46 Hospice Care ..........................................................................................................................................46 Hospital - Inpatient Stay..........................................................................................................................46 Lab, X-Ray and Diagnostic - Outpatient..................................................................................................47 Major Diagnostic and Imaging - Outpatient.............................................................................................47 Mental Health Care and Substance-Related and Addictive Disorders Services.....................................47 Non-Preventive Nutritional Counseling ...................................................................................................48 Ostomy Supplies.....................................................................................................................................48 Pharmaceutical Products - Outpatient ....................................................................................................49 Physician Fees for Surgical and Medical Services .................................................................................49 Physician's Office Services - Sickness and Injury...................................................................................49 Pregnancy - Maternity Services ..............................................................................................................50 Preventive Care Services........................................................................................................................50 Prosthetic Devices ..................................................................................................................................50 Reconstructive Procedures.....................................................................................................................51 Rehabilitation Services - Outpatient Therapy and Manipulative Treatment............................................51 Scopic Procedures - Outpatient Diagnostic and Therapeutic .................................................................52 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services ...........................................................52 Surgery - Outpatient................................................................................................................................53 Temporomandibular Joint (TMJ) Services ..............................................................................................53 Therapeutic Treatments - Outpatient ......................................................................................................54 Transplantation Services.........................................................................................................................54 Urgent Care Center Services..................................................................................................................55 Urinary Catheters....................................................................................................................................55 Virtual Care Services ..............................................................................................................................55 Wigs ........................................................................................................................................................55 Section 2: Exclusions and Limitations...................................................56 How Are Headings Used in this Section? ...............................................................................................56 Plan Does Not Pay Benefits for Exclusions ............................................................................................56 Where Are Benefit Limitations Shown?...................................................................................................56 Alternative Treatments............................................................................................................................56 Dental......................................................................................................................................................56 Devices, Appliances and Prosthetics......................................................................................................57 Drugs.......................................................................................................................................................58 Experimental or Investigational or Unproven Services ...........................................................................59 Foot Care ................................................................................................................................................59 Gender Dysphoria...................................................................................................................................59 Medical Supplies and Equipment............................................................................................................60 Nutrition...................................................................................................................................................60 Personal Care, Comfort or Convenience ................................................................................................61 Physical Appearance ..............................................................................................................................62 Procedures and Treatments....................................................................................................................62 Providers.................................................................................................................................................63 Reproduction...........................................................................................................................................63 Services Provided under another Plan....................................................................................................64