Noblesville Schools Medical Plan 51 Section 1: Covered Health Care Services • Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998. Benefits include mastectomy bras. Benefits for lymphedema stockings for the arm are provided as described under Durable Medical Equipment (DME), Orthotics and Supplies. Benefits are provided only for external prosthetic devices and do not include any device that is fully implanted into the body. Internal prosthetics are a Covered Health Care Service for which Benefits are available under the applicable medical/surgical Covered Health Care Service categories in this SPD. If more than one prosthetic device can meet your functional needs, Benefits are available only for the prosthetic device that meets the minimum specifications for your needs. If you purchase a prosthetic device that exceeds these minimum specifications, the Plan will pay only the amount that the Plan would have paid for the prosthetic that meets the minimum specifications, and you will be responsible for paying any difference in cost. The prosthetic device must be ordered or provided by, or under the direction of a Physician. Benefits are available for repairs and replacement, except as described in Section 2: Exclusions and Limitations, under Devices, Appliances and Prosthetics. Reconstructive Procedures Reconstructive procedures when the primary purpose of the procedure is either of the following: • Treatment of a medical condition. • Improvement or restoration of physiologic function. Reconstructive procedures include surgery or other procedures which are related to an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not a changed or improved physical appearance. Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that you may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure. Please note that Benefits for reconstructive procedures include breast reconstruction following a mastectomy, and reconstruction of the non-affected breast to achieve symmetry. Other services required by the Women's Health and Cancer Rights Act of 1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same level as those for any other Covered Health Care Service. You can call the Claims Administrator at the telephone number on your ID card for more information about Benefits for mastectomy-related services. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment Short-term outpatient rehabilitation services limited to: • Physical therapy. • Occupational therapy. • Manipulative Treatment. • Speech therapy. • Pulmonary rehabilitation therapy. • Cardiac rehabilitation therapy. • Post-cochlear implant aural therapy. • Cognitive rehabilitation therapy.