Noblesville Schools Medical Plan 59 Section 2: Exclusions and Limitations 10. Certain Pharmaceutical Products for which there are therapeutically equivalent (having essentially the same efficacy and adverse effect profile) alternatives available to another Pharmaceutical Product, unless otherwise required by law or approved by the Claims Administrator. Such determinations may be made up to six times during a calendar year. 11. Certain Pharmaceutical Products that have not been prescribed by a Specialist. 12. Compounded drugs that contain certain bulk chemicals. Compounded drugs that are available as a similar commercially available Pharmaceutical Product. 13. Certain Specialty medications ordered by a Physician through your Plan Sponsor’s designated specialty pharmacy administrator. Experimental or Investigational or Unproven Services Experimental or Investigational and Unproven Services and all services related to Experimental or Investigational and Unproven Services are excluded. The fact that an Experimental or Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental or Investigational or Unproven in the treatment of that particular condition. This exclusion does not apply to Covered Health Care Services provided during a clinical trial for which Benefits are provided as described under Clinical Trials in Section 1: Covered Health Care Services. Foot Care 1. Routine foot care. Examples include: ▪ Cutting or removal of corns and calluses. ▪ Nail trimming, nail cutting, or nail debridement. ▪ Hygienic and preventive maintenance foot care including cleaning and soaking the feet and applying skin creams in order to maintain skin tone. This exclusion does not apply to preventive foot care due to conditions associated with metabolic, neurologic or peripheral vascular disease. 2. Treatment of flat feet. 3. Treatment of subluxation of the foot. Gender Dysphoria 1. Cosmetic Procedures, including the following: ▪ Abdominoplasty. ▪ Blepharoplasty. ▪ Body contouring, such as lipoplasty. ▪ Brow lift. ▪ Calf implants. ▪ Cheek, chin, and nose implants. ▪ Injection of fillers or neurotoxins. ▪ Face lift, forehead lift, or neck tightening. ▪ Facial bone remodeling for facial feminizations.