Blue Cross Blue Shield of Texas - Diabetes Policy

TEXAS: Diabetes. TexasAdministrative Code. Code Section 1358.001 – 1358.057 and 28 TAC 21.2601-21.2606.

BCBS Diabetes Policy

Excerpts: Contract: Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage: NOTE FOR TEXAS CONTRACTS: Legislative mandates for insured (individual or group) business require coverage for diabetic equipment and supplies that are approved by the United States Food and Drug Administration, if such equipment or supplies are determined to be medically necessary and appropriate by a treating physician.

CPT Codes: 95250 (IL/NM/OK) New Codes Effective 1/2006: 95251 (IL/NM/OK) 95250 (TX) New Codes Effective 1/2006: 95251 (TX)

HCPCS Codes: S1031 (IL/NM/OK) S1030 (IL/NM/OK) E0607, E2100, E2101, S1030, S1031 (TX) A4253

New Codes Effective 1/2006: A4233, A4234, A4235, A4236, A9275 - end policy

- begin contract The Contract rules in Texas: http://www.txhealthpool.org/08012007%20Specimen%20Policy.pdf

Contract excerpts: 10. Diabetes Care and treatment of diabetes for an Insured Person who has been diagnosed with: insulin dependent or non-insulin dependent diabetes; elevated blood glucose levels induced by pregnancy; or another medical condition associated with elevated blood glucose levels for the following services and supplies: a. Diabetes equipment and supplies as follows (see Prescription Drug benefit for other covered supplies and equipment): 1) Injection aids, including devices used to assist with insulin injection and needleless systems; 2) Biohazard disposal containers; 3) Insulin pumps, both external and implantable, and associated appurtenances, that include: insulin infusion sets and devices; insulin pump batteries and cartridges; adhesive and other required disposable supplies for insulin pumps; and durable and disposable devices to assist in the injection of insulin; 4) Repairs and necessary maintenance of insulin pumps not otherwise provided for under a manufacturer’s warranty or purchase agreement, and rental fees for pumps during the repair and necessary maintenance of insulin pumps, neither of which shall exceed the purchase price of a similar replacement pump; 5) Podiatric appliances, including up to two pair of therapeutic footwear per year, for the prevention of complications associated with diabetes; 6) Other treatment and monitoring equipment, approved by the United States Food and Drug Administration (FDA), if Medically Necessary and deemed appropriate by the treating Physician through a written order; and 7) Unless covered by the Prescription Drug benefit, the following diabetes equipment and supplies: a) Blood glucose monitors, including noninvasive glucose monitors and monitors for use by or adapted for the legally blind; b) Test strips for use with a corresponding glucose monitor; c) Visual reading strips and urine testing strips and tablets that test for glucose, ketones and protein; d) Medications available without a prescription for controlling the blood sugar level.

b. Diabetes self-management training for which a Practitioner has written an order for the Insured Person or for the Caretaker of an Insured Person as follows: 1) a diabetes self-management training program recognized by the American Diabetes Association; 2) diabetes self-management training given by a multidisciplinary team, the non-doctor members of which are coordinated by a Certified Diabetes Educator, who is certified by the National Certification Board for Diabetes Educators, or a person who has completed at least 24 hours of continuing education that meets guidelines established by the Texas Board of Health and includes a combination of diabetes-related educational principles and behavioral strategies; such team consisting of at least a dietician and nurse educator and possibly including a pharmacist or a social worker; provided that all team members, except a social worker, must have recent didactic and experiential preparation in diabetes clinical and educational issues, as determined by the team member’s licensing agency, in consultation with the commissioner of public health, unless the member’s licensing agency, in consultation with the commissioner of health, determines that the core educational preparation for the member’s license includes the skills the member needs to provide diabetes self-management training; 3) a Certified Diabetes Educator, certified by the National Certification Board for Diabetes Educators; or 4) diabetes selfmanagement training in which one or more of the following components are provided: the nutrition counseling component provided by a licensed dietician, for which the dietician shall be paid; the pharmaceutical component provided by a pharmacist, for which the pharmacist shall be paid; any component of training provided by a physician assistant or registered nurse, for which the physician assistant or registered nurse shall be paid, except for providing a nutrition counseling or pharmaceutical component unless a licensed dietician or pharmacist is unavailable to provide that component; or any component of the training provided by a doctor of medicine; provided that a person may not provide a component of diabetes self-management training unless the subject matter of the component is within the scope of the person’s practice and the person meets the education requirements, as determined by the person’s licensing agency, in consultation with the commissioner of public health. For purposes of the diabetes benefit only, a Practitioner means a doctor of medicine, advance practice nurse, doctor of dentistry, physician assistant, doctor of podiatry or other licensed person with prescriptive authority. For the purposes of the self-management training, a Caretaker means a family member or significant other of the Insured Person who is responsible for ensuring that an Insured Person, who is not able to manage his or her diabetes, due to age or infirmity, is properly managed, including oversight of diet, administration of medications and use of equipment and supplies. Self-management training includes: 1) the development of an individualized management plan created for and in collaboration with the Insured Person; and 2) medical nutritional counseling and instructions on the proper use of diabetes equipment and supplies. Self-management training will be provided to the Insured Person or to a Caretaker for the Insured Person upon: 1) the initial diagnosis of diabetes; 2) a written order of a Practitioner indicating that a significant change in the Insured Person’s symptoms

Prescription Drug Plan: 21. Prescription Drugs: Once an Insured Person has satisfied the Prescription Drug Deductible each calendar year, the Policy will pay the amount of Covered Expenses in excess of the applicable Copayment. Covered outpatient prescription drugs may be provided through a Participating Pharmacy, the Mail Order Program, the Specialty Medications Program or a Non-Participating Pharmacy. This benefit does not apply to an Insured Person eligible for Medicare. Definitions: Average Wholesale Price means any one of the recognized published averages of the prices charged by wholesalers in the United States for a drug product they sell to a pharmacy. Branded Generic Drug means a prescription drug that has the same active ingredient(s) as a Brand Name Drug and a limited number of manufacturers, for which the price is similar to the price of a Brand Name Drug. For purposes of this Policy, Branded Generic Drugs are covered as Brand Name Drugs. Brand Name Drug means a prescription drug protected by a registered trademark. Compounded Drug means a drug formulation made by a pharmacist upon receipt of a valid prescription for an Insured Person from a licensed practitioner. A Compounded Drug is an alternative to a commercially available product, made by modifying a manufactured product to: adjust the dose; change the form of the drug; or prepare an alternative that does not contain preservatives, dyes or other allergens. A Compounded Drug must contain a United States Food and Drug Administration (FDA) approved legend drug that is covered by this Policy. For purposes of this Policy, Compounded Drugs are covered as Non- Formulary Brand Name Drugs. Copayment means the amount paid by the Insured Person for each Prescription Order dispensed or refilled at a Participating Pharmacy. Drug Utilization Review means a focused review of significant drug interactions, drug-disease precautions and appropriate drug use parameters. Formulary Brand Name Drug means a Brand Name Drug that is subject to the Formulary Drug Copayment. Formulary Brand Name Drugs are identified on the Formulary Brand Name Drug List, which is developed using monographs written by the American Medical Association, Academy of Managed Care Pharmacies, and other pharmacy and medical related organizations, describing clinical outcomes, drug efficacy, and side effect profiles. The Pharmacy Manager will periodically review the Formulary Brand Name Drug List and adjust it to add or delete drugs. The Formulary Brand Name Drug List and any modifications thereto will be made available to Insured Persons. Insured Persons may also contact the Pharmacy Manager to determine if a particular drug is on the Formulary Brand Name Drug List. Drugs that do not appear on the Formulary Brand Name Drug List will be subject to the Non- Formulary Brand Name Drug Copayment. Generic Drug means a prescription drug not protected by a registered trademark. Maximum Allowable Cost (MAC) means the maximum cost for which a Participating Pharmacy will be reimbursed by the Administrator for selected products. Network means a group of independent pharmacies or chain of pharmacies having a particular agreement with the Pharmacy Manager for providing prescription drug services. Non-Formulary Brand Name Drug means a Brand Name Drug and all Compounded Drugs, which are subject to the higher Non-Formulary Brand Name Drug Copayment. Non-Participating Pharmacy means a pharmacy that has not entered into an agreement with the Pharmacy Manager to provide prescription drug services. Participating Pharmacy means an independent pharmacy or chain of pharmacies that has entered into an agreement to provide prescription drug services in the Pharmacy Manager’s Network, chosen for this Policy. Pharmacy Manager means Medco Health Solutions, Inc. Pharmacy Allowable Charge means the lesser of the pharmacy’s usual and customary charge or the amount that would have been allowed by the Policy for the same prescription if dispensed by a Participating Pharmacy. Prescription Drug Deductible means the amount each Insured Person must pay each calendar year for covered prescription drugs before benefits are payable. The Prescription Drug Deductible is shown in the Policy Schedule. Charges applied to the PrescriptionDrug Deductible will not apply to any required Copayments for covered prescription drugs, the Calendar Year Deductible or the Coinsurance Maximum amount. Prescription Order means a written or verbal order from a Physician to a pharmacist for a drug or device to be dispensed. Prior Authorization means a clinical system used to manage the utilization, including Medical Necessity, of prescription drugs. Specialty Medications means a prescription drug for which the annual cost is $6,000 or more and for which one or more of the following is required: specialized patient training and coordination of care (services, supplies or devices) prior to therapy initiation and during therapy; unique requirements for patient compliance and safety monitoring; unique requirements for handling, shipping and storage of the drug; or potential for significant waste of high-cost product. Prior Authorization: Certain prescription drugs will require Prior Authorization by the Pharmacy Manager before the Insured Person can obtain a covered prescription drug at a Participating Pharmacy. Prior Authorization will be required on drugs that meet one or more of the following criteria: risk of inappropriate utilization; toxicity risk unless used correctly; use outside FDA-approved indications; or high cost medications. Examples of prescription drugs that require Prior Authorization are growth hormone drugs and rheumatoid arthritis agents. A list of the drugs that require Prior Authorization can be obtained on the Pool web site, www.txhealthpool.org or by calling the Pharmacy Manager’s toll free number on the back of the Insured Person’s Identification Card. Quantity Limits: To ensure proper dosage and use, some prescription drugs may be subject to a quantity limit per prescription and/or per 30-day supply. Benefits: Benefits are payable for expenses for covered outpatient prescription drugs, subject to the provisions, limitations, exclusions and conditions of this Policy. Benefits are subject to the Prescription Drug Deductible and the applicable Copayment, but are not subject to the Calendar Year Deductible. Charges for outpatient prescription drugs, including charges applied to the Prescription Drug Deductible or to Copayments, do not apply to the Calendar Year Deductible or the Coinsurance Maximum for Covered Expenses from Preferred Providers. The following prescription expenses are covered when dispensed by a licensed pharmacist and prescribed by a Physician for use by an Insured Person: a. drugs and medicines that by law can only be obtained with a Prescription Order; b. prescription contraceptive drugs or devices, approved by the FDA, not requiring Physician office administration; c. Injectable drugs; and d. Diabetic equipment and supplies as follows: 1) blood glucose monitors, including noninvasive glucose monitors and monitors for use by or adapted for the legally blind; 2) test strips for use with a corresponding glucose monitor; 3) lancet and lancet devices; 4) visual reading strips and urine testing strips and tablets that test for glucose, ketones and protein; 5) insulin and insulin analog preparations; 6) insulin syringes, including prefilled unit dose insulin syringes or cartridges; 7) prescription drugs and drugs available without a prescription for controlling the blood sugar level; and 8) glucagon emergency kits. Retail Participating Pharmacy Program: To obtain a covered prescription drug at a Participating Pharmacy, an Insured Person must: (1) present a current, valid Identification Card; (2) provide a valid Prescription Order; (3) pay to the pharmacy the Prescription Drug Deductible, if not met, and the appropriate Copayment for the drugs received; and (4) provide the necessary recipient information and signatures required by the pharmacy. The Pharmacy Manager will pay the Participating Pharmacy an amount contractually agreed upon by the Pharmacy, less the Prescription Drug Deductible, if not met, and the appropriate Copayment. Identification Cards for each Insured Person will be provided. The Identification Card must be presented to a Participating Pharmacy in order for an Insured Person to receive full program benefits. The card will contain information needed by the Participating Pharmacy to identify the Insured Person and the Pool Policy. A Participating Pharmacy is not permitted to file claims for reimbursement unless the card is presented at the time prescription drugs are received from the Pharmacy. The applicable drug Copayment per prescription must be paid by an Insured Person before prescription drug benefits are payable through a Participating Pharmacy. The Retail Drug Copayment per prescription is: Generic Drugs: $10 Formulary Brand Name Drugs: $25 Non-Formulary Brand Name Drugs: $40

If a Generic Drug is not available, the Insured Person will pay only the applicable Formulary Brand Name Drug or Non- Formulary Brand Name Drug Retail Copayment. If the Insured Person receives the Brand Name Drug when a Generic Drug is available, the Insured Person will be required to pay the applicable Brand Name Drug Retail Copayment plus the difference between the MAC price for the Generic Drug and the cost of the Brand Name Drug. A covered prescription will not exceed a 30- day supply, except for certain pre-packaged medications for which a greater than 30-day is provided; for these drugs, the Copayment is the applicable amount shown above, multiplied by the total number of months covered by the Prescription Order, not to exceed a 90-day supply. Participating Pharmacies are required to file electronically their claims for reimbursement with the Pharmacy Manager. If the Participating Pharmacy, however, does not file the claim electronically and instead requires the Insured Person to pay the charges of the pharmacy and submit a paper claim to the Pharmacy Manager, the Pharmacy Manager will pay a benefit directly to the Insured Person equal to the Pharmacy Allowable Charge, after deduction of the Prescription Drug Deductible, if not met, and the applicable Copayment. A covered prescription will not exceed a 30-day supply. Mail Order Program: To obtain a mail order prescription, an Insured Person must: (1) ask the Physician to write a prescription for up to a 90-day supply, plus refills, if appropriate; and (2) send the prescription, including the Prescription Drug Deductible, if not met, and the appropriate Mail Order Copayment, to the Pharmacy Manager’s Mail Order facility. For Mail Order Program enrollment information, the Insured Person should contact the Pharmacy Manager at the toll free number on the back of the Identification Card. Mail order refills can be placed by mail or telephone or via the Internet. Additional information is provided in the prescription drug program membership packet. The Mail Order Copayment per prescription, for up to a 90-day supply is: Generic Drugs: $25 Formulary Brand Name Drugs: $60 Non-Formulary Brand Name Drugs: $100 If a Generic Drug is not available, the Insured Person will pay only the applicable Formulary Brand Name Drug or Non- Formulary Brand Name Drug Mail Order Copayment. If the Insured Person receives the Brand Name Drug when a Generic Drug is available, the Insured Person will be required to pay the applicable Brand Name Drug Mail Order Copayment plus the difference between the MAC price for the Generic Drug and the Cost of the Brand Name Drug. A covered prescription will not exceed a 90-day supply. Specialty Medication Program: The Pharmacy Manager’s Specialty Medication Program provides comprehensive services to Insured Persons who are receiving treatment for complex disease states. The program allows the Pharmacy Manager to monitor patient compliance, educate Physicians and Insured Persons as well as to provide convenient distribution of Specialty Medications. Specialty Medications can be obtained from the Pharmacy Manager’s Specialty Medication program or at a Participating Pharmacy, provided that coverage for Specialty Medications at a Participating Pharmacy is limited to the original prescription and one refill, with any subsequent prescriptions or refills to be filled through the Pharmacy Manager’s Specialty Medication program. Specialty Medications will be subject to the Prescription Drug Deductible, if not met, and the applicable Retail Drug Copayment and will not exceed a 30-day supply. Additional Pharmacy Clinical Programs: To best manage the care of each Insured Person, additional Pharmacy Clinical Programs may be applied. These include, but are not limited to: Health Education programs; retrospective, concurrent and prospective drug utilization review activities; compliance monitoring programs; and pharmacy case management. Appeals: An Insured Person may appeal the decision of the Pharmacy Manager regarding coverage of a prescription drug by contacting the Pharmacy Manager, at the toll free number shown on the back of the Identification Card. Non-Participating Pharmacy: When an Insured Person obtains prescription drugs under a valid Prescription Order at a Non-Participating Pharmacy, the Insured Person must pay the charges of the pharmacy and submit a claim to the Pharmacy Manager. The Pharmacy Manager will pay a benefit equal to 90% of the Pharmacy Allowable Charge after deduction of the Prescription Drug Deductible, if not met, and the applicable drug Copayment. A covered prescription will not exceed a 30-day supply. Exclusions: In addition to the limitations otherwise listed in the Policy, Covered Expenses under this Benefit WILL NOT INCLUDE charges for: a. Outpatient prescription drugs and medicines, devices, equipment and supplies of any kind provided to an Insured Person eligible for Medicare. b. Drugs or medications that have an over-the-counter equivalent or that can be lawfully obtained without a Prescription Order, except insulin and insulin analogs. c. Any charge incurred for the administration of prescription drugs by a Physician. d. Drugs and substances that are Experimental or Investigational in nature. e. Drugs taken or given while an Insured Person is confined on an inpatient or outpatient basis in a Hospital, extended care facility, Skilled Nursing Home or similar institution that has a facility for providing drugs. f. Replacement of lost, stolen, destroyed or damaged prescriptions. g. Vitamins, prescription vitamins (except prenatal prescription vitamins), dietary supplements, cosmetic, health and beauty aids. h. Charges for drugs in excess of the Pharmacy Allowable Charges in the area where the drugs are dispensed. i. Therapeutic devices or appliances, support garments and other non-medical items regardless of their intended use, except as provided for treatment of diabetes. j. Rogaine, minoxidil or any other drugs, medications, solutions or preparations used or intended for use in treatment of hair loss, hair thinning or any related condition, whether to facilitate or promote hair growth, to replace lost hair or otherwise. k. Cosmetic drugs, except for acne medication, including Retin-A, Accutane, Avita and Differin, for an Insured Person under age 30 for treatment of acne vulgaris. l. Smoking cessation products. m. Blood and blood plasma. n. Appetite suppressants or any other drugs prescribed for weight loss. o. Injectable drugs for treatment of allergies. p. Infertility medications. q. Drugs or medications for treatment of sexual dysfunctions or disorders. r. Biological sera. s. Drugs or medications prescribed for an Injury or Illness arising out of employment. t. Drugs or medications furnished by any government organization or agency unless there is an unconditional legal obligation on the part of the Insured Person to pay such expenses, except Medicaid. u. Prescription Orders written by Physicians located outside the United States to be dispensed in the United States. v. Drugs or medications prescribed for treatment of Chemical Dependency. w Drugs, including abortifacients, or devices intended to terminate a pregnancy.

SECTION 9. EXCLUSIONS AND LIMITATIONS Benefits otherwise provided by this Policy will not be payable for services or expenses or any loss resulting from or in connection with: a. Services, supplies or treatment provided: prior to the Effective Date of coverage or after the termination date of coverage for an Insured Person; or for the portion of any Hospital or other inpatient facility admission that occurs before the Effective Date of coverage or after the termination date of coverage for an Insured Person. b. Any service or supply that is not Medically Necessary. c. Charges for treatment, services or supplies that are Experimental or Investigational in nature. d. Any expense determined by the Pool to be in excess of the Allowable Amount. e. Any penalty or fee for the failure to keep a scheduled visit with a Physician; or any charges for completion of any insurance forms or for acquisition of medical records. f. Any charge for services or supplies that are not within the scope of authorized practice of the institution or person rendering the services or supplies. g. Any charges for physical therapy, occupational therapy or speech language therapy provided by an educational institution or school district. h. Elective procedures, treatments or medications therefore, including but not limited to, abortions, sterilization reversals, sexual transformations, sexual dysfunctions, sexual inadequacies or disorders, or treatment for impotence. i. Any treatment provided by an Immediate Family Member of an Insured Person, except as provided for diabetes self-management training.

j. Any loss to which a contributing cause was the Insured Person's being engaged in an illegal occupation or activity, or commission of or attempt to commit a felony. k. War or any act of war, declared or undeclared; or participation in a riot, insurrection or rebellion. l. Injury or Sickness, regardless of cause, if such charges are incurred while serving in the armed forces or auxiliary units. Premium will be refunded on a pro rata basis for any Insured Person who enters military service; all coverage for that person will be suspended until military service is over. m. Any loss for which Worker’s Compensation or Employer’s Liability or Occupational Disease Benefits are payable. n. Cosmetic or reconstructive surgery, except as provided in the Benefits Provisions. Surgery performed to treat a mental, emotional or nervous disorder through change in appearance is excluded. o. Bariatric surgical procedures or complications related to such surgeries, even if the Insured Person has other health conditions that are related to, caused or impacted by excess weight, obesity or morbid obesity, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction. p. Aviation of any type, except for an air ambulance when Medically Necessary or as a passenger on a regularly scheduled flight on a commercial airline. q. Charges incurred outside the United States if the Insured Person traveled to the location for the purposes of receiving medical services, drugs or supplies. r. Care received in Veterans Administration Hospitals or facilities for a service-connected disability. s. Services or treatment provided in a government hospital unless there is a legal obligation to pay in the absence of insurance. This does not exclude coverage for the treatment of mental health and mental retardation provided by a tax supported institution of the state of Texas, including community centers for mental health and mental retardation services, provided charges are regularly and customarily charged to non-indigent patients and if benefits under this Policy would otherwise be provided. t. Services or treatment for which the Insured Person is not legally required to pay, except Medicaid. u. Personal items such as TV, admitting kits, cots for Immediate Family Members, guest meals and other items that are not Medically Necessary. v. Any dental services or supplies except as necessitated by Accidental Injury. Covered Expenses must be incurred within 12 months of the date of Injury. Injuries caused by chewing or biting down are excluded. w. Eyeglasses, contact lenses, hearing aids or the examination for prescription or fitting thereof, radial keratotomy or any eye surgery solely for the purpose of correcting refractive defects; treatment of myopia and other errors of refraction; orthoptics or visual training. x. Alcoholism or drug addiction. y. Any service or supply to eliminate or reduce a dependency on or addiction to tobacco or a controlled substance. z. Overdose of or Illness or Injury resulting from use of drugs, narcotics, hallucinogens, controlled or uncontrolled substances, unless administered on and according to the advice of a Physician. aa. Illness or Injury to which a contributing cause was the Insured Person’s being under the influence of or resulting from the use of intoxicants, including but not limited to, alcoholic pancreatitis, alcoholic hepatitis or alcoholic cirrhosis of the liver. bb. Any service or supply associated with an autopsy or postmortem examination unless requested by Us. cc. Private duty nursing services, except as provided in the Home Health Care benefit in the Benefits Provisions. dd. Any service or supply in connection with the diagnosis or treatment of infertility, male or female, and any form or attempt of artificial fertilization or implantation, including artificial insemination, in-vitro fertilization, and gamete intra-fallopian transfer. ee. Augmentation or reduction mammoplasty, except as provided in the Benefits Provisions, or removal of prosthetic devices, except in the case of cancer. ff. Room and board charges incurred during a Hospital admission for diagnostic or evaluation procedures unless the tests could not have been performed on an outpatient basis without adversely affecting the Insured Person's physical condition or the quality of medical care provided. gg. Charges incurred in connection with a Hospital stay or other inpatient stay primarily for environmental change, physical therapy, custodial care or rest cures. hh. Transportation, except as provided for ambulance services in the Miscellaneous Services benefit in the Benefits Provisions. ii. Any service or supply for the diagnosis or treatment of temporomandibular joint dysfunction, unless due to Accidental Injury. jj. Any service or supply received by an Insured Person as a result of or in connection with a court order, except a medical support order requiring coverage for a dependent child. kk. Any service or supply in connection with routine foot care, including the removal of warts, corns or calluses, the cutting and trimming of toenails, or foot care for flat feet, fallen arches, chronic foot strain, or symptomatic complaints of the feet in the absence of severe systemic disease; or any arch supports, orthopedic shoes or support hose, or similar type devices/appliances regardless of intended use, unless such use is for prevention of amputation in connection with treatment of diabetes. ll. Any occupational therapy services that do not consist of traditional physical therapy modalities and that are not part of an active, multi-disciplinary physical rehabilitation program designed to restore lost or impaired bodily function. mm. Any medical social services or vocational counseling. nn. Any services or supplies provided as, or in conjunction with, chelation therapy, except for treatment of acute metal poisoning. oo. Confinement or treatment in any convalescent home, sanitarium, convalescent rest or nursing facilities or facilities primarily affording custodial or educational care or facilities for the aged, except as specifically provided in the Skilled Nursing Facility benefit in the Benefits Provisions. pp. Any service or supply used for preventive care, except preventive care provided for chronic illness, cancer or HIV/AIDS or as specifically provided in the Benefits Provisions. qq. Any service or supply provided for inpatient or outpatient mental health, except as specifically provided for treatment of Serious Mental Illness in the Benefits Provisions. rr. Any service or supply provided for prescription drugs, except as specifically provided in the Benefits Provisions. ss. Nutritional counseling or food supplements, except as provided for Home Infusion Therapy or treatment of Phenylketonuria (PKU) or other heritable diseases in the Benefits Provisions. tt. Growth hormone drugs or treatments, except as provided in the Benefits Provisions. uu. Any services for transplants or replacements, except as specifically provided in the Benefits Provisions. vv. Genetic testing or counseling, except as provided in the Benefits Provisions, biofeedback, travel expenses, holistic therapies, acupuncture, hypnosis or massage therapy. ww. Any services, supplies or medications used for the primary purpose of evaluation for or diagnosis or treatment of the condition known as Idiopathic Environmental Intolerance (IEI) or Multiple Chemical Sensitivities (MCS) or Environmental Sensitivities (ES) or any other term by which these conditions may be known. xx Charges for pregnancy or maternity care, including but not limited to normal deliveries, elective caesarean sections and elective abortions, except as provided for Complications of Pregnancy.

or condition requires changes in the Insured Person’s regime; or 3) a written order of a Practitioner that periodic or episodic continuing education is warranted by the development of new techniques and treatment for diabetes.