Only charges which are covered by this Plan and are incurred by a Covered Person while covered under this Plan may be considered Eligible Charges. A charge is considered to be incurred on the date a service is performed or a purchase is made. Eligible Charges are the actual charges (but not more than the reasonable charges) incurred for an Illness or Injury for one or more of the following:

1. Room and Board and routine nursing services for each day of confinement in a Hospital or Free-Standing Chemical Dependency Treatment Center (see your Schedule of Benefits to determine if your Plan has coverage for Chemical Dependency). The Newborns' and Mothers' Health Protection Act of 1996 (NMHPA) provides that group health plans generally may not, under federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than forty-eight (48) hours following a normal vaginal delivery, or less than ninety-six (96) hours following a cesarean section, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods. Coverage for days beyond this will be based on Medical Necessity.
2. Intensive or Cardiac Care Room and Board if Medically Necessary.
3. Medical services and supplies furnished by a Hospital.
4. Anesthetics and their use.
5. Fees of licensed Physicians for medical Treatment including, but not limited to, fees for surgical procedures. This also includes fees of a Registered Nurse Practitioner (R.N.P.) for medical Treatment which is within the lawful scope of his/her license.
6. Services of an assistant surgeon, when Medically Necessary, will be covered up to 20% of the Usual and Customary allowance for the primary surgeon for the procedure involved. Assistant surgeon must be a licensed Physician who actively assists the operating surgeon in the performance of surgical services.
7. Services of a Registered Nurse (R.N.), or Licensed Practical Nurse (L.P.N.) for Skilled Nursing. Benefits will not be paid to a relative (by blood, marriage, or legal adoption).
8. Services of a licensed physical therapist. (Prior to therapy, we must have a letter or physical therapy order from a Medical Doctor stating medical necessity, diagnosis, treatment plan, expected duration of treatment, and prognosis.)
9. X-rays (other than dental), laboratory tests, and other diagnostic services which:
(a) are performed as a result of definite symptoms of an Illness or Injury; or
(b) reveal the need for medical Treatment.
10. X-ray and radiation therapy.
11. The transport of a Covered Person:
(a) within the United States and Canada;
(b) by means of a professional ambulance service (air ambulance when ordered by Physician for medical purposes);
(c) to, but not returning from, a Hospital or Sanitarium; and
(d) to the nearest available adequate Hospital. Subsequent transport by Medical Necessity only.
12. Medical supplies as follows:
(a) drugs and medicines (you must use your prescription card if your Plan has a prescription card provision or you will not receive a prescription benefit once a Covered Person has been on the Plan for thirty (30) days. Exceptions may be made for eligible prescriptions which are not covered by your prescription card as determined by individual review. If this Plan is secondary for a Covered Person, you must submit your prescription to Phillips Administrative Service, Inc., for reimbursement of your Co-pay) which: (i) are approved by the Food and Drug Administration;
(ii) legally require the written prescription of a Physician for dispensing;
(iii) must be dispensed by a licensed Pharmacist or Physician; (b) blood or other fluids;
(c) artificial limbs, eyes, and breasts. With preauthorization, approved routine maintenance, repair, and adjustment of prosthetic devices covered no more than one (1) time in any twelve (12)-month period. Replacement, with preauthorization, one (1) every five (5) years with written documentation from Physician showing need for replacement. Coverage limited to the cost of the most efficient and economical service which can safely be provided to the patient as determined by the Third Party Administrators' Physician reviewers. Exceptions to the five (5) year requirement may be made for replacements which are Medically Necessary for children who are growing; or, to accommodate tissue changes for which the maximum adjustments have been made;
(d) prosthetic breasts. Initial prothesis with replacement covered once every twenty-four (24) months. Two (2) prosthetic bras will be covered in the first (1^st) twelve (12) months, with coverage for one (1) prosthetic bra every twelve (12) months thereafter.
(e) contact lenses or lenses for standard glasses only if required promptly after, and because of, cataract surgery;
(f) casts, splints, trusses, braces, crutches, and surgical dressings;
(g) rental of, or purchase of, if more cost effective by review of clinical information by Third Party Administrator Hospital-type equipment including, but not limited to, wheelchair, Hospital bed, iron lung, and oxygen equipment (ownership may be retained by the Company);
(h) non-prescription diabetic and colostomy supplies. You must use your prescription card provision or you will not receive a benefit once a Covered Person has been on the Plan for thirty (30) days. If this Plan is secondary for a Covered Person, you must submit your prescription to Phillips Administrative Service, Inc., for reimbursement of your Co-pay;
(i) vitamins and minerals that relate directly to the treatment of an eligible Illness or Injury, that legally require the written Prescription of a Physician for dispensing, and must be dispensed by a licensed Pharmacist or Physician. You must use your prescription card provision or you will not receive a prescription benefit once a Covered Person has been on the Plan for thirty (30) days. Exceptions may be made for eligible prescriptions not covered by your prescription card as determined by individual review. If this Plan is secondary for a Covered Person, you must submit your prescription to Phillips Administrative Service, Inc., for reimbursement of your Co-pay; and
(j) Medically Necessary vitamin or mineral injections done in a Physician's office or Hospital. Each case will be individually reviewed for eligibility.
13. Charges for services performed in an Outpatient Surgical Center.
14. Acupuncture is covered only if referred by a Medical Doctor, if covered by your Plan (see your Schedule of Benefits to determine if your Plan has coverage for acupuncture). Must be performed by a Medical Doctor or a certified licensed acupuncturist. (If other than an M.D., we must have a copy of the provider's state license.)
15. Room and Board charges for each day of confinement in a Skilled Nursing Facility if the confinement:
(a) follows a Hospital confinement for which at least three (3) straight days of Hospital Room and Board charges were included as Eligible Charges under the Plan;
(b) begins within fourteen (14) days after the Covered Person is released from such Hospital confinement;
(c) is for treatment of the same Illness or Injury which resulted in such Hospital confinement; and
(d) is one during which a Physician is present and consults with the Covered Person at least once every seven (7) days.
Room and Board charges means charges made by a Skilled Nursing Facility for the cost of room, meals, and services (such as general nursing services) provided to all inpatients on a routine basis. No payment will be made for Skilled Nursing Facility confinement: (i) for charges which are excluded from Coverage by the terms of this Plan;
(ii) to the extent that the charges are paid under any other terms of this Plan;
(iii) for charges for any days of such confinement after the one hundred twentieth (120^th) day;
(iv) for charges incurred in connection with drug addiction, chronic brain syndrome, alcoholism, mental retardation, senility, or any mental disorder.

16. Services of a licensed speech therapist only for the restoration of speech when speech loss is due to:
(a) cerebral vascular accident (stroke);
(b) cerebral tumor;
(c) laryngectomy;
(d) congenital as determined by clinical notes and medical evidence;
(e) a result of accidental Injury. (Therapy must be incurred while you are covered on this Plan); or
(f) other medical reasons as determined by individual review.
17. Voluntary sterilization, if covered by your Plan. (See your Schedule of Benefits to determine if your Plan has coverage for voluntary sterilization.)
18. Routine Newborn Care for a newborn child, who is a Covered Person at the time of birth. Routine Newborn Care includes:
(a) Hospital charges for Room and Board, services and supplies, but only while mother is confined for delivery, and in-hospital Physician charges; and
(b) charges related to circumcision.
The Newborns= and Mothers= Health Protection Act of 1996 (NMHPA) provides that coverage for a Hospital stay following a normal vaginal delivery may generally not be limited to less than forty-eight (48) hours for both the mother and newborn child. Coverage for a Hospital stay following a cesarean section may generally not be limited to less than ninety-six (96) hours for both the mother and newborn child. Coverage for any days beyond this will be based on Medical Necessity.
19. Hospice care for a Covered Person who is a Aterminally ill patient.@ A Aterminally ill patient@ is someone who has a life expectancy of six (6) months or less as certified in writing by the Physician who is in charge of the patient=s care and treatment. Hospice services must be furnished in your home by a Hospice care team through a Home Health Agency or Hospice, or on an inpatient basis in a free-standing Hospice facility, Hospital-based Hospice, extended care Hospice facility, or nursing home Hospice. Eligible Hospice care expenses for a Covered Person will be limited to the following:
(a) Skilled Nursing Care, physical or occupational therapy or speech services, drugs and medications, durable medical equipment, counseling, and other supportive services and supplies provided to meet the physical, psychological, spiritual, and social needs of the dying;
(b) short-term inpatient care, including respite care and care for pain control, and acute and chronic symptom management;
(c) instruction for care of the terminally ill, counseling, and other supportive services for the individual=s family.

No payment will be made for: (i) services performed by volunteers, family members, or persons who do not regularly charge for their services;
(ii) homemaker or housekeeping services, except by home health aides as ordered by a Hospice treatment plan;
(iii) legal or financial counseling services.
20. We will pay up to $125.00, but not more than the purchase price, toward the purchase of a wig when necessary for a Covered Person who is undergoing radiation therapy or chemotherapy for a covered medical condition. We must have a written request from your Physician, along with proof of purchase. This benefit has a lifetime limit of one (1) wig per Covered Person.
21. Home Health Care provided by a Home Health Care Provider for medical care if:
(a) the Covered Person requires on an intermittent basis, nursing services, therapy, or other services provided by a Home Health Care Provider;
(b) the Covered Person is Totally Disabled and is essentially confined to the home;
(c) the Covered Person would otherwise have been confined as an Inpatient in a Hospital or a Skilled Nursing Facility;
(d) the Covered Person is examined by the attending Physician at least once every sixty (60) days; and
(e) the plan of treatment including Home Health Care is: (i) established in writing by the attending Physician prior to the commencement of such treatment;
(ii) certified by the attending Physician at least once every month. Eligible Home Health Care services will not include: (a) custodial care;
(b) meals or nutritional services;
(c) housekeeper services;
(d) services or supplies not specified in the Home Health Care plan;
(e) services of a relative of the Covered Person;
(f) services of any social worker;
(g) transportation services;
(h) care for tuberculosis or Chemical Dependency;
(i) care for the deaf or blind;
(j) care for senility, mental handicaps, or those who have mental disorders.
22. Birthing Centers.
23. Generic Drugs.
24. Voluntary abortions, if covered by your Plan (see your Schedule of Benefits to determine if your Plan has coverage for voluntary abortions).
25. Annual Routine Exams as provided by your Plan (see your Schedule of Benefits for your Plan=s coverage).
26. Routine Mammogram tests at such time as ordered by Physician.
27. Well-child care including vaccinations and immunizations as provided by your Plan (see your Schedule of Benefits for your Plan=s coverage).
28. Employee or Dependent pregnancy covered as any other Illness. (Dependents must meet definition described herein). (See your Schedule of Benefits for any exceptions.)
29. Amniocentesis or Chorionic Villa Sampling covered when done for medical reasons or when due to the mother=s age, if she will be thirty-five (35) or older at the expected delivery date.
30. Outpatient Diabetic Instruction allows coverage for services and supplies used in outpatient diabetes self-management programs for a Covered Person when they are provided by a health care professional for the treatment of diabetes. This benefit will cover charges for one (1) diabetic instruction program up to a lifetime maximum payment of $120.00.
31. Any reasonable, sound, generally recognized medical procedure, not specifically excluded, which is provided by a licensed provider who is acting within the scope of his/her license, may be considered an Eligible Charge.
32. Removal of impacted teeth (including x-rays and examination).
33. Bone Marrow Transplants for diagnoses which are routinely treated with bone marrow transplants, that are not experimental or investigational, and are Medically Necessary. Eligible bone marrow transplants will include coverage for Medically Necessary services and supplies rendered in connection with a transplant, including pretransplant procedures such as donor costs for bone marrow harvesting, post-operative care, and transplant-related chemotherapy. Donor costs include all costs incurred in connection with medical services required to remove the bone marrow from the donor's body, preserving the bone marrow and transporting the bone marrow to the site where the transplant is being performed. Denial by donor's coverage must be documented. Documentation is the responsibility of the patient. No payment will be made for the search for the bone marrow. No Treatment will be covered for bone marrow transplants which are considered experimental for the expressed diagnosis. If the donor is covered under this Plan and the recipient is not, this Plan will not pay any benefits toward the donor costs. (See your Schedule of Benefits to determine if your Plan's coverage for Bone Marrow Transplants is different. If different, coverage is based on the information in your Schedule of Benefits.)
34. This Plan also includes coverage for surcharges required by Massachusetts General Laws (MGL), Chapter 18G, Section 18A as inserted by Chapter 47 of the Acts of 1997, or as later amended, and surcharges required according to the New York Health Care Reform Act of 1996 (NYHRCA), or as later amended.

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