SSMC Employee Health Benefit Plan
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meet the CMS coverage criteria in effect at the time expenses are Incurred. Exclusion includes all related
services, including but not limited to medical services, drugs, high dose chemotherapy or radiation therapy
or any other treatment that is integral to the Exper imental care.
7. Organ Donors. Expenses Incurred by organ donors are not Covered. However, donor expenses for
covered transplants will be considered Incurred by the transplant recipient (who is a Covered Person) when
the expenses are not covered by the donor's health coverage.
8. Drugs /Vitamins/Supplements. Medicines or drugs obtainable without a prescription or over the counter
drugs, whether or not ordered by a Physician; vitamins or nutritional supplements whether or not obtainable
only by prescription; drugs and medicines that are not Medically Necessary, according to Plan provisions.
Exception: Prescription birth control or contraceptive drugs specifically included in the Plan.
9. Home Medical Supplies. Medical Supplies for home use that are not directly supplied by professional
home care services during an approved Home Health Care Plan or Hospice Care Plan , or that are not for
the operation of covered Durable Medical Equipment unless the Supplies are otherwise specifically
included for coverage. Items primarily intended for comfort or to support activities of daily living, such as
diapers, ice bags, heating pads, incontinent pants, support stockings, nutritional supplements, cervical or
lumbar pillows are not covered.
10. Personal Items. Personal comfort items such as telephone, radio, television or hair stylist or barber
services charged by any facility or other Provider.
11. Durable Medical Equipment/Braces/Prosthetics/Devices. Services or Supplies related to duplicate
medical equipment, braces, Prosthetics or other devices; or the replacement of Durable Medical Equipment,
braces, Prosthetics or other devices due to loss, theft or destruction. The purchase of Durable Medical
Equipment that can be rented unless the length of time the equipment will be needed makes the purchase
less costly than the rental. The purchase or replacement of any biomechanical Prosthetic device.
Specialized equipment when standard equipment is adequate for the patient's condition. Services or
Supplies related to durable equipment, braces, Orthotics or splints used primarily for athletic use. Personal,
household, or environmental items including, but not limited to, air conditioners, air-purification units,
communication devices, computers, hot tubs, swimming pools, any type pillows, blankets or mattress
covers, orthopedic mattresses, exercise equipment, elevators and stair lifts, blood pressure monitors,
thermometers, stethoscopes, scales, elastic bandages or stockings, clothing, first-aid Supplies, non-Hospital
adjustable beds, special equipped vehicles will not be covered.
12. Vision. Services or Supplies related to orthoptic or vision therapy, eye exercises, visual aids, eyeglasses or
contact lenses, or their repairs, and related examinations to decide the need for, adjustments or repair of
them. Treatment or Surgery for the correction of a refraction error, including but not limited to radial
keratotomy. Exception: Plan includes coverage for lenses for aphakia and soft lenses or sclera shells
intended for treatment of Illness or Injury and initial contacts following cataract or other intra-ocular
Surgery and the initial pair of glasses due to Accidental Injury or disease of the eye Incurred while a
Covered Person under the Plan.
13. Hearing. Services or Supplies related to hearing aids, tinnitus masking devices, (or similar devices),
communication devices, and examinations to decide the need for, adjustments or repair of them.
Exception: Expenses related to an initial hearing aid for hearing loss that occurred while covered under the
Plan and was caused by an Accidental Injury, covered surgical procedure or disease.
