I:\Legal\LEGAL\ST PATRICK HOSPITAL-Medical\Plan Document ...

Medical Benefits15. Charges for drugs requiring the written prescription of a Physician or a Licensed Health CareProvider and Medically Necessary for the treatment of an Illness or Injury. Coverage also includesprescription contraceptive drugs not available through the Pharmacy Benefit regardless of MedicalNecessity.Conditions of coverage for outpatient prescription drugs and supplies available throughthe Pharmacy Benefit are as stated in the Pharmacy Benefit section of the Plan.16. Charges for x-rays, CAT scans, MRIs, microscopic tests, and laboratory tests.17. Charges for Allergy testing.18. Charges for radiation therapy or treatment and chemotherapy.19. Charges for blood transfusions, blood processing costs, blood transport charges, blood handlingcharges, administration charges, and the cost of blood, plasma and blood derivatives. Any creditallowable for replacement of blood plasma by donor or blood insurance will be deducted from thetotal Maximum Eligible Expense or Procedure Based Limit.20. Charges for oxygen and other gases and their administration.21. Charges for electrocardiograms, electroencephalograms, pneumoencephalograms, basalmetabolism tests, or similar well-established diagnostic tests generally accepted by Physiciansthroughout the United States.22. Charges for the cost and administration of an anesthetic.23. Charges by a Physician or Licensed Health Care Provider for dressings, sutures, casts, splints,trusses, crutches, braces, adhesive tape, bandages, antiseptics or other Medically Necessarymedical supplies, jobst garmet, limited to 2 per Benefit Period, except for dental braces, which arespecifically excluded.24. Charges for adhesive tape, bandages, antiseptics or other over-the-counter first aid suppliesexcept only upon prior approval of the Plan. Approval will be based on guidelines of costeffectiveness and Medically Necessary treatment of an Illness or Injury as determined bythe Plan Administrator.25. Charges for the Durable Medical Equipment, Orthopedic Devices, or Prosthetic Appliances asfollows:A. Rental of, up to the purchase price of, a wheelchair, Hospital bed, respirator or otherDurable Medical Equipment required for therapeutic use, or the purchase of thisequipment if economically justified, whichever is less. For Durable Medical Equipment forwhich purchase is not medically feasible, rental charges will be paid without limitationbased upon purchase price.B. Purchase of Orthopedic Devices or Prosthetic Appliances, including but not limited toartificial limbs, eyes, larynx.C. Replacement or repair of Durable Medical Equipment, Orthopedic Devices, ProstheticAppliances.Western Montana Providence Health & Services - SPD 22Group #2000204 - January 1, 2011