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

Medical Benefit Exclusions10. Charges in connection with eye refractions, the purchase or fitting of eyeglasses or contactlenses. This exclusion will not apply to the initial purchase of eyeglasses or contact lensesfollowing cataract surgery or intraocular surgery.11. Charges in connection hearing aids, or such similar aid devices.12. Charges for dental treatment on or to the teeth, the nerves or roots of the teeth, gingival tissue oralveolar processes, except as a result of an Accidental Injury and specifically listed as a coveredbenefit. This exception will not in any event be deemed to include charges for treatment for therepair or replacement of a denture.13. Charges related to or in connection with fertility studies, sterility studies, procedures to restore orenhance fertility, artificial insemination, or in-vitro fertilization, or any other assisted reproductivetechnique.14. Charges for marital counseling, family counseling, recreational counseling or milieu therapy.15. Group therapy, except for the treatment of Alcoholism and/or Chemical Dependency.16. Charges in connection with services or supplies provided for the treatment of obesity and weightreduction, except as specifically covered under the Bariatric Surgery Benefit.17. Charges for alternative care which are not related to an actual Illness or Injury or which exceedthe maximum benefit as stated in the Schedule of Medical Benefits.18. Charges for holistic medical procedures, massage therapy or rolfing.19. Hair transplant procedures, wigs and artificial hairpieces, or drugs which are prescribed topromote hair growth.20. Charges for any services, care or treatment for sexual dysfunction, trans-sexualism, genderdysphoria or sexual reassignment including related drugs, medications, surgery, medical orPsychiatric Care or treatment.21. Charges for any surgical, medical or Hospital services and/or supplies rendered in connection withradial keratotomy, LASIK or any other procedure designed to correct farsightedness,nearsightedness or astigmatism.22. Charges related to Custodial Care.23. Charges for artificial organ implant procedures.24. Charges for non-prescription contraceptives supplies or devices, or the removal of contraceptivedevices, unless Medically Necessary.25. Charges for services of a direct-entry midwife or lay midwife or the practice of direct-entrymidwifery. A Direct-entry midwife is one practicing midwifery and licensed pursuant to M.C.A. 37-27-101 et seq.“Direct-entry midwife” means a person who advises, attends, or assists a woman duringpregnancy, labor, natural childbirth, or the postpartum period and who is not a licensed CertifiedNurse Midwife.26. Home and water births.27. Charges for services provided under a court order or as a condition of parole or probation.28. Charges for any sterilization or reversal of sterilization procedure.Western Montana Providence Health & Services - SPD 36Group #2000204 - January 1, 2011