55 32. Coverage for the children of your children, unless such children are otherwise determined to be your qualified eligible dependents within the meaning of Section 152 of the Internal Revenue Code and legal documentation is provided to the Fund as requ ired during the enrollment process . 33. Vitamins or nutritional supplements, except for infant formula needed for the treatment of inborn errors of metabolism, a nd vitamins as required under the ACA . 34. Massage therapy. 35. Fees associa ted with the donation of blood. 36. Cosmetics, dietary supplemen ts, and health and beauty aids. 37. Court ordered treatment or hospitalization, unless such treatment is prescribed by a physician o r an Allied Health Professional, and is listed as a covered bene fit under the term of the Plan. 38. Treatment of erectile dysfunction, except for penile implants and external devices for a medical condition under the terms of the Plan and as set forth in the SPD, and male androgens as provided under the Prescription Drug Coverage. 39. Non - medical counseling or ancillary services, including, but not limited to, custodial services, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back to school, return to work services, driving safety and training, educational therapy or other non - medical ancillary services for learning disabilities, developmental delays, autism, or mental retardation. 40. Therapy or treatment intended prim arily to improve general physical condition or for the purpose of enhancing job, school, athletic, or recreational performance, including, but not limited to, routine, long term or maintenance care which is provided after the resolution of an acute medical problem and when significant therapeutic improvement i s not expected. 41. Personal items or comfort items such as personal care kits provided on admission to the Hospital, television, telephone, complimentary meals, newborn infant photographs, birth announcem ents, or other items which are not for specific treatment of an injury or illness . 42. Artificial aids including, but not limited to, corrective orthopedic shoes, pre - fabricated arch supports, elastic stockings, garter belts, corsets, dentures, and wigs (excep t as required under the Women’s Health and Cancer Rights Act). 43. Aids or devices that assist with nonverbal communications, including, but not limited to, communication boards, prerecorded speech devices, laptop computers, desktop computers, personal digital assistants, Braille typewriters, visual alert systems for the deaf, and memory books. 44. Medical treatment where payment of claims has been denied by the primary plan because the treatment was received from a non - participating provider, or because of failure to follow the primary plan’s rules for coverage, unless the primary plan Explanation of Benefits (“EOB”) statement shows that the patient is liable for payment. 45. Telephone, e - mail, and internet consultations, and telemedicine. 46. Claims that are received mor e than one year after the date of service, unless shorter filing limits are required under an in - network provider’s contract with the Preferred Provider Organization. 47. Any services, supplies, or treatments not identified as a covered benefit under the terms of the Pl an and as set forth in the SPD.

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