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<br />Ronda Municipal Insurance Trust <br /> <br />Medical Master Plan of Beneflts <br /> <br />for reverse sterilization. <br /> <br />(l3) Infertility or medications prescribed to assist with fertility. <br /> <br />(14) Contraceptive devices or appliances. <br /> <br />(l5) Services, supplies or medications prescribed for the treatment of sexual <br />disorders. <br /> <br />(16) Artificial insemination or in vitro-fertilization andj or any other form of <br />artificial impregnation. <br /> <br />(17) Elective abortions. <br /> <br />(l8) Services associated with autopsy or postmortem examination, including the <br />autopsy. <br /> <br />(19) Blood and blood plasma. <br /> <br />(20) Services or supplies associated with the treatment of morbid obesity, <br />including gastric bypasses, gastric balloons, stomach stapling, jejunal <br />bypasses, jaw wiring, and services of a similar nature unless medically <br />necessary. Services and supplies associated with weight loss programs, <br />nutritional supplements, appetite suppressants, and supplies of a similar <br />nature. <br /> <br />(21) Private duty nursing by an RN or LPN whether in an inpatient hospital <br />setting or skilled nursing facility. <br /> <br />(22) Biofeedback and other forms of self-care or self-help training and any related <br />diagnostic testing, including exercise programs. <br /> <br />(23) Foot care not related to the diagnosis or treatment of a condition. <br /> <br />(24) Nicotine withdrawal programs, facilities and supplies. <br /> <br />(25) Transplants of any type except heart, heart-lung, bone marrow, cornea <br />tissue, kidney, and liver transplants. <br /> <br />(26) Services or supplies which, in the opinion of the Trust, are experimental or <br />not provided in accordance with accepted professional medical standards in <br />the United States. <br /> <br />(27) Services and supplies which, in the opinion of the Trust, are not medically <br />necessary for the diagnosis or treatment of illness, injury or bodily <br />malfunction. The fact that a physician may prescribe, order, recommend, or <br />approve a service or supply does not of itself make it medically necessary or <br />make the expense an allowable expense. <br /> <br />(28) Professional medical or surgical services rendered by an individual who is <br />related to the covered participant by blood or marriage. <br /> <br />(29) Treatment, care, services or supplies which are obtained without cost to the <br />participant. <br /> <br />(30) Service or supplies furnished to a participant or paid under any of the <br />following plans or insurance coverages: <br /> <br />(a) Any plan, 'program or insurance policy providing benefits for hospital, <br />medical andj or other health care expenses under a group master policy <br />including: but not limited to, policies issued to any health maintenance <br />organization or any entity to which such policies may legally be issued in <br /> <br />..'1"'~1l'\",p","""tt.. ~M"<V4I" +tal' ~"Ct-AI.IQ >"If q~M~"~ '7/QQ:\ <br /> <br />P"'d..., 1 <br />