EXCLUSIONS AND LIMITATIONS This Article lists services, treatments, equipment and supplies, and the benefits that are limited or excluded. NHP will not pay for services, treatment, equipment and supplies that are excluded. NHP will not pay for services, treatment, equipment and supp lies that are provided to treat a complication resulting from excluded services, treatment, equipment and supplies. NHP will pay for limited benefits only to the extent and under the circumstances described below. Some of the listed exclusions may be Medi cally Necessary, but still are not covered under this plan. Others may be examples of services that NHP determines are not Medically Necessary or not medical in nature .

IMPORTANT: NHP will use this Policy to determine if a service or supply is covered. NHP will not pay for services or supplies that this Policy does not cover. This is the case even if a Practitioner prescribes, recommends or approves the service or supply.

Covered Services, services, treatment, equipment and supplies , do NOT include: 1. A Pre-Existing Condition until a continuo us period of 12 months has elapsed from the Member ’s Effective Date. This provision does not apply to Members under the age of 19. 2. A newborn’s well baby charges including, but not limited to, hospital expenses, nurse ry charges and charges incurred for circumcision .

3. Abort ions. Any service or complication related to abortion is not covered. 4. Ac upuncture, acupressure and similar ser vices.

5. All art ificial conception procedures. This includes, but is not limited to: • Prescriptions; • Lab and diagnostic procedures; • In-vitro fertilization; • Artificial insemination; • Intrauterine insemination; • Micromanipulation procedures of sperm such as intracytoplasmic sperm injection (ICSI); • Sperm penetration and movement studies; • Sperm banking; • Advanced reproductive technologies. These include in -vitro fertilization (IVF), zygote intra -fallopian transfer (ZIFT) and gamete intra -fallopian transfer (GIFT) whose primary purpose is to achieve pregnancy; • Procedures related to fertility problems that are considered Unproven, Experimental and Investigational or for Research Purposes.

6. All artificial and anim al to human organ transplants. All organ donor services not specifically covered under Article II, Benefits Provisions section. 7. Alternative Medicine Charges including but not limited to acupuncture, holistic medicine, homeopathy, hypnosis, aroma therapy, reike therapy, herbal therapy, vitamins or dietary products, naturopathy, thermography, orthomolecular therapy, contact reflex analysis, BEST or AIT therapy, iridology, colonic irrigation, magnetic innervation therapy, electromagnetic therapy and neurofeedback.

8. Any item or supply available over the counter. 9. Any injury or Illness caused by war or to which war contributed whether or not the Member was a civilian or in active service. 10. Any injury or Illness as the result of involvement in a riot or other act or civil disobedience. 11. Any services or supplies for Bodily Injuries sustained while the Member is committing or attempting to commit a felony. Any services or supplies arising from the Member engaging in an illegal occupation or the Member’s commission or attempted commission on an assault or other illegal act if the Member is convicted of a crime on account of such illegal assault or other act. 12. Any supplies or services furnished for the protection or convenience of or to meet a requirement of third parties. This includes medical, physical, mental health conditions or substance use disorders or examinations. Third parties include, but are not limited to, attorneys, school systems, employers and insurers or court ordered commitments, except as outlined under Benefit Provisions- Preventive Visits. This also includes sex offender treatment programs and a screening interview or treatment program related to driving under the influence of alcohol or drugs. Mandated AA and NA meetings along with anger management. NHP does cover health services mandated by a court as a stipulation of parole, probation, sentencing or any other reason, if Medically Necessary. NHP does provide coverage if mandated pursuant to Wis. Stat. 609.65 wherein an enrollee is examined, evaluated or treated for a nervous or mental disorder pursuant to an emergency detention, commitment or court order. 13. Any service or expense you incur (a) before your effective date of coverage, (b) after the date your coverage under this Policy terminates or (c) after you are disenrolled from NHP. If a Member is an Inpatient on the Effective Date of Coverage, no benefits are available until the Member is discharged from the Hospital. 14. Any service provided in a school system. 15. Any treatment that is not Medically Necessary and appropriate. This applies to any procedure, service, device, supply or drug. It also applies to durable medical equipment, prosthetic devices and technology. 16. Any treatment that is not medical in nature or that is solely for the purpose of athletic performance and/or participation including rehabilitative services for injuries sustained while competing in a professional athletic contest.. This applies to any procedure, service, device, supply or drug. It also applies to durable medical equipment, prosthetic devices and technology. 17. Any treatment that is provided mainly for the Member’s vocation, comfort, convenience, exercise, physical fitness or recreation. Any treatment that is provided mainly as an adaptation of the Member’s environment or that is a common household item. This applies to any procedure, service, device, supply or drug. It also applies to durable medical equipment, splints or braces, prosthetic devices and technology. 18. Any treatment that is habilitative in nature. This applies to any procedure, service, device, supply or drug. It also applies to durable medical equipment, prosthetic devices and technology. 19. Any treatment that is provided in the absence of a Bodily Injury or Illness. This applies to any procedure, service, device, supply or drug. It also applies to durable medical equipment, prosthetic devices and technology. 20. Any treatment furnished or ordered for a Member by a Family Member or any person residing with the insured including treatment furnished or ordered by the Member. This includes prescriptions, services or supplies. Family Members include your lawful spouse, child, parent, grandparent, brother, sister or any person related in the same way to your covered Dependent. 21. Any treatment that is used for hair analysis, hair loss, hair growth or any form of alopecia. This includes, but is not limited to hair replacements, wigs, toupees and hair replacement therapies. This applies to any procedure, service, device, supply or drug. It also applies to durable medical equipment, prosthetic devices and technology. 22. Any type of holistic or homeopathic treatment. 23. Attempt of suicide or an intentionally self-inflicted a Bodily injury or Illness while sane or insane. 24. Augmentive and alternative communication aids, such as talk boards. NHP does not cover the fitting of such items. This does not apply to treatment specifically outlined in Article II ~ Benefit Provision Section of this Policy. 25. Autism services not covered include: Acupuncture, Respite care, Custodial Care, Care provided in a residential treatment facility, inpatient treatment, or day treatment facility, Chelation therapy, Child care fees, Cranial sacral therapy, Hyperbaric Oxygen Therapy, Special diets or supplements, Auditory integration training, Facility or location or the use of a facility or location when treatment, therapy or services are provided outside of a Member’s home, Animal-based therapy including hippotherapy, and services rendered by any Practitioner who is not qualified to provide intensive-level services or non-intensive level services. 26. Autopsy and any other post-mortem service. 27. Batteries, unless specifically outlined in Article II ~ Benefit Provision Section of this Policy. 28. Behavioral training. 29. Blood storage unless in conjunction with a scheduled surgery and NHP gives prior approval; 30. Blood products that are replaced by donation. 31. Care received in an emergency room if used for non-emergency care such as suture removal. 32. Complications resulting from a Member leaving a hospital or other facility or discontinuing treatment against a practitioner’s written orders. 33. The cost of missed appointments. 34. The cost of release and review of medical records, including copy costs, except when requested by NHP. 35. The cost of Chelation treatment. 36. The cost of communications, lodging and transport or travel time. The cost of ambulance service, as outlined in Article II, Benefit Provisions Section of this Policy, is not excluded. 37. Cost of a standby practitioner, unless the service is Medically Necessary. 38. Cryopreservation of body fluids or tissues.

39. Custodial Care. 40. Dental care or treatment. This applies to periodontic care, dentures, mouth guards, osteotomy, teeth whitening and bleaching. However, coverage will be provided for certain dental procedures resulting from injury, including but not limited to: treatment for a chewing injury, dental appliances, and/or supplies. This exclusion does not apply to treatment specifically outlined in Article II, Benefit Provision Section of this Policy. 41. Dental implants. This does not apply to treatment specifically outlined in Article II, Benefit Provisions Section of this Policy. 42. Diagnostic admissions. 43. Eating Disorders including but not limited to anorexia nervosa or bulimia. 44. Enteral nutrition including nutritional supplements, vitamins, minerals; special infant formulas; special meals or food, except when the Member is confined as an Inpatient.

45. Experimental or Investigative Procedures. Medical or surgical procedures that are not Medically Necessary or that are considered Unproven, Experimental, Investigational or for Research Purposes. This applies to complications from such procedures. NHP’s Medical Director will make such determinations. NHP will base its decisions on generally accepted standards of the U.S. medical community. 46. Genetic Testing including Amniocentesis, chorionic villi sampling done solely for sex determination or not Medically Necessary. 47. Glasses or contact lenses. This includes measurement, fitting and adjustment. 48. Growth Hormone Therapy. 49. Hazardous Activities. No coverage will be provided for a bodily injury resulting from participation in parachuting, hang gliding, motorcycle riding, boating or auto racing. 50. Health club memberships, costs of fitness programs, exercise programs and equipment. 51. Health services provided by Non-Participating Providers and Non-Participating Practitioners. This does not apply to: • Services provided with NHP’s Authorization; • Emergency care provided in an emergency room or Hospital-based Urgent Care Facility when, due to the Member’s location when care became necessary, a Participating Provider or Practitioner could not practically furnish the care; • Urgent Care provided in an emergency room or Hospital-based Urgent Care Facility outside NHP’s Service Area. 52. Health services for disabilities or conditions resulting from military service, including participation in the National Guard and Civilian auxiliary forces. This applies only if the Member is legally entitled to services provided by a government agency. Government facilities must be reasonably available to the Member. NHP will determine whether services are reasonably available. This exclusion may be limited by Federal law. 53. Health services for job, employment or work related Bodily Injuries or Illnesses that occur during or result from the course of a Member’s occupation or employment are excluded if: a. Workers’ Compensation is in effect, even when a claim is not filed with the Workers’ Compensation plan; b. by applicable law, Workers’ Compensation is required to be in effect, and it is not in effect; or c. an expense is denied, in whole or in part, by Workers’ Compensation for any reason. For purposes of this item, Workers’ Compensation includes any similar type of coverage provided by, required under, permitted as a substitute for, or is in addition to Workers’ Compensation, under any applicable act or law 54. Hearing aids cords. 55. Home births and all related services. 56. Hospital admissions are excluded unless anticipated surgery is performed the day of admission or by noon on the following day. 57. Human Chorionic Gonadotropin injections. 58. Hypnosis therapy. 59. Immunizations and health services including physical examinations for travel, marriage, licensing, employment, recreation and insurance purposes. 60. Infertility services, supplies, and prescriptions which are not for treatment of illness or injury (i.e. that are for the purpose of achieving pregnancy). The diagnosis of infertility alone does not constitute an illness. 61. Inpatient Hospital services that NHP or its designee does not certify as being Medically Necessary and appropriate care including hospitalizations that could appropriately be in a less acute setting. 62. Kidney disease services for which Medicare provides reimbursement. 63. Lyme disease vaccine. 64. Maintenance Therapy of any kind. This includes, but is not limited to, cardiac rehabilitation, chiropractic, physical, speech and occupational therapy for the purpose of maintenance. 65. Marriage counseling. 66. Massage therapy. 67. Member cost sharing. This applies to the amount of any Deductible, Co-Payments or Co- Insurance. Cost sharing amounts are shown in the Summary of Member Responsibility Table and in any Rider attached to this COC. 68. Mental Health Conditions including mental health residential treatment 69. Methadone Maintenance Treatment for Opiate Dependence. 70. Models, equipment or devices that have features over and above those that are Medically Necessary for the Member. 71. Motor vehicles or customizing of vehicles. This includes, but is not limited to, lifts for wheelchairs, scooters and stair lifts. 72. Neuropsychological testing for Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder 73. Oral surgery. This includes: • Jaw adjustments to correct malocclusion; • Surgical removal of impacted or infected teeth and surgical or non-surgical removal of third molars; • Surgical removal of teeth due to anomalies of tooth position of fully erupted teeth; • Alveolectomy or alveoplasty; • Apicoectomy (excision of apex of tooth root); • Treatment of periodontitis and gingivitis; • Orthognathic surgery; • Osteotomy surgery; and • Reconstructive orthognathic surgery. 74. Orthodontic services and surgery except for the treatment of TMD as specifically outlined in Article II –Benefits provision section of this Policy. 75. Out of area services, the need for which could have been foreseen or predicted. 76. Prayer or spiritual healing including pastoral and spiritual counseling. 77. Pregnancy Services. 78. Prescription and other drugs. This exclusion also applies to all over the counter medications. This applies to take home drugs dispensed on Hospital discharge. This does not apply to drugs a Member receives while an inpatient or as part of an authorized Home Health Care program. 79. Private duty nursing. 80. Private room charges. 81. Repairs or replacements of DME, orthotics, prosthetics or prescription drugs due to Accidental loss, theft or negligent misuse. 82. Reversal of voluntarily induced Infertility or any related services or complications. 83. Routine foot care. This includes, but is not limited to, trimming corns and calluses, hypertrophy or hyperplasia of the skin and subcutaneous tissue of the feet and nails. This also includes other hygienic and preventive maintenance care such as cleaning and soaking the foot, use of skin creams to maintain patient’s skin tone, and any other service performed in the absence of localized Illness, injury, or symptoms involving the foot. NHP does cover services for a metabolic or peripheral disease or if skin or tissue is infected. 84. Sclerotherapy for veins of the extremities.

85. Services and supplies for which no charge is made or for which you would not be required to pay if you did not have this coverage. 86. Services for teeth cracked or broken due to biting or chewing. 87. Services provided outside the United States. 88. Services solely to improve the Member’s appearance. NHP will not pay for services that are not for the correction of a functional defect caused by a Bodily Injury or Illness provided care is not received. This includes Reconstructive, plastic, or Cosmetic Surgery. This includes breast augmentation, breast reduction and liposuction. Psychological impact is not a functional defect caused by a Bodily Injury or Illness. Coverage is available for reconstructive care following a mastectomy surgery. Coverage is available for correction of a functional defect caused by Bodily Injury if care is provided within 12 months of the Bodily Injury. Coverage is included for treatment of congenital abnormality if treatment is provided up to an including age 18. 89. Sex change treatments and procedures. This includes but is not limited to services and supplies related to gender identification disorders. 90. Shoe inserts, unless custom made and Medically Necessary. 91. Sterilizations. This includes, but is not limited to, tubal ligations and vasectomies. 92. Sublingual (under the tongue) allergy testing and treatment. 93. Surgical and non-surgical treatment of the jaw joint. This applies to craniomaxillary, craniomandibular disorder or other conditions of the joint linking the jaw bone and skull. However, NHP will cover such treatment if the condition is a consequence of neoplasms, arthritis, ankylosing spondylitis or disseminated lupus erythematous; or if the condition is a consequence of acute dislocation and fractures occurring less than one (1) year before treatment begins. NHP also covers treatment for Temporomandibular Disorder (TMD). 94. Surgery to correct vision. This includes, but is not limited to: • Radial Keratotomy (RK); • Astigmatic Keratotomy (AK); • Automated Lamellar Keratoplasty (ALK); • Excimer Laser; • Photorefractive Keratotomy (PRK); • Phototherapeutic Keratotomy (PTK); • Laser assisted Insitu Keratomileusis (LASIK); • Corneal modulation; • Refraction Keratoplasty and • Orthoptic pleoptic training aids. 95. Taxes 96. Telephone consultations. 97. Therapy, treatment or services for Developmental or Learning Disability or Delay. 98. Treatment for obesity or weight reduction, even if morbid obesity is present. Treatment NHP does not cover includes, but is not limited to, weight loss or weight management programs including drugs, liposuction, abdominoplasty, balloon atherterization, any form of reconstructive surgery, ileal bypass, gastric bypass or stapling and complications from such procedures, regardless of secondary benefits resulting from weight loss. 99. Treatment of sexual or erectile dysfunction (including impotence). This includes any procedure, service, supply, drug, device or technology used to treat these conditions. 100. Treatment and/or services related to a non-covered benefit, including complications or side effects of a non-covered benefit. 101. Treatment for addiction, including but not limited to gambling addiction, sexual addiction, hoarding, shopping and spending addictions. 102. Treatment provided for or related to education, vocational rehabilitation, self help or work hardening services. This applies to any such testing, services, supplies or procedures. 103. Treatment and services for Rett’s Disorder and sensory integration or defensiveness. 104. Treatment or services furnished and/or billed by an adult or child daycare organization. 105. Treatment or services which are not furnished or supplied by a Provider under the direction of a Practitioner. 106. Treatment that does not satisfy the Policy definition of a Covered Service as specifically outlined in Article II – Benefits Provision section of this Policy. 107. Treatment that is not rendered within the scope of the practitioner’s or provider’s certificate, license, or authority. 108. Treatment that is paid for by a government plan, program, hospital or other facility, unless by law NHP must pay . 109. Treatment, diagnosis or care provided over the internet, telemedicine or telehealth services.

110. Treatment of sleep disorders. 111. Treatment of Bodily injuries or Illnesses resulting from illegal drug use or the improper use of prescribed or non-prescribed medications. 112. Treatment of Substance Abuse Disorders 113. Treatment rendered to inmates. Covered services do not include services and supplies while in custody of any local, state or federal law enforcement authority, while in jail or prison or on work release. 114. Vision therapy including eye exercises. The following health care services are not covered by the Point of Service Plan: 1) Services described in the “Benefit Provisions” section of the Policy under Hearing Acuity Testing as listed under Provider and Practitioner Services and Preventive Visits if provided by Non-Participating Providers. 2) Services not provided in full compliance with the “Obtaining Health Services” section of this Policy. The term Primary Care Practitioner shall mean “treating Practitioner.” 3) Services or supplies not ordered by an authorized Provider or Practitioner except as specifically stated as applicable to the Point of Service Plan. 4) With the exception of kidney disease services, out of network services related to all organ and tissue transplants and immunosuppressive drugs; all artificial organ implants; all animal to human organ transplants; and all organ donor services. 5) Expenses or charges in excess of the Usual, Customary, and Reasonable charge. 6) Services obtained without Prior Authorization as described in Article III Obtaining Health Services. The following limitations apply to the Point of Service Plan: 1. A maximum of (60) sixty days per benefit period in a Skilled Nursing Facility in total shall be covered, whether in a Participating or Non-Participating facility, per Member per admission.

2. A maximum of (40) forty Home Health Care visits in total shall be covered, whether for a Participating or Non-Participating facility, per Member in any 12-month period.