 Replacement of lost, broken, or damaged lenses or frames.  Two pairs of glasses in lieu of bifocals. BENEFIT EXCLUSIONS AND LIMITATIONS In addition to any exclusions listed in “Benefit Details,” this Plan does not cover the following:  Services not provided by a Participating Provider or obtained in accordance with Kaiser’s standard referral and authorization requirements, except for Emergency Services and Urgent Care or as covered under coordination of benefits provisions.  Services provided by Non-Participating Providers are not covered inside or outside of the Service Area except for: Emergency Services and Urgent Care; as specifically provided in the Out-of-Area coverage section; or when otherwise specifically provided.  Experimental or investigational Services, supplies, and drugs. This exclusion does not apply to Services that are covered under “Services Provided in Connection with Clinical Trials” in the “Benefit Details” section of this EOC.  Certain Exams and Services. Physical examinations and other Services are excluded when: (a) required for obtaining or maintaining employment or participation in employee programs, (b) required for insurance or governmental licensing, (c) court ordered or required for parole or probation, or (d) received while incarcerated.  Services for which no charge is made, or for which a charge would not have been made if the Member had no health care coverage or for which the Member is not liable; Services provided by a family member.  Drugs and medicines not prescribed by a PCP, Participating Provider, or any licensed dentist, except for Emergency Services and Urgent Care.  Cosmetic Services. Services that are intended primarily to change or maintain your appearance and will not result in significant improvement in physical function. This exclusion does not apply to Services that are covered under “Reconstructive surgery Services” and “Transgender surgical Services” in the “Benefit Details” section or Medically Necessary Gender Affirming Treatment.  Custodial Care. Assistance with activities of daily living (for example, walking, getting in and out of a bed or chair, bathing, dressing, eating, using the toilet, and taking medicine), or personal care that can be performed safely and effectively by persons who, in order to provide the care, do not require licensure, certification, or the presence of a supervising licensed nurse.  Conditions caused by or arising from acts of war.  Dental Services. This exclusion does not apply to Services that are covered under “Accidental injury to teeth,” “Hospital Services” or “Outpatient surgery visits.”  Surrogacy. Services for anyone in connection with a Surrogacy Arrangement whether traditional or gestational, except for otherwise-covered Services provided to a Member who is a surrogate. A “Surrogacy Arrangement” is one in which a woman (the surrogate) agrees to become pregnant and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), whether or not the woman receives payment for being a surrogate. See “Surrogacy Arrangements” in the “Reductions” section for information about your obligations to us in connection with a Surrogacy Arrangement, including your obligations to reimburse us for any Services we cover and to provide information about anyone who may be financially responsible for Services the baby (or babies) receive.  Reversal of voluntary sterilization.  Testing and treatment of infertility and sterility, including but not limited to artificial insemination, and in-vitro fertilization. EWCLGDED1983ACT0124 73 WAPEBB-CL-ACT