3162095v1 - Segal Master Plan Document/SPD: COPY ONLY!!!!
Colostomy or ostomy (orthotic) supplies are payable under the Non-durable supplies row. The Plan covers a single wig, toupee or hairpiece to a maximum of $200 per person per contract year (plan year). See Corrective Appliances in the Medical Exclusions chapter. To help determine what Prosthetic or Orthotic Appliances are covered, see the ... ................
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