| Autism Spectrum Disorder Diagnosis |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Benign Brain Tumor |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Invasive Cancer |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Non-Invasive Cancer |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Skin Cancer |
| Initial Benefit: 5% of Benefit Amount (not less than $250) |
| Recurrence Benefit: 100% of Initial Benefit (not less than $250) |
| |
| Coronary Artery Bypass Graft (CABG) |
| Initial Benefit: 50% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit Amount |
| Where surgery involving either a median sternotomy or minimally invasive procedure is performed. |
| |
| Childhood Cerebral Palsy |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Childhood Cleft Lip or Cleft Palate |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Childhood Cystic Fibrosis |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Childhood Diabetes (Type 1) |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Childhood Downs Syndrome |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Childhood Sickle Cell Anemia |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Childhood Spina Bifida |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Coma |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Loss of: Ability to Speak; Hearing; or Sight |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Paralysis of 2 or More Limbs |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Heart Attack |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Sudden Cardiac Arrest |
| Initial Benefit: 50% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Bacterial Cerebrospinal Meningitis* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| COVID-19 * |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Diphtheria* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Encephalitis* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Legionnaire's Disease* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Malaria* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Necrotizing Fasciitis* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Osteomyeltsis* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Rabies* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Tetanus* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Tuberculosis* |
| Initial Benefit: 25% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Kidney Failure |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Major Organ Transplant |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| For Bone Marrow, Heart, Lung, Pancreas & Liver |
| |
| ALS |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Alzheimer's Disease |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Multiple Sclerosis |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Muscular Dystrophy |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Parkinson's Disease (Advanced) |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Systemic Lupus Erythematosus (SLE) |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: None |
| |
| Sever Burn |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Stroke |
| Initial Benefit: 100% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| Transient Ischemic Attack |
| Initial Benefit: 10% of Benefit Amount |
| Recurrence Benefit: 100% of Initial Benefit |
| |
| * Payable after 3 Consecutive Days of Hospitalization |
| Health Screening Benefit |
| Benefit Amount: $50 |
| Payable if an eligible covered person takes one of the screening/prevention measures listed below. Times Payable per Calendar Year: 1 time per Employee, 1 time per Spouse/Domestic Partner, 1 time per Dependent Child. Eligible Screening / Prevention Measures: |
| |
| Routine Health Check-Up Exam |
| Biopsies For Cancer |
| Blood Chemistry Panel |
| Blood Test To Determine Total Cholesterol |
| Blood Test To Determine Triglycerides |
| Bone Marrow Testing |
| Breast MRI |
| Breast Ultrasound |
| Breast Sonogram |
| Cancer Antigen 15-3 Blood Test For Breast Cancer (CA 15-3) |
| Cancer Antigen 125 Blood Test For Ovarian Cancer (CA 125) |
| Carcinoembryonic Antigen Blood Test For Colon Cancer (CEA) |
| Carotid Doppler |
| Chest X-Rays |
| Clinical Testicular Exam |
| Colonoscopy |
| Complete Blood Count (CBC) |
| Coronavirus Testing Skin Exam |
| Dental Exam |
| Digital Rectal Exam (DRE) |
| Doppler Screening For Cancer |
| Doppler Screening For Peripheral Vascular Disease |
| Echocardiogram |
| Electrocardiogram (EKG) |
| Electroencephalogram (EEG) |
| Endoscopy |
| Fasting Plasma Glucose Test |
| Fasting Blood Glucose Test |
| Flexible Sigmoidoscopy |
| Hearing Test |
| Hemoccult Stool Specimen |
| Hemoglobin A1c |
| Human Papillomavirus (HPV) Vaccination |
| Immunizations |
| Lipid Panel |
| Mammogram |
| Oral Cancer Screening |
| PAP Smears Or Thin Prep PAP Test |
| Prostate-Specific Antigen (PSA) Test |
| Serum Cholesterol Test To Determine Ldl And Hdl Levels |
| Serum Protein Electrophoresis |
| Skin Cancer Biopsy |
| Skin Cancer Screening |
| Stress Test On Bicycle Or Treadmill |
| Successful Completion Of Smoking Cessation Program |
| Tests For Sexually Transmitted Infections (STI's) |
| Thermography |
| Two-Hour Post-Load Plasma Glucose Test |
| Ultrasounds For Cancer Detection |
| Ultrasound Screening Of The Abdominal Aorta For Abdominal Aortic Aneurysms |
| Virtual Colonoscopy |
