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 |