Plan Benefit Highlights + This benefit does not include any drugs/ medicines covered under the drugs MONTHLY PREMIUMS and medicine benefit or the hormone therapy benefit. Actual Charges means BASIC Age 18-40 Age 41-50 Age 51-60 Age 61+ the amount actually paid by or on behalf of the insured person and accepted by the provider for services provided. Individual $16.30 $23.60 $32.60 $44.20 Medical Imaging Benefit Pays the indemnity amount for either an MRI; CT Single Parent Family $24.40 $35.20 $48.70 $65.90 scan; CAT scan; or PET scan when performed at the request of a physician. Family $31.80 $45.70 $63.30 $85.80 Hormone Therapy Benefit Drugs and medicines covered under the drugs and medicine benefit or the radiation/chemotherapy/immunotherapy benefit are not included. This benefit does not cover associated administrative processes. ENHANCED Age 18-40 Age 41-50 Age 51-60 Age 61+ Administrative/Lab Work Benefit Pays when procedures related to radiation therapy/chemotherapy/immunotherapy treatment occur and benefits Individual $21.00 $30.80 $42.40 $57.30 are payable during the same calendar month as the radiation therapy/ Single Parent Family $31.40 $45.80 $63.30 $85.60 chemotherapy/immunotherapy benefit. Benefits for blood, plasma and platelets Blood, Plasma and Platelets Benefit Family $40.80 $59.50 $82.30 $111.30 are only provided under this benefit. Laboratory processes and colony stimulating factors are not covered. ENHANCED PLUS Age 18-40 Age 41-50 Age 51-60 Age 61+ Bone Marrow/Stem Cell Transplant Benefit Harvesting of bone marrow or stem cells from a donor are not covered under Individual $25.80 $38.10 $52.70 $71.00 this benefit. Single Parent Family $38.50 $56.80 $78.60 $106.00 Hospital Confinement Benefit Payable while confined to a Hospital for at least 18 continuous hours. *A Hospital is not an institution, or part thereof, Family $50.10 $73.80 $102.20 $137.90 used as: a hospice unit, including any bed designated as a hospice or swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended care facility; a skilled nursing facility; or a facility primarily affording Plan Benefit Highlights custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction. Only loss for Cancer The policy pays only for loss resulting from definitive This benefit is not payable for outpatient treatment. Cancer treatment including direct extension, metastatic spread or Drugs and Medicine Benefit Pays for anti-nausea and pain medication recurrence. Proof must be submitted to support each claim. The policy prescribed by a physician and administered while also receiving radiation also covers other conditions or diseases directly caused by Cancer or the therapy/chemotherapy/immunotherapy, a covered surgery, or a bone marrow/ treatment of Cancer. The policy does not cover any other disease, sickness, stem cell transplant. It does not include associated administrative processes or incapacity, even though after contracting Cancer it may have been or drugs or medicines covered under the radiation therapy/chemotherapy/ aggravated or affected by Cancer or the treatment of Cancer except for immunotherapy benefit or the hormone therapy benefit. conditions specifically provided in the dread disease benefit. Attending Physician Benefit Pays for one physician’s visit per day when the Cancer means a disease of autonomous growth (malignancy) in which services of a physician, other than a surgeon, are required while confined in a there is uncontrolled growth, function, or spread (local or distant) of Hospital. cells in any part of the body. This includes Cancer in situ and malignant U.S. Government/Charity Hospital /HMO Benefit Payable when an itemized melanoma. It does not include other conditions which may be considered list of services is not available due to confinement in a charity Hospital or a precancerous or having malignant potential such as: leukoplakia; Hospital owned or operated by the U.S. government or covered under an hyperplasia; acquired immune deficiency syndrome (AIDS); polycythemia; HMO or diagnostic related group where no charges are made for treatment actinic keratosis; myelodysplastic and non–malignant myeloproliferative of Cancer or a covered dread disease. This benefit will be paid in lieu of most disorders; aplastic anemia; atypia; non–malignant monoclonal benefits covered under this policy. gammopathy; carcinoid; or pre–malignant lesions, benign tumors or polyps. Ambulance Benefit If air and ground ambulance services are both required All diagnosis of Cancer must be positively diagnosed by a legally licensed on the same day, we will only pay the higher benefit amount. The covered doctor of medicine certified by the American Board of Pathology or person must be admitted as an inpatient and Hospital confined for at least 18 American Board of Osteopathic Pathology. Benefits under this policy pays consecutive hours. the benefit amount shown per covered person due to a covered Cancer Transportation and Lodging Benefits Pays a benefit for transportation by unless otherwise specified. scheduled bus, plane or train, or by car and outpatient lodging to receive Diagnostic, Prevention and Cancer Screening Benefit Pays for a generally radiation therapy, chemotherapy, or immunotherapy treatment, bone marrow medically recognized internal Cancer screening test when a charge is or stem cell transplant, or surgery in a Hospital not available locally and at least incurred for the test. Tests include but are not limited to mammogram, 50 miles from the covered person’s residence. Payable for the covered person thinprep pap test, prostate-specific antigen blood test (PSA), colonoscopy, and one adult family member. If traveling in the same car or lodging in the and chest x–ray. Refer to the policy for more examples. Screening tests same room, the benefit is payable only for the covered person. Travel must be payable under this benefit will ONLY be paid under this benefit and does within the United States or its Territories. not include any test payable under the medical imaging benefit. This Surgical Benefit Payable when a surgical operation is performed for covered benefit is available without a diagnosis of Cancer. diagnosed Cancer, skin Cancer, or reconstructive surgery due to Cancer. Cancer Screening Follow-Up Benefit Payable for one invasive follow–up Benefits are calculated up to a maximum benefit by multiplying the surgical screening test needed due to an abnormal result from a covered screening unit value assigned to the procedure, as shown in the most current physician’s test. Diagnostic surgeries which result in a positive diagnosis of Cancer will relative value table, by the unit dollar amount shown in the policy. Two be paid under the surgical benefit. or more surgical procedures performed through the same incision will be Pays the Actual considered one operation and benefits will be limited to the most expensive Radiation/Chemotherapy/Immunotherapy Benefit procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer Charges up to the maximum amount shown when radiation therapy, are not covered under this benefit. Bone marrow surgeries, surgeries to chemotherapy, or immunotherapy is received as defined in the policy, per implant a permanent prosthetic device, are not covered under this benefit. 12-month period. The 12-month period begins on the first day the covered This benefit is payable for reconstructive breast surgery performed on a radiation therapy, chemotherapy, or immunotherapy is received. This benefit nondiseased breast to establish symmetry with a diseased breast when does not cover other procedures related to radiation/ chemotherapy/ reconstructive surgery on the diseased breast is performed while covered immunotherapy. under this policy, in the manner determined by the Physician and the Covered Person to be appropriate.