Covered Services
Level 1 Benefits
Prosthesis This benefit is payable if you receive an implantable or non-implantable prosthetic device, such as a voice box, hairpiece or removable breast prosthesis as a direct result or consequence of the treatment of internal cancer. Lifetime maximum for surgically implanted prosthesis is $4,000 for Level 1. Lifetime maximum for other devices is $400 for Level 1. Excludes coverage for a Breast Transverse Rectus Abdominis Myocuntaneous (TRAM) flap procedure. Skin Cancer This benefit is payable for procedures performed if you are diagnosed with skin cancer and includes the amount payable for anesthesia services. The amount payable varies based on the procedure performed. ▪▪ Biopsy Only ▪▪ Reconstructive surgery following previous excision of skin cancer
Surgically Implanted - $2,000 Other Devices - $200
$100 $250 $375 $600
▪▪ Excision of skin cancer without flap or graft ▪▪ Excision of skin cancer with flap or graft
Radiation and Chemotherapy If you receive cytotoxic medications or radiation (approved by the FDA or NCI-listed) administered by medical personnel in a hospital, clinic or doctor’s office as internal cancer treatment for the purpose of changing or destroying abnormal tissue, the following benefits will be paid: ▪▪ Injected Cytotoxic Medications ▪▪ Pump Dispensed Cytotoxic Medications
$300 Weekly $300 First Prescription &
per Refill $150 per
▪▪ Oral Cytotoxic Medications
Prescription $300 Weekly $400 Weekly $450 Weekly $400 Weekly
▪▪ Cytotoxic Medications Administration by Any Other Method ▪▪ External Radiation Therapy ▪▪ Insertion of Interstitial or Intracavity Administration of Radioisotopes or Radium ▪▪ Oral or I.V. Radiation
This benefit is not payable for the same day the Experimental Treatment benefit is payable. These benefits are not payable for treatment planning, therapeutic devices, immunotherapy, laboratory tests, diagnostic x-rays, dosimetry or simulation associated with these procedures. Maximums apply: Oral Cytotoxic Medications are subject to a $450 monthly maximum for Level 1. A $4,000 benefit year maximum applies to each of the other listed treatments for Level 1. Extended-care Facility Pays the amount shown for you for each day you are confined in an extended-care facility. This benefit is payable if the extended care confinement occurs within 30 days of a period of hospital confinement due to internal cancer and you have received a Hospital Confinement benefit. Limited to a maximum of 90 days per benefit year per covered person. This benefit is not payable for any day the Hospital Confinement benefit is payable. $200 Daily Hospice Pays the daily amount shown for hospice care for you for terminal illness as a result of internal cancer. Limited to a maximum of 100 days during the covered person’s lifetime. This benefit is not payable for any day the Extended-Care Facility benefit, the Home Health Care benefit or the Hospital Confinement benefit is payable. $100 Daily
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