2020 211239 - CI 3.5 Plan Summary - 10.2019

Example of Initial & Recurrence Benefit Payments The example below illustrates an employee who elected an Initial Benefit of $20,000 and has a Total Benefit of 3 times the Initial Benefit Amount or $60,000.

Illness – Covered Condition

Payment

Total Benefit Remaining

Initial Benefit payment of $20,000 or 100%

Heart Attack – first diagnosis

$40,000

Heart Attack – second diagnosis, two years later Kidney Failure – first diagnosis, three years later

Recurrence Benefit payment of $10,000 or 50%

$30,000

Initial Benefit payment of $20,000 or 100%

$10,000

In most states there is a preexisting condition limitation. If advice, treatment or care was sought, recommended, prescribed or received during the three months prior to the effective date of coverage, we will not pay benefits if the covered condition occurs during the first six months of coverage. The preexisting condition limitation does not apply to heart attack or stroke. SUPPLEMENTAL BENEFITS MetLife provides coverage for the Supplemental Benefits listed below. This coverage would be in addition to the Total Benefit Amount payable for the previously mentioned Covered Conditions. Health Screening Benefit 10 MetLife will provide an annual benefit of $50 per calendar year for taking one of the eligible screening/prevention measures. MetLife will pay only one health screening benefit per covered person per calendar year. Eligible screening/prevention measures may include:

annual physical exam biopsies for cancer

• flexible sigmoidoscopy • hemoccult stool specimen

blood test to determine total cholesterol blood test to determine triglycerides

• hemoglobin A1C

• human papillomavirus (HPV) vaccination

bone marrow testing

• lipid panel

breast MRI

• mammogram

breast ultrasound breast sonogram

• oral cancer screening

• pap smears or thin prep pap test • prostate-specific antigen (PSA) test

• 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)

• serum cholesterol test to determine LDL and HDL levels

• serum protein electrophoresis

carotid doppler

• skin cancer biopsy • skin cancer screening

chest x-rays

clinical testicular exam

• skin exam

colonoscopy

• stress test on bicycle or treadmill

digital rectal exam (DRE) Doppler screening for cancer

• successful completion of smoking cessation program • tests for sexually transmitted infections (STIs)

• Doppler screening for peripheral vascular disease

• thermography

echocardiogram

• two hour post-load plasma glucose test • ultrasounds for cancer detection • ultrasound screening of the abdominal aorta for abdominal aortic aneurysms

electrocardiogram (EKG)

endoscopy

• fasting blood glucose test • fasting plasma glucose test

• virtual colonoscopy

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