GUARDIAN CANCER INSURANCE
Benefits
Employee Coverage* PREMIER PLAN 3
Type of Plan
Pre-existing condition limitation
PRQWKORRNEDFNSHULRG PRQWKH[FOXVLRQSHULRGFRQWLQXLW\RIFRYHUDJH
Air Ambulance Alternative Care
WULSOLPLWWULSVSHUKRVSLWDOFRQILQHPHQW
YLVLWXSWRYLVLWV
Ambulance Anesthesia Anti-Nausea
WULSOLPLWWULSVSHUKRVSLWDOFRQILQHPHQW
RIVXUJHU\EHQHILW
GD\XSWRSHUPRQWK
Attending Physician Blood/Plasma/Platelets Bone Marrow/Stem Cell
GD\ZKLOHKRVSLWDOFRQILQHG/LPLWYLVLWV
GD\XSWRSHU\HDU
%RQH0DUURZ 6WHP&HOO EHQHILWIRU QG WUDQVSODQWEHQHILWLIDGRQRU
Cancer Screening
IROORZ - XSVFUHHQLQJ GD\XSWRPRQWK
Experimental Treatment
Extended Care Facility/Skilled Nursing Care Government or Charity Hospital
GD\XSWR GD\VSHU\HDU
GD\LQOLHXRIDOORWKHUEHQHILWV YLVLWXSWRYLVLWVSHU\HDU
Home Health Care Hormone Therapy
7UHDWPHQWXSWRWUHDWPHQWVSHU\HDU
Hospice
GD\XSWRGD\VOLIHWLPH
GD\IRUILUVWGD\V GD\IRU VW GD\WKHUHDIWHUSHUFRQILQHPHQW GD\IRUILUVWGD\V GD\IRU VW GD\WKHUHDIWHUSHUFRQILQHPHQW
Hospital Confinement
ICU Confinement
Inpatient Special Nursing
GD\XSWRGD\VSHU\HDU LPDJHXSWRSHU\HDU GD\GD\VSHUSURFHGXUH GD\XSWR GD\VSHU\HDU
Medical Imaging
Outpatient or Ambulatory Surgical Center Outpatient and Family Member Lodging
Physical or Speech Therapy
YLVLWXSWRYLVLWVSHUPRQWKOLIHWLPHPD[ 6XUJLFDOO\,PSODQWHG GHYLFHOLIHWLPHPD[ 1RQ - 6XUJLFDOO\ GHYLFHOLIHWLPHPD[
Prosthetic
Radiation Therapy Chemotherapy and Immunotherapy
$FWXDO&RVWXSWRDEHQHILW\HDUPD[LPXP
%UHDVW75$0)ODS%UHDVWUHFRQVWUXFWLRQ %UHDVW6\PPHWU\)DFLDOUHFRQVWUXFWLRQ
Reconstructive Surgery
Reproductive Benefit Second Surgical Opinion
HJJKDUYHVWLQJHJJRUVSHUPVWRUDJHOLIHWLPHPD[
VXUJLFDOSURFHGXUH
%LRSV\2QO\ 5HFRQVWUXFWLYH6XUJHU\ ([FLVLRQRIDVNLQFDQFHU ([FLVLRQRIDVNLQFDQFHUZLWKIODSRUJUDIW
Skin Cancer
*The services, exclusions, and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. This document is a summary of the major features of the referenced insurance coverage. It is intended for illustrative purposes only and does not constitute a contract. The insurance plan documents, including the policy and certificate, comprise the contract for coverage. The full plan description, including the benefits and all terms, limitations and exclusions that apply will be contained in your insurance certificate. The plan documents are the final arbiter of coverage. Coverage terms may vary by state and employer-sponsored plan. The premium amounts reflected in this summary are an approximation; if there is a discrepancy between this amount and the premium deducted from your paycheck, the latter prevails. 6FKHGXOHDPRXQWXSWR Transportation/Companion Transportation PLOHXSWRSHUURXQGWULSHTXDOEHQHILWIRUFRPSDQLRQ Waiver of Premium ,QFOXGHG Cancer Insurance Monthly Rates IssueAge Employee Employee & Spouse Employee & Child Family <40 $25.80 $50.0 $25.81 $50.10 41-50 $38.10 $73.7 $38.11 $73.80 51-60 $52.70 $102. $52.71 $102.20 61+ $71.00 $137. $71.01 $137. Surgical Benefit
6800$5<2)3/$1/,0,7$7,216$1'(;&/86,216&RQGLWLRQDO8QGHUZULWLQJLVRQHPHGLFDOTXHVWLRQDVDSDUWRIWKHHQUROOPHQWIRU m. $SUH - H[LVWLQJFRQGLWLRQLQFOXGHVDQ\FRQGLWLRQIRUZKLFKDQHPSOR\HHLQWKHVSHFLILHGWLPHSHULRGSULRUWRFRYHUDJHLQWKLVSODQFRQVXOWVZLWKDSK\VLFLDQ UHFHLYHVWUHDWPHQWRUWDNHVSUHVFULEHGGUXJV3OHDVHUHIHUWRWKHSODQGRFXPHQWVIRUVSHFLILFWLPHSHULRGV6WDWHYDULDWLRQV ma \DSSO\7KLVSODQZLOOQRWSD\ EHQHILWVIRU ż 6HUYLFHVRUWUHDWPHQWQRWLQFOXGHGLQWKH6FKHGXOHRI,QVXUDQFH ż 6HUYLFHVRUWUHDWPHQWSURYLGHGE\DIDPLO\PHPEHU ż 6HUYLFHVRUWUHDWPHQW UHQGHUHGIRUKRVSLWDOFRQILQHPHQWRXWVLGHWKH8QLWHG6WDWHV ż $Q\FDQFHUGLDJQRVHGVROHO\RXWVLGHRIWKH8QLWHG6WDWHV ż 6HUYLFHVRUWUHDWPHQWSURYLGHG SULPDULO\IRUFRVPHWLFSXUSRVHV ż 6HUYLFHVRUWUHDWPHQWIRUSUHPDOLJQDQWFRQGLWLRQV ż 6HUYLFHVRUWUHDWPHQWIRUFRQGLWLRQVZLWKPDOLJQDQWSRWHQWLDO ż 6HUYLFHV RUWUHDWPHQWIRUQRQ - FDQFHUVLFNQHVVHV&DQFHUFDXVHGE\FRQWULEXWHGWRE\RUUHVXOWLQJIURP SDUWLFLSDWLQJLQDIHORQ\ULRW RULQVXUUHFWLRQ LQWHQWLRQDOO\ FDXVLQJDVHOI - LQIOLFWHGLQMXU\ FRPPLWWLQJRUDWWHPSWLQJWRFRPPLWVXLFLGHZKLOHVDQHRULQVDQH DFRYHUHGSHUVRQ·VPHQWDORUHPRWLRQDOGLVRUGHUDOFRKROLVPRU GUXJDGGLFWLRQ HQJDJLQJLQDQ\LOOHJDODFWLYLW\ RUVHUYLQJLQWKHDUPHGIRUFHVRUDQ\DX[LOLDU\XQLWRIWKHDUPHGIRUFHVRI an \FRXQWU\&DQFHUDULVLQJIURPZDURU DFWRIZDUHYHQLIZDULVQRWGHFODUHG*3 -1-CAN-IC-12
37
Made with FlippingBook Digital Publishing Software