Cancer Screening Benefits Part I. Cancer Screening/Wellness Benefit per calendar year $25 $75 $100 $125 Part II. Additional Invasive Diagnostic Test or Surgical Benefit per calendar year $25 $75 $100 $125
Cancer Benefits
Air Ambulance per trip limit 2 trips per confinement $1,000 $1,000 $1,000 $1,000 Ambulance per trip limit 2 trips per confinement $200 $200 $200 $200
Anesthesia-Benefit for General is 25% of Surgical Procedures Per procedure for local anesthesia $25 $30 $40 $50
Antinausea Medication per day administered or per prescription filled $20 $40 $50 $60 Maximum per month $80 $160 $200 $240
Blood/Plasma/Platelets/Immunoglobulins per day up to $10,000 per cal year $200 $200 $200 $200
Bone Marrow Stem Cell Transplant per lifetime $10,000 $10,000 $10,000 $10,000 Bone Marrow Stem Cell Donation Benefit per lifetime $1,000 $1,000 $1,000 $1,000
Companion Transportation ($ per mile) up to $1,500 per round trip 0.50 0.50 0.50 0.50
Experimental Treatment per day up to $10,000 per lifetime $300 $300 $300 $300
Family Care per day $60 $60 $60 $60
Hair/External Breast/Voice Box Prosthesis per calendar year $200 $200 $200 $200
Home Health Care Services per day up to greater of 30 days/calendar year or 2 times the days confined to hospital $75 $75 $75 $75
Hospice per day, no lifetime limit $70 $70 $70 $70
Hospital Confinement, Days 1-30, benefit per day $100 $200 $300 $400
Hospital Confinement, Days 31+, benefit per day $200 $400 $600 $800
Hospital Confinement in a US Government Hospital Days 1-30, benefit per day $100 $200 $300 $400
Hospital Confinement in a US Government Hospital Days 31+, benefit per day $200 $400 $600 $800
Lodging per day up to 70 days per calendar year $75 $75 $75 $75
Medical Imaging Studies per study, $500 calendar year max $250 $250 $250 $250
Outpatient Surgical Center per day $200 $200 $300 $400
Calendar year maximum $600 $600 $900 $1,200
Peripheral Stem Cell Transplant lifetime maximum $5,000 $5,000 $5,000 $5,000
Private Full Time Nursing Services per day $150 $150 $150 $150
Prosthesis/Artificial Limb per device, limit 1 per site, $6,000 lifetime $3,000 $3,000 $3,000 $3,000
Radiation/Chemotherapy per day $100 $200 $300 $300 (no monthly limit for chemotherapy injected or radiation delivered by medical personnel) Monthly Maximum Self Injected $800 $1,600 $2,400 $2,400 Pump $400 $800 $1,200 $1,200 Topical $400 $800 $1,200 $1,200 Oral $400 $800 $1,200 $1,200 Any Other Method Not Listed $400 $800 $1,200 $1,200
Reconstructive Surgery per unit value $40 $40 $60 $60 Maximum per procedure for Surgery and Anesthesia, limit 2 per site $2,500 $2,500 $3,000 $3,000
Second Medical Opinion limit once per malignant condition $300 $300 $300 $300
Skilled Nursing Care Facility per day up to days confined in hospital $100 $100 $100 $100
Skin Cancer Initial Diagnosis once per lifetime $300 $300 $300 $300
Supportive or Protective Care Drugs & Colony Stimulating Factors per day $50 $100 $150 $200 calendar year maximum $400 $800 $1,200 $1,600
Surgical Procedures-Unit Value $40 $50 $60 $70 maximum per procedure $2,500 $3,000 $5,000 $6,000
Transportation (per mile) up to $1,500 per trip 0.50 0.50 0.50 0.50 Waiver of Premium Yes Yes Yes Yes Optional Riders A choice of optional riders is available and can be purchased at an additional cost to provide extra coverage and benefits. Specified Disease Paid for hospital confinement for covered specified diseases.
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$300 per day when hospitalized
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$125,000 lifetime maximum
The specified diseases covered under this rider are: Adrenal Hypofunction
(Addison’s Disease)
Botulism
Bubonic Plague
Cerebral Palsy
Cholera
Cystic Fibrosis
Diphtheria
Encephalitis, including Encephalitis contracted
from West Nile Virus.
Huntington’s Chorea
Legionnaires Disease
Lou Gehrig’s Disease
(Amyotrophic Lateral Sclerosis) Lyme Disease
Malaria
Meningitis (bacterial)
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis
Necrotizing Fasciitis
Osteomyelitis
Poliomyelitis
Rabies
Reye’s Syndrome Scleroderma
Scarlet Fever
Sickle Cell Anemia Systemic Lupus Tetanus
Toxic Epidermal Necrolysis
Toxic Shock Syndrome
Tuberculosis (Mycobacterial)
Tularemia
Typhoid Fever
Variant Creutzfeldt- Jakob Disease (Mad Cow)
Yellow Fever First Diagnosis Paid for the first diagnosis of internal (not skin) cancer.
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$1,000 units from $1,000 - $5,000
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Pays 1.5 times amount for children on family coverage. Progressive Payment Paid for the first diagnosis of internal (not skin) cancer. The progressive payment accumulates $50 per month for each month the policy has been in force after the first 30 days.
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Issue age for Progressive Payment rider is 17-64. . •
• The policy is guaranteed renewable.
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Coverage is portable. n employee can take this coverage with him if he changes jobs or leaves your company.
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The spouse may be listed as the primary insured on a Cancer policy if the employee is not eligible for coverage
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Cancer 1000 coverage offers innovative benefits to help address current treatment costs for the care of cancer
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All eligible applicants in an account have the same premium, regardless of risk class or age Eligibility Requirements • Issue ages 17-69 for both the employee and spouse.
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Dependent children (as defined in the policy). Participation Requirements To offer this plan, we require only 3 eligible participants apply. Premium Information • Premiums are based on level of coverage chosen.
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Premium levels are available for Employee; Employee and Dependent Children; and Employee, Spouse and Dependent Children plans.
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Premiums are not age banded.
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Cancer screening tests performed during the waiting period will not be covered.
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Cancer diagnosed during the waiting period will not be covered. • • •
