Services Subject to a Deductible----Inherited Metabolic Disorders, Adult Wellness and Preventive Care, Prostate Cancer Screening and Pap Smear Screening
Participating Provider Services Subject to Calendar Year Deductible
(The following introductory wording is a summary. See "Benefits and Claim Procedures: Health Insurance co-pays and deductibles: A Primer" for complete wording.
(Typical wording*)
Subject to all Policy limitations, exclusions, applicable deductibles, co-pays and maximums, the Company agrees to pay for Policy-defined Covered Expenses for the following described services, if they are Medically Necessary:
12. Inherited Metabolic Disorders: Benefits include Covered Expenses for Medical Foods prescribed or ordered under the supervision of a Participating Provider, as Medically Necessary for the therapeutic treatment of an Inherited Metabolic Disorder. This Benefit is limited to a maximum of [$5,000] in a twelve (12) month period. |
"Medical Foods" means modified low protein foods and metabolic formulas.
"Modified low protein foods" and "metabolic formulas" are carefully processed and formulated to certain very strict requirements to assist people with inherited metabolic disorders to have optimal growth, health and metabolic balance.
This benefit provides specific coverage for people who have an inherited metabolic disorder, which is a disease caused by an inherited abnormality of body chemistry.
13. Adult Wellness and Preventive Care: Services Provided to You and Your Spouse (if such spouse is listed as an Other Insured) for necessary Adult Wellness Preventive Care by a Participating Provider no more than once every [twelve (12) months] up to a Calendar Year maximum payment by Us of [$250] per person per Calendar Year.
Adult Wellness Preventive Care does not include charges (i) by Participating Providers for any physical therapy, occupational therapy, or other Outpatient therapy or treatment, or any form of medical or surgical treatment of an Injury of Sickness; or (ii) any service, care, test or treatment by a Non-Participating Provider. |
This benefit is separate from and in addition to mammography screening, pap smear screening, prostate screening and osteoporosis screening coverage in the policy.
14. Prostate Cancer Screening: Services Provided by Participating Providers during an annual physical examination for the detection of prostate cancer, and a prostate-specific antigen test used for the detection of prostate cancer for each male Insured who is:
a. at least fifty (50) years of age and asymptomatic; or
b. at least forty (40) years of age with a Family history of prostate cancer or another prostate cancer risk factor.
The prostate cancer screening must be performed by a participating Provider, and shall consist of a prostate-specific antigen blood test and a digital rectal examination. |
This is self-explanatory.
15. Pap Smear Screening: Services Provided by Participating Providers for an annual Pap Smear Provided to female Insureds (or more often if deemed necessary by a Participating Provider), including the examination by such Provider, the laboratory fee, and the Provider's interpretation of the laboratory results.
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This benefit provides coverage for the routine pap smear exam at least annually and more often if the doctor deems it necessary.
*Wording may vary from contract to contract and from state to state.
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