CeltiCare Preferred Health Plan Significant Variations in Coverage by State

Below is a synopsis of the major variations in the CeltiCare Preferred product, from that outlined in your sales brochure. Refer to the insurance Certificate or Policy for exact terms and conditions, as it is the primary binding agreement between the insured and Celtic.

ALABAMA

• Colorectal Screening – in accordance with the American Cancer Society screening guidelines.

ALASKA

• 10 Day Free Look
• Term Life Option – Not Available
• Colorectal Cancer Screening - in accordance with the current American Cancer Society guidelines. Coverage includes examination and laboratory tests for any nonsymptomatic insured person age 50 or over, or for an insured person less than 50 years of age who may be classified as high risk for colorectal cancer.
• Phenylketonuria Treatment Charges- administered under the supervision of a physician. Coverage includes testing, diagnosis and dietary formulas which are medically necessary for the therapeutic treatment of phenylketonuria.

ARIZONA

• Inherited Metabolic Disorders for protein modified foods if prescribed by a physician. Limited to $5,000 per year.
• Manipulative Therapy - No annual or lifetime maximum.
• Contraceptive Coverage.
• Cancer Drug Coverage-prescription drugs prescribed for the treatment of cancer which have not been approved by the FDA for treatment of that specific type of cancer for which they are being prescribed. Drugs must meet certain medical criteria.
• Gastrointestinal Disorder Formula – for amino based formula prescribed by a physician. Services are covered at 75% of eligible expenses of charges incurred up to $20,000 per calendar year.
• Cancer Clinical Trial Coverage – includes patient costs for eligible expenses for the insured’s voluntary participation in a phase I, II, III or IV cancer clinical trial.

ARKANSAS

• 10 Day Free Look
• Term Life Option - Not available.
• Contraceptive Coverage.
• Children’s Preventive Health Care - Benefits are payable at specific intervals through age 18.
• Immunizations – not subject to deductible, coinsurance or co-pays.
• Temporomandibular Joint Disorder (TMJ) - covered same as sickness.
• Manipulative Therapy - No annual or lifetime maximum.
• Routine Nursery Care & Pediatric Charges – up to 5 days for newborn child.
• Phenylketonuria – treatment and dietary formula if prescribed by a physician.
• Colorectal Cancer Screening.
• Dental Anesthesia -General anesthesia and associated hospital or outpatient surgical facility charges for a dependent child under the age of seven or a person with a diagnosed mental or physical condition or a person with a significant behavioral problem, if deemed medically necessary by the primary care physician. Any dental plan would be primary.
• Impairment of speech or hearing- charges for necessary care and treatment but not hearing devices. This shall include those communicative disorders generally treated by a speech pathologist or audiologist.
• Outpatient Chemotherapy and Renal Dialysis – including hemodyalysis and peritoneal dialysis.
• Musculoskeletal Disorders – coverage for surgical and non-surgical treatment affecting any bone or joint in the face, neck or head including TMJ or craniomandibular disorder if prescribed or administered by a physician or dentist.
• Chemotherapy, Specialty Drugs, Bio-Tech Medications – administered parenterally in an outpatient setting. The eligible expense is 75% of the Prescription Benefit Manager’s charge for these medications.

CALIFORNIA

• Pre-Existing Conditions - 6/6. Credit given for prior creditable coverage. Well Child Care –including immunizations, covered through age 18.
• Temporomandibular Joint Disorder (TMJ) – coverage for diagnosis and surgical treatment of TMJ.
• Contraceptive Coverage. Dental General Anesthesia -if medically necessary for an insured either developmentally disabled or under 7 years of age.
• Severe Mental Illness/Serious Emotional Disturbances -same as any sickness, excluding alcohol, drug and substance abuse.
• Osteoporosis – medically necessary services for the diagnosis, treatment and management of osteoporosis
• Phenylketonuria – Enteral formula and special food products when prescribed by a physician.
• Prosthetic devices -initial and subsequent prosthetic devices needed to restore a method of speaking as a result of a laryngectomy.
• Othotic/Prosthetic devices – initial and replacement as prescribed by a physician.
• Cancer Clinical Trials-coverage provided for an insured diagnosed with cancer and accepted into a phase I through IV clinical trial for cancer.
• Home Health Care Charges – up to 100 visits per calendar year in lieu of hospital or extended care facility confinement.

COLORADO

• 10 Day Free Look
• Term Life Option - Not available.
• Child Health Supervision Services - Covered up to age 13. Deductible does not apply.
• Routine Nursery Care – Newborns covered up to 48/96 hours.
• Cleft Lip and Cleft Palate - for newborns to the extent that is medically necessary.
Home Health Care - Up to 60 visits per year. Intractable Pain - up to $500 per year. Dental General Anesthesia - for dental procedures provided in a hospital or outpatient surgical facility for a dependent child who meets the requirements of the policy. Such services must be pre-certified.
• Inherited Enzymatic Disorder -for protein modified foods if prescribed by a physician. Including phenylketonuria.
• Cancer Screenings - deductible does not apply to mammography or prostate screenings.
• Cervical Cancer Vaccines as recommended by a physician.
• Hospice Care Charges – maximum of $9,100 per episode of hospice care.
• Congenital Defects and Birth Abnormalities – covered for children up to 5 years of age, includes physical, occupational and speech therapy up to 20 visits for each therapy per calendar year.
• Early Intervention Service Charges – for medically necessary services provided by a qualified early intervention service provider to an eligible child in accordance with Part C of the “Individuals with Disabilities Education Act, ages birth to 3 years old. Services provided shall have a maximum of $5725 per insured person per calendar year.

CONNECTICUT

• 10 Day Free Look
• Term Life Option - Not available.
• Pre-existing Conditions – 12/12. credit given for prior qualifying coverage within 120 days of effective date, 150 days if coverage terminated due to involuntary loss of employment.
• Outpatient RX Drug Card: Deductible $100 (preferred, non preferred and specialty drugs) Generic: $20 copay, Preferred Brand: $40 copay, Non-Preferred Brand/Specialty Drug 40% coinsurance.
• Manipulative Therapy – no annual or lifetime maximum. Removal of breast implant -up to a maximum of $1,000 per calendar year.
• Replacement prosthetic devices -covered up to $300.00 per breast per calendar year.
• Contraceptive Coverage. Early Intervention Services - Up to $5,000 per year. The maximum will not contribute toward any annual or lifetime maximum benefit amount. Home Health Care - Up to 80 visits per year. Deductible is capped at $50.
• Mental and Nervous Disorders Charges - Inpatient and outpatient services are covered as any other sickness.
• Low Protein Modified Foods when prescribed by a physician for treatment of inherited metabolic diseases.
• Specialized Formulas- when medically necessary and prescribed by a physician for treatment of a disease or condition for children up to age 3.
• Hearing Aids up to $1,000 within a 24 month period and limited to children 12 years of age or younger.
• Dental General Anesthesia - general anesthesia and associated inpatient, outpatient or day dental services if deemed medically necessary, to be of significant dental complexity requiring dental procedures to be performed in the hospital, or the insured has a developmental disability that places the person at serious risk.
• Lyme Disease Treatment. Cancer Clinical trials.
• Colorectal Cancer Screening – covered based on standards established by the American Cancer Society as to family history, age and frequency. Ostomy supplies – medically necessary supplies and appliances related to ostomy surgery, up to $1,000 per calendar year.
• Accidental Ingestion of a Controlled Substance - Inpatient: up to 30 days per calendar year. Outpatient: up to $500 per calendar year.
• Pain Management – coverage is provided for access to a pain management specialist including all means medically necessary to make a diagnosis and develop a treatment plan.
• Craniofacial Disorders - coverage for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders for insured persons eighteen years of age or younger. Coverage will not be provided for Cosmetic Surgery.
• Infertility – coverage for the diagnosis and treatment of infertility through age 39.
• Mammogram – includes coverage for an ultrasound screening for women at increased risk of breast cancer and additional criteria. Medical Social Services – up to $200 per year for a terminally ill patient.
• Wig – prescribed by an oncologist due to chemotherapy, up to $350 per calendar year.
• Prostate Cancer – screening lab and diagnostic tests. Provided for symptomatic men with biological family history and one screening per calendar year age 50 and over.
• Inpatient Mastectomy Coverage – at least 48 hours of inpatient care following a mastectomy or lymph node dissection.
• Neuropsychological Testing – when ordered by a licensed physician for assessment of any cognitive or developmental delays due to chemotherapy or radiation treatment.

DELAWARE

• Baseline Lead Poisoning Screening Test - One test at age 12; screening and diagnostic evaluations under age 6 for those who are at high risk.
• Routine Nursery Care - Covered for newborn child, including a hearing screening prior to discharge.
• Child Immunizations - covered from birth through age 18.
• Contraceptive Coverage.
• CA – 125 monitoring of ovarian cancer subsequent to treatment.
• Serious Mental Illness same as any other sickness, including alcoholism, drug and substance abuse.
• Colorectal Screening – for person at any age at high risk and over 50 includes sigmoidoscopy, colonoscopy, barium enemas as recommended by a physician.
• Inherited Metabolic Diseases – diagnosing monitoring and controlling the disease through low protein food products and medical formula.

DISTRICT OF COLUMBIA

• Preventive and Primary Care Services - Covered for dependent children up to 18 years of age.
• Alcohol and Drug Dependency Charges - Twelve days per calendar year for detoxification. additional treatment up to 60 days for inpatient or residential care. outpatient covered at 75% for the first 40 visits, 60% thereafter.
• Psychiatric Care Charges - Inpatient 60 days per calendar year, outpatient covered at 75% for the first 40 visits, 60% thereafter. Lifetime maximum up to one-third of lifetime maximum for physical illness.
• Cancer Screenings – mammography benefit and pap smear test not subject to deductible and coinsurance and age restrictions.
• Colorectal Cancer Screening -Coverage for an examination and laboratory tests for any non-symptomatic insured person age 50 years of age or older.

FLORIDA

• Child Health Supervision Services- Birth to age 16. Deductible does not apply.
• Transportation costs - of a newborn child up to a maximum of $1,000.
• Osteoporosis -medically necessary diagnosis and treatment.
• Cleft Lip and Cleft Palate – covered if under the age of 18.
• Enteral formulas – coverage through age 24, up to $2,500 per calendar year when prescribed by a physician.
• Mammography – not subject to the deductible or coinsurance.
• Term Life Option - Not available.
• General Dental Anesthesia/Hospital services – general anesthesia and associated hospital or outpatient surgical facility charges for a dependent child under the age of seven or a person with a developmental disability if deemed medically necessary by the primary care physician.

GEORGIA

• 10 Day Free Look
• Term Life Option - Not available.
• Managed Indemnity Product - Not available.
• Child Wellness - From birth through the age of 5 years. Deductible does not apply.
• Contraceptive Coverage. Bone Density Test -for the prevention, diagnosis & treatment of osteoporosis.
• Dental Anesthesia -general anesthesia and associated hospital or ambulatory surgical facility charges in conjunction with dental care if an insured is developmentally disabled or for a child under 8 years of age if deemed medically necessary by the primary care physician.
• Chlamydia screening – annual test covered for females up to age 29.
• Colorectal Cancer Screening -covered based on standards established by the American Cancer Society as to family history, age and frequency.
• Telemedicine and Telehealth Services - covered in accordance with generally accepted health care practices and services. Transplants-heart and bone marrow transplants for breast cancer or Hodgkin’s disease are covered the same as any other sickness.
• Prescription Inhalants- will provide coverage for prescriptions inhalants without limitations on the number of days before an inhaler refill may be obtained if such inhalants have been prescribed by a treating physician
• Off Label Drug Use- coverage provided for use of prescription drugs prescribed for the treatment of a particular indication that have not been approved by the FDA for that particular indication for which they are being prescribed for, provided the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia.
• Outpatient Prescription Drug Benefit - If non­participating pharmacy is used you must pay 100% of the actual charges and file a claim with Celtic for reimbursement.
• Temporomandibular Joint Disorder (TMJ) -covered same as sickness.
• Psychiatric Care Charges – Inpatient psychiatric care up to 30 days per insured person per calendar year.
• Outpatient psychiatric care charges for psychiatric care visits are paid up to 48 visits per insured person per calendar year.
• Outpatient prescription drugs are covered under our outpatient prescription drug benefit provision and limited up to a maximum of $1,000 per insured person per calendar year.
• Alcoholism – Inpatient coverage up to $2500 per insured person per calendar year. Outpatient coverage limited to $1,000 per insured person per calendar year. $10,000 lifetime max for inpatient and outpatient combined.
• Approved Clinical trials - routine patient care for an insured child diagnosed with cancer prior to their nineteenth birthday.
• Diagnosis for Infertility – coverage will be provided for medical services which are medically necessary for the diagnosis of infertility. Does not include coverage for treatment or surgical procedures for infertility.

ILLINOIS

• Serious Mental Illness – Coverage includes 45 days of hospitalization as an inpatient per calendar year and 60 visits for outpatient treatment including group and individual outpatient treatment per calendar year, excluding visits for the management of medication.
• Dental General Anesthesia – coverage is provided for general anesthesia and related facility charges when the mental/physical condition of the insured requires a hospital setting.
• Contraceptive Coverage.
• Breast Examination - coverage for clinical breast examinations at certain ages.
• Amino acid-based elemental formula - for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when prescribed by a physician.
• Coverage for a human papillomavirus vaccine (HPV).
• Colorectal cancer screening with sigmoidoscopy or fecal occult blood testing for: an insured person age 50 or over every three years; or an insured person age 30 or older who may be classified as high risk for colorectal cancer.
• Inpatient Alcoholism Treatment while hospital confined. Inpatient Mastectomy Coverage following a mastectomy.
• Contraceptive Coverage for an insured person and any dependents for all outpatient contraceptive services and all outpatient contraceptive drugs and devices approved by the FDA.

INDIANA

• 30 Day Free Look
• Manipulative Therapy - No annual or lifetime maximum.
• Pervasive Developmental Disorders -coverage is provided in accordance with a treatment plan developed and monitored by a physician.
• Coverage For Medical Food that is: medically necessary; and prescribed by a covered insured person's treating physician for treatment of the covered insured person's inherited metabolic disease.
• Term Life Option - Not available.
• Psychiatric Care – Covered as any other sickness.

IOWA

• Contraceptive Coverage including outpatient contraceptive services.
• Dental General Anesthesia – coverage is provided for general anesthesia and related facility charges if an insured is developmentally disabled or for a child under the age of five if deemed medically necessary by the primary care physician.
• Human Papilloma Virus Vaccine – for all females as recommended by a physician.

KANSAS

• 10 Day Free Look
• Term Life Option- Not available.
• Inpatient Alcoholism, Drug Abuse, Mental or Nervous Condition Charges –limited to 30 days per calendar year.
• Outpatient Alcoholism, Drug Abuse, Mental or Nervous Condition Charges -100% of the first $100. 80% of the next $100. 50% of the next $1,640 in a year. $7,500 lifetime maximum.
• Immunizations - Covered for dependent children age 0 to 72 months. Deductible, coinsurance and co-pay amounts do not apply.
• Dental Care Anesthesia – charges for the administration and associated facility charges when an insured is severely disabled or for a minor five years of age and under or a person who has a medical or behavioral condition which requires hospitalization or dental anesthesia when dental care is required.
• Maternity Coverage – optional Osteoporosis services coverage.-for diagnosis, treatment and management when services.

LOUISIANA

• 10 Day Free Look
• Cancer Screenings – (mammography, pap smear and prostate screenings) deductible does not apply
• Colorectal Cancer Screening.
• Cancer Drug - coverage for all medically necessary services associated with the administration of the drug.
• Attention Deficit/Hyperactivity Disorder - Covered up to $2,500 per calendar year/$10,000 lifetime maximum. Outpatient eligible expenses up to $50 per visit. Initial diagnosis paid up to $600.
• Cleft lip and cleft palate - Covered.
• Immunizations - Birth up to age 6. Interpreter / translator -Services performed by a qualified interpreter/translator are covered.
• Speech/language Pathology Therapy -covered when rendered by a licensed speech pathologist or licensed audiologist.
• Hearing Aids - coverage limited to $1400 for each hearing impaired ear every 36 months.
• Inherited Metabolic Disease - coverage limited to $200 per month.
• Manipulative Therapy - No annual maximum.
• Transportation Costs – of a newborn to the nearest available hospital or neonatal special care unit for treatment of illness, injury, congenital defects or complications of premature birth.
• Dental General Anesthesia – coverage is provided for general anesthesia and related facility charges when the mental/physical condition of the insured requires a hospital setting.
• Osteoporosis – coverage for medically necessary diagnosis and treatment, when services are provided by a licensed medical provider.

MICHIGAN

• Pre-existing Condition - 6/12
• 10 Day Free Look Term Life Option - Not available.
• Substance Abuse - Coverage for intermediate and outpatient care up to $3,671.00 per calendar year. This benefit amount is adjusted on an annual basis based on the Consumer Price Index.
• Antineoplastic Therapy Charges – Coverage for any federally approved drug used in antineoplastic therapy.
• Ambulance Benefit – No annual maximum
• Off Label Drug Use -Coverage shall be provided for the use of a drug for clinical indications other than those stated in the labeling approved by the Federal Food and Drug Administration (FDA) if certain criteria is met.

MISSISSIPPI

• Pre-Existing Limitation – 6/12
• Manipulative Therapy - No annual or lifetime maximum.
• Temporomandibular Joint Disorder and Craniomandibular Disorder Charges - Diagnostic services and surgery up to $5,000 per lifetime
• Dental Anesthesia – charges and associated facility charges when the mental or physical condition of the child or mentally handicapped adult requires dental treatment to be rendered under physician-supervised general anesthesia in a hospital setting, surgical center or dental office. Cancer Drug Coverage – coverage for treatment of cancer with a drug if recognized for that type of cancer in one of the standard reference compendia or medical literature.
• Inpatient Psychiatric Care Charges – while hospital confined up to 30 days per insured person per calendar year. Partial hospitalization up to 60 days per calendar year.
• Outpatient Psychiatric Care Charges – Outpatient psychiatric visits covered up to $50 per visit up to a maximum of 52 visits per insured person per calendar year. Outpatient prescription drugs are limited to $1,000 maximum per insured person per calendar year under the outpatient prescription drug benefit provision.

MISSOURI

• 10 Day Free Look
• Term Life Option - Not available
• Mammogram – eligible regardless of age if recommended by a physician and there’s a family history of breast cancer.
• Immunizations - for dependent children up to age 5. Not subject to deductible or coinsurance.
• Child Health Supervision -thru age 12, subject to deductible and coinsurance requirements.
• Lead Poisoning Screening test.
• Speech or Hearing Disorder Charges, including newborn screening screening, audiological assessment and follow-up, and initial amplification.
• Inpatient psychiatric care treatment - up to 90 days per calendar year.
• Outpatient Psychiatric Care Treatment – covered only if enrolled in a full day or partial treatment program.
• Mental Health Diagnosis – two sessions per calendar year with a licensed practitioner for the purpose of diagnosis or assessment
• Contraceptive Coverage
• Autologous Bone Marrow and Stem Cell Transplant Charges – for the treatment of breast cancer.
• Osteoporosis charges -medically necessary services for the diagnosis, treatment and appropriate management of osteoporosis including bone mass measurement.
• Human leukocyte antigen testing, Coverage is limited to a maximum cost of [$75] and one test per lifetime;
• Formula and low protein modified food products for the treatment of phenylketonuria or any inherited disease of amino and organic acids for any insured person less than six years of age up to a maximum of $5000 per calendar year.
• Colorectal cancer examination and laboratory tests for cancer for any nonsymptomatic insured person, in accordance with the current American Cancer Society guidelines.
• Chemical Dependency charges: nonresidential treatment up to a maximum of 26 days per calendar year. Residential treatment to a maximum 21 days per calendar year, limited to a lifetime maximum of 10 episodes.
• Early Intervention Services Charges provided by early intervention specialists who are health care professionals licensed by the state of Missouri. Coverage is limited to $3,000 per insured person per calendar year with a lifetime benefit maximum of $9,000 per insured person.
• Dental Anesthesia Charges coverage for the administration of general anesthesia and office or medical care facility charges for dental care, rendered by a dentist, provided to the following insured persons: A child under the age of five; A person who is severely disabled; or a person who has a medical or behavioral condition which requires hospitalization or general anesthesia when dental care is provided.
• Cancer Clinical Trials – routine patient care for an approved phase II, phase III or phase IV clinical trial.

NEBRASKA

• Colorectal Cancer Screenings.
• Immunizations coverage for children from birth to six years of age.
• Alcoholism -thirty days of inpatient coverage for the primary treatment of alcoholism in any three­hundred-sixty-five-day benefit period with at least two such inpatient treatment periods available during the lifetime of the certificate, and sixty outpatient treatment visits during the lifetime of the certificate.
• TMJ/Craniomandibular Disorder Charges – Diagnostic services and surgery up to $2500 per lifetime.
• Dental General Anesthesia – coverage is provided for general anesthesia and related facility charges if an insured is developmentally disabled or for a child under the age of eight.
• Newborn Child Coverage – for newly born children of the insured person from the moment of birth. The coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

NEW HAMPSHIRE

• Pre-Existing Conditions - 3/9. credit given for prior creditable coverage.
• Manipulative Therapy - No annual maximum.
• Contraceptive Coverage.
• Dental General Anesthesia - for dental procedures meeting certain criteria, rendered in a hospital or outpatient surgical facility for a dependent child under age 6 or a person with a developmental disability.
• Nonprescription Enteral Formulas - and food products if prescribed by a physician, up to $1,800 per year.
• Scalp hair prostheses - resulting from the treatment from any form of cancer or leukemia, or permanent loss of scalp hair due to injury. Coverage limited to $350 per calendar year.
• Maternity Coverage – optional.
• Off Label Drug Use- coverage provided for use of prescription drugs prescribed for the treatment of a particular indication that have not been approved by the FDA for that particular indication for which they are being prescribed for, provided the drug has been recognized for treatment of that indication in one or more of the standard medical reference compendia.
• Cost of Testing for Bone Marrow Donation – coverage for expenses arising from human leukocyte antigen testing.
• Coverage for Children’s Early Interventions
• Therapy Services - coverage for expenses arising from the services of licensed and credentialed occupational therapists, physical therapists, speech-language pathologists, and clinical social workers working with children from birth to 36 months of age with an identified developmental disability and/or delay as long as the providing therapist receives a referral from the child’s primary care physician if applicable. The benefits are limited to $3200.00 per child per calendar year and not to exceed $9600 by the child’s third birthday.
• Obesity and Morbid Obesity coverage for the diseases and ailments caused by obesity and morbid obesity and treatment for such, including bariatric surgery. The insured person shall be at least 18 years of age.

NEW MEXICO

• Immunizations -Coverage for childhood immunizations is provided at a level in accordance with the recommendations of the American Academy of Pediatrics.
• Early Intervention Services – coverage for dependent children from birth through 3 years of age a maximum benefit of $3500 per calendar year for medically necessary early intervention services as approved by the Department of Health.
• Circumcision Charges – Circumcision coverage for newborn males.
• General Anesthesia and Hospitalization for Dental Surgery - coverage for hospitalization and general anesthesia provided in a hospital or ambulatory surgical center for an insured person or dependent child.
• Temporomandibular Joint Disorder (TMJ) - treatment covered same as sickness.
• Home Health Care: 100 visits per calendar year.
• Mastectomy or Breast Cancer Treatment - charges for up to 48 hours or inpatient care following a mastectomy and up to 24 hours of inpatient care following a lymph node dissection for the treatment of breast cancer.
• Cancer Clinical Trials - routine patient care for an approved phase II, III or phase IV clinical trial. Treatment of genetic inborn errors of metabolism that involve amino acid, carbohydrate and fat metabolism and for which medically standard methods of diagnosis, treatment and monitoring exist.
• Alcoholism – inpatient up to 30 days per year; outpatient – up to 30 visits per year.
• Contraceptive Coverage.
• Hearing aid coverage – which includes a hearing aid and any related expenses for the full cost of one hearing aid per hearing-impaired ear up to $2200 every 36 months for insured children under the age of 18 or 21 if still attending high school.
• Human papillomavirus vaccine – females 9 to 14 years of age.

NORTH CAROLINA

• 10 Day Free Look
• Term Life Option - Not available
• Pre-Existing Conditions -Credit given for prior qualifying coverage.
• Temporomandibular Joint Disorder (TMJ) -Up to a lifetime maximum of $3,500.
• Pap Smear – includes the exam, lab fee and physician interpretation.
• Colorectal Cancer Screening -covered based on standards established by the American Cancer Society.
• Cancer Clinical Trials -routine patient care for an approved phase II, III or phase IV clinical trial.
• Contraceptive Coverage Pastoral Counselor Services -when rendered by a certified fee-based practicing pastoral counselor.
• Newborn Hearing Screening.
• Dental Anesthesia -for dental procedures and general anesthesia rendered in a hospital or outpatient surgical facility, for a dependent child or adolescent with a developmental disability or behavioral disorder.
• Off label drug use – for treatment of cancer.
• Osteoporosis – coverage for medically necessary diagnosis and treatment, when services are provided by a licensed medical provider.
• Bone Mass Measurement is covered.
• PPO Plans - There is an out-of-network/out-of­pocket maximum. This amount is double the in­network/out-of-pocket maximum.
• Reconstructive Breast Surgery – covered regardless of whether or not the mastectomy was performed under our coverage-provision has been expanded to include other services.
• Transplant benefit – travel and lodging caps removed, however arrangements must be made through the insurer.

OHIO

• Term Life Option – not available
• Child Health Supervision Services – from the moment of birth through 8 years of age. The maximum amount the first year is $500 and $150 every year after.
• Biologically Based Mental Illness – same as any other illness based on certain requirements. Alcoholism Charges – inpatient and outpatient services up to $550 per year.
• Outpatient Psychiatric Care Charges – services up to $550 per year.
• Off Label Drug Use – coverage provided for use of prescription drugs prescribed for the treatment of a particular indication that have not been approved by the FDA for that particular indication for which they are being prescribed for, provided the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia.

OKLAHOMA

• 10 Day Free Look
• Osteoporosis - Bone Density Test up to $150.
• Mammography - Benefits are reimbursed at 100% up to $115. Coinsurance and deductible do not apply.
• Child Health Supervision Services -benefits include immunizations and are payable at specific intervals through age 18, deductible, coinsurance or copay will not apply.
• Dental General Anesthesia -for medically necessary dental procedures when an insured person is severely disabled or for a minor 8 years of age or under who has a medical or emotional condition which requires hospitalization.

SOUTH CAROLINA

• 10 Day Free Look
• Term Life Option - Not available
• Cleft lip and cleft palate - Covered
• Organ Transplant - Medical expenses of a live donor, will be reimbursed to the extent that benefits remain and are available under this policy after the insured person’s own eligible expense have been paid.

SOUTH DAKOTA

• 10 Day Free Look
• Alcoholism - Inpatient treatment in approved licensed hospitals and residential facilities covered same as sickness up to 30 days in any six month period and 90 days during the lifetime of policy.
• Phenylketonuria - Coverage for testing, diagnosis and treatment.
• Biologically Based Mental Illness - covered same as any other sickness, excluding alcoholism, drug and substance abuse.
• Dental Anesthesia - coverage is provided for general anesthesia and related facility charges for a child under age 5 or for a severely disabled individual.

TENNESSEE

• 10 Day Free Look
• Term Life Option - Not available
• Chlamydia screening – test covered along with annual pap test up to age 29.
• Phenylketonuria – treatment and formulas.
• Manipulative Therapy - No annual or lifetime maximum.
• Hearing/Speech/Language Disorders – coverage provided if treatment is received from a licensed audiologist or speech pathologist.
• Temporomandibular Joint Disorder (TMJ). Phase I & II covered.
• Well Child coverage – from birth and infants in well –child care unit.

TEXAS

• 10 Day Free Look
• Term Life Option - Not available
• Child Immunization - from birth through age 6. Immunization charges not subject to the deductible, coinsurance or copay. Charges for other services rendered at the time of immunizations are subject to the deductible, coinsurance and copay requirements.
• Hearing Impairment – coverage provided for newborn screening test from birth through 30 days of age. Follow-up care provided through age 24 months. Services not subject to the deductible; however coinsurance, copay requirements apply.
• Home Health Care - 60 visits per year.
• Prescription Drugs - includes birth control drugs and formulas for treating phenylketonuria or other heritable diseases if prescribed by a physician.
• Off Label Drug Use – coverage provided for treatment of a covered chronic or disabling condition if FDA approved for at least one indication and is recognized for treatment of the indication in peer review medical literature or a prescription drug reference compendium.
• Psychiatric Care -Also covers charges for: 1) psychiatric day treatment facility. 2) treatment provided through a crisis stabilization unit. and 3) treatment provided in a residential treatment center for children and adolescents as required by Texas law.
• Telemedicine and Telehealth Services- covered in accordance with generally accepted health care practices and services.
• Colorectal Cancer Screening – covered in accordance with the standards established by the American Cancer Society.
• Craniofacial reconstructive surgery – covered for children under 18 years of age.
• Acquired Brain Injury – coverage for all integrative cognitive and rehabilitative therapies as a result of or related to an acquired brain injury.
• Home Health Care Charges – up to 60 visits per calendar year, but only if a hospital or extended care facility confinement would otherwise be needed.
• Child Hearing Impairment Screening Test – from birth through age 30 days. Necessary follow up care until 24 months old.

WEST VIRGINIA

• 10 Day Free Look
• Temporomandibular/Craniomandibular Disorders(TMJ) -covered unless declined at the time of application.
• Alcoholism - inpatient confinement up to 30 days per year. outpatient paid at 50% up to $750 per calendar year. Lifetime maximum $10,000 inpatient and outpatient combined.
• Home Health Care - 100 visits.
• Immunizations - Covered through age 16, not subject to deductible or copay.
• Contraceptive Coverage – for prescription contraceptive drugs or devices, contraceptive services.
• Hearing Loss –coverage for testing for hearing loss in newborns. Subject to deductible and coinsurance.
• Temporomandibula/Craniomandibular Disorders – medical services,orthotics and surgery included.
• Human Papolloma Virus test – for women 18 years and older.
• Kidney Disease Screening – including lab testing as recommended by the National Kidney Foundation.
• Clinical Trials – coverage for patient cost for cancer trials and clinical trials for other life threatening conditions with therapeutic intent. Certain requirements must be met for coverage.

WISCONSIN

• 10 Day Free Look
• Blood Lead Tests -For children under 6 years of age. Minimum of 2 screenings one at 12 months and 1 at 24 months of age.
• Home Health Care - 40 visits.
• Manipulative Therapy - No annual or lifetime maximum.
• Skilled Nursing Facility or Extended Care Facility - Up to 30 days of confinement per occurrence.
• Temporomandibular Joint Disorder (TMJ) – only if the condition is caused by congenital developmental disease or injury.
• Dental Care – charges for hospital and ambulatory surgical facilities, including general anesthesia for a child under age 5 or an individual with a chronic disability or a medical condition that requires hospitalization or general anesthesia for dental care.
• Immunizations – for dependent children from birth to age 6. The deductible, coinsurance or copayments do not apply.
• Kidney Disease Treatment – inpatient or outpatient including dialysis, transplantation and donor-related services up to a maximum of $30,000 per policy year.

WYOMING

• Pre-existing Conditions – 6/12. Credit given for prior qualifying coverage within 90 days of effective date.

This information is based on a publication dated 3/1/2009 and may change in the future. See your specific policy certificate for details. In the event of a conflict between this information and the details of a policy, the policy will prevail.