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HSA Plan

Network

100% coverage

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

100% coverage

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

100% coverage

Non-Network

40% coinsurance after deductible

For preventive care and services ordered as part of the exam to be covered as preventive, they must be coded by the provider as routine — without indication of injury or illness.

One per calendar year is covered as preventive. Additional screenings beyond one (1) per calendar year are covered as diagnostic unless otherwise specified.

The cancer screening benefit includes, but is not limited to:

  • Breast Cancer, Screening: mammograms, no age limit*. Standard two-dimensional (2-D) breast mammography and breast tomosynthesis (three-dimensional [3-D] mammography)
  • Cervical Cancer, Screening: pap smears – no age limit
  • Prostate Cancer, Screening: no age limit
  • Colorectal Cancer, Screening: no age limit

*Additional mammograms are covered, if ordered by a provider, for any woman with a history of breast cancer or whose mother or sister has a prior history of breast cancer.


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