Page 9 - 2017-18 Centennial Benefits Guide Staff
P. 9
Schedule of Dislocations $100 per calendar year for each
Hip $2,000 insured for these tests
Knee $1,000
Ankle $800 Biopsy for skin cancer
Collarbone (sternoclavicular) $500 Colonoscopy
Lower jaw $300
Shoulder $300 Breast ultrasound
Hand (other than ingers) $300
Collarbone (acromioclavicular and $100 Flexible sigmoidoscopy
separation)
Elbow $300 CA 15-3
Wrist $300 Stress test
Finger/toe $100
Open reduction (requires surgery) 2x non-surgical beneit (above) CA 125
Additional Beneits
Blood/plasma/platelets $300 (EE)/$200 (SP or CH) Thermography
Emergency dental work—extraction/ Up to $300
crown CEA/HDL/LDL
Lacerations Up to $800 Cholesterol test
Lodging (per night) $100 per night (max 30 nights)
Prosthetic device or artiicial limb (1/2+) $500/$1,000 Chest x-ray
Ruptured disc (with surgical repair) $400 Serum protein for myeloma
Tendon/ligament/rotator cuff repair Ligament: $500/knee cartilage: $1,000/
(repair of one/multiple/exploratory only) rotator cuff: $500
Transportation $300 per round trip (max 3)
Annual wellness beneit payable for covered individuals each year (after
having the policy for 30 days).
$50 per calendar year for each insured for these tests
Annual physical Glucose screening,
PSA Vaccinations (lu shot,
Triglyceride screening pneumonia, tetanus,
MMR, chicken pox, polio,
Pap smear diphtheria)
CA 9-1 Hemocult stool analysis
Vision/hearing
Centennial Contractors 9
Hip $2,000 insured for these tests
Knee $1,000
Ankle $800 Biopsy for skin cancer
Collarbone (sternoclavicular) $500 Colonoscopy
Lower jaw $300
Shoulder $300 Breast ultrasound
Hand (other than ingers) $300
Collarbone (acromioclavicular and $100 Flexible sigmoidoscopy
separation)
Elbow $300 CA 15-3
Wrist $300 Stress test
Finger/toe $100
Open reduction (requires surgery) 2x non-surgical beneit (above) CA 125
Additional Beneits
Blood/plasma/platelets $300 (EE)/$200 (SP or CH) Thermography
Emergency dental work—extraction/ Up to $300
crown CEA/HDL/LDL
Lacerations Up to $800 Cholesterol test
Lodging (per night) $100 per night (max 30 nights)
Prosthetic device or artiicial limb (1/2+) $500/$1,000 Chest x-ray
Ruptured disc (with surgical repair) $400 Serum protein for myeloma
Tendon/ligament/rotator cuff repair Ligament: $500/knee cartilage: $1,000/
(repair of one/multiple/exploratory only) rotator cuff: $500
Transportation $300 per round trip (max 3)
Annual wellness beneit payable for covered individuals each year (after
having the policy for 30 days).
$50 per calendar year for each insured for these tests
Annual physical Glucose screening,
PSA Vaccinations (lu shot,
Triglyceride screening pneumonia, tetanus,
MMR, chicken pox, polio,
Pap smear diphtheria)
CA 9-1 Hemocult stool analysis
Vision/hearing
Centennial Contractors 9
