Provisions Governing Colorectal Cancer Screenings

Some features of the Plan described on this page have been affected by the December 2010 Summary of Material Modifications (SMM), effective January 1, 2011. Click here to access the SMM.

Covered Medical Expenses include colon and rectal cancer screening in accordance with the Age and Frequency Table below.

Colon and Rectal Cancer Screening Age and Frequency Table
Risk Category Definition of Risk Category Recommended (Covered) Procedure and Frequency Minimum Age of First Screening Alternate Covered Procedures (In Lieu of Recommended Procedure)
Average
Age 50 or older and no other risk factors
Colonoscopy every 10 years
50
Fecal occult blood test or fecal immunochemical test every year, plus flexible sigmoidoscopy every 5 years
Moderate
One first degree relative with colorectal cancer or pre-cancerous polyps diagnosed at age 60 or older
Colonoscopy every 10 years
40
High
More than one first degree relative with colorectal cancer or pre-cancerous polyps, or one diagnosed with colorectal cancer or pre-cancerous polyps under age 60
Colonoscopy every 3 years
40, or 10 years younger than the age at which the youngest affected first degree relative is diagnosed, whichever is less
No alternatives are medically indicated*

* No alternatives are medically recommended, but the Plan will cover an annual fecal occult blood test or fecal immunochemical test, and a flexible sigmoidoscopy every 3 years.

Notes: A "year" means a consecutive 12-month period.
Your "first degree relatives" are your mother, father, brothers and sisters.
Virtual colonoscopies and DNA tests are not covered.

How Colon and Rectal Cancer Screening Benefits Are Paid - The reasonable and customary charges for a covered screening procedure will be paid under the Comprehensive Benefit, subject to the calendar year deductible, Plan payment percentages, out-of-pocket maximum, and the calendar year and lifetime maximum benefit limitations.

Rules Governing Benefits for Colon and Rectal Cancer Screening

  1. Benefits will be paid only if the covered person meets the minimum age requirement for that procedure as shown in the table.
  2. You will be considered to be in the average risk category unless your medical records provide evidence that you are at moderate or high risk.
  3. The Plan will cover either the recommended or the alternative procedures shown in the table, but not both. However:
    1. If you meet the minimum age requirement and are at average or moderate risk:
      • If you have a covered flexible sigmoidoscopy in lieu of a colonoscopy, your next covered procedure can be either another flexible sigmoidoscopy or a colonoscopy, provided that, in either case, the procedure is performed at least five years after the first flexible sigmoidoscopy.
      • If, however, you have a covered colonoscopy, your next covered procedure can be either another colonoscopy or a flexible sigmoidoscopy, provided that, in either case, the procedure is performed at least ten years after the first colonoscopy.
    2. If you meet the minimum age requirement and are at high risk, and if you have a covered flexible sigmoidoscopy or a covered colonoscopy, your next covered procedure (either a colonoscopy or a flexible sigmoidoscopy), must be performed at least three years after the first procedure.
  4. The colorectal cancer screening benefits described in this section apply only if a covered person does NOT have a colorectal disease or symptoms of a disease. If disease or symptoms are present, benefits are paid the same as any other illness.