Figure: 28 TAC §21.2106(b)(7)

NOTICE OF CERTAIN MANDATORY BENEFITS

This notice is to advise you of certain coverage or benefits provided by your contract with (name of
carrier).

Coverage of Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer

Coverage is provided for each woman enrolled in the plan who is 18 years of age or older for expenses
incurred for an annual, medically recognized diagnostic examination for the early detection of ovarian and
cervical cancer. Coverage required under this section includes a CA 125 blood test and, at a
minimum, a conventional Pap smear screening or a screening using liquid-based cytology methods, as
approved by the FDA, alone or in combination with a test approved by the FDA for the detection of the
human papillomavirus.