Figure: 28 TAC §21.2106(b)(4)

NOTICE OF CERTAIN MANDATORY BENEFITS

This notice is to advise you of certain coverage and/or benefits provided by your contract with [name of carrier].

Examinations for Detection of Prostate Cancer

Benefits are provided for each covered male for an annual medically recognized diagnostic examination for the detection of prostate cancer. Benefits include:

        (a) a physical examination for the detection of prostate cancer; and
        (b) a prostate-specific antigen test for each covered male who is
                (1) at least 50 years of age; or
                (2) at least 40 years of age with a family history of prostate cancer or other prostate cancer risk factor.

If any person covered by this plan has questions concerning the above, please call [name of carrier] at [customer service or related department phone number], or write us at [carrier’s customer service or related department address].

Form Number 258 Prostate