Figure: 28 TAC §21.2106(b)(3)
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].
Coverage and/or Benefits for Reconstructive Surgery After Mastectomy-Annual
Your contract, as required by the federal Womens Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema).
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 [carriers customer service or related department address].
Form Number 1764 Reconstructive Surgery After Mastectomy-Annual