The Benefit Plan provides coverage for the following medical and surgical services provided to a covered person in connection with a mastectomy:

  1. Reconstruction of the breast on which the mastectomy was performed;
  2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
  3. Prostheses and treatment of physical complications of all stages of mastectomy.

Benefits will be subject to annual deductibles, co-payment provisions and other Plan provisions and limitations in a manner consistent with the provisions and limitations applicable to other Plan benefits.