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Pre-Existing Conditions and Smokers

A condition is considered pre-existing if a member had symptoms or received treatment within the last 36 months prior to their membership effective date.

Controlled high blood pressure, high cholesterol, sleep apnea, and non-insulin dependent diabetes are not considered pre-existing conditions.  “Control” means the individual is taking his or her medications as prescribed and has not been hospitalized for the condition.

Maintenance medications for any of these conditions can be considered to be part of a Need only if the condition was diagnosed after the membership effective date.

Any other conditions that exist at the time of enrollment that have evidenced symptoms and/or received treatment and/or medication within the past 36 months are not eligible for sharing during the first year of membership.  During the second year of membership up to $25,000 of expenses related to the medical condition are eligible for sharing, and up to $50,000 is eligible for sharing in the third year.  Thereafter, the condition is no longer considered pre-existing and is eligible for full sharing in accordance with the Guidelines.

Smokers pay a $45 monthly surcharge.

Tobacco users age 50 and older have a $25,000 per Need sharing limit for the top four disease states associated with tobacco usage:  heart disease, stroke, COPD, and cancer.  See the Select Membership Guidelines for more information.

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