Diagnostic X-Ray and Lab (DXL) Benefit

The DXL Benefit is for eligible employees, retirees and spouses. It also applies to employees, retirees and spouses who are continuing their coverage by making COBRA self-payments. No benefits are payable under this benefit for dependent children.

Unlike the Routine Exam Benefit, the DXL Benefit applies to x-ray and lab services that are necessary to diagnose or treat a non-occupational injury or sickness, as well as to x-rays and lab services for routine diagnostic health screening that are ordered by a doctor as part of a routine physical examination.

Covered Expenses; Benefits Payable - The Plan pays 100% of the first $150 of covered expenses you incur during a calendar year. Any amount of covered expenses over $150 for x-ray and lab charges during a year WILL BE considered under the Comprehensive Benefit. Covered expenses under the DXL Benefit include the reasonable and customary charges incurred for outpatient x-rays, EKGs, MRIs, computerized scans, sonograms, mammograms, blood tests, urinalysis, and other tests that are consistent with prevailing medical standards and appropriate for the patient's age, sex and medical history. Covered expenses include interpretation of covered tests by a radiologist or pathologist. The services can be performed in a hospital outpatient department, an outpatient radiology center or laboratory, or at a doctor's office.

Exclusions - Not covered under the DXL Benefit are charges made for radiation therapy or charges made in connection with chiropractic care, mental or nervous disorders, substance abuse, non-surgical TMJ, non-pre-certified or out-of-network TMJ/jaw surgery (see No. 18 on page 48), vision care, dental treatment, tests that are not consistent with prevailing medical standards, or any other type of treatment that is subject to special benefit limitations (see the Schedule of Benefits for the types of treatment subject to special benefit limitations.) Charges for certain types of treatments and conditions (such as obesity and cosmetic surgery) are also not covered (see What the Plan Does Not Cover starting on page 72).