Limited Medical Indemnity Benefit Plans

Transcription

1 Limited Medical Indemnity Benefit Plans Prepared for: Form #USAPLMB

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3 SECTION 1 Overview of the Plans SECTION 2 Limited Medical Indemnity Insurance Benefits Limited Medical Indemnity Insurance Benefits Limitations and Exclusions SECTION 3 Rx Benefits Insured Generic Rx

4 SECTION 1 Overview of the Plans You are eligible to receive the following benefits by becoming a member of the American Advantage Association. Total Monthly Fees* 250 Plan 250 Plus Plan 500 Plan 1000 Plan Individual $ $ $ $ Member / Spouse $ $ $ $ Member / Children $ $ $ $ Family $ $ $ $ The Limited Medical Indemnity Insurance Benefits listed below are underwritten by United States Fire Insurance Company, rated A by AM Best Limited Insurance Benefits 250 Plan 250 Plus Plan 500 Plan 1000 Plan See page 7 for monthly premium rates. Maternity: Excluded Pre-existing Conditions: 12/12 applied to Hospital, Surgery and related only Physician s Office Visit Benefit (30 day waiting period for sickness) Wellness Physician s Office Visit Benefit (30 day waiting period for sickness) Emergency Room Benefit Lab and X-ray Benefit Hospital Admission Benefit Hospital Confinement Daily Benefit ICU Confinement Daily Benefit Surgery Benefit (See pages 8-11 for surgical schedule) Benefit (See pages 8-11 for surgical schedule) $80.00 per visit Max 3 visits per covered $90.00 per visit Max 1 visit per covered NA NA NA $ Max 30 days per covered $ Max 15 days per covered NA NA $90.00 per visit Max 3 visits per covered $90.00 per visit Max 1 visit per covered $50.00 per visit Max 3 visit per covered $50.00 per visit Max 3 tests per covered $ payment per covered $ Max 30 days per covered $ Max 15 days per covered See pages 8-11 for surgical schedule Max 1 surgery per policy year See pages 8-11 for surgical schedule Scheduled Benefit $90.00 per visit Max 5 visits per covered $90.00 per visit Max 1 visit per covered $ per visit Max 3 visit per covered $ per visit Max 3 tests per covered $1, payment per covered $ Max 30 days per covered $ Max 15 days per covered See pages 8-11 for surgical schedule Max 1 surgery per policy year See pages 8-11 for surgical schedule Scheduled Benefit Skilled Nursing Benefit NA NA NA Ambulance NA NA $ trip per policy year IP Mental Health NA NA NA OP Mental Health NA NA NA $90.00 per visit Max 5 visits per covered $90.00 per visit Max 1 visit per covered $ per visit Max 3 visit per covered $ per visit Max 3 tests per covered $1, payment per covered $1, Max 30 days per covered $1, Max 15 days per covered See pages 8-11 for surgical schedule Max 1 surgery per policy year See pages 8-11 for surgical schedule Scheduled Benefit $ Max 10 visits $ trip per policy year $ Max 10 visits $ Max 5 visits These limited medical indemnity insurance benefits are underwritten by United States Fire Insurance Company, rated A by AM Best 2010, and are subject to the terms, definitions, conditions, exclusions and limitations of the group policy. Coverage is not provided for loss due to a pre-existing condition for 12 months from the Covered Person s effective membership date. Coverage is not provided for members age 65 or over. Coverage will terminate at the end of the monthly billing cycle prior to turning age month Pre-existing Condition Limitations only apply to Hospital, ICU/CCU Surgery and. 30 day waiting period for sickness applies. Changes to coverage underwritten by United States Fire Insurance Company can only be made if the change is the result of a qualifying life event. A qualifying life event means marriage, divorce, the death of your spouse, or the birth or adoption of a child. If coverage is cancelled, persons may not re-enroll in coverage with United States Fire Insurance Company until six-months after their termination date. Benefits are not available in AK, AR, CT, KS, LA, ME, MD, MA, MT, NH, NJ, NY, NC, OR, RI, VT, & WA. MEMBERS CAN BE ENROLLED ONLY ONCE. DUPLICATE OR MULTIPLE MEMBERSHIPS, INCLUDING LIMITED MEDICAL INDEMNITY INSURANCE UNDERWRITTEN BY UNITED STATES FIRE INSURANCE COMPANY, IS NOT ALLOWED. THIS IS NOT BASIC HEALTH INSURANCE OR MAJOR MEDICAL COVERAGE AND IS NOT DESIGNED AS A SUBSTITUTE FOR BASIC HEALTH INSURANCE OR MAJOR MEDICAL COVERAGE. 4

5 The Insured Generic Rx Benefit listed below is underwritten by Companion Life Insurance Company. Insured Generic RX 250 Plan 250 Plus Plan 500 Plan 1000 Plan See page 10 for monthly premium rates. Insured Generic Rx *Total monthly fees may vary depending on your state of residence. Total monthly fees include association membership fee, insurance premium rates, and marketing and administration fees. The non-insured benefits listed below are provided through the American Advantage Association. Association Membership Benefits 250 Plan 250 Plus Plan 500 Plan 1000 Plan Monthly Fee for Association Membership $49.95 $49.95 $49.95 $49.95 SHOPPING & ENTERTAINMENT BENEFITS Discount Shopping and Entertainment Price Protection - Low Price Guarantee Extended Service Protection Online Comparison Shopping Warranty Registration Travel BENEFITS Full Service Travel Agency Travel Insurance Benefits Health & Wellness MyEWellness Discount Prescription Benefit VIP Health & Wellness AUTO BENEFITS Roadside Assistance Services Auto Deductible Benefit Home Benefits Home Deductible Home Emergency Medical Expense Benefit Emergency Cash (Loss of Use Coverage) Rent or Mortgage Emergency Lodging Early Mortgage Pay-Off Plan LEGAL and Financial BENEFITS Family Legal Plan Benefits Tax Preparation & Advice Services Lost or Stolen Credit Card Assistance Identity Theft Restoration Identity Theft Insurance Benefits DISCOUNT MEDICAL BENEFITS NA $ monthly max $10 Co-Pay / $50 Deductible $ monthly max $10 Co-Pay / $50 Deductible $ monthly max $10 Co-Pay / $50 Deductible Consult a Doctor Aetna Discount Dental Services Coast to Coast Vision Discount Tier Rx Benefit Lab and Imaging Services Please see USAdvantagePlans Premier Plus booklet for more information on the association benefits. 5

6 SECTION 2 Limited Medical Indemnity Insurance Benefits Limited Medical Indemnity Insurance Benefits Physician s Office Visit Benefit Benefits are paid if a covered person visits a doctor s office for medically necessary treatment or care of an injury or sickness covered under the policy. 30 day waiting period for sickness applies. Wellness Physician s Office Visit Benefit Benefits are paid if a covered person visits a doctor s office for medically necessary wellness care covered under the policy. 30 day waiting period for sickness applies. ER Benefit If a Covered Person requires Medically Necessary treatment by a Doctor in a Hospital emergency room for a Medical Emergency due to an Injury or Sickness, coverage is provided for treatment, services and supplies. Benefits are paid an indemnity amount depending on plan selected. Lab and X-ray Benefit Benefits are paid for x-rays and laboratory testing including Pap test, colorectal screening, prostate cancer screening, mammography and bone density screening. Benefits are paid an indemnity amount depending on plan selected. Hospital Admission Benefit Benefits are paid as a Hospital Admission Benefit as shown on the Certificate Schedule if any Covered Person incurs charges and is admitted to a Hospital as the result of injuries received in a Covered Accident or Covered Sickness while this coverage is in force. Pays an indemnity benefit depending on plan selected. This benefit is paid in addition to hospital, semi-private room, or intensive care or cardiac care unit. One admission benefit per covered. Hospital Confinement Daily Benefit Benefits are paid if a covered person is confined as an inpatient in a hospital because of a covered injury or sickness. Pays an indemnity benefit depending on plan selected. ICU Confinement Daily Benefit Benefit is paid in addition to the Hospital Confinement Room benefit described above. For purposes of this benefit, Period of Confinement means one continuous ICU or CCU confinements, or two or more separate ICU or CCU confinements for the same or a related cause that are each separated by less than 72- hours. Pays an indemnity benefit depending on plan selected. Surgery Benefit When surgery for a Covered Person is performed in an Outpatient Surgery Facility or while Confined to a Hospital, coverage is provided for the use of the operating and recovery room, including the Doctor s charges for performing surgery. Benefits are also provided for medical services and supplies used in the performance of the surgery. Pays a scheduled surgical benefit per covered with an Annual Maximum depending on plan selected. Please see pages 8-11 for surgical schedule. Benefit Benefits are paid if a covered person undergoes medically necessary surgery at the direction of a doctor for a covered injury or sickness. Benefits are paid at 25% of the paid surgical benefit depending on plan selected. Benefit paid for anesthesia services for pre-operative screening and the administration of anesthesia during a surgical procedure whether performed as an inpatient or on an outpatient basis. Please see pages 8-11 for surgical schedule. 6

7 Skilled Nursing Benefit (1000 plan only) Benefits are provided at $100 per day for a maximum of 10 days per covered for room and board while a Covered Person is Confined as a registered bed-patient in the facility. Such Confinement must start within 14 days after the end of a covered Hospital Confinement of at least 3 continuous days and be ordered by a Doctor to recover from an Injury or Sickness that caused the prior Hospital Confinement. Ambulance Benefits are paid when a Covered Person requires the services of a licensed professional ambulance company for transportation to or from a Hospital (or other facility licensed and qualified to provide proper care). IP Mental Health (1000 plan only) Benefits are provided at $100 per day for a maximum of 10 days per covered while a Covered Person is confined in a Hospital for the treatment and care of Mental or Nervous Disorder and the stay is prescribed by a Doctor as Medically Necessary for the Covered Person s condition. OP Mental Health (1000 plan only) Benefits are provided at $100 per day for a maximum of 5 days per covered while a Covered Person is confined in a Rehabilitation Facility for the treatment and care of Mental or Nervous Disorder and the stay is prescribed by a Doctor as Medically Necessary for the Covered Person s condition. These limited medical indemnity insurance benefits are underwritten by United States Fire Insurance Company, rated A by AM Best 2010, and are subject to the terms, definitions, conditions, exclusions and limitations of the group policy. Coverage is not provided for loss due to a pre-existing condition for 12 months from the Covered Person s effective membership date. Coverage is not provided for members age 65 or over. Coverage will terminate at the end of the monthly billing cycle prior to turning age month Pre-existing Condition Limitations only apply to Hospital, ICU/CCU Surgery and. 30 day waiting period for sickness applies. Changes to coverage underwritten by United States Fire Insurance Company can only be made if the change is the result of a qualifying life event. A qualifying life event means marriage, divorce, the death of your spouse, or the birth or adoption of a child. If coverage is cancelled, persons may not re-enroll in coverage with United States Fire Insurance Company until six-months after their termination date. Benefits are not available in AK, AR, CT, KS, LA, ME, MD, MA, MT, NH, NJ, NY, NC, OR, RI, VT, & WA. MEMBERS CAN BE ENROLLED ONLY ONCE. DUPLICATE OR MULTIPLE MEMBERSHIPS, INCLUDING LIMITED MEDICAL INDEMNITY INSURANCE UNDERWRITTEN BY UNITED STATES FIRE INSURANCE COMPANY, IS NOT ALLOWED. THIS IS NOT BASIC HEALTH INSURANCE OR MAJOR MEDICAL COVERAGE AND IS NOT DESIGNED AS A SUBSTITUTE FOR BASIC HEALTH INSURANCE OR MAJOR MEDICAL COVERAGE. The insurance premium is the premium rate charged for the insurance coverage underwritten by United States Fire Insurance Company and offered through your membership in the American Advantage Association. The insurance premium rates for the following memberships are: Plan: 250 Plan 250 Plus Plan 500 Plan 1,000 Plan Individual $48.55 $72.50 $ $ Member/Spouse $ $ $ $ Member/Children $91.03 $ $ $ Family $ $ $ $ Insurance premium rates may vary depending on your state of residence. 7

8 If a surgical procedure can not be located on this list, you need to contact the administrator to determine the appropriate dollar reimbursement. Procedure 1000 Plan 500 Plan 250 Plus Plan $10,000 25% $5,000 25% $2,500 25% ABDOMEN Appendectomy Removal of gallbladder $5,000 $1,250 $2,500 $625 $1,250 $313 Total Gastrectomy $8,500 $2,125 $4,250 $1,063 $2,125 $531 Gastrotomy Laparotomy, exploratory AMPUTATION Amputation of upper arm Amputation of finger/thumb Amputation of leg at hip $5,000 $1,250 $2,500 $625 $1,250 $313 Amputation of lower leg $5,000 $1,250 $2,500 $625 $1,250 $313 Amputation of toe BREAST Removal of breast Removal of breast lesion Breast reconstruction $5,000 $1,250 $2,500 $625 $1,250 $313 CHEST Exploratory Thoracotomy $5,000 $1,250 $2,500 $625 $1,250 $313 Bronchoscopy (esophagoscopy) Esophagectomy $8,500 $2,125 $4,250 $1,063 $2,125 $531 Lung, removal of or portion of (Lobectomy) $5,000 $1,250 $2,500 $625 $1,250 $313 Valvotomy or commissurotomy, closed $5,000 $1,250 $2,500 $625 $1,250 $313 Aortic, Mitral, or Tricuspid Valvuloplasty, open with bypass $8,500 $2,125 $4,250 $1,063 $2,125 $531 Tetralogy of Fallot with Bypass $8,500 $2,125 $4,250 $1,063 $2,125 $531 Double valve procedure replacement and or repair $8,500 $2,125 $4,250 $1,063 $2,125 $531 DISLOCATION, REDUCTION OF Treat ankle dislocation Treat clavicle dislocation Treat elbow dislocation Treat hip dislocation Reset dislocated jaw Treat shoulder dislocation Treat wrist dislocation Treat knee dislocation $5,000 $1,250 $2,500 $625 $1,250 $313 8

9 Procedure 1000 Plan 500 Plan 250 Plus Plan $10,000 25% $5,000 25% $2,500 25% ARTHROTOMY Ankle arthroscopy/surgery Elbow arthroscopy/surgery Hip arthroscopy/surgery Knee arthroscopy/surgery $5,000 $1,250 $2,500 $625 $1,250 $313 Shoulder arthroscopy/surgery $5,000 $1,250 $2,500 $625 $1,250 $313 EAR, NOSE, THROAT Fenestration $5,000 $1,250 $2,500 $625 $1,250 $313 Mastoidectomy-single $5,000 $1,250 $2,500 $625 $1,250 $313 Extensive mastoid surgery $5,000 $1,250 $2,500 $625 $1,250 $313 Adnoidectomy (independent procedure) Sinusotomy, frontal, external simple (Trephine) Submucous resection of nasal septum (septectomy) Laryngectomy, without neck dissection Tonsillectomy, with or without adenoidectomy-under age 18 Tonsillectomy, with or without adenoidectomy-18 and over Tracheotomy (independent procedure) EYE Cataract, operation for intracapsular, extracapsular $5,000 $1,250 $2,500 $625 $1,250 $313 unilateral Repair detached retina $5,000 $1,250 $2,500 $625 $1,250 $313 Removal of eye $5,000 $1,250 $2,500 $625 $1,250 $313 FRACTURE, TREATMENT OF Treatment of ankle fracture Treat finger fracture, each Treatment of nose fracture Treat fracture radius & ulna Treatment of fibula fracture GENITO_URINARY TRACT Cervix amputation (cervicectomy) Circumcision Newborn Clamp Dilation & Curettage (non- Puerperal) Partial hysterectomy $5,000 $1,250 $2,500 $625 $1,250 $313 Total hysterectomy $5,000 $1,250 $2,500 $625 $1,250 $313 Vaginal hysterectomy $5,000 $1,250 $2,500 $625 $1,250 $313 Kidney -Nephropexy $5,000 $1,250 $2,500 $625 $1,250 $313 9

10 Procedure 1000 Plan 500 Plan 250 Plus Plan $10,000 25% $5,000 25% $2,500 25% GENITO_URINARY TRACT Kidney transplant, unilateral or bilateral, recipient with $8,500 $2,125 $4,250 $1,063 $2,125 $531 nephrectomy Ureterotomy Cystotomy Prostate, removal of (Prostatectomy) exposure, prostate $5,000 $1,250 $2,500 $625 $1,250 $313 Extensive prostate surgery $5,000 $1,250 $2,500 $625 $1,250 $313 Removal of epididymis Cyctocele, operation for anterior colporrhaphy Rectocele operation for posterior colporrhaphy Rectocele and cystocele A&P colporrhaphy GOITRE Adenoma or benign tumor of thyroid excecion Thyroidectomy $5,000 $1,250 $2,500 $625 $1,250 $313 HERNIA Repair Inguinal-unilateral Repair Umbilical-under age 5 Repair Umbilical-over age 5 Repair Ventral (incisional) Repair Femoral Repair Epigastric LIGAMENTS AND TENDONS Revise lower leg tendons Repair hand tendon Repair finger/hand tendon $5,000 $1,250 $2,500 $625 $1,250 $313 Transplant hand tendon $5,000 $1,250 $2,500 $625 $1,250 $313 OBSTETRICAL Removel of placenta and/or immediate or early repair of pereneum and/or cervix Cesarean Section, complete procedure including delivery Cesarean Section and Hysterectomy, total or subtotal Ectopic (tubal, extra-uterine) pregnancy Miscarriage, including dilation and curettage $5,000 $1,250 $2,500 $625 $1,250 $313 $5,000 $1,250 $2,500 $625 $1,250 $313 $5,000 $1,250 $2,500 $625 $1,250 $313 10

11 Procedure 1000 Plan 500 Plan 250 Plus Plan PILONIDAL CYST OR SINUS Removal of pilonidal lesion Drainage of pilonidal cyst RECTUM $10,000 25% $5,000 25% $2,500 25% Fissure (Fissurectomy) cutting operation for (Independent Procedure) Incise external hemorrhoid Destruction of hemorrhoids Hemorrhoidectomy and Fistulotomy or Fistulectomy Papillectomy, single tag (independent procedure) SKULL Osteoplastic craniotomy (other than operation for $8,500 $2,125 $4,250 $1,063 $2,125 $531 brain tumor) Trephine Hemispherectomy $8,500 $2,125 $4,250 $1,063 $2,125 $531 SPINE OR SPINAL CORD Laminectomy Spinal cord tumor operation $5,000 $1,250 $2,500 $625 $1,250 $313 TUMOR Remove tumor of arm/elbow $5,000 $1,250 $2,500 $625 $1,250 $313 Remove tumor, neck/chest VARICOSE VEINS Revision of leg vein TRANSPLANT & PARTIAL ORGAN REMOVAL Lung Transplant $10,000 $2,500 $5,000 $1,250 $2,500 $625 Lung Transplant with bypass $10,000 $2,500 $5,000 $1,250 $2,500 $625 Heart and Lung Transplant $10,000 $2,500 $5,000 $1,250 $2,500 $625 Liver Transplant $10,000 $2,500 $5,000 $1,250 $2,500 $625 Liver - partial removal $10,000 $2,500 $5,000 $1,250 $2,500 $625 Pancreas - partial removal $10,000 $2,500 $5,000 $1,250 $2,500 $625 *For surgical procedures not listed, the benefit amount will be determined based on a percentage of a fixed relative value scale. The percentage used will be the same percentage as used in determining the benefit amount for the listed procedures. 11

12 Limitations and Exclusions United States Fire Insurance Company Limited Medical Indemnity Insurance Benefits Limitations and Exclusions Benefits will not be paid for charges or loss caused by, or resulting from, any of the following: 1. Suicide or any intentionally self-inflicted Injury; 2. Any drug, narcotic, gas or fumes, or chemical substance voluntarily taken, administered, absorbed or inhaled unless prescribed by, and taken according to the directions of, a Doctor (accidental ingestion of a poisonous substance is not excluded.). 3. Commission, or attempt to commit, a felony; 4. Participation in a riot or insurrection; 5. Driving under the influence of a controlled substance, unless administered on the advice of a Doctor; 6. Driving while Intoxicated. Intoxicated will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs. 7. Declared or undeclared war or act of war; 8. Nuclear reaction or the release of nuclear energy. However, this exclusion will not apply if the loss is sustained within 180-days of the initial incident and: 9. The loss was caused by fire, heat, explosion or other physical trauma which was a result of the release of nuclear energy; and 10. The Covered Person was within a 25-mile radius of the site of the release either: a. At the time of the release; or b. Within 24-hours of the start of the release; or c. Occurs while he is in the issue state of this Certificate; 11. Routine health checkups or immunizations for Covered Person aged 6 and older; expenses for allergies, allergy serum or allergy testing, unless specifically provided for in this Certificate; 12. Surgery to correct vision or hearing; eyeglasses, contact lenses and hearing aids, braces, appliances, or examinations or prescriptions therefore, 13. Dental care, x-rays, or treatment other than Injury to sound, natural teeth and gums resulting from an accidental Injury and rendered within 6-months of the Injury; 14. Spinal manipulations and manual manipulative treatment or therapy; 15. Rest cures or custodial care, or treatment of sleep disorders; 16. Treatment, services or supplies received outside of the U.S. except for acute Sickness or Injury sustained during the first 30-days of travel outside the U.S.; 17. Any drug, treatment, or procedure that either promotes or prevents conception or childbirth regardless of what the drug, treatment, or procedure was originally prescribed or intended for; 18. Blood or Blood plasma, except for charges by a Hospital for the processing or administration of blood; 19. Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy; 12

13 20. Cosmetic surgery. This Exclusion does not apply to reconstructive surgery: a. On an injured part of the body following trauma, infection or other disease of the involved part; b. Of a congenital disease or anomaly of a covered dependent newborn or adopted infant; or c. On a non-diseased breast to restore and achieve symmetry between two breasts following a covered Mastectomy; 21. The repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; dentures, partial dentures, braces or fixed or removable bridges; 22. Treatment or removal of warts, moles, boils, skin blemishes or birthmarks, bunions, acne, corns, calluses, the cutting and trimming of toenails, care for flat feet, fallen arches or chronic foot strain; 23. Personal items such as television, telephone, lotions, shampoos, extra beds, meals for guests, take home items, or other items for comfort and convenience; 24. Treatment of Mental or Nervous Disorders, or alcohol or substance abuse, unless specifically provided for under this Certificate; 25. Prescription medicines, unless specifically provided for under this Certificate; 26. Any Injury that is caused by flight or travel in, or upon: a. An aircraft or other, craft designed for navigation above or beyond the earth s atmosphere except as a fare-paying passenger; b. An ultra light, hanggliding, parachuting or bungi-cord jumping; c. A snowmobile; d. Any two or three wheeled motor vehicle; e. Any off-road motorized vehicle not requiring licensing as a motor vehicle; f. Any watercraft or other craft designed for water use above or beneath the water, except as a fare-paying passenger; 27. Any accidental Injury where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator s license; 28. Services, treatment or loss: a. Rendered in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay; b. Payable by any automobile insurance policy without regard to fault. (Does not apply in any state where prohibited); c. Which a Covered Person would not have to pay if he did not have insurance; d. Provided by a Doctor, Nurse or any other person who is employed or retained by a Covered Person or who is a member of a Covered Person s Immediate Family; e. Covered by state or federal worker s compensation, employers liability, occupational disease law, or similar laws; f. Injury or Sickness sustained while on active duty in the armed forces of any country. This does not include Reserve or 29. National Guard duty for training. Upon receipt of proof of service, we will refund, any unearned premium paid on a pro rata basis; 30. Hemorrhoids, tonsils, adenoids, middle ear disorders, any disease or disorder of the reproductive organs unless the loss is incurred at least 6-months after the Covered Person becomes insured under this Certificate; 31. Elective treatment or surgery and treatment, procedures, products or services that are experimental or investigative. Experimental or Investigative means a drug, device or medical treatment or procedure that: a. Cannot lawfully be marketed without approval of the United States Food and Drug Administration and approval for marketing has not been given at the time of being furnished; b. Has Reliable Evidence indicating it is the subject of ongoing clinical trials or is under study to determine its maximum tolerated dose, toxicity, safety, efficacy, or its efficacy as compared with the standard means of treatments or diagnosis; or c. Has Reliable Evidence indicating that the consensus of opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, efficacy, or its efficacy as compared with the standard means of treatment or diagnosis. Reliable Evidence means (i) published reports and articles in authoritative medical and scientific literature; (ii) the written protocol(s) of the treating facility or the protocols of another facility studying substantially the same drug, device, medical treatment or procedure; or (iii) the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure. Please note that exclusions vary by state. 13

14 SECTION 3 Rx Benefits Insured Generic Rx Retail Services $10 co-pay for covered outpatient generic drugs when prescriptions are filled at participating pharmacies $50 annual deductible per family member $250 monthly maximum benefit per insured person, $500 monthly maximum per family Co-pay applies to each 30 day supply Over 58,000 participating pharmacies Up to 25% off brand medications Mail Order Services $30 co-pay for covered outpatient generic drugs when filled through our mail order service, maximum supply of 90 days Purchases are applied toward the annual deductible and monthly maximum* This benefit is provided to Members by a group policy issued to American Advantage Association by Companion Life Insurance Company. All benefits provided by this insurance are subject to the terms, definitions, conditions, exclusions and limitations of the group policy. A brief list of exclusions includes the following: injectables, experimental drugs, vitamins, infertility, cosmetic drugs and brand name drugs. Please refer to the Description of Coverage for a complete list of exclusions and limitations. Coverage becomes effective on the date provided in your membership materials. *BRAND PURCHASES CANNOT BE APPLIED TO THE DEDUCTIBLE. THIS BENEFIT IS NOT AVAILABLE IN CA, CT, GA, HI, ME, MD, MN, NV, NJ, NM, NY, OR, SD, TN, VT, & WA. MEMBERS IN THESE STATES WILL RECEIVE THE 4-TIER RX BENEFIT. The Insured Generic Rx premium rates for the following memberships are: Plan: 250 Plan 250 Plus Plan 500 Plan 1,000 Plan Individual NA $14.02 $14.02 $14.02 Member/Spouse NA $27.33 $27.33 $27.33 Member/Children NA $23.83 $23.83 $23.83 Family NA $36.45 $36.45 $36.45 Benefits are provided through your membership in the American Advantage Association. 14

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