Glasses, Prescription Sunglasses, Prescription Safety Goggles (work related) or Contact Lenses LASIK Eye Surgery (no waiting period)

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1 Standard Health Benefits for services and supplies provided by KEMH, Mid-Atlantic Wellness Institute and Government Approved Testing Facilities in Bermuda Inpatient and Outpatient care & services (including emergency department, in/outpatient surgery, ground ambulance and diagnostic testing) Professional charges billed by KEMH/MAWI Hospice Inpatient Care Home Care Medical Services Cardiac Care and Diabetes Outpatient Programs Government Approved Private Testing Facility Artificial Limbs and Appliances Prosthetic Devices & implantable appliances Chronic Disease Management Program All other non-standard-hospital benefit services & supplies PW, SP or PRIV on your insurance card As per the Act, 100% of the Lifetime maximum as per the Act (amounts over $30,000 are applied to Major Medical benefits) 100% of the Bermuda Hospital 100% of the Bermuda Hospital 100% of the Bermuda Hospital Vision Care Annual Eye Exam (performed by an Optometrist) Glasses, Prescription Sunglasses, Prescription Safety Goggles (work related) or Contact Lenses LASIK Eye Surgery (no waiting period) VC on your insurance card $ (1 Exam every 12 months) $ maximum every 24 months Not Applicable Prescribed Medications (may be utilized outside of Bermuda) PD on your insurance card 80% brand or generic. Maximum of $3,000 per calendar year

2 Preventative Health Care and Chronic Disease Management (may be used locally or overseas) Asthma, Allergy, Audiology, COPD or Smoking Cessation Initial Consult Asthma, Allergy, Audiology, COPD or Smoking Cessation Subsequent Visits (individual or group sessions) Nutritional Initial Consult (Registered Dieticians/Approved Nutritionists; includes Nutrifit) Nutritional Subsequent Visits (Registered Dieticians/Approved Nutritionists; includes Nutrifit H/O on your insurance card $ $48.00 (6 visits per calendar year) $ $48.00 (6 visits per calendar year) Diabetic Counseling Initial Consult $ Diabetic Counseling Subsequent Visits (group or individual) $37.00 (6 visits per calendar year) Annual General Health Exam General Practitioner $ Annual General Health Exam Specialist $ Routine Diagnostic Testing Performed w/ Annual Exam (no waiting period) Therapeutic Optometry Diagnostics (approved therapeutic optometrists) Annual GYN Exam Well Baby Care Pediatric Annual Exam Diagnostic Testing & Imaging at a Private Facility (no waiting period) Private Cardiac Care or BF&M registered Weight Management Program (Ocean Rock, BWOC, Medical Nutrition Therapy) Immunizations and Injections $ maximum per calendar year Local: 100% of the BF&M Overseas: matches overseas determination of coverage 100% or 50% $ (1 visit every 12 months) $85.00 (maximum 8 visits per calendar year) $ (valid for children age 2 to 16 years old) Local: 100% of the Bermuda Overseas: matches overseas determination of coverage 100% or 50% $ per session (23 visits per calendar year) Please see Major Medical section for these benefits

3 Home or Office Medical, Surgical and Psychiatric Benefits (may be used locally or overseas) General Practitioner Office Visit H/O on your insurance card Local: $75.00 Overseas: 100% up to $250 per visit General Practitioner or Specialist Home Visit $ Specialist Initial Consult Specialist Follow-up Visit In Office Surgery Physical/Occupational/Speech Therapy, TENS, Chiropractor, Therapeutic Massage or Smoking Cessation Acupuncture Lymphedema Services Chiropodist/Podiatrist Psychiatry - outpatient or in the office Clinical Psychology or Licensed Counselors and Therapists (Individual sessions - outpatient or in the office) Clinical Psychology or Licensed Counselors and Therapists (Group Therapy- outpatient or in the office) Local:$ per Consult Overseas: 100% up to $325 per visit (1 consult every 6 months for a new/different diagnosis) Local: $75.00 Overseas: 100% up to $250 per visit Local: 100% of the Medical & Dental Charges Overseas: matches overseas determination of coverage 100% or 50% $68.00 per visit ($1, maximum per year) $ (28 visits per calendar year) $60.00 (12 visits per calendar year) $ (25 visits per calendar year) $93.00 (12 visits per calendar year) $44.00 (24 visits per calendar year) Major Medical Lifetime Amounts Lifetime Maximum per Insured person Under age 65 (including children) - $1 million Over age 65 - $500, Maximum per calendar year Up to $100, Deductible None

4 Major Medical - Worldwide Benefits Inpatient Treatment for Substance Abuse Inpatient Physical Rehabilitation Room & Board Ground Ambulance Skilled Nursing Facility Room & Board Commercial Air Fare Airfare expenses are ineligible for care that is not preapproved by the Company or is out of network Overseas Hotel Accommodations Accommodation expenses are ineligible for care that is not preapproved by the Company or is out of network Mid Atlantic Wellness Institute rate per day. (Maximum of two 28-day admissions per lifetime) Maximum $45,000 per calendar year 100% billed charges; unlimited per calendar year $25, per calendar year Maximum $4, per calendar year Maximum $ per day (up to $18, per calendar year) Major Medical - Local & Worldwide Benefits Home Health Nursing Care Private Doctor's Professional Fees for services to hospital in/out patients (includes OB, Surgical, Medical, Sub-specialities, Anesthesia) Sclerotherapy Air Ambulance/Medical Air Evacuation Durable Medical Equipment (includes medical alarm device hardware) Orthotics, Surgical Hose, Wigs and Surgical Bras (2 per year) Maximum of 4 hours per day (up to $25, per calendar year) Local: 100% of billed charges; Medical & Dental Overseas: Matches overseas determination of cover (50% or 100%) Up to $5, in any 6 years (maximum of 6 treatments) 100% billed charges; unlimited per year (must be pre-approved by the Company) 80% up to $15, per calendar year Items utilize the durable medical equipment benefit

5 Major Medical - Local & Worldwide Benefits Genetic Testing Allergy Testing Allergy Injections Prosthetic Devices & implantable appliances Immunizations and Injections $4, per lifetime (must be pre-approved) $ maximum per lifetime 80% of billed charges to a maximum of $ per calendar year Locally: 100% billed charges; unlimited per calendar year. Overseas: matches overseas coverage determination (reimbursed at 50% or 100%) 80% of the Average Wholesale Price Repatriation of Remains Maximum of $5, Overseas Hospital Benefits (includes hospital based inpatient/outpatient care and associated professional fees)* Coverage Type Pre-Approved/In Network *** In Network (Not Pre-Approved)** Not in Network** Network Type Smart Care Individual Health 100% of billed charges 50% of billed charges 50% of billed charges Smart Care Preferred Provider network *Refer to H/O section of this Schedule for in-office care reimbursements ** Does not qualify for airfare or lodging reimbursement *** In network Providers are preferred and updated regularly. Please contact our Nurse Case Managers by at or visit to verify the Provider s status

6 Smart Care Individual Health Schedule of Dental Benefits Description or Type of Coverage Smart Care Dental Benefits Pre-Treatment Estimate $1, Basic Dental (cleaning, scaling, root planning, fluoride, polish) BD on your insurance card Medically Necessary services 100% paid in accordance with the ODA Fee Guide* Calendar Year Maximum: $1400 Lifetime Maximum: unlimited Basic Dental & Endodontic services (all other services not listed above) BD on your insurance card Medically Necessary services 100% paid in accordance with the ODA Fee Guide. Calendar Year Maximum: unlimited Lifetime maximum: unlimited Periodontal Treatment BD on your insurance card Restorative 50% of the ODA Fee Guide. Calendar Year Maximum: $2,000 Lifetime Maximum: unlimited Not Applicable Orthodontic Not Applicable *ODA means Ontario Dental Association Fee Guide

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