Florida - miesesinsurancebroker.com INSURANCE.pdf · 80.02.351.1-FL B (1/16) A variety of health benefits plans to fit your needs at affordable rates Visit for more information. Florida

80.02.351.1-FL B (1/16)

A variety of health benefits plans to fit your needs at affordable ratesVisit www.coventryone.com for more information.

Florida A guide for individuals and families

http://www.coventryone.com

Things to think about when choosing your 2016 health benefits plan*:

How your health care needs may be changingMaybe you’re planning to add to your family. Or maybe you had major surgery this year and expect next year to be less eventful! Planning ahead can help you find the right balance between your monthly payment and what you’ll pay out of pocket.

The total cost for your planWhen comparing your plan options, make sure you’re looking at more than just the monthly payment (also called premium). Take a close look at the plan benefits too. Look for terms like “copay” and “deductible.” These will tell you what you could pay for your care when you go to the doctor, pick up a prescription, or have a hospital stay.

Who is in your plan’s networkNetworks can be different depending on the plan you pick. Even plans offered by the same health benefits company could have different networks with different hospitals and doctors. Check that all your doctors are in the network you choose.

* Your health benefits plan company may automatically enroll you in the same plan, or a similar plan, for 2016. You can change your plan during Open Enrollment.

Coventry does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.CoventryOne health benefits products are underwritten by Coventry Health Care of Florida, Inc.

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Local health planCoventry has provided health insurance benefits coverage for more than 25 years. We’re proud of our relationships with the community and our members, and we look forward to serving you.

National strength Aetna (NYSE: AET) is one of the nation’s leading diversified health care benefits companies, serving an estimated 45 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services, workers’ compensation administrative services and health information technology services.

Whether you need a little coverage or a lot, CoventryOne is right for you with:• Affordable plan options that can help you meet

your needs

• Valuable extras that help keep your costs down

• Online tools for easy access

• Friendly, efficient customer service

You’re covered when you need careOur plans include all the Essential Health Benefits, such as:

• Doctor’s office visits, hospital and outpatient care

• Preventive care for adults and children

• Prescription drugs (including a mail-order program)

• Routine gynecological exams including Pap tests

Coventry Health Care, an Aetna company

Free access to a 24-hour Care Line with the AMR for Care Now program – Available in Broward, Miami-Dade and Palm Beach counties

Call AMR for Care Now toll-free at 1-855-FOR-CARE (1-855-367-2273), 24 hours a day, seven days a week, including holidays. AMR for Care Now provides you with access to health care professionals who can address questions and concerns regarding your health care and access to health care services including:

• Arrange a same day or next day appointment with your primary care physician;

• Arrange for an appointment at an urgent care facility; and

• Speaking with a registered nurse who can provide you helpful information and instruction regarding general health care issues and access to health care services.

With AMR for Care Now you will get immediate answers and help in making the best health care decisions for you.

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Extras to help you get more from your health plan

Helpful online tools

Secure online tools help you get the information you need, when you need it:

• Check claims status

• Request or print a new ID card

• Order prescription refills

• Research costs for drugs, procedures and conditions

• Find a doctor at www.coventryone.com

And much, much more.

Coventry® Mobile

While on the go, our mobile app gives you health information at your fingertips. With the app, you can:

• Check the status of a medical claim and view a detailed summary

• View your current benefits usage details

• Verify your doctor is in-network

• Locate a hospital or urgent care center near you

• View your ID card, current medications, allergy and immunization details, family history and more — and email or fax this information to your health care provider

With CoventryOne, you’ll get extra features such as:

• Discounts on services and programs typically not covered under health benefits plans

• Health savings account offered with qualifying plans*

Support for your well-being

We’re committed to supporting our members’ health and wellness. That’s where Coventry WellBeingSM comes in. You’ll have access to:

• Online health management. This program offers tips for getting in shape, eating right and living well. You can use it to customize your fitness, nutrition and life skills goals.

• Health risk assessments. We offer online health risk assessments for common conditions such as high blood pressure and heart disease.

• Email reminders for tests, screenings and immunizations. It can be easy to forget about preventive care. You can sign up online for email reminders about scheduling screening tests and when to get certain vaccines.

Comprehensive Medical Assessment

Be proactive with your health

Taking care of your health is more than just visiting your doctor when you’re sick. The comprehensive medical assessment looks at your overall health — everything from your head down to your toes.

Reap the benefits of a health assessment that’s just for you

• Find out if you have any diseases or conditions

• Learn ways to manage your health and diseases

• Get help coordinating your health care services

• Increase your options for getting health care

This is not a requirement to become a member. This is a benefit to help you on your journey to better health. After you become a member you can call the phone number on your member ID card to schedule your assessment.

The Coventry Advantage

*Investment services are independently offered by the HSA Administrator.


Shopping for a health benefits plan may be new for you. Here are some important terms to keep in mind while you shop for coverage.

Benefit A service, medical supply or drug that health benefits helps pay for. Some examples are doctor visits, tests and X-rays.

CoinsuranceThe amount you pay after meeting your yearly deductible. For example, if you have an X-ray after you’ve met your deductible for the year, we’ll pay most of the allowed amount, and you’ll pay a certain percentage of it. The percentage you pay is called coinsurance. This is a form of cost sharing. It’s a specified percentage you must pay for covered health services.

Copay (copayment)A set cost you pay when you receive a covered service. Most plans have copays for doctor visits. You pay your copay to the physician or other health care provider.

Cost sharingYou pay a share of the costs for services through your deductible, coinsurance and copays. This doesn’t include your monthly payment. The percentage you pay is based on the plan level you choose.

Deductible The set amount you pay each year before we pay any benefits, unless otherwise stated.

Health insurance exchangeThe health insurance exchange (or marketplace) is a new way to shop for health insurance. Online stores help you find, compare and choose a health insurance plan that fits your needs.

Health savings accountA health savings account, or HSA, is a savings and spending account that can be funded with tax-advantaged contributions that earn interest or investment returns. You can use it to pay qualified health care expenses, save money for future medical expenses, or save for post-retirement expenses.

Out of pocket The total amount you pay for covered services — including copays, deductibles and coinsurance.

PremiumThe set amount you pay each month for your health insurance coverage.

Provider networkA group of health care providers that works with us to offer services to our members at a discounted price. In-network benefits apply when you receive care from physicians or facilities that are part of our network.

Utilization managementServices that help you get the right care from the right doctor at the right time.

Important terms you should know.

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Health maintenance organization (HMO) plans provide coverage for in-network and emergency out-of-network care.

If you enroll in a Health Maintenance Organization (HMO) plan, you must select a primary care physician (PCP) to manage your care. Referrals may be required.

Choosing your plan What does a Health Maintenance Organization (HMO) mean?

Your plan options

Plans are grouped in three types: Bronze, Silver and Gold. The plan type lets you know how much you pay for premiums and out-of-pocket costs. Generally, the more you pay for your premium, the less you pay for your doctor visits and other care.

Plan category Premium Out-of-pocket costs (costs you pay when you get care)

Bronze $ $$$

Silver $$ $$

Gold $$$ $

Note: Not all plan types are available in every state. Check the plans on the following pages for what’s available in your state.

If you are under 30 years old or have a very low income, you might be able to buy what’s called a “catastrophic plan.” These are not available in all states.

Native American and Alaskan Natives

If you’re a Native American or an Alaskan Native, you may qualify for low-cost or no-cost health insurance coverage. Our Native American plans are available on the exchange. Visit www.healthcare.gov to see if you’re eligible and enroll.

Premium subsidies

You may qualify for help making your monthly payments. Help is based on the size of your family and your income. You can view the chart at www.healthcare.gov.

Health savings account (HSA) with bronze deductible-only plan

If you choose the bronze deductible-only plan, you have the option of selecting an HSA administered through our partner, HealthEquity®.

Family premium pricing

Your monthly payment will be the total of the rates for each person on the plan, based on their age and tobacco use. We will only charge you for your three oldest dependents under the age of 21.

Purchasing your plan — you can:

• Apply online at www.coventryone.com or call us at 1-877-907-4044

• Apply online at www.healthcare.gov, the Federally Facilitated Marketplace (FFM)

• Work with your local health insurance broker

Choosing your benefits

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http://www.healthcare.gov




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Choose a primary care physician (PCP) to manage your health

A primary care physician (PCP) knows you and your medical history best. They’ll coordinate your care and help you get the most from your health benefits. A PCP handles preventative care, as well as common medical conditions.

Specialist

A specialist is a doctor who is an expert in a certain kind of disease or injury. If you see a specialist, check to see if he/she is in the plan’s network. If you need to see a specialist, you’ll need a referral from your PCP.

Network providers – they are easy to find

It’s important to know which doctors and hospitals are part of your network. You can find this information online.

• Doctors, hospitals and other medical providers, go to www.coventryone.com and select “Find a Doctor.”

• Pharmacies, go to www.coventryone.com and select “Find a Pharmacy.” For preferred pharmacies, it will say, “Preferred pharmacy: You may get up to one month supply.”

• Mental health or substance abuse providers, go to www.psychcare.com and select “Find a Provider,” then select “Commercial.”

• Pediatric vision care providers, go to www.eyemed.com and select “Find a Provider.” Then choose the network “Insight.”

• Pediatric dental providers, go to www.cvtydental.com and select “Search for a Provider” and “Pediatric Dental.” Pediatric dental does not apply to plans purchased on the health care exchange.

It’s important to know which doctors and hospitals are part of your network before you choose your health plan. Not all doctors are part of every product or network we offer. You can find this information at www.coventryone.com.

Choosing a provider



http://www.psychcare.com

http://www.eyemed.com

http://www.cvtydental.com


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Provider network information

In-network care

A provider network is a list of doctors, hospitals and other providers that work with us to provide you with health care. These providers are “participating” or “in-network.” You will receive the highest level of covered services when seeing an in-network provider.

Out-of-network care

Out-of-network benefits are not available for HMO plans, except for emergency care.

Emergency and travel coverage: If you have a medical emergency, get treatment right away. Emergency services will be covered as if you received care from an in-network provider. You have this coverage while you’re traveling or at home. This includes students who are away at school.

High Performance Network (HPN)

Carelink from CoventryOne

When enrolled in a Carelink plan, you’ll have access to an exclusive network made up of local hospitals and doctors that are part of a health system. These plans offer coordinated care, an improved patient experience, and lower monthly cost.

Remember to visit our online provider search to locate doctors and hospitals in our networks. Note: Providers vary by network. You can find this information at www.coventryone.com.

CoventryOne provider networks — Select a network with doctors you trust


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Florida CoventryOne Health Plan Network OptionsChoose one of the provider networks listed below, then choose one of the eleven plans on the following pages.

This material is for information only. Rates and benefits vary by location. Health benefits plans contain exclusions and limitations. Investment services are independently offered by the HSA Administrator. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Providers are independent contractors and are not agents of Coventry. Provider participation may change without notice. Coventry does not provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to change.

Provider networkAvailable in these counties Network type

Out-of-network coverage

PCP selection required

PCP referral required

Buying Options

South Florida: Broward, Miami-Dade and Palm Beach

North Florida: Clay, Duval, Escambia, St. Johns, Santa Rosa and Volusia

Carelink High-performance

No Yes Yes On Exchange and Off Exchange

South Florida: Broward, Martin, Miami-Dade, Palm Beach and St. Lucie

Full No Yes No Off Exchange

Central Florida: Brevard, Hernando, Hillsborough, Pasco, Pinellas and Polk

Full No Yes Yes Off Exchange

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Off Exchange Catastrophic* CoventryOne Health Plan options in Florida

CoventryOne health benefits products are underwritten by Coventry Health Care of Florida, Inc.

FL Coventry Catastrophic OA HMO PDFL Coventry Catastrophic Carelink HMO PD

FL Coventry Catastrophic HMO PD

Member benefits In network you pay In network you payDeductible (ded) individual/family¹ (applies to out-of-pocket maximum)

$6,850/$13,700 $6,850/$13,700

Member coinsurance 0% 0%

Out-of-pocket maximum individual/family¹ (maximum you will pay for all covered services)

$6,850/$13,700 $6,850/$13,700

Primary care visit Visits 1 – 3: $20 copay; ded waived Visits 4+: Covered in full after ded

Visits 1 – 3: $20 copay; ded waived Visits 4+: Covered in full after ded

Specialist visit Covered in full after ded Covered in full after ded

Hospital stay Covered in full after ded Covered in full after ded

Outpatient surgery (ambulatory surgical center/hospital) Covered in full after ded Covered in full after ded

Emergency room (copay waived if admitted) Covered in full after ded Covered in full after ded

Urgent care Covered in full after ded Covered in full after ded

Preventive care/screening/immunization (age and frequency visit limits apply)

Covered in full; ded waived Covered in full; ded waived

Annual routine gyn exam (annual pap/mammogram) Covered in full; ded waived Covered in full; ded waived

Diagnostic lab Covered in full after ded Covered in full after ded

Diagnostic X-ray Covered in full after ded Covered in full after ded

Imaging (CT/PET scans, MRIs) Covered in full after ded Covered in full after ded

Vision

Pediatric eye exam (1 visit per year) Covered in full after ded Covered in full after ded

Pediatric glasses/contacts (coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year)

Covered in full after ded Covered in full after ded

Pediatric dental

Dental checkup/preventive dental care (2 visits per year) Covered in full after ded Covered in full after ded

Basic dental care Covered in full after ded Covered in full after ded

Major dental care Covered in full after ded Covered in full after ded

Orthodontia (medically necessary only) Covered in full after ded Covered in full after ded

Pharmacy

Pharmacy deductible Integrated with medical ded Integrated with medical ded

Preferred generic drugs Generic: Covered in full after ded Generic: Covered in full after ded

Preferred brand drugs Covered in full after ded Covered in full after ded

Nonpreferred drugs Generic & Brand: Covered in full after ded

Generic & Brand: Covered in full after ded

Specialty drugs** P: Covered in full after ded NP: Covered in full after ded

P: Covered in full after ded NP: Covered in full after ded

1 The family deductible and/or out-of-pocket limit can be met by a combination of family members. Each covered family member only needs to satisfy his or her individual deductible and/or out-of-pocket limit.

* Unlike metal-level coverage, this plan is a catastrophic plan offering. Only individuals who are younger than age 30 or have a hardship exemption may enroll in this plan.

**P=Preferred specialty drugs; NP=Nonpreferred specialty drugs.

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This material is for information only. Rates and benefits vary by location. Health benefits plans contain exclusions and limitations. Investment services are independently offered by the HSA Administrator. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Providers are independent contractors and are not agents of Coventry. Provider participation may change without notice. Coventry does not provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to change.80

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This plan comparison guide shows in-network benefits only.

Out-of-network benefits are not available for HMO plans, except in an emergency.

Out-of-network benefits are available for Point of Service (POS) and Preferred Provider Organization (PPO) plans.

To learn more details about specific plans, including whether a plan includes out of network benefits, see the Summary of Benefits and Coverage at http://www.sbcfl.coventryone.com.

This information is a partial description of the benefits and in no way details all of the benefits, limitations, or exclusions of the plan. Please refer to the individual policy, schedule of benefits, and applicable riders to determine exact terms, conditions and scope of coverage, including all exclusions and limitations and defined terms.

http://www.sbcfl.coventryone.com


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FL Coventry Bronze $15 Copay OA HMO PDFL Coventry Bronze $15 Copay HMO PDFL Coventry Bronze $15 Copay Carelink HMO PD

FL Coventry Bronze Ded Only HSA Eligible OA HMO PDFL Coventry Bronze Ded Only HSA Eligible HMO PDFL Coventry Bronze Ded Only HSA Eligible Carelink HMO PD


$6,850/$13,700 $6,450/$12,900



$6,850/$13,700 $6,450/$12,900

Primary care visit $15 copay; ded waived Covered in full after ded





Urgent care $100 copay; ded waived Covered in full after ded







Vision

Pediatric eye exam (1 visit per year) Covered in full; ded waived Covered in full; ded waived


Covered in full; ded waived Covered in full after ded

Pediatric dental

Dental checkup/preventive dental care (2 visits per year) Covered in full; ded waived Covered in full after ded

Basic dental care Covered in full after ded Covered in full after ded

Major dental care Covered in full after ded Covered in full after ded

Orthodontia (medically necessary only) Covered in full after ded Covered in full after ded

Pharmacy






Specialty drugs* P: Covered in full after ded NP: Covered in full after ded




*P=Preferred specialty drugs; NP=Nonpreferred specialty drugs.

Off Exchange Bronze CoventryOne Health Plan options in Florida

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FL Coventry Silver $10 Copay 2750 OA HMO PDFL Coventry Silver $10 Copay 2750 HMO PDFL Coventry Silver $10 Copay 2750 Carelink HMO PD

Member benefits In network you payDeductible (ded) individual/family¹ (applies to out-of-pocket maximum)

$2,750/$5,500

Member coinsurance 40%


$6,850/$13,700

Primary care visit $10 copay; ded waived

Specialist visit $75 copay; ded waived

Hospital stay 40% after ded

Outpatient surgery (ambulatory surgical center/hospital) 40% after ded

Emergency room (copay waived if admitted) $500 copay after ded

Urgent care $75 copay; ded waived


Covered in full; ded waived

Annual routine gyn exam (annual pap/mammogram) Covered in full; ded waived

Diagnostic lab 40% after ded

Diagnostic X-ray 40% after ded

Imaging (CT/PET scans, MRIs) 40% after ded

Vision

Pediatric eye exam (1 visit per year) Covered in full; ded waived



Pediatric dental

Dental checkup/preventive dental care (2 visits per year) Covered in full; ded waived

Basic dental care 30% after ded

Major dental care 50% after ded

Orthodontia (medically necessary only) 50% after ded

Pharmacy In network preferred In network


Preferred generic drugs Low Cost Generic: $5 copay; ded waived Generic: $15 copay; ded waived

Low Cost Generic: $20 copay; ded waivedGeneric: $20 copay; ded waived

Preferred brand drugs $45 copay after ded $55 copay after ded

Nonpreferred drugs Generic & Brand: $80 copay after ded2

Generic & Brand: $90 copay after ded

Specialty drugs* P: 40% after ded NP: 50% after ded

P: 40% after dedNP: 50% after ded


Off Exchange Silver CoventryOne Health Plan option in Florida


2For the Carelink HMO plan only, the copay for nonpreferred drugs is $62 (for in network preferred).*P=Preferred specialty drugs; NP=Nonpreferred specialty drugs.

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FL Coventry Gold $10 Copay OA HMO PDFL Coventry Gold $10 Copay HMO PDFL Coventry Gold $10 Copay Carelink HMO PD


$1,400/$2,800



$5,000/$10,000













Vision




Pediatric dental

Dental checkup/preventive dental care (2 visits per year) Covered in full; ded waived

Basic dental care 30% after ded

Major dental care 50% after ded

Orthodontia (medically necessary only) 50% after ded


Pharmacy deductible $250 per member $250 per member




Nonpreferred drugs Generic & Brand: $65 copay after ded







Off Exchange Gold CoventryOne Health Plan option in Florida

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On Exchange Catastrophic* CoventryOne Health Plan option in Florida

FL Coventry Catastrophic Carelink HMO


$6,850/$13,700



$6,850/$13,700

Primary care visit Visits 1 – 3: $20 copay; ded waived Visits 4+: Covered in full after ded

Specialist visit Covered in full after ded

Hospital stay Covered in full after ded

Outpatient surgery (ambulatory surgical center/hospital) Covered in full after ded

Emergency room (copay waived if admitted) Covered in full after ded

Urgent care Covered in full after ded




Diagnostic lab Covered in full after ded

Diagnostic X-ray Covered in full after ded

Imaging (CT/PET scans, MRIs) Covered in full after ded

Vision

Pediatric eye exam (1 visit per year) Covered in full after ded


Covered in full after ded

Pediatric dental

Dental checkup/preventive dental care (2 visits per year) Not covered

Basic dental care Not covered

Major dental care Not covered

Orthodontia (medically necessary only) Not covered

Pharmacy

Pharmacy deductible Integrated with medical ded

Preferred generic drugs Generic: Covered in full after ded

Preferred brand drugs Covered in full after ded


Specialty drugs** P: Covered in full after ded NP: Covered in full after ded








* Unlike metal-level coverage, this plan is a catastrophic plan offering. Only individuals who are younger than age 30 or have a hardship exemption may enroll in this plan.

**P=Preferred specialty drugs; NP=Nonpreferred specialty drugs.



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On Exchange Bronze CoventryOne Health Plan options in Florida

FL Coventry Bronze $15 Copay Carelink HMO

FL Coventry Bronze Ded Only HSA Eligible Carelink HMO


$6,850/$13,700 $6,450/$12,900



$6,850/$13,700 $6,450/$12,900

Primary care visit $15 copay; ded waived Covered in full after ded





Urgent care $100 copay; ded waived Covered in full after ded







Vision

Pediatric eye exam (1 visit per year) Covered in full; ded waived Covered in full; ded waived


Covered in full; ded waived Covered in full after ded

Pediatric dental

Dental checkup/preventive dental care (2 visits per year) Not covered Not covered

Basic dental care Not covered Not covered

Major dental care Not covered Not covered

Orthodontia (medically necessary only) Not covered Not covered

Pharmacy






Specialty drugs* P: Covered in full after ded NP: Covered in full after ded





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FL Coventry Silver $10 Copay 2750 Carelink HMO


$2,750/$5,500



$6,850/$13,700













Vision




Pediatric dental










Nonpreferred drugs Generic & Brand: $62 copay after ded




On Exchange Silver CoventryOne Health Plan option in Florida




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FL Coventry Gold $10 Copay Carelink HMO


$1,400/$2,800



$5,000/$10,000













Vision




Pediatric dental






Pharmacy deductible $250 per member $250 per member




Nonpreferred drugs Generic & Brand: $65 copay after ded Generic & Brand: $80 copay after ded



On Exchange Gold CoventryOne Health Plan option in Florida




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Apply for coverage beginning November 1, 2015Steps to apply

Although you may apply for coverage up until January 31, 2016, applying after December 15, 2015 may result in a gap in coverage.

Enrollment Dates

If you apply between …Your coverage will take effect …

November 1, 2015 – December 15, 2015 January 1, 2016

December 16, 2015 – January 15, 2016 February 1, 2016

January 16, 2016 – January 31, 2016 March 1, 2016

If you have a qualifying life event after the open enrollment period, you may be eligible for a special open enrollment. Some of the qualifying life events are marriage, divorce and having a baby.. See a full list of qualifying events at www.healthcare.gov.

Apply for a CoventryOne plan — Applying is easy with these steps

1. Choose your plan. We have different plans to fit your budget and help meet your needs. You can select a plan at www.coventryone.com. You can shop on the Health Insurance Marketplace at www.healthcare.gov. Or, you can work with a broker. Open enrollment will run from November 1, 2015 – January 31, 2016.

2. Check to see if you qualify for help making monthly payments by applying for a plan on the Health Insurance Marketplace website. The Marketplace will determine whether or not you qualify for help making your monthly payments. Help is based on the size of your family and your income. Be sure to complete all questions. You can get more information at www.healthcare.gov.

3. Apply online. You can submit your application online at www.coventryone.com or at the Health Insurance Marketplace website, if you qualify for financial help. Fill out one application for you and any family members who will be covered by the health insurance plan. Be sure to fill in all information. When you’re done, check over the application to make sure the information is correct. Then print a copy for your records.

4. Make your first monthly payment. After you’re accepted and enrolled, you’ll receive instructions for making your first monthly payment. Your enrollment will be complete after we receive that payment.






Getting the health care benefits you need

Prior authorization

Some medical services and prescription drugs require prior authorization. Prior authorization means that we must approve covered medical services in advance. This helps you and your family receive the right care in the right place at the right time. In-network providers usually take care of prior authorizations for you. You are responsible for verifying that prior authorization has been obtained.

Case management

If you have a serious medical condition, you may benefit from case management. A Coventry case management nurse will work with you and your doctor to coordinate resources that will help you meet your health care needs.

Disease management

If you have asthma or diabetes we’ll send you information to help you manage your condition. You may also receive reminders if you are past due for an important test or service.

Prescription drug program

Your plan covers prescription drugs. Your costs can vary based on the drug and the pharmacy you use. Some important things to remember:

• You should check our prescription drug list, also called a formulary, to find out how a prescription drug is covered.

• Your copay could be lower if you use a preferred pharmacy. A preferred pharmacy is a retail pharmacy, or pharmacy chain, that we work with to provide you with lower prices. Go to www.coventryone.com and choose “Find a Pharmacy” to find a preferred pharmacy.

• Some prescription drugs require prior authorization. Your doctor can contact us if prior authorization is required.

Getting the health care benefits you need

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Eligibility and requirementsTo qualify for a CoventryOne plan, you must be:

• A resident of the state in which you are applying and a state in which we offer coverage

• Not be entitled to or enrolled in Medicare

We offer dependent coverage up to age 30.

Your coverage

Your coverage stays in effect as long as you pay the required monthly payment on time and as long as you are eligible for the plan.* Coverage will end if you become ineligible due to any of the following circumstances:

• Don’t pay your monthly bill

• Move to another state

• Get duplicate coverage

Levels of coverage and enrollment

Your monthly payment may change based on the rating factors in your state. You may pay the lowest rate available (known as the standard premium charge). Or, you may pay more due to age, where you live and tobacco use.

Notice of Privacy Practices for Company’s Members

The Company appreciates the opportunity to provide health care benefits plans to our members and their families. In the course of providing the health care benefit plans we administer or offer, the Company must collect, use, and disclose nonpublic personal information. The Company has adopted a Notice of Privacy Practices that describes the members’ rights with respect to their personal information and how the Company will use, disclose and protect such information.

You can view our Privacy Policy by visiting www.coventryone.com. Just click “Privacy Policy” on the black bar at the bottom of the page.

Exclusions and limitations Certain services and supplies are not covered by your health plan. Below is a partial list of exclusions that may apply. Please refer to the Evidence of Coverage for a complete listing.

• Any service or supply that is not medically necessary

• Any service or supply that is not covered or that is directly or indirectly a result of receiving a noncovered service

• Any service or supply for which you have no financial liability or that was provided at no charge

• Procedures and treatments that are experimental or investigational

• Court-ordered services or services that are a condition of probation or parole

• Cosmetic services and surgery, and the complications incurred as a result of those services and surgeries

• Adult dental care, appliances, dentures, implants or X-rays, including any provider services or X-ray examinations involving one or more teeth, the tissue or structure around them, the alveolar process or the gums

• Immunizations for travel or employment, or unexpected mass immunizations directed or ordered by public health officials for general population groups

• Work-related injuries or illnesses covered by workers’ compensation laws

• Infertility services and supplies — any medical service, office visit, lab, diagnostic test, prescription drug, equipment, medicine, supply or procedure directly or indirectly related to promoting conception by artificial means

• Maintenance treatment or therapy that is not part of an active treatment plan intended to or reasonably expected to improve the member’s medical condition or functional ability

• Any service for which a prior authorization is required and is not obtained

*Your insurance company may automatically enroll you in the same plan, or a similar plan, for 2016. You can change your plan during Open Enrollment.

http://coventryone.com/privacy-policy/index.htm


31

Notes

Simple and affordable. We’ve got you covered.Enroll today

www.coventryone.com Toll-free: Call 1-877-907-4044

This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Health benefits plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Coventry. Provider participation may change without notice. Coventry does not provide care or guarantee access to health services. Investment services are independently offered by the HSA Administrator. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about CoventryOne plans, refer to www.coventryone.com.Coventry does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Health information programs provide general health information and are not a substitute for diagnosis or treatment by physician or other health care professional.

www.coventryone.com

80.02.351.1-FL B (1/16)




80.03.361.1-06 A (1/16)

Quality Health plans & benefits Healthier living Financial well-being Intelligent solutions Coventry Health Plans for Florida Rating Area 6 Counties – Monthly Rates (Effective 01/01/2016*) Broward

Coventry Catastrophic

Carelink HMO PD

Age

Non Tobacco Tobacco

0-20 $95.01 $95.01

21 $149.62 $164.58 22 $149.62 $164.58 23 $149.62 $164.58 24 $149.62 $164.58 25 $150.21 $165.24 26 $153.21 $168.53 27 $156.80 $172.48 28 $162.63 $178.90 29 $167.42 $184.16 30 $169.81 $186.80 31 $173.40 $190.74 32 $177.00 $194.69 33 $179.24 $197.16 34 $181.63 $199.80 35 $182.83 $201.11 36 $184.03 $202.43 37 $185.22 $203.75 38 $186.42 $205.06 39 $188.81 $207.70 40 $191.21 $210.33 41 $194.80 $214.28 42 $198.24 $218.06 43 $203.03 $223.33 44 $209.01 $229.91 45 $216.04 $237.65 46 $224.42 $246.87 47 $233.85 $257.23 48 $244.62 $269.08 49 $255.24 $280.77 50 $267.21 $293.93 51 $279.03 $306.94 52 $292.05 $321.25 53 $305.22 $335.74 54 $319.43 $351.37 55 $333.64 $367.01 56 $349.05 $383.96 57 $364.61 $401.07 58 $381.22 $419.34 59 $389.45 $428.39 60 $406.06 $446.66 61 $420.42 $462.46 62 $429.85 $472.83 63 $441.67 $485.83 64 $448.70 $493.57 65+** $448.70 $493.57

Coventry Bronze Ded Only HSA Eligible Carelink HMO

PD

Age

Non Tobacco Tobacco

0-20 $108.01 $108.01

21 $170.10 $187.11 22 $170.10 $187.11 23 $170.10 $187.11 24 $170.10 $187.11 25 $170.78 $187.86 26 $174.18 $191.60 27 $178.26 $196.09 28 $184.90 $203.39 29 $190.34 $209.37 30 $193.06 $212.37 31 $197.14 $216.86 32 $201.22 $221.35 33 $203.78 $224.15 34 $206.50 $227.15 35 $207.86 $228.64 36 $209.22 $230.14 37 $210.58 $231.64 38 $211.94 $233.14 39 $214.66 $236.13 40 $217.38 $239.12 41 $221.47 $243.61 42 $225.38 $247.92 43 $230.82 $253.90 44 $237.63 $261.39 45 $245.62 $270.18 46 $255.15 $280.66 47 $265.86 $292.45 48 $278.11 $305.92 49 $290.19 $319.20 50 $303.79 $334.17 51 $317.23 $348.95 52 $332.03 $365.23 53 $347.00 $381.70 54 $363.16 $399.47 55 $379.32 $417.25 56 $396.84 $436.52 57 $414.53 $455.98 58 $433.41 $476.75 59 $442.76 $487.04 60 $461.64 $507.81 61 $477.97 $525.77 62 $488.69 $537.56 63 $502.13 $552.34 64 $510.12 $561.13 65+** $510.12 $561.13

Coventry Bronze $15 Copay Carelink HMO PD

Age

Non Tobacco Tobacco

0-20 $110.39 $110.39

21 $173.85 $191.23 22 $173.85 $191.23 23 $173.85 $191.23 24 $173.85 $191.23 25 $174.54 $192.00 26 $178.02 $195.82 27 $182.19 $200.41 28 $188.97 $207.87 29 $194.54 $213.99 30 $197.32 $217.05 31 $201.49 $221.64 32 $205.66 $226.23 33 $208.27 $229.10 34 $211.05 $232.16 35 $212.44 $233.69 36 $213.83 $235.22 37 $215.22 $236.75 38 $216.61 $238.28 39 $219.40 $241.33 40 $222.18 $244.39 41 $226.35 $248.98 42 $230.35 $253.38 43 $235.91 $259.50 44 $242.86 $267.15 45 $251.04 $276.14 46 $260.77 $286.85 47 $271.72 $298.90 48 $284.24 $312.66 49 $296.58 $326.24 50 $310.49 $341.54 51 $324.23 $356.65 52 $339.35 $373.29 53 $354.65 $390.11 54 $371.16 $408.28 55 $387.68 $426.45 56 $405.59 $446.14 57 $423.67 $466.03 58 $442.96 $487.26 59 $452.52 $497.78 60 $471.82 $519.00 61 $488.51 $537.36 62 $499.46 $549.41 63 $513.20 $564.52 64 $521.37 $573.51 65+** $521.37 $573.51

How to calculate your monthly payment

Look for the plan name(s) you're considering. Find your age and tobacco use status in the columns below each plan to see your monthly payment. Do the same for each person in your family. Your monthly payment will be the total of the rates for each person on the plan, based on their age and tobacco use. We will only charge you for your three oldest dependents under the age of 21.

*Networks may not be available in all zip codes and are subject to change. ** Age 65+ rates are not available to new applicants.

www.CoventryOne.com

Coventry Health Plans for Florida Rating Area 6 Counties – Monthly Rates (Effective 01/01/2016*) Broward

Coventry Silver $10 Copay

2750 Carelink HMO PD

Age

Non Tobacco Tobacco

0-20 $131.59 $131.59

21 $207.23 $227.96 22 $207.23 $227.96 23 $207.23 $227.96 24 $207.23 $227.96 25 $208.06 $228.87 26 $212.21 $233.43 27 $217.18 $238.90 28 $225.26 $247.79 29 $231.89 $255.08 30 $235.21 $258.73 31 $240.18 $264.20 32 $245.16 $269.67 33 $248.26 $273.09 34 $251.58 $276.74 35 $253.24 $278.56 36 $254.90 $280.39 37 $256.55 $282.21 38 $258.21 $284.03 39 $261.53 $287.68 40 $264.84 $291.33 41 $269.82 $296.80 42 $274.58 $302.04 43 $281.21 $309.34 44 $289.50 $318.45 45 $299.24 $329.17 46 $310.85 $341.93 47 $323.90 $356.30 48 $338.83 $372.71 49 $353.54 $388.89 50 $370.12 $407.13 51 $386.49 $425.14 52 $404.52 $444.97 53 $422.75 $465.03 54 $442.44 $486.69 55 $462.13 $508.34 56 $483.47 $531.82 57 $505.03 $555.53 58 $528.03 $580.83 59 $539.43 $593.37 60 $562.43 $618.67 61 $582.32 $640.56 62 $595.38 $654.92 63 $611.75 $672.93 64 $621.49 $683.64 65+** $621.49 $683.64

Coventry Gold $10 Copay Carelink HMO PD

Age

Non Tobacco Tobacco

0-20 $156.42 $156.42

21 $246.33 $270.97 22 $246.33 $270.97 23 $246.33 $270.97 24 $246.33 $270.97 25 $247.32 $272.05 26 $252.25 $277.47 27 $258.16 $283.97 28 $267.77 $294.54 29 $275.65 $303.21 30 $279.59 $307.55 31 $285.50 $314.05 32 $291.41 $320.56 33 $295.11 $324.62 34 $299.05 $328.96 35 $301.02 $331.12 36 $302.99 $333.29 37 $304.96 $335.46 38 $306.93 $337.63 39 $310.87 $341.96 40 $314.82 $346.30 41 $320.73 $352.80 42 $326.39 $359.03 43 $334.28 $367.70 44 $344.13 $378.54 45 $355.71 $391.28 46 $369.50 $406.45 47 $385.02 $423.52 48 $402.76 $443.03 49 $420.25 $462.27 50 $439.95 $483.95 51 $459.41 $505.36 52 $480.85 $528.93 53 $502.52 $552.78 54 $525.93 $578.52 55 $549.33 $604.26 56 $574.70 $632.17 57 $600.32 $660.35 58 $627.66 $690.43 59 $641.21 $705.33 60 $668.55 $735.41 61 $692.20 $761.42 62 $707.72 $778.49 63 $727.18 $799.90 64 $738.76 $812.63 65+** $738.76 $812.63


www.CoventryOne.com


Coventry does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. This material is for information only. Rates are subject to change on rate increases implemented to the whole book of business in accordance with state laws and regulations, and any optional benefits selected. Health/ Dental insurance plans contain exclusions and limitations. Information is believed to be accurate as of the production date; however, it is subject to change. Investment services are independently offered by the HSA Administrator.

80.03.361.1-06 A (1/16)

Quality Health plans & benefits Healthier living Financial well-being Intelligent solutions Coventry Health Plans for Florida Rating Area 6 Counties – Monthly Rates (Effective 01/01/2016*) Broward

Coventry Catastrophic OA

HMO PD

Age

Non Tobacco Tobacco

0-20 $115.49 $115.49

21 $181.87 $200.06 22 $181.87 $200.06 23 $181.87 $200.06 24 $181.87 $200.06 25 $182.60 $200.86 26 $186.24 $204.86 27 $190.60 $209.66 28 $197.69 $217.46 29 $203.51 $223.86 30 $206.42 $227.07 31 $210.79 $231.87 32 $215.15 $236.67 33 $217.88 $239.67 34 $220.79 $242.87 35 $222.25 $244.47 36 $223.70 $246.07 37 $225.16 $247.67 38 $226.61 $249.27 39 $229.52 $252.47 40 $232.43 $255.67 41 $236.80 $260.48 42 $240.98 $265.08 43 $246.80 $271.48 44 $254.07 $279.48 45 $262.62 $288.88 46 $272.81 $300.09 47 $284.26 $312.69 48 $297.36 $327.09 49 $310.27 $341.30 50 $324.82 $357.30 51 $339.19 $373.11 52 $355.01 $390.51 53 $371.02 $408.12 54 $388.29 $427.12 55 $405.57 $446.13 56 $424.30 $466.73 57 $443.22 $487.54 58 $463.41 $509.75 59 $473.41 $520.75 60 $493.60 $542.96 61 $511.06 $562.16 62 $522.51 $574.77 63 $536.88 $590.57 64 $545.43 $599.97 65+** $545.43 $599.97

Coventry Bronze Ded Only HSA Eligible OA HMO PD

Age

Non Tobacco Tobacco

0-20 $131.30 $131.30

21 $206.77 $227.44 22 $206.77 $227.44 23 $206.77 $227.44 24 $206.77 $227.44 25 $207.59 $228.35 26 $211.73 $232.90 27 $216.69 $238.36 28 $224.76 $247.23 29 $231.37 $254.51 30 $234.68 $258.15 31 $239.64 $263.61 32 $244.61 $269.07 33 $247.71 $272.48 34 $251.02 $276.12 35 $252.67 $277.94 36 $254.32 $279.76 37 $255.98 $281.58 38 $257.63 $283.40 39 $260.94 $287.04 40 $264.25 $290.67 41 $269.21 $296.13 42 $273.97 $301.36 43 $280.58 $308.64 44 $288.85 $317.74 45 $298.57 $328.43 46 $310.15 $341.17 47 $323.18 $355.50 48 $338.07 $371.87 49 $352.75 $388.02 50 $369.29 $406.22 51 $385.62 $424.18 52 $403.61 $443.97 53 $421.81 $463.99 54 $441.45 $485.59 55 $461.09 $507.20 56 $482.39 $530.63 57 $503.89 $554.28 58 $526.84 $579.53 59 $538.22 $592.04 60 $561.17 $617.28 61 $581.02 $639.12 62 $594.04 $653.45 63 $610.38 $671.42 64 $620.10 $682.11 65+** $620.10 $682.11

Coventry Bronze $15 Copay OA HMO PD

Age

Non Tobacco Tobacco

0-20 $134.19 $134.19

21 $211.33 $232.46 22 $211.33 $232.46 23 $211.33 $232.46 24 $211.33 $232.46 25 $212.17 $233.39 26 $216.40 $238.04 27 $221.47 $243.62 28 $229.71 $252.68 29 $236.47 $260.12 30 $239.86 $263.84 31 $244.93 $269.42 32 $250.00 $275.00 33 $253.17 $278.49 34 $256.55 $282.21 35 $258.24 $284.07 36 $259.93 $285.92 37 $261.62 $287.78 38 $263.31 $289.64 39 $266.69 $293.36 40 $270.08 $297.08 41 $275.15 $302.66 42 $280.01 $308.01 43 $286.77 $315.45 44 $295.22 $324.75 45 $305.16 $335.67 46 $316.99 $348.69 47 $330.30 $363.33 48 $345.52 $380.07 49 $360.52 $396.58 50 $377.43 $415.17 51 $394.12 $433.54 52 $412.51 $453.76 53 $431.11 $474.22 54 $451.18 $496.30 55 $471.26 $518.38 56 $493.02 $542.33 57 $515.00 $566.50 58 $538.46 $592.31 59 $550.08 $605.09 60 $573.54 $630.89 61 $593.83 $653.21 62 $607.14 $667.86 63 $623.84 $686.22 64 $633.77 $697.14 65+** $633.77 $697.14

How to calculate your monthly payment

Look for the plan name(s) you're considering. Find your age and tobacco use status in the columns below each plan to see your monthly payment. Do the same for each person in your family. Your monthly payment will be the total of the rates for each person on the plan, based on their age and tobacco use. We will only charge you for your three oldest dependents under the age of 21.


www.CoventryOne.com

Coventry Health Plans for Florida Rating Area 6 Counties – Monthly Rates (Effective 01/01/2016*) Broward

Coventry Silver $10 Copay

2750 OA HMO PD

Age

Non Tobacco Tobacco

0-20 $159.96 $159.96

21 $251.91 $277.10 22 $251.91 $277.10 23 $251.91 $277.10 24 $251.91 $277.10 25 $252.92 $278.21 26 $257.96 $283.75 27 $264.00 $290.40 28 $273.83 $301.21 29 $281.89 $310.08 30 $285.92 $314.51 31 $291.96 $321.16 32 $298.01 $327.81 33 $301.79 $331.97 34 $305.82 $336.40 35 $307.83 $338.62 36 $309.85 $340.83 37 $311.86 $343.05 38 $313.88 $345.27 39 $317.91 $349.70 40 $321.94 $354.13 41 $327.99 $360.78 42 $333.78 $367.16 43 $341.84 $376.03 44 $351.92 $387.11 45 $363.76 $400.13 46 $377.86 $415.65 47 $393.73 $433.11 48 $411.87 $453.06 49 $429.76 $472.73 50 $449.91 $494.90 51 $469.81 $516.79 52 $491.73 $540.90 53 $513.89 $565.28 54 $537.83 $591.61 55 $561.76 $617.93 56 $587.70 $646.47 57 $613.90 $675.29 58 $641.86 $706.05 59 $655.72 $721.29 60 $683.68 $752.05 61 $707.87 $778.65 62 $723.74 $796.11 63 $743.64 $818.00 64 $755.48 $831.02 65+** $755.48 $831.02

Coventry Gold $10 Copay OA HMO PD

Age

Non Tobacco Tobacco

0-20 $190.15 $190.15

21 $299.44 $329.39 22 $299.44 $329.39 23 $299.44 $329.39 24 $299.44 $329.39 25 $300.64 $330.70 26 $306.63 $337.29 27 $313.81 $345.20 28 $325.49 $358.04 29 $335.07 $368.58 30 $339.87 $373.85 31 $347.05 $381.76 32 $354.24 $389.66 33 $358.73 $394.60 34 $363.52 $399.87 35 $365.92 $402.51 36 $368.31 $405.14 37 $370.71 $407.78 38 $373.10 $410.41 39 $377.90 $415.68 40 $382.69 $420.95 41 $389.87 $428.86 42 $396.76 $436.44 43 $406.34 $446.98 44 $418.32 $460.15 45 $432.39 $475.63 46 $449.16 $494.08 47 $468.03 $514.83 48 $489.59 $538.55 49 $510.85 $561.93 50 $534.80 $588.28 51 $558.46 $614.30 52 $584.51 $642.96 53 $610.86 $671.95 54 $639.31 $703.24 55 $667.75 $734.53 56 $698.60 $768.46 57 $729.74 $802.71 58 $762.98 $839.27 59 $779.45 $857.39 60 $812.68 $893.95 61 $841.43 $925.57 62 $860.30 $946.32 63 $883.95 $972.35 64 $898.02 $987.83 65+** $898.02 $987.83


www.CoventryOne.com


Coventry does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. This material is for information only. Rates are subject to change on rate increases implemented to the whole book of business in accordance with state laws and regulations, and any optional benefits selected. Health/ Dental insurance plans contain exclusions and limitations. Information is believed to be accurate as of the production date; however, it is subject to change. Investment services are independently offered by the HSA Administrator.

or needing a bridge to Medicare eligibility

other coverage to begin

or out of work

Short Term MedicalSM plans do not provide:• Coverage for preexisting conditions; • Mandated coverage necessary to avoid a

penalty under the Affordable Care Act.

Health insurance available only to members of FACT.These health insurance plans are issued as association group plans and available only to members of FACT, the Federation of American Consumers and Travelers. Golden Rule Insurance Company is the underwriter and administrator of these plans.Policy Forms C-014.1 and other state variations, GRI-STAG15-C-VAL-02 and state variations, GRI-STAG15-C-PLS-02 and state variations, GRI-STAG15-C-PLE-02 and state variations, GRI-STAG15-C-CPY-02 and state variations, and GRI-STAG15-C-CPV-02 and state variations. For more policy form numbers, see Short Term MedicalSM State Variations insert (43853i-G).

Short Term MedicalSM Plans Health plans for Individuals & Families in times of transition and change

until the next Open Enrollment

43853C1-G-0516 (includes: 43853-G-0516, 43853i-G-0516) 1 of 16

* UnitedHealth Group Annual Form 10-K for year ended 12/31/15.

This is an outline only and is not intended to serve as a legal interpretation of benefits. Reasonable effort has been made to have this outline represent the intent of contract language. However, the contract language stands alone and the complete terms of the coverage will be determined by the policy. State specific differences may apply. This brochure must be used in conjunction with the Short Term MedicalSM State Variations Insert (43853i-G).

experienceNEARLY 70 YEARS IN THE BUSINESS OF INSURING INDIVIDUALS

Why choose us?

highly ratedGOLDEN RULE INSURANCE COMPANY RATED “A” BY A.M. BEST (03-31-15)

networkNATIONWIDE NETWORK CAN MEAN BIG SAVINGS

You are the One with UnitedHealthOneSM

UnitedHealthOneSM is the brand name used by the UnitedHealthcare family of companies offering personal health insurance products. Golden Rule Insurance Company, a UnitedHealthcare company, is the underwriter and administrator of plans featured in this brochure. We have been serving the specific needs of individuals and families buying their own coverage for nearly 70 years.

Strength & ExperienceUnitedHealthcare Employer and Individual provides approximately 30 million Americans access to health care.* We offer an array of consumer-oriented health benefit plans.

Highly RatedGolden Rule Insurance Company is rated “A” (Excellent) by A.M. Best (03-31-15). This worldwide independent organization examines insurance companies and other businesses, and publishes its opinion about them. This rating is an indication of our financial strength and stability.

Nationwide Network – Big SavingsWith network providers, you will not be balance billed for eligible expenses. Health care professionals in the network agree to provide you quality care at lower fees. With access to 1 million physicians and other health care professionals, and approximately 6,000 hospitals and other facilities,* chances are your current doctor is already a part of the nationwide network.

Visit UHOne.com to find providers in the UnitedHealthcare Choice Plus network.

2 of 16

BenefitActual

ChargesNetwork

Repriced ChargesNetwork Savings

Doctor Office Visit - established patient $84.81 $41.70 51%

MRI $1,197.98 $372.92 69%

Lipid Panel (Cholesterol) $73.90 $8.54 88%

CBC (Complete Blood Count) $28.44 $3.58 87%

Metabolic Panel (Blood sugar/kidney and liver function) $44.25 $4.89 89%

General Panel (General blood work) $152.19 $21.21 86%

UnitedHealthcare Choice Plus NetworkOur nationwide network of doctors and hospitals provides you with great value for your health care dollars. We contract with providers offering quality care at a significant discount. Getting your non-emergency care from a doctor or hospital not in our network will cost you more.

Sample Savings with Our Network (Services provided 05/2015-12/2015)1

Receive quality care at reduced costs because our network providers have agreed to lower fees for covered expenses. Here are some examples of the savings:

1 All these services were received from network providers in ZIP Code 336--. Your actual savings may be more or less than this illustration. Discounts vary by provider, geographic area, and type of service.

2 Your actual out-of-pocket expenses for covered expenses may exceed the stated coinsurance percentage because actual provider charges may not be used to determine insurer and insured’s payment obligations. Considering these factors, seeing in-network providers can result in a big savings for what you pay for your health care.

Nonemergency covered expenses

Using non-network providers you pay:2

• All charges above what is considered an eligible expense (see page 12 for details);• A penalty of 25% of the eligible expense, which does not count toward the deductible; and• A deductible equal to 2 times the network deductible.There is no out-of-pocket maximum for non-network providers.

How our plans work• You can receive care from any doctor

or hospital in our network.• If you’re looking for a specialist,

no referral is needed.• You receive maximum benefits from the

plan when you use network providers.• Using a non-network doctor or hospital for

non-emergency care will cost you more.

3 of 16

A Choice of Coverage to Fit Your Specific Needs• You select the term from 30 to 360 days,1 deductible, and coinsurance that fit your budget. See pages 6-7 for details. • Once you meet your deductible for the term, you pay a percentage of covered expenses (coinsurance)

up to a maximum out-of-pocket amount. • Then insurance pays 100% of the remaining covered expenses up to the lifetime maximum benefit.

1 30-184 days in AZ, IN, MI, OK, and VA. 2 History and exam only: 2 visit limit for terms 180 days or less; 4 visit limit for terms 181 days and over. Additional visits subject to deductible and coinsurance.3 Not available in all states.

1 2 3COVERED EXPENSES

WHO BENEFITSMOST?

PLANFEATURES

PLANS AT A GLANCE

• More coverage than Value. • Rx drug coverage included. • Option to add a $20 copay

on generic Rx drugs.

Great for those seeking predictable out-of-pocket expenses.

• Pay selected deductible. • Then pay coinsurance,

(select from 2 options) up to: - $2,000 per term/cause, or - $5,000 per term/cause.

Families with young children who have regularly scheduled doctor office visits.

• Pay selected deductible. • Then pay coinsurance, up to

$10,000 per term/cause.

• Copay for network doctor office visits.2

• No Rx drug coverage.• Option to add Rx drug

coverage or a $20 copay on generic Rx drugs.

Anyone who prefers the convenience of copay benefits for minor or routine health care expenses.

• Pay selected deductible. • Then pay coinsurance, up to

$10,000 per term/cause.

• Copay for network doctor office visits.2

• Rx drug coverage included. • Options to remove Rx drug

coverage, add a 4-Tier Rx drug card, or add a $20 copay on generic Rx drugs.

Great for those seeking predictable out-of-pocket expenses and for those who are considering longer term lengths.



• Increased lifetime maximum benefit up to $1.5 million.

• Rx drug coverage included.• Option to add a $20 copay

on generic Rx drugs.

• Our lowest premium plan. • In exchange, you take more

responsibility for medical expenses.

• No Rx drug coverage.

Consumers looking for minimal coverage.



Short Term MedicalSM

Value


Copay Value


Plus Elite3

Lifetime Maximum Benefit:$1,000,000






Copay


Plus

4 of 16

Benefit Amounts: $1,000 $1,500 $2,500 $5,000 $10,000

* Examples provided are for illustration purposes only and assume all expenses are covered. Adding a $5,000 Supplemental Accident Benefit would add $30 in monthly premium for a single person and $60 in monthly premium for a family. All of these services were received in September 2015 from network providers in ZIP Code 462--. Your actual savings may be more or less than this illustration and will vary by several factors. Policy Form 6-C-410

Per Cause Deductible Option Lower your premium with our Per Cause Deductible. With this option, you have a separate deductible for each illness or injury. You take more responsibility, but save about 10% on premium. Note: Rx benefits remain per term even if you choose the Per Cause Deductible.

Supplemental Accident Optional BenefitReduce or eliminate your out-of-pocket exposure for accident-related injuries for additional premium. Supplemental Accident helps cover your deductible or other out-of-pocket medical expenses (before the health insurance starts paying covered expenses) for unexpected injuries. You select a maximum amount per accident, per covered person.

Savings example for $25,665 femur fracture*

No health plan

Short Term MedicalSM Plus plan only ($5,000 deductible + 30% coinsurance)

Same plan with a $5,000 Supplemental Accident Benefit

What you could pay: $25,665 $10,000 $5,000

Optional BenefitsFurther customize your health insurance coverage to meet your specific needs. Rx options require additional premium (except Remove Rx coverage).

Supplemental Accident Provisions Expenses must be eligible for payment under the health insurance and incurred within 90 days of an injury. Benefit cannot exceed your total covered medical out-of-pocket expenses that are neither paid nor reimbursed by the underlying health insurance. Any benefit amount paid by the Supplemental Accident benefit will first be credited to the deductible and

coinsurance of the health insurance. The payment will be made either to your health care provider under your assignment of benefits, or to you if you have already paid your provider. No cash payments to the insured except for reimbursement of submitted claims for covered expenses already paid by you and not paid by the underlying health insurance. Exclusions and Limitations of the health plan apply to this additional benefit.

Option Plans available Details

Add 4-Tier Rx Coverage

Short Term MedicalSM Copay

Tier 1 drugs: $20 copay, no deductible. Tier 2-4 drugs have combined $500 deductible per person, per term, then: Tier 2 drugs: $40 copay, Tier 3 drugs: $75 copay, and Tier 4 drugs: you pay 40% coinsurance. Limited to a $3,000 maximum Rx benefit per person, per term.

Add a Generic $20 Rx Copay

Short Term MedicalSM: Plus, Copay Value, Copay, and Plus Elite

Applies to all tiers with no deductible to meet. Name-brand drugs subject to regular plan benefits. May not be combined with 4-Tier Rx coverage. Limited to a $3,000 maximum Rx benefit per person, per term.

Remove Rx Coverage

Short Term MedicalSM Copay

Lowers your premium. Discount Card only.

Add Rx Coverage Short Term MedicalSM Copay Value

Adds 30% coinsurance on prescriptions after you meet your deductible. Limited to a $3,000 maximum Rx benefit per person, per term.

Prescription (Rx) Drug Options (You may only choose one.)

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4 For copay plans, non-network office visits subject to deductible and coinsurance, $50 copay does not apply.

5 Generic Rx drugs only. Deductible does not apply.

Highlights of Network Covered Expenses

Choose a plan. You have several choices.

Choose a term.This is your length of coverage. 1 2

1 Not available in all states.2 30-184 days in AZ, IN, MI, OK, and VA.3 30-184 days in AZ, IN, MI, and OK.

Choose a coinsurance.For Plus and Plus Elite plans, choose 20% or 30%.

Choose a deductible type and amount.Choose either per term (length of coverage) or per cause (illness or injury). The deductible amount you choose applies to each covered person.

Short Term MedicalSM can “bridge the gaps” in health insurance coverage.

3 4

Short Term MedicalSM Value Short Term MedicalSM Plus Short Term MedicalSM Copay Value Short Term MedicalSM Copay Short Term MedicalSM Plus Elite1

Coverage Term 30-360 days2 30-360 days2 30-360 days2 30-360 days2 30-360 days3

Deductible Type Per Term Option: Per Cause to lower premium

Per Term Option: Per Cause to lower premium




Deductible Amount (per person) You pay: $1,000, $1,500, $2,500, $5,000, or $10,000 $1,000, $1,500, $2,500, $5,000, or $10,000 $1,000, $1,500, $2,500, $5,000, or $10,000 $1,000, $1,500, $2,500, $5,000, or $10,000 $1,000, $1,500, $2,500, $5,000, or $10,000

Coinsurance Choices (% you pay of covered expenses after deductible, per person) You pay: 30% 20% or 30% 30% 30% 20% or 30%

Coinsurance Out-of-Pocket Maximum (after deductible, per person) You pay: $5,000 or $10,000 $2,000 or $5,000 $10,000 $10,000 $2,000 or $5,000

Lifetime Maximum Benefit (per covered person) We pay: $1 million $1 million $1 million $1 million $1.5 million

Doctor Office (Illness & Injury)

Office Visit, History, and Exam only (referrals for primary care physician/specialist not required)

You pay: 30% after deductible 20% after deductible or 30% after deductible

$50 copay4 – no deductible: - 2 visit limit* for a term 180 days or less; or - 4 visit limit* for a term 181 days and over. * Per covered person, per term. Additional visits

subject to deductible and coinsurance.

$50 copay4 – no deductible: - 2 visit limit* for a term 180 days or less; or - 4 visit limit* for a term 181 days and over. * Per covered person, per term. Additional visits

subject to deductible and coinsurance.

20% after deductible or 30% after deductible

Pharmacy

Name Brand and Generic Prescription (Rx) Drugs Plans/Options with Rx coverage: limited to $3,000 maximum Rx benefit per person, per term.

You pay:

Not covered. Discount Card – card can help you save an average of 20-25% on your Rx drugs. Discounts vary by pharmacy, geographic area, and drug.

20% or 30% after deductible. Preferred Price Card (You pay for Rx drugs at the point of sale, at the lowest price available, and submit a claim to us.)

Option: Add a Generic $20 Rx Copay5

Not covered. Discount Card only – can help you save an average of 20-25% on your Rx drugs. Discounts vary by pharmacy, geographic area, and drug.

Option: Add a Generic $20 Rx Copay5 OR Option: Add Rx coverage. 30% after deductible. Preferred Price Card (You pay for prescriptions at the point of sale, at the lowest price available, and submit a claim to us.)

30% after deductible. Preferred Price Card (You pay for Rx drugs at the point of sale, at the lowest price available, and submit a claim to us.)

Option: Add 4-Tier Rx Coverage (see page 5) OR Option: Add a Generic $20 Rx Copay5 OR Option: Opt for no Rx coverage to lower premium.

20% or 30% after deductible. Preferred Price Card (You pay for Rx drugs at the point of sale, at the lowest price available, and submit a claim to us.)

Option: Add a Generic $20 Rx Copay5

OutpatientX-ray and Lab, Mammogram, Pap Smear, PSA screening You pay: 30% after deductible 20% after deductible or

30% after deductible 30% after deductible 30% after deductible 20% after deductible or 30% after deductible

Emergency Room Fees – Illness Not covered unless admitted. You pay: 30% after deductible 20% after deductible or

30% after deductible 30% after deductible 30% after deductible 20% after deductible or 30% after deductible

Emergency Room Fees – Injury You pay: 30% after deductible 20% after deductible or 30% after deductible 30% after deductible 30% after deductible 20% after deductible or 30% after deductible

Mental Disorders and Substance Abuse You pay: Not covered 20% after deductible or 30% after deductible

(limited benefit - see page 8)30% after deductible (limited benefit - see page 8)

30% after deductible (limited benefit - see page 8)

20% after deductible or 30% after deductible (limited benefit - see page 8)

InpatientRoom and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, Nurses

You pay: 30% after deductible 20% after deductible or 30% after deductible 30% after deductible 30% after deductible 20% after deductible or

30% after deductible

Supplemental Accident Optional Benefit Available Yes Yes Yes Yes Yes

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Ambulance ServicesGround ambulance service to a hospital for necessary emergency care.

Autism Spectrum DisordersTreatment of autism spectrum disorders. Outpatient applied behavior analysis limited to $50,000 per calendar year, per covered person.

Dental AnesthesiaDental anesthesia (excluding actual dental services) provided in a hospital or outpatient surgical facility and facility fees when the provider certifies that due to the patient’s age or condition, hospitalization or general anesthesia is required in order to safely and effectively perform the procedures. The covered person must:• Be under 7 years of age requiring, without delay,

necessary dental treatment for a significantly complex dental condition;

• Be diagnosed with a serious mental or physical condition; and/or

• Have a significant behavioral problem.No benefits payable for treatment of temporomandibular joint (TMJ) disorders.

Dental ServicesDental expenses for an injury to natural teeth suffered after the coverage effective date. Expenses must be incurred within 6 months of the accident. No benefits payable for injuries due to chewing as limited in the policy.

Diabetes• Diabetes equipment, supplies, and services. • Diabetes self-management training when medically

necessary as determined by a physician, prescribed by a physician, and provided by an appropriately licensed health care professional limited to: - One diabetes self-management training program per

covered person, per lifetime. - Additional diabetes self-management training

prescribed by a physician as medically necessary due to a significant change in the covered person’s symptoms or condition.

Diagnostic Testing

Durable Medical EquipmentRental of wheelchair, hospital bed, and other durable medical equipment.

Home Health CareHome health care prescribed and supervised by a doctor and provided by a licensed home health care agency. Covered expenses for home health aide services will be limited to 7 visits per week and a lifetime maximum of 365 visits. Each 8-hour period of home health aide services will be counted as one visit. Private duty registered nurse services will be limited to a lifetime maximum of 1,000 hours. Intermittent private duty registered nurse visits are not to exceed 4 hours each and are limited to $75 per visit (2 hours per visit are applied toward the lifetime maximum of registered nursing).

No benefits payable for respite care, custodial care, or educational care.

Hospital ServicesDaily hospital room and board at most common semiprivate rate; eligible expenses for an intensive care unit; inpatient use of an operating, treatment, or recovery room; outpatient use of an operating, treatment, or recovery room for surgery; services and supplies, including drugs and medicines, which are routinely provided in the hospital to persons for use only while they are inpatients; emergency treatment of an injury, even if not admitted; and emergency treatment of an illness, but if not admitted for that illness, emergency room charges will not be covered.Hospital does not include a nursing or convalescent home or an extended care facility.

Medical Supplies• Dressings and other necessary medical supplies.• Cost and administration of an anesthetic or oxygen.

Mental Disorders and Substance Abuse• Treatment of mental disorders, mental incapacity, or

substance abuse covered the same as any other illness. • Outpatient doctor visits limited to $50 per visit. • Policy term maximum of $3,000 due to mental

disorders, mental incapacity, or substance abuse per covered person.

Mental disorders and substance abuse are not covered with the Short Term MedicalSM Value plan.

Covered ExpensesSubject to all policy provisions, the following expenses are covered. To be considered for reimbursement, expenses must qualify as covered expenses and are subject to eligible expense limits unless you use a network provider.

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Newborn Care• Routine in-hospital care of a newborn limited to the

first 5 days following birth or when the mother ceases to be an inpatient, whichever occurs first.

• Pregnancy not covered, except for complications.

Outpatient Surgery

Physician Fees• Professional fees of doctors, medical practitioners,

and surgeons. • Assistant surgeon fee limited to 20% of eligible

expenses of the procedure.

Prescription Drugs (if applicable)If you purchase name-brand when generic is available, you pay your generic copay plus the additional cost above the generic price. Visit goldenrule.welcometouhc.com for a current Prescription Drug List.

Preventive Care• Children’s preventive health services for covered

children as defined in the certificate.• Mammograms, Pap smears, colorectal cancer

examinations, prostate-specific antigen testing, and other preventive care as specified in the certificate.

ProstheticsBasic artificial limbs, artificial eyes, and larynx and breast prosthesis. Replacement only if required by a physical change in the covered person and the item cannot be modified.

Rehabilitation and Extended Care Facility (ECF) Must begin within 14 days of a 3-day or longer hospital stay for the same illness or injury. Limited to 60 days per policy term for both rehabilitation and ECF expenses.

Spine and Back DisordersBenefits for outpatient treatment of spine and back disorders limited to $50 per visit and 6 visits in any 3-month period.

Therapeutic Treatments• Radiation therapy and chemotherapy.• Hemodialysis, processing, and administration of blood

or components (but not the cost of the actual blood or components).

Transplant Expense BenefitThe following transplants are covered the same as any other illness: cornea, artery or vein grafts, heart valve grafts, prosthetic tissue and joint replacement, and prosthetic lenses for cataracts.

For all other covered transplants, see your certificate for “Listed Transplants” under Transplant Expense Benefits. The covered person must be a good candidate, as determined by us. The transplant must not be experimental or investigational. Covered expenses for “Listed Transplants” are limited to 2 during a 10-year period, per covered person.

Golden Rule has arranged for certain hospitals around the country (“Centers of Excellence”) to perform specified transplant services. If you use one of our “Centers of Excellence,” the specified transplant will be considered the same as any other illness and will include transportation and lodging incentive (for a family member) of up to $5,000. If a “Center of Excellence” is not used, covered expenses for the “Listed Transplant” will be limited to one transplant in any 12-month period with a maximum benefit of $100,000 for all expenses associated with the transplant.

If a “Center of Excellence” is not used, the acquisition cost for the organ or bone marrow is not covered.

No benefits payable for:• Search and testing in order to locate a suitable donor.• A prophylactic bone harvest and peripheral blood stem

cell collection when no “listed transplant” occurs.• Animal-to-human transplants.• Artificial or mechanical devices designed to replace a

human organ temporarily or permanently.• Procurement or transportation of the organ or tissue,

unless expressly provided in this provision.• Keeping a donor alive for the transplant operation.• A live donor where the live donor is receiving a

transplanted organ to replace the donated organ.• A transplant under study in an ongoing Phase I or II

clinical trial as set forth in the USFDA regulation.

Covered Expenses, continuedMedical Expense Benefits - subject to deductible and copay/coinsurance (if applicable)

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General ExclusionsBenefits will not be paid for services or supplies that are not administered or ordered by a doctor and medically necessary to the diagnosis or treatment of an illness or injury, as defined in the policy.No benefits are payable for expenses:• For a preexisting condition — A condition:

(1) for which medical advice, diagnosis, care, or treatment was recommended or received within the 24 months immediately preceding the date the covered person became insured under the policy/certificate; or (2) that had manifested itself in such a manner that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment within the 12 months immediately preceding the date the covered person became insured under the policy/certificate.

A pregnancy existing on the effective date of coverage will also be considered a preexisting condition.

NOTE: Even if you have had prior Golden Rule coverage and your preexisting conditions were covered under that plan, they will not be covered under this plan.

• That would not have been charged if you did not have insurance.

• Incurred while your coverage is not in force.• Imposed on you by a provider (including a hospital) that

are actually the responsibility of the provider to pay.• For services performed by an immediate family member.• That are not identified and included as covered

expenses under the policy or in excess of the eligible expenses.

• For services that are not covered expenses.• For services or supplies that are provided prior to the

effective date or after the termination date of the coverage.

• For weight modification or surgical treatment of obesity, including wiring of the teeth and all forms of intestinal bypass surgery.

• For breast reduction or augmentation.• For drugs, treatment, or procedures that promote

conception.• For sterilization or reversals of sterilization.• For fetal reduction surgery or abortion (unless life of

mother would be endangered).• For treatment of malocclusions, disorders of the

temporomandibular joint (TMJ) or craniomandibular disorders.

• For modification of the physical body in order to improve psychological, mental, or emotional well-being, such as sex-change surgery.

• Not specifically provided for in the policy, including telephone consultations, failure to keep an appointment, television expenses, or telephone expenses.

• For marriage, family, or child counseling.• For standby availability of a medical practitioner when

no treatment is rendered.• For dental expenses, including braces and oral surgery,

except as provided for in the policy.• For cosmetic treatment. • For reconstructive surgery unless incidental to or

following surgery or for a covered injury, or to correct a birth defect in a child who has been a covered person since childbirth until the surgery.

• For diagnosis or treatment of learning disabilities, attitudinal disorders, or disciplinary problems.

• For diagnosis or treatment of nicotine addiction.• For charges related to, or in preparation for, tissue or

organ transplants, except as expressly provided for under Transplant Services.

• For injuries from participation in professional or semi-professional sports or athletic activities for financial gain, as determined by Golden Rule.

• For high-dose chemotherapy prior to, in conjunction with, or supported by ABMT/BMT, except as specifically provided under the Transplant Expense Benefits provision.

• For eye refractive surgery, when the primary purpose is to correct nearsightedness, farsightedness, or astigmatism.

• While confined for rehabilitation, custodial care, educational care, nursing services, or while at a residential treatment facility, except as provided for in the policy.

• For eyeglasses, contact lenses, hearing aids, eye refraction, visual therapy, or any exam or fitting related to these devices, except as provided for in the policy.

• Due to pregnancy (except complications), except as provided in the policy.

• For diagnostic testing while confined primarily for well-baby care, except as provided in the policy.

• For treatment of mental disorders, or court-ordered treatment for substance abuse, except as provided in the policy.

Plan ProvisionsThis brochure is only a general outline of the coverage provisions. It is not an insurance contract, nor part of the insurance certificate. You will find complete coverage details in the policy and certificate.

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Plan Provisions, continued

General Exclusions, continuedNo benefits are payable for expenses:• For preventive care or prophylactic care, including

routine physical examinations, premarital examinations, and educational programs, except as provided in the policy.

• Incurred outside of the U.S., except for emergency treatment.

• Resulting from declared or undeclared war; intentionally self-inflicted bodily harm (whether sane or insane); or participation in a riot or felony (whether or not charged).

• For or related to durable medical equipment or for its fitting, implantation, adjustment or removal or for complications therefrom, except as provided for in the policy.

• For surrogate parenting• For treatments of hyperhidrosis (excessive sweating).• For alternative treatments, except as specifically

covered by the policy, including: acupressure, acupuncture, aromatherapy, hypnotism, massage therapy, rolfing, and other alternative treatments defined by the Office of Alternative Medicine of the National Institutes of Health.

• Resulting from or during employment for wage or profit, if covered or required to be covered by workers’ compensation insurance under state or federal law. If you entered into a settlement that waives your right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply. Should a workers’ compensation insurance carrier deny coverage for a covered person’s claim, this exclusion will still apply unless the denial is appealed and upheld to the proper government agency.

• Resulting from intoxication, as defined by state law where the illness or injury occurred, or while under the influence of illegal narcotics or controlled substances, unless administered or prescribed by a doctor.

• For vocational or recreational therapy, vocational rehabilitation, outpatient speech therapy, or occupational therapy, except as provided for in the policy.

• Resulting from experimental or investigational treatments, or unproven services.

Coordination of Benefits (including Medicare) If after coverage is issued, a covered person becomes insured under another health plan or Medicare, benefits will be determined under the Coordination of Benefits (COB) clause.COB allows two or more plans to work together so the total amount of all benefits is never more than 100% of covered expenses. COB also takes into account medical coverage under auto insurance contracts. To determine which plan is primary, refer to “order of benefits” in your certificate.

DependentsFor purposes of this coverage, eligible dependents are your lawful spouse and eligible children. Eligible children must be under 26 years of age at time of application.

Effective Date Your certificate will take effect on the later of: • The requested effective date on your application; or • The day after the postmark date affixed by the U.S. Postal

Service,* but only if the following conditions are satisfied:A. Your application and the appropriate premium

payment are actually received by us within 15 days of your signing;**

B. You are a member of the Federation of American Consumers and Travelers (FACT);

C. Your application is properly completed and unaltered;D. You have answered “no” to question 2 (if other

questions are answered “yes,” we will exclude the person(s) listed);

E. You are a resident of a state in which the certificate form can be issued; and

F. If the application is submitted by an agent or broker, the agent or broker is properly licensed and appointed to submit applications to Golden Rule.

* If mailed and not postmarked by the U.S. Postal Service or if the postmark is not legible, the effective date will be the later of: (1) the date you requested; or (2) the date received by Golden Rule. If the application is sent by any electronic means including fax, your coverage will take effect on the later of: (1) the requested effective date; or (2) the day after the date received by Golden Rule.

** Your account will be immediately charged.

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Plan Provisions, continued

Eligible ExpenseAn eligible expense means a covered expense as follows:• For Network Providers: the contract fee for the provider.• For Non-Network Providers: when a covered expense is

received as the result of an emergency or as otherwise approved by us, the eligible expense is the lesser of the billed charge or the amount negotiated with the provider. Except as noted above, the eligible expense is the first of the following that can be applied:1. The fee negotiated with the provider;2. 110% of the fee Medicare allows for the same or

similar service in the same area;3. The fee set by us after comparing rates from one or

more regional or national databases, or schedules for the same or similar service from a geographical area determined by us; or

4. The fee charged by the provider.

Non-RenewableYour Short Term MedicalSM certificate is not renewable. You may apply for additional short term coverage (subject to state restrictions), however a condition which was a covered expense under a prior certificate would be considered preexisting under a subsequent certificate. Additional certificates will not be continuations of any previous certificate.

We may cancel coverage if there is fraud or material misrepresentation made by or with the knowledge of a covered person in filing a claim for benefits.

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HEALTH PLAN NOTICES OF PRIVACY PRACTICESMEDICAL INFORMATION PRIVACY NOTICE(Effective January 1, 2016)We (including our affiliates listed at the end of this notice) are required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or “disclose” that information to others. You also have rights regarding your health information that are described in this notice. We are required by law to abide by the terms of this notice.The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care. We will comply with the requirements of applicable privacy laws related to notifying you in the event of a breach of your health information.We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide to you in our next annual distribution, either a revised notice or information about the material change or how to obtain a revised notice. We will provide this information either by direct mail or electronically in accordance with applicable law. In all cases, we will post the revised notice on our websites, such as www.uhone.com, www.myuhone.com, www.myallsavers.com, or www.myallsaversmember.com. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future. We collect and maintain oral, written and electronic information to administer our business and to provide products, services and information of importance to our customers. We maintain physical, electronic and procedural security safeguards in the handling and maintenance of our enrollees’ information, in accordance with applicable state and Federal standards, to protect against risks such as loss, destruction or misuse. How We Use or Disclose Information. We must use and disclose your health information to provide information:• To you or someone who has the legal right to act for you

(your personal representative) in order to administer your rights as described in this notice; and

• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected.

We have the right to use and disclose health information for your treatment, to pay for your health care and operate our business. For example, we may use or disclose your health information:• For Payment of premiums due us, to determine your coverage

and to process claims for health care services you receive including for subrogation or coordination of other benefits you may have. For example, we may tell a doctor whether you are eligible for coverage and what percentage of the bill may be covered.

• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care. For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.

• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care coverage. For example, we might conduct or arrange for medical review, legal services, and auditing functions, including fraud and abuse detection or compliance programs.

• To Provide Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services.

• To Plan Sponsors. If your coverage is through an employer group health plan, we may share summary health information and enrollment and disenrollment information with the plan sponsor. In addition, we may share other health information with the plan sponsor for plan administration if the plan sponsor agrees to special restrictions on its use and disclosure of the information in accordance with Federal law.

• For Underwriting Purposes. We may use or disclose your health information for underwriting purposes; however, we will not use or disclose your genetic information for such purposes.

• For Reminders. We may use health information to contact you for appointment reminders with providers who provide medical care to you.

We may use or disclose your health information for the following purposes under limited circumstances:• As Required by Law. We may disclose information when

required to do so by law.• To Persons Involved With Your Care. We may use or disclose

your health information to a person involved in your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity. If you are unavailable or unable to object we will use our best judgment to decide if the disclosure is in your best interests. Special restrictions apply regarding when we may disclose health information to family members and others involved in a deceased individual’s care. We may disclose health information to any persons involved, prior to the death, in the care or payment for care of a deceased individual, unless we are aware that doing so would be inconsistent with a preference previously expressed by the deceased.

• For Public Health Activities such as reporting disease outbreaks. • For Reporting Victims of Abuse, Neglect or Domestic

Violence to government authorities, including a social service or protective service agency.

• For Health Oversight Activities such as governmental audits and fraud and abuse investigations.

• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.

• For Law Enforcement Purposes such as providing limited information to locate a missing person or report a crime.

• To Avoid a Serious Threat to Health or Safety by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster.

• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.

33638-X-0516 Products are either underwritten or administered by: All Savers Insurance Company, All Savers Life Insurance Company of California, Golden Rule Insurance Company, PacifiCare Life and Health Insurance Company, UnitedHealthcare Insurance Company, and/or UnitedHealthcare Life Insurance Company.

• For Workers’ Compensation including disclosures required by state workers’ compensation laws that govern job-related injury or illness.

• For Research Purposes such as research related to the prevention of disease or disability, if the research study meets Federal privacy law requirements.

• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.

• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.

• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us and pursuant to Federal law, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract and as permitted by Federal law.

• Additional Restrictions on Use and Disclosure. Certain Federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information: HIV/AIDS; mental health; genetic tests; alcohol and drug abuse; sexually transmitted diseases and reproductive health information; and child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law. Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you. This includes, except for limited circumstances allowed by Federal privacy law, not using or disclosing psychotherapy notes about you, selling your health information to others or using or disclosing your health information for certain promotional communications that are prohibited marketing communications under Federal law, without your written authorization. Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or “revoke” your written authorization, except if we have already acted based on your authorization. To revoke an authorization, call the phone number listed on your health plan ID card.

What Are Your Rights. The following are your rights with respect to your health information.• You have the right to ask to restrict uses or disclosures of

your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that may authorize certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.

• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a PO Box instead of your home address). We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you. In certain circumstances, we will accept verbal requests to receive confidential communications; however, we may also require you to confirm your request in writing. In addition, any request to modify or cancel a previous confidential communication request must be made in writing. Mail your request to the address listed below.

• You have the right to see and obtain a copy of health information that we maintain about you such as claims and case or medical management records. If we maintain your health information electronically, you will have the right to request that we send a copy of your health information in an electronic format to you. You can also request that we provide a copy of your information to a third party that you identify. In some cases you may receive a summary of this health information. You must make a written request to inspect and copy your health information or have it sent to a third party. Mail your request to the address listed below. In certain limited circumstances, we may deny your request to inspect and copy your health information. If we deny your request, you may have the right to have the denial reviewed. We may charge a reasonable fee for any copies.

• You have the right to ask to amend information we maintain about you such as claims and case or medical management records, if you believe the health information about you is wrong or incomplete. Your request must be in writing and provide the reasons for the requested amendment. Mail your request to the address listed below. If we deny your request, you may have a statement of your disagreement added to your health information.

• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information: (i) for treatment, payment, and health care operations purposes; (ii) to you or pursuant to your authorization; and (iii) to correctional institutions or law enforcement officials; and (iv) other disclosures for which Federal law does not require us to provide an accounting.


• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. In addition, you may obtain a copy of this notice at our websites such as www.uhone.com, www.myuhone.com, www.myallsavers.com, or www.myallsaversmember.com. You have the right to be considered a protected person. (New Mexico only) A “protected person” is a victim of domestic abuse who also is either: (i) an applicant for insurance with us; (ii) a person who is or may be covered by our insurance; or (iii) someone who has a claim for benefits under our insurance.

Exercising Your Rights• Contacting your Health Plan. If you have any questions about

this notice or want to exercise any of your rights, please call the toll-free phone number on your ID card.

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the address listed below.

• Submitting a Written Request. Mail to us your written requests to exercise any of your rights, including modifying or cancelling a confidential communication, requesting copies of your records, or requesting amendments to your record at the following address:

• Privacy Office, 7440 Woodland Drive, Indianapolis, IN 46278-1719• You may also notify the Secretary of the U.S. Department

of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

Fair Credit Reporting Act Notice. In some cases, we may ask a consumer-reporting agency to compile a consumer report, including potentially an investigative consumer report, about you. If we request an investigative consumer report, we will notify you promptly with the name and address of the agency that will furnish the report. You may request in writing to be interviewed as part of the investigation. The agency may retain a copy of the report. The agency may disclose it to other persons as allowed by the Federal Fair Credit Reporting Act. We may disclose information solely about our transactions or experiences with you to our affiliates.

MIB. In conjunction with our membership in MIB, Inc., formerly known as Medical Information Bureau (MIB), we or our reinsurers may make a report of your personal information to MIB. MIB is a not-for-profit organization of life and health insurance companies that operates an information exchange on behalf of its members.If you submit an application or claim for benefits to another MIB member company for life or health insurance coverage, the MIB, upon request, will supply such company with information regarding you that it has in its file.If you question the accuracy of information in the MIB’s file, you may seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. Contact MIB at: MIB, Inc., 50 Braintree Hill Park Ste. 400, Braintree, MA 02184-8734, 1-866-692-6901, www.mib.com.

FINANCIAL INFORMATION PRIVACY NOTICE (Effective January 1, 2016)We (including our affiliates listed at the end of this notice) are committed to maintaining the confidentiality of your personal financial information. For the purposes of this notice, “personal financial information” means information, other than health information, about an insured or an applicant for coverage that identifies the individual, is not generally publicly available and is collected from the individual or is obtained in connection with providing coverage to the individual.Information We Collect. Depending upon the product or service you have with us, we may collect personal financial information about you from the following sources:• Information we receive from you on applications or other forms,

such as name, address, age, medical information and Social Security number;

• Information about your transactions with us, our affiliates or others, such as premium payment and claims history; and

• Information from a consumer reporting agency. Disclosure of Information. We do not disclose personal financial information about our insureds or former insureds to any third party, except as required or permitted by law. For example, in the course of our general business practices, we may, as permitted by law, disclose any of the personal financial information that we collect about you, without your authorization, to the following types of institutions:• To our corporate affiliates, which include financial service

providers, such as other insurers, and non-financial companies, such as data processors;

• To nonaffiliated companies for our everyday business purposes, such as to process your transactions, maintain your account(s), or respond to court orders and legal investigations; and

• To nonaffiliated companies that perform services for us, including sending promotional communications on our behalf.

We restrict access to personal financial information about you to employees, affiliates and service providers who are involved in administering your health care coverage or providing services to you. We maintain physical, electronic and procedural safeguards that comply with Federal standards to guard your personal financial information. Confidentiality and Security. We maintain physical, electronic and procedural safeguards, in accordance with applicable state and Federal standards, to protect your personal financial information against risks such as loss, destruction or misuse. These measures include computer safeguards, secured files and buildings, and restrictions on who may access your personal financial information.Questions About this Notice. If you have any questions about this notice, please call the toll-free phone number on your ID card.The Notice of Privacy Practices, effective January 1, 2016, is provided on behalf of All Savers Insurance Company; All Savers Life Insurance Company of California; Golden Rule Insurance Company; PacifiCare Life and Health Insurance Company; UnitedHealthcare Insurance Company; and UnitedHealthcare Life Insurance Company.To obtain an authorization to release your personal information to another party, please go to the appropriate website listed in this Notice.


This short term major medical policy is nonrenewable. Short Term MedicalSM is issued for a specific period of time. If your needs for coverage extend beyond this plan, you may apply for additional short term plans.* This requires a new application and is not an extension of your current plan. Any illness or condition you develop while covered by your current plan would be considered “preexisting” when you apply for a new short term plan and, as such, will not be a covered expense.Please see insert for state variations. In most cases, coverage will be determined by the master policy issued in Arkansas and subject to Arkansas law. We will notify you in advance of any changes in coverage or benefits. Not available in all states. Nonrefundable $20 application fee required. * Not available in Wisconsin. In Michigan, no more than 184 days of combined coverage in a 12-month period.

Short Term MedicalSM PlansOur plans offer easy-to-understand health insurance designed for individuals and families in times of transition and change with up to $1,500,000 of coverage.

Plans only available to members of FACT, the Federation of American Consumers and Travelers (see below). If you’re not already a member, enroll now to be eligible to apply for these plans.

What is FACT?FACT is an independent consumer association whose members benefit from the “pooling” of resources. Benefits range from medical savings to consumer service discounts. FACT’s principal office is in Jonesboro, Arkansas. FACT and Golden Rule Insurance Company are separate organizations. Neither is responsible for the performance of the other. FACT has contracted with Golden Rule Insurance Company to provide its members with access to these health insurance plans. FACT does not receive any compensation from Golden Rule Insurance Company.

Is there a cost for joining FACT?Yes, there are membership dues and they can be paid with your regular health insurance premium, as opposed to making a separate payment.

What are the basic FACT membership benefits?FACT makes it easy for members to choose from a full menu of important benefits, including:

As a member of FACT, your information is kept private and is not shared with any third parties. Please visit the FACT website, usafact.org/privacy_policy.html, for a complete FACT Privacy Statement. FACT may change or discontinue any of its membership benefits at any time. For the most current information, including full detailed lists of member benefits, visit FACT’s website at usafact.org or call toll-free at (800) USA-FACT.

• Accidental Death Benefits• Consumer Information & Hotline• Retail & Service Discounts

• Travel Discounts• Pet Coverage• Scholarships

© 2016 United HealthCare Services, Inc. UnitedHealthOneSM is a brand representing a portfolio of insurance products offered to individuals and families through the UnitedHealthcare family of companies. 43853-G-0516

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Alabama Policy Form C-014.1

There are no state variations.

Arizona Policy Forms GRI-STAG15-C-VAL-02, GRI-STAG15-C-PLS-02, GRI-STAG15-C-PLE-02, GRI-STAG15-C-CPY-02 and GRI-STAG15-C-CPV-02

Coverage term limited to 30-184 days.

Arkansas Policy Form C-014.1

Hearing aids are covered when purchased from a professional licensed by the state of Arkansas. Limited to $1,400 per ear in a 3-year period per covered person. No deductible, copayment, or coinsurance.

Florida Policy Form C-014.1-09

• An eligible child may remain covered through age 30.• Routine follow-up care to determine whether a breast

cancer has recurred in a person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care or treatment for purposes of determining preexisting conditions unless evidence of breast cancer is found during or as a result of the follow up care.

• Transportation charges for a newborn to and from the nearest appropriate facility for medically necessary care limited to a maximum of $1,000.

• Covered expenses are expanded to include: - General anesthesia and services at a hospital or

outpatient surgical facility for necessary dental care for an eligible child: less than 8 years old with a significantly complex dental condition or development disability for which treatment in dental office would be ineffective; or who has one or more medical conditions that create a significant or undue risk if the necessary dental care was not performed in a hospital or outpatient surgical center.

- Medically necessary services and treatment for cleft lip and palate for an eligible child under age 18.

- Diagnostic or surgical procedures involving bones or joints of the jaw and facial region, if, under accepted medical standards, the procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury.

Illinois Policy Form C-014.1

• The definition of an eligible child is expanded to include an unmarried dependent under 30 years of age who: (a) Is an Illinois resident; (b) has served in the U.S. Armed Forces; (c) received a release or discharge other than dishonorable; and (d) has submitted a copy of a DD2-14 Certificate of Release or Discharge from active duty.

• The definition of “spouse” is expanded to include civil union partner.

• Covered Expenses are expanded to include: - Inpatient treatment of alcoholism. - Outpatient contraceptive services and devices as

required by law. - Surveillance test for ovarian cancer for covered females

at risk. - One annual FDA-approved screening for human

papillomavirus. The cost and administration of FDA-approved human papillomavirus vaccine.

- Habilitative services for covered persons under age 19 diagnosed with a congenital, genetic, or early acquired syndrome. Treatment must be from licensed practitioners.

- Medically necessary amino acid-based elemental formulas for the treatment of eosinophilic disorders or short bowel syndrome.

- FDA-approved shingles vaccine, ordered by a doctor for persons age 60 and older.

- Pain medication and therapy related to treatment of breast cancer to the same extent as any other illness.

- Oral anti-cancer medication subject to the same cost-sharing requirements as intravenous or injected anti-cancer medication, regardless of the setting in which it is administered.

- Routine patient care incurred by a covered person in a qualified cancer trial to the same extent as coverage for routine patient care for a covered person not enrolled in a qualified clinical cancer trial. Specific details included in the certificate.

- For a female covered person, one clinical breast exam per calendar year.

- Breast cancer screening (exempt from deductible, copayments, coinsurance, when provided by a network provider) limited to: one routine mammography exam per calendar year for each female covered person; additional mammograms at medically necessary intervals; and a comprehensive ultrasound when a mammogram shows heterogeneous or dense breast tissue.

• General Exclusions and Limitations are modified as follows: Covered expenses will not include, and no benefits will be paid for charges incurred for modification of the physical body in order to improve the psychological, mental, or emotional well-being of the covered person, except for charges for sex-change surgery or any other surgical or non-surgical treatment of gender dysphoria or gender identity disorder will be a covered expense, subject to all other limitations and exclusions of the policy.

Short Term MedicalSM State VariationsPlease see below for state availability and applicable state-specific benefits, exclusions, and limitations. This insert must be used with the Short Term MedicalSM brochure (43853-UL).

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Indiana Policy Form C-014.1

• Application fee is refundable.• Coverage term limited to 30-184 days. • The definition of preexisting condition is replaced with:

“Preexisting condition” means a condition for which the covered person received medical advice or treatment within the 12 months immediately preceding the date he or she became insured under the policy.

Iowa Policy Form C-014.1

• The spine and back limitation does not apply.• The definition of “spouse” is expanded to include

a partner in a civil union or same sex marriage.

Michigan Policy Form C-014.1

Coverage term limited to 30-184 days.

Mississippi Policy Form C-014.1

The references to 24 and 12 months in the definition of preexisting condition are both changed to 6 months.

Nebraska Policy Form C-014.1


North Carolina Policy Form C-014.1-32

• The definition of complications of pregnancy includes medically necessary fetal reduction.

• The definition of preexisting condition is replaced with: “Preexisting condition” means those conditions for which medical advice, diagnosis, care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the covered person’s coverage. A pregnancy existing on the effective date of coverage will also be considered a preexisting condition.

• If your plan provides FDA-approved prescription drugs for certain types of cancer, coverage will not be excluded because the prescribed drug has not been FDA approved to treat a certain type of cancer. Full details included in your certificate.

• The General Exclusion provision for expenses resulting from intoxication or while under the influence of illegal narcotics or a controlled substance, will not apply.

• The General Exclusion provision for expenses incurred due to an injury or illness arising out of, or in the course of, employment for wage or profit is hereby deleted and replaced with the following: Covered expenses will not include services or supplies for the treatment of an occupational injury or illness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services or supplies are the liability of the

employee, employer, or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act.

• Under the Coordination of Benefits provision, the definition of plan will not include blanket, franchise individual, medical benefits under group or individual auto contracts, or homeowner coverage.

• Covered expenses are expanded to include: - General anesthesia, facility fees, and other related

charges incurred in conjunction with dental care (but not the actual dental services) provided in a hospital or an outpatient surgical facility, when medically necessary to safely and effectively perform the procedure, for: an eligible child under 9 years of age; covered persons with serious mental or physical conditions or with significant behavioral problems.

- Diagnosis and evaluation of osteoporosis or low bone mass for qualified individuals.

- A newborn hearing screening when ordered by the attending doctor.

- An annual screening for ovarian cancer using a transvaginal ultrasound and rectovaginal pelvic examination for women age 25 and older who are at risk for ovarian cancer.

- Medically necessary costs of health care services associated with a clinical trial, medically necessary monitoring, and the diagnosis and treatment of complications to the extent these costs are not funded by national agencies, commercial manufacturers, distributors or other sponsors of participants in the clinical trial. Covered expenses do not include clinical trial costs of the actual investigational drug or device, services that are not health care services, services provided solely to satisfy data collection, services not provided for direct clinical management, or non-USFDA approved drugs provided after the clinical trial has been concluded.

- Medically necessary services, equipment, supplies, medications, and laboratory procedures used in the treatment of diabetes, including self-management training.

- Mammography screenings. Specific details in certificate at issue.

- FDA-approved tests or screenings for the detection of the human papillomavirus (HPV).

Short Term MedicalSM State Variations, continued

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North Carolina, continued• Covered expenses are expanded to include:

- Diagnosis, evaluation, and treatment of lymphedema, including equipment, supplies, and self-management training.

- Medically necessary breast prosthesis. - Diagnostic, surgical and non-surgical treatment of

temporomandibular joint disorders (TMJ), including splinting and use of intraoral prosthetic appliances. Non-surgical treatment of TMJ is limited to a lifetime maximum of $3,500 per covered person. Non-surgical treatment of TMJ disorders does not include tooth extraction, orthodontic braces, crowns, bridges, dentures, treatment for periodontal disease, dental root implants, or root canals.

Ohio Policy Forms GRI-STAG15-C-VAL-34, GRI-STAG15-C-PLS-34, GRI-STAG15-C-PLE-34, GRI-STAG15-C-CPY-34 and GRI-STAG15-C-CPV-34

• Short Term MedicalSM Plus Elite is not available.• Transplant Expense Benefits are limited to 2 transplants

per policy term. If a designated “Center of Excellence” is not used, covered expenses for a listed transplant will be limited to 1 transplant per policy term and a maximum benefit of $100,000 for all expenses associated with the transplant.

• Diagnosis or treatment of a mental disorder, including substance abuse, or for mental incapacity subject to the following additional limitations: - Outpatient treatments of substance abuse are further

limited to $50 per visit for the fees of a medical practitioner.

- Diagnosis and treatment of mental disorders on an outpatient basis will be limited to $550 per covered person, per policy term.

Oklahoma Policy Form C-014.1-35

• Coverage term limited to 30-184 days. • The spine and back limitation does not apply.• The General Exclusions provision for injury or illness by an

act of declared or undeclared war is replaced with: No benefits payable for any charges which are caused by war or an act of war, declared or undeclared, while serving in the military or naval service, or any auxiliary unit of the United States.

Pennsylvania Policy Form C-014.1


Texas Policy Form C-014.1

• The definition of preexisting condition is replaced with: “Preexisting condition” means an injury or illness for which the covered person received medical advice or treatment within the 12 months immediately preceding the applicable effective date the covered person became insured under the policy. A pregnancy existing on the effective date of coverage will also be considered a preexisting condition.

• Inpatient chemical dependency is limited to a lifetime maximum of 3 separate series of treatments per covered person. No benefits payable for addiction or dependency on tobacco products or foods; outpatient detoxification; drug maintenance, as opposed to rehabilitation.

• Treatment of a mental disorder while under the supervision of a doctor of medicine or osteopathy in a psychiatric day treatment facility, or in a residential treatment center for children and adolescents or a crisis stabilization unit, will be covered the same as inpatient benefits for any other illness.

• Diagnosis and treatment of serious mental illness (as defined in the certificate) limited to: 45 days of inpatient treatment each calendar year; 60 outpatient visits each calendar year (not including medication management visits).

• Reconstructive surgery for craniofacial abnormalities caused by congenital defects, developmental abnormalities, trauma, tumors, infection or disease limited to covered dependents under age 18.

• Covered expenses are expanded to include: - Diagnosis and treatment of acquired brain injury,

as specified in the certificate. - Up to $200 every five years for screening tests for

atherosclerosis and abnormal artery structure and function, as defined in the certificate.

- Habilitative services for an eligible child with congenital, genetic, or early acquired disorder.

- One test for hearing loss within the first 30 days after birth and related necessary diagnostic follow up care during the first 24 months after birth. Deductible does not apply.

- Diagnostic and surgical treatment of temporomandibular joint disorders (TMJ) and craniomandibular joint disorders.


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© 2016 United HealthCare Services, Inc.Golden Rule Insurance Company is the underwriter and administrator of these plans. UnitedHealthOneSM is a brand representing a portfolio of insurance products offered to individuals and families through the UnitedHealthcare family of companies. 43853i-G-0516

Virginia Policy Form C-014.1

• Coverage term limited to 30-184 days. • Short Term MedicalSM Plus Elite is not available.• The reference to 24 months in the definition of preexisting

conditions is changed to 12 months.• Under Coordination of Benefits, the definition of plan will

not include medical benefits under group or individual automobile contracts.

West Virginia Policy Form C-014.1-47

• Covered expenses for the treatment of Type I, Type II, or gestational diabetes are expanded to include the following medically necessary equipment and supplies: monitor supplies, injection aids, orthotics, and insulin infusion devices.

• Covered expenses for diabetes self-management training services are deleted and replaced with the following: Covered expenses for diabetes self-management training services are limited to $100 per covered person, per calendar year.

• When determining covered expenses for dental expenses, injury will include damage to the natural teeth incurred as a result of chewing if the damage was caused by a non-edible foreign object found in food.

• Covered expenses are expanded to include an annual kidney disease screening using any combination of blood pressure testing, urine albumin or urine protein testing as recommended by the National Kidney Foundation.

• Covered expenses are expanded to include charges for general anesthesia, facility fees, and other related charges incurred in conjunction with dental care (but not the actual dental services) that are provided in a hospital or an outpatient surgical facility to a covered person as defined in the policy.

Wisconsin Policy Form C-014.1

• A child called to active military duty prior to age 27 may be eligible after age 27 if a full-time student.

• Eligible children must be under 27 years of age at time of application. If age 26 at time of application, must also be unmarried.

• Home health aide services are limited to 40 home health care visits in a 12-month period. Specific details on Home Health Care Services are included in the certificate at issue.

• Kidney disease treatment is limited to dialysis, transplantation, and donor-related services. Maximum benefit is $30,000 per covered person annually.

• The spine and back limitation does not apply.• Treatment of temporomandibular joint (TMJ) is covered.

Non-surgical treatment is limited to $1,250 per calendar year. Specific details included in certificate at issue.

• Treatment for mental or nervous disorders, including substance abuse, will be covered the same as any other illness. Covered expenses will include transitional treatment arrangements for a covered person and outpatient counseling services for a member of the covered person’s immediate family (spouse, children, parents, grandparents, or siblings) to enhance the treatment of the covered person.


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Documents

Florida - miesesinsurancebroker.com INSURANCE.pdf · 80.02.351.1-FL B (1/16) A variety of health benefits plans to fit your needs at affordable rates Visit for more information. Florida