PROGRAM GUIDEpantheracoverage.com/img/cat50.pdfhis is NO a Maor Medical Plan . This group health plan is a limited medical plan as described by the benefits covered in the schedule

18-AGE-006 - Panthera CAT50 Brochure • 4/4 • 5.5”W x 8.5”H • Built at 100% Proofed at 100% • Color CompHCK2 • Designed by Tad Dobbs • September 27, 2018

PROGRAM GUIDEFor Plan Participants of

Data Partnership Group, LP

This is NOT a Major Medical Plan. This group health plan is a limited medical plan as described by the benefits covered in the schedule of benefits which include information on copays, deductibles, and limitations. Please review carefully. This is not a Major Medical or Comprehensive Medical Insurance Coverage, and is neither a minimum Essential Health Benefit Plan under Affordable Care Act nor a policy of Worker’s Compensation Insurance under state law. This group health plan is sponsored by Data Partnership Group, LP, 1600 Parkwood Circle, Suite 200, Atlanta, GA 30339. Not available in ME, MD, MT, NH, NJ, WA.

Table of Contents Access Your Medical Benefits Online 24/7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Find a Network Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Schedule of Benefits & Plan Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Cancellation / Refund Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6


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Access Your Medical Benefits Online 24/7 For your complete Plan Document and Summary Plan Description, please access your Member Portal at: https://1enrollment.com/agmembers Your Member ID, Username and Password has been emailed to the email address on your account profile. If you have any questions, please contact your dedicated customer service professionals at (866) 239-5150 (M-F 8:00 am to 6:00 pm) for assistance.

We have partnered with Hawaii-Mainland Administrators, LLC (HMA) to administer claims payment for your medical and WellDyneRx pharmacy coverage.

Your Membership PortalTo create an account, go to: https://members.hmatpa.com.

To create an account on the member portal:1. Click “Create Account”2. Enter Your Name, Email Address, Last 4 digits of your SSN, Date of

Birth and Member ID3. Accept Terms of Use Policy

Some Features of the Member Portal allow you to view the following:• Member Information• Benefit Details• Provider Search• Plan Documents and Forms

• Claims• Prior Authorization• Expense Limits

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Find a Network Provider Your plan allows you to enjoy great savings through First Health Network and First Access Wrap Networks, which can significantly reduce your out-of-pocket expenses. First Health is a brand name of First Health Group Corp., an indirect wholly-owned subsidiary of Aetna, Inc. As a reminder, out-of-network services are not covered by your plan. Therefore, it is important to choose an in-network provider. To locate an in-network provider, visit: www.locateyourprovider.com and follow the easy step-by-step instructions on how to access a participating provider.

Limited Benefit PlanComplementary

Competitive Health, Inc.

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Schedule of Benefits & Plan Design Limited Inpatient Hospital Benefit Plan The CAT 50 Plan covers limited inpatient hospital care in accredited hospitals for each enrolled participant. Coverage includes inpatient surgery, but not outpatient or elective surgeries. This Plan does not cover out-of-network services. This Plan is not subject to the Patient Protection and Affordable Care Act.

Plan Year for Benefits is October 1 to September 30.

Annual Plan Year Deductible $5,000

Out of Pocket Maximum n/a

Annual Plan Year Limit $50,000

Member Coinsurance 0%

TPA HMA, LLC

Networks First Health Network and MultiPlan Network for limited benefit plans.

Medical Service

What You Will Pay

Limitations & ExceptionsNetwork Provider (You will pay less)

Out of Network Provider (You will pay more)

Inpatient Hospital Benefitsincluding MHSA (Mental Health and Substance Abuse)

$5,000 deductible,

then 0% coinsurance

Not CoveredOutpatient or elective surgery not covered. Pre-existing conditions within past twelve months excluded.

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ExclusionsPreexisting ConditionsPre-existing conditions – The preexisting condition limitation will apply for as long as the policy is in force. For example, if a person was treated for colon cancer in the 12 months prior to purchasing the policy, that would be a preexisting condition. The policy would not pay benefits for any services or treatments related to that person’s colon cancer for as long as the person has the policy.

“Preexisting condition” means an illness, injury, or condition:

1. For which medical advice, diagnosis, care, or treatment was recommended to or received by a covered person within 12 months immediately preceding the effective date the covered person became insured under the policy; or

2. That manifested symptoms which would cause an ordinarily prudent person to seek diagnosis or treatment within the 12 months immediately preceding the applicable effective date the covered person became insured under the policy.

Other Exclusions and LimitationsNo benefits are payable for or relating to any of the following:1. Any care or treatment which is not specifically provided for in the policy2. An illness or injury occurring before the policy effective date, after

termination of the policy, or during any time that coverage is not in force3. Intentionally self-inflicted bodily harm (whether the covered person is sane

or insane).4. Any act of declared or undeclared war5. Active service in the armed forces of any country, or related auxiliaries

including the National Guard or military reserve6. The covered person taking part in a riot7. The covered person’s commission or attempt to commit a felony, whether or

not charged8. The covered person being intoxicated, as defined by applicable state law

in the state in which the loss occurred, or under the influence of illegal narcotics or controlled substance unless administered or prescribed by a doctor or voluntary taking of any over the counter drug unless taken in accordance with the manufacturers recommended dosage.

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9. Cosmetic treatment10. Abortions (including complications of abortions).11. Hospital confinement primarily to receive rehabilitation, custodial care,

educational care, or nursing services (unless expressly provided for by the policy)

12. Elective surgery that is not medically necessary13. Donating an organ14. Operating a taxi or any other livery (passenger transportation) services for

wage, compensation, or profit15. Any injury sustained while paid to participate or instruct in: horseback

riding, racing, speed testing any non-motorized vehicle/conveyance, skiing, rock or mountain climbing

16. Any injury sustained while participating, demonstrating, instructing, guiding, or accompanying others in: sports (semi- or professional or intercollegiate not including intramural sports), parachute jumping, hang gliding, skydiving, bungee jumping, parakiting, racing or speed testing any motorized vehicle/conveyance, rodeo sports, or scuba/skin diving (60 or more feet in depth).

17. Any injury sustained while performing the duties of any type of non-commercial aircraft crew member, including giving or receiving training on any aircraft.

18. Care or treatment which would be provided without cost to you or your covered dependent in the absence of insurance covering the charge

19. Care or treatment not administered or ordered by a doctor or are not medically necessary to the diagnosis or treatment of an illness or injury

20. Routine well-baby care of a newborn infant while inpatient21. An illness or injury sustained while the covered person is incarcerated in a

state or federal prison or other detention facility22. Court ordered treatment programs for substance abuse or other conditions23. Care or treatment rendered outside the U.S. states or territories24. Dental expenses25. Facilities, and all treatments in said facilities, which specialize in inpatient

substance abuse and mental health rehabilitation26. Skilled nursing services or skilled nursing facilities27. Any care or treatments not provided on an inpatient basis at an

accredited hospital28. Intensive Care Unit (“ICU”), Critical Care Unit (“CCU”) and Neonatal Intensive

Care (“NICU”) expenses are allowable at the hospital semi-private room.

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Cancellation / Refund policy:This plan has a 30 day right-to-review for cancellation. Period begins on the effective date of the plan. If no claims, including usage of prescription programs, have been utilized, then the plan may be eligible for refund and all medical claims will be denied retroactive to the effective date.

Contact us Today!(866) 239-5150

www.pantheracoverage.com4201 Spring Valley Road, Suite 1500 • Dallas, Texas 75244


CAT50 3/8/19