PROGRAM GUIDE...Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures, and patient ... LP 23548 Calabasas Road, Ste 206E Calabasas, CA, USA 91302

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PROGRAM GUIDEFor Plan Participants of

Data Partnership Group, LP

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

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

Schedule of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Limitations, Intervals and Requirements. . . . . . . . . . . . . . . . . . . . . . . . . .4Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Prescription Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13


This is NOT a Major Medical Plan. This group health plan is limited to covering preventive and wellness services as required by the Patient

Protection and Affordable Care Act as well as other benefits noted in the Schedule of Benefits, which describes the benefits covered by the plan

and how these benefits are covered, including information on copays, deductibles, and limitations. This plan does not cover benefits unless they

are listed in the Schedule of Benefits, so please review that list carefully. This group health plan is sponsored by Data Partnership Group, LP 23548

Calabasas Road, Ste 206E Calabasas, CA, USA 91302. Not available in MD, ME, NH, WA.

Supplemental Hospital Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Cancellation / Refund Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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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

This is NOT a Major Medical Plan. This group health plan is limited to covering preventive and wellness services as required by

the Patient Protection and Affordable Care Act as well as other benefits noted in the Schedule of Benefits, which describes the

benefits covered by the plan and how these benefits are covered, including information on copays, deductibles, and limitations.

This plan does not cover benefits unless they are listed in the Schedule of Benefits, so please review that list carefully. This group

health plan is sponsored by Data Partnership Group, LP 23548 Calabasas Road, Ste 206E Calabasas, CA, USA 91302. Not available

in MD, ME, NH, WA.

AAccess Yccess Your Mour Mediedical Bencal Benefefiits Ots Onlinlinne 24e 24/7/7

For you 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 800-656-2204 (M-F 8:00 am to 6:00 pm) for assistance.

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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.findprovidersnow.com and follow the easy step-by-step instructions on how to access a participating provider.






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Schedule of Benefits & Plan Design The following table represents the type of medical services currently covered under this plan as well as the permitted interval and any requirements of such medical services, with no waiting periods and no pre-existing condition limitations.

Medical Service

What You Will Pay

Limitations & ExceptionsNetwork Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

Primary Care Office Visit

$25 Member Copay Not Covered

Combined limit of 3 visits per plan year.

Specialist Office Visit

$50 Member Copay Not Covered

Preventive and Wellness Services

100% by Plan1 Not Covered

Preventive services performed in a hospital facility are considered out-of-network and are not covered.You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. See Schedule of Wellness and Preventive Services below.

1 No cost to member.






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Preventive Health Services: Limitations, Intervals, and Requirements The following table represents the type of medical services currently covered under this plan as well as the permitted interval and any requirements of such medical services. If a medical service does not have a specific interval under law or regulation, the interval for that medical service is once per year.

Preventive Health Services

Benefit Interval Description

Abdominal aortic aneurysm screening 1 per lifetime By ultrasonography in men ages 65-75 years

who have ever smoked

Adult Annual Physical 1 per plan year Standard Preventive Adult Physical.

Alcohol misuse: screening and

counseling1

Screenings for adults age 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse

Aspirin: preventive medication As prescribed

Initiating low-dose aspirin use for the primary prevention of cardiovascular disease and colorectal cancer in adults aged 50 to 59 years who have a 10% or greater 10-year cardiovascular risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years

Use of low-dose aspirin (81 mg/d) after 12 weeks of gestation in pregnant women who are at high risk for preeclampsia

Bacteriuria screening 1Screening for asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16 weeks’ gestation or at the first prenatal visit, if later.

Blood pressure screening 1 Screening for high blood pressure in adults

aged 18 or older






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BRCA risk assessment and genetic counseling/testing

1

Screening to women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.

Breast cancer preventive medications

1Risk-reducing medications, such as tamoxifen or raloxifene for women who are at increased risk for breast cancer and at low risk for adverse medication effects.

Breast cancer screening

1 time every2 years

Screening mammography for women aged 50 to 74 years. Coverage limited to 2D mammograms only.

Breastfeeding interventions 2 Interventions during pregnancy and after

birth to support breastfeeding

Cervical cancer screening: with cytology (Pap smear)

1 time every3 years Women age 21 to 65 years

Cervical cancer screening: with combination of cytology and human papillomavirus (HPV) testing

1 time every5 years

Women age 30 to 65 years who want to lengthen the screening interval

Chlamydia screening 1Sexually active women age 24 and younger and in older women who are at increased risk infection

Colorectal cancer screening

1 time every5 years

Starting in adults at age 50 years and continuing until age 75 years

Contraceptive methods and counseling As prescribed

Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity, not including abortifacient drugs






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Dental caries prevention: infants and children up to age 5 years

1

Application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption and prescription of oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient

Depression screening 1

Screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years.Screening should be implemented withadequate systems in place to ensureaccurate diagnosis, effective treatment, andappropriate follow-up.

Screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

Diabetes screening 1

Screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.

Falls prevention: exercise or physical therapy

1 Community-dwelling adults age 65 years and older who are at increased risk for falls

Falls prevention: vitamin D supplementation

As prescribed Community-dwelling adults age 65 years and older who are at increased risk for fal

Folic acid supplementation As purchased

Daily supplement containing 0.4 to 0.8 mg (400 to 800 μg) of folic acid for all women planning or capable of pregnancy

Gestational diabetes mellitus screening 1 Asymptomatic pregnant women after 24

weeks of gestation

Gonorrhea prophylactic medication

1Prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum






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Gonorrhea screening 1Sexually active women age 24 years and younger and in older women who are at increased risk for infection

Healthy diet and physical activity counseling to prevent cardiovascular disease

1

Adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention.

Hemoglobinopathies screening 1 Screening for sickle cell disease in

newborns

Hepatitis B screening 1Adolescents and adults at high risk for infections

Pregnant women at their first prenatal visit

Hepatitis C virus (HCV) infection screening 1

Adolescents and adults at high risk for infection

Adults born between 1945 and 1965

HIV screening 1

Adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.

Pregnant women including those who present in labor who are untested and whose HIV status is unknown

Hypothyroidism screening 1 Screening for congenital hypothyroidism in

newborns

Intimate partner violence screening 1

Women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services.






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Lung cancer screening 1

With low-dose computed tomography in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Obesity screening and counseling 1

To children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.Screening all adults. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions

Osteoporosis screening 1

In Women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors

Phenylketonuria screening 1 Screening for phenylketonuria in newborns

Preeclampsia screening 1 Pregnant women with blood pressure

measurements throughout pregnancy

Rh incompatibility screening: first pregnancy visit

1Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care

Rh incompatibility screening: 24–28 weeks’ gestation

1Repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 to 28 weeks’ gestation, unless the biological father is known to be Rh (D)-negative

Sexually transmitted infections counseling 1

Intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections

Skin cancer behavioral counseling 1

Counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer






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Statin preventive medication As prescribed

Adults without a history of cardiovascular disease (CVD) (i.e., symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults ages 40 to 75 years.

Tobacco use counseling and interventions

2

Ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA) approved pharmacotherapy for cessation to adults who use tobaccoAsk all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobaccoInterventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents

Tuberculosis screening 1 Adults at increased risk

Syphilis screening 1In persons who are at increased risk for infection

All pregnant women

Vision screening 1 time every 2 years

All children aged 3 to 5 years to detect amblyopia or its risk factors

Well-woman visits 1

Adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception care and many services necessary for prenatal care.






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Immunizations

Vaccine RequirementsHepB-1 NewbornHepB-2 Aged 4 weeks – 2 monthsHepB-3 Aged 24 weeks – 18 monthsDTaP-1 Aged 6 weeks – 2 monthsDTaP-2 Aged 10 weeks – 4 monthsDTaP-3 Aged 14 weeks – 6 monthsDTap-4 Aged 12-18 monthsDTaP-5 Aged 4-6Hib-1 Aged 6 weeks – 2 monthsHib-2 Aged 10 weeks – 4 monthsHib-3 Aged 14 weeks – 6 monthsHib-4 Aged 12-15 monthsIPV-1 Aged 6 weeks – 2 monthsIPV-2 Aged 10 weeks – 4 monthsIPV-3 Aged 14 weeks – 18 monthsIPV-4 Aged 4-6PCV-1 Aged 6 weeks – 2 monthsPCV-2 Aged 10 weeks – 4 monthsPCV-3 Aged 14 weeks – 6 monthsPCV-4 Aged 12-15 monthsMMR-1 Aged 12-15 monthsMMR-2 Aged 13 months – 6

Vericella-1 Aged 12-15 monthsVericella-2 Aged 15 months – 6

HepA-1 Aged 12-23 monthsHepA-2 Aged 18 months or older






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Benefit Interval DescriptionInfluenza, inactivated (flu shot) Aged 6 months or older

LAIV (intranasal) Aged 2-49MCV4-1 Aged 2-12MCV4-2 Aged 11 years, 8 weeks – 16MPSV4-1 Aged 2 or olderMPSV4-2 Aged 7 or older

Td Aged 7-12Tdap Aged 7 or older

PPSV-1 Aged 2 or olderPPSV-2 Aged 7 or olderHPV-1 Aged 9-12HPV-2 Aged 9 years, 4 weeks – 12 years, 2 monthsHPV-3 Aged 9 years, 24 weeks – 12 years, 6 months

Rotavirus-1 Aged 6 weeks – 2 monthsRotavirus-2 Aged 10 weeks – 4 monthsRotavirus-3 Aged 14 weeks – 6 months

Herpes Zoster Aged 60 years or older

Preventive and Wellness Benefits: Exclusions Some health care services are not covered by the Plan. The following is an example of services that are generally not covered.

1. Any medical service, treatment or procedure not specified as coveredunder this Plan;

2. Office visits, physical examinations, immunizations and tests whenrequired solely for the following:a. Sportsb. Camp






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c. Employmentd. Travele. Insurancef. Marriageg. Legal proceedings

3. Routine foot care for treatment of the following:a. Flat feetb. Cornsc. Bunionsd. Callusese. Toenailsf. Fallen archesg. Weak feeth. Chronic foot strain

4. Rehabilitative therapies

5. Dental procedures

6. Any other expense, bill, charge, or monetary obligation not coveredunder this Plan, including but not limited to all non-medical serviceexpenses, bills, charges and monetary obligations. Unless the medicalservice is explicitly provided by this Schedule of Benefits or otherwiseexplicitly provided in the Summary Plan Description (SPD), this Plandoes not cover the medical service or any related expense, bill, chargeor monetary obligation to the medical service.






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Schedule of Benefits Prescription Benefits

We provide prescription benefits for you and your covered dependents. This is a very limited preventive generic only prescription benefit. Please contact the Customer Service Department at 1 (844) 208-1591 or WellDyneRx Customer Service at 1 (888) 479-2000, for questions regarding your prescription coverage. We look forward to serving your prescription needs and helping you and your family stay healthy.

Register onlineThis is the best way to make sure you have access to all the information you need to understand your benefits. And we’ll easily be able to contact you if we need to share information about a medication you’re taking or a change to your benefits plan.

Show your new ID cardWhen you fill your next prescription at the pharmacy. This will help the pharmacist better process your prescription and ensure that you are charged the correct amount.

Prescription Delivery ServiceUse if you’re taking medication on an ongoing basis. By doing this, you can save time and may save money, and our pharmacy team will help ensure that you don’t run out of your medication.

Send your prescriptions electronicallyAsk your doctor whenever possible, whether it’s to WellDyneRx or your local pharmacy. This will speed up the process so you get your medications faster, with no holdup.

You can find answers to many of your questions on our website www.welldynerx.com, through our phone system, and with our mobile app.

Your WellDyneRx prescription program will be available for use approximately 48 hours after your effective date.






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Schedule of Benefits & Plan Design Supplemental Hospital Benefit The following table represents the supplemental hospital benefit covered under this plan as well as the permitted interval and any requirements of such medical services. This plan does not utilize a network for any facilities.

Medical Service

Plan Benefit

Limitations & ExceptionsNetwork Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

Hospitalization(Room and Board) including MHSA (Mental Health and Substance Abuse)

$5,000 Supplemental Hospital Benefit

Limit to $1,000 per day; maximum of 5 days per calendar year. Neonatal intensive care (NICU) not covered. Pre-existing conditions within past twelve months excluded.

Exclusions Preexisting

We will not pay for benefits under the policy for a loss which manifests due to, results from, is caused or contributed to, or contributed by a preexisting condition. 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 hospitalization related to that person’s colon cancer for as long as the person has the policy.






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“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 precedingthe effective date the covered person became insured under the policy; or

2. That manifested symptoms which would cause an ordinarily prudentperson to seek diagnosis or treatment within the 12 months immediatelypreceding the applicable effective date the covered person becameinsured under the policy.

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 illegalnarcotics or controlled substance unless administered or prescribed bya doctor or voluntary taking of any over the counter drug unless taken inaccordance with the manufacturers recommended dosage.

9. Cosmetic treatment10. Pregnancy, childbirth or abortions (including complications of pregnancy,

childbirth or abortions).11. Hospital confinement primarily to receive rehabilitation, custodial care,

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

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 profit






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15. Any injury sustained while paid to participate or instruct in: horsebackriding, 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 intercollegiatenot 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 onany aircraft.

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

19. Care or treatment not administered or ordered by a doctor or are notmedically 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. Care or treatment of mental disorders, substance abuse, or for court ordered

treatment programs for substance abuse23. Care or treatment rendered outside the U.S. states or territories24. Dental expenses






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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!(844) 208-1591

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


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