Situation

CHOICE PLUS

NETWORK

CHOICE PLUS

NON-NETWORK

Acupuncture Services

Not Covered

Not Covered

Allergy Care

$20 copay per visit then 90% of eligible expenses.

No Copayment applies when a Physician charge is not assessed.

80% of eligible expenses after satisfying $300 deductible.

Cancer Resource Services (CRS)

Access to the CRS Centers of Excellence Network gives patients care that is planned, coordinated and provided by a team of experts who specialize in their specific cancer. Potential benefits include accurate diagnosis, appropriate therapy (neither too little nor too much), higher survival rates and decreased costs.

Network benefits are available for patients who receive care at a designated Cancer Resource Services Network facility.

Participation in this program is voluntary for the enrollee. To ensure network benefits are received under this program, patients, or someone on their behalf, must contact Cancer Resource Services at 1-866-936-6002 before receiving care. More information is also available at www.urncrs.com.

Coverage for Clinical Trials at a Cancer Resource Services designated facility is not covered as part of this benefit.

Travel and Lodging Assistance is available as part of the Cancer Resource Services program. $50/$100 per diem with a Lifetime Maximum of $10,000.

Specialized Cancer Case Management Services is not covered as part of this benefit.

Chemotherapy

90% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.

Congenital Heart Disease Resource Services (CHDRS)

Congenital heart defects are the number one cause of death for children from a birth defect during the first year of life.

Additionally, fifty percent of pediatric patients referred for a heart transplant have some form of congenital heart disease.  By aligning with the Transplant Centers of Excellence Network, the CHD Centers of Excellence Network provides expanded treatment options for these patients.

Access to the CHD Centers of Excellence Network gives patients care that is planned, coordinated and provided by a team of experts who specialize in treating Congenital Heart Disease.  Potential benefits include accurate diagnosis, appropriate surgical interventions, higher survival rates and decreased costs.

Network benefits are available for patients who receive care at a designated CHD Centers of Excellence Network facility.

Participation in this program is voluntary for the enrollee.  To help ensure network benefits are received under this program, patients, or someone on their behalf, should contact CHD Resource Services at 1-888-936-7246 before receiving care.  More information is also available at www.urnweb.com.

Travel and Lodging Assistance is available as part of the Congenital Heart Disease Resource Services program. $50/$100 per diem with a Lifetime Maximum of $10,000.

Notify Care Coordination

Please remember that for Benefits you must notify Care Coordination before receiving services.

Dental Services

Services when all of the following are true:

●  Treatment is necessary

because of accidental damage to a sound, natural tooth.

●  Dental damage does not

occur as a result of normal activities of daily living or extraordinary use of the teeth.

●  Dental services are

received from a Doctor of Dental Surgery, "D.D.S." or Doctor of Medical Dentistry, "D.M.D."

●  The dental damage is

severe enough that initial contact with a Physician or dentist occurred within 72 hours of the accident.

The following are also considered Covered Health Services:

●  Dental transplant

preparation;

●  Initiation of

immunosuppressives (medication used to reduce inflammation and suppress the immune system); and

·  Direct treatment of cancer or cleft palate.

The Physician or dentist must certify that the tooth is virgin or unrestored, and that it:

●  Has no decay;

·  Has no filling on more than two surfaces;

●  Has no gum disease

associated with bone loss;

·  Has no root canal therapy;

·  Is not a dental implant; and

●  Functions normally in

chewing and speech.

Dental services for final treatment to repair the damage must be both of the following:

●  Started within three

months of the accident.

●  Completed within 12

months of the accident.

Notify Care Coordination

Please remember that you should notify Care Coordination as soon as possible, but at least 5 business days before follow-up (post-Emergency) treatment begins. (You do not have to provide notification before the initial Emergency treatment.)

The following services are not covered:

·  Services for the evaluation

and treatment of temporomandibular joint dysfunction (TMJ), when the services are considered dental in nature, including oral appliances;

●  Preventive dental care;

●  Diagnosis or treatment of

the teeth or gums. Examples include:

●  Extraction (including wisdom teeth),

·  restoration and replacement of

teeth;

●  Medical or surgical

treatments of dental conditions; and

●  Services to improve

dental clinical outcomes;

·  Dental implants and braces;

·  Dental X-rays, supplies and appliances and all associated expenses, including hospitalizations and anesthesia; and

·  Treatment of congenitally missing (missing at birth), malpositioned, or super numerary (extra) teeth, even if part of a Congenital Anomaly.

Note: See exclusions described under Jawbone Surgery.

Physician’s Office Services

$35 copay per visit then 90% of eligible expenses.

Outpatient Services received at a Hospital or Alternate Facility

90% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.

Durable Medical Equipment

The plan pays for Durable Medical Equipment that is:

●  Ordered or provided by a

Physician for outpatient use;

●  Used for medical

purposes;

●  Not consumable or

disposable;

●  Not of use to a person in

the absence of a sickness, injury or disability;

●  Durable enough to

withstand repeated use; and

·  Appropriate for use in the home.

If more than one piece of DME can meet your functional needs, you will receive Benefits only for the most cost effective piece of equipment.  Benefits are provided for a single unit of DME (example: one insulin pump) and for repairs of that unit.

90% of eligible expenses.

Benefits are provided for the replacement of a type of Durable Medical Equipment once every three Calendar Years.

Care Coordination will decide if the equipment should be purchased or rented. You must purchase or rent the Durable Medical Equipment from the vendor Care Coordination identifies.

Custom molded orthotics are covered.

80% of eligible expenses after satisfying $300 deductible.

Notify Care Coordination

Please remember that for Benefits you must notify Care Coordination before obtaining any single item of Durable Medical Equipment that costs more than $1,000 (either purchase price or cumulative rental of a single item).  If you don't notify Care Coordination, Benefits will be subject to a $300 penalty.

Benefits are provided for the replacement of a type of Durable Medical Equipment once every three Calendar Years.

Care Coordination will decide if the equipment should be purchased or rented. You must purchase or rent the Durable Medical Equipment from the vendor Care Coordination identifies.

Custom molded orthotics are covered.

Home Health Care

Services received from a Home Health Agency that are:

●  Ordered by a Physician;

●  Provided by or supervised by a registered nurse in your home;

●  Not considered Custodial

Care; and

●  Provided on a part-time,

intermittent schedule and when skilled home health care is required.

Care Coordination^SM will decide if Skilled Home Health Care is needed by reviewing both the skilled nature of the service and the need for Physician-directed medical management.

Skilled Home Health care is skilled nursing, teaching, and rehabilitation services when:

●  They are delivered or

supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome and provide for the safety of the patient;

●  A physician orders them;

●  They are not delivered for the purpose of assisting with activities of daily living, including, but not limited to, dressing, feeding, bathing or transferring from a bed to a chair;

●  They require clinical

training in order to be delivered safely and effectively; and

●  They are not Custodial

Care.

Custodial Care is defined as services that do not require special skills or training and that:

●  Provide assistance in

activities of daily living (including but not limited to feeding, dressing, bathing, ostomy care, incontinence care, checking of routine vital signs, transferring and ambulating);

●  Do not seek to cure, or

which are provided during periods when the medical condition of the patient who requires the service is not changing; or

●  Do not require continued

administration by trained medical personnel in order to be delivered safely and effectively.

90% of eligible expenses.

The following services are not covered:

●  Custodial Care.

●  Domiciliary care.

●  Respite care.

●  Rest cures.

Any combination of Network and Non-Network Benefits is limited to 140 visits per Calendar Year, combined with Private Duty Nursing. One visit equals four hours of skilled home health care services.

80% of eligible expenses after satisfying $300 deductible.

Notify Care Coordination

Please remember that for Benefits you should notify Care Coordination 5 business days before receiving services.

If you don't notify Care Coordination, Benefits will be subject to a $300 penalty.

The following services are not covered:

●  Custodial Care.

●  Domiciliary care.

●  Respite care.

●  Rest cures.

Any combination of Network and Non-Network Benefits is limited to 140 visits per Calendar Year, combined with Private Duty Nursing. One visit equals four hours of skilled home health care services.

Hospice Care

Hospice Care is an integrated program recommended by a Physician which provides comfort and support services for the terminally ill. Hospice care can be provided on an inpatient or outpatient basis and includes physical, psychological, social and spiritual care for the terminally ill person, and short-term grief counseling for immediate family members.  Benefits are only available when hospice care is received from a licensed hospice agency.

100% of eligible expenses.

Any combination of Network and Non-Network Benefits is limited to 180 days during the entire period of time you are covered under the Policy.

100% of eligible expenses.

Any combination of Network and Non-Network Benefits is limited to 180 days during the entire period of time you are covered under the Policy.

Notify Care Coordination

Please remember that for Benefits you should notify Care Coordination 5 business days before receiving services.

If you don't notify Care Coordination, Benefits will be subject to a $300 penalty.

Kidney Resource Services (KRS)

Not Applicable

Not Applicable

Private Duty Nursing – Outpatient

The Plan covers private duty nursing care given on an outpatient basis by a licensed nurse such as a Registered Nurse (R.N.), Licensed Practical Nurse (L.P.N.), or Licensed Vocational Nurse (L.V.N.).

90% of eligible expenses.

Any combination of Network and Non-Network Benefits is limited to 140 visits per Calendar Year, combined with Home Health Care. One visit equals four hours of skilled home health care services.

The following service is not covered:

●  Private duty nursing

received on an inpatient basis.

80% of eligible expenses after satisfying $300 deductible.

Any combination of Network and Non-Network Benefits is limited to 140 visits per Calendar Year, combined with Home Health Care. One visit equals four hours of skilled home health care services.

The following service is not covered:

●  Private duty nursing

received on an inpatient basis.

Prosthetic Devices

Benefits are paid by the Plan for prosthetic devices and appliances that replace a limb or body part, or help an impaired limb or body part work.  Examples include, but are not limited to:

●  Artificial limbs;

●  Artificial eyes; and

●  Breast prosthesis following mastectomy as required by the Women’s Health and Cancer Rights Act of 1998 including mastectomy bras and lymphedema stockings for the arm.

If more than one prosthetic device can meet your functional needs, benefits are available only for the most cost-effective prosthetic device.  The device must be ordered or provided either by a Physician, or under a Physician’s direction.

90% of eligible expenses.

Benefits are provided for the replacement of a type of prosthetic device once every five Calendar Years.

80% of eligible expenses after satisfying $300 deductible.

Benefits are provided for the replacement of a type of prosthetic device once every five Calendar Years.

Reconstructive Procedures

Reconstructive Procedures are services performed when a physical impairment exists and the primary purpose of the procedure is to improve or restore physiologic function for an organ or body part.

Improving or restoring function means that the organ or body part is made to work better.

Benefits for reconstructive procedures include breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry.

Note: See exclusions described under Physical Appearance.

Same as

●  Physician's Office

Services

●  Professional Fees

●  Hospital-Inpatient Stay

●  Outpatient Diagnostic

and Therapeutic Services.

You can contact Care Coordination at the telephone number on your ID card for more information about Benefits for mastectomy related services.

Same as

●  Physician's Office

Services

●  Professional Fees

●  Hospital-Inpatient Stay

●  Outpatient Diagnostic

and Therapeutic Services.

You can contact Care Coordination at the telephone number on your ID card for more information about Benefits for mastectomy related services.

Notify Care Coordination

Please remember that you must notify Care Coordination 5 business days before receiving services. When you provide notification, Care Coordination can verify whether the service is Reconstructive or Cosmetic. Cosmetic Procedures are always excluded from coverage.

If you don't notify Care Coordination, Benefits for the Hospital Inpatient Stay will be subject to a $300 penalty.

Rehabilitation Services Outpatient Therapy

Short‑term outpatient rehabilitation services for:

●  Physical therapy;

●  Occupational therapy;

●  Speech therapy;

●  Pulmonary rehabilitation

therapy; and

●  Cardiac rehabilitation

therapy.

Rehabilitation services must be performed by a licensed therapy provider, under the direction of a Physician. We have the right to exclude from coverage rehabilitation services that are not expected to result in significant physical improvement in your condition within two months of the start of treatment.

Please note that we will pay Benefits for speech therapy only when the speech impediment or speech dysfunction results from Injury, Sickness, Stroke, Congenital Anomaly or is needed following the placement of a cochlear implant.

Please note we also have the right to deny any type of therapy, service or supply for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or recurring.

The following services are not covered:

●  Speech therapy to treat

stuttering, stammering, or other articulation disorders.

$35 copay per visit then 100% of eligible expenses.

Any combination of Network and Non-Network Benefits is limited as follows:

●  60 visits of physical,

occupational and speech therapy combined per Calendar Year.

●  36 visits of pulmonary rehabilitation therapy per Calendar Year.

●  36 visits of cardiac

rehabilitation therapy per Calendar Year.

Restorative Speech Therapy ONLY is considered an eligible expense.

Treatment of a speech impediment or speech dysfunction that results from Injury, stroke autism or a Congenital anomaly is covered.

80% of eligible expenses after satisfying $300 deductible.

Any combination of Network and Non-Network Benefits is limited as follows:

●  60 visits of physical,

occupational and speech therapy combined per Calendar Year.

●  36 visits of pulmonary rehabilitation therapy per Calendar Year.

●  36 visits of cardiac

rehabilitation therapy per Calendar Year.

Restorative Speech Therapy ONLY is considered an eligible expense.

Treatment of a speech impediment or speech dysfunction that results from Injury, stroke autism or a Congenital anomaly is covered.

Skilled Nursing Facility Inpatient Rehabilitation Facility Services

Benefits are available when skilled nursing and/or Inpatient Rehabilitation Facility services are needed on a daily basis. Benefits are also available in a Skilled Nursing Facility or Inpatient Rehabilitation Facility for treatment of a Sickness or Injury that would have otherwise required an Inpatient Stay in a Hospital.

The intent of skilled nursing is to provide Benefits if, as a result of an Injury or illness, you require:

●  an intensity of care less

than that provided at a general acute Hospital but greater than that available in a home setting; or

●  a combination of skilled

nursing, rehabilitation and facility services.

You are expected to improve to a predictable level of recovery.

The following services are not covered:

●  Custodial Care.

●  Domiciliary care.

90% of eligible expenses.

Any combination of Network and Non-Network Benefits is limited to 180 days per Calendar Year.

80% of eligible expenses after satisfying $300 deductible.

Any combination of Network and Non-Network Benefits is limited to 180 days per Calendar Year.

Notify Care Coordination

Please remember that you must notify Care Coordination as follows:

●  For elective admissions: 5 business days before admission.

●  For Emergency admissions (also termed non-elective admission): within 2 business days, or as soon as is reasonably possible.

If you don't notify Care Coordination, Benefits will be subject to a $300 penalty.

Spinal Treatment, Chiropractic and Osteopathic Manipulative Therapy

Benefits are payable when provided by a spinal treatment specialist in the specialist’s office. Covered Health Services include chiropractic and osteopathic manipulative therapy.

Benefits are not available if treatment ceases to be therapeutic and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or recurring.

The following services are not covered:

●  Spinal treatment to treat a condition unrelated to alignment of the vertebral column such as asthma or allergies.

$35 copay per visit then 100% of eligible expenses.

Any combination of Network and Non-Network Benefits for Spinal Treatment is limited to one visit per day and up to 30 visits per Calendar Year.

80% of eligible expenses after satisfying $300 deductible.

Any combination of Network and Non-Network Benefits for Spinal Treatment is limited to one visit per day and up to 30 visits per Calendar Year.

Transplantation Services

Inpatient facility services (including evaluation for transplant, organ procurement and donor searches) for transplantation procedures must be ordered by a Network Provider. Benefits are available for any of the organ and tissue transplants listed below when the transplant meets the definition of a Covered Health Service and is not Experimental and Investigational, or Unproven:

·  Heart;

·  Heart/lung;

·  Lung;

·  Kidney;

·  Kidney/pancreas;

·  Liver;

·  Liver/kidney;

·  Liver/intestinal;

·  Pancreas;

·  Intestinal; and

·  Bone marrow (either from you or from a compatible donor) and peripheral stem cell transplants, with or without high dose chemotherapy.

Benefits are also available for cornea transplants that are provided by a Network Provider at a network Hospital. You are not required to notify United Resource Networks or Care Coordination^SM of a cornea transplant nor is the cornea transplant required to be performed at a Designated United Resource Networks Facility.

The search for bone marrow/stem cells from a donor who is not biologically related to the patient is a Covered Health Service. If a separate charge is made for a bone marrow/stem cell search, the Plan will pay up to $25,000 for all charges made in connection with the search.

Voluntary

90% of eligible expenses.

Notify Care Coordination^SM

You must notify Care Coordination^SM as soon as the possibility of a transplant arises (and before the time a pre-transplantation evaluation is performed at a transplant center).

Travel and Lodging

United Resource Networks will assist the patient and family with travel and lodging arrangements related to:

·  Congenital Heart Disease (CHD); and

·  Transplantation services ; and

·  Cancer-related treatments.

For travel and lodging services to be covered, the patient must be receiving services at a Designated United Resource Networks Facility.

The Plan covers expenses for travel, lodging and meals for the patient, provided he or she is not covered by Medicare, and a companion as follows:

·  Transportation of the patient and one companion who is traveling on the same day(s) to and/or from the site of the cancer-related treatment, the CHD service, or the transplant for the purposes of an evaluation, the procedure or necessary post-discharge follow-up;

·  Eligible Expenses for lodging and meals for the patient (while not a Hospital inpatient) and one companion. Benefits are paid at a per diem (per day) rate of up to $50 per day for the patient or up to $100 per day for the patient plus one companion; or

·  If the patient is an enrolled Dependent minor child, the transportation expenses of two companions will be covered and lodging and meal expenses will be reimbursed at a per diem rate up to $100 per day.

Travel and lodging expenses are only available if the recipient lives more than 50 miles from the Designated United Resource Networks Facility (for CRS and Transplantation) or the CHD facility. The Company must receive valid receipts for such charges before you will be reimbursed. Examples of travel expenses may include:

·  Airfare at coach rate;

·  Taxi or ground transportation; or

·  Mileage reimbursement at the IRS rate for the most direct route between the patient’s home and the Designated United Resource Networks Facility.

Voluntary

80% of eligible expenses after satisfying $300 deductible.

Notify Care Coordination^SM

You must notify Care Coordination^SM as soon as the possibility of a transplant arises (and before the time a pre-transplantation evaluation is performed at a transplant center). If you don't notify Care Coordination^SM, Benefits will be subject to a $300 penalty.