OPTIMA. Benefit Rich Comprehensive Medical Health Insurance. Available to Association Members and their Families

Transcription

1 OPTIMA Benefit Rich Comprehensive Medical Health Insurance Available to Association Members and their Families PBG-1100 Underwritten by: American Republic Insurance Company, Des Moines, Iowa

2 Plan Highlights OPTIMA The CAREAdvantage OPTIMA plan is a comprehensive major medical plan that offers a wide range of deductibles and coinsurance options. In addition, there are four levels of coverage to choose from: Elite, Premier, Select and Classic. There are also optional benefi ts which allow for additional customization of your plan. Searching for a more economical health plan, but still with good coverage? Then take a look at either CAREAdvantage CHOICE or CAREAdvantage ACCESS for lower premium options. CAREAdvantage plans come standard with an initial 12-month rate guarantee and a maximum renewal rate increase guarantee of 15% per year for the fi rst 2 annual renewals. A special option is the ability for you to choose a lower annual renewal rate increase for 3 years. This innovative feature provides you with peace of mind knowing exactly what your health insurance premium increases will be for the fi rst 3 years of coverage. You can even choose to lock-in your initial premium with no increase for 3 years. Get the right balance of cost, coverage and service with CAREAdvantage plans: Customized Solutions tailor coverage for a more personalized fi t Flexible health care plans providing a full range of benefi ts Select only the benefi ts needed avoid paying for coverage that you don t want Affordable and Predictable Rates helps keep health care expenses manageable Plans for every budget - coverage options that help balance the need for insurance yet stay within a budget Control health expenses better with the Annual Renewal Rate Increase Guarantee that locks in premium rate increases for the fi rst 3 years of coverage Superior Service customers are our top priority Streamlined application processes help eliminate time-consuming paperwork Automated claims payment system promptly processes claim Problems? - talk live with knowledgeable service representatives Protection from a Financially Strong Company Since 1929, the American Republic Insurance Company (American Republic) has been delivering customized health care solutions at affordable prices to individuals and families across the nation. Based on providing ethical and reliable service to customers, American Republic has a long-standing tradition of caring about those they have the privilege to serve. Their mission of providing customers with high-quality health insurance protection, that preserves the customer s freedom of choice, is part of the tradition. This has earned them the reputation of being referred to as The Care Company. Plus, a highly-respected A- (Excellent) rating by A.M. Best Company stands as further testimony to American Republic Insurance Company s fi nancial strength and stability. The A- (Excellent) rating (January 2009) is the fourth highest of 15 possible ratings given by A.M. Best Company. As an independent non-government company, A.M. Best does not recommend products or services, but does provide independent opinions of a company s overall fi nancial strength.

3 Covered Expenses Coverage Provided On or Off the Job, 24 Hours a Day, 7 Days a Week. CAREAdvantage OPTIMA covers eligible expenses for covered services that are medically necessary for the treatment of an injury or sickness, subject to coverage provisions. Benefits will be paid for covered expenses incurred during any calendar year that exceed any Deductibles, Coinsurance, Copay(s) and Access Fee(s) that may apply. Inpatient Hospital Confi nement and Administered Services and Supplies Outpatient Surgery and Administered Services and Supplies Emergency Room Services and Supplies Urgent Care Facility Services and Supplies Offi ce Visits Wellness Services Outpatient Prescription Drugs Outpatient X-Ray & Lab Outpatient MRIs, CAT and PET Scans Ground Ambulance and Air Ambulance Air Ambulance Benefi t up to $10,000 per calendar year. Durable Medical Equipment Home Health Care Up to 40 visits per calendar year. Hospice Up to $100 per day on an outpatient basis; up to $200 per day on an inpatient basis with a $5,000 Lifetime Maximum Benefit. Skilled Nursing Up to 60 days per calendar year. Radiation/Chemotherapy Breast Reconstruction Acute Rehabilitation Organ Transplants When performed in a Center of Excellence - $1,000,000 per transplant maximum. When not performed in a Center of Excellence - $100,000 Lifetime Maximum Benefit. Outpatient Occupational, Physical and Speech Therapies $50 per visit up to $2,000 per calendar year for all therapies combined. Emergency Foreign Travel $100,000 Lifetime Maximum Benefi t. Treatment of Allergies Up to $500 per calendar year. Treatment of Sleep Apnea $2,000 Lifetime Maximum Benefi t. Treatment of Growth Disorders $15,000 Lifetime Maximum Benefi t. Spinal Manipulation (on an outpatient basis) Up to $50 per visit and $500 maximum per calendar year. Sterilization $500 Lifetime Maximum Benefi t. There is a 12-month waiting period. This brochure provides a description of some of the important features of your plan. The benefits, exclusions and limitations listed are typical, but your state may have slight differences. Please see the accompanying State Variations insert for additional details. The insurance contract sets forth in detail the rights and obligations of both you and the Company. This plan is not being sold as an employee benefit plan. For further details about this or other coverage, please contact your agent or American Republic Insurance Company.

4 Plan Selections All benefi ts are per person, per calendar year.. Please reference Plan Defi nitions on opposite page. Deductible You Pay $1,000 $2,000 $3,000 $4,000 $5,000 (In-Network) (Out-Of-Network is 2 times the In-Network amount) Coinsurance In-Network Out-Of-Network (After Deductible) You Pay We Pay You Pay We Pay 80%/20% 60%/40% 20% of $5,000 80% of $5,000, then 100% 40% of $10,000 60% of $10,000, then 100% 20% of $10,000 80% of $10,000, then 100% 40% of $20,000 60% of $20,000, then 100% 20% of $20,000 80% of $20,000, then 100% 40% of $40,000 60% of $40,000, then 100% 40% of $5,000 60% of $5,000, then 100% 50% of $10,000 50% of $10,000, then 100% 40% of $10,000 60% of $10,000, then 100% 50% of $20,000 50% of $20,000, then 100% 40% of $20,000 60% of $20,000, then 100% 50% of $40,000 50% of $40,000, then 100% Annual Rate Increase Guarantee Options (For 36 months) 0% 5% 10% 15% Choose a Level of Coverage Elite Premier Select Classic Optional Coverages Offi ce Visits Per Visit Copay $30 $40 $30 $40 Maximum Number of Visits No Limit No Limit 3 3 Then Deductible & Coinsurance No No Yes Yes Deductible & Coinsurance $50 per visit indemnity; 2 visits per year Outpatient X-Ray & Lab Per Visit Copay $25 $25 $50 $50 Per Test Limit $200 $200 $200 $200 Calendar Year Max No Limit $1,000 No Limit $1,000 Outpatient MRIs, CAT & PET Scans Access Fee None None $250 $500 Then Deductible & Coinsurance No Yes Yes Yes Per Test Limit $1,000 No Limit No Limit No Limit Outpatient Prescription Drug Generic Deductible $0 $0 $0 $0 Generic Copay $15 $15 $15 $15 Brand Deductible $200 $500 $500 $500 Formulary Copay $30 $30 $30 $30 Non-Formulary Copay $45 $45 $45 $45 Brand Calendar Year Max None None $2,000 $1,000 Deductible & Coinsurance after $25 Access Fee No Coverage No Coverage Generic Only; $20 Copay Prescription Discount Card Wellness Services 6-month waiting period; $40 Copay; $300 Calendar Year Max No Coverage Lifetime Maximum $4,000,000 $2,000,000 Calendar Year Maximum Emergency Room Equals Lifetime Maximum Subject to Deductible and Coinsurance after $100 Access Fee $100,000 $250,000 Maternity Benefi t (Optional) Coverage Year Benefi t Per Unit # Units Selected Up to 8 units available 1 $250 2 $375 3 or more $500

5 Plan Definitions Deductible The deductible is the amount of covered expenses you must pay each calendar year for covered medical expenses before coinsurance charges are applied. Only three deductibles must be satisfied per family per year. The deductible for out-of-network expenses is two times the in-network amount and is a separate deductible that does not apply to the in-network deductible. Coinsurance Coinsurance is the portion of eligible expenses up to a specified limit in addition to the individual or family deductible that you pay and any applicable Copay or Access Fee. Eligible expenses are the usual and customary amount allowed by the Company for covered services for providers in the same locality. For in-network expenses, the actual negotiated amount agreed upon with the network is considered the usual and customary allowance. Copays, Access Fees, and Outpatient Prescription Drug expenses do not count toward satisfying the basic deductible and coinsurance amounts. Annual Rate Increase Guarantee (first 36 months) Every CAREAdvantage plan comes with a built-in inflation protection feature that limits the annual increase in premium rates for the first 36 months. Initial rates on all plans are guaranteed for the first 12 months and renewal increases for the second and third years are guaranteed not to exceed 15% each year. You have the option to reduce your renewal rate increases for the second and third years to 10%, 5% or 0% annually for an additional premium. Levels of Coverage CAREAdvantage plans make available four Levels of Coverage for Office Visits, Outpatient X-Ray & Lab, Outpatient MRIs, CAT & PET Scans, and Outpatient Prescription Drug benefits. Choose from Elite, Premier, Select and Classic. In each plan, Elite represents the best benefit combination, while Classic represents a more affordable benefit combination. Optional Coverage The Level of Coverage you choose can be customized by selecting an Optional Coverage to replace a specific benefit. Choosing an Optional Coverage often results in lower premiums for the plan selected. Copay An amount that you must pay to the health care Provider each time certain visits take place or certain services are provided. Copays do not count toward satisfying Deductibles or Coinsurance amounts. Access Fee An amount that you must pay each time you receive certain treatments, services and supplies. An Access Fee, unlike a copay, is subtracted from Covered Expenses before applying any Deductible or Coinsurance amounts. Access Fee may be waived in certain situations. Maximum Number of Visits Represents the limit on the number of visits covered per insured person, per calendar year. Per Test Limit The amount the company will pay per test. Any charges above the limit, if any, must be paid by you. Calendar Year Max Is the limit we will pay for the covered benefit per insured person, per calendar year. Office Visits The Office Visit Copay covers your in-network office visit charge, and any drugs, surgical procedures, or miscellaneous charges associated with that office visit (from the same provider and incurred on the same day). The maximum numbers of visits are per person, per calendar year. For Select and Classic plans, after maximum copay visits are reached, then charges are subject to in-network Deductible and Coinsurance. Out-of-Network office visits are subject to deductible and coinsurance. The optional indemnity benefit pays the dollar amount listed for a specific number of in-network visits during a calendar year. Any charges above the dollar amount or for visits above the visit limit are not covered. Out-of-network benefits are covered at 50% of the in-network amount. Outpatient X-Ray and Lab Benefit Helps pay for Laboratory tests and Radiological exams. Outpatient MRIs, CAT Scans and PET Scans Helps pay for Diagnostic services. Outpatient Prescription Drug Benefit Helps pay for drugs prescribed to you by a doctor or in a doctor s office. For a 90-day supply from a participating mail order pharmacy, your copay is two times the applicable drug copay. Specialty drugs are always subject to Deductible and Coinsurance. When selecting Generic Only option, there is no coverage for Brand or Specialty drugs. If the Prescription Discount Card is selected, then there is no coverage for any drugs, only a discount. Wellness Services Benefit Helps pay for routine physicals, preventive screenings and immunizations. There is a 6-month waiting period from the coverage issue date before the benefit can be used. Lifetime Maximum The maximum amount the plan pays for all eligible medical expenses you incur in your lifetime. Annual Maximum The maximum amount the plan pays for all eligible medical expenses you incur in a calendar year. Emergency Room Benefit Helps you pay for services, supplies and treatment received through a hospital emergency room. A $100 Access Fee must first be satisfied. The Emergency Room Access Fee is waived if you are admitted as a hospital inpatient within 24 hours. Maternity Benefit (Optional) The Maternity benefit provides coverage to help pay expenses associated with a normal pregnancy, childbirth, and newborn hospital expenses. Up to eight units of coverage can be purchased. The benefit per unit is $250 in coverage year 1, $375 in coverage year 2 and $500 in coverage years 3 and after. Benefits are determined by the coverage year in which the pregnancy ends. You cannot be pregnant at time of application.

6 Plan Information PPO Network Providers The CAREAdvantage OPTIMA plan gives you access to preferred provider organization (PPO) hospitals and doctors in your selected network and participating pharmacies in our pharmacy network. When you choose participating providers, you receive the maximum benefi ts from your coverage and take advantage of negotiated rates for covered services that are usually less than the rates normally charged by the network provider. When covered services or supplies are received from a PPO network provider, the actual agreed-upon price charged by the provider is considered the usual and customary allowance for eligible expenses. If you use providers outside the PPO network you may have additional expenses to pay if the amount charged by the provider is more than the usual and customary amount allowed by the Company for the same or comparable service or supplies for other providers in the same locality. The provider can bill you for the balance of charges over and above what your coverage allows. The Company reserves the right to change the preferred provider network. Preauthorization You must call for authorization prior to inpatient and outpatient surgeries or any scheduled hospital or skilled nursing stay, home health or hospice care, or transplants or replacements. See your insurance contract for a complete list. Authorization is not required before treatment in an emergency situation; however, a later authorization is required. For human organ or bone marrow transplants or replacements, authorization is required at the time your doctor fi rst indicates a transplant or replacement may be needed. Benefi ts may be reduced if preauthorization procedures are not followed or treatment is unauthorized. (Provisions may vary by state.) Pre-existing Conditions This coverage is designed to pay for accidents that occur or sickness that first manifests itself after the date of issue. We will not pay for a pre-existing condition or disease for up to 12 months after issue which is not admitted on the application. Pre-existing condition means a condition for which medical advice was given or treatment was recommended by a physician within a 12-month period prior to the issue date of coverage for that covered person. Pre-existing conditions admitted on the application will be covered after the issue date unless excluded by name or specific description. Any false statement, misrepresentation or omissions in the application may result in benefits being denied or the contract being rescinded, subject to the Time Limit on Certain Defenses. (Provisions may vary by state.) Premiums and Renewability You may renew the coverage for any covered person by paying the premiums as they come due. We may decline to renew the coverage for nonpayment of premiums, fraud, loss of eligibility, if we cancel the master policy, or if we discontinue all policies/certifi cates of the same type in a specifi c state or nationwide. See your insurance contract for additional details. Initial premium rates are guaranteed from coverage issue date for 12 months so long as your area of residence, benefi t selections and covered persons remain the same. After 12 months, premiums are guaranteed not to increase more than the Annual Rate Increase Guarantee percentage selected for the next 24 months. We reserve the right to change premium rates on any renewal date after 36 months has expired. Benefi ts and premiums will vary depending on plan, coverage choices and optional benefi ts which you select. Applications are individually underwritten and each person is assigned a rate class. Should a rate class premium change be necessary in the future, it will only be changed if made on all forms in the same class as determined by us and not on an individual basis. At most ages, the premium will increase because a covered person is one year older. Such premium changes will accumulate, but will be limited to the annual rate increase percentage selected during the first 36 months of coverage. Common Accident Deductible When more than one person incurs eligible expenses due to the same accident, only one basic deductible applies. Other Coverage If you have other coverage or become eligible for Medicare, benefits may be reduced. Plan provisions determine whether the benefits of this coverage are considered before or after those of the other coverage. Satisfaction Guaranteed You have our guarantee that your protection through American Republic s program is of the highest quality. If you are not 100% satisfi ed with your coverage, you may return your policy or certifi cate of coverage within 10 days of receiving it and your money will be promptly refunded.

7 Exclusions & Limitations The exclusions and limitations listed below are typical, but your state may have slight differences. Please see your insurance contract for specific details. Coverage will not be provided for pre-existing conditions; treatment, services and/or supplies not covered under the plan; or expenses incurred before the Issue Date or after the cover age terminates, except as provided. No benefits will be provided for: pregnancy, prenatal care or normal childbirth, except for covered complications of pregnancy or as specifically provided routine newborn or well-child care, except as specifically provided any drug (including birth control pills), supply, treatment, or procedure used for the prevention of conception and/or childbirth, except as specifically provided routine physical exams or other services or supplies not needed for medical treatment, except as specifically provided expenses resulting from or engaging in an illegal act or occupation or committing or attempting to commit a felony illness or injury caused by or resulting from use of alcohol, illegal drugs, voluntary use of any controlled substance or use of prescription or over-the-counter drugs that are not taken in the dosage or purpose prescribed illness or injury resulting from participation in a high-risk activity for pay or commercial purposes including, but not limited to: skydiving, parachuting, bungee jumping, rodeo participation or organized contests of speed infertility treatment or any treatment to promote conception over-the-counter drugs, whether or not prescribed by a physician routine hearing care, artificial hearing devices or other means of enhancing, creating or restoring auditory comprehension routine vision care; glasses; contact lenses; vision therapy, exercise or training, except as specifically provided surgery to correct visual acuity including, but not limited to, LASIK and other laser surgery treatment of mental or nervous disorders, except as specifically provided expenses resulting from suicide, attempted suicide or intentional self-infl icted injury appliances for or medical or surgical expenses of the jaw dental care, except as specifically provided treatment of temporomandibular joint dysfunction (TMJ) and craniomandibular joint dysfunction (CMD) smoking cessation programs treatment of hair loss, acne or rosacea and related conditions treatment or complications from treatment that are not medically necessary expenses incurred during military service or participation in war, whether declared or not breast reduction or augmentation or complications, except as specifically provided bunions; removal of corns, calluses or toenails; foot inserts; or orthopedic shoes or supportive devices for the feet cosmetic services, cosmetic peels, and reconstructive or plastic surgery that does not alleviate a functional impairment growth hormone therapy, except as specifically provided private duty nursing or having a standby provider services, supplies or treatment related to sex transformation, gender reassignment, or sexual function transportation, living expenses, services or supplies for personal convenience or custodial care, except as specifically provided treatment for a hernia, removal of adenoids and/or tonsils, varicose veins, hemorrhoids, middle ear disorders or disorders of the reproductive system for the first six months the coverage is in force unless deemed as emergency care treatment of a developmental delay, behavior modification or learning disabilities treatment payable or reimbursable by Medicare Parts A-D or other governmental program except Medicaid treatment, services or supplies for which no charge would be made if you did not have health insurance treatment, services or supplies provided by a person ordinarily living in your home, a member of your immediate family or your employer or business partner treatment, services or supplies received outside the United States, including drugs, except as specifically provided treatment, supplies or services that are defined as experimental or investigational weight modification programs or surgical treatment of obesity work-related illness or injury eligible for benefits under worker s compensation or similar laws Additional exclusions and limitations apply to the outpatient prescription drug benefit. See your contract for details.

8 Our commitment goes beyond your insurance coverage... At American Republic, every health insurance plan you choose automatically includes extra tools to help you make better health care decisions. We ve chosen HealthEquity to provide you with all of these services at no cost to you and some of these include: Easy Health Assessment Program helps you get a better handle on your current health and shows you smart ways to take better care of yourself Symptom Checker helps you diagnose and understand a health-related condition Care Guides understand the best way to care for various health conditions Hospital Comparison Tool research and compare hospitals based on cost and quality Take advantage of these services by activating your free account. Simply log on to once your coverage is issued. Underwritten by: American Republic Insurance Company National Headquarters Des Moines, Iowa (800) PBG-1100 American Republic and the double eagle logo are registered servicemarks of American Republic Insurance Company American Republic Insurance Company Forms AC4800A, AC4800A-OK, AC4800A-PA, AC4800A-TN, AC4800A-PPO, AC4800A-TX, AC4801A-TX Plan availability varies by state.