SHAPE A SCHEDULE OF BENEFITS

Transcription

1 Benefit Local Office Visits/Physician Consultation (per visit/occurrence) Walk-in Clinics Primary Care Specialist SHAPE A Participating Provider Covered Person pays: $25 Co-payment $35 Co-payment $50 Co-payment Laboratory Diagnostic / Imaging Ultra Sound Prescription Medical Supplies Laboratory Diagnostic / Imaging Ultra Sound Prescription Medical Supplies If the cost is under $100: Covered Person pays $20 Copayment If the cost is over $100: Covered Person pays 20% Copayment Covered Person pays: CAT Scan MRI Scan PET Scan $100 Co-payment $200 Co-payment $1,000 Co-payment Pre-Certification required Preventive Care Newborn Dependent's Wellness Check-up (Physician's charges only) Newborn must be enrolled within 31 days of birth and premium paid Immunization Colina pays 100% Routine Immunization for dependent children age 0-12 years

2 Preventive Care Please contact Colina for benefits Mammogram one per calendar year (for insured females age 35 years and older) Pap Smear one per calendar year (for insured females age 18 years and older) Annual Prostate Exam one per calendar year (for insured males age 35 years and older) PSA Test one per calendar year (for insured males age 35 years and older) Routine Physical Exam one per calendar year (to include a CBC, SMAC 25 & lipid test capped $75) In-Office Surgical Expenses In-office Surgery Covered Person pays $200 co-pay per visit, then Colina pays 100% Pre-certification required for procedures $ and above In-Office Anesthesia In-office Anesthesia Colina pays 100% (Subject to Unit Charge) All payments are based upon Reasonable and Customary charges. Non pre-certification requires Covered Person to pay deductible plus 50% Co-insurance of Reasonable and Customary charges, subject to the respective benefit maximums. Pre-Certification is required for the following: - Hospitalizations - Out-Patient surgical procedures (whether provided at a hospital, ambulatory surgical Centre or a physician s office) - Magnetic Resonance Imaging services - Durable Medical Equipment - Rehabilitation/ Skilled Nursing Facility Confinements - Home Health Services - Human Organ Transplants - In-Patient Treatment - Behavioral Health Disorders - Air Transportation (ambulance or commercial airfare) - Outside The Bahamas daily allowances - Return of deceased/repatriation

3 Exclusions SHAPE A No benefits are payable for: 1. The evaluation of routine and other treatment of learning disabilities; 2. Routine laboratory/diagnostic testing (see schedule of benefits); 3. Pregnancies whose conception occurs within 12 months of the effective date of the policy; 4. Any expenses incurred by a Covered Person within the first 90 days after the effective date of the policy except for : a) Services rendered for infections; and b) services rendered for accidents and/or emergencies; 5. Vision exams or hearing exams (except when necessary because of Injury to a natural eye or ear, sustained while covered under this Policy, if such eye refraction or examination is also performed while covered); eyeglasses or contact lenses or their fitting (except contact lenses required due to cataract surgery); hearing aids, or their fitting, or cochlear implants; dental exams; or orthopedic shoes or other supportive devices for the feet, such as, but not limited to, arch supports and orthodontic devices, or any other preventive services and supplies; 6. Expenses due to an Injury or Illness arising out of, or caused by, employment for wage or profit, or for which benefits would be payable under National Insurance, or similar law, whether or not such benefits have been applied for or paid; 7. Any expenses incurred by a Covered Person for, or as the result of, a disclosed Pre-Existing Condition during the first 12 consecutive months of a Covered Person's coverage under this Policy; or for any condition not covered under this Policy; 8. Any expenses incurred by a Covered Person for, or as the result of, intentionally self-inflicted Injury or Illness or suicide or attempted suicide, while sane or insane; 9. Rental or purchase of air conditioners, air purifiers, vaporizers, motorized transportation equipment, escalators or elevators, swimming pools, waterbeds, exercise equipment or other similar items or equipment; 10. Charges in excess of any maximum benefit limit which has been reached, for the rest of the period of time to which such limit applies; 11. Charges incurred on or after the date insurance under this Policy stops, except to the extent allowed in the Extension Benefits Provision in this Policy; 12. Any treatment or service provided by a Close Relative; or by a person who ordinarily resides in the Covered Person's home; or rendered in any facility owned or operated by a Close Relative; 13. Charges for recreational or educational therapy, services and supplies (including videos), and for

4 acupuncture, acupressure, hypnosis or biofeedback; 14. Any portion of a charge which represents the co-payment for the treatment rendered or the services or supplies provided; or any charge for treatment, services or supplies which are not Medically Necessary, or for which a charge would not have been made in the absence of insurance, or for which no charges have been made, or for which the Covered Person is not legally obligated to pay; 15. Any treatment of an Illness or Injury resulting from war or any act of war, declared or undeclared; or voluntary participation in an assault, felony, or in any illegal act; or for voluntary participation in civil commotions, conspiracies, riots, insurrection; or public disturbances; or incurred as the result of participation in any sports (professional or amateur), which could endanger the Covered Person's life (whether due to the Covered Person's irresponsibility, lack of knowledge or expertise, and/or other aggravating circumstances), including, but not limited to, parachuting, skydiving, water skiing, diving, mountain climbing, bungee jumping, motor vehicle or powerboat racing, hand gliding, ballooning and reckless endangerment of any form. 16. The following drugs, medicines or supplies, even if prescribed by a Physician: a) vitamins, (unless prescribed to treat a medically diagnosed condition) dietary supplements, appetite suppressants, hair regenerative or cosmetics, or health and beauty aids or nicorette gum (or related smoking cessation drugs); b) Experimental or Investigative drugs, medicines, or supplies; c) Over-the-counter (OTC) drugs or supplies, which do not require a Physician's prescription by the jurisdiction where the drug or supply is obtained, and any prescription that is available as an OTC medication, even if prescribed by a Physician; contraceptive drugs or devices, prescription or otherwise, unless prescribed for other than contraceptive purposes; to treat a medically diagnosed condition; d) drugs prescribed for non-medical conditions, or drugs for conditions which are not covered under this Policy; In addition to the above, the following out-patient drugs are not covered: a) Accutane (Isotretinoin); b) All forms of Retin (Retinoid Acid); c) AIDS specific drugs not yet approved for use and still in the experimental stage; d) Progesterone suppositories (except in complications of pregnancy); e) Fertility drugs; f) Immunosuppressants (unless under the control of a Physician); g) Monoxidil for topical use. 17. The following surgical procedures and related services or supplies, including, but not limited to, Hospital confinements, prescription drugs, and diagnostic laboratory tests or X-rays: a) cosmetic or plastic surgery, or other services and supplies, to repair or reshape an essentially normal body structure for the improvement of a Covered Person's appearance or self-esteem, whether or not for psychological or emotional reasons except: (1) for correction of damage caused by Injury sustained while covered, if such treatment or surgery

5 is also performed while so covered; or (2) in connection with a congenital defect, malformation or birth abnormality of a newborn child, up to the maximum benefit payable as shown in the Schedule of Benefits; or (3) diagnosed Medically Necessary Correction to abnormal parts of the body; b) radial keratotomy surgery or eye surgery mainly to correct refractive errors; c) for treatment of sexual dysfunctions; or surgery to change gender or to improve or restore sexual function, including but not limited to impotence and penile prosthesis; d) for reversal of sterilization procedures for male or female, or for any type of birth control supplies or procedures, including abortions for social or psychological reasons; or e) infertility, any form of fertility test and or treatment or exams including hormone treatment and related procedures and including any expenses for pregnancies, pre-natal or post-natal treatments of the newborn child/children born as a result of fertility treatments. 18. medical or dental services or supplies for the treatment of jaw joint problems, including, but not limited to, temporomandibular joint syndrome (TMJ), craniomandibular disorders or other conditions of the joint linking the jaw bone and the skull, and the complex of muscles, nerves and other tissues relating to that joint; 19. any service or supply provided in connection with weight loss, weight control, or the treatment of obesity, whether by diet programs, injection of any fluid, food supplement, or use of any medications or surgery of any kind, unless for the Medically Necessary treatment of Endogenous Morbid Obesity diagnosed by a Physician; Endogenous Morbid Obesity means 100 or more pounds over ideal weight, as determined by The Metropolitan Height & Weight Tables for Men and Women which are caused by some metabolic abnormality. 20. any Custodial Care, Hospice Care, or Geriatric Care, including, but not limited to, care in institutions that are sanatoriums, institutions for rest, rehabilitation centres, long-term care facilities, spas and hydroclinics, or in institutions that are not Hospitals, and care needed during a period of enforced isolation or quarantine even if required by health authorities; 21. any dental or orthodontic care, whether or not in connection with a jaw condition, except charges incurred for the repair or replacement of sound natural teeth damaged by an Injury which occurred while Covered under this Policy and within 90 days from the date of the Injury; 22. personal or comfort items such as radio, television, barber or beauty services; 23. charges by any provider of care or service who or which is not duly licensed or certified to render the treatment or services provided; or any service or supply not prescribed by a qualified Physician; 24. charges for maternity care for Dependent Children or for Spouses not covered under this Policy; 25. any service or supply not provided in accordance with accepted medical or professional standards of practice; or which is Experimental or Investigative in nature, or is research oriented; 26. any service or supply not specifically listed as a benefit under this Policy; 27. weekend charges incurred for Hospital Confinements that start on Friday, Saturday or Sunday,

6 unless: a) the attending Physician certifies that such weekend admission is Medically Necessary; or b) such weekend Hospital confinement is in connection with a surgery scheduled for the day that next follows the date of admission (Saturday, Sunday or Monday). 28. Charges for elective abortions.