DELTA DENTAL INSURANCE

Transcription

1 DELTA DENTAL INSURANCE Low Option w/o Orthodontic Services High Option w/ Orthodontic Services John D Webb 600 S. Santa Fe, Suite C Salina, KS (888) webbandassocinc@ofgfinancial.com

2 Maximum Contract Benefit Per Person: The Maximum Benefit for all Covered Services for each Enrollee in any one Contract Year is: One Thousand Dollars ($1,000.00). Summary of Proposed Dental Plan Benefits U S D # LYONS - LOW Effective for October 1, 2014 Benefit % Paid Premier/PPO 100% Diagnostic: DIAGNOSTIC & PREVENTIVE (Not subject to deductible) Includes the following procedures necessary to evaluate existing dental conditions and the dental care required: Oral examinations two (2) times per Contract year. Diagnostic x-rays bitewings two (2) times per Contract year for dependents under age eighteen (18) and once each twelve (12) months for adults age eighteen (18) and over. Full mouth x-rays or panoramic x-rays once each five (5) years. Deductible Limitations: Coverage for diagnostic and preventive services is not subject to any deductible amount. For all other covered benefits, the Contract Year deductible is: $50 x 3 100% Preventive: Provides for the following: Prophylaxis (Cleanings) - two (2) times per Contract year. Topical Fluoride two (2) times each Contract year for dependent children under age nineteen (19). Sealants once (1) per lifetime for dependent children under age sixteen (16) when applied only to permanent molars with no caries (decay) or restorations on the occlusal surface and with the occlusal surface intact. BASIC (Subject to deductible) 50% Space Maintainers: Ancillary: 50% 50% Oral Surgery: 50% Monthly Rates: MAJOR (Subject to deductible) Employee: Employee + Spouse: Employee + Child(ren): $22.04 $41.28 $44.61 Not Covered 50% Special Restorative: Prosthodontics: When teeth cannot be restored with a filling material listed in Regular Restorative Dentistry, provides for individual crowns. Includes denture repairs only. Family: $72.62 * 2015-Rate Cap 8% Regular Restorative: Included for dependent children under age fourteen (14) and only for premature loss of primary molars. Provides for one (1) emergency examination per plan year by the Dentist for the relief of pain. Provides for extractions and other oral surgery including pre and postoperative care. Provides amalgam (silver) restorations; composite (white) resin restorations on all teeth; and stainless steel crowns for dependents under age twelve (12). Dependent Ages: Not Covered Endodontics: Includes procedures for root canal treatments and root canal fillings. Dependents are covered to age twentysix (26). Not Covered Periodontics: a. Includes procedures for the treatment of diseases of the tissues supporting the teeth. Periodontal maintenance, including evaluation, is counted towards the limitation for prophylaxis. b. Surgical periodontal procedures. Participation/Contribution: 25% of eligible employees 0% employer contribution Not Covered ORTHODONTICS (Subject to deductible) Orthodontics: Orthodontic appliances and treatment. This is a summary of benefits only and does not bind Delta Dental of Kansas to any coverage. Please refer to the Description of Dental Care Coverage for complete coverage information, including exclusions and limitations. Coverage as described in the employer group s Agreement to Provide Dental Benefits (contract) is binding on all parties and supersedes all other written or oral communications. DD (9/18/2012) 07/01/2014 CMS

3 Maximum Contract Benefit Per Person: The Maximum Benefit for all Covered Services for each Enrollee in any one Contract Year is: One Thousand Five Hundred Dollars ($1,500.00). The Maximum Benefit for Orthodontic Services for each Enrollee is: One Thousand Dollars ($1,000.00) during such person's lifetime. Payment for the Orthodontic Services shall not be included in determining the Maximum Benefit for each Contract Year. Deductible Limitations: Coverage for diagnostic and preventive services is not subject to any deductible amount. For all other covered benefits, the Contract Year deductible is: $50 x 3 Summary of Proposed Dental Plan Benefits Benefit % Paid Premier/PPO 100% Diagnostic: DIAGNOSTIC & PREVENTIVE (Not subject to deductible) Oral examinations two (2) times per Contract year. Diagnostic x-rays bitewings two (2) times per Contract year for dependents under age eighteen (18) and once each twelve (12) months for adults age eighteen (18) and over. Full mouth x-rays or panoramic x-rays once each five (5) years. 100% Preventive: Provides for the following: Prophylaxis (Cleanings) - two (2) times per Contract year. Topical Fluoride two (2) times each Contract year for dependent children under age nineteen (19). Sealants once (1) per lifetime for dependent children under age sixteen (16) when applied only to permanent molars with no caries (decay) or restorations on the occlusal surface and with the occlusal surface intact. 50% BASIC (Subject to deductible) Space Maintainers: 50% Ancillary: 50% Oral Surgery: 50% 50% U S D # LYONS - HIGH Effective for October 1, 2014 Regular Restorative: Endodontics: Includes the following procedures necessary to evaluate existing dental conditions and the dental care required: Included for dependent children under age fourteen (14) and only for premature loss of primary molars. Provides for one (1) emergency examination per plan year by the Dentist for the relief of pain. Provides for extractions and other oral surgery including pre and postoperative care. Provides amalgam (silver) restorations; composite (white) resin restorations on all teeth; and stainless steel crowns for dependents under age twelve (12). Includes procedures for root canal treatments and root canal fillings. 50% Periodontics: a. Includes procedures for the treatment of diseases of the tissues supporting the teeth. Periodontal maintenance, including evaluation, Dependent Ages: is counted towards the limitation for prophylaxis. Dependents are covered to age twentysix (26). b. Surgical periodontal procedures. Monthly Rates: MAJOR (Subject to deductible) Employee: Employee + Spouse: Employee + Child(ren): $32.36 $64.27 $ % 50% Special Restorative: Prosthodontics: When teeth cannot be restored with a filling material listed in Regular Restorative Dentistry, provides for individual crowns. Includes bridges, partial and complete dentures, including repairs and Family: $ adjustments. * 2015-Rate Cap 8% Participation/Contribution: 25% of eligible employees 0% employer contribution ORTHODONTICS (Subject to deductible) 50% Orthodontics: Includes orthodontic appliances and treatment, interceptive and corrective, for dependent children under age nineteen (19). This is a summary of benefits only and does not bind Delta Dental of Kansas to any coverage. Please refer to the Description of Dental Care Coverage for complete coverage information, including exclusions and limitations. Coverage as described in the employer group s Agreement to Provide Dental Benefits (contract) is binding on all parties and supersedes all other written or oral communications. DD (9/18/2012) 07/01/2014 CMS

4 AMERITAS VISION INSURANCE John D Webb 600 S. Santa Fe, Suite C Salina, KS (888) webbandassocinc@ofgfinancial.com

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7 American Fidelity Assurance Company Short Term Disability Income Insurance Lori J. Likes 4606 Sequoia Hutchinson, KS (800) , Ext. #3538

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16 RELIANCE STANDARD LIFE INSURANCE COMPANY GROUP TERM LIFE INSURANCE John D. Webb 600 S. Santa Fe, Suite C Salina, Kansas (888) webbandassocinc@ofgfinancial.com

17 Group Term Life Insurance Special Open Enrollment The group term life insurance offered through your Section 125 plan, as underwritten by Reliance Standard Life Insurance Company, provides a simple way to secure coverage at low group rates. Plan Features: Guarantee issue by attained age (initial enrollment only): Under age $150, to $25, No Guarantee Issue Additional coverage amounts up to 5 times salary, not to exceed $300,000. Additional coverage requires completion of underwriting questionnaire and acceptance by the company. Accelerated death benefit if insured is diagnosed with terminal condition. Portability available for terminations other than retirement if you have not attained age 70. Election must be made within 31 days of termination. New Feature-see brochure for details. Sample Employee Monthly Premiums $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 Under Age 19 $1.23 $2.45 $3.68 $4.90 $6.13 $7.35 $8.58 $9.80 $11.03 $ to 24 $1.38 $2.75 $4.13 $5.50 $6.88 $8.25 $9.63 $11.00 $12.38 $ to 29 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $ to 34 $1.88 $3.75 $5.63 $7.50 $9.38 $11.25 $13.13 $15.00 $16.88 $ to 39 $2.63 $5.25 $7.88 $10.50 $13.13 $15.75 $18.38 $21.00 $23.63 $ to 44 $3.50 $7.00 $10.50 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $ to 49 $6.25 $12.50 $18.75 $25.00 $31.25 $37.50 $43.75 $50.00 $56.25 $ to 54 $11.25 $22.50 $33.75 $45.00 $56.25 $67.50 $78.75 $90.00 $ $ to 59 $18.75 $37.50 $56.25 $75.00 $93.75 $ $ $ $ $ to 64 $28.50 $57.00 $85.50 $ $ $ $ $ $ $ & Older $42.75 $85.50 $ $ $ $ $ $ $ $ Coverage for spouse limited to 50% of Employee s insured amount (less than age 60 guaranteed issue $20,000 for new hires; all others are underwritten). Premiums will change automatically each year when you attain an age that qualifies you for a new age bracket rate. Spouse Monthly Premiums $10,000 $20,000 $30,000 $40,000 $50,000 Under Age 34 $1.87 $3.74 $5.61 $7.48 $ to 39 $2.31 $4.62 $6.93 $9.24 $ to 44 $3.63 $7.26 $10.89 $14.52 $ to 49 $5.61 $11.22 $16.83 $22.44 $ to 54 $8.91 $17.82 $26.73 $35.64 $ to 59 $13.20 $26.40 $39.60 $52.80 $ to 69 $19.80 $39.60 $59.40 $79.20 $99.00 Coverage terminates at age 70. Coverage for children is $2.00 per month. 10 days to 6 months 6 months to age 19 (25 if full-time student) Benefit $500 $10,000 Employees wishing to enroll in this benefit will receive further information in the brochure which will be distributed to you during the enrollment period, from your representative. Form RS-2225.GTL.07.PS13.O99

18 Effect of Prior Coverage If you were participating in and insured by the Participating Employer s prior plan on thedate immediately prior to the Participating Employer s Effective Date shown on the Policy Schedule and are Actively-At-Work on such date, all amounts that were in force under the Participating Employer s prior plan on the date immediately preceding the Participating Employer s Effective Date with the Company are guarantee issue up to the maximum benefit amount available under this plan. Employees currently insured for less than the Guarantee Issue Amount can increase coverage up to the Guarantee Issue Amount during the initial Open Enrollment period without providing Evidence of Insurability. During the Open Enrollment period, currently insured Emplo yees can also request an increase in the amount of coverage in excess of the Guarantee Issue Amount but are required to provide Evidence of Insurability satisfactory to the Company before the amounts in excess of the Guarantee Issue Amount will become effe ctive. For each Insured Person s or Insured Dependent s individual coverage, coverage will be deemed continuous and uninterrupted and no change will have retroactive effect. However, if you elect to increase your amount of coverage, the increased amounts will be subject to any other plan provisions. Bene it Limitations Benefits will reduce 50% at age 70. No Life Insurance benefits will be payable under the Policy for death caused by suicide or self-destruction, or any attempt at it within 24 months after the person s coverage under the Reliance Standard Life Insurance Company Policy becomes effective. Termination of Employee Voluntary Life Insurance Your Voluntary Life Insurance ends if: 1. your employment ends; 2. you are no longer Actively-At-Work; 3. premiums are not paid; 4. you are no longer an eligible employee; 5. Voluntary Life Insurance is no longer provided by the Participating Employer; 6. the policy terminates; 7. you enter the military, naval or air force of a ny country or international organization on a full-time active-duty basis.; or 8. the Participating Employer s coverage under the policy ends. Effective Date of Dependent Coverage You may apply for Family Life Insurance Benefits for your spouse, less than age 70 at the time of application, or child. Such benefit that is less than or equal to the Guarantee Issue Amount begins on the latest of the following: 1. the Participating Employer s Effective Date, if you apply for Family Life Insurance prior to s uch date; 2. your Effective Date if application for Family Life Insurance is made within 31 days of your eligibility date; 3. the date we approve the application for Family Life Insurance, subject to proof of Evidence of Insurability, if application is made more than 31 days after your eligibility date; 4. the date we approve the application for Family Life Insurance, if application is made within 31 days of you acquiring a new spouse or child; 5. the date we approve the application for Family Life Insurance, subject to proof of Evidence of Insurability, if application is made more than 31 days after acquiring a new spouse or child. Any Family Life Insurance benefit that is in excess of the guarantee issue amount will become effective when we approve the required Evidence of Insurability. No Family Life Insurance benefit will be effective until the required premium is paid. Note: Dependent coverage may only be taken in conjunction with Employee coverage. Dependent coverage may not be taken on a stand-alone basis. A spouse or child who is insured as an Employee under this plan cannot also be insured as a dependent. If both you and your spouse are insured under this plan as employees, only one of you may insure your children as dependents. Termination of Family Coverage Your Insured Spouse s or Insured Child s Life Insurance ends if: 1. your coverage ends; 2. the Participating Employer s coverage under the policy ends; 3. you are no longer eligible for Family Life Insurance; 4. you notify us in writing to discontinue the Family Life Insurance; 5. the premium is not paid; 6. Family Life Insurance is no longer provided by the policy; 7. your Insured Spouse or Insured Child ceases to qualify for coverage under the policy, 8. your Insured Spouse or Insured Child enters the military, naval or air force of any country or international organization on a full -time active duty basis; or 9. your Spouse attains age 70 It is important to enroll for RELIANCE STANDARD LIFE INSURANCE COMPANY S Voluntary Term Life Insurance when you are first eligible. If you do not enroll as a new hire, and you decide you d like coverage or increased coverage at a later time, you will be required to provide evidence of insurability. Your future opportunities to enroll in the plan may be li mited, and you may be denied coverage. If you enroll in the plan as a new hire, you will not have to provide medical evidence of insurability to qualify for coverage up to the Guarantee Issue Amount. You will need to provide evidence for amounts over the Guarantee Issue Amount. This is an informational flyer and you will be receiving a brochure containing all of the details of the plan at enrollment. This flyer provides a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in Policy number VG , on Policy Form number LRS The Policy is subject to the laws of the state in which it is issued. Please keep this information as a reference. Bay Bridge Administrators P.O. Box Austin, Texas Underwritten by: BAY BRIDGE ADMINISTRATORS Your solutions begin at the Bridge Form RS-2225.GTL.07.PS13.O99

19 CANCER & SPECIFIED DISEASE INSURANCE WITH OPTIONAL INTENSIVE CARE RIDER Underwritten by Humana Insurance Company John D. Webb 600 S. Santa Fe, Suite C Salina, Kansas (888) webbandassocinc@ofgfinancial.com

20 Donor Benefits Wellness Benefits Many Benefits have No Lifetime Maximum Covers Certain Lodging and Transportation Cancer & Specified Disease Plan Plan pays money directly to you and you can use the money any way you want. Relatives Loans Savings Liquidation of Assets Cancer Plan Benefits Renewable for Life Portable (take it withyou) In and Out of Hospital benefits Pays regardless of other coverage BAY BRIDGE ADMINISTRATORS RS Your solutions begin at the Bridge Underwritten by Humana Insurance Company Cancer & Specified Disease Policy Form HIC-CAN-POL-KS 5/09

21 Benefit BBAC-0001 BBAC Wellness Benefit. For Cancer screening tests such as mammogram, flexible sigmoidoscopy, pap smear, chest X-ray, hemocult stool specimen, or prostate screen. No Lifetime Maximum 2 Positive Diagnosis Test. Payable for a test that leads to positive diagnosis of Cancer or Specified Disease within 90 days. This benefit is not payable if the same Cancer or Specified Disease recurs. 3 First Diagnosis Benefit. One-time benefit payable when a Covered Person is first diagnosed with Cancer (other than Skin Cancer) or a specified disease. Must occur after the Policy Effective Date. 4 Second and Third Surgical Opinions. Covers written opinions received after a positive diagnosis and before surgery. No Lifetime Maximum 5 Non-Local Transportation. Payable for transportation to a Hospital, clinic or treatment center which is more than 60 miles and less than 700 miles from a Covered Person s home. No Lifetime Maximum 6 Adult Companion Lodging and Transportation. Payable for one adult companion to stay with a Covered Person who is confined in a Hospital that is more than 60 miles and less than 700 miles from his or her home. Covered expenses include a single room in a motel or hotel up to 60 days per confinement; and the actual charge of round trip coach fare by a common carrier or a mileage allowance for the use of a personal vehicle. This benefit is not payable for lodging expense incurred more than 24 hours before the treatment nor for lodging expense incurred more than 24 hours following treatment. No Lifetime Maximum 7 Ambulance. For ambulance service if the Covered Person is taken to a Hospital and admitted as an inpatient. No Lifetime Maximum 8 Surgery. Covers actual surgeon s fee for an operation up to the amount listed on the schedule in the policy. Benefits for surgery performed on an outpatient basis will be 150% of the schedule benefit amount, not to exceed the actual surgeon s fees. No Lifetime Maximum 9 Donor Benefit Bone Marrow and Stem Cell Transplant. We will pay the following expenses incurred by the Covered Person and his or her live donor: (a) Medical expense allowance of two times the selected Hospital Confinement benefit. (b) Actual charges for round trip coach fare on a Common Carrier to the city where the transplant is performed; or personal automobile expense allowance of 50 cents per mile. Mileage is measured from the home of the Donor or Covered Person to the Hospital in which the Covered Person is staying. We will pay for up to 700 miles per Hospital stay. (c) Actual Charges up to $50 per day for lodging and meals expense for donor to remain near Hospital. 10 Bone Marrow and Stem Cell Transplant. We will pay Actual Charges per Covered Person for surgical and anesthetic charges associated with bone marrow transplant and/or peripheral stem cell transplant 11 Anesthesia. For services of an anesthesiologist during a Covered Person s surgery. For anesthesia in connection with the treatment of skin Cancer. No Lifetime Maximum 12 Ambulatory Surgical Center. We will pay the expense incurred at an Ambulatory Surgical Center. No Lifetime Maximum 13 Drugs and Medicines. Payable for drugs and medicine received while the Covered Person is Hospital confined. No Lifetime Maximum Up to $50 per calendar year Up to $300 per calendar year Up to $100 per calendar year Up to $300 per calendar year $2,500 Lifetime Maximum $7,500 Lifetime Maximum Actual Charges Actual charges by a common carrier or 50 cents per mile if a personal vehicle is used. Up to $75 per day for lodging. 50 cents per mile if a personal vehicle is used. Actual Charges Up to $1,500. Outpatient surgery at 150% of the schedule not to exceed the actual surgeon s fees. (a) $200 per day (b) Actual charges for round trip coach fare; or personal automobile expense of 50 cents per mile. (c) Actual charges up to $50 per day Actual charges to a combined lifetime maximum of $15,000 Up to 25% of surgical benefit paid. $100 maximum per Covered Person Actual Charges Actual charges by a common carrier or 50 cents per mile if a personal vehicle is used. Up to $75 per day for lodging. 50 cents per mile if a personal vehicle is used. Actual Charges Up to $4,500. Outpatient surgery at 150% of the schedule not to exceed the actual surgeon s fees. (a) $400 per day (b) Actual charges for round trip coach fare; or personal automobile expense of 50 cents per mile. (c) Actual charges up to $50 per day Actual charges to a combined lifetime maximum of $15,000 Up to 25% of surgical benefit paid. $100 maximum per Covered Person $250 Per Day $250 Per Day Up to $25 per day, $600 per calendar year Up to $25 per day, $600 per calendar year Form Number: HIC-CAN-SB-KS Page 1

22 Benefit BBAC-0001 BBAC Outpatient Anti-Nausea Drugs. Payable for drugs prescribed by a Physician to suppress nausea due to Cancer or Specified Disease. No Lifetime Maximum Up to $250 per calendar year Up to $250 per calendar year 15 Radiation, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy. Covers treatment administered by a Radiologist, Chemotherapist or Oncologist on an inpatient or outpatient basis. No Lifetime Maximum 16 Miscellaneous Therapy Charges. Covers charges for physical exams, lab work or x-rays in connection with radiation and chemotherapy treatment. Service must be performed while receiving treatment(s) in Item 15 or within 30 days following a covered treatment. 17 Self-Administered Drugs. We will pay the actual expenses incurred for selfadministered chemotherapy, including hormone therapy, or immunotherapy agents. This benefit is not payable for planning, monitoring, or other agents used to treat or prevent side effects, or other procedures related to this therapy treatment. No Lifetime Maximum 18 Colony Stimulating Factors. We will pay expenses incurred for: [a] cost of the chemical substances and [b] their administration to stimulate the production of blood cells. Treatment must be administered by an Oncologist or Chemotherapist. No Lifetime Maximum 19 Blood, Plasma and Platelets. For blood, plasma and platelets, and transfusions: including administration. No Lifetime Maximum 20 Physician's Attendance. For one visit per day while Hospital confined. No Lifetime Maximum 21 Private Duty Nursing Service. For private nursing services ordered by the Physician while Hospital confined. No Lifetime Maximum 22 National Cancer Institute Designated Comprehensive Cancer Treatment Center Evaluation/Consultation Benefit. We will pay the expense incurred if an Insured Person is diagnosed with Internal Cancer and seeks evaluation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Insured Person s place of residence, We will also pay the transportation and lodging expenses incurred. This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation Benefits of the policy. 23 Breast Prosthesis. Covers the prosthesis and its implantation if it is required due to breast cancer. No Lifetime Maximum 24 Artificial Limb or Prosthesis. Covers implantation of an artificial limb or prosthesis when an amputation is performed. 25 Physical or Speech Therapy. Payable when therapy is needed to restore normal bodily function. No Lifetime Maximum 26 Extended Benefits. If a Covered Person is confined in a Hospital for 60 continuous days We will pay a Hospital Confinement Benefit beginning on the 61st day for Hospital Confinement. This benefit is payable in place of the Hospital Confinement Benefit. No Lifetime Maximum Actual charges up to $1,000 per day Actual charges up to a lifetime maximum of $10,000 Actual charges up to $4,000 per month Actual charges up to $500 per month Actual charges up to $200 per day Up to $35 per day Up to $100 per day Expenses incurred limited to a lifetime maximum up to $750 for evaluation Expenses incurred limited to a lifetime maximum up to $350 for transportation and lodging Actual Charges $1,500 lifetime maximum per amputation. Up to $35 per session $300 per day Actual charges up to $10,000 per month Actual charges up to a lifetime maximum of $10,000 Actual charges up to $4,000 per month Actual charges up to $1,000 per month Actual charges up to $200 per day Up to $35 per day Up to $100 per day Expenses incurred limited to a lifetime maximum up to $750 for evaluation Expenses incurred limited to a lifetime maximum up to $350 for transportation and lodging Actual Charges $1,500 lifetime maximum per amputation. Up to $35 per session $600 per day 27 Extended Care Facility. Limited to number of days of prior Hospital confinement. Must begin within 14 days after Hospital confinement, and be at the direction of the attending Physician. No Lifetime Maximum 28 At Home Nursing. Limited to number of days of prior Hospital confinement. Must begin immediately following a Hospital confinement, and be authorized by the attending Physician. No Lifetime Maximum 29 New or Experimental Treatment. We will pay the expenses incurred by a Covered Person for New or Experimental Treatment judged necessary by the attending Physician and received in the United States or in its territories. No Lifetime Maximum Up to $50 per day Up to $100 per day Up to $7,500 per calendar year Up to $50 per day Up to $100 per day Up to $7,500 per calendar year Form Number: HIC-CAN-SB-KS Page 2

23 Benefit BBAC-0001 BBAC Hospice Care. If a Covered Person elects to receive hospice care, We will pay the expenses incurred for care received in a Free Standing Hospice Care Center. No Lifetime Maximum 31 Government or Charity Hospital. Payable if the Covered Person is confined in a U. S. Government Hospital or a Hospital that does not charge for its services. Paid in place of all other benefits under the policy. No Lifetime Maximum 32 Hairpiece. We will pay the actual expense incurred per Covered Person for a hairpiece when hair loss is a result of Cancer Treatment. 33 Rental or Purchase of Durable Goods. We will pay the actual expenses incurred for the rental or purchase of the following pieces of durable medical equipment: a respirator or similar mechanical device, brace, crutches, hospital bed, or wheelchair. No Lifetime Maximum 34 Waiver of Premium. After 60 continuous days of disability due to Cancer or Specified Disease, We will waive premiums starting on the first day of policy renewal. 35 Hospital Confinement. Payable for each day a Covered Person is charged the daily room rate by a Hospital, for up to 60 days of continuous stay. The benefit for covered children under age 21 is two times the Covered Person s daily benefit. No Lifetime Maximum Up to $50 per day Up to $50 per day $200 per day $200 per day Actual charge up to a lifetime maximum of $150 Actual charges up to $1,500 per calendar year After 60 days Actual charge up to a lifetime maximum of $150 Actual charges up to $1,500 per calendar year After 60 days $100 per day $200 per day OTHER SPECIFIED DISEASES COVERED: Addison s Disease Scarlet Fever Amyotrophic Lateral Sclerosis Multiple Sclerosis Sickle Cell Anemia Cystic Fibrosis Muscular Dystrophy Tay-Sachs Disease Diphtheria Myasthenia Gravis Tetanus Encephalitis Niemann-Pick Disease Toxic Epidermal Necrolysis Epilepsy Osteomyelitis Tuberculosis Hansen s Disease Poliomyelitis Tularemia Legionnaire s Disease Rabies Typhoid Fever Lupus Erythematosus Reye s Syndrome Undulant Fever Malaria Rheumatic Fever Whipple s Disease Rocky Mountain Spotted Fever Meningitis (epidemic cerebrospinal) Lyme Disease RENEWABILITY As long as premiums are paid on time, you have the right to renew your policy and riders. PREMIUMS The premium for the policy and riders may change at any time. The change in premium will apply to all policies and riders of this form number issued in your State of residence. A grace period of 31 days will be granted for the payment of each premium after the first. Your policy remains in force during the grace period. Premiums for this policy are calculated at age at issue class as of the effective date of the policy. You lock in your age class for the life of the policy. The premium for this policy and rider if selected may change but will not change because you attain the next premium rate age classification. PAYMENT OF BENEFITS We will pay the benefits for the necessary treatment of a Covered Person s Cancer or Specified Disease provided he or she is covered under this Policy and this Policy remains in force. Payment will be made in accordance with all applicable Policy provisions. Benefits are payable for a Positive Diagnosis that begins after the effective date of this Policy and while this policy has remained in force. The Positive Diagnosis must be for Cancer or Specified Disease, as they are defined in the Policy. All benefits are subject to the terms of the Policy. Form Number: HIC-CAN-SB-KS Page 3

24 If a Positive Diagnosis is made for Cancer or Specified Disease within 12 months after a Tentative Diagnosis, benefits will be paid from the date of the Tentative Diagnosis after the Policy Effective Date. If the Positive Diagnosis of Cancer or Specified Disease can only be confirmed post-mortem, then We will pay benefits beginning on the first day of confinement for the terminal admission for up to 45 days. a. With respect to the Wellness Benefit, on the date the expense is incurred. b. Subject to the Maximum Benefit Amount stated across from each Benefit EXCEPTIONS AND OTHER LIMITATIONS The Policy pays benefits only for diagnoses resulting from Cancer or Specified Diseases, as defined in the Policy. It does not cover: 1. any other disease or sickness; 2. injuries; 3. any disease, condition, or incapacity that has been caused, complicated, worsened, or affected by: a. Specified Disease or Specified Disease treatment; or b. Cancer or Cancer treatment, or unless otherwise defined in the Policy 4. care and treatment received outside the United States or its territories; 5. treatment not approved by a Physician as medically necessary; 6. Experimental Treatment by any program that does not qualify as Experimental Treatment as defined in the Policy. Benefits will not be paid for the following: Cancer or Specified Disease diagnosed before the Policy Effective Date; or losses not directly due to Cancer or Specified Disease. PRE-EXISTING CONDITION LIMITATION During the first 12 months of a Covered Person s insurance, losses incurred for Pre-Existing Conditions are not covered. During the first 12 months following the date a Covered Person makes a change in coverage that increases his or her benefits, the increase will not be paid for Pre-Existing Conditions. After this 12 month period, however, benefits for such conditions will be payable unless specifically excluded from coverage. This 12 month period is measured from the effective date of coverage for each Covered Person. A Pre-Existing Condition means Cancer or a Specified Disease, for which a Covered Person has received medical consultation, treatment, care, services, or for which diagnostic test(s) have been recommended or for which medication has been prescribed during the 12 months immediately preceding the effective date of coverage. ADDITIONAL INFORMATION Coverage is subject to each applicant submitting evidence of insurabilty on themselves and their dependents (if applying) which is acceptable to Humana Insurance Company. No coverage will be issued until your application is approved. If approved, your effective date of coverage will be indicated in the policy that is issued to you. Family Plan Coverage may include the following: you; your spouse who is not legally separated or divorced from you; your unmarried dependent children under age 21 (25 if full-time student), including a natural child from the moment of birth, stepchild, foster or legally adopted child, or child in the process of adoption (including a child while you are a party to a proceeding in which the adoption of such child by you is sought); a child for whom you are required by a court order to provide medical support, and grandchildren who are dependent on you for federal income tax purposes at the time of application, who has not reached age 25. CLAIM PROVISIONS Notice of Claim. Written notice of claim must be given to Us within 90 days after a Covered Person s loss, or as soon thereafter as reasonably possible. Written notice given by or on behalf of the claimant to Us with information sufficient to identify the Covered Person, is deemed notice to Us. Form Number: HIC-CAN-SB-KS Page 4

25 OPTION TO ADD ADDITIONAL BENEFITS HOSPITAL INTENSIVE CARE INSURANCE RIDER FORM NUMBER HIC-ICR-KS 5/09 This coverage will provide you with benefits if you go into a Hospital Intensive Care Unit (ICU). Benefits Your benefits start the first day you go into ICU. The benefit is payable for up to 45 days per ICU stay. Hospital Intensive Care Confinement Benefit You may choose the benefit of $325, $625, $725, or $825 per day. It is reduced by one-half at age 75. Double Benefits We will double the daily benefits for each day you are in an ICU as a result of Cancer or a Specified Disease. We will also double the benefit for an injury that results from: being struck by an automobile, bus, truck, motorcycle, train, or airplane; or being involved in an accident in which the named insured was the operator or was a passenger in such vehicle. ICU confinement must occur within 48 hours of the accident. Emergency Hospitalization and Subsequent Transfer to an ICU We will pay the benefit selected by you for the highest level of care in a Hospital that does not have an ICU, if you are admitted on an emergency basis, and you are transferred within 48 hours to the ICU of another Hospital. Step Down Unit We will pay a benefit equal to one half the chosen daily benefit for confinement in a Step Down Unit. Exceptions and Other Limitations Except as provided in Step Down Unit and Emergency Hospitalization and Subsequent Transfer to an ICU, coverage does not provide benefits for: surgical recovery rooms; progressive care; intermediate care; private monitored rooms; observation units; telemetry units; or other facilities which do not meet the standards for a Hospital Intensive Care Unit. Benefits are not payable: if you go into an ICU before the Policy Effective Date; if you go into an ICU for intentionally self-inflicted bodily injury or suicide attempts; if you go into an ICU due to being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on the advice of a Physician and taken according to the Physician s instructions. The term intoxicated refers to that condition as defined by law in the jurisdiction where the accident or cause of loss occurred. Upon receipt of your policy, please review it and your application. If any information is incorrect, please contact the Administrator at This is not a Medicare Supplement Policy. If you are eligible for Medicare, see the Medicare Supplement Buyer s Guide available from the Company. THIS POLICY ONLY COVERS CANCER AND THE DISEASES SPECIFIED ABOVE, UNLESS THE HOSPITAL INTENSIVE CARE RIDER IS SELECTED. Form Number: HIC-CAN-SB-KS Page 5

26 BAY BRIDGE ADMINISTRATORS Your solutions begin at the Bridge P.O. Box Austin, Texas (800)

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29 USD 405 Aflac Representative Leigh Anne Stelter District Sales Manager 820 Broadway Larned, KS Cancer Insurance Hosp. Confinement Insurance

30 AFLAC CANCER CARE CANCER INDEMNITY Insurance Classic We ve been dedicated to helping provide peace of mind and financial security for nearly 60 years. A78375RKS IC(10/12)

31 aflac cancer care cancer indemnity insurance Policy Series A78000 CC Classic Added Protection for You and Your Family Chances are you know someone who s been affected, directly or indirectly, by cancer. You also know the toll it s taken on them physically, emotionally, and financially. That s why we ve developed the Aflac Cancer Care insurance policy. The plan pays a cash benefit upon initial diagnosis of a covered cancer, with a variety of other benefits payable throughout cancer treatment. You can use these cash benefits to help pay out-of-pocket medical expenses, the rent or mortgage, groceries, or utility bills the choice is yours. And while you can t always predict the future, here at Aflac we believe it s good to be prepared. The Aflac Cancer Care plan is here to help you and your family better cope financially and emotionally if a positive diagnosis of cancer ever occurs. That way you can worry less about what may be ahead. how it works Aflac Cancer CARE - CLASSIC coverage is selected. Policyholder suffers from frequent infections & high fevers. Physician visit & bone marrow biopsy reveals diagnosis of leukemia. Aflac Cancer CARE - CLASSIC insurance policy provides the following: $33,175 Total Benefits The above example is based on a scenario for Aflac Cancer Care Classic that includes the following benefit conditions: Physician visit (Cancer Wellness Benefit) of $75, bone marrow biopsy (Surgical/Anesthesia Benefit) of $125, NCI Evaluation/Consultation Benefit of $500, Initial Diagnosis Benefit of $4,000, venous port (Surgical/Anesthesia Benefit) of $125, Injected Chemotherapy Administration Benefit (10 weeks) of $4,000, Immunotherapy Benefit (3 months) of $1,050, Antinausea Benefit (3 months) of $300, Hospital Confinement Benefit (10-week hospitalization) of $22,000, Blood/Plasma Benefit (10 transfusions) of $1,000. The FACTS say you need the protection of Aflac s Cancer Care plan: fact no. 01 fact no. 02 IN THE UNITED STATES, MEN HAVE SLIGHTLY LESS THAN A IN THE UNITED STATES, WOMEN HAVE SLIGHTLY MORE THAN A 1 -in in- 3 LIFETIME RISK OF developing cancer. 1 LIFETIME RISK OF developing cancer. 1 1 Cancer Facts & Figures 2012, American Cancer Society. The policy has limitations and exclusions that may affect benefits payable. For costs and complete details of the coverage, contact your Aflac insurance agent/producer. This brochure is for illustrative purposes only. Refer to the policy for benefit details, definitions, limitations, and exclusions. Aflac herein means American Family Life Assurance Company of Columbus.

32 Classic Cancer Care Benefit Overview Benefit Name Benefit Amount Cancer Wellness Benefit Mammography Benefit $75 per year, per Covered Person $70 per year, per Covered Person Cancer Diagnosis Benefits: Initial Diagnosis Benefit Insured/Spouse: $4,000; Dependent Child: $8,000; payable once per Covered Person Medical Imaging With Diagnosis Benefit NCI Evaluation/Consultation Benefit $135; two payments per year, per Covered Person; no lifetime max $500 payable only once per Covered Person Cancer Treatment Benefits: Injected Chemotherapy Administration Benefit $400 per week; no lifetime max Nonhormonal Oral/Injected Chemotherapy Benefit $250 per prescription, per month up to $750 max per month for Chemotherapy Benefits 2 Hormonal Oral/Injected Chemotherapy Benefit $250 per prescription, per month up to 24 months; after 24 months $75 per month up to $750 max per month for Chemotherapy Benefits 2 Topical Chemotherapy Benefit $150 per prescription, per month up to $750 max per month for Chemotherapy Benefits 2 Radiation Therapy Benefit Experimental Treatment Benefit Immunotherapy Benefit Antinausea Benefit Stem Cell Transplantation Benefit Bone Marrow Transplantation Benefit Blood and Plasma Benefit Surgical/Anesthesia Benefit Skin Cancer Surgery Benefit Additional Surgical Opinion Benefit Hospitalization Benefits: $350 per week; no lifetime max $350 per week if charged; $100 per week if no charge; no lifetime max $350 once per month; $1,750 lifetime max per Covered Person $100 per month; no lifetime max $7,000; lifetime max $7,000 per Covered Person $7,000; $7,000 lifetime max per Covered Person; $750 to donor Inpatient: $100 times the number of days paid under the Hospital Confinement Benefit; Outpatient: $175 per day; no lifetime max $100 $3,400 (Anesthesia: additional 25% of Surgical Benefit); maximum daily benefit not to exceed $4,250; no lifetime max on number of operations $35 $400; no lifetime max on number of operations $200 per day; no lifetime max Hospital Confinement Benefit: Hospitalization for 30 days or less Hospitalization for Days 31+ Outpatient Hospital Surgical Room Charge Benefit Insured/Spouse: $200 per day; Dependent Child: $250 per day; no lifetime max Insured/Spouse: $400 per day; Dependent Child: $500 per day; no lifetime max $200 (payable in addition to Surgical/Anesthesia Benefit); no lifetime max on number of operations Continuing Care Benefits: Extended-Care Facility Benefit $100 a day, limited to 30 days per year, per Covered Person Home Health Care Benefit $100 per day; limited to 30 days per year, per Covered Person Hospice Care Benefit $1,000 for the 1st day; $50 per day thereafter; $12,000 lifetime max per Covered Person Nursing Services Benefit Surgical Prosthesis Benefit Nonsurgical Prosthesis Benefit $100 per day; no lifetime max $2,000; lifetime max $4,000 per Covered Person $175 per occurrence; lifetime max $350 per Covered Person Reconstructive Surgery Benefit $220 $2,000 (Anesthesia: 25% of Reconstructive Surgery Benefit); no lifetime max on number of operations Egg Harvesting and Storage (Cryopreservation) Benefit Ambulance, Transportation, Lodging, and Other Benefits: $1,000 to have oocytes extracted; $350 for storage; $1,350 lifetime max per Covered Person Ambulance Benefit Transportation Benefit Lodging Benefit Bone Marrow Donor Screening Benefit $250 ground or $2,000 air; no lifetime max $.40 per mile; max $1,200 per round trip; no lifetime max $65 per day; limited to 90 days per year $40; limited to one benefit per Covered Person, per lifetime 2 Up to three different chemotherapy medicines per calendar month. REFER TO THE FOLLOWING OUTLINE OF COVERAGE FOR BENEFIT DETAILS, DEFINITIONS, LIMITATIONS, AND EXCLUSIONS.

33 American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters 1932 Wynnton Road Columbus, Georgia Toll-Free AFLAC ( ) The policy described in this Outline of Coverage provides supplemental coverage and will be issued only to supplement insurance already in force. LIMITED BENEFIT SPECIFIED-DISEASE INSURANCE Outline of Coverage for Policy Form Series A78300 THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Medicare Supplement Buyer s Guide furnished by Aflac. A78325KS (10/12) A78325KS Aflac All Rights Reserved

34 1. Read Your Policy Carefully: This Outline of Coverage provides a very brief description of some of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth, in detail, the rights and obligations of both you and Aflac. It is, therefore, important that you READ YOUR POLICY CAREFULLY. 2. Cancer Insurance Coverage is designed to supplement your existing accident and sickness coverage only when certain losses occur as a result of the disease of Cancer or an Associated Cancerous Condition. Coverage is provided for the benefits outlined in Part (3). The benefits described in Part (3) may be limited by Part (5). 3. All treatments below, except prescription drugs, must must be NCI or Food and Drug Administration (FDA) approved for the treatment of Cancer or Associated Cancerous Condition, as applicable. Prescription drugs will be covered if the prescription drug is recognized for treatment of the indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature. The prescribing Physician shall submit to the insurer documentation supporting the proposed off-label use or uses if requested by the insurer. A. CANCER WELLNESS BENEFITS: 1. CANCER WELLNESS: Aflac will pay $75 per Calendar Year when a Covered Person receives one of the following: breast ultrasound CEA (blood test for colon breast MRI Cancer) CA15-3 (blood test for breast Cancer tumor) Pap smear ThinPrep biopsy flexible sigmoidoscopy hemoccult stool specimen (lab confirmed) chest X-ray CA 125 (blood test for ovarian Cancer) PSA (blood test for prostate Cancer) testicular ultrasound thermography colonoscopy virtual colonoscopy This benefit is limited to one payment per Calendar Year, per Covered Person. These tests must be performed to determine whether Cancer or an Associated Cancerous Condition exists in a Covered Person and must be administered by licensed medical personnel. No lifetime maximum. 2. mammography BENEFIT: Aflac will pay $70 (seventy dollars) per Calendar Year when charges are incurred for an annual screening by low dose mammography for the presence of occult breast Cancer. This benefit is limited to one payment per Calendar Year, per Covered Person. No lifetime maximum. 3. BONE MARROW DONOR SCREENING: Aflac will pay $40 when a Covered Person provides documentation of participation in a screening test as a potential bone marrow donor. This benefit is limited to one benefit per Covered Person per lifetime. B. CANCER DIAGNOSIS BENEFITS: 1. initial DIAGNOSIS BENEFIT: Aflac will pay the amount listed below when a Covered Person is diagnosed as having Internal Cancer or an Associated Cancerous Condition while this policy is in force, subject to Part 2, Limitations and Exclusions, Section B, of the policy. Named Insured or Spouse $4,000 Dependent Child $8,000 This benefit is payable under the policy only once for each Covered Person. In addition to the Positive Medical Diagnosis, we may require additional information from the attending Physician and Hospital. 2. medical IMAGING WITH DIAGNOSIS BENEFIT: Aflac will pay $135 when a charge is incurred for a Covered Person who receives an initial diagnosis or follow-up evaluation of Internal Cancer or an Associated Cancerous Condition, using one of the following medical imaging exams: CT scans, MRIs, bone scans, thyroid scans, multiple gated acquisition (MUGA) scans, positron emission tomography (PET) scans, transrectal ultrasounds, or abdominal ultrasounds. This benefit is limited to two payments per Calendar Year, per Covered Person. No lifetime maximum. 3. national CANCER INSTITUTE EVALUATION/CONSULTATION BENEFIT: Aflac will pay $500 when a Covered Person seeks evaluation or consultation at an NCI-Designated Cancer Center as a result of receiving a diagnosis of Internal Cancer or an Associated Cancerous Condition. The purpose of the evaluation/ consultation must be to determine the appropriate course of treatment. This benefit is not payable the same day the Additional Surgical Opinion Benefit is payable. This benefit is also payable at the Aflac Cancer Center & Blood Disorders Service of Children s Healthcare of Atlanta. This benefit is payable only once per Covered Person. C. CANCER TREATMENT BENEFITS: 1. DIRECT NONSURGICAL TREATMENT BENEFITS: All benefits listed below are not payable based on the number, duration, or frequency of the medication(s), therapy, or treatment received by the Covered Person (except as provided in Benefit C1a). Benefits will not be paid under the Experimental Treatment Benefit or Immunotherapy Benefit for any medications or treatment paid under the Chemotherapy Benefits, Injected Chemotherapy Administration Benefit, or the Radiation Therapy Benefit. A78325KS 6 (10/12) A78325KS Aflac All Rights Reserved

35 a. CHEMOTHERAPY BENEFITS: (1) nonhormonal ORAL/INJECTED CHEMOTHERAPY BENEFIT: Aflac will pay $250 per Calendar Month during which a Covered Person is prescribed, receives, and incurs a charge for Nonhormonal Oral/Injected Chemotherapy for the treatment of Cancer or an Associated Cancerous Condition. (2) HORMONAL Oral/Injected CHEMOTHERAPY BENEFIT: Aflac will pay $250 per Calendar Month for up to 24 months during which a Covered Person is prescribed, receives, and incurs a charge for Hormonal Oral/Injected Chemotherapy for the treatment of Cancer or an Associated Cancerous Condition. After 24 months of paid benefits of Hormonal Oral/Injected Chemotherapy for a Covered Person, Aflac will pay $75 per Calendar Month during which a Covered Person is prescribed, receives, and incurs a charge for Hormonal Oral/Injected Chemotherapy for the treatment of Cancer or an Associated Cancerous Condition. Examples of Hormonal Oral Chemotherapy treatments include but are not limited to Nolvadex, Arimidex, Femara, and Lupron and their generic versions, such as tamoxifen. (3) topical CHEMOTHERAPY BENEFIT: Aflac will pay $150 per Calendar Month during which a Covered Person is prescribed, receives, and incurs a charge for a Topical Chemotherapy for the treatment of Cancer or an Associated Cancerous Condition. Chemotherapy benefits are limited to the Calendar Month in which the charge for the medication(s) or treatment is incurred. If the prescription is for more than one month, the benefit is limited to the Calendar Month in which the charge is incurred. Total benefits are payable for up to three different Chemotherapy medicines per Calendar Month, up to a maximum of $750 per Calendar Month. Refills of the same prescription within the same Calendar Month are not considered a different Chemotherapy medicine. No lifetime maximum. b. injected CHEMOTHERAPY ADMINISTRATION BENEFIT: Aflac will pay $400 once per Calendar Week for administration fee for the treatment of Cancer or Associated Cancer Condition injected by medical personnel in a Physician s office, clinic or a Hospital. The Surgical/Anesthesia Benefit provides amounts payable for insertion and removal of a pump. Benefits will not be paid for each week of continuous infusion of medications dispensed by a pump, implant, or patch. This benefit is limited to the Calendar Week in which the charge for the medication(s) or treatment is incurred. No lifetime maximum. c. RADIATION THERAPY BENEFIT: Aflac will pay $350 once per Calendar Week during which a Covered Person receives and incurs a charge for Radiation Therapy for the treatment of Cancer or an Associated Cancerous Condition. This benefit will not be paid for each week a radium implant or radioisotope remains in the body. This benefit is limited to the Calendar Week in which the charge for the therapy is incurred. No lifetime maximum. d. experimental TREATMENT BENEFIT: Aflac will pay $350 once per Calendar Week during which a Covered Person receives and incurs a charge for Physician-prescribed experimental Cancer chemotherapy medications. Aflac will pay $100 once per Calendar Week during which a Covered Person receives Physician-prescribed experimental Cancer chemotherapy medications as part of a clinical trial that does not charge patients for such medications. Chemotherapy medications must be approved by the NCI as a viable experimental treatment for Cancer. This benefit does not pay for laboratory tests, diagnostic X-rays, immunoglobulins, Immunotherapy, colony-stimulating factors, and therapeutic devices or other procedures related to these experimental treatments. Benefits will not be paid for each week of continuous infusion of medications dispensed by a pump, implant, or patch. This benefit is limited to the Calendar Week in which the charge for the chemotherapy medications is incurred. No lifetime maximum. Benefits will not be paid under the Experimental Treatment Benefit for any medications paid under the Immunotherapy Benefit. 2. indirect/additional THERAPY BENEFITS: The following benefits are not payable based on the number, duration, or frequency of Immunotherapy or anti-nausea drugs received by the Covered Person. a. immunotherapy BENEFIT: Aflac will pay $350 per Calendar Month during which a Covered Person receives and incurs a charge for Physician-prescribed Immunotherapy as part of a treatment regimen for Internal Cancer or an Associated Cancerous Condition. This benefit is payable only once per Calendar Month. It is limited to the Calendar Month in which the charge for Immunotherapy is incurred. Lifetime maximum of $1,750 per Covered Person. Benefits will not be paid under the Immunotherapy Benefit for any medications paid under the Experimental Treatment Benefit. b. antinausea BENEFIT: Aflac will pay $100 per Calendar Month during which a Covered Person receives and incurs a charge for antinausea drugs that are prescribed in conjunction with Radiation Therapy Benefits, Chemotherapy Benefits, or Experimental Treatment Benefits. This benefit is payable only once per Calendar Month and is limited to the Calendar Month in which the charge for antinausea drugs is incurred. No lifetime maximum. A78325KS 7 (10/12) A78325KS Aflac All Rights Reserved