United Health Plan Info
bettym2010
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Jun 30, 2010
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About This Presentation
Co Pay Select Platinum
and
Co Pay Saver Platinum
on pg 7 are the most popular plans
Slide Content
What Choices
Empower You?
Health Plans For Individuals and Families
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Empower You?
Health Plans For Individuals and Families
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Why Choose Us for Health Insurance?
UnitedHealthcare
More than 26 milion customers entrust UnitedHealthcace with thee health insurance needs” Our network plans can
ease access to high-quality care from physidans and hospitals natanwide Together we combine our strength and
"ably with nearly three decades o experience serving customers ol size
UnitedHealthOne
UnitedHeatthOne ithe brand name ofthe UitedHeathcare family of companies that offers personal heath insurance
Product. Golden Rule Insurance Company, a UnitedHesthcae company; the underwriter and administrator of these
Plans With over 60 years of experince serving individual and families, Golden Rule provides high-quality products,
timely claims handling and outstanding customer service.
Experience and Expertise
Golden Rule's experience and expense has driven the development o eo use and innovative heath insurance
oducts. recognized leader — and one of the nation ges providers of heath savings account plans — Golden
Rule continues bung plans that meet the needs of indviduals and families
Our Goal: Your Satisfaction
We understand the importance of your time and concern forthe valve of your health-care dolar. You wl ind we go ar
beyond the Industry average processing an ovensheiming majority of heath Insurance clams nes than two weeks
and offering strong discounts when using our vast network of quality heaih care providers Our goal for every customer
is ominsurace plan ata price that fis is or her needs and budget UnitedHealthOne — Choices you want. Coverage you
eed
Were easy to reach witha tlre customer servic line: (80) 657-8205. We respond quickly o customer questions and
UnitedHealthcare
More than 26 milion customers entrust UnitedHealthcace with thee health insurance needs” Our network plans can
ease access to high-quality care from physidans and hospitals natanwide Together we combine our strength and
"ably with nearly three decades o experience serving customers ol size
UnitedHealthOne
UnitedHeatthOne ithe brand name ofthe UitedHeathcare family of companies that offers personal heath insurance
Product. Golden Rule Insurance Company, a UnitedHesthcae company; the underwriter and administrator of these
Plans With over 60 years of experince serving individual and families, Golden Rule provides high-quality products,
timely claims handling and outstanding customer service.
Experience and Expertise
Golden Rule's experience and expense has driven the development o eo use and innovative heath insurance
oducts. recognized leader — and one of the nation ges providers of heath savings account plans — Golden
Rule continues bung plans that meet the needs of indviduals and families
Our Goal: Your Satisfaction
We understand the importance of your time and concern forthe valve of your health-care dolar. You wl ind we go ar
beyond the Industry average processing an ovensheiming majority of heath Insurance clams nes than two weeks
and offering strong discounts when using our vast network of quality heaih care providers Our goal for every customer
is ominsurace plan ata price that fis is or her needs and budget UnitedHealthOne — Choices you want. Coverage you
eed
Were easy to reach witha tlre customer servic line: (80) 657-8205. We respond quickly o customer questions and
Quality Coverage from a Proven Company
Leave it to the experts
For over 6 yen our experience and expertise inthe
inva heat market hs driven the development of
plans that tr to make heath coverage more afordble
{or more Americans Because ur primary fous serving
indias and fomi we understand the unique needs
<A people eye.
Don't just take our word for it
Golden Rules rated” (Ecole) by AM. Best and "As"
(Strong) by Standard and Poors These wide,
Independent ergarizations examine insurance companies
and other businesses and publish ter opinions about
them These ratings ae an indication o our financial
strength and stability.
Fast claims processing
We recognize the cial importance of being responsive
tothe service needs of our customers Thats why more
‘than 94% fal heat insurance claims ae procested
thin 1O working daysor lasse"
Big network, big savings
You can find mary provider in your area with more than
180000 physicians and care professionals and 4900
hospitals nationwide inthe UnitedHealthare network”
Plus, our network an offer you provider discounts of upto
35-4586 on qualty health care"
Initial rate guarantees
‘Benefit from securing youInital premium amount for 12
months with an option on al plans to extend upto 24
‘months
Benefits for a lifetime
Each of ur pans gives you the protection ofa $3 milion
"eme benefit with an option to enhance you plan 10 à
55 mien Ifeime benefit.
Coverage for your children
‘Your chien can benef from coverage until they many
‘or ntl they each the age of
Get the specialized care you need
Ayou require care fom aspecals.areferal isnot
required making easier for you to rece the care you
eed.
In case of emergency
Fram tt 1 tate, country to county et assed
owing that you have a medial emergency coverage is.
valable. even when aeg ouside De US.
Membership has its benefits
FACT members have access to not only UntedHealthOne
‘neath plans from Golden Ale, but lo discounts on
lon, dental prescription drug and even travel expenses
See the back cover af this brochure formore.
se caro,
ee
pre paca de ie
ere tr
Leave it to the experts
For over 6 yen our experience and expertise inthe
inva heat market hs driven the development of
plans that tr to make heath coverage more afordble
{or more Americans Because ur primary fous serving
indias and fomi we understand the unique needs
<A people eye.
Don't just take our word for it
Golden Rules rated” (Ecole) by AM. Best and "As"
(Strong) by Standard and Poors These wide,
Independent ergarizations examine insurance companies
and other businesses and publish ter opinions about
them These ratings ae an indication o our financial
strength and stability.
Fast claims processing
We recognize the cial importance of being responsive
tothe service needs of our customers Thats why more
‘than 94% fal heat insurance claims ae procested
thin 1O working daysor lasse"
Big network, big savings
You can find mary provider in your area with more than
180000 physicians and care professionals and 4900
hospitals nationwide inthe UnitedHealthare network”
Plus, our network an offer you provider discounts of upto
35-4586 on qualty health care"
Initial rate guarantees
‘Benefit from securing youInital premium amount for 12
months with an option on al plans to extend upto 24
‘months
Benefits for a lifetime
Each of ur pans gives you the protection ofa $3 milion
"eme benefit with an option to enhance you plan 10 à
55 mien Ifeime benefit.
Coverage for your children
‘Your chien can benef from coverage until they many
‘or ntl they each the age of
Get the specialized care you need
Ayou require care fom aspecals.areferal isnot
required making easier for you to rece the care you
eed.
In case of emergency
Fram tt 1 tate, country to county et assed
owing that you have a medial emergency coverage is.
valable. even when aeg ouside De US.
Membership has its benefits
FACT members have access to not only UntedHealthOne
‘neath plans from Golden Ale, but lo discounts on
lon, dental prescription drug and even travel expenses
See the back cover af this brochure formore.
se caro,
ee
pre paca de ie
ere tr
Which Plan Best Fits Your Needs?
A Variety of Plans to Choose From
\Whetheryou are seeking lower-cost helt insurance, experienced a recent change in employment or family status, oF
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A Variety of Plans to Choose From
\Whetheryou are seeking lower-cost helt insurance, experienced a recent change in employment or family status, oF
le aad ler a ered
remy eer Dr peurs
a Ss e E
CE
aol ‘aes wth chien who have
mets er Gsm Hp le 6
Re
ua
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Be ce Me Om æ
a RE Soe
cs
en
a ea BE Er 3
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ne
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Ben am Go
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Dag spare cnc ap Ue ls diran aya ati entrenan
Ces
The Network Advantage
Quality Care at Significant Savings
Access tthe ight doctors can be the most important par of your heath cre
Our network gives you:
Access to an extensive network of doctor, ay and lab actes, hospital, and other anclar providers”
Quality care at reduced costs because these providers have agreed to lowe fees for covered expenses.
Lower premiums — savings upto 35%-45% over the same plans without a network.
Please note: Covered expenses for nonemergency care received from a provider outside your network re:
Subject to reasonable and customary charges:
+ Reduced by 25%;
‘Subject to an additonal deduchbie amount equalto the per person, calendaryear deductible,
For Services of Non-Network Provides: Your actual out-of packet expenses for covered expenses may exced the
stated coinsurance percentage because actual provider charges may not be used to determine insurer and member
payment obligations.
‘Sample savings with our network:
(Services provided August to September 2008"*
ou red gs
Of es 5 m0 Cn
logan $ ¿us
ci BE Shun
ok Oeste he lai sum soo
an m an per om
ee en en
nn 2 m
ennemie
To find orview network providers for any network. visit mm golden com
Quality Care at Significant Savings
Access tthe ight doctors can be the most important par of your heath cre
Our network gives you:
Access to an extensive network of doctor, ay and lab actes, hospital, and other anclar providers”
Quality care at reduced costs because these providers have agreed to lowe fees for covered expenses.
Lower premiums — savings upto 35%-45% over the same plans without a network.
Please note: Covered expenses for nonemergency care received from a provider outside your network re:
Subject to reasonable and customary charges:
+ Reduced by 25%;
‘Subject to an additonal deduchbie amount equalto the per person, calendaryear deductible,
For Services of Non-Network Provides: Your actual out-of packet expenses for covered expenses may exced the
stated coinsurance percentage because actual provider charges may not be used to determine insurer and member
payment obligations.
‘Sample savings with our network:
(Services provided August to September 2008"*
ou red gs
Of es 5 m0 Cn
logan $ ¿us
ci BE Shun
ok Oeste he lai sum soo
an m an per om
ee en en
nn 2 m
ennemie
To find orview network providers for any network. visit mm golden com
Copay Plans
Mm ve
Designed for individuals and fas, our copay plans are more Ike traditional employe plans wih a copayment or
routine healthcare expenses. When you use a network doctor fr an office vs we pay 100% of history and exam fees
after 535 copay with Copay Select Office vist expenses ouside your network are not eligible for copay benefits.
fer a 3-month waling period, you pay $35 forthe doctor office vist with Copay Select Xray ad lab tests are
‘covered after you pay your chosen coinsurance (0%, 20%, oF 30%.
Tee 1 drugs — $15 copay.
+ Tler2-4 drugs — combined 5200 deductible per person per calendar yes, then
— $35 copay for Tier2 drugs.
— 565 copay or Ter 3 drugs
— 25% coinsurance (you pay for Tier 4 drugs.
‘You choose $3 milionor$S mili lifetime maximum benef per covered person,
+ Covered inpaent and outpatient expenses ae reimbursed after you chosen colnsrance and the deductible
The Copay Saver plan provides the convenience of copays for doctor office visi limited to 2 ists per person per
calendar yea fora lower monthly premium.
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‘Who might benefit most from a Copay Select” plant
‘Anyone who prefers the convenience of copay benefits for routine heath-cre expenses.
+ Families with young hldren who have regular scheduled doctor ofc its.
+ Adults who want copay benefits fo preventive care and prescription drugs.
an 292010102808
Mm ve
Designed for individuals and fas, our copay plans are more Ike traditional employe plans wih a copayment or
routine healthcare expenses. When you use a network doctor fr an office vs we pay 100% of history and exam fees
after 535 copay with Copay Select Office vist expenses ouside your network are not eligible for copay benefits.
fer a 3-month waling period, you pay $35 forthe doctor office vist with Copay Select Xray ad lab tests are
‘covered after you pay your chosen coinsurance (0%, 20%, oF 30%.
Tee 1 drugs — $15 copay.
+ Tler2-4 drugs — combined 5200 deductible per person per calendar yes, then
— $35 copay for Tier2 drugs.
— 565 copay or Ter 3 drugs
— 25% coinsurance (you pay for Tier 4 drugs.
‘You choose $3 milionor$S mili lifetime maximum benef per covered person,
+ Covered inpaent and outpatient expenses ae reimbursed after you chosen colnsrance and the deductible
The Copay Saver plan provides the convenience of copays for doctor office visi limited to 2 ists per person per
calendar yea fora lower monthly premium.
eae sr! ugs pe Tan pr nte ei ein dos eta te
‘yelper on once Hebets pope aged gdp
‘Who might benefit most from a Copay Select” plant
‘Anyone who prefers the convenience of copay benefits for routine heath-cre expenses.
+ Families with young hldren who have regular scheduled doctor ofc its.
+ Adults who want copay benefits fo preventive care and prescription drugs.
an 292010102808
Benefit Highlight
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Health Savings Account (HSA) Plans
HS Plans simply combine a lower-cost, high deductible health insurance plan and a tx favored savings account.
High deductible plans typically cost alot ess than many copay or traditional plans. This means lower premiums fr you
‘You can then take the premium savings and place it into your health savings account
You get tax deduction on the money you putin your HSA.
+ Your dallrscan grow txcdefred
+ You spend the savings taste o help pay your deductible o for qualified medical care (lung prescription,
vision, or dental care.
hat you don't use in your account wl continue to accumulate year after yea. Then, you ever need it for
health-care expenses, the money wil be thee
+ With Golden Rules HSA custodian yout also am Interes on your savings, beginning with the fst dollar
deposited.
With our HSA plans, after a3-monthwalting period you pay $35 copay In-natwork for he doctor office it.
stos Ortesis
res vu Aa
Seien impr tin
ho might benefit mst from a Health Savings Account plan?
Persons interested in more contol over other healthcare dollars ae spent.
+ Families interested in one calendar year deductible per fry.
+ Those interested in trading low deductible health insurance for a higher deductible lan to save money on
‘monthly premiums and taxes.
an 292010102808
HS Plans simply combine a lower-cost, high deductible health insurance plan and a tx favored savings account.
High deductible plans typically cost alot ess than many copay or traditional plans. This means lower premiums fr you
‘You can then take the premium savings and place it into your health savings account
You get tax deduction on the money you putin your HSA.
+ Your dallrscan grow txcdefred
+ You spend the savings taste o help pay your deductible o for qualified medical care (lung prescription,
vision, or dental care.
hat you don't use in your account wl continue to accumulate year after yea. Then, you ever need it for
health-care expenses, the money wil be thee
+ With Golden Rules HSA custodian yout also am Interes on your savings, beginning with the fst dollar
deposited.
With our HSA plans, after a3-monthwalting period you pay $35 copay In-natwork for he doctor office it.
stos Ortesis
res vu Aa
Seien impr tin
ho might benefit mst from a Health Savings Account plan?
Persons interested in more contol over other healthcare dollars ae spent.
+ Families interested in one calendar year deductible per fry.
+ Those interested in trading low deductible health insurance for a higher deductible lan to save money on
‘monthly premiums and taxes.
an 292010102808
Benefit Highlight
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UnitedHealthOnè*
Golden Re Insurance Company, a UnitedHealthcare company she underwriter and administrator ofthese plans.
an 29 2010 102008
Golden Re Insurance Company, a UnitedHealthcare company she underwriter and administrator ofthese plans.
an 29 2010 102008
About Your HSA
We have chosen OptumHealth Bank, a leading
administrator of health savings accounts (HSA), as our
financial institution, Your HSA funds are deposited at
(OptumHealth Bank in a custodial account.
(OptumHealth Bank, Member FDIC, will service your
account and send information directly to you about
your HSA
You will receive your new Health Savings Account
Card and PIN in separate mailings. Once you
activate your card, you can use it at:
+ Any pointof service location (uch asa
¡doctors office or pharmacy) that accepts
‘MasterCard® debit cards
+ Any ATM displaying the MasterCard® brand
mark. (1.50 per transaction OptumHealth
Bank fee. In addition, the bank/ATM you use to
withdraw funds may charge you its own fee
(variable by bank) forthe transaction)
You can also access your HSA funds through:
+ Online bil payment at OptumHeathBank com
+ Checks, you choose to purchase them,
HSA deposits are set up on the same payment plan as
Premiums for Golden Rule health insurance coverage.
Lump sum deposits are also accepted by
(OptumHealth Bank: however you must continue to
deposit the $25 monthly minimum with your
premium payment. OptumHealth Bank wll provide
online monthly statements detaing your account
balance and activity. Ifyou prefer to have statements
mailed to your home, simply notify OptumHealth
Bank You can opt out of electronic statements at is
‘Web site (OptumHealthBank com, cal customer
Service to do so, or send your request to PO. Box
271629, Salt Lake City, UT 84127-1629.
HSA Management by OptumHealth Bank
Account Information by Phone or
Online
With an OptumHealth Bank HSA, your account
Information is available, day or night, through
Tollfree customer service — representatives
are available to assist you Monday through
Friday, a.m. to7 pam. Eastem time at
1-866-234-8913,
+ Interactive voice response for selfsevic, 24/7
+ OptumkealthBank.com
Youcan:
+ Make contributions to your HSA.
Pay ils online
+ Check curent balance,
+ See how much interest has been pal,
+ Transfer funds.
+ Check ast five (5) account transactions
(deposits and/or withdrawal)
+ Activate the Health Savings Account card
+ Report the card lost or stolen
+ Setorreset password.
+ View frequently asked questions.
+ View monthly statements.
OptumHealthBank..
HSA Balance Annual Perentage Monay Mii
Between Yan cess toFunds Maitenance Monthly Deposit
Ss sn ax
$ 5000 sa ax
10000. 195555 ms Heath vgs cout ad as
21000-54980 os
$5000: $4959 108
51000 im D
AS jt ang taime.
eS) monty mine fe ved bent ae lance neh 500.
van 29 2010 102808
We have chosen OptumHealth Bank, a leading
administrator of health savings accounts (HSA), as our
financial institution, Your HSA funds are deposited at
(OptumHealth Bank in a custodial account.
(OptumHealth Bank, Member FDIC, will service your
account and send information directly to you about
your HSA
You will receive your new Health Savings Account
Card and PIN in separate mailings. Once you
activate your card, you can use it at:
+ Any pointof service location (uch asa
¡doctors office or pharmacy) that accepts
‘MasterCard® debit cards
+ Any ATM displaying the MasterCard® brand
mark. (1.50 per transaction OptumHealth
Bank fee. In addition, the bank/ATM you use to
withdraw funds may charge you its own fee
(variable by bank) forthe transaction)
You can also access your HSA funds through:
+ Online bil payment at OptumHeathBank com
+ Checks, you choose to purchase them,
HSA deposits are set up on the same payment plan as
Premiums for Golden Rule health insurance coverage.
Lump sum deposits are also accepted by
(OptumHealth Bank: however you must continue to
deposit the $25 monthly minimum with your
premium payment. OptumHealth Bank wll provide
online monthly statements detaing your account
balance and activity. Ifyou prefer to have statements
mailed to your home, simply notify OptumHealth
Bank You can opt out of electronic statements at is
‘Web site (OptumHealthBank com, cal customer
Service to do so, or send your request to PO. Box
271629, Salt Lake City, UT 84127-1629.
HSA Management by OptumHealth Bank
Account Information by Phone or
Online
With an OptumHealth Bank HSA, your account
Information is available, day or night, through
Tollfree customer service — representatives
are available to assist you Monday through
Friday, a.m. to7 pam. Eastem time at
1-866-234-8913,
+ Interactive voice response for selfsevic, 24/7
+ OptumkealthBank.com
Youcan:
+ Make contributions to your HSA.
Pay ils online
+ Check curent balance,
+ See how much interest has been pal,
+ Transfer funds.
+ Check ast five (5) account transactions
(deposits and/or withdrawal)
+ Activate the Health Savings Account card
+ Report the card lost or stolen
+ Setorreset password.
+ View frequently asked questions.
+ View monthly statements.
OptumHealthBank..
HSA Balance Annual Perentage Monay Mii
Between Yan cess toFunds Maitenance Monthly Deposit
Ss sn ax
$ 5000 sa ax
10000. 195555 ms Heath vgs cout ad as
21000-54980 os
$5000: $4959 108
51000 im D
AS jt ang taime.
eS) monty mine fe ved bent ae lance neh 500.
van 29 2010 102808
Deductible, Coinsurance, and Monthly Health Savings Account (HSA) Deposit Options
S100" Single
Dee son | ss | sm
wort o 9 9
Gone wre | Manon | uno
Dead eprom ea ios Me o
Veau so sas
det xr
Masia m
per.
en) ann
1400" amy
Dede aso | sm | sm
wart so ® | 9
Grane gos pros eR
des Me | Ve MeO
Yet 250 sm sm
det aru
num m
paar,
ein) ann
Who is responsible for my HSA?
As custodian OptumHealth Bank is responsible or
your HSA funds, OptumHealth Banks deposit are
insured by the Federal Deposit Insurance Corporation
colo,
Please be aware that the money market and mutual
fund investment options are NOT guarantee by
OptumHealth Bank, are NOT FDICinsurd, and may
lose value We encourage you to read the
prospectus of each fund carefully before investing
and seek the advice ofan Investment professional
youtrust
ES
som | 520 | 250 | sm | sm
so | som | sum Son | som
sso | so sn 5560
En]
Indus ed ma bte a at
SO ae 2 andater
RSA amy
mom | so | sso | som | som
so | mom sum som sum
sao | ss Sao sum sa
sn
Indus aed $+ ma bte an abo
SO 0 Wander
You will receive a Health Savings Account card from
OptumHealth Bank shorty after your qualified
‘medical coverage becomes effective. HSA
withdrawals can be made by simply using your
Health Savings Account card at any pointof service
location (such asa doctors office or pharmacy) that
accepts MasterCard” debit cards.
It you prefer you can purchase the qualified health
insurance coverage from Golden Rule and set up your
savings account with another qualified custodian,
an 29 2010 102898
S100" Single
Dee son | ss | sm
wort o 9 9
Gone wre | Manon | uno
Dead eprom ea ios Me o
Veau so sas
det xr
Masia m
per.
en) ann
1400" amy
Dede aso | sm | sm
wart so ® | 9
Grane gos pros eR
des Me | Ve MeO
Yet 250 sm sm
det aru
num m
paar,
ein) ann
Who is responsible for my HSA?
As custodian OptumHealth Bank is responsible or
your HSA funds, OptumHealth Banks deposit are
insured by the Federal Deposit Insurance Corporation
colo,
Please be aware that the money market and mutual
fund investment options are NOT guarantee by
OptumHealth Bank, are NOT FDICinsurd, and may
lose value We encourage you to read the
prospectus of each fund carefully before investing
and seek the advice ofan Investment professional
youtrust
ES
som | 520 | 250 | sm | sm
so | som | sum Son | som
sso | so sn 5560
En]
Indus ed ma bte a at
SO ae 2 andater
RSA amy
mom | so | sso | som | som
so | mom sum som sum
sao | ss Sao sum sa
sn
Indus aed $+ ma bte an abo
SO 0 Wander
You will receive a Health Savings Account card from
OptumHealth Bank shorty after your qualified
‘medical coverage becomes effective. HSA
withdrawals can be made by simply using your
Health Savings Account card at any pointof service
location (such asa doctors office or pharmacy) that
accepts MasterCard” debit cards.
It you prefer you can purchase the qualified health
insurance coverage from Golden Rule and set up your
savings account with another qualified custodian,
an 29 2010 102898
Health Savings Accounts (HSA) — Summary of the Law
Elli — Those coved nde aqui high deduce eth
pan an ct covered y ter heath surance pt nor
al ermorden, and who may
abe chimedasa rendent on ante pesas um
HSA Contrbutlens — 100% dub for graine
Quad MeialWihdrawas — Tee
Interest Earned — xl use for qulficó medal
eee tie
one Wirral, — Ice + 10% paty (und
age Sy ncemetacony erage 6S andor)
Death Disable — Income axe —00 pena
Dedicada pde im ay be ated analyse chang inte Cone Pied Ths or ab soma espa
‘eer ba. os tac abr or ae tao.
Optional Insurance Benefit:
HSA Hospital Indemnity Rider
‘The optional HSA Hospital Indemnity Riders
designed to help protect against major
hospitalization expenses during the early months of
‘coverage while cash accumulates in your savings
account.
‘The HSA Hospital Indemnity Rider provides a lump-
sum cash benefit on the third day of hospital
‘confinement. This money can be used to help pay
our deductible or for any other purpose.
‘The cash benefit amount depends on your deductible
amount and decreases overtime (see table).
‘The optional rider pays once, regardless of the
number of hospitalizations, and there are no benefits
{under this rider if the hospitalization would not have
been covered by the medical coverage. In addition,
‘you only pay the premium amount once.
Note: HSA Hospital Indemnity Riders not available for
plans with 51,250 (single) or $2500 family) deductibles.
‘The rider does not change, waive, or extend any part
‘of the palicy/certifcate other than as set forth above.
Please see the attached brochure for complete details
regarding applicable exclusions and limitations.
Hospital indemnity Rider ash Benefit,
Moth
RA al re rpm dre soe te de
Fuma 109,
Jan29 2010 102808
‘Sngle Benet
sim
son
sus
suso
$S8838É
ES
355
so
Fam Benet
6
2980
am
an
ans
20
ss
sis
5135
sms
ss
a
so
sw
Gi Reason ony
us edndOe
pt MA
Elli — Those coved nde aqui high deduce eth
pan an ct covered y ter heath surance pt nor
al ermorden, and who may
abe chimedasa rendent on ante pesas um
HSA Contrbutlens — 100% dub for graine
Quad MeialWihdrawas — Tee
Interest Earned — xl use for qulficó medal
eee tie
one Wirral, — Ice + 10% paty (und
age Sy ncemetacony erage 6S andor)
Death Disable — Income axe —00 pena
Dedicada pde im ay be ated analyse chang inte Cone Pied Ths or ab soma espa
‘eer ba. os tac abr or ae tao.
Optional Insurance Benefit:
HSA Hospital Indemnity Rider
‘The optional HSA Hospital Indemnity Riders
designed to help protect against major
hospitalization expenses during the early months of
‘coverage while cash accumulates in your savings
account.
‘The HSA Hospital Indemnity Rider provides a lump-
sum cash benefit on the third day of hospital
‘confinement. This money can be used to help pay
our deductible or for any other purpose.
‘The cash benefit amount depends on your deductible
amount and decreases overtime (see table).
‘The optional rider pays once, regardless of the
number of hospitalizations, and there are no benefits
{under this rider if the hospitalization would not have
been covered by the medical coverage. In addition,
‘you only pay the premium amount once.
Note: HSA Hospital Indemnity Riders not available for
plans with 51,250 (single) or $2500 family) deductibles.
‘The rider does not change, waive, or extend any part
‘of the palicy/certifcate other than as set forth above.
Please see the attached brochure for complete details
regarding applicable exclusions and limitations.
Hospital indemnity Rider ash Benefit,
Moth
RA al re rpm dre soe te de
Fuma 109,
Jan29 2010 102808
‘Sngle Benet
sim
son
sus
suso
$S8838É
ES
355
so
Fam Benet
6
2980
am
an
ans
20
ss
sis
5135
sms
ss
a
so
sw
Gi Reason ony
us edndOe
pt MA
High Deductible Plans
With high deductible plans youre keeping more of your money and taking responsibility fr coveing minor or routine
health-care expenses — if hey come up The higher the deductse, the lower your premiums.
Saver 80"is ou lowest premium plan. This pla provides coverage for hospital confinement surgical procedures in e
out of the hospital (ut notin the doctors offi} and the more costly outpatient expenses, such 3 CAT scan and MR
Golden Rules top sling high deductible plan — Plan 100" — pays 100% of covered expenses once you meet your
calendar year deductible, Your benefits are not complicated with muliple copays or coinsurance
+ You choose $3 millon or $5 milion time maximum benefit per covered person,
Plan 100° and Plan 80 include preventive care and child immunizations with no wating period
+ Add optional benefits to increase coverage see Optional Benefits on page 12for detal,
‘Who might benefit most from a High Deductible Plan?
‘Anyone wing to take responsibilty for routine health cave expense in exchange for lower premiums.
+ Anyone seeking lower-cost protection from unexpected accidents and iInesses.
+ Endyretrees needing a bridge to Medicare.
an 292010102808
With high deductible plans youre keeping more of your money and taking responsibility fr coveing minor or routine
health-care expenses — if hey come up The higher the deductse, the lower your premiums.
Saver 80"is ou lowest premium plan. This pla provides coverage for hospital confinement surgical procedures in e
out of the hospital (ut notin the doctors offi} and the more costly outpatient expenses, such 3 CAT scan and MR
Golden Rules top sling high deductible plan — Plan 100" — pays 100% of covered expenses once you meet your
calendar year deductible, Your benefits are not complicated with muliple copays or coinsurance
+ You choose $3 millon or $5 milion time maximum benefit per covered person,
Plan 100° and Plan 80 include preventive care and child immunizations with no wating period
+ Add optional benefits to increase coverage see Optional Benefits on page 12for detal,
‘Who might benefit most from a High Deductible Plan?
‘Anyone wing to take responsibilty for routine health cave expense in exchange for lower premiums.
+ Anyone seeking lower-cost protection from unexpected accidents and iInesses.
+ Endyretrees needing a bridge to Medicare.
an 292010102808
Benefit Highlight Plan 100° Plan 80%
Great es Yup sn an Yup 229 pos SD so,
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CR paros apar para
Corner o som ‘300
pide tc
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tes lr nacen OA Mas pisar aL) (pn het
Pins Us ju
eat — Hogares Hogar apte ele ns
Prima re Ppt ea ind 0 mo w
retin gs
ea and Patient — tot
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3 coca eb) ep pi acera
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ites era ee)
era Msi teen rm soe se pate
bre Pofenalpinekaemataalik Ob nl pinananatacläk
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ci tone Note ee apo 2 te ele exc
baser Nodes pate die exc
re sera]
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Pot anna ape cat ee ap Date ele par rien
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patent pes Bees
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itl pet Sey Noda due Vapor 2 ie Visor ae
Sen st Sen ares taste apo Date ele pr dt
cn
ents atten, Det Nag ee po 2 ate ele Vapor tete
rin Doa Sar je ii
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Speed Dd nn Notes ec apts ele cone
e ps ps
Mena eva Dd pue Hogar ap ele tcs
‘net ps
patent ere Benes
oem ese Crest Option, Nodes date apa te die up ek
Po eo, Pr rs Pra
Bienen een ges Mies
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ns nn "
‘san 292010 102808
Great es Yup sn an Yup 229 pos SD so,
(nampa ec SAR ino SR coo SS ISSO
CR paros apar para
Corner o som ‘300
pide tc
eiii Beet Sn ‘on Sen
(ere Senami Sapin adié Sen gb he nl
Ine Gure fe Ds Don
tes lr nacen OA Mas pisar aL) (pn het
Pins Us ju
eat — Hogares Hogar apte ele ns
Prima re Ppt ea ind 0 mo w
retin gs
ea and Patient — tot
E dette apa tN tes ele Dcdo
3 coca eb) ep pi acera
Dc nt ego
ites era ee)
era Msi teen rm soe se pate
bre Pofenalpinekaemataalik Ob nl pinananatacläk
WlnesPrentneareeefs rating
EJ
ci tone Note ee apo 2 te ele exc
baser Nodes pate die exc
re sera]
me gate ea apte ele nd
Pot anna ape cat ee ap Date ele par rien
Ping note
patent pes Bees
ead necia Note apte te ep tte
Der eta ann ent)
itl pet Sey Noda due Vapor 2 ie Visor ae
Sen st Sen ares taste apo Date ele pr dt
cn
ents atten, Det Nag ee po 2 ate ele Vapor tete
rin Doa Sar je ii
gen ons Ans Vapor Seopa, VO ft, up SOD eta,
AS "hee ctr "sonar dete
gen ms Nag ee ape pa SD Fate,
"subarea
Oberer pet ees Not etc apa 2 te ele up ts dc
Speed Dd nn Notes ec apts ele cone
e ps ps
Mena eva Dd pue Hogar ap ele tcs
‘net ps
patent ere Benes
oem ese Crest Option, Nodes date apa te die up ek
Po eo, Pr rs Pra
Bienen een ges Mies
Oberen Snes Nodes delete apte ele You tte
ns nn "
‘san 292010 102808
Plan Enhancements & Optional Benefits
eirmod
Plan Enhancements
$5 Million Lifetime Maximum.
Topo inte VA,
pase yur otage $5,000 of coe expenses perpen.
24-Month Initial Rate Guarantee
Extend out gurantee to 4 months Des ot appa ent
ads anges.
No Annual Ma)
Drug
Topos ot alte wi Sve 3 o Copay Se
imines the 53000 entre.
um Prescription
$25 Office Visit Copay
Topo ral wth pay See,
Reduce te cost of doar fev copay rom 35 525.
2 Additional Dr. Office
‘Wisin arable with opy Ser.
ne he numberof Dat fice Vas om 10 4er enn er
calendar
sits
Prescription Drug* Copay
option bie ihn aed Pan 0, abe
<embed he No An Manon recto Du Pan
fname
bent you
+ Ter gs — S15 op.
+ Te 24 ro om dete pr pen pe
ery de
— eds on.
ergs — 365 cep.
Ten — Jouy 25 ane
Optional Benefits
Preventive Care
Ts op arabe with Pa 10% Pan 0%, Saver 80% and
(pay Sore ot bei AK,
+ Sopena fie vim are,
EOS
+ Teflowing dans o prevent cre tate promedio
cnc wth te eta ces rex fom the
fect and coran ute permed nte doctors
fier:
Ch underage 19) and at inna
— Mamnogram eval and Pap ses.
— Lina antics es,
— tone denty sees.
Gandara tes
— ktestsand digitale ams
FO agpoved screenings fr HP
+ Cony sae
— 3-monthwatng pt lined
— ts fe tt.
‘Supplemental Accident
Ts tene pies on avenge fr npc jes ans
noyer 5051.00 of fist or ange
treatment ani win 0 san accent Pan dci
stb gtr than equal tothe mana beet ane
Maternity Benefit
Tsun anale vá Pn 100, Pan Sr Conny
Select and apy Soe rl in RM or YA
Total ene helps cor css o ot prepa and
Ge Vu ay 20% pa BR lore senses Ars
benefyeas, he maimum oe pes omo 6750.
he comdespensswilbe consi o inbusenen fra
preg egeing reihe maty en's effete dt.
Benefits. Maximum Covered sprse Maximum Me oy
142 ‘2500 ‘200
(Maximum 3000 mer peer eran) 364 5500 sum
ES 37300 emo
yeu pense name band when gnc late yoy or
enc ple torso hve te ete pe
seemed asses dnd spinnt
2 ‘gen mn he app dager a a
an 292010 102808
eirmod
Plan Enhancements
$5 Million Lifetime Maximum.
Topo inte VA,
pase yur otage $5,000 of coe expenses perpen.
24-Month Initial Rate Guarantee
Extend out gurantee to 4 months Des ot appa ent
ads anges.
No Annual Ma)
Drug
Topos ot alte wi Sve 3 o Copay Se
imines the 53000 entre.
um Prescription
$25 Office Visit Copay
Topo ral wth pay See,
Reduce te cost of doar fev copay rom 35 525.
2 Additional Dr. Office
‘Wisin arable with opy Ser.
ne he numberof Dat fice Vas om 10 4er enn er
calendar
sits
Prescription Drug* Copay
option bie ihn aed Pan 0, abe
<embed he No An Manon recto Du Pan
fname
bent you
+ Ter gs — S15 op.
+ Te 24 ro om dete pr pen pe
ery de
— eds on.
ergs — 365 cep.
Ten — Jouy 25 ane
Optional Benefits
Preventive Care
Ts op arabe with Pa 10% Pan 0%, Saver 80% and
(pay Sore ot bei AK,
+ Sopena fie vim are,
EOS
+ Teflowing dans o prevent cre tate promedio
cnc wth te eta ces rex fom the
fect and coran ute permed nte doctors
fier:
Ch underage 19) and at inna
— Mamnogram eval and Pap ses.
— Lina antics es,
— tone denty sees.
Gandara tes
— ktestsand digitale ams
FO agpoved screenings fr HP
+ Cony sae
— 3-monthwatng pt lined
— ts fe tt.
‘Supplemental Accident
Ts tene pies on avenge fr npc jes ans
noyer 5051.00 of fist or ange
treatment ani win 0 san accent Pan dci
stb gtr than equal tothe mana beet ane
Maternity Benefit
Tsun anale vá Pn 100, Pan Sr Conny
Select and apy Soe rl in RM or YA
Total ene helps cor css o ot prepa and
Ge Vu ay 20% pa BR lore senses Ars
benefyeas, he maimum oe pes omo 6750.
he comdespensswilbe consi o inbusenen fra
preg egeing reihe maty en's effete dt.
Benefits. Maximum Covered sprse Maximum Me oy
142 ‘2500 ‘200
(Maximum 3000 mer peer eran) 364 5500 sum
ES 37300 emo
yeu pense name band when gnc late yoy or
enc ple torso hve te ete pe
seemed asses dnd spinnt
2 ‘gen mn he app dager a a
an 292010 102808
Youve made the decision to help protect our familys health
bbyseeking insurance; should’ you consider helping protect
thelr finado! future too?
Term fe insurance maybe an deal benefit to make sure you
provide or your loved ones future.
Consider your current Francia picture and ask, "Without a
tem life insurance benefit pad to myloved ones upon my
death, would they beable te
Pay forfuneralexpenses?
Pay the mortgage or other debt?
Save forcollege orreire comfortably”
Remember t select this option as you apply forheath
eovenge
san ap a ms
‘Yeamay ae an pl tem sac ee ro ada
pass who. over pesan under tea ln ale our
pese must be age 18 de Tete len expieswhena
once poson mcg.
‘oust on of he bene amounts You may sc fet aus
Forn you pose
Benefit Amounts: 550000,
Sn sısanıo
Ts ee pies 85000 In comageln te eve fan acetal
et you andor our spas yor pause ao covered pean
‘une the apo Yad yar spa mos e age Bre The
cinta eth eet ees when otr psn each age 6
maybe purchase with or without teem ie eet
etry are eg ts ben
eg A AS MAS SAS MES DR
pen y mo ons
Po pee oc sec
UnitedHealthOné*
bbyseeking insurance; should’ you consider helping protect
thelr finado! future too?
Term fe insurance maybe an deal benefit to make sure you
provide or your loved ones future.
Consider your current Francia picture and ask, "Without a
tem life insurance benefit pad to myloved ones upon my
death, would they beable te
Pay forfuneralexpenses?
Pay the mortgage or other debt?
Save forcollege orreire comfortably”
Remember t select this option as you apply forheath
eovenge
san ap a ms
‘Yeamay ae an pl tem sac ee ro ada
pass who. over pesan under tea ln ale our
pese must be age 18 de Tete len expieswhena
once poson mcg.
‘oust on of he bene amounts You may sc fet aus
Forn you pose
Benefit Amounts: 550000,
Sn sısanıo
Ts ee pies 85000 In comageln te eve fan acetal
et you andor our spas yor pause ao covered pean
‘une the apo Yad yar spa mos e age Bre The
cinta eth eet ees when otr psn each age 6
maybe purchase with or without teem ie eet
etry are eg ts ben
eg A AS MAS SAS MES DR
pen y mo ons
Po pee oc sec
UnitedHealthOné*
UnitedHealthOne*
an 29 2010 102098
an 29 2010 102098
Something to Smile About.
Keeping your smile beautiful doesnt have to be
‘expensive. You can now upgrade your health plan
‘with an optional dental benefit that can help keep
you smiling brightly. UnitedHealthcar’s extensive
network of dental care providers can offer you
significant savings.
UnitedHealthcare Dental Benefit
Rider — Two Options to Choose From
UnitedHealthcare Dental Premier™ Benefit
Rider
Best optionif your dentists notin our
network
Visit wwwnyuhcdentalcom/godenule for alist
of dentists
+ Paysmore than Dental Value for care from non-
network dentists
UnitedHealthcare Dental Value™ Benefit
Rider (not availabe in al areas)
+ Best option ifyou use a network dentist.
Vis www myuhcdentalcomvgoldenule fora ist
of dentists
+ Lowest premiums
‘With both of our options, you can take
advantage of:
+ Preventive care covered at 100% with NO
deductible or waiting period.
+ Accessto an extensive network that today has
Over 73,000 dentists!
+ Two options with the flexibility of using in-and
out-ofnetwork dentists
+ ASSOcalendaryear deductible per person
{limited to 3 individual $50 deductibles per
family for Basic Services and Major Services.
Then we pay 80% for Basic Service and 50%
or Major Services:
+ Realendar-year maximum benefit of 51000
per covered person.
"Siemon wating er See creme wat pod
aprte.
Were here to help you.
Use www.myuhedental.com/goldenrule to find a
dentist in your area, access your plan information, see
your claim status find general dental information,
and more. You also can call customer service anytime
toll-free at (866) 877-6187 and speak toa dental
specialist for fast, knowledgeable service.
an 292010 102808
Keeping your smile beautiful doesnt have to be
‘expensive. You can now upgrade your health plan
‘with an optional dental benefit that can help keep
you smiling brightly. UnitedHealthcar’s extensive
network of dental care providers can offer you
significant savings.
UnitedHealthcare Dental Benefit
Rider — Two Options to Choose From
UnitedHealthcare Dental Premier™ Benefit
Rider
Best optionif your dentists notin our
network
Visit wwwnyuhcdentalcom/godenule for alist
of dentists
+ Paysmore than Dental Value for care from non-
network dentists
UnitedHealthcare Dental Value™ Benefit
Rider (not availabe in al areas)
+ Best option ifyou use a network dentist.
Vis www myuhcdentalcomvgoldenule fora ist
of dentists
+ Lowest premiums
‘With both of our options, you can take
advantage of:
+ Preventive care covered at 100% with NO
deductible or waiting period.
+ Accessto an extensive network that today has
Over 73,000 dentists!
+ Two options with the flexibility of using in-and
out-ofnetwork dentists
+ ASSOcalendaryear deductible per person
{limited to 3 individual $50 deductibles per
family for Basic Services and Major Services.
Then we pay 80% for Basic Service and 50%
or Major Services:
+ Realendar-year maximum benefit of 51000
per covered person.
"Siemon wating er See creme wat pod
aprte.
Were here to help you.
Use www.myuhedental.com/goldenrule to find a
dentist in your area, access your plan information, see
your claim status find general dental information,
and more. You also can call customer service anytime
toll-free at (866) 877-6187 and speak toa dental
specialist for fast, knowledgeable service.
an 292010 102808
With Dental Coverage From
UnitedHealthcare — You Have the
Advantage.
With a UnitedHealtheare dental rider, your family has
access to over 73,000 network dentists. The result can
be significant discounts on quality care, and you
never flea claim form. A healthy smile can be easier
than you thought.
UnitedHealthcare Dental Network Savings Examples (as of May 2008)
Dentists
Procedure on cot) etal Charge
[Adal Pros mm $7500
hid Pps sam
[Cia ail ppc te
on) so”
Ana One Su Payot
=."
EL sm
sae Copas Oe u
steers sta
Meta aa en ses
Rell th Sot Tie
om sn
Preventive services have no waiting period and
include routine dental exams, routine Krays,
‘leaning, Nuoride treatment, sealants, and space
Base services have a 6-month wating period and
include dental exams, X-rays, routine extractions,
treatment to ease dental pain, and simple filings.
Major services have a 12-month waiting period and
include treatment for diseases ofthe pulp including
root canals), bone and other tissues supporting the
teeth, crowns, inlays, onlays, veneers, bridges,
dentures, and oral surgery for impactons.
Bath Op etl Premier Dental
ce Outotnetwork —— Outakneork
YouPay Vara Vara
so sam $700
EJ am $500
0 sus son
sum sum sa
$600 son so
$1 som son
950 on som
suso ste 51589
enge isses sondeo ea hes ne ape bereft ete row pes,
ae natch dt ements ante bid cena ug:
ps nat dnt et o stone nwa rea us anterior ae
Mts ter een pd ely aca eo de pa ag mat ea
reg it el al
Jan 292010 102808
UnitedHealthcare — You Have the
Advantage.
With a UnitedHealtheare dental rider, your family has
access to over 73,000 network dentists. The result can
be significant discounts on quality care, and you
never flea claim form. A healthy smile can be easier
than you thought.
UnitedHealthcare Dental Network Savings Examples (as of May 2008)
Dentists
Procedure on cot) etal Charge
[Adal Pros mm $7500
hid Pps sam
[Cia ail ppc te
on) so”
Ana One Su Payot
=."
EL sm
sae Copas Oe u
steers sta
Meta aa en ses
Rell th Sot Tie
om sn
Preventive services have no waiting period and
include routine dental exams, routine Krays,
‘leaning, Nuoride treatment, sealants, and space
Base services have a 6-month wating period and
include dental exams, X-rays, routine extractions,
treatment to ease dental pain, and simple filings.
Major services have a 12-month waiting period and
include treatment for diseases ofthe pulp including
root canals), bone and other tissues supporting the
teeth, crowns, inlays, onlays, veneers, bridges,
dentures, and oral surgery for impactons.
Bath Op etl Premier Dental
ce Outotnetwork —— Outakneork
YouPay Vara Vara
so sam $700
EJ am $500
0 sus son
sum sum sa
$600 son so
$1 som son
950 on som
suso ste 51589
enge isses sondeo ea hes ne ape bereft ete row pes,
ae natch dt ements ante bid cena ug:
ps nat dnt et o stone nwa rea us anterior ae
Mts ter een pd ely aca eo de pa ag mat ea
reg it el al
Jan 292010 102808
‘This brochures only genera outine ofthe coverage provisions is nat an insurance contrac no part of he surance poli
‘find complete coverage detain the pol:
Covered Expenss
Sabet polyps elo dense cod.
+ Oleo: opera
+ Rte ann wo peral
+ Farmer ved pes unr age16- ercer
+ Rasiekys- meper aloja
+ Sing (manga acer
Algen
Ses sel cows teh,
Space mses peste hs pinay ech sae 6.
Rept erating ment et parent
nd me taney Perth pe
+ Retansbandpdpacmison te
+ fuori darts crores pie one roy Spas.
+ alain Meds Bp Fecha
Dainge onl Bern Gt mall ess ost
coe, fot ena Sp ac Sra Bont
Exped ethane and Sajal cin pace
Salas co pertsteseandpemaentinobr sy 36noct,
wage.
eins
+ Prentiss eno valingptad anne ne a
cams mute ay daring fermen sae ange
mia
+ Bassas podia sa
a tai; Maestra paa e
1 Moss 12 meva pad are eme
rss pb (run a an) brenda
port ete os yok ees rs der,
dosage frites
+ Renton dened yapa entes
"otero ca ru Berthe fies
ne crane tendres à
a.
+ Keen chaud artnet muet
+ ent pts apn tes
+ Meme pote ere amas
an
+ Rettom arn thease cfenghymen orage a po ie.
‘omdjesmisirare orseqidtobeina by vas
opresor feia
jeer a nt atasco perrito
tener heed ensure cpt ar
irre xn op
+ etre,
here dtl tech ae der
raro
+ Aetrhoplaleroberbds dues and banesto
‘hos pers prod rude pa
+ Peatom roy ica ham (nero
inane rparpstannaféoy escroto.
1 Age COPs
Vapor.
+ horses aaa dere
2 ek dong el deri socia tea
caiman
+ ek sty Fes dr ram sed
Fear he
+ Akne nnd
Pr moon
+ Metro anges and meme
tame
+ eraser esrb pena
dled.
SON ON URGES MOLES OF RASDMELE D STA
‘Cups ers dnsenäkdasenay enga sem
credo Dei cars ode rem rm
Ing te un Reda gon
Des
Dental aie a as, Bo Stl HUE
Lf Coi vio Pariiping UM Deal rates
ce, Ba, Ben, Chere roy uste, obres Eagle, Bert,
Gin ron Gun Hse Jason, ona, Lt, Miner, Mot,
uray, Pa, Pl iki i Banca Saunt Sn an, Sang,
Segui Tele ua
‘find complete coverage detain the pol:
Covered Expenss
Sabet polyps elo dense cod.
+ Oleo: opera
+ Rte ann wo peral
+ Farmer ved pes unr age16- ercer
+ Rasiekys- meper aloja
+ Sing (manga acer
Algen
Ses sel cows teh,
Space mses peste hs pinay ech sae 6.
Rept erating ment et parent
nd me taney Perth pe
+ Retansbandpdpacmison te
+ fuori darts crores pie one roy Spas.
+ alain Meds Bp Fecha
Dainge onl Bern Gt mall ess ost
coe, fot ena Sp ac Sra Bont
Exped ethane and Sajal cin pace
Salas co pertsteseandpemaentinobr sy 36noct,
wage.
eins
+ Prentiss eno valingptad anne ne a
cams mute ay daring fermen sae ange
mia
+ Bassas podia sa
a tai; Maestra paa e
1 Moss 12 meva pad are eme
rss pb (run a an) brenda
port ete os yok ees rs der,
dosage frites
+ Renton dened yapa entes
"otero ca ru Berthe fies
ne crane tendres à
a.
+ Keen chaud artnet muet
+ ent pts apn tes
+ Meme pote ere amas
an
+ Rettom arn thease cfenghymen orage a po ie.
‘omdjesmisirare orseqidtobeina by vas
opresor feia
jeer a nt atasco perrito
tener heed ensure cpt ar
irre xn op
+ etre,
here dtl tech ae der
raro
+ Aetrhoplaleroberbds dues and banesto
‘hos pers prod rude pa
+ Peatom roy ica ham (nero
inane rparpstannaféoy escroto.
1 Age COPs
Vapor.
+ horses aaa dere
2 ek dong el deri socia tea
caiman
+ ek sty Fes dr ram sed
Fear he
+ Akne nnd
Pr moon
+ Metro anges and meme
tame
+ eraser esrb pena
dled.
SON ON URGES MOLES OF RASDMELE D STA
‘Cups ers dnsenäkdasenay enga sem
credo Dei cars ode rem rm
Ing te un Reda gon
Des
Dental aie a as, Bo Stl HUE
Lf Coi vio Pariiping UM Deal rates
ce, Ba, Ben, Chere roy uste, obres Eagle, Bert,
Gin ron Gun Hse Jason, ona, Lt, Miner, Mot,
uray, Pa, Pl iki i Banca Saunt Sn an, Sang,
Segui Tele ua
Keep an eye on your familys vision health by adding our
optional Vision Benefit rider to your health plan today. Our
extensive vision care networkincludes 24000 private
Practice and retail chain providers” Well help keep your
You may use a non network provider, but by saying
Imnetwork you are eligible to receive better discounts:
family seeing dearly, so you can focus on savings! + Eye exam — $10 copay ~once every 12 months.
Were here to help you. + Frames — $25 copay - once every 24 months.
Use www myuhcvsion.com/goldenrle1o find a provider + Lenses— $25 copay - once every 12 months.
in your area, access your plan information, see your lim + Contacts leu of glasses — $25 copay - once
status find general vision information, and more. ‘every 12 months
See how you can save by using our Vision network
Inner Ingato Outatretot
ServieMatial VouPay WePay Wera
Becumenceery mts § Mapa 10% ths 40
FamesonecieyZUmnts SIS or thos 45
Sie soa ees $ Bay 10% tows 40
alles $ Ban 10% [RT
‘Wc eta eses $ cp 10% thos 90
Cnacsin evo ses $ ap os Uptosas
etalon dns ean ha dr pee
"ame dos fe he ne Sci oP rn cin un, eta man SO
DO. ee Nap th tn ae
‘rns
el a nt nn poe nn ye oro a
rm a evan ar pe wir sree er.
Pts
ERGO Aer ma tes moe lp
aa te UnitedHealtiÜne”
optional Vision Benefit rider to your health plan today. Our
extensive vision care networkincludes 24000 private
Practice and retail chain providers” Well help keep your
You may use a non network provider, but by saying
Imnetwork you are eligible to receive better discounts:
family seeing dearly, so you can focus on savings! + Eye exam — $10 copay ~once every 12 months.
Were here to help you. + Frames — $25 copay - once every 24 months.
Use www myuhcvsion.com/goldenrle1o find a provider + Lenses— $25 copay - once every 12 months.
in your area, access your plan information, see your lim + Contacts leu of glasses — $25 copay - once
status find general vision information, and more. ‘every 12 months
See how you can save by using our Vision network
Inner Ingato Outatretot
ServieMatial VouPay WePay Wera
Becumenceery mts § Mapa 10% ths 40
FamesonecieyZUmnts SIS or thos 45
Sie soa ees $ Bay 10% tows 40
alles $ Ban 10% [RT
‘Wc eta eses $ cp 10% thos 90
Cnacsin evo ses $ ap os Uptosas
etalon dns ean ha dr pee
"ame dos fe he ne Sci oP rn cin un, eta man SO
DO. ee Nap th tn ae
‘rns
el a nt nn poe nn ye oro a
rm a evan ar pe wir sree er.
Pts
ERGO Aer ma tes moe lp
aa te UnitedHealtiÜne”
Covered Expenses
Satta ply ns the loin on expense cored:
+ Comprhens je caminos Bnftsar midi 1 sam per
ment.
1 Projet Boer m purpose
sbalsesper 12 mamisand 1 parol famesper Amos:
~ Spctadesesas ad by anophtmeog oropomes
‘ames andthe feng ndstsequen asen o mir
confetanleeny.or
~ Becivecerta nes taria ol pci peda ese,
æfamesand
1 May say ttes a pfs eves on
prsabedord loin carat suey orto coe estem
laut pis at omar once pee tes
Pas oe This bent progam designed cora ion ester
than mes Cosmetica duende ses ei eses
photonics dlrs ep ink a 2 progres mul
Less ing fes rs ing fans res, famosa
«cstmor thanthe pln alone, comets pio mec
processes and (tar) rote ens.
your coved dependents cosmetic ete an ly te
metal necesary cess ofthe alowedleesand your euros
dependent eresporie fatal cso he comet et
Definitions
+ Comprehensive eye examination mers an omiten yan
imag repone to teinte heal of tee
ing acom ts andrefache examinations tomes hee
Forcoecielens
+ Medical necessary mars comprende camion r
respon year cesa and appt dem e
heathothe orcamt uy Ts eterna idee y
bed nou atom an apporte kersedopimaget
ropas amp ee aan psi year
lt costed cy esa tE peas
eine te coemdpenanor ra (notario
‘ecard per dogs compos (One,
Arne) til Hand oie fe,
“equ and poa dass rame othe corps.
+ Vion benefit refered provider san gitano o
opter whohas coded with the son beneftneworandis
lensed and chs led t pac von cae andre
sin mots
+ Valon benefit non prefered providers opto,
prometi pica, rt Kesedand qe on cre prior
hat tac even bereft toca perio
rer and once mae,
das Painting en Pis ruleta Da,
Ben, Cheyenne are, Cons sta, Come, uste, Does, lin,
Gand Gris Hse Horn Jason Fos, Cr Lal,
Mira Mol ua Pr, Pin Ro Gade, Rot, aqua Sn ua,
Sn Migue Sedgwick Summit Tels Wishing, anda.
How the Vision Program Works
pment deduce avr andre may df when sens ae
ended aba hy hy
A sn bene prefered pr or
Bite pre poet,
‘Wehiveacotactha vn bent et Von beef pare
oes ape dau tree es Yoo ae med depends
aya pola copayment, Ses aroun aire Von
‘eft prefered prestan age to act bene amenas
payment covered pers.
Meta rc wh en bene on gfe pres You
our coved dependent mus aan sabe payment deduce
“materna Aer action lp copayments deducible
manten bees aint up tothe apie alone
man
het amount al chape cash alone amour he son
‘net no etw pies may BI yon yu cd peer the
Exclusions and Limitations:
Noeneftsare paler along an expenses:
+ Onhop rin ep wing andan ascaespaemena
teng
none (alert psp on):
2 Bphrement essa frames fund under hi lan wh ae
lastre except omiten when serves are rise
alt
+ Messi retmenot e ges
+ Any je ara ray corel covered y anemplogr
sand employment;
+ Goethe ametofan opeimentar mes our:
+ Come rare such. butt ited Rada
roy a Prato rave Katey (PA;
+ Be contes E pescipon padel andfames a
eher Taman ped;
+ Presptonspetae ses andas dete cont essa
ren any tmnt peed
+ Bywmarexept pesatin ent
res hates talon and
+ Secs reten atar ld exuded the General xs
anda etn cf te cert chy,
Discounts on Laser Eye Surgery
Analice wi tease Vin Neo mc allows cur pees
ces tosubstantl cos ere sage proces om
publ provides tech US.
ases same pense,
Satta ply ns the loin on expense cored:
+ Comprhens je caminos Bnftsar midi 1 sam per
ment.
1 Projet Boer m purpose
sbalsesper 12 mamisand 1 parol famesper Amos:
~ Spctadesesas ad by anophtmeog oropomes
‘ames andthe feng ndstsequen asen o mir
confetanleeny.or
~ Becivecerta nes taria ol pci peda ese,
æfamesand
1 May say ttes a pfs eves on
prsabedord loin carat suey orto coe estem
laut pis at omar once pee tes
Pas oe This bent progam designed cora ion ester
than mes Cosmetica duende ses ei eses
photonics dlrs ep ink a 2 progres mul
Less ing fes rs ing fans res, famosa
«cstmor thanthe pln alone, comets pio mec
processes and (tar) rote ens.
your coved dependents cosmetic ete an ly te
metal necesary cess ofthe alowedleesand your euros
dependent eresporie fatal cso he comet et
Definitions
+ Comprehensive eye examination mers an omiten yan
imag repone to teinte heal of tee
ing acom ts andrefache examinations tomes hee
Forcoecielens
+ Medical necessary mars comprende camion r
respon year cesa and appt dem e
heathothe orcamt uy Ts eterna idee y
bed nou atom an apporte kersedopimaget
ropas amp ee aan psi year
lt costed cy esa tE peas
eine te coemdpenanor ra (notario
‘ecard per dogs compos (One,
Arne) til Hand oie fe,
“equ and poa dass rame othe corps.
+ Vion benefit refered provider san gitano o
opter whohas coded with the son beneftneworandis
lensed and chs led t pac von cae andre
sin mots
+ Valon benefit non prefered providers opto,
prometi pica, rt Kesedand qe on cre prior
hat tac even bereft toca perio
rer and once mae,
das Painting en Pis ruleta Da,
Ben, Cheyenne are, Cons sta, Come, uste, Does, lin,
Gand Gris Hse Horn Jason Fos, Cr Lal,
Mira Mol ua Pr, Pin Ro Gade, Rot, aqua Sn ua,
Sn Migue Sedgwick Summit Tels Wishing, anda.
How the Vision Program Works
pment deduce avr andre may df when sens ae
ended aba hy hy
A sn bene prefered pr or
Bite pre poet,
‘Wehiveacotactha vn bent et Von beef pare
oes ape dau tree es Yoo ae med depends
aya pola copayment, Ses aroun aire Von
‘eft prefered prestan age to act bene amenas
payment covered pers.
Meta rc wh en bene on gfe pres You
our coved dependent mus aan sabe payment deduce
“materna Aer action lp copayments deducible
manten bees aint up tothe apie alone
man
het amount al chape cash alone amour he son
‘net no etw pies may BI yon yu cd peer the
Exclusions and Limitations:
Noeneftsare paler along an expenses:
+ Onhop rin ep wing andan ascaespaemena
teng
none (alert psp on):
2 Bphrement essa frames fund under hi lan wh ae
lastre except omiten when serves are rise
alt
+ Messi retmenot e ges
+ Any je ara ray corel covered y anemplogr
sand employment;
+ Goethe ametofan opeimentar mes our:
+ Come rare such. butt ited Rada
roy a Prato rave Katey (PA;
+ Be contes E pescipon padel andfames a
eher Taman ped;
+ Presptonspetae ses andas dete cont essa
ren any tmnt peed
+ Bywmarexept pesatin ent
res hates talon and
+ Secs reten atar ld exuded the General xs
anda etn cf te cert chy,
Discounts on Laser Eye Surgery
Analice wi tease Vin Neo mc allows cur pees
ces tosubstantl cos ere sage proces om
publ provides tech US.
ases same pense,
Covered Expenses
ie a oly :
Copay Select™, HSA 100°, HSA 70%, Plan 100°, and Plan 80°
Tobe and frenbinement expenses mus qty as ren penes Epes ae bo sabes sont ná tomar iis es
ou network pve We recomentar detal plano on pges15-1Band the sat vaca pages 192.
Medical Expense Bent
+ ay spa om and a mung serves the mot
conmen seni te.
+ Qargestrinenive are it
+ Hospital emerge com resent anna oes
(bjt tan ado 5100 copay exh tie hemergengy
‘oom suse fo aniesotreingin cient — oes
ota OSA Par
+ Services and spl, nung gs and mens, wih ae
‘eel pie bythe hosp topes re hey
areipaiens.
+ tsa es of docs and uo (unt fr sandy
sb
+ Dresng stes str oterncesany medal supe.
reson es or up ses oes pal
op.
Dagastictesing ig aden vrasomgaphi or
bar ses or ut the espa
Local mae service tothe eres hos o
roces enegeng cr Alambre, vin US.
request y ple mesial auhoriiesathestect
eng.
+ Garg tor opting, men, rece wom fos.
+ Dettepeses de any ic damage ta teeth it
‘expenses ae lcd within te mont
+ Suga weament TH sore setas on page 1)
+ stand rise festes open, and other gs.
+ Raton heaprer chema
+ Pesci ds
+ Hemodas, procesa administration fond and
compren,
+ Mammogaph, ap sen and SA estes
+ Afi yes yo, eas prose, or a ar ts
but ot cone,
Surya dat fer at an pate sia fay,
nding series ad supp.
+ Octal tay owing covered amet fortune
andi
+ eh ná extended cae ity serves hat eg
iho sf 3. or mee ost say ferthesame
"sory. Combined lend ye mim 60 dy o
‘th eatin ad tene cuac expres
Preventive Care Expense Benefits
Tr mon wating per wes beet ota let
an nan.
(Pan 10 ana jee pale ec am
nd ance pena py See HSA 10 nd A
‘Sempron ny pla fie nou}
Conte pense are expanded to nde chagestrtheolowng
henincaredfor prete are:
+ Rosie fe ts cig we bby
+ Giloodimmaniates ruche hunde yeast
ae
+ Was anio et.
+ one deity sarna.
+ Becton E
+ Garesteste.
Teflon ar ot sitet toe tre month wating poe:
+ Mannogaphy sens.
+ evil snes and pap ses.
+ reste sprl amiens and ign eal rotos.
reventar pese Benefit nde ando bees wi
be pa for computes a tography (A rT sr, magnetic
rence imaging (A) or pston enon map (PE a)
toed on aie pevenve bs.
Seepage. 9nd for coeage des.
Formationen ations lan pve inci asp
pense ent, ited Exc for ADS or led Disease,
Nation quemen, Pressing Condos, Genel Exhsos,
General ination, and ther Pan Pros ead pages 1-18.
‘pil destin home ams eran de.
an 292010102808
ie a oly :
Copay Select™, HSA 100°, HSA 70%, Plan 100°, and Plan 80°
Tobe and frenbinement expenses mus qty as ren penes Epes ae bo sabes sont ná tomar iis es
ou network pve We recomentar detal plano on pges15-1Band the sat vaca pages 192.
Medical Expense Bent
+ ay spa om and a mung serves the mot
conmen seni te.
+ Qargestrinenive are it
+ Hospital emerge com resent anna oes
(bjt tan ado 5100 copay exh tie hemergengy
‘oom suse fo aniesotreingin cient — oes
ota OSA Par
+ Services and spl, nung gs and mens, wih ae
‘eel pie bythe hosp topes re hey
areipaiens.
+ tsa es of docs and uo (unt fr sandy
sb
+ Dresng stes str oterncesany medal supe.
reson es or up ses oes pal
op.
Dagastictesing ig aden vrasomgaphi or
bar ses or ut the espa
Local mae service tothe eres hos o
roces enegeng cr Alambre, vin US.
request y ple mesial auhoriiesathestect
eng.
+ Garg tor opting, men, rece wom fos.
+ Dettepeses de any ic damage ta teeth it
‘expenses ae lcd within te mont
+ Suga weament TH sore setas on page 1)
+ stand rise festes open, and other gs.
+ Raton heaprer chema
+ Pesci ds
+ Hemodas, procesa administration fond and
compren,
+ Mammogaph, ap sen and SA estes
+ Afi yes yo, eas prose, or a ar ts
but ot cone,
Surya dat fer at an pate sia fay,
nding series ad supp.
+ Octal tay owing covered amet fortune
andi
+ eh ná extended cae ity serves hat eg
iho sf 3. or mee ost say ferthesame
"sory. Combined lend ye mim 60 dy o
‘th eatin ad tene cuac expres
Preventive Care Expense Benefits
Tr mon wating per wes beet ota let
an nan.
(Pan 10 ana jee pale ec am
nd ance pena py See HSA 10 nd A
‘Sempron ny pla fie nou}
Conte pense are expanded to nde chagestrtheolowng
henincaredfor prete are:
+ Rosie fe ts cig we bby
+ Giloodimmaniates ruche hunde yeast
ae
+ Was anio et.
+ one deity sarna.
+ Becton E
+ Garesteste.
Teflon ar ot sitet toe tre month wating poe:
+ Mannogaphy sens.
+ evil snes and pap ses.
+ reste sprl amiens and ign eal rotos.
reventar pese Benefit nde ando bees wi
be pa for computes a tography (A rT sr, magnetic
rence imaging (A) or pston enon map (PE a)
toed on aie pevenve bs.
Seepage. 9nd for coeage des.
Formationen ations lan pve inci asp
pense ent, ited Exc for ADS or led Disease,
Nation quemen, Pressing Condos, Genel Exhsos,
General ination, and ther Pan Pros ead pages 1-18.
‘pil destin home ams eran de.
an 292010102808
Covered Expenses (continued)
Saver Plans — Copay Saver and Saver 80
Tobe considered forrenbunement expenses mus qua as ce pere Esprss a so saeco sont nd tomar nis les
ou network prove, We recomendo te mare detal pln information on pages 15-108 the sate ans nage 192
Inpatient Expense Benefits
Daly hs? rom and oan musing sericea the mat
conmen emit.
+ Gags forinenive re ait
+ rags, meine esis, tus ss oriherneesany
medal ppt,
+ Aral ns, ee lay o breast uta
relent
+ ots es of dots and surgeons (ut nt for stay
Pe
+ Henodss peces. and administration of oad or
‘compen,
2 Gps fran operating, etme or recone mon fr
sae.
+ Cstand ministre ofan are onen or ote gases.
+ Radio teayor remata, and gps tt
"Adal sega or abras.
+ around am serve e esos o
ees emerge) ae ambiance, ti US.
request y alce mesial authors at these athe
eng
Outpatient Expense Benef
+ ages for pan rey an ua ugly,
ding be fee fo the primar gone sant
Surgen, ande sii anesthe Gage peed
ie docs snot creed.
1 Head, raten and cemotheapy.
+ resp gs topa agaist orn etn in ana
+ Marnogaph, op sme and SA testes,
+ spa mery oom resent anny oes
(otto man sh on pages 7 08 1.
+ Ascanand Mi tesi.
+ Dips singt, nd permed vii Mayr
{0 sage ornate cafe,
+ Copay Save plan inde te docto oe copay its per
eon per ere page.
+ Copy Sr pains coa or gn precip
rags se page
Important note about Saver Plans:
Penis or Ste las arias bese coverage sat
oie for ost patentes Opt expenses
‘peal stein he plo are not od Pease eee Saree
Fr Ipatenta Outpatient Expense Benefits. Fr infomation on
‘onl plan pios ding splat pense Beet,
ation Requtenen essing Condens, mite rn.
for MSc Heed Des, ener xin, Geer
Units ad Oe Pan Pros, ed pags 1:8
Some espese at coed unde the Sens node
+ Outpatient otr ice ves ie ent provided under
Copy Save — se age grs testing, piton
agote tencia pried under Copy Save — se page
‘hand ater patent msi serves note ay ied
ns the paie, Outpatient Tas Expense Benes:
+ Outpatient pfs es fee pial heaps,
(unbe medkaleqspment and medal sips, ects
‘ved under te Home Heth re peas Benet
+ apess inured for menalernences dorer
+ Presenter af is ules the option Peeve Cre
beef sad): an
+ Outpatient expenses fra un promedina dors
fe,
gl arg om mahnt nd
an 292010102808
Saver Plans — Copay Saver and Saver 80
Tobe considered forrenbunement expenses mus qua as ce pere Esprss a so saeco sont nd tomar nis les
ou network prove, We recomendo te mare detal pln information on pages 15-108 the sate ans nage 192
Inpatient Expense Benefits
Daly hs? rom and oan musing sericea the mat
conmen emit.
+ Gags forinenive re ait
+ rags, meine esis, tus ss oriherneesany
medal ppt,
+ Aral ns, ee lay o breast uta
relent
+ ots es of dots and surgeons (ut nt for stay
Pe
+ Henodss peces. and administration of oad or
‘compen,
2 Gps fran operating, etme or recone mon fr
sae.
+ Cstand ministre ofan are onen or ote gases.
+ Radio teayor remata, and gps tt
"Adal sega or abras.
+ around am serve e esos o
ees emerge) ae ambiance, ti US.
request y alce mesial authors at these athe
eng
Outpatient Expense Benef
+ ages for pan rey an ua ugly,
ding be fee fo the primar gone sant
Surgen, ande sii anesthe Gage peed
ie docs snot creed.
1 Head, raten and cemotheapy.
+ resp gs topa agaist orn etn in ana
+ Marnogaph, op sme and SA testes,
+ spa mery oom resent anny oes
(otto man sh on pages 7 08 1.
+ Ascanand Mi tesi.
+ Dips singt, nd permed vii Mayr
{0 sage ornate cafe,
+ Copay Save plan inde te docto oe copay its per
eon per ere page.
+ Copy Sr pains coa or gn precip
rags se page
Important note about Saver Plans:
Penis or Ste las arias bese coverage sat
oie for ost patentes Opt expenses
‘peal stein he plo are not od Pease eee Saree
Fr Ipatenta Outpatient Expense Benefits. Fr infomation on
‘onl plan pios ding splat pense Beet,
ation Requtenen essing Condens, mite rn.
for MSc Heed Des, ener xin, Geer
Units ad Oe Pan Pros, ed pags 1:8
Some espese at coed unde the Sens node
+ Outpatient otr ice ves ie ent provided under
Copy Save — se age grs testing, piton
agote tencia pried under Copy Save — se page
‘hand ater patent msi serves note ay ied
ns the paie, Outpatient Tas Expense Benes:
+ Outpatient pfs es fee pial heaps,
(unbe medkaleqspment and medal sips, ects
‘ved under te Home Heth re peas Benet
+ apess inured for menalernences dorer
+ Presenter af is ules the option Peeve Cre
beef sad): an
+ Outpatient expenses fra un promedina dors
fe,
gl arg om mahnt nd
an 292010102808
Provisions That Apply to All Plans
Transplant Expense Benefit
Thefotowing pect wasps are lg orage under
thee Benes pin:
Comes tanins rey orn ga, erate gas, and
rosette eae, nig econ
Enga prices conecten wth tract.
nant iio coverage under he Tampa pense
efter
ero beat an unge. et. a bone mow
tents.
Glen Au ts rango era hop ronde ty
(ero aser Ce Excellence pero ehe
armes yon anf ues oxen the
Spx aslo wb cn same am ares.
Swine ano ná long cera fay
rene fut $500. Obere, ecu fr de gun
ca one mano wänotbe corel, nd ned esprses esto
{he vara ibe its 100000 fn apa na
io pd,
Togualyas cord expense under he Tap Epes eit,
the coed prion mus bea good and andıhe pat as
tet be experiment resarcir these ses we
Cors co ere he yet arnt pepe.
falo cotos ehe forbane mar transpant
mag:
Age ane man ans BMT reste opi
lymphoma rn og prom, sr paie
Amp and nn mao sena nc memes
eaten se combines Sage ot”
elos meas some Wir Arch stone,
lem map maple melo, Fancansanea malgunt
sad an men money le
Algo an mao rss (AB or men:
Hans mgnom, or Hans mphuna aut moho
and neto kei mip pena, esr nce,
StgeteWVnewoistoms, ea ving’ soma an to
mie octo unas, Wns Tumor abaya,
Tram soma, ad gam.
Yo must rails by phone nr before the dy corre pes:
+ esis te oath ay aan ina hostal; or
+ evalu fran ran or ve transplant,
Fr compl with Notification Requirements wil est in2 20%
‘eduction In bei, omas 1.200,
Pimp fr tone set mese patent
esp sd Jo mast contac sas soos eon
psa,
Our rt oes ot guantes ie payment of
bets the aroun feet Cpl fad payment of
beeisaresuje ol tems and mins le pol Yes may
ntact olen ae for fr reve mager ae.
sevice dene due, a emite
Preexisting Conditions
Feet tons voten theft mt
ate vides need pean Misco wit
pi o ts hat ea lo al en
einai ot xao ner
etes.
A pressing non san nary rss wih cod
evn cecoed mi cer este ith ment pre
Val aie dr coverage ns la or
ei mante slo wh wae ort isn
eran ose azi reine wih 1 mans te
Sopa eerie nee reg td nes ty.
Limited Exclusion for AIDS or HIV-
Related Disease
ADS esa ss rete he same any ote es
‘as the onset ADS or HV eed seis) aged efe
"Decora hasbeen face rene er (fist molested
free coverage haben info oe yen agde fst
antested efor age haben for fr enya ADS HV.
fede dias dans wi ee be covered Det es ed
sin set fer plan ceca
an 292010102808
Transplant Expense Benefit
Thefotowing pect wasps are lg orage under
thee Benes pin:
Comes tanins rey orn ga, erate gas, and
rosette eae, nig econ
Enga prices conecten wth tract.
nant iio coverage under he Tampa pense
efter
ero beat an unge. et. a bone mow
tents.
Glen Au ts rango era hop ronde ty
(ero aser Ce Excellence pero ehe
armes yon anf ues oxen the
Spx aslo wb cn same am ares.
Swine ano ná long cera fay
rene fut $500. Obere, ecu fr de gun
ca one mano wänotbe corel, nd ned esprses esto
{he vara ibe its 100000 fn apa na
io pd,
Togualyas cord expense under he Tap Epes eit,
the coed prion mus bea good and andıhe pat as
tet be experiment resarcir these ses we
Cors co ere he yet arnt pepe.
falo cotos ehe forbane mar transpant
mag:
Age ane man ans BMT reste opi
lymphoma rn og prom, sr paie
Amp and nn mao sena nc memes
eaten se combines Sage ot”
elos meas some Wir Arch stone,
lem map maple melo, Fancansanea malgunt
sad an men money le
Algo an mao rss (AB or men:
Hans mgnom, or Hans mphuna aut moho
and neto kei mip pena, esr nce,
StgeteWVnewoistoms, ea ving’ soma an to
mie octo unas, Wns Tumor abaya,
Tram soma, ad gam.
Yo must rails by phone nr before the dy corre pes:
+ esis te oath ay aan ina hostal; or
+ evalu fran ran or ve transplant,
Fr compl with Notification Requirements wil est in2 20%
‘eduction In bei, omas 1.200,
Pimp fr tone set mese patent
esp sd Jo mast contac sas soos eon
psa,
Our rt oes ot guantes ie payment of
bets the aroun feet Cpl fad payment of
beeisaresuje ol tems and mins le pol Yes may
ntact olen ae for fr reve mager ae.
sevice dene due, a emite
Preexisting Conditions
Feet tons voten theft mt
ate vides need pean Misco wit
pi o ts hat ea lo al en
einai ot xao ner
etes.
A pressing non san nary rss wih cod
evn cecoed mi cer este ith ment pre
Val aie dr coverage ns la or
ei mante slo wh wae ort isn
eran ose azi reine wih 1 mans te
Sopa eerie nee reg td nes ty.
Limited Exclusion for AIDS or HIV-
Related Disease
ADS esa ss rete he same any ote es
‘as the onset ADS or HV eed seis) aged efe
"Decora hasbeen face rene er (fist molested
free coverage haben info oe yen agde fst
antested efor age haben for fr enya ADS HV.
fede dias dans wi ee be covered Det es ed
sin set fer plan ceca
an 292010102808
Provisions That Apply to All Plans (continued)
General Exclusions
oem ar pate for expenses wich
+ re eto pegan except fo cmplcns of regar
rose neva ce ls penal org td
ral
re ruine presente are uns reine
pag.
+ re ince wile cone primary fra, habitat,
educar remises.
+ Result rom rin he cose employment o age orp if
‘the cone persona rs egret bese by
eres compensation insurance puta apple state
federal yo ee m serment ars acer
persons rear tre mesa Benes under wore”
‘onpesatonlaw irn hs en wl tap
+ Ar inl, orina juni with, station
+ or dental expenses or sage, ess conse
‘ection being aso any examination ortiga
thee
+ Ar formen fhe ps nudges
‘eduction rages.
einer cometio sehen, sc a wiht
man er sua tent cb,
+ Mod not haven darge he absence.
+ forest crecio rss o
‘stigmas,
su om wat enol sfc am wheter
sneer insane) e paria à ony wheter ot
aged
‘efor weamentfenperorandua oe sade xcept
say be oie founder coved expenses.
+ Nene rial human ran tsps, il er
malo, roce of rar ofthe oa
ose the ose à dona lv,
+ reiner mariage, ey rc cosa.
+ roro oa py bitten,
+ rence seis performed animes my
mente,
+ resp rover inthe pally orice whe
os rates atin foe
refran drag teste x procedure that prams
concepto,
reframe hat presents conception obit
fs em scan a defi y ppal state Lai the
state where fhe nes or cure run teen
ilegal artis cooled uns ules administered
es pesed ya coe
refor eo soga pre
refor ated to teament o ype eee
seo.
eter fe eboney
Aloma esten, pts spel ened as
covered expenses unde te polera nc:
esper aan, some pot, mage
‘tea lg. enter forms of aerate tement as
derby te fl of Amate Meine the Naor
Insts
ees wl ot be pa frere er pli tte nt meda
cetro the digress temen fan ne ras
ad nte poly
General Limitations
+ Esperss cure covered osnorreatment oo,
desis, mide ex disorder, eri er, on
andes le reece vgs ae not cone eg the
‘ved pro's frat sr mont fora der he pl
Wis ria wl ot apy sms proved onan
“emegeno as. Tmegengy means a medal conden
mann by ae gs sympt that ced
even esa lacio ess Min ange
necios re within hours.
+ Cord egeses lot dde moe thn what as
mind be the resteabe and stay ge fora
Peer
+ spas cio aveage under ih Tarp pense
Beta ed two wasps ina 1 ea ti
+ Cages fan asian surgeon eid 20% he
inary geo core ee
Card senses fo sul ameno xd tooth
tacos aretes 10000 per corps.
+ Asagnsesorteamens mental borders deis nthe
Pl nado substance use, ae ited 1a eine
‘manu benefit of 3.00 pt corten aver Pan sitet
0 tae ans Covered expenses rotpaten ago
‘watt mentales re teed 50 pe it,
Asian teres ran natin areas mary
For duc rehablatr cr ot med.
General Exclusions
oem ar pate for expenses wich
+ re eto pegan except fo cmplcns of regar
rose neva ce ls penal org td
ral
re ruine presente are uns reine
pag.
+ re ince wile cone primary fra, habitat,
educar remises.
+ Result rom rin he cose employment o age orp if
‘the cone persona rs egret bese by
eres compensation insurance puta apple state
federal yo ee m serment ars acer
persons rear tre mesa Benes under wore”
‘onpesatonlaw irn hs en wl tap
+ Ar inl, orina juni with, station
+ or dental expenses or sage, ess conse
‘ection being aso any examination ortiga
thee
+ Ar formen fhe ps nudges
‘eduction rages.
einer cometio sehen, sc a wiht
man er sua tent cb,
+ Mod not haven darge he absence.
+ forest crecio rss o
‘stigmas,
su om wat enol sfc am wheter
sneer insane) e paria à ony wheter ot
aged
‘efor weamentfenperorandua oe sade xcept
say be oie founder coved expenses.
+ Nene rial human ran tsps, il er
malo, roce of rar ofthe oa
ose the ose à dona lv,
+ reiner mariage, ey rc cosa.
+ roro oa py bitten,
+ rence seis performed animes my
mente,
+ resp rover inthe pally orice whe
os rates atin foe
refran drag teste x procedure that prams
concepto,
reframe hat presents conception obit
fs em scan a defi y ppal state Lai the
state where fhe nes or cure run teen
ilegal artis cooled uns ules administered
es pesed ya coe
refor eo soga pre
refor ated to teament o ype eee
seo.
eter fe eboney
Aloma esten, pts spel ened as
covered expenses unde te polera nc:
esper aan, some pot, mage
‘tea lg. enter forms of aerate tement as
derby te fl of Amate Meine the Naor
Insts
ees wl ot be pa frere er pli tte nt meda
cetro the digress temen fan ne ras
ad nte poly
General Limitations
+ Esperss cure covered osnorreatment oo,
desis, mide ex disorder, eri er, on
andes le reece vgs ae not cone eg the
‘ved pro's frat sr mont fora der he pl
Wis ria wl ot apy sms proved onan
“emegeno as. Tmegengy means a medal conden
mann by ae gs sympt that ced
even esa lacio ess Min ange
necios re within hours.
+ Cord egeses lot dde moe thn what as
mind be the resteabe and stay ge fora
Peer
+ spas cio aveage under ih Tarp pense
Beta ed two wasps ina 1 ea ti
+ Cages fan asian surgeon eid 20% he
inary geo core ee
Card senses fo sul ameno xd tooth
tacos aretes 10000 per corps.
+ Asagnsesorteamens mental borders deis nthe
Pl nado substance use, ae ited 1a eine
‘manu benefit of 3.00 pt corten aver Pan sitet
0 tae ans Covered expenses rotpaten ago
‘watt mentales re teed 50 pe it,
Asian teres ran natin areas mary
For duc rehablatr cr ot med.
Provisions That Apply to All Plans (continued)
+ Cord up penses int Gagnon treatment of
amy spine bak sores ae imite 0 maumum 12.000
pele yer A an ar Mess a ot et hs
Titan.
+ Cored exgeses ardt no mare than 34 dy ssl lor
am or opt preston dug re rtf.
Effective Date
Foci, eee dt ora male platon le he ate
o) requested five dt. Fany shown nh ah
(the date upon wich he gal aplican actualy eed y
Gade fle
Foran appa sent any electoncmetot nding the
tive ate fries wether of) he eased
effete ate fay town the apps o) e de aferthe
«te pon ihe plans tay eee y Glen ue
effect dae fo Mess e sane sry
are rep pio average ihn 62 dy pp fe his
corre and ds epiemeninmatn thet
plan rinse replacement nfomatn st isos
then aplican er sane the effective ate for eses
be 1 dy ette te rns. nese at
Bel pr tat thy vi ened as pes canons
And correu tend as been eee pes
for ams.
Premium
We may as the premium ates fom ino me. Pen ates
ne setby ds. and you vn eslora rem ange
‘egress beat. The pl pan, age and sexof coed
psn pean eve of ees, ie the certifi as enn
Fac, 28 you pc ofen actos hatmay be sein
set ae ses Premama wären e ages rin
Home Health Care
o qual oder Rome heath are muse provided though
ened ome hehe age.
Core ense or home ea ae serves ae dt seen
its per verda Mete minum of 365 it, Rep ase
Serves ene cine maximum 1 00h
Hospice Care
To qualify o benefits. Hospice Cr program fa terial
(order mus be Kens hy the sein which pets.
Bees fran re hoc ae mie 180
creed pers Heime. Core expenses romand board ae
Inte the mst comme separate com ate ofthe host or
rig hme white ose sacd
Dependents
exposes thi come, ge dependents ou
‘pune dela cen Ege hen mist be nar nd
des ge me pation.
Termination of a Covered Person
covered psn arrage wl emite cn the dt that persan no
longer meets the eighty queens a the rte
ont rando enormen.
Continued Eligibility Requirements
‘coed een’ eighty wl seo tr ofthe dea
under
+ Cases be pesée or
+ eames ised der an inhi pan pong mean
pt upc mea sens ree (doesnt
pt standalone nce race on pes)
Renewability
Yeu nen ey pig tpi ices de We
ay ee evel
> Fate pyre ar
+ ede ee a eras priest
‘eee testo oe eh.
Underwriting
org eis spent eth st
Yau moves ne fap. Pus ae sete
log Mes odd nar con tomato en
Yer pa jur rage na as
dones.
an 292010102808
+ Cord up penses int Gagnon treatment of
amy spine bak sores ae imite 0 maumum 12.000
pele yer A an ar Mess a ot et hs
Titan.
+ Cored exgeses ardt no mare than 34 dy ssl lor
am or opt preston dug re rtf.
Effective Date
Foci, eee dt ora male platon le he ate
o) requested five dt. Fany shown nh ah
(the date upon wich he gal aplican actualy eed y
Gade fle
Foran appa sent any electoncmetot nding the
tive ate fries wether of) he eased
effete ate fay town the apps o) e de aferthe
«te pon ihe plans tay eee y Glen ue
effect dae fo Mess e sane sry
are rep pio average ihn 62 dy pp fe his
corre and ds epiemeninmatn thet
plan rinse replacement nfomatn st isos
then aplican er sane the effective ate for eses
be 1 dy ette te rns. nese at
Bel pr tat thy vi ened as pes canons
And correu tend as been eee pes
for ams.
Premium
We may as the premium ates fom ino me. Pen ates
ne setby ds. and you vn eslora rem ange
‘egress beat. The pl pan, age and sexof coed
psn pean eve of ees, ie the certifi as enn
Fac, 28 you pc ofen actos hatmay be sein
set ae ses Premama wären e ages rin
Home Health Care
o qual oder Rome heath are muse provided though
ened ome hehe age.
Core ense or home ea ae serves ae dt seen
its per verda Mete minum of 365 it, Rep ase
Serves ene cine maximum 1 00h
Hospice Care
To qualify o benefits. Hospice Cr program fa terial
(order mus be Kens hy the sein which pets.
Bees fran re hoc ae mie 180
creed pers Heime. Core expenses romand board ae
Inte the mst comme separate com ate ofthe host or
rig hme white ose sacd
Dependents
exposes thi come, ge dependents ou
‘pune dela cen Ege hen mist be nar nd
des ge me pation.
Termination of a Covered Person
covered psn arrage wl emite cn the dt that persan no
longer meets the eighty queens a the rte
ont rando enormen.
Continued Eligibility Requirements
‘coed een’ eighty wl seo tr ofthe dea
under
+ Cases be pesée or
+ eames ised der an inhi pan pong mean
pt upc mea sens ree (doesnt
pt standalone nce race on pes)
Renewability
Yeu nen ey pig tpi ices de We
ay ee evel
> Fate pyre ar
+ ede ee a eras priest
‘eee testo oe eh.
Underwriting
org eis spent eth st
Yau moves ne fap. Pus ae sete
log Mes odd nar con tomato en
Yer pa jur rage na as
dones.
an 292010102808
Provisions That Apply to All Plans (continued)
Conditions Prior to Legal Action
Tobe ree pts ble Ripon, e oy quest yoo
pros wäh ten rte fit ost à oto pio
leu acon Tino mus dent e a ofthe gene
ining rat acs nd noma sping option
Uns ribeye, amy act arena <ontcia or pte
maes ovas te onc ans atu ae re
green sees once within 3 dase wien
me.
Group— CoB
eater coverage sis. coved perso becomes ised under
‘pola, bed wie termin nde the Corian a
ees C8) cue, DB alt mor las to wk gets
‘otha the a amount fallen wä vere mor an 100%
le expenses CO ao takes nt acount meal age
er ao ranean
Medicare — Carve-Out
onze pens wordt ogo Metre egy and buin
Media erage may cine vera under tee pls Beets
willbe prided acord tothe Medicare Care -ut Benet
Reduction poison Basal, “arve-ot pays the une
een wht Glen fie ents oma wel dt
y Meir.
an 292010102808
Conditions Prior to Legal Action
Tobe ree pts ble Ripon, e oy quest yoo
pros wäh ten rte fit ost à oto pio
leu acon Tino mus dent e a ofthe gene
ining rat acs nd noma sping option
Uns ribeye, amy act arena <ontcia or pte
maes ovas te onc ans atu ae re
green sees once within 3 dase wien
me.
Group— CoB
eater coverage sis. coved perso becomes ised under
‘pola, bed wie termin nde the Corian a
ees C8) cue, DB alt mor las to wk gets
‘otha the a amount fallen wä vere mor an 100%
le expenses CO ao takes nt acount meal age
er ao ranean
Medicare — Carve-Out
onze pens wordt ogo Metre egy and buin
Media erage may cine vera under tee pls Beets
willbe prided acord tothe Medicare Care -ut Benet
Reduction poison Basal, “arve-ot pays the une
een wht Glen fie ents oma wel dt
y Meir.
an 292010102808
State Variations
Arizona
2 Terenas nd mente
ion fa pressng oaton ae
tanga sons.
+ Tented exten A dost.
+ Pray ps ae un ihn
resinous ral
Facial alar, Reta
feed.
Arkansas
1 Tecan TM das ost
ao
med near ars
rome estar ee
+ Alsina este oe
ac rat pers.
District of Columbia
+ Mmes amendes sed
Inte pel wie tte
lend ya largo einen
esplanade aly
pers art
cadete ly pale
21798 cine ape
sine eds ate
(ocean Maxim tner
fea eco peste ass due
na ce mated V3 pal
+ Mama abuse and
Inte pat. tdt 12 pr
nda pte desi)
(osprey rate
reten og rn cod
eden ay 40 pate ts pr
endesa fete
mnt rfi ss
kin pbs sealer
or carr Aten
pater visite er ale
Poe car
1 Bpensesfermammogapby eansand Pa
ms ote deci,
aprem oros.
+ Wet cesen femtittoage nt
areaconndopene drt othe
vain pied
+ Theedsonfepessinamedasareit
tie oer pen beginnen
‘ede be she nara dost
ao
Florida
+ Grecdéiéhetapentansentesa
tect dur wating
ps
1 ao wth "th
Spar Herr Carmes
‘eves et speedy
acer pie a oe psn or
"ag ua ina
alent deepen
seer. ea
Spey iman andre.
‘thei th rg media sar,
+ gle den muse maria
ea ge athe tine tapi,
Paray ns Gun sue ita
prensng cdi edsong le
oc spars Review eat
former de
Indiana
1 Tree hi AS seta.
+ Tepes on ero
eset tha 2m rth
Applebees ange
mot Ms meta pedo
Bert pers pr dh
anale coenge.
lowa
+ Tespeanb men on not neh
+ Thepessig tens rar
pomo breed pese cod
ip age
+ Tete exon ADS desata.
+ Tecla bert sot coer
matey epee nt 0 dy ater be
leen dt.
Maryland
+ Thee bio ADS este
Michigan
+ Deere mine dont
preto ad ischangdt
‘mots.
+ Provider Network Continuo
‘Treatment po ans e
twa hie oe rin ment er
eyes or fis sgt
vit ecos pri were
ssh nett and ew y os
tbe propane
pride at o ay ontarien
et oe
+ Grane Produ ferien Phone
umber: 80 7-205 Yen eqs. me
vo ries vel mbr
fateh Deprmento Canes
andy Sees.
+ Bperssnaed or Sognsnd nent
lpn revered expense ae
erie.
Mississippi
2 ares 2nd met nthe
isn lapso odin ae
ung tots.
lfusecalnesattare not.
‘editors oe Oty
+ Pong ral flor any etal
mus toys physi ots beth
epische cn errar
Sally esc reojo nd yay
+ Accor ote
creces and
rep nds
+ Glen he andre
ewe
+ going nding promi en,
Acme mes toner
con
Missouri
+ Teil che AD des rap)
© Saeco Band sats
ruby pas (ura ise vos
pressig onto sen ar ala
web api.
+ eco ries eine
arm dosage
sacd ham een
sue arp i eae.
+ Tec ride nie nee
Dern em i burn Bde oct
ana
+ Nata Pues dera
+ Corinto 2 pre
re Mesa Lor eter
dci coa anti pod.
‘ota cid hy,
Nebraska
+ Otis you creed
pee en kom ue
recover notte eee
vete.
Arizona
2 Terenas nd mente
ion fa pressng oaton ae
tanga sons.
+ Tented exten A dost.
+ Pray ps ae un ihn
resinous ral
Facial alar, Reta
feed.
Arkansas
1 Tecan TM das ost
ao
med near ars
rome estar ee
+ Alsina este oe
ac rat pers.
District of Columbia
+ Mmes amendes sed
Inte pel wie tte
lend ya largo einen
esplanade aly
pers art
cadete ly pale
21798 cine ape
sine eds ate
(ocean Maxim tner
fea eco peste ass due
na ce mated V3 pal
+ Mama abuse and
Inte pat. tdt 12 pr
nda pte desi)
(osprey rate
reten og rn cod
eden ay 40 pate ts pr
endesa fete
mnt rfi ss
kin pbs sealer
or carr Aten
pater visite er ale
Poe car
1 Bpensesfermammogapby eansand Pa
ms ote deci,
aprem oros.
+ Wet cesen femtittoage nt
areaconndopene drt othe
vain pied
+ Theedsonfepessinamedasareit
tie oer pen beginnen
‘ede be she nara dost
ao
Florida
+ Grecdéiéhetapentansentesa
tect dur wating
ps
1 ao wth "th
Spar Herr Carmes
‘eves et speedy
acer pie a oe psn or
"ag ua ina
alent deepen
seer. ea
Spey iman andre.
‘thei th rg media sar,
+ gle den muse maria
ea ge athe tine tapi,
Paray ns Gun sue ita
prensng cdi edsong le
oc spars Review eat
former de
Indiana
1 Tree hi AS seta.
+ Tepes on ero
eset tha 2m rth
Applebees ange
mot Ms meta pedo
Bert pers pr dh
anale coenge.
lowa
+ Tespeanb men on not neh
+ Thepessig tens rar
pomo breed pese cod
ip age
+ Tete exon ADS desata.
+ Tecla bert sot coer
matey epee nt 0 dy ater be
leen dt.
Maryland
+ Thee bio ADS este
Michigan
+ Deere mine dont
preto ad ischangdt
‘mots.
+ Provider Network Continuo
‘Treatment po ans e
twa hie oe rin ment er
eyes or fis sgt
vit ecos pri were
ssh nett and ew y os
tbe propane
pride at o ay ontarien
et oe
+ Grane Produ ferien Phone
umber: 80 7-205 Yen eqs. me
vo ries vel mbr
fateh Deprmento Canes
andy Sees.
+ Bperssnaed or Sognsnd nent
lpn revered expense ae
erie.
Mississippi
2 ares 2nd met nthe
isn lapso odin ae
ung tots.
lfusecalnesattare not.
‘editors oe Oty
+ Pong ral flor any etal
mus toys physi ots beth
epische cn errar
Sally esc reojo nd yay
+ Accor ote
creces and
rep nds
+ Glen he andre
ewe
+ going nding promi en,
Acme mes toner
con
Missouri
+ Teil che AD des rap)
© Saeco Band sats
ruby pas (ura ise vos
pressig onto sen ar ala
web api.
+ eco ries eine
arm dosage
sacd ham een
sue arp i eae.
+ Tec ride nie nee
Dern em i burn Bde oct
ana
+ Nata Pues dera
+ Corinto 2 pre
re Mesa Lor eter
dci coa anti pod.
‘ota cid hy,
Nebraska
+ Otis you creed
pee en kom ue
recover notte eee
vete.
State Variations (continued)
North carolina
+ Nese etme THU roe up
tealteinemaénno! 00.
+ Tierna sega wesenrt
FW eset a
+ Pays are wits
proang ondes ea ae ale
Foca ant sente plate
fen raat.
+ cape Messer
(oe pers pd unter
Case Compensation at
+ Te preng dns fete
treatment tn ant te
place ate ages
Temen The nti peri ay
ercer esas cone y quin
prcmenge
+ eco A dont
+ Reser ae riel aut oct
wie eddy Sal ivan
Bene parao tan che ceed
open Sa tet orbe
stony dares anda tial
etl avant op pan,
ende)
+ So medeal cit
Ciel zac Campa
Ti esSnd De
ISO 4578-720,
Ohio
+ Oral exp Sean Teli
ranma bein rite das.
tc vseerte amen dere rane
bu send afro
Gao mena si
‘2000 eco pas posais
tami pace opt
treinta see eto
SO eri and pts esa
medial pact rp apo
dame men ea ae inte
to Spec pesa er al
+ Tetto ri ost
+ Sef tocan Sand ora
ple usan ose wit peo
dns exe ar bb ge
a.
+ Ute eager tes
“pins nds e
vaig pod
+ ipsa mentalen nen
rates raiemedate
ay cases tas ete a
‘nied mae ble S50 pet
cea
Dan metal
‘ase sed a
temas Decre
+ Men carpi et et
cia]
ben han le
‘epee el bjt restar
‘say dupe néant
“ee amau el athe pe pes,
‘leary dee)
Oklahoma
+ apne frmamogapheans aer
set ted cine.
+ Thespeand bt in ds tna
+ Tepestg cottons 1 montag
pes nae ee pers cody
ng pr menge.
+ Grecddinmna arts
tothe tbe erating pr
Pennsylvania
Gods aot sec
tote deliberating pe
+ omas plone PA
ante eek dao ane
erotic.
South Carolina
+ repressig creeo
et tin 2 mnt rt
pee eve und
moi. Ms met atom
core cd aang
plane
Tennessee
+ rbd pls gun vtt
pedi endorses) late
ocios dew pata
Fever des.
Texas
+ apy Sve recon dis tone
€ met ot dade amende
mas abris.
+ Fama cesa fte ameno!
iran ecc same sony
bere
+ Toga ute entity
atea eqs ac pen.
+ Wiese ercer
pan sa mfastemay es
rm metan herr
‘openssh ea vie
peinada gas ee ages
‘este Maier and
(ta wb tn hy Gel ie
done sine ao
geraten mar
une emetic
«cdas es jet
De te asi bee and
ae teme pay Fr ape ih
press gan rent
i payer
realest ce abe
+ aes Central xls
‘oe a sted apt cored pes
wie ced 2,
+ Apreciado any cos
Felice ponte mea
sortent mento
emo pra decae
eve
+ init ents ar pride ag
andre enc eee
MOS 00 Ote dan nse
dt 5 OR potreros
rond andre ed ent
OSO etc ener
+ May necesa ed em and
mas ase mein os
cesary adapte he ment.
a es ey demie y Caen
Ron een si pel.
- Tier nds pronto
es acoumpese uy protón
x wheter posed underage
race,
+ Cocinas went
ee dev ero
+ Near qee o mas
+ Ted wating ptf he ogee
ees esp
Virginia
+ Media cereus
bens pale Med”
Omen
North carolina
+ Nese etme THU roe up
tealteinemaénno! 00.
+ Tierna sega wesenrt
FW eset a
+ Pays are wits
proang ondes ea ae ale
Foca ant sente plate
fen raat.
+ cape Messer
(oe pers pd unter
Case Compensation at
+ Te preng dns fete
treatment tn ant te
place ate ages
Temen The nti peri ay
ercer esas cone y quin
prcmenge
+ eco A dont
+ Reser ae riel aut oct
wie eddy Sal ivan
Bene parao tan che ceed
open Sa tet orbe
stony dares anda tial
etl avant op pan,
ende)
+ So medeal cit
Ciel zac Campa
Ti esSnd De
ISO 4578-720,
Ohio
+ Oral exp Sean Teli
ranma bein rite das.
tc vseerte amen dere rane
bu send afro
Gao mena si
‘2000 eco pas posais
tami pace opt
treinta see eto
SO eri and pts esa
medial pact rp apo
dame men ea ae inte
to Spec pesa er al
+ Tetto ri ost
+ Sef tocan Sand ora
ple usan ose wit peo
dns exe ar bb ge
a.
+ Ute eager tes
“pins nds e
vaig pod
+ ipsa mentalen nen
rates raiemedate
ay cases tas ete a
‘nied mae ble S50 pet
cea
Dan metal
‘ase sed a
temas Decre
+ Men carpi et et
cia]
ben han le
‘epee el bjt restar
‘say dupe néant
“ee amau el athe pe pes,
‘leary dee)
Oklahoma
+ apne frmamogapheans aer
set ted cine.
+ Thespeand bt in ds tna
+ Tepestg cottons 1 montag
pes nae ee pers cody
ng pr menge.
+ Grecddinmna arts
tothe tbe erating pr
Pennsylvania
Gods aot sec
tote deliberating pe
+ omas plone PA
ante eek dao ane
erotic.
South Carolina
+ repressig creeo
et tin 2 mnt rt
pee eve und
moi. Ms met atom
core cd aang
plane
Tennessee
+ rbd pls gun vtt
pedi endorses) late
ocios dew pata
Fever des.
Texas
+ apy Sve recon dis tone
€ met ot dade amende
mas abris.
+ Fama cesa fte ameno!
iran ecc same sony
bere
+ Toga ute entity
atea eqs ac pen.
+ Wiese ercer
pan sa mfastemay es
rm metan herr
‘openssh ea vie
peinada gas ee ages
‘este Maier and
(ta wb tn hy Gel ie
done sine ao
geraten mar
une emetic
«cdas es jet
De te asi bee and
ae teme pay Fr ape ih
press gan rent
i payer
realest ce abe
+ aes Central xls
‘oe a sted apt cored pes
wie ced 2,
+ Apreciado any cos
Felice ponte mea
sortent mento
emo pra decae
eve
+ init ents ar pride ag
andre enc eee
MOS 00 Ote dan nse
dt 5 OR potreros
rond andre ed ent
OSO etc ener
+ May necesa ed em and
mas ase mein os
cesary adapte he ment.
a es ey demie y Caen
Ron een si pel.
- Tier nds pronto
es acoumpese uy protón
x wheter posed underage
race,
+ Cocinas went
ee dev ero
+ Near qee o mas
+ Ted wating ptf he ogee
ees esp
Virginia
+ Media cereus
bens pale Med”
Omen
State Variations (continued)
+ Corso of Benefits ats Gee
enge bse apeson becomes
‘sured enter go pr
entlasten
"etanol rf (DB use e
plante mind pay bss
eB ks deis oler
Some ende vien
ln aio paid tan
ppm CO oecoga enanas
tr ana dependen ih gar.
count pes pl
(ensure hear
eo determine pny
‘nde tert under
manette cu ce
(ie pesonsanachempheipendent
ana eme or pans
potédwemelnge.
+ ray pas Gate svt
reting nnd abe
Fost slave plate
feet a
West Virginia
+ Tiene minum ral
Gags wanenofmenalren,
ing bn dus 31000.
+ eco A) sides tao.
1 Cor inmates tte.
tote debe ap
+ Fray pias ane oa
presos ae ae ala
Fact pat Reeth ga
munter,
Wisconsin
+ Telit xan DS dost.
+ Ten ad tation ee.
* Gourd epensesfral dogs
‘tne etalon and
sabia ate bjt deci
Andean adela
em beneftfSTORDupatent
Moments int mime
bene 2000
+ linked venga enel
does spi
+ Cord nuts ae rt
teed va ei
+ Cond egenes frtame heh ie
‘erated Ona ont
pe.
an 292010102808
+ Corso of Benefits ats Gee
enge bse apeson becomes
‘sured enter go pr
entlasten
"etanol rf (DB use e
plante mind pay bss
eB ks deis oler
Some ende vien
ln aio paid tan
ppm CO oecoga enanas
tr ana dependen ih gar.
count pes pl
(ensure hear
eo determine pny
‘nde tert under
manette cu ce
(ie pesonsanachempheipendent
ana eme or pans
potédwemelnge.
+ ray pas Gate svt
reting nnd abe
Fost slave plate
feet a
West Virginia
+ Tiene minum ral
Gags wanenofmenalren,
ing bn dus 31000.
+ eco A) sides tao.
1 Cor inmates tte.
tote debe ap
+ Fray pias ane oa
presos ae ae ala
Fact pat Reeth ga
munter,
Wisconsin
+ Telit xan DS dost.
+ Ten ad tation ee.
* Gourd epensesfral dogs
‘tne etalon and
sabia ate bjt deci
Andean adela
em beneftfSTORDupatent
Moments int mime
bene 2000
+ linked venga enel
does spi
+ Cord nuts ae rt
teed va ei
+ Cond egenes frtame heh ie
‘erated Ona ont
pe.
an 292010102808
NOTICE OF INFORMATION PRACTICES + Frech Gomme Fin ch ty, Exc Yu iis
(Woe rl an lr xs «Cr th Pe yes
OE oF ancy PRACTICES ORNE Sante een
IEA, een me alton arn ee a
A «ga on
guar * Foca op spices "bet a
Sons
Sommes. en
mener ln
eo ni oe chor ter eerie We a
la o aviacion aula aia ml coi
cn a cn da en OA eo e lat a dep te
Teams “rf real man sc cos sad rot DÉCRET como
po epica een sai, "Fey Ponte ra date ln een
E E A o
ey RE nun
Veras tocar as pias ns RD a In
is im Te aan han GR Vene ae
oem > mauelancayinalydearcteen tos al rd Ola
on et Dach ben et mem De nei am nee rn hy nas tor
metio eo remoto ara Re Ha dl toco Se Dar
dl
Deere aroun ¢ posse NB
Se mt zn nen, HE e oa tera ta) pe san LE rotule
anses ea Fe, orme ee
A M Mn AS stogomaldeaae,
men o TE AA
MR een tee, er
BEE Innen ga an
A ann ASS gate san émane
re
ra a ham PR APE is Due DLR
A a A Gr ee
+ Cu A A
es eyo pr ud FAN EON PTC ME
ek Carte mesa cel pl mn report rs
pudo: Pantene: ee
+ ote si ew ne eit E
EEE reia Eee ETS
er Ne teeth,
PR Rene RP | Srna ash ade ll
E ca + orde tome ds RO ads tonte ra sähe
spe mucosa uss D pos eng ea
Éd ai u en
an a en namie Mr een una ters
eme Sue niet on Een ne sea ewe
ieee a + Hin ns eco fe
ee ers et, mare
= rege en Wop oy me o
a CR TE ia cau
my Sc trat rg ee, (ree, aa:
: einge ean porn ‘Ris nn ma
Pa me Vo e DO Se
een en
o A me
BE =
Bee ES
D pa qu menée TS e,
ER amas,
ee lee Be ee
Er ESO, teens game
ciedad «tata ppt um Seo rey nk
ech e tinier fateh
‘Fara Etc Pops ss e tied Scan ee ee ne Gray Al estare
iterator Bee Seno A
rs MN. nues
ee EEE ESS
8 st nu abit ec Mec co ra go Pate réa Cory Pan Lt rg D
isda rate pay mana Sets Conn erh pag ne ae gy menden
(Woe rl an lr xs «Cr th Pe yes
OE oF ancy PRACTICES ORNE Sante een
IEA, een me alton arn ee a
A «ga on
guar * Foca op spices "bet a
Sons
Sommes. en
mener ln
eo ni oe chor ter eerie We a
la o aviacion aula aia ml coi
cn a cn da en OA eo e lat a dep te
Teams “rf real man sc cos sad rot DÉCRET como
po epica een sai, "Fey Ponte ra date ln een
E E A o
ey RE nun
Veras tocar as pias ns RD a In
is im Te aan han GR Vene ae
oem > mauelancayinalydearcteen tos al rd Ola
on et Dach ben et mem De nei am nee rn hy nas tor
metio eo remoto ara Re Ha dl toco Se Dar
dl
Deere aroun ¢ posse NB
Se mt zn nen, HE e oa tera ta) pe san LE rotule
anses ea Fe, orme ee
A M Mn AS stogomaldeaae,
men o TE AA
MR een tee, er
BEE Innen ga an
A ann ASS gate san émane
re
ra a ham PR APE is Due DLR
A a A Gr ee
+ Cu A A
es eyo pr ud FAN EON PTC ME
ek Carte mesa cel pl mn report rs
pudo: Pantene: ee
+ ote si ew ne eit E
EEE reia Eee ETS
er Ne teeth,
PR Rene RP | Srna ash ade ll
E ca + orde tome ds RO ads tonte ra sähe
spe mucosa uss D pos eng ea
Éd ai u en
an a en namie Mr een una ters
eme Sue niet on Een ne sea ewe
ieee a + Hin ns eco fe
ee ers et, mare
= rege en Wop oy me o
a CR TE ia cau
my Sc trat rg ee, (ree, aa:
: einge ean porn ‘Ris nn ma
Pa me Vo e DO Se
een en
o A me
BE =
Bee ES
D pa qu menée TS e,
ER amas,
ee lee Be ee
Er ESO, teens game
ciedad «tata ppt um Seo rey nk
ech e tinier fateh
‘Fara Etc Pops ss e tied Scan ee ee ne Gray Al estare
iterator Bee Seno A
rs MN. nues
ee EEE ESS
8 st nu abit ec Mec co ra go Pate réa Cory Pan Lt rg D
isda rate pay mana Sets Conn erh pag ne ae gy menden
Toe UD ren SOUL LG PEL PE
vor ca fon ‘Fu UMTSOURLABLT.
Prop:
otra ee
ORNE DIC FECTIVE VELIOS PRON O OVER ARE ME NO ESOS THOR TO ATEROR WANE MTF THE
‘aloe como ORNE BURN
SOLA PS a GENE ACORDES RO
Tome :
Cail tv
Spas pre
ONOOASPRORTO CEIC AFABLE MOR —MITETOAPPUCATREGADINGRUIGNOTOF —_ACOPYOFURATHORZATONTOOETNAND DE
INS HE CONDOM RCP) DT MOSCAS SURE PON
Sets ba Fx Earn oo abastece une rete Pe a Corp
iret te lo anar RA peat Monster aah
1 Teagan amas AS ei onto ue
ent sepa poe Cae ‘argo, ec eto EL
a e ts, em e
seat hnolon _ Peine om: op ea pc ma
pete esca ron Dinant acto pen
tr ir AAN
3 Aisa reg, eben de Hamer neo abot we case
cap nord beacons keno ac ta
«Morand eh elle beein Ti ee nr on
tree eps tis an ao amd a nn
potent rite reia
SRE a dorer
Se 2, Water due consideration, you sil wish to terminate ee
wien e rm
er reir De en
ran mae dome.
commence ports cee
6 Meer sso by Golden ule ac) à You maywishtosearethe adc cour present | AJA Zas validas de
applied in 5 das from dae opel rots agent earingthe proposed replacement xg.
pi od dl co tonto your presea plan. Yu shouldbe + Ke) oy os authorized representative may aba
Lau certain that you understand all the relevant factors. copy otis asthoriation by writing to Golden Re.
ae A ie Bei
a Sa oir
A E creeme,
See ica i
Tre
u zen
of) he request fee da, Fa how 1 OP OF YOUR AUTHORIZATION FOR ELECTRON FUNDS + The information that is user chen accerdance
ne na) namen een
Se mn a,
nennen BERRY, nn
A ma
en 2e ne
ane serca ena
A
A nd an
Wesens ran blemas one cbc
ray boue mr prnl dp opt De
RC an hc a ‘jase thomas arent
a vpo cenefas erben
e ara rei ate roue compite pen andere
DE sg rit ar ral ta
EP AS DOCUMENT.
HS PONT RFORMTON. nl
vor ca fon ‘Fu UMTSOURLABLT.
Prop:
otra ee
ORNE DIC FECTIVE VELIOS PRON O OVER ARE ME NO ESOS THOR TO ATEROR WANE MTF THE
‘aloe como ORNE BURN
SOLA PS a GENE ACORDES RO
Tome :
Cail tv
Spas pre
ONOOASPRORTO CEIC AFABLE MOR —MITETOAPPUCATREGADINGRUIGNOTOF —_ACOPYOFURATHORZATONTOOETNAND DE
INS HE CONDOM RCP) DT MOSCAS SURE PON
Sets ba Fx Earn oo abastece une rete Pe a Corp
iret te lo anar RA peat Monster aah
1 Teagan amas AS ei onto ue
ent sepa poe Cae ‘argo, ec eto EL
a e ts, em e
seat hnolon _ Peine om: op ea pc ma
pete esca ron Dinant acto pen
tr ir AAN
3 Aisa reg, eben de Hamer neo abot we case
cap nord beacons keno ac ta
«Morand eh elle beein Ti ee nr on
tree eps tis an ao amd a nn
potent rite reia
SRE a dorer
Se 2, Water due consideration, you sil wish to terminate ee
wien e rm
er reir De en
ran mae dome.
commence ports cee
6 Meer sso by Golden ule ac) à You maywishtosearethe adc cour present | AJA Zas validas de
applied in 5 das from dae opel rots agent earingthe proposed replacement xg.
pi od dl co tonto your presea plan. Yu shouldbe + Ke) oy os authorized representative may aba
Lau certain that you understand all the relevant factors. copy otis asthoriation by writing to Golden Re.
ae A ie Bei
a Sa oir
A E creeme,
See ica i
Tre
u zen
of) he request fee da, Fa how 1 OP OF YOUR AUTHORIZATION FOR ELECTRON FUNDS + The information that is user chen accerdance
ne na) namen een
Se mn a,
nennen BERRY, nn
A ma
en 2e ne
ane serca ena
A
A nd an
Wesens ran blemas one cbc
ray boue mr prnl dp opt De
RC an hc a ‘jase thomas arent
a vpo cenefas erben
e ara rei ate roue compite pen andere
DE sg rit ar ral ta
EP AS DOCUMENT.
HS PONT RFORMTON. nl
Health Insurance for Individuals and Families Built with YOU in Mind.
These heath insurance plans are issue as association
group plans and avaiable only to members of FACT, the
Federation of American Consumers and Travelers you
not already a member you are require to jon FACT.
Whatis FACT?
FACTisan independent consumer association whose
members benefit frm the pooling” of resources,
‘Benefits range from medial savings to consumer service
count FACTS principe of sin Edwardvile nos
FACT and Golden Rule are separate organization Nether
is responsible forthe performance of the other FACT has
contracted with Golden let provide ts members with
access to these heath insurance plans. FACT doesnot
receive any compensation from Golden Aue.
Is there a cost for joining FACT?
Yes, the membership dues are simply $3 a month andcan
be aid wth your regular heath insurance premium, as
‘opposed to making a separate payment
FACT privacy notice
Asa member of FACT, your information ikep private and
Hs not shred with any third partes Please vst
wor asacor/priacy. poly fora complete FACT
Privacy Statement
What are FACT' assoclation benefits?
FACT makes it possible for members to pick and choose
foma fllmenu of important benefits including:
+ Dental care discounts — you can save up to 35% on
‘general dental ca, Kays cosmetic dents, and
orthodontics,
+ Visioncare discounts — typical savings of 5%-40%
for eye exams, eyeglasses, contact lenses, and LAS
eye conection surgery
Hearing ids & care discounts.
+ Prescription dug discounts.
+ Wellness benefit
+ Durable medica equipment
+ Diabetes needs
+ OFC meds
+ Scholarships grant
+ Consumer newsletter &buletins
Job search employee search assistance.
+ Consumer otine libra
+ Discount on everything from travel & auto mutes
to renal car, amusement parks, motel
FACT may change or continue any ofts membership
benefits at anytime. For the most cent information
walt FACTS Web ste at wnrwuseactorg or caltllres at
(800) USA-FACT.
These heath insurance plans are issue as association
group plans and avaiable only to members of FACT, the
Federation of American Consumers and Travelers you
not already a member you are require to jon FACT.
Whatis FACT?
FACTisan independent consumer association whose
members benefit frm the pooling” of resources,
‘Benefits range from medial savings to consumer service
count FACTS principe of sin Edwardvile nos
FACT and Golden Rule are separate organization Nether
is responsible forthe performance of the other FACT has
contracted with Golden let provide ts members with
access to these heath insurance plans. FACT doesnot
receive any compensation from Golden Aue.
Is there a cost for joining FACT?
Yes, the membership dues are simply $3 a month andcan
be aid wth your regular heath insurance premium, as
‘opposed to making a separate payment
FACT privacy notice
Asa member of FACT, your information ikep private and
Hs not shred with any third partes Please vst
wor asacor/priacy. poly fora complete FACT
Privacy Statement
What are FACT' assoclation benefits?
FACT makes it possible for members to pick and choose
foma fllmenu of important benefits including:
+ Dental care discounts — you can save up to 35% on
‘general dental ca, Kays cosmetic dents, and
orthodontics,
+ Visioncare discounts — typical savings of 5%-40%
for eye exams, eyeglasses, contact lenses, and LAS
eye conection surgery
Hearing ids & care discounts.
+ Prescription dug discounts.
+ Wellness benefit
+ Durable medica equipment
+ Diabetes needs
+ OFC meds
+ Scholarships grant
+ Consumer newsletter &buletins
Job search employee search assistance.
+ Consumer otine libra
+ Discount on everything from travel & auto mutes
to renal car, amusement parks, motel
FACT may change or continue any ofts membership
benefits at anytime. For the most cent information
walt FACTS Web ste at wnrwuseactorg or caltllres at
(800) USA-FACT.
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