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Fundamental Care - Limited Medical Plan Summary of Benefits

For members of the Association for Better Health. IMPORTANT INFORMATION: Each insured member and each insured family member receives the following benefits each coverage year. Insurance benefits payable for sickness and accidents only. Pre-existing condition limitations apply only to Inpatient, Maternity Coverage and Critical Illness benefit*.

OUTPATIENT (1) FCLFCX01
Critical Med Plan
Physician office visit pre-pay (2)
Benefit amount per day
N/A
N/A
Accident maximum benefit amount per year up to;
Benefit % payable
N/A
N/A
Emergency Room (sickness) benefit amount per day
Surgery benefit amount per day
Anesthesia benefit amount per day
N/A
N/A
N/A
Diagnostic, x-ray, lab benefit amount per day
Class I: Laboratory- Blood work, CMP, Lipid Panel, ECG, Pap/PSA, urinalysis and all other laboratory tests
N/A
Class II: Radiology, Ultrasound, Mammogram, Sonogram, Angiogram N/A
Class III: Imaging, CT, PET N/A
Class IV: Other Diagnostic tests - Endoscopy, Bronchoscopy, Colonscopy without Biopsy, MRI N/A
Additional Outpatient Non-Insurance Benefits(3) N/A
INPATIENT (1)
Day 1 hospital confinement benefit amount per day
Days 2+ hospital confinement benefit amount per day
Maximum benefit
$2,000 per day x 1 day
$2,000 per day thereafter
19 days per year
Surgery benefit amount (incl. maternity) per day
Anesthesia benefit amount per day
N/A
N/A
ICU benefit amount per day N/A
Accident Medical - payable for accident only
Benefit % payable
$20,000 per year
80% U&C; $0 Deductible
PRESCRIPTION (3)
Retail - Generic Rx Copay N/A
Retail - Preferred Brand Rx Copay N/A
Mail Order - Generic Rx Copay N/A
Mail Order - Preferred Brand Rx Copay N/A
Monthly benefit maximum - MEMBER/FAMILY N/A
AD&D (4)
Accidental Death & Dismemberment Benefit Amount N/A
CRITICAL ILLNESS (4)
Critical Illness Benefit Amount $20,000
OTHER SERVICES (4)
First Health PPO Discounts Yes
MDLIVE N/A
SupportLinc Member Assistance Program N/A
Myewellness N/A
Association Member Benefits (ABH) Yes

* Expenses related to maternity are not covered within the first 9-months after effective date of coverage. Expenses related to Inpatient care are subject to a 12-month pre-existing condition limitation. The Critical Illness benefit is subject to a 24-month pre-existing condition limitation. (1)Fixed Hospital Indemnity, Accident Medical, Critical Illness and AD&D Plans are underwritten by First Continental Life and Accident Insurance Company. (2)The office visit pre-pay is offered through First Health PPO Network. (3) Non-insurance services not provided by First Continental Life and Accident Insurance Company. (4) AD&D benefit amount listed is for Member|Spouse|Child(ren). (5) Payable for 10 conditions: Cancer, Heart Attack, Renal Failure, Stroke, Major Organ Transplant, Multiple Sclerosis, Coronary Artery Bypass Surgery, Alzheimer's, ALS, Terminal Illness. NOTICE: The insurance described in this summary provides limited benefits. Limited benefit plans are insurance products with reduced benefits and are not an alternative to or integrated with comprehensive coverage. This insurance does not coordinate with any other insurance plan. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act. Coverage is subject to exclusions and limitations and are not available in all US states. Product availability and plan design features, including eligibility requirements, descriptions of benefits, exclusions or limitations may vary depending on state laws. Full terms and conditions of coverage, including effective dates of coverage, benefits, limitations, and exclusions, are set forth in the policy. Please see full brochure for plan rates, exclusions, and limitations. In addition to the insurance premium for the Limited Benefit Medical Insurance products being offered, the total rate charged to you may include monthly fees for non-insurance products and services and $5.95 per month association dues. This page is a summary of the plans and benefits available under this program.

Monthly Rates** Critical Med Plan: Under 30 yrs of Age 30 to 49 Years of Age 50 to 64 Years of Age
Member Only $72 $90 $135
Member+Spouse $122 $53 $230
Member+Child(ren) $115 $144 $216
Member+Family $194 $243 $365

*Rates do not include Association dues of $5.95 or monthly service fee of $9.00 PMPM