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Home My WebLink AboutExhibit5S851t A SarOrAos Unc6'000. H1ariR:ve Tri-Level Limited -Benefit Medical Plan Level I wee Level 2 Eritplcyxe,.. ;$ Physician Office Visit Co -Pay Outpatient Basic Medical Expense Benefit Non -Emergency Care in Emergency Room In -Hospital Medical Daily In -Hospital Benefit loyee CIGNA $15 $1000/year,, Paid at 80% — $50 Dedfyear $500 max/yea;; Paid at 50% — $100 DedfOcc. Benefit Amount is appled toward the Outpatient Basic Medical Expense Benefit $10.000/year Paid at 100% to a maximum of $100/day for 100 days Expense Benefit ! Additional In -Hospital Surgery and Maternity Benefit Accident Medicol Benefit Accidental Death Benefit Prescription Discount Prescription Benefit CIGNA 24-Hour Employee Assistance Program Physician OffkeVisit Ca -Pay Outpatient Basic Medical Expense Benefit N/A $5,000/year, Paid at 80% to a max of $2,500/Occurrence $50 DediOcc. Max of 2 Occ/year $10,000 Discount for brand name or generic N/A 24 hour availability, face-to-face visits with a counselor $10 $1,500/year, Paid at 80% — $100 Ded./year Non -Emergency Can in Emergency Room $500 max/year, Paid at 50% — $100 Ded&Occ. Benefit Amount is 1Ei11t°ss I applied toward the Outpatient Basic Medical Expense Benefit Level 3 In -Hospital Medical Expense Benefit Daily in -Hospital Benefit Additional In -Hospital Surgery and Maternity Benefit Accident Medical Benefit Accidental Death Benefit Prescription Discount Prescription Benefit CIGNA 24-Hour Employee Assistance Program Physicion Office Visit Co -Pay Non -Emergency Core in Emergency Room In -Hospital Medical Expense Benefit Daily in -Hospital Benefit Additional In -Hospital Surgery and Maternity Benefit Accident Medico/ Benefit $25,000/year Paid at 100% to a maximum of $250/day for 100 days Paid at 100% to a maximum of $1.500 Surgery, $1,500 Matemity/Occ. $10,000/year. Paid at 80% to a maximum of $5,000/Occ. $100 Ded,/Occ. Max of 2 Occ./year $15,000 Discount for brand name or generic Paid at 100% after a Per Prescription Deductible of $15/Generic. $25/ Brand, subject to a max. of $300/year and applied toward the Basic Medical Expense Benefit 24 hour availability, face-to-face visits with a counselor 1 $500 max/year,, Paid at 50% — $100 DedfOcc. Benefit Amount is applied toward the Outpatient Basic Medical Expense Benefit $50,000/year Paid at 100% to a maximum of $500/day for 100 days Paid at 100% to a maximum of $2,500 Surgery; $2,500 Maternity/Oct. $15,000/year, Paid at 80% to a maximum of $5,000/Occ. $ISO Ded /Occ. Maximum of 3 Occ/year Accidental Death Benefit Prescription Discount Prescription Benefit CIGNA 24-Hour Employee Assistance Program $25,000 Discount for brand name or generic Paid at 100% after a Per Prescription Deductible of $15/Generic. $25/ Brand, subject to a max. or $600/year and applied toward the Basic Medical Expense Benefit 24 hour availability, :ace -to -face visits with a counseior 4or000w •,:oomfoot el;,rs moot roagnO dr,s rot rail*H'KtPIE akr n' r.re .0.ari'r1'73leek,lhixs' tkst.eotgetegi W;4..5 ±k:rpere: srods..5 :sn aytnttiiraN,aOf CANA iyyvimc ,Oprrxrw;r.rot* : —mx Loral LA tonna:.aan,16,:tric.zcr:A:o:+rr.frOAr,kr.W.Artit* rlows woe,:sserc A0 AO.%telt Cciaar. ane:CNA r. •Hlt. ir. 011007 Limitations and Exclusions DEPENDENT ELIGIBILITY Your eligible dependents are your spouse and your unmarred dependent children under 19 years of age. The age limit is under 25 if the child is enrolled full-time in an accredited school or college. Your dependent information will be specified after you enroll and have received your summary plan description booklet. In Texas, unmarried dependent children are eligible until age 25. PRE-EXISTING CONDITION LIMITATION (Medical)" Pre-existing conditions are riot covered under the Starbridge medical plans. A pre-existing condition is any condition for which you have been medically diagnosed, treated by, sought advice from, or consulted with, a physician during the 6 months before becoming insured under this plan. This provision will not apply to any expenses incurred after the end of a continuous period of 6 months of coverage under the policy during which no expense is incurred, no diagnosis, treatment, or advice is received, and a physician has not been consulted; or 12 months of continuous coverage under the policy. The definition may vary from state to state. The pre-existing condition limitation above does not apply to newborn or adopted children, or to any pregnancy. My pre-existing condition limitation can be reduced by the period of time you were previously insured for the condition, provided you were validly insured under a prior plan with creditable coverage immediately prior to being insured under this plan, and became insured under this plan within 63 days of termination of your prior plan. WHEN STARBRIDGE COVERAGE ENDS Your insurance will terminate on the earliest of: 1. The date ending the last period for which You made any required premium contribution; 2. The date You enter the armed forces* of any country; 3. The date You are no longer a member of a class eligible for insurance; 4. Wlth respect to a coverage, the date on which that coverage is canceled: 5. The date the policy is terminated or 6. The date your Employer ceases to provide this plan. The insurance of a covered Dependent will terminate on the earliest of: 1. The date Your insurance terminates; 2. The date he/she enters the armed forces' of any country; or 3. The date he/she ceases to be a Dependent. BENEFIT LIMITATIONS' Coverage is not provided for services, supplies or equipment for which a charge is not customarily made in the absence of insurance. No coverage is provided for loss caused by or resulting from: 1. Injury or Sickness arising out of or in the course of employment; or which is compensable under any Workers' Compensation or Occupational Disease Act or Law; 2. Declared or undeclared war; or act of war; 3. Expenses which are not ordered or under the written direction of a Physician; 4. Cosmetic surgery. This does not apply to: a. Reconstructive surgery incidental to or following surgery resulting from trauma, infection, or other diseases of the involved part; or b. Reconstructive surgery because of a congenital disease or anomaly of a coveredDependent newborn or adopted infant; or c. Reconstructive surgery on a non -diseased breast to restore and achieve symmetry between two breasts following a mastectomy. 5. Hearing examinations or hearing aids; 6. Vision services and supplies related to eye refractions or eye examinations, eyeglasses or contact lenses or prescriptions or fitting of eyeglasses other than for a disease process, and radial keratotomy, keratomileusis or excimer laser photo refractive keratectomy or similar type procedures or services; 7. Charges made by a health care provider if such provider is a member of the Covered Person's Immediate Family or is living with the Covered Person; 8. Any period of Custodial Care confinement in a Hospital or Skilled Nursing Facility; 9. Charges for Horne Health Care Services, unless provided in lieu of a Hospital confinement. 10. The Covered Person's commission of a felony; 11. Charges in connection with manipulations of the musculoskeletal System, which includes manipulation of the muscles. joints, soft tissue, bone, spine, as well as traction and massage and applications of heat and cold; 12. The treatment of mental or nervous disorders, alcoholism, or any form of substance abuse, except as specifically provided; 13. Intentionally self-inflicted Injury or suicide attempt while sane or insane 14. Dental care and treatment, except that required by Injury and rendered within 6 months of the Injury; 15. Treatment which is determined to be Experimental or Investigational. 16, For Accidental Death: a. Death within 2 years from the Covered Person's effective date of coverage as a result of suicide, while sane or insane; b. Medical or surgical treatment of Sickness or disease; or c. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline. FOOTNOTES "This provision or limitation varies by state. Please contact the Starbridge Call Center for additional information. 'Membership in the reserves is not deemed entry into the armed forces. This brochure is intended as a brief summary of the Starbridge Plan; the Insurance Certificate, the insurance policy and state specific variations, are the official documents governing this Plan. Administered by; Star HRG, P.O. Box 55270, Phoenix, AZ 85078-5270 At Star HRG product policies are issued by The MEGA Life and Health Insurance Company and reinsured and administered by Connecticut General Life Insurance Company. For groups sitused in New York, products are underwritten by AMLIGO. /- RG A Suness Unit of CIGNA keaW Care Star HRG, A Business Unit of CIGNA HealthCare • 2222 West Dunlap Avenue • Suite 350 • Phoenix, AZ 602.956.4200 • www.starhrg.com 85021