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Health ProtectorGuard

Hospital & Doctor Fixed Indemnity Insurance

Predictable 1st dollar benefits

for doctor care, hospital stays, and more

Table of Contents

Using the Network 2

Summary Product Grids 3

Hospital Services 5

Surgical Services 6

Doctor Visits 7

Wellness/Preventive Care 8

Pharmacy Services 9

Outpatient Services 10

Exclusions & Limitations 11

Plan Provisions 12

Notice of Privacy Practices 13

Other Notices 16

THIS PRODUCT PROVIDES LIMITED BENEFITS.

HEALTH PROTECTORGUARD IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A

SUBSTITUTE FOR THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE

CARE ACT (ACA). LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL

COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.

This product provides benefits in a stated amount regardless of the actual expenses incurred.

Golden Rule Insurance Company is the underwriter of these insurance plans.

Policy Forms HPG2-GRI -50 (AK), -01 (AL), -02 (AZ), -03 (AR), -05 (CO), -07 (DE), -09 (FL), -10 (GA), -51 (HI), -14 (IA), -11 (ID), -12 (IL), -13 (IN), -16 (KY),

-17 (LA), -18 (ME), -19 (MD), -21 (MI), -22 (MN), -23 (MS), --24 (MO), -26 (NE), -27 (NV), -32 (NC), -34 (OH), -35 (OK), -36 (OR), -37 (PA), -38 (RI), -39 (SC),

-41 (TN), -42 (TX), -43 (UT), -45 (VA), -47 (WV), -48 (WI), and -49 (WY)

Oct 23 2020 11:30:09 am

Health ProtectorGuard offers coverage with simple, straight-forward benefits for

doctor visits, hospital stays and more. Design your coverage by selecting one of

six insurance plans to fit your needs and budget.

This is an outline only and is not intended to serve as a legal interpretation of beneﬁ ts. Reasonable eﬀ ort has been made to have this outline represent the intent of contract language.

However, the contract language stands alone and the complete terms of the coverage will be determined by the policy.

(Back to Cover)

Key features of these insurance plans:

• Choose any licensed doctor or hospital in the country.

• There is no lifetime maximum benefit.

• No coordination with other forms of insurance,

which means you’re paid a fixed amount for a

covered service regardless of when or how other

health insurance you may have pays the claim.

Save using MultiPlan’s nationwide network

Health ProtectorGuard benefits are paid the same,

regardless of which

licensed

providers you use.

You can save with discounts available through the

MultiPlan Limited Benefit Plan Network. MultiPlan

offers access to 4,670 hospitals and 900,000

healthcare professionals* Network providers have

agreed to offer discounts on covered services

which are reflected in your final bill. (Discounts for

non-covered services are at the provider’s discretion.)

Discounted costs for services mean you may be

able to reduce your out-of-pocket costs for medical

services.

If you have a major medical plan, you may need to

stay with certain networks and providers to get the

most coverage out of that plan. Be sure to take that

into consideration.

How to receive benefits:

• In order for the MultiPlan Network for Limited

Benefit Plans discounts to apply, benefits must

be paid directly to the provider. Ask your

provider for the assignment of benefits form.

• Claims for covered services are submitted by the

provider who is then paid by the insurance

plan.

If the payment is less than the claim amount, you

pay the difference to the provider. If the payment is

more than the claim amount, after the provider is

paid, the remaining benefit is paid to you by check.

• Alternatively, you may submit a claim form for

covered services you have paid, and we will

reimburse you directly.

Note: A MultiPlan network flat fee of $3.25 per

policy is charged per month. It is collected each

month that the policy is in force and there is no

pro-rating for a partial month. This fee is in addition

to the premium you pay for the insurance plan.

HOSPITAL

SERVICES

SURGICAL

SERVICES

Find Your Doctor

Visit

multiplan.com/HealthProtectorGuard

to see if your doctor is a part of the MultiPlan Network for

Limited Benefit Plans. MultiPlan’s network is not insurance.

It is a discount program only.

Reference: MultiPlan Network Composition Summary, May 2019

OUTPATIENT

SERVICES

DOCTOR

VISITS

WELLNESS/

PREVENTIVE

PHARMACY

SERVICES

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Oct 23 2020 11:30:09 am

SURGICAL SERVICES

Outpatient Facility Fee

(maximum per calendar-year)

We pay:

$500 per day

(2 days)

$500 per day

(2 days)

$1,000 per day

(2 days)

$500 per day

(3 days)

$500 per day

(3 days)

$1,000 per day

(3 days)

Surgeon: 4-Tier Surgical Schedule

(unlimited days per calendar-year)

Tier 1

We pay:

$10,000 $10,000 $10,000 $10,000 $10,000 $10,000

Tier 2 $5,000 $5,000 $5,000 $5,000 $5,000 $5,000

Tier 3 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000

Tier 4 $500 $500 $500 $500 $500 $500

Assistant Surgeon - Surgical Schedule

Tiers 1 & 2 only (per day)

We pay: 20% of surgeon beneﬁ t schedule above

Anesthesiologist (per day) We pay: 30% of surgeon beneﬁ t schedule above

Not available in OH.

If more than one surgery in any given day, the largest beneﬁ t amount is paid.

Services received for injuries (and illnesses in ID and MD) are eligible for coverage as of your client’s plan eﬀ ective date; services received due to

illnesses are eligible for coverage beginning on the 6th day following the eﬀ ective date. Preexisting conditions apply. See page 12 for details.

Waiting periods do not apply in ID and MD. There is no waiting period for a loss which results from an accident in VA.

Choice Value Choice Plus Select Value

Primary

Preferred

Select

Preferred

Premier Plus

HOSPITAL SERVICES

Inpatient Hospital Confinement (unlimited) We pay: $1,000 per day $2,000 per day $3,000 per day $4,000 per day $5,000 per day $5,000 per day

Increasing Injury Reimbursement

(unlimited) Inpatient Hospitalization

Benefits increase 25% each year, years

2-5, for injury-related hospital stays.

Year 2

We pay:

$1,250 per day $2,500 per day $3,750 per day $5,000 per day $6,250 per day $6,250 per day

Year 3 $1,500 per day $3,000 per day $4,500 per day $6,000 per day $7,500 per day $7,500 per day

Year 4 $1,750 per day $3,500 per day $5,250 per day $7,000 per day $8,750 per day $8,750 per day

Year 5 $2,000 per day $4,000 per day $6,000 per day $8,000 per day $10,000 per day $10,000 per day

Inpatient Hospital Intensive Care Unit (ICU) or

Critical Care Unit (CCU) (maximum per confinement)

We pay:

$2,000 per day

(31 days)

$4,000 per day

(31 days)

$6,000 per day

(31 days)

$2,000 per day

(60 days)

$2,000 per day

(60 days)

$10,000 per day

(31 days)

ICU/CCU beneﬁ t amounts are in addition to Inpatient Hospital Conﬁ nement beneﬁ ts.

Inpatient Physician Visits (maximum

during Inpatient Hospital Confinement)

We pay:

$100 per visit

(1 visit per day)

$100 per visit

(1 visit per day)

$100 per visit

(1 visit per day)

$100 per visit

(1 visit per day)

$100 per visit

(1 visit per day)

$100 per visit

(2 visits per day)

Emergency Room

(maximum per calendar-year)

We pay:

$200 per day

(2 days)

$200 per day

(2 days)

$300 per day

(2 days)

$300 per day

(3 days)

$300 per day

(3 days)

$500 per day

(2 days)

Ambulance-Ground or Water

(maximum per calendar-year)

We pay:

$500 per trip

(1 trip)

$500 per trip

(1 trip)

$500 per trip

(1 trip)

$500 per trip

(1 trip)

$500 per trip

(1 trip)

$1,000 per trip

(1 trip)

Ambulance-Air

(maximum per calendar-year)

We pay:

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

HEALTH PROTECTORGUARD PLANS

PAY BENEFITS FOR THESE ELIGIBLE

COMPREHENSIVE MEDICAL SERVICES:

HOSPITAL

SERVICES

SURGICAL

SERVICES

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Choice Value Choice Plus Select Value

Primary

Preferred

Select

Preferred

Premier Plus

DOCTOR VISITS

Office Visits/Urgent Care Visits for Injury

or Illness: Benefit per visit (maximum per

calendar-year)

We pay:

$100

(2 visits)

$100

(2 visits)

$100

(5 visits)

$100

(10 visits)

$100

(10 visits)

$100

(5 visits)

See rollover beneﬁ t details on page 7.

Second Surgical Opinion

(maximum per calendar-year)

We pay:

$250

(1 day)

$250

(1 day)

$500

(1 day)

$500

(1 day)

$500

(1 day)

$500

(1 day)

WELLNESS/PREVENTIVE

Wellness/Preventive Care Visit (maximum per

calendar-year after initial 6-month waiting period)*

We pay:

$100

(1 day)

$100

(1 day)

$200

(1 day)

$250

(1 day)

$250

(1 day)

$250

(1 day)

PHARMACY SERVICES

Prescription Drugs (Per Rx ﬁ ll) We pay:

Discount Card

only

Generic: $20

Brand: $40

Discount Card

only

Generic: $10

Brand: $40

Generic: $10

Brand: $40

Generic: $20

Brand: $40

Maximum Rx Fills Per calendar-year

(Combined Brand and Generic)

N/A 12 N/A

12 12 12

OUTPATIENT SERVICES

Outpatient Lab/X-ray - Non-preventive/Non-routine:

Beneﬁ t per test (maximum per calendar-year)

We pay:

$200

(1 test)

$200

(1 test)

$300

(1 test)

$100

(3 tests)

$100

(3 tests)

$300

(1 test)

Outpatient Diagnostic Imaging Services:

Beneﬁ t per test (maximum per calendar-year)

We pay:

$500

(1 test)

$500

(1 test)

$500

(1 test)

$500

(1 test)

$500

(1 test)

$1,000

(1 test)

Oral Chemotherapy: Beneﬁ t per month

(maximum per calendar-year)

We pay:

$1,000

(3 months)

$1,000

(3 months)

$1,000

(3 months)

$1,000

(3 months)

$1,000

(3 months)

$2,000

(6 months)

Outpatient Chemotherapy and Radiation - Non-Oral:

Beneﬁ t per day (maximum per calendar-year)

We pay:

$1,000

(40 days)

$1,000

(40 days)

$1,000

(40 days)

$500

(20 days)

$500

(20 days)

$2,000

(60 days)

Not available in CO and MN.

Services received for injuries (and illnesses in ID and MD) are eligible for coverage as of your client’s plan eﬀ ective date; services received due to

illnesses are eligible for coverage beginning on the 6th day following the eﬀ ective date. Preexisting conditions apply. See page 12 for details.

Waiting periods do not apply in ID and MD. There is no waiting period for a loss which results from an accident in VA.

HEALTH PROTECTORGUARD PLANS

PAY BENEFITS FOR THESE ELIGIBLE

DAY-TO-DAY MEDICAL SERVICES:

OUTPATIENT

SERVICES

DOCTOR

VISITS

WELLNESS/

PREVENTIVE

PHARMACY

SERVICES

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Oct 23 2020 11:30:09 am

Why Health ProtectorGuard?

You and your family can apply for

coverage at any time of the year since

Health ProtectorGuard is not subject

to open enrollment periods.

Hospital & Ambulance Benefits

Choice Value Choice Plus Select Value

Primary

Preferred

Select

Preferred Premier Plus

Inpatient Hospital Confinement (unlimited) We pay: $1,000 per day $2,000 per day $3,000 per day $4,000 per day $5,000 per day $5,000 per day

Increasing Injury Reimbursement*

(unlimited)

Inpatient Hospitalization

Benefits increase 25% each year, years

2-5, for injury-related hospital stays.

Year 2

We pay:

$1,250 per day $2,500 per day $3,750 per day $5,000 per day $6,250 per day $6,250 per day

Year 3 $1,500 per day $3,000 per day $4,500 per day $6,000 per day $7,500 per day $7,500 per day

Year 4 $1,750 per day $3,500 per day $5,250 per day $7,000 per day $8,750 per day $8,750 per day

Year 5 $2,000 per day $4,000 per day $6,000 per day $8,000 per day $10,000 per day $10,000 per day

Inpatient Hospital Intensive Care Unit (ICU) or

Critical Care Unit (CCU) (maximum per confinement)

We pay:

$2,000 per day

(31 days)

$4,000 per day

(31 days)

$6,000 per day

(31 days)

$2,000 per day

(60 days)

$2,000 per day

(60 days)

$10,000 per day

(31 days)

ICU/CCU beneﬁ t amounts are in addition to Inpatient Hospital Conﬁ nement beneﬁ ts.

Inpatient Physician Visits (maximum

during Inpatient Hospital Confinement)

We pay:

$100 per visit

(1 visit per day)

$100 per visit

(1 visit per day)

$100 per visit

(1 visit per day)

$100 per visit

(1 visit per day)

$100 per visit

(1 visit per day)

$100 per visit

(2 visits per day)

Emergency Room

(maximum per calendar-year)

We pay:

$200 per day

(2 days)

$200 per day

(2 days)

$300 per day

(2 days)

$300 per day

(3 days)

$300 per day

(3 days)

$500 per day

(2 days)

Ambulance-Ground or Water

(maximum per calendar-year)

We pay:

$500 per trip

(1 trip)

$500 per trip

(1 trip)

$500 per trip

(1 trip)

$500 per trip

(1 trip)

$500 per trip

(1 trip)

$1,000 per trip

(1 trip)

Ambulance-Air

(maximum per calendar-year)

We pay:

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

$5,000 per trip

(1 trip)

* Not available in OH.

Increasing Injury Reimbursement

For each year you renew your insurance

plan, your inpatient hospital confinement benefit,

specifically related to injuries, will increase. This means if anyone covered by the policy has

a hospital stay related to an injury the hospital confinement benefit is replaced with the

“Increasing Injury Reimbursement” benefit earned starting year 2 of your insurance plan. The

benefit does not compound from policy year to year. (This increase does not apply to Inpatient

Reimbursement related to sickness.)

If the effective date of coverage is prior to July 1, then the Second Year of coverage will begin on the

following January 1. If the effective date is on or after July 1, the Second Year will begin January 1 following

12 consecutive months of coverage. Subsequent years after the Second Year will begin the following January 1.

• All insurance plan options offer benefits for unlimited days of confinement

for inpatient hospital stays.

• The ICU benefit pays while confined in the intensive care unit or critical

care unit of a hospital and is paid in addition to the inpatient hospital

confinement benefit. See below for maximum days per confinement.

Hospital Services

HOSPITAL

SERVICES

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Surgical Services

Why Health ProtectorGuard?

Designed to offer simple, straight-forward

benefits, the Health ProtectorGuard

insurance plan you choose will pay the

eligible fixed-benefit amount, regardless

of the amount charged by providers.

Surgical Benefits

Choice Value Choice Plus Select Value

Primary

Preferred

Select

Preferred Premier Plus

Outpatient Facility Fee

(maximum per calendar-year)

We pay:

$500 per day

(2 days)

$500 per day

(2 days)

$1,000 per day

(2 days)

$500 per day

(3 days)

$500 per day

(3 days)

$1,000 per day

(3 days)

Surgeon: 4-Tier Surgical Schedule

(unlimited days per calendar-

year)

Tier 1

We pay:

$10,000 $10,000 $10,000 $10,000 $10,000 $10,000

Tier 2 $5,000 $5,000 $5,000 $5,000 $5,000 $5,000

Tier 3 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000

Tier 4 $500 $500 $500 $500 $500 $500

Assistant Surgeon - Surgical Schedule

Tiers 1 & 2 only (per day)

We pay: 20% of surgeon beneﬁ t schedule above

Anesthesiologist (per day) We pay: 30% of surgeon beneﬁ t schedule above

If more than one surgery in any given day, the highest tiered amount is paid. Surgeries are unlimited per calendar year, but only 1 surgeon beneﬁ t per day is paid.

The assistant surgeon beneﬁ t is paid for covered surgical services rendered by an assistant surgeon or by a licensed surgical assistant who is performing duties within the scope of

his or her license. The beneﬁ t is paid per surgery in conjunction with the Surgeon beneﬁ t.

• Surgeon benefits apply whether surgery is performed in a hospital,

an outpatient surgical facility, or a doctor’s office/clinic.

• All insurance plans have unlimited days of surgical benefits.

• Anesthesiologist benefits are paid each day anesthesia is administered

for inpatient or outpatient surgery.

SURGICAL

SERVICES

4-Tier Surgical Schedule (based on surgery type)

Tier 1 Extreme Listed Conditions: Significant, non-diagnostic, invasive

surgical procedures requiring general anesthesia and open incision.

Procedures include open heart surgery (including bypass), major organ

transplant, and brain surgery.

Tier 2 Major Listed Conditions: Non-diagnostic, open incision, surgical

procedures requiring general anesthesia. Procedures may include knee

replacement, hip replacement, rotator cuff repair, and major organ

removal or repair performed on organ within chest, abdomen or pelvic

cavity that is not included in Tier 1.

Tier 3 Non-Major Listed Conditions: Surgical procedures requiring

general anesthesia or conscious sedation such as colonoscopy, removal

of tonsils or adenoids, stent placement, insertion of pacemaker, balloon

angioplasty, heart catherization and laparoscopic hernia repair.

Tier 4 Local/Minor Listed Conditions: Surgical procedures requiring

local or regional anesthesia such as emergency C-sections and closed

treatment of a fracture or dislocation.

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Doctor Visits

Why Health ProtectorGuard?

You have the freedom to choose a licensed

doctor or hospital in the United States for

your care. When you choose a provider in the

MultiPlan Network for Limited Benefit Plans

and assign your benefits, you will benefit from

discounts on the services provided.

Rollover Benefit

If you can rollover your unused data, why not your doctor visits too? This unique

benefit allows you to rollover any unused doctor office (illness or injury) or urgent

care visits remaining at the end of a calendar year to the next calendar year.

A maximum of 5 visits are allowed to rollover. Not available in OH.

If the effective date of coverage is prior to July 1, then any eligible unused visits

may rollover on the following January 1. If the effective date is on or after July 1,

then unused visits cannot begin accruing until January 1 following 12 consecutive

months of coverage.

Doctor Visits

Choice Value Choice Plus Select Value

Primary

Preferred

Select

Preferred Premier Plus

Office Visits/Urgent Care Visits for Injury or

Illness: Benefit per visit (maximum per

calendar-year)

We pay:

$100

(2 visits)

$100

(2 visits)

$100

(5 visits)

$100

(10 visits)

$100

(10 visits)

$100

(5 visits)

See rollover beneﬁ t details below.

Second Surgical Opinion

(maximum per calendar-year)

We pay:

$250

(1 day)

$250

(1 day)

$500

(1 day)

$500

(1 day)

$500

(1 day)

$500

(1 day)

• Regardless of the charge for your doctor visit we pay the set

amounts below for eligible services.

• Urgent Care is provided at a medical facility providing immediate,

non-routine urgent care for an injury or illness treated on a walk-in basis.

DOCTOR

VISITS

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Oct 23 2020 11:30:09 am

Wellness/Preventive Care

A Wellness/Preventive care visit is eligible after a 6-month waiting period.

Services eligible under this benefit may include the following: annual physicals,

immunizations (other than a flu shot), mammograms, and blood screenings.

For Wyoming Residents:

This policy does not contain comprehensive adult wellness

benefits as defined by Wyoming law.

• Regardless of the charge for your doctor visit we pay the set amount below.

• A Wellness/Preventive care visit is eligible after a 6-month waiting period.

Why Health ProtectorGuard?

These insurance plans are guaranteed

renewable to age 65. You and your family

cannot be singled out for a rate increase or

cancellation based on changes to your

health alone. See page 12 for more details.

Plans:

Wellness/Preventive Care Benefit

Choice Value Choice Plus Select Value

Primary

Preferred

Select

Preferred Premier Plus

Wellness/Preventive Care Day (maximum per

calendar-year after initial 6-month waiting period)

We pay:

$100

(1 day)

$100

(1 day)

$200

(1 day)

$250

(1 day)

$250

(1 day)

$250

(1 day)

* This beneﬁ t is not available on plans in CO and MN.

According to the Centers for Disease Control and Prevention, “If everyone in the US received

recommended clinical preventive care, we could save over 100,000 lives each year. Preventive health

care can help you stay healthier throughout your life.”

— Centers for Disease Control and Prevention, Office of the Associate Director for Policy - Prevention, December 23, 2015

WELLNESS/

PREVENTIVE

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Pharmacy Services

Prescription Drug Discount Card

A National Prescription Savings Network (NPSN) discount card is automatically

included with every insurance plan and is free for you and your dependents to

use. Most U.S. pharmacies honor this card offering savings of up to 50-75%.

The card is pre-activated and ready to use upon receipt. The card can be used

even if the insurance plan you selected does not offer prescription benefits.

The NPSN card is not insurance. It is a discount program only.

How to receive benefits:

• Every time you get a prescription, give the pharmacist your card and

ask for discounts on your prescription drugs.

• You pay the pharmacy directly and, if your insurance plan provides

prescription benefits, submit a claim form for reimbursement.

• Reimbursement is paid directly to you and you receive the applicable

benefit amount based on the

insurance

plan you selected and type of

prescription drug (generic or brand). A listing of covered drugs is available

online at searchrx.com/UHO or by calling 1-877-890-8077.

• Name Brand and Generic medication benefits on select insurance plans.

• A Prescription Drug Discount Card is included with all insurance plans.

Why Health ProtectorGuard?

Golden Rule Insurance Company is rated “A”

(Excellent) by A.M. Best, a widely recognized

rating agency that rates insurance

companies on their relative financial

strength and stability. (08/03/17) F

or the

latest rating, access www.ambest.com.

Pharmacy Services

Choice Value Choice Plus Select Value

Primary

Preferred

Select

Preferred Premier Plus

Prescription Drugs (Per Rx ﬁ ll) We pay:

Discount Card

only

Generic: $20

Brand: $40

Discount Card

only

Generic: $10

Brand: $40

Generic: $10

Brand: $40

Generic: $20

Brand: $40

Maximum Rx Fills Per calendar-year

(Combined Brand and Generic)

N/A 12 N/A

12 12 12

PHARMACY

SERVICES

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Outpatient Services

Outpatient Lab/X-ray pays a set amount when you undergo an X-ray or lab test to

diagnose an eligible injury or illness.

Outpatient Diagnostic Imaging Services includes benefits for the following:

angiogram, arteriogram, thallium stress test, electroencephalogram (EEG),

myelogram, positron emission tomography (PET) scan, magnetic resonance

imaging (MRI), and computed tomography (CT) scan.

• Major and minor testing like labs, X-ray, and diagnostic imaging

are included.

• Outpatient chemotherapy and radiation are reimbursed at the set

amounts below.

Why Health ProtectorGuard?

There is no lifetime maximum benefit so

you may continue to receive benefits up

to the limits each year.

Testing Benefits

Choice Value Choice Plus Select Value

Primary

Preferred

Select

Preferred Premier Plus

Outpatient Lab/X-ray - Non-preventive/Non-routine:

Beneﬁ t per test (maximum per calendar-year)

We pay:

$200

(1 test)

$200

(1 test)

$300

(1 test)

$100

(3 tests)

$100

(3 tests)

$300

(1 test)

Outpatient Diagnostic Imaging Services:

Beneﬁ t per test (maximum per calendar-year)

We pay:

$500

(1 test)

$500

(1 test)

$500

(1 test)

$500

(1 test)

$500

(1 test)

$1,000

(1 test)

Treatment Benefits

Oral Chemotherapy: Beneﬁ t per month

(maximum per calendar-year)

We pay:

$1,000

(3 months)

$1,000

(3 months)

$1,000

(3 months)

$1,000

(3 months)

$1,000

(3 months)

$2,000

(6 months)

Outpatient Chemotherapy and Radiation - Non-Oral:

Beneﬁ t per day (maximum per calendar-year)

We pay:

$1,000

(40 days)

$1,000

(40 days)

$1,000

(40 days)

$500

(20 days)

$500

(20 days)

$2,000

(60 days)

OUTPATIENT

SERVICES

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Oct 23 2020 11:30:09 am

Exclusions and/or Limitations

The policy may limit or exclude benefits for any loss caused

by, resulting from, for, or relating to any of the following:

• A loss occurring before the policy effective date, after

termination of the policy, during any time that coverage is

not in force, or incurred during a waiting period.

• Any act of war; intentionally, self-inflicted, bodily harm

(whether sane or insane); or participation in a riot; or

commission or attempt to commit a felony.

• Active service in the armed forces or related auxiliaries.

• A covered person being intoxicated as defined by applicable

state law or under the influence of narcotics or controlled

substances (does not apply in MD, MI, OK, OR).

• Cosmetic treatment.

• Pregnancy or childbirth (except for complications of

pregnancy or as required by a state).

• Hospital confinement that begins on a Friday or Saturday

unless it is an emergency, or medically necessary inpatient

surgery is scheduled for the day after the date of admission.

• Hospital confinement primarily to receive rehabilitation,

custodial care, educational care, or nursing services

(unless expressly provided for by the policy).

• Any injury sustained while paid to participate or instruct

in: horseback riding, racing or speed testing, skiing, or rock

or mountain climbing.

• Any injury sustained while participating, demonstrating,

instructing, guiding, or accompanying others in: sports

(semi- or professional or intercollegiate not including

intramural sports), parachute jumping, hang gliding,

skydiving, bungee jumping, parakiting, racing or speed

testing any motorized vehicle/conveyance, rodeo sports,

or scuba/skin diving (60 or more feet in depth). Does not

apply in IL, OK, TX, VA.

• Operating a taxi or any other passenger transportation for

wage, compensation, or profit (does not apply in TX, VA).

• Routine well-baby care of a newborn infant while inpatient,

except as expressly provided for by the policy.

• Injuries sustained while operating, riding in, or descending

from any type of non-commercial aircraft. In most states,

this is only excluded if the covered person is a pilot, officer,

or member of the crew of such aircraft or is giving or

receiving any kind of training or instructions or otherwise

has any duties that require him or her to be aboard the

aircraft.

• Services performed by an immediate family member.

• Expenses/surcharges imposed by a provider (including a

hospital), but which are actually the responsibility of the

provider to pay.

• Services or supplies that are not medically necessary to

the diagnosis or treatment of an illness or injury.

• Any loss sustained while the covered person is incarcerated

in any prison or other detention facility.

• Any loss related to the treatment of mental disorders or

substance abuse (in AR, drug use disorder).

• Any loss related to an abortion (unless the life of the mother

would be endangered if the fetus were carried to term).

• Any loss for dental expenses, except as expressly provided

for by the policy.

• Any loss related to any examination or fitting related to

eyeglasses, contact lenses, hearing aids, eye refraction,

or visual therapy.

• Any services rendered outside of the U.S., except for

emergency treatment for a covered person.

• Experimental or investigational treatment(s).

• Office and/or urgent care visits that relate solely to

alternative treatments as defined by the National Center

for Complementary and Integrative Health of the National

Institute of Health.

Eligibility

At time of application, the primary insured and spouse (as

defined by state) must be between 18-64 years of age (drop

off on 65th birthday) and eligible children 0-25 years of age

(drop off on 26th birthday) or as required by state.

Basic Policy Details

State-specific differences may apply.

Other Details

(all insurance plans)

This is only a general

outline of the basic policy

provisions and exclusions.

State-specific differences

may apply. It is not an

insurance contract, nor

part of the insurance

policy. You will find

complete details in the

policy.

This brochure may be used in

the following states:

Alabama

Alaska

Arizona

Arkansas

Colorado

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kentucky

Louisiana

Maine

Maryland

Michigan

Minnesota

Mississippi

Missouri

Nebraska

Nevada

North Carolina

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

Tennessee

Texa s

Utah

Virginia

West Virginia

Wisconsin

Wyoming

11 of 16

Oct 23 2020 11:30:09 am

THIS IS NOT QUALIFYING HEALTH CARE COVERAGE (“MINIMUM ESSENTIAL COVERAGE”)

THAT SATISFIED THE HEALTH COVERAGE REQUIREMENT OF THE AFFORDABLE CARE ACT.

Misstatement of Age, Gender, or Tobacco Use

If the covered person’s age, gender, or use of tobacco

has been misstated on the covered person’s application

for coverage under the policy, any future premiums may be

adjusted and past premiums may be refunded or owed to

us based on the correct gender or tobacco status. (VA only

- If age is misstated, benefits will be based on what the

premium paid would have purchased at the correct age.)

If a covered person’s age has been misstated and we would

not have issued coverage for that covered person, we will

refund the premium paid minus any benefit amounts paid

by us, and coverage would be void from the effective date.

Notice of Claim

We must receive notice of claim within 30 days of the date

the loss began or as soon as reasonably possible.

Premium

Premium rates are guaranteed for 12 months then subject

to change. The age, gender, and tobacco class of a

covered person and type and level of coverage are some

factors that could be used to determine your premium rate.

You will be given at least a 31-day notice (or longer if

required by your state) of any change in your premium. We

will make no change in your premium solely because of

claims made by a covered person under the policy or a

change in a covered person’s health.

Preexisting Conditions

We will not pay benefits under the policy for a loss which

manifests due to, results from, is caused by, or contributed

to a preexisting condition. The preexisting condition

limitation will not apply longer than 12 months (or as

required by state) after a covered person’s applicable

effective date under the policy.

“Preexisting condition” means an illness, injury or condition:

• For which medical advice, diagnosis, care, or treatment

was recommended to or received by a covered person

within 12 months immediately preceding the effective date

the covered person became insured under the policy; or

• That manifested symptoms which would cause an

ordinarily prudent person to seek diagnosis or treatment

within the 12 months immediately preceding the applicable

effective date the covered person became insured under

the policy, except in CO, NE, or NC.

Renewability and Termination

The policy is renewable until the earliest of the following:

• The primary insured’s 65th birthday (or next premium due

date, dependent on state) or death. If the policy includes

dependents, it may be continued after the primary

insured’s death or 65th birthday:

- By the spouse, if a covered person

- Otherwise, by an eligible child who is a covered person;

• Nonpayment of premiums when due.

• The date we receive a request from you to terminate the

policy; or

• The date there is fraud or a misrepresentation made by or

with the knowledge of a covered person.

Underwriting

Insurance plans are subject to health underwriting.

If you provide incorrect or incomplete information on your

application for insurance your coverage may be voided or

claims denied.

Waiting Periods

• There is a 5-day waiting period before benefits will be

payable due to an illness. Services received due to

illnesses are eligible for coverage beginning on the 6th day

following the effective date. Does not apply in ID or MD.

• There is a 6-month waiting period before benefits are

payable for the Wellness/Preventive Care benefit.

The waiting period does not apply in ID or MD. In TN, the

waiting period is changed to 30 days.

• There is no waiting period for a loss which results from an

accident in VA.

Other Details

(all insurance plans)

This is only a general

outline of the basic policy

provisions and exclusions.

State-specific differences

may apply. It is not an

insurance contract, nor

part of the insurance

policy. You will find

complete details in the

policy.

This brochure may be used in

the following states:

Alabama

Alaska

Arizona

Arkansas

Colorado

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kentucky

Louisiana

Maine

Maryland

Michigan

Minnesota

Mississippi

Missouri

Nebraska

Nevada

North Carolina

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

Tennessee

Texa s

Utah

Virginia

West Virginia

Wisconsin

Wyoming

12 of 16

Oct 23 2020 11:30:09 am

HEALTH PLAN NOTICES OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

MEDICAL INFORMATION PRIVACY NOTICE

(Effective January 1, 2019)

We (including our affiliates listed at the end of this notice) are required by law to protect

the privacy of your health information. We are also required to send you this notice, which

explains how we may use information about you and when we can give out or “disclose”

that information to others. You also have rights regarding your health information that are

described in this notice. We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we

maintain that reasonably can be used to identify you and that relates to your physical or

mental health condition, the provision of health care to you, or the payment for such

health care. We will comply with the requirements of applicable privacy laws related to

notifying you in the event of a breach of your health information.

We have the right to change our privacy practices and the terms of this notice. If we make

a material change to our privacy practices, we will provide to you in our next annual distribution,

either a revised notice or information about the material change or how to obtain a revised

notice. We will provide this information either by direct mail or electronically in accordance

with applicable law. In all cases, we will post the revised notice on our websites, such as

www.uhone.com, www.myuhone.com, www.uhone4me.com, www.myallsavers.com, or

www.myallsaversconnect.com.

We reserve the right to make any revised or changed notice

effective for information we already have and for information that we receive in the future.

We collect and maintain oral, written and electronic information to administer our

business and to provide products, services and information of importance to our

customers. We maintain physical, electronic and procedural security safeguards in the

handling and maintenance of our enrollees’ information, in accordance with applicable

state and Federal standards, to protect against risks such as loss, destruction or misuse.

How We Use or Disclose Information.

We must

use and disclose your health information to

provide information:

• To you or someone who has the legal right to act for you (your personal representative)

in order to administer your rights as described in this notice; and

• To the Secretary of the Department of Health and Human Services, if necessary, to

make sure your privacy is protected.

We have the right to

use and disclose health information for your treatment, to pay for

your health care and operate our business. For example, we may use or disclose your

health information:

•

For Payment

of premiums due us, to determine your coverage and to process claims for

health care services you receive including for subrogation or coordination of other

benefits you may have. For example, we may tell a doctor whether you are eligible for

coverage and what percentage of the bill may be covered.

•

For Treatment.

We may use or disclose health information to aid in your treatment or the

coordination of your care. For example, we may disclose information to your physicians

or hospitals to help them provide medical care to you.

•

For Health Care Operations.

We may use or disclose health information as necessary to

operate and manage our business activities related to providing and managing your

health care coverage. For example, we might conduct or arrange for medical review, legal

services, and auditing functions, including fraud and abuse detection or compliance

programs. We may also de-identify health information in accordance with applicable

laws. After that information is de-identified, the information is no longer subject to this

notice and we may use the information for any lawful purpose.

•

To Provide Information on Health Related Programs or Products

such as alternative medical

treatments and programs or about health-related products and services.

•

To Plan Sponsors.

If your coverage is through an employer group health plan, we may

share summary health information and enrollment and disenrollment information with

the plan sponsor. In addition, we may share other health information with the plan

sponsor for plan administration if the plan sponsor agrees to special restrictions on its

use and disclosure of the information in accordance with Federal law.

•

For Underwriting Purposes.

We may use or disclose your health information for underwriting

purposes; however, we will not use or disclose your genetic information for such purposes.

•

For Reminders.

We may use or disclose health information to contact you for

appointment reminders with providers who provide medical care to you.

We may

use or disclose your health information for the following purposes under limited

circumstances:

•

As Required by Law.

We may disclose information when required to do so by law.

•

To Persons Involved With Your Care.

We may use or disclose your health information to a

person involved in your care, such as a family member, when you are incapacitated or in

an emergency, or when you agree or fail to object when given the opportunity. If you are

unavailable or unable to object we will use our best judgment to decide if the disclosure is in

your best interests. Special rules apply regarding when we may disclose health

information to family members and others involved in a deceased individual’s care. We may

disclose health information to any persons involved, prior to the death, in the care or

payment for care of a deceased individual, unless we are aware that doing so would be

inconsistent with a preference previously expressed by the deceased.

•

For Public Health Activities

such as reporting disease outbreaks to a public health authority.

•

For Reporting Victims of Abuse, Neglect or Domestic Violence

to government authorities,

including a social service or protective service agency.

•

For Health Oversight Activities

such as licensure, governmental audits and fraud and

abuse investigations.

•

For Judicial or Administrative Proceedings

such as in response to a court order, search

warrant or subpoena.

•

For Law Enforcement Purposes

such as providing limited information to locate a missing

person or report a crime.

•

To Avoid a Serious Threat to Health or Safety

by, for example, disclosing information to public

health agencies or law enforcement authorities, or in the event of an emergency or

natural disaster.

33638-X-201902

Products are either underwritten or administered by: All Savers Insurance Company, All Savers Life Insurance Company of California, Golden Rule

Insurance Company, Oxford Health Insurance, Inc., UnitedHealthcare Insurance Company, and/or UnitedHealthcare Life Insurance Company.

13 of 16

Oct 23 2020 11:30:09 am

•

For Specialized Government Functions

such as military and veteran activities, national

security and intelligence activities, and the protective services for the President and

others.

•

For Workers’ Compensation

including disclosures required by state workers’ compensation

laws that govern job-related injury or illness.

•

For Research Purposes

such as research related to the prevention of disease or disability,

if the research study meets Federal privacy law requirements.

•

To Provide Information Regarding Decedents.

We may disclose information to a coroner or

medical examiner to identify a deceased person, determine a cause of death, or as

authorized by law. We may also disclose information to funeral directors as necessary

to carry out their duties.

•

For Organ Procurement Purposes.

We may use or disclose information to entities that

handle procurement, banking or transplantation of organs, eyes or tissue to facilitate

donation and transplantation.

•

To Correctional Institutions or Law Enforcement Officials

if you are an inmate of a

correctional institution or under the custody of a law enforcement official, but only if

necessary (1) for the institution to provide you with health care; (2) to protect your health

and safety or the health and safety of others; or (3) for the safety and security of the

correctional institution.

•

To Business Associates

that perform functions on our behalf or provide us with services if

the information is necessary for such functions or services. Our business associates

are required, under contract with us and pursuant to Federal law, to protect the privacy

of your information and are not allowed to use or disclose any information other than

as specified in our contract and as permitted by Federal law.

•

Additional Restrictions on Use and Disclosure.

Certain Federal and state laws may require

special privacy protections that restrict the use and disclosure of certain health

information, including highly confidential information about you. Such laws may

protect the following types of information: Alcohol and Substance Abuse, Biometric

Information, Child or Adult Abuse or Neglect, including Sexual Assault, Communicable

Diseases, Genetic Information, HIV/AIDS, Mental Health, Minors’ Information,

Prescriptions, Reproductive Health, and Sexually Transmitted Diseases.

If a use or disclosure of health information described above in this notice is prohibited

or materially limited by other laws that apply to us, it is our intent to meet the

requirements of the more stringent law.

Except for uses and disclosures described and limited as set forth in this notice, we will

use and disclose your health information only with a written authorization from you. This

includes, except for limited circumstances allowed by Federal privacy law, not using or

disclosing psychotherapy notes about you, selling your health information to others or

using or disclosing your health information for certain promotional communications that

are prohibited marketing communications under Federal law, without your written

authorization. Once you give us authorization to release your health information, we

cannot guarantee that the person to whom the information is provided will not disclose

the information. You may take back or “revoke” your written authorization, except if we

have already acted based on your authorization. To revoke an authorization, call the phone

number listed on your health plan ID card.

What Are Your Rights.

The following are your rights with respect to your health information.

•

You have the right to ask to restrict

uses or disclosures of your information for treatment,

payment, or health care operations. You also have the right to ask to restrict

disclosures to family members or to others who are involved in your health care or

payment for your health care. We may also have policies on dependent access that

may authorize certain restrictions.

Please note that while we will try to honor your request

and will permit requests consistent with our policies, we are not required to agree to any restriction.

•

You have the right to ask to receive confidential communications

of information in a different

manner or at a different place (for example, by sending information to a

PO Box instead of your home address). We will accommodate reasonable requests

where a disclosure of all or part of your health information otherwise could endanger

you. In certain circumstances, we will accept verbal requests to receive confidential

communications; however, we may also require you to confirm your request in writing.

In addition, any request to modify or cancel a previous confidential communication

request must be made in writing. Mail your request to the address listed below.

•

You have the right to see and obtain a copy

of health information that we maintain about you

such as claims and case or medical management records. If we maintain your health

information electronically, you will have the right to request that we send a copy of your

health information in an electronic format to you. You can also request that we provide a

copy of your information to a third party that you identify. In some cases you may receive

a summary of this health information. You must make a written request to inspect and

copy your health information or have it sent to a third party. Mail your request to the

address listed below. In certain limited circumstances, we may deny your request to

inspect and copy your health information. If we deny your request, you may have the right

to have the denial reviewed. We may charge a reasonable fee for any copies.

•

You have the right to ask to amend information

we maintain about you such as claims and

case or medical management records, if you believe the health information about you is

wrong or incomplete. Your request must be in writing and provide the reasons for the

requested amendment. Mail your request to the address listed below.

If we deny your request, you may have a statement of your disagreement added to your

health information.

•

You have the right to receive an accounting

of certain disclosures of your information

made by us during the six years prior to your request. This accounting will not include

disclosures of information: (i) for treatment, payment, and health care operations

purposes; (ii) to you or pursuant to your authorization; and (iii) to correctional institutions

or law enforcement officials; and (iv) other disclosures for which Federal law does not

require us to provide an accounting.

33638-X-201902

Products are either underwritten or administered by: All Savers Insurance Company, All Savers Life Insurance Company of California, Golden Rule

Insurance Company, Oxford Health Insurance, Inc., UnitedHealthcare Insurance Company, and/or UnitedHealthcare Life Insurance Company.

14 of 16

Oct 23 2020 11:30:09 am

•

You have the right to a paper copy of this notice.

You may ask for a copy of this notice at

any time. Even if you have agreed to receive this notice electronically, you are still

entitled to a paper copy of this notice. In addition, you may obtain a copy of this notice at

our websites such as

www.uhone.com, www.myuhone.com, www.uhone4me.com,

www.myallsavers.com, or www.myallsaversconnect.com.

•

You have the right to be considered a protected person.

(New Mexico only)

A “protected person” is a victim of domestic abuse who also is either: (i) an applicant

for insurance with us; (ii) a person who is or may be covered by our insurance; or

(iii) someone who has a claim for benefits under our insurance.

Exercising Your Rights

•

Contacting your Health Plan.

If you have any questions about this notice or want to

exercise any of your rights, you may contact a UnitedHealthOne Customer Call Center

Representative. For Golden Rule members call us at 800-657-8205 (TTY 711). For All

Savers members, call us at 1-800-291-2634 (TTY 711).

•

Filing a Complaint.

If you believe your privacy rights have been violated, you may file a

complaint with us at the address listed below.

•

Submitting a Written Request.

Mail to us your written requests to exercise any of your

rights, including modifying or cancelling a confidential communication, requesting copies

of your records, or requesting amendments to your record at the following address:

• Privacy Office, 7440 Woodland Drive, Indianapolis, IN 46278-1719

•

You may also notify the Secretary of the U.S. Department of Health and Human Services of your

complaint.

We will not take any action against you for filing a complaint.

Fair Credit Reporting Act Notice.

In some cases, we may ask a consumer-reporting

agency to compile a consumer report, including potentially an investigative consumer

report, about you. If we request an investigative consumer report, we will notify you

promptly with the name and address of the agency that will furnish the report. You may

request in writing to be interviewed as part of the investigation. The agency may retain a

copy of the report. The agency may disclose it to other persons as allowed by the

Federal Fair Credit Reporting Act.

We may disclose information solely about our transactions or experiences with you to our

affiliates.

MIB.

In conjunction with our membership in MIB, Inc., formerly known as Medical

Information Bureau (MIB), we or our reinsurers may make a report of your personal

information to MIB. MIB is a not-for-profit organization of life and health insurance

companies that operates an information exchange on behalf of its members.

If you submit an application or claim for benefits to another MIB member company for

life or health insurance coverage, the MIB, upon request, will supply such company

with information regarding you that it has in its file.

If you question the accuracy of information in the MIB’s file, you may seek a correction

in accordance with the procedures set forth in the Federal Fair Credit Reporting Act.

Contact MIB at: MIB, Inc., 50 Braintree Hill Park Ste. 400, Braintree, MA 02184-8734,

1-866-692-6901,

www.mib.com.

FINANCIAL INFORMATION PRIVACY NOTICE

(Effective January 1, 2019)

We (including our affiliates listed at the end of this notice) are committed to maintaining

the confidentiality of your personal financial information. For the purposes of this

notice, “personal financial information” means information, other than health

information, about an insured or an applicant for coverage that identifies the individual,

is not generally publicly available and is collected from the individual or is obtained in

connection with providing coverage to the individual.

Information We Collect.

Depending upon the product or service you have with us, we may

collect personal financial information about you from the following sources:

• Information we receive from you on applications or other forms, such as name,

address, age, medical information and Social Security number;

•

Information about your transactions with us, our affiliates or others, such as premium

payment and claims history; and

•

Information from a consumer reporting agency.

Disclosure of Information.

We do not disclose personal financial information about our

insureds or former insureds to any third party, except as required or permitted by law.

For example, in the course of our general business practices, we may, as permitted by

law, disclose any of the personal financial information that we collect about you,

without your authorization, to the following types of institutions:

• To our corporate affiliates, which include financial service providers, such as other

insurers, and non-financial companies, such as data processors;

• To nonaffiliated companies for our everyday business purposes, such as to process

your transactions, maintain your account(s), or respond to court orders and legal

investigations; and

• To nonaffiliated companies that perform services for us, including sending promotional

communications on our behalf.

We restrict access to personal

financial information about you to employees, affiliates and

service providers who are involved in administering your health care coverage or

providing services to you. We maintain physical, electronic and procedural safeguards

that comply with Federal standards to guard your personal financial information.

Confidentiality and Security. We maintain physical, electronic and procedural

safeguards, in accordance with applicable state and Federal standards, to protect

your personal financial information against risks such as loss, destruction or misuse.

These measures include computer safeguards, secured files and buildings, and

restrictions on who may access your personal financial information.

Questions About this Notice.

If you have any questions about this notice, you may contact a

UnitedHealthOne Customer Call Center Representative. For Golden Rule members call us

at 1-800-657-8205 (TTY 711). For All Savers members, call us at 1-800-291-2634 (TTY 711).

The Notice of Privacy Practices, effective January 1, 2019, is provided on behalf of All

Savers Insurance Company; All Savers Life Insurance Company of California; Golden

Rule Insurance Company; Oxford Health Insurance, Inc.; UnitedHealthcare Insurance

Company; and UnitedHealthcare Life Insurance Company. To obtain an authorization to

release your personal information to another party, please go to the appropriate

website listed in this Notice.

33638-X-201902

Products are either underwritten or administered by: All Savers Insurance Company, All Savers Life Insurance Company of California, Golden Rule

Insurance Company, Oxford Health Insurance, Inc., UnitedHealthcare Insurance Company, and/or UnitedHealthcare Life Insurance Company.

15 of 16

Oct 23 2020 11:30:09 am

Conditions Prior To Coverage (Applicable with or without the Conditional Receipt)

Subject to the limitations shown below, insurance will become effective if the following conditions are met:

1. The application is completed in full and is unconditionally accepted and approved by Golden Rule Insurance Company.

2. The first full premium, according to the mode of premium payment chosen, has been paid on or prior to the effective date, and any check is honored on first

presentation for payment.

3. The policy is: (a) issued by Golden Rule Insurance Company exactly as applied for within 45 days from date of application; (b) delivered to the proposed insured;

and (c) accepted by the proposed insured.

Failure to include all material medical information or correct information regarding the tobacco use of any applicant may cause the Company to deny a future

claim and to void your coverage as though it has never been in force. After you have completed the application and before you sign it, reread it carefully.

Be certain that all information has been properly recorded.

Keep this document. It has important information.

45173-G-1120

I authorize Golden Rule Insurance Company’s (GRIC) New Business and

Medical History Review departments to obtain health information that they need

to underwrite or verify my application for insurance. Any health care provider,

pharmacy benefit manager, consumer-reporting agency, MIB, Inc., formerly

known as Medical Information Bureau (MIB), or insurance company having any

information as to a diagnosis, the treatment, or prognosis of any physical or

mental conditions about my family or me is authorized to give it to GRIC’s New

Business and Medical History Review departments. This includes information

related to substance use or abuse.

I understand any existing or future requests I have made or may make to restrict

my protected health information do not and will not apply to this authorization,

unless I revoke this authorization.

GRIC may release this information about my family or me to the MIB or any

member company for the purposes described in GRIC’s Notice of Privacy

Practices.

I (we) have received GRIC’s Notice of Privacy Practices.

This authorization shall remain valid for 30 months from the date below.

I (we) understand the following:

• A photocopy of this authorization is as valid as the original;

• I (we) or my (our) authorized representative may obtain a copy of this

authorization by writing to GRIC;

• I (we) may request revocation of this authorization as described in GRIC’s Notice

of Privacy Practices;

• GRIC may condition enrollment in its health plan or eligibility for benefits on my

(our) refusal to sign this authorization;

• The information that is used or disclosed in accordance with this authorization

may be redisclosed by the receiving entity and may no longer be protected by

federal or state privacy laws regulating health insurers.

I have retained a copy of this authorization.

052F-G-0816

Authorization to Obtain and Disclose Health Information

16 of 16

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