Fill - Free fillable Table of Contents FL IN MS NE TN (United Healthcare) PDF form

Table of Contents

What is TriTerm Medical? 2

Plan Information 3

Network 4

Options & Other Products 5

Benefits 6

Exclusions & Limitations 9

Plan Provisions 11

State Variations 13

Notice of Privacy Practices 18

FACT Information 21

FL TriTerm Medical Value

Insert 22

States:

FL IN

MS NE TN

TX WV

NOTICE - This brochure

includes two parts:

• 45746E-G-1221 (pages

1-21) applies to all TriTerm

Medical plans in the states

listed in upper left corner

of this page EXCEPT

Florida TriTerm Medical

Value plans.

• 45746iFL-G-0121 (pages

22-30) applies to Florida

TriTerm Medical Value

plans ONLY.

45746C1-G-1221

Health insurance available only to members of FACT. These health insurance plans are issued as association group plans and available only to members of FACT, the Federation of

American Consumers and Travelers. Golden Rule Insurance Company is the underwriter and administrator of these plans. See last page for more FACT details.

This coverage is not an Affordable Care Act (ACA) plan. See page 9 of this brochure for information about Exclusions and Limitations, followed by state variations. This is a general

summary. This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check

your certificate carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency

services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your certificate might also have lifetime and/or annual dollar

limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.

Certiﬁcate Forms GRI-STAG-EXT1B-E-C-VAL (applies to Value plans where available, except Florida), GRI-STAG-EXT1B-E-C (applies to all other plans), and other state variations

TriTerm Medical Plans

INTERNET/FMO

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What is TriTerm Medical? 3-Year Short Term

TERMS

Apply once for insurance coverage terms that equal one day less than 3 years.*

$2 million lifetime maximum benefit per covered person.

Eligible expenses for preexisting conditions are covered after 12 months on the plan.

PREVENTIVE CARE

COVERAGE

You don’t have to be sick to access care

with most TriTerm Medical plans. After

6 months on the plan, take your family to

the doctor for wellness checks — a $200

beneﬁt per term, per person.

DOCTOR OFFICE

COVERAGE

Doctor visits are covered on most

TriTerm Medical plans. With some

plans, you pay a $50 copay for the

ﬁrst 4 doctor visits (per term, per

person) with no deductible to meet.

PRESCRIPTION

DRUGS

Most TriTerm Medical plans have

prescription coverage. Copay

Select plans have a $25 copay

for common (Tier 1) prescriptions.

This is an outline only and is not intended to serve as a legal interpretation of benefits. Reasonable effort 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. It is important to note there are State Variations, Exclusions and/or Limitations, and Plan Provisions. This plan is

medically underwritten. No benefits will be paid during the first 12 months for a health condition that exists prior to the date insurance takes effect.

*Indiana only: Each term equals 364 days.

TERM 1

364 DAYS

TERM 2

365 DAYS*

TERM 3

365 DAYS*

TERMS

Nov 12 2021 08:13:42 am

TERMS

TERM 1

364 DAYS

TERM 2

365 DAYS

TERM 3

365 DAYS

TERMS

Plan 80 Max

Earliest effective date is 5 days after application.

Plan 80 Max Plan 100 Max

Value

(Available in IN, MS, NE & TX;

for FL, see insert)

Copay Select Max

Deductible (per person, per term; max 2 per family)

You pay

up to:

$2,500, $5,000, $7,500,

$10,000 or $12,500

$2,500, $5,000, $7,500,

$10,000 or $12,500

$5,000, $7,500,

$10,000 or $12,500

$2,500, $5,000, $7,500,

$10,000, $12,500 or $15,000

Coinsurance (% you pay after deductible, per term)

You pay:

30% 20% 0% 30% or 50%

Coinsurance Out-of-Pocket Maximum

(after deductible, per person, per term)

You pay

up to:

$4,500 $2,000 $0 $10,000

Maximum Beneﬁt (per person, lifetime

)

We pay

up to:

$2 million $2 million $2 million $2 million

Medical

Doctor Oﬃce Visit, History, and Exam only

(per person, per term)

You pay:

$50 copay for

ﬁrst 4 visits

20% after deductible

No charge

after deductible

Chosen coinsurance

after deductible

Urgent Care Center $75 copay $75 copay

Preventive Care

($200 max beneﬁt per person,

per term, after 6-month waiting period for term 1 only)

$50 copay

Preventive Care

Not Covered

Emergency Room (Accident and Illness) (for illness

only: additional $500 deductible if not admitted)

After deductible: 30%

Chosen coinsurance

after deductible

Inpatient Hospital Services,

Outpatient Surgery, Labs & X-rays

After deductible: 30%

Chosen coinsurance

after deductible

Pharmacy

Outpatient Prescription

(Rx) Drugs

($5,000 max covered

expenses per person,

per term)

Tier 1

You pay:

$25 copay

20% after deductible

Using the member ID card,

you pay for prescriptions

at the point of sale, at the

lowest price available.

No charge

after deductible

Using the member ID card,

you pay for prescriptions

at the point of sale, at the

lowest price available.

Not Covered

Discount card provided.

Rx Deductible

(per person, per term)

$500 deductible, then:

Tier 2 $55 copay

Tier 3 $75 copay

Tier 4 50% after Rx deductible

Add Supplemental Accident Beneﬁt

Matches medical deductible selected (page 11)

We pay

up to:

$2,500, $5,000, $7,500,

$10,000, or $12,500

$2,500, $5,000, $7,500,

$10,000, or $12,500

$5,000, $7,500,

$10,000, or $12,500

$2,500, $5,000, $7,500,

$10,000, $12,500 or $15,000

Earliest eﬀective date is 5 days after application. The amount of beneﬁts provided depends upon the plan selected, and the premium will vary with the amount of beneﬁts selected.

These plans only pay beneﬁts for eligible expenses from a network provider. See details on page 4. Copays do not apply to deductible, coinsurance, or coinsurance out-of-pocket

maximum. This coverage does not qualify as “Minimum Essential Coverage” as deﬁned in the Aﬀordable Care Act and may not cover all Essential Health Beneﬁts in your state.

For Indiana

plans: each term equals 364 days; Maximum Beneﬁt is per person, per term.

Subsequent visits are subject to deductible then coinsurance. Doctor oﬃce visit copays are for injury and illness

and cannot be used for preventive services, other than those required due to state mandates.

Preventive Care beneﬁt does not include Children’s Preventive Health Services (CPHS). For

CPHS beneﬁts, see page 6.

Discounts vary by pharmacy, geographic area, and Rx drug.

Additional premium required.

Highlights of Covered

Network Expenses

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Nov 12 2021 08:13:42 am

TERMS

UnitedHealth Group Annual Form 10-K for year ended 12/31/20.

Access to a Wide Network

of Care & Cost-Saving

Get the most out of your beneﬁts by staying in network. We help make it easier with:

Nationwide Network

Use any doctor in your network

across the nation. See any

network specialist without

needing a referral.

Access to Quality Care from:

1.4 million physicians and other

health care professionals.

More than 6,500 hospitals

and other facilities.

No Balance Billing

Network providers will not

charge you more than the

network-negotiated rate.

In-network providers agree

to provide quality care at

lower cost to you.

Visit UHOne.com and

select Find A Doctor

to search for network

providers in your state.

UnitedHealthcare

Choice Network

These plans only pay benefits for

eligible expenses from a network

provider. There are no non-network

benefits. No benefits are payable for

non-emergency care from a non-

network provider. Emergency treatment

from a non-network provider will be

treated as a network eligible service.

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Nov 12 2021 08:13:42 am

Additional premium is required for the coverage above. Accident ProGap, Dental & Vision require separate applications, and separate policies are issued.

If Supplemental Accident is added to the TriTerm Medical plan, you cannot be issued an Accident ProGap plan. Product design and availability

may vary by state. For costs, beneﬁts, exclusions, limitations, eligibility, waiting periods and renewal terms, contact your broker.

TERMS

More Coverage Choices

Underwritten by Golden Rule Insurance Company (GRIC)

ACCIDENT PROGAP

Need more than just accident coverage?

A standalone Accident ProGap plan takes

the next step by combining Accident

Expense insurance with beneﬁts for critical

illness, hospitalization from sickness, and

accidental death and dismemberment, as well.

This plan pairs well with a medical plan to

help with out-of-pocket costs like deductibles.

DENTAL & VISION

Additionally, consider coverage for those

frequent family expenses with standalone

Dental & Vision insurance. Dental plans

help take care of your smile with beneﬁts

for services ranging from routine cleanings

to root canals. Vision plans cover routine

eye exams and can help pay for glasses,

contacts or both.

OPTIONAL SUPPLEMENTAL

ACCIDENT BENEFIT

Reduce or eliminate your out-of-pocket

exposure for accident-related injuries.

Supplemental Accident helps cover your

deductible or other out-of-pocket medical

expenses (before the health insurance starts

paying covered expenses) for unexpected

injuries. See page 11 for details.

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Medical Benefits

(insurance plans)

The following medical

benefits are provided using

network providers and are

subject to Plan Provisions,

Exclusions and/or Limitations,

the deductible, any

applicable copay or

coinsurance, and all policy

provisions (unless otherwise

stated). Some state

exceptions may apply (see

State Variations.) You will find

complete coverage details in

the certificate.

TERMS

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Ambulance Services

• Ground ambulance service to the nearest hospital that can

provide services for necessary emergency care.

• Air ambulance services requested by police or medical

authorities at the site of emergency or in locations that

cannot be reached by ground ambulance.

Cancer Treatment Expenses

• Radiation therapy and chemotherapy.

• Expenses in connection with a mastectomy for a covered

person who elects breast reconstruction, including all

stages of reconstruction of the breast on which the

mastectomy has been performed; surgery and

reconstruction of the other breast to produce a symmetrical

appearance; and prostheses and treatment for physical

complications of mastectomy, including lymphedemas.

• The cost of one wig per covered person, up to $500, necessitated

by hair loss due to cancer treatments or traumatic burns.

• One mastectomy bra per year if the covered person has

undergone a covered mastectomy.

Children’s Preventive Health Services

Services for any covered person eligible by reason of age,

subject to deductible and coinsurance. Immunization services

that qualify as children’s preventive health care services are

exempt from any deductible amounts, coinsurance

provisions, or copayment amounts.These benefits are not

subject to the $200 Preventive Care maximum benefit.

Dental Injuries

Dental expenses for an injury to natural teeth suffered after

the coverage effective date. Expenses must be incurred

within 6 months of the accident.

No beneﬁts payable for injuries due to chewing.

Diabetes

• Diabetes equipment, supplies, and services.

• Diabetes self-management training and education when

medically necessary as determined by physician or health

care professional. Limited to one training program per person,

per lifetime, unless additional training is prescribed due to a

significant change in symptoms or condition.

Diagnostic Testing

Testing using radiologic, ultrasonographic, or laboratory

services (psychometric, behavioral and educational testing

are not included).

Doctor Oﬃce Visit Copay (History and Exam only)

For Copay plans only, copay of $50 per office visit for

treatment, excluding surgery, performed by a doctor,

limited to 4 visits per person, per term. Additional office

visits will be subject to the applicable deductible amount

and coinsurance percentage. The office visit copayment

amount does not apply to office visits for preventive care

services.

Durable Medical Equipment

• Rental of standard non-motorized wheelchair, hospital bed,

standard walker, wheelchair cushion, or ventilator.

• Cost of one Continuous Passive Motion (CPM) machine per

covered person following a covered joint surgery.

Home Health Care

To qualify for benefits, home health care must be provided

through a licensed home health-care agency. Covered

expenses for home health aide services will be limited to 7

visits per week and a lifetime maximum of 365 visits.

Benefits for home health care will not extend beyond the

term of your plan. Each 8-hour period of home health aide

services will be counted as one visit. Private duty

registered nurse services will be limited to a lifetime

maximum of 1,000 hours. Intermittent private duty

registered nurse visits are not to exceed 4 hours each and

are limited to $75 per visit (2 hours per visit are applied

toward the lifetime maximum for private-duty nursing).

No beneﬁts payable for respite care, custodial care, or

educational care.

Hospice Care

To qualify for benefits, a hospice for a terminally ill covered

person must be licensed by the state in which it operates.

Benefits for inpatient care in a hospice are subject to

deductible and coinsurance and limited to 180 days in a

covered person’s lifetime.

Nov 12 2021 08:13:42 am

Hospice Care, continued

Covered expenses for room and board are limited to the

most common semiprivate room rate of the hospital or

nursing home with which the hospice is associated (or $200

per day maximum if not associated with hospital or nursing

home). Bereavement counseling maximum of $250.

Hospital Services

Daily hospital room and board at most common

semiprivate rate; eligible expenses for an intensive care

unit; inpatient use of an operating, treatment, or recovery

room; outpatient use of an operating, treatment, or

recovery room for surgery; services and supplies, including

drugs and medicines, which are routinely provided in the

hospital to persons for use only while they are inpatients;

emergency treatment of an injury or illness. Covered

expenses for use of the emergency room are subject to an

additional $500 deductible for each emergency room visit

for an illness unless the covered person is directly

admitted to the hospital for further treatment of that illness.

Hospital does not include a nursing or convalescent home

or an extended care facility.

Medical Supplies

• Dressings and other necessary medical supplies.

• Cost and administration of an anesthetic or oxygen.

Outpatient Surgery

Surgery in a doctor’s office or at an outpatient surgical

facility, including services and supplies.

Physician Fees

• Professional fees of doctors, medical practitioners,

and surgeons.

• Assistant surgeon fee limited to 16% of eligible expenses of

the procedure.

Preventive Care (excluding Value plans)

Preventive care expenses, including but not limited to

immunizations, urinalysis and blood tests, bone density

screenings, Electrocardiograms (EKG’s), cardiac stress

tests, mammography screenings, cervical and pap smears,

Human Papillomavirus (HPV) screenings and vaccinations,

and ovarian cancer surveillance tests. Limited to a maximum

benefit of $200 per covered person, per term. Covered

expenses provided under the Medical Benefits provision will

not be applied to this maximum. Preventive Care does not

include computerized axial tomography (CAT or CT scan),

magnetic resonance imaging (MRI), positron emission

tomography (PET scan) performed on a routine or preventive

basis, or Children’s Preventive Health Services. For

Children’s Preventive Health Services, see page 6.

Prosthetics

Artificial eyes or larynx, breast prosthesis, orthotic and

prosthetic devices/services. Orthotic and prosthetic

devices/services limited to one device/service or

replacement every 3 years unless proven to be medically

necessary. If more than one device can meet covered

person’s functional needs, only the charge for the most

cost effective device will be considered a covered expense.

Reconstructive Surgery

• Reconstructive surgery incidental to or following surgery or

an injury that was covered under the certificate or is performed

to correct a birth defect in a child who has been a covered

person from its birth until the date surgery is performed.

• Reconstructive craniofacial surgery and related services for

a covered person of any age diagnosed as having a

craniofacial anomaly if the surgery is medically necessary to

improve functional impairment that results from the

craniofacial anomaly, as determined by a nationally approved

cleft-craniofacial team, approved by the American Cleft

Palate-Craniofacial Association in Chapel Hill, North Carolina.

Rehabilitation and Extended Care Facility (ECF)

To qualify for benefits, a Rehabilitation or Extended Care

Facility must be licensed by the state in which it operates.

Services or confinement must begin within 14 days of a

3-day or more hospital stay, for the same illness or injury.

Combined policy max of 60 days per person, per term for

both rehabilitation and ECF expenses. This benefit

excludes mental disorders or substance abuse.

Medical Benefits

(insurance plans)

The following medical

benefits are provided using

network providers and are

subject to Plan Provisions,

Exclusions and/or Limitations,

the deductible, any

applicable copay or

coinsurance, and all policy

provisions (unless otherwise

stated). Some state

exceptions may apply (see

State Variations.) You will find

complete coverage details in

the certificate.

TERMS

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Spine and Back Disorders

All plans except Value:

$5,000 maximum covered expenses per person, per term

for outpatient services. This limit does not apply to

inpatient expenses or outpatient surgery.

Value plans:

Limited to inpatient and surgical treatment.

Therapeutic Treatments

• Hemodialysis, processing, and administration of blood or

components (but not the cost of the actual blood or

components).

• Occupational therapy following a covered treatment for

traumatic hand injuries.

Transplant Expense Beneﬁt

The following transplants are covered the same as any

other illness

: cornea, artery or vein grafts, heart valve

grafts, prosthetic tissue and joint replacement, and

prosthetic lenses for cataracts.

For all other covered transplants, see the certificate for

“Listed Transplants” under Transplant Expense Benefits.

The covered person must be a good candidate, as

determined by us. The transplant must not be experimental

or investigational. Covered expenses for “Listed

Transplants” are limited to 2 during a 36 month policy

maximum duration, per person.

GRIC has arranged for certain hospitals around the country

(“Centers of Excellence” or COE) to perform specified

transplant services. At a designated COE, covered

expenses include the acquisition cost and transportation

and lodging limited to $5,000 per transplant. If COE not

used: Limit of 1 transplant per 36 month policy maximum

duration, per person, limited to max benefits of $100,000;

acquisition, transportation and lodging not covered.

No beneﬁts payable for:

• Search and testing in order to locate a suitable donor.

• A prophylactic bone marrow harvest and peripheral blood

stem cell collection when no “listed transplant” occurs.

• Animal-to-human transplants.

• Artificial or mechanical devices designed to replace a

human organ temporarily or permanently.

• Procurement or transportation of the organ or tissue, unless

expressly provided in this provision.

• Keeping a donor alive for the transplant operation.

• A live donor where the live donor is receiving a transplanted

organ to replace the donated organ.

• A transplant under study in an ongoing Phase I or II clinical

trial as set forth in the USFDA regulation.

Additional Beneﬁts

• Diagnosis of and treatment of autism spectrum disorders,

including evidence-based treatments.

• Outpatient applied behavior analysis for the treatment of

autism spectrum disorders up to a maximum of $50,000

per coverage term, per covered person.

• Colorectal cancer examinations and laboratory tests in

accordance with the published American Cancer Society

guidelines.

• One digital rectal examination and one prostate specific

antigen test per coverage term per covered person for

screening for the early detection of prostate cancer (exempt

from the deductible.)

• Medically necessary care and treatment of loss or impairment

of speech and hearing, including communicative disorders.

• Treatment of medical disorders requiring specialized

nutrients or formulas, including treatment with medical

foods, regardless of whether the delivery method is enteral

or oral.

• Routine in-hospital newborn infant care expenses provided

while an inpatient within first five days following covered

person’s birth or before the mother ceases to be an

inpatient, whichever occurs first.

• Medically necessary gastric pacemaker.

• Telemedicine services to the same extent that those

services provided would otherwise be covered expenses

under the certificate, including facility fee to originating site.

Combined reimbursement to the originating site and distant

site limited to the covered expense for the service when

provided in person.

Medical Benefits

(insurance plans)

The following medical

benefits are provided using

network providers and are

subject to Plan Provisions,

Exclusions and/or Limitations,

the deductible, any

applicable copay or

coinsurance, and all policy

provisions (unless otherwise

stated). Some state

exceptions may apply (see

State Variations.) You will find

complete coverage details in

the certificate.

TERMS

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Nov 12 2021 08:13:42 am

Some states may require that you have

Minimum Essential Coverage in order

to avoid a penalty. The Short-term,

limited duration insurance benefits

under this coverage do not meet all

federal requirements to qualify as

“Minimum Essential Coverage” for

health insurance under the Affordable

Care Act (“ACA”). This plan of

coverage does not include all Essential

Health Benefits as required by the

ACA. Be sure to check your certificate

carefully to make sure you are aware of

any exclusions or limitations regarding

coverage of preexisting conditions or

health benefits (such as hospitalization,

emergency services, maternity care,

preventive care, prescription drugs,

and mental health and substance use

disorder services). Your certificate

might also have lifetime and/or annual

dollar limits on health benefits. If this

coverage expires or you lose eligibility

for this coverage, you might have to

wait until an open enrollment period to

get other health insurance coverage.

You may be able to get longer term

insurance that qualifies as “Minimum

Essential Coverage” for health

insurance under the ACA.

TERMS

Other Information

(insurance plans)

This is only a general

outline of the benefits,

provisions and exclusions.

It is not an insurance

contract, nor part of the

insurance

certificate

. Some

state exceptions may apply

(see State Variations.)

You will find complete

details in the

certificate

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Exclusions and/or Limitations

Benefits will not be paid for services or supplies that are

not administered or ordered by a doctor and medically

necessary to the diagnosis or treatment of an illness or

injury, as defined in the certificate, or, where applicable,

covered under the Preventive Care Expense Benefits

provision.

For Value plans only, no benefits are payable for

expenses:

• For outpatient prescription drugs.

• For outpatient treatment of spine and back disorders.

For all plans, no beneﬁts are payable for expenses:

• For non-emergency services or supplies received from a

provider who is not a network provider, except as

specifically provided for by the certificate.

• For a preexisting condition — A condition for which

medical advice, diagnosis, care, treatment, any diagnostic

procedure(s), or further evaluation was recommended or

received within the 24 months immediately prior to the date

the covered person became insured under the certificate;

or a condition that had manifested itself in a manner that

would have caused an ordinarily prudent person to seek

medical advice, diagnosis, care, or treatment within the 12

months immediately prior to the date the covered person

became insured under the certificate; or a pregnancy existing

on the effective date of coverage.

NOTE: Even if you have had prior GRIC coverage and your

preexisting conditions were covered under that plan, they

will not be covered under this plan for the first 12 months of

coverage.

• That would not have been charged if you did not have

insurance.

• Imposed on you by a provider (including a hospital) that are

actually the responsibility of the provider to pay.

• For services performed by an immediate family member.

• That are not identified and included as covered expenses

under the

certificate

or in excess of the eligible expenses.

• For services or supplies that are provided prior to the

effective date or after the termination date of the coverage.

• For weight modification or surgical treatment of obesity,

including wiring of the teeth and all forms of intestinal

bypass surgery.

• For breast reduction or augmentation, except as provided

for in

certificate

• For drugs, treatment, or procedures that promote

conception, including but not limited to artificial

insemination or treatment for infertility or impotency.

• For sterilization or reversals of sterilization.

• For fetal reduction surgery or abortion (unless life of mother

would be endangered).

• For treatment of malocclusions, disorders of the

temporomandibular joint (TMJ) or craniomandibular

disorders, except as provided for by the

certificate

• For modification of the physical body in order to improve

psychological, mental, or emotional well-being, such as

sex-change surgery.

• Not specifically provided for in the

certificate

, including

telephone consultations, failure to keep an appointment,

television expenses, or telephone expenses.

• For marriage, family, or child counseling.

• For standby availability of a medical practitioner when no

treatment is rendered.

• For hospital room and board and nursing services if admitted

on a Friday or Saturday, unless for an emergency, or for

medically necessary surgery that is scheduled for the next day.

• For dental expenses, including braces and oral surgery,

except as provided for in the

certificate

• For cosmetic treatment.

Certificate Details

State-specific differences may apply.

Nov 12 2021 08:13:42 am

TERMS

Other Information

(insurance plans)

This is only a general

outline of the benefits,

provisions and exclusions.

It is not an insurance

contract, nor part of the

insurance

certificate

. Some

state exceptions may apply

(see State Variations.)

You will find complete

details in the

certificate

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General Exclusions, continued

For all plans, no beneﬁts are payable for expenses:

• For diagnosis or treatment of learning disabilities, attitudinal

disorders, or disciplinary problems, except as provided for

the certificate

• For diagnosis or treatment of nicotine addiction.

• For surrogate parenting.

• For treatments of hyperhidrosis (excessive sweating).

• For charges related to, or in preparation for, tissue or organ

transplants, except as expressly provided for under Transplant

Expense Benefits in the certificate.

• For injuries from participation in professional or

semi-professional sports or athletic activities for financial

gain, as determined by GRIC.

• For high-dose chemotherapy prior to, in conjunction with, or

supported by ABMT/BMT, except as specifically provided

under the Transplant Expense Benefits provision in the

certificate.

• For eye refractive surgery, when the primary purpose is to

correct nearsightedness, farsightedness, or astigmatism.

• While confined for rehabilitation, custodial care, educational

care, or nursing services, except as provided for in the

certificate

• For eyeglasses, contact lenses, hearing aids, eye refraction,

visual therapy, or any exam or fitting related to these

devices, except as provided for in the

certificate

• Due to pregnancy (except complications), except as

provided in the

certificate

• For any expenses, including for diagnostic testing incurred

while confined primarily for well-baby care, except as

provided in the

certificate

• For treatment of mental disorders, or court-ordered

treatment for substance abuse.

• For preventive care or prophylactic care, including routine

physical examinations, premarital examinations, and

educational programs, except as provided in the

certificate

• Incurred outside of the U.S., except for emergency treatment.

• Resulting from declared or undeclared war; intentionally

self-inflicted bodily harm (whether sane or insane); or

participation in a riot or felony (whether or not charged).

• For or related to durable medical equipment or for its fitting,

implantation, adjustment or removal or for complications

therefrom, except as provided for in the

certificate

• For alternative treatments, except as specifically covered by

the

certificate

, including: acupressure, acupuncture,

aromatherapy, hypnotism, massage therapy, rolfing, and

other alternative treatments defined by the Office of

Alternative Medicine of the National Institutes of Health.

• Resulting from or during employment for wage or profit,

if covered or required to be covered by workers’ compensation

insurance under state or federal law. If you entered into a

settlement that waives your right to recover future medical

benefits under a workers’ compensation law or insurance

plan, this exclusion will still apply.

• Resulting from intoxication, as defined by state law where

the illness or injury occurred, or while under the influence of

illegal narcotics or controlled substances, unless

administered or prescribed by a doctor.

• For joint replacement, unless related to an injury covered by

the certificate.

• For injuries sustained during or due to participating,

instructing, demonstrating, guiding, or accompanying

others in any of the following: sports (professional, or semi-

professional, or intercollegiate), parachute jumping, hang-

gliding, racing or speed testing any motorized vehicle or

conveyance, scuba/skin diving (when diving 60 or more feet

in depth), skydiving, bungee jumping, or rodeo sports.

• For injuries sustained during or due to participating,

instructing, demonstrating, guiding, or accompanying

others in any of the following if the covered person is paid

to participate or to instruct: operating or riding on a

motorcycle, racing or speed testing any non-motorized

vehicle or conveyance, horseback riding, rock or mountain

climbing, or skiing.

Nov 12 2021 08:13:42 am

TERMS

Other Information

(insurance plans)

This is only a general

outline of the benefits,

provisions and exclusions.

It is not an insurance

contract, nor part of the

insurance

certificate

. Some

state exceptions may apply

(see State Variations.)

You will find complete

details in the

certificate

11 of 21

General Exclusions, continued

No beneﬁts are payable for expenses:

• For vocational or recreational therapy, vocational

rehabilitation, or occupational therapy, except as provided

for in the certificate.

• Resulting from experimental or investigational treatments, or

unproven services.

• Expenses incurred by a covered person for the treatment of

tonsils, adenoids, middle ear disorders, hemorrhoids,

hernia, or any disorders of the reproductive organs will not

be covered during the covered person’s first 6 months of

coverage under the policy. This exclusion will not apply if the

treatment is provided on an emergency basis.

Optional Supplemental Accident Beneﬁt for

TriTerm Medical Plans Forms SA-S-1899G-GRI, SA-S-1899RG-GRI,

and state variations

Reduce or eliminate your out-of-pocket exposure for an accident-

related injury for additional premium. Supplemental Accident

benefit matches your deductible, paying for treatment of an

unexpected injury within 90 days of an accident. The benefit

maximum amount ($2,500, $5,000, $7,500, $10,000, $12,500,

or $15,000) is per accident, per covered person. NOTE: The

$2,500 benefit amount is not an option with TriTerm Plan 100

Max. The $15,000 benefit amount is only an option on the

TriTerm Value Plan.

Application Fee

Nonrefundable $40 application fee required in most states.

Coordination of Beneﬁts (including Medicare)

If after coverage is issued, a covered person becomes

insured under another health plan or Medicare, benefits will

be determined under the Coordination of Benefits (COB)

clause.

COB allows two or more plans to work together so the total

amount of all benefits is never more than 100% of covered

expenses. COB also takes into account medical coverage

under auto insurance contracts. To determine which plan is

primary, refer to “order of benefits” in the certificate.

Dependents

For purposes of this coverage, eligible dependents are your

lawful spouse and eligible children. Eligible children must

be unmarried and under 26 years of age at time of

application.

Eﬀective Date

Expenses for injuries and illnesses are eligible for

coverage as of your plan’s eﬀective date. Your certiﬁcate

will take eﬀect on the later of:

• The requested effective date on your application; or

• The 5th day after the date received by GRIC,* but only if the

following conditions are satisfied:

- A. Your application and the appropriate premium payment

are actually received by us within 15 days of your

signing;**

- B. Your application is properly completed and unaltered;

- C. Your application is approved after review by GRIC.

- D. You are a resident of a state in which the

certificate

form can be issued; and

- E. If the application is submitted by an agent or broker, the

agent or broker is properly licensed and appointed to

submit applications to GRIC.

* If mailed and not postmarked by the U.S. Postal Service or if the

postmark is not legible, the effective date will be the later of: (1) the date

you requested; or (2) the 5th day after the date received by GRIC.

If the application is sent by any electronic means including fax, your

coverage will take effect on the later of: (1) the requested effective date;

or (2) the 5th day after the date received by GRIC.

** Your account will be immediately charged.

Eligibility

At time of application, the primary insured must be a

minimum of 19 years of age.

Eligible Expense

An eligible expense means a covered expense as follows:

• For Network Providers: The contracted fee for the provider.

• For Non-Network Providers: As defined in the

certificate

Nov 12 2021 08:13:42 am

TERMS

Other Information

(insurance plans)

This is only a general

outline of the benefits,

provisions and exclusions.

It is not an insurance

contract, nor part of the

insurance

certificate

. Some

state exceptions may apply

(see State Variations.)

You will find complete

details in the

certificate

12 of 21

Emergency

“Emergency” means an unforeseen or sudden medical

condition manifesting itself by acute signs or symptoms

which could reasonably result in death or serious

disability if medical attention is not provided within 24

hours.

No Non-Network Beneﬁts

• These plans only pay benefits for eligible expenses

from a network provider. Visit UHOne.com to search for

providers. (No benefits are payable for non-emergency

care from a non-network provider.)

• Emergency treatment from a non-network provider will be

treated as a network eligible service.

• Emergency treatment means you will owe the difference

between what the non-network provider bills and what we

pay for a network eligible expense.

Non-Renewable

TriTerm Medical is issued for a specific period of time.

We may cancel coverage if there is fraud or material

misrepresentation made by or with the knowledge of a

covered person in filing a claim for benefits. Coverage will

remain in force until the termination date shown in your

certificate. We will notify you in advance of any changes in

coverage or benefits, unless the policy terminates earlier

for any reason stated in the Termination section.

Premium

The premium amount is expected to change for each

term.

Rating Factors

The plan, age and sex of covered persons, type and level

of benefits, tobacco use status, underwriting class status,

time the certificate has been in force, and place of

residence on the premium due date are some of the

factors used in determining your premium rates. From

time to time, we may change the rate table used. Each

premium will be based on the rate table in effect on that

premium’s due date. At least 31 days’ notice of any plan

to take an action or make a change, permitted by the

premium provision in the certificate, will be mailed to you

at your last address as shown in our records. We will

make no change in your premium solely because of

claims made under the certificate or a change in a

covered person’s health.

Termination

The certificate will terminate on the earliest of:

• The date all covered persons under the certificate move

out of the state where the certificate was issued.

• The primary insured’s death. If the

certificate

includes

dependents, it may be continued after the primary

insured’s death by a spouse, if a covered person;

otherwise, by the youngest child who is a covered person.

• Nonpayment of premiums when due.

• The termination date shown on the Data Page of the

certificate

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

certificate

• The date of the primary insured’s 65th birthday.

• The date you accept any contribution from your employer

for any portion of the premium, or the date you and your

employer treat the plan as employer-provided insurance for

any purpose, including tax purposes.

Nov 12 2021 08:13:42 am

Florida Certiﬁcate Form GRI-STAG-EXT1B-E-C-09

• Eligible child must be under age 31 and unmarried. A child

that is unmarried and remains chiefly dependent on you or

your spouse for support and maintenance due to mental or

physical disability will be considered an eligible child under

the policy/certificate regardless of age. The disabled child’s

coverage will not terminate due to age. The dependent may

remain covered for the duration of the coverage term.

• Provision is included for Extension of Benefits upon

Termination of the Master Policy: If a covered person is an

inpatient in a hospital on the date that the master policy is

terminated and the master policy is replaced without any

gap in coverage by a group health insurance policy with

another insurer or by a self-funded health care plan,

benefits for covered expenses for the continuous hospital

confinement will be extended. These extended benefits will

be paid solely for covered expenses incurred during the

inpatient hospital confinement. Any extended benefit will

cease on the earliest of:

A. The date the covered person’s hospital confinement

ends; or

B. The date the benefits for the hospital confinement would

have ceased under any other provision of the policy/

certificate.

Indiana Certiﬁcate Form GRI-STAG-EXT1B-E-C-13 and

GRI-STAG-EXT1B-E-C-VAL-13

• Plans have three terms of 364 days each.

• The Maximum Benefit is $2 million per person, per term.

• Application fee is refundable if coverage is not issued or not

taken.

• Preexisting condition is defined as: A condition for

which medical advice, care, treatment, or diagnostic

procedure was received within the 12 months immediately

preceding the date the covered person became insured

under the policy.

Mississippi Certiﬁcate Forms GRI-STAG-EXT1B-E-C-23 and

GRI-STAG-EXT1B-E-C-VAL-23

• Application fee is $6.

• “Preexisting condition” means an injury or illness for which

medical advice, diagnosis, care or treatment was

recommended to or received by a covered person within

the 6 months immediately preceding the applicable

effective date the covered person became insured under

the policy; or which, in the opinion of a qualified doctor: (1)

probably began prior to the applicable effective date the

covered person became insured under the policy; and (2)

manifested symptoms which would cause an ordinarily

prudent person to seek diagnosis or treatment within the 6

months immediately preceding the applicable effective date

the covered person became insured under the policy.

• Benefits are expanded to include general anesthesia and

associated facility fees incurred in conjunction with dental

care (regardless of whether the dental care itself is covered)

for a covered person when the mental or physical condition

of the child or mentally handicapped adult requires dental

treatment to be rendered under physician-supervised

general anesthesia in a hospital setting, outpatient surgical

facility, or dental office. Covered expenses do not include

treatment rendered for temporomandibular joint (TMJ)

disorders.

• Covered expenses include annual screening by low-dose

mammography for the presence of occult breast cancer for

covered persons thirty-five (35) years of age or older. This

would not be considered preventive care.

• The exclusion for or related to surrogate parenting does not

apply.

State Variations

(insurance plans)

Please see state availability

and applicable state-specific

benefits, exclusions, and

limitations.

TERMS

13 of 21

Nov 12 2021 08:13:42 am

Nebraska Certiﬁcate Forms GRI-STAG-EXT1B-E-C-26 and

GRI-STAG-EXT1B-E-C-VAL-26

• “Emergency” means a medical or behavioral condition, the

onset of which is sudden, that manifests itself by symptoms

of sufficient severity, including, but not limited to, severe

pain, that a prudent layperson, possessing an average

knowledge of medicine and health, could reasonably

expect the absence of immediate medical attention to

result in: placing the health of the covered person afflicted

with such condition in serious jeopardy, or in the case of a

behavioral condition, placing the health of such persons or

others in serious jeopardy; serious impairment to bodily

functions of the covered person; serious impairment of any

bodily organ or part of the covered person; or serious

disfigurement of the covered person.

• Annual mammography screenings are not considered

Preventive Care and are not subject to the Preventive Care

limits.

• Colorectal screening coverage is as follows: screening

coverage for a colorectal cancer examinations and laboratory

tests for colorectal cancer in a non-symptomatic covered

person fifty years of age or older. Covered expenses shall

include a maximum of: one screening fecal occult blood test

annually and a flexible sigmoidoscopy every five years; a

colonoscopy every ten years, or a barium enema every five to

ten years; or any combination of the most reliable medically

recognized screening test available when deemed

appropriate by the covered person’s medical practitioner

• Benefits are expanded to include the following:

∘ Up to $3,000 for medically necessary hearing aids for an

eligible child under the age of 19, for each ear affected

by a hearing impairment.

∘ Up to maximum lifetime dollar amount of $2,500 for

medically necessary surgical and non-surgical treatment

of temporomandibular joint (TMJ) disorder and

craniomandibular disorder.

∘ The reasonable cost of general anesthesia and

hospitalization in a hospital or ambulatory surgical center, for

a covered eligible child to receive dental care if he or she: is

age eight (8) or under; or Is developmentally disabled.

Tennessee Certiﬁcate Form GRI-STAG-EXT1B-E-C-41

• The $5,000 limit on Spine and Back Disorders does not

apply.

• “Emergency” is defined as: a medical condition manifesting

itself by acute symptoms of sufficient severity (including

severe pain) such as prudent layperson, who possesses an

average knowledge of health and medicine, could

reasonably expect the absence of immediate medical

attention to result in:

∘ Placing the health of the covered person in serious

jeopardy;

∘ Serious impairment to bodily functions; or

∘ Serious dysfunction of any bodily organ or part.

• The covered expense for diabetes self-management training

does not require certification of completion. It is limited to

visits certified by a physician to be medically necessary:

∘ upon the diagnosis of diabetes;

∘ because of a significant change in the covered person’s

symptoms or condition which necessitates changes in

the covered person’s self-management; and

∘ for re-education or refresher training.

• Covered expenses were expanded to include a

mammography screening for diagnostic purposes on

referral by a patient’s physician limited to the following:

∘ A baseline mammogram for covered person’s thirty-five

(35) to forty (40) years of age.

∘ A mammogram every two (2) years, or more frequently

based upon the recommendation of a physician, for

covered person’s forty (40) to fifty (50) years of age

and over.

• Transplant Expense Benefits are not limited to the “Listed

Transplants.”

• Transplant Expense Benefits do not cover any transplant

determined to be experimental or investigational treatment.

State Variations

(insurance plans)

Please see state availability

and applicable state-specific

benefits, exclusions, and

limitations.

TERMS

14 of 21

Nov 12 2021 08:13:42 am

Texas Certiﬁcate Form GRI-STAG-EXT1B-E-C-42 and

GRI-STAG-EXT1B-E-C-VAL-42

• “Eligible child” is expanded to include stepchild; a child

you or your spouse is seeking to adopt through legal

proceedings; a child entitled, by virtue of a court order, to

have coverage provided by you or your spouse; and your

grandchild who is considered your dependent for federal

income tax purposes at the time application for coverage

is made.

• “Emergency” means medical conditions of a recent onset

and severity, including but not limited to severe pain, that

would lead a prudent layperson possessing an average

knowledge of medicine and health to believe that the

person’s condition, sickness, or injury is of such a nature that

failure to get immediate medical care could result in: placing

the patient’s health in serious jeopardy; serious impairment

to bodily functions; serious dysfunction of any bodily organ

or part; serious disfigurement; or in the case of a pregnant

woman, serious jeopardy to the health of the fetus.

• Preexisting condition is defined as: a condition for which

medical advice, or treatment, any diagnostic procedure(s),

or further evaluation was recommended or received within

the 12 months immediately preceding the date the covered

person became insured under the policy; or a condition

that would have caused an ordinarily prudent person to

seek medical advice, diagnosis, care, or treatment within

the 12 months immediately preceding the date the covered

person became insured under the policy; or a pregnancy

existing on the effective date of coverage.

• Covered expense for outpatient applied behavior analysis

is limited to covered persons 10 years of age or older.

• Covered expense for diabetes self-management training

includes training provided to a covered person or a

covered person’s caretaker. The limit of one training

program per covered person, per lifetime, does not apply.

However, training must be after initial diagnosis of diabetes;

authorized on written order of a medical practitioner after a

significant change in symptoms that requires changes in

self-management regime; or for periodic or episodic

continuing education when prescribed by a medical

practitioner as needed due to the development of new

techniques and treatments.

• Benefits are expanded to include the following:

∘ The most appropriate prosthetic device or orthotic

device that adequately meets the medical needs of the

covered person, as recommended by the covered

person’s physician, podiatrist, prosthetist or orthotist.

∘ The treatment of breast cancer; a minimum of 48 hours

of inpatient care following a mastectomy and 24 hours of

inpatient care following a lymph node dissection.

∘ The cost of a newborn screening test kit.

∘ Diagnostic mammogram. (The 35 year age limit does not

apply.) This is not considered Preventive Care, so it is

not subject to Preventive Care limit.

∘ Expenses incurred by covered persons who have been

diagnosed with insulin dependent or non-insulin

dependent diabetes, elevated blood glucose levels

induced by pregnancy, or any other medical condition

associated with elevated blood glucose levels.

∘ Screening for autism spectrum disorders for an eligible

child at 18 and 24 months of age.

∘ Medically necessary amino acid modified preparation,

low protein modified food products, any other special

dietary products and formulas prescribed by a doctor for

the therapeutic treatment of phenylketonuria (PKU),

galactosemia, organic adicdemias and disorders of

amino acid metabolism.

∘ Medically accepted bone mass measurement for the

detection of low bone mass and to determine the risk of

osteoporosis and fractures associated with osteoporosis

for a covered person who is: postmenopausal woman

who is not receiving estrogen replacement therapy; an

individual with vertebral abnormalities, primary

hyperparathyroidism, or a history of bone fractures; or

an individual who is receiving long-term glucocorticoid

therapy, or being monitored to assess the response to or

efficacy of an approved osteoporosis drug therapy.

State Variations

(insurance plans)

Please see state availability

and applicable state-specific

benefits, exclusions, and

limitations.

TERMS

15 of 21

Nov 12 2021 08:13:42 am

Texas, continued

∘ One screening test for hearing loss administered within

the first 30 days after birth, and related necessary

diagnostic follow-up care during the first 24 months after

birth. Charges incurred for the screening test and follow-

up care shall be exempt from the deductible amount.

∘ Cognitive rehabilitation therapy, cognitive communication

therapy, neurocognitive therapy and rehabilitation,

neurobehavioral, neurophysiological, neuropsychological,

and psychophysiological testing or treatment,

neurofeedback therapy, remediation, post-acute transition

services, or community reintegration services necessary

as a result of and related to an acquired brain injury.

∘ Diagnostic and surgical treatment of temporomandibular

joint disorders and craniomandibular joint disorders.

∘ Up to $200 every five years for one of the following

noninvasive screening tests for atherosclerosis and

abnormal artery structure and function: Computerized

tomography (CT) scanning measuring coronary artery

calcification; or Ultrasonography measuring carotid

intima-media thickness and plaque. Benefits are limited

to male covered persons between the ages of 45 and 76

and female covered persons between the ages of 55 and

76 who are diabetic or have an intermediate or high risk

of developing coronary heart disease based on the

Framingham Health Study Coronary Prediction algorithm.

∘ Routine patient care costs for services, items or drugs

provided in connection with a Phase l, ll, lll or lV clinical

trial if the clinical trial is conducted in relation to the

prevention, detection or treatment of a life-threatening

disease or condition and is approved by: The Centers

for Disease Control and Prevention; The National

Institutes of Health; The United States Food and Drug

Administration (USFDA); The United States Department

of Defense; The United States Department of Veterans

Affairs; or an institutional review board of an institution

in the state of Texas that has an agreement with the

Office for Human Research Protections of the United

States Department of Health and Human Services.

∘ Annual screening for the early detection of ovarian

cancer and cervical cancer for covered persons 18

years of age or older, including: A CA 125 blood; and

conventional Pap smear screening or a screening using

liquid-based cytology methods, as approved by the

United States Food and Drug Administration for the

detection of the human papillomavirus.

∘ Annual screening by low-dose mammography for the

presence of occult breast cancer for covered persons

35 years of age or older.

∘ Diagnosis or treatment of mental disorders or substance

abuse the same as any other illness, including services

received in: A psychiatric day treatment facility; a

residential treatment center for children or adolescents;

and a crisis stabilization unit.

∘ Medically necessary hearing aids or cochlear implants

for a covered eligible child up to age 18 years, limited to

one hearing aid in each ear every three years and one

cochlear implant in each ear with internal replacement

as audiologically or medically necessary.

• Transplant benefits are modified as follows:

∘ Covered expenses include expenses actually incurred by a

covered person for those services and supplies listed

which are: administered or ordered by a doctor; provided

in connection with a listed transplant; medically necessary

to the diagnosis or treatment of an injury or illness; and not

excluded anywhere in the policy. These covered expenses

will be paid as a limited expansion of the Medical Benefits.

They will be subject to the terms of that provision, including

deductibles, coinsurance, exclusions and limitations.

∘ If a designated Center of Excellence is not used,

covered expenses for a listed transplant will be reduced

by 25% after application of any deductible amounts

coinsurance provisions or copayment amounts, limited

to a maximum of one.

• The 6 months waiting period does not apply for expenses

incurred by a covered person for the treatment of tonsils,

adenoids, middle ear disorders, hemorrhoids, hernia, or

any disorders of the reproductive organs.

State Variations

(insurance plans)

Please see state availability

and applicable state-specific

benefits, exclusions, and

limitations.

TERMS

16 of 21

Nov 12 2021 08:13:42 am

West Virginia Certiﬁcate Form GRI-STAG-EXT1B-E-C-47

• “Eligible child” is expanded to include a child that is

unmarried and remains chiefly dependent on you or your

spouse for support and maintenance due to mental or

physical disability will be considered an eligible child under

the certificate regardless of age. The disabled child’s

coverage will not terminate due to age. The dependent may

remain covered for the duration of the coverage term.

State Variations

(insurance plans)

Please see state availability

and applicable state-specific

benefits, exclusions, and

limitations.

TERMS

17 of 21

Nov 12 2021 08:13:42 am

TERMS

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.

18 of 21

Nov 12 2021 08:13:42 am

TERMS

•

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.

19 of 21

Nov 12 2021 08:13:42 am

TERMS

•

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.

20 of 21

Nov 12 2021 08:13:42 am

TERMS

21 of 21

* As of 12/18/20. For the latest rating, access www.ambest.com.

45746E-G-1221

Who we are

Golden Rule Insurance Company, a UnitedHealthcare

company, is the underwriter of plans featured in this

brochure. We have been serving the specific needs

of individuals and families buying their own coverage

for over 75 years. Plans are administered by

United Healthcare Services, Inc.

Golden Rule Insurance Company is rated “A” (Excellent)

by A.M. Best.* This worldwide independent organization

examines insurance companies and other businesses,

and publishes its opinion about them. This rating is an

indication of our financial strength and stability.

Our plans offer easy-to-understand health insurance designed for individuals and

families in times of transition and change. Plans only available to members of

FACT, the Federation of American Consumers and Travelers (see below). If you’re

not already a member, you can enroll with your TriTerm Medical application to be

eligible to apply for these plans.

What is FACT?

FACT is an independent consumer association whose members benefit from

the “pooling” of resources. Benefits range from medical savings to consumer

service discounts. FACT’s principal office is in Jonesboro, Arkansas. FACT

and Golden Rule Insurance Company are separate organizations. Neither is

responsible for the performance of the other. FACT has contracted with Golden

Rule Insurance Company to provide its members with access to these health

insurance plans. FACT does not receive any compensation from Golden Rule

Insurance Company.

Is there a cost for joining FACT?

Yes, there are membership dues and they can be paid with your regular health

insurance premium, as opposed to making a separate payment.

What are the basic FACT membership benefits?

FACT makes it easy for members to choose from a full menu of important

benefits, including:

As a member of FACT, your information is kept private. Please visit the FACT

website, www.usafact.org/privacy-policy, for a complete FACT Privacy

Statement. FACT may change or discontinue any of its membership benefits

at any time. For the most current information, including full detailed lists of

member benefits, visit FACT’s website at www.usafact.org or call toll-free at

(800) USA-FACT.

•

Accidental Death Benefit

•

In-Hospital Benefit, Ambulance

Reimbursement, and Medical

Evacuation Coverage

•

Telemedicine Access

•

Dental, Vision, Hearing Aid, and

Prescription Discounts

•

ID Theft and Cyber Protection

•

Online Health, Wellness, and

Fitness Classes

•

Travel Discounts

•

Pet Coverage

•

Scholarships and Community

Grants

•

Disaster Aid and Small Business

Recovery Program

Nov 12 2021 08:13:42 am

Table of Contents

Plan Information & Network 2

Benefits 3

Exclusions & Limitations 6

Plan Provisions 8

State:

TriTerm Medical Value Plan

Plans underwritten by Golden Rule Insurance Company.

This insert must be used with our TriTerm brochure 45746E-G for the state of Florida.

Certiﬁcate Form GRI-STAG-EXT1B-P-C-VAL-09 applies to Florida TriTerm Medical Value plan only.

INTERNET/FMO

Nov 12 2021 08:13:42 am

TERMS

Florida Value

TERM 1

364 DAYS

TERM 2

365 DAYS

TERM 3

365 DAYS

TERMS

Earliest effective date is 5 days after application.

Deductible (per person, per term; max 2 per family)

You pay

up to:

$2,500, $5,000, $7,500, $10,000,

$12,500 or $15,000

Coinsurance (% you pay after deductible, per term)

You pay:

30% or 50%

Coinsurance Out-of-Pocket Maximum

(after deductible, per person, per term)

You pay

up to:

$10,000

Maximum Beneﬁt (per person, lifetime)

We pay

up to:

$2 million

Medical

Doctor Oﬃce Visit (History and Exam only)

(per person, per term)

You pay:

Chosen coinsurance

after deductible

Urgent Care Center $75 copay

Preventive Care

Not Covered

Emergency Room (Accident and Illness) (for illness

only: additional $500 deductible if not admitted)

Chosen coinsurance

after deductible

Inpatient Hospital Services,

Outpatient Surgery, Labs & X-rays

Chosen coinsurance

after deductible

Pharmacy

Outpatient Prescription (Rx) Drugs

Not Covered

Discount card provided.

Add Supplemental Accident Beneﬁt

Matches medical deductible selected (page 8)

We pay

up to:

$2,500, $5,000, $7,500, $10,000,

$12,500 or $15,000

Earliest eﬀective date is 5 days after application. The amount of beneﬁts provided depends

upon the plan selected, and the premium will vary with the amount of the beneﬁts selected.

Non-network beneﬁts vary. See details above right. Copays do not apply to deductible, coinsurance,

or coinsurance out-of-pocket maximum. This coverage does not qualify as “Minimum Essential Coverage”

as deﬁned in the Aﬀordable Care Act and may not cover all Essential Health Beneﬁts in your state. ¹

Additional premium required.

For Children’s Preventive Health Services, see page 3.

Discounts

vary by pharmacy, geographic area, and Rx drug.

Visit UHOne.com and

select Find A Doctor

to search for network

providers in your

state.

UnitedHealthcare Choice Plus Network

In addition to the in-network benefits, these plans pay

reduced non-network benefits. Using non-network

providers will cost you more due to a non-network penalty -

see below.

For non-emergency care received from Non-

Network Providers you pay: (a) all charges above what is

considered an eligible expense; (b) a penalty of 25% of the

eligible expense, which does not count toward the deductible;

and (c) a deductible amount equal to 2 times the network

deductible. There is no out-of-pocket maximum for non-

network providers. Your actual out-of-pocket costs may be

more than the stated coinsurance because the

bill from a

non-network provider may not be used to calculate what

we pay and what you pay.

Highlights of Covered

Network Expenses

THIS INFORMATION APPLIES TO FLORIDA TRITERM MEDICAL VALUE PLANS ONLY.

2 of 9 TriTerm Medical Value Plans

Nov 12 2021 08:13:42 am

Medical Benefits

(insurance plans)

The following medical

benefits are provided using

network providers and are

subject to Plan Provisions,

Exclusions and/or Limitations,

the deductible, any

applicable copay or

coinsurance, and all policy

provisions (unless otherwise

stated). You will find complete

coverage details in the

certificate.

TERMS

3 of 9 TriTerm Medical Value Plans

THIS INFORMATION APPLIES TO FLORIDA TRITERM MEDICAL VALUE PLANS ONLY.

Ambulance Services

• Ground ambulance service to the nearest hospital that can

provide services for necessary emergency care.

• Air ambulance services requested by police or medical

authorities at the site of emergency or in locations that

cannot be reached by ground ambulance.

Cancer Treatment Expenses

• Radiation therapy and chemotherapy.

• Expenses in connection with a mastectomy for a covered

person who elects breast reconstruction, including all

stages of reconstruction of the breast on which the

mastectomy has been performed; surgery and

reconstruction of the other breast to produce a symmetrical

appearance; and prostheses and treatment for physical

complications of mastectomy, including lymphedemas.

• The cost of one wig per covered person, up to $500, necessitated

by hair loss due to cancer treatments or traumatic burns.

• One mastectomy bra per year if the covered person has

undergone a covered mastectomy.

Children’s Preventive Health Services

Services for any covered person eligible by reason of age,

subject to deductible and coinsurance. Immunization

services that qualify as children’s preventive health care

services are exempt from any deductible amounts,

coinsurance provisions, or copayment amounts.

Dental Injuries

Dental expenses for an injury to natural teeth suffered after

the coverage effective date. Expenses must be incurred

within 6 months of the accident.

No beneﬁts payable for injuries due to chewing.

Diabetes

• Diabetes equipment, supplies, and services.

• Diabetes self-management training and education when

medically necessary as determined by physician or health

care professional. Limited to one training program per person,

per lifetime, unless additional training is prescribed due to a

significant change in symptoms or condition.

Diagnostic Testing

Testing using radiologic, ultrasonographic, or laboratory

services (psychometric, behavioral and educational testing

are not included).

Durable Medical Equipment

• Rental of standard non-motorized wheelchair, hospital bed,

standard walker, wheelchair cushion, or ventilator.

• Cost of one Continuous Passive Motion (CPM) machine per

covered person following a covered joint surgery.

Home Health Care

To qualify for benefits, home health care must be provided

through a licensed home health-care agency. Covered

expenses for home health aide services will be limited to 7

visits per week and a lifetime maximum of 365 visits.

Benefits for home health care will not extend beyond the

term of your plan. Each 8-hour period of home health aide

services will be counted as one visit. Private duty

registered nurse services will be limited to a lifetime

maximum of 1,000 hours. Intermittent private duty

registered nurse visits are not to exceed 4 hours each and

are limited to $75 per visit (2 hours per visit are applied

toward the lifetime maximum for private-duty nursing).

No beneﬁts payable for respite care, custodial care, or

educational care.

Hospice Care

To qualify for benefits, a hospice for a terminally ill covered

person must be licensed by the state in which it operates.

Benefits for inpatient care in a hospice are subject to

deductible and coinsurance and limited to 180 days in a

covered person’s lifetime.

Covered expenses for room and board are limited to the

most common semiprivate room rate of the hospital or

nursing home with which the hospice is associated (or

$200 per day maximum if not associated with hospital or

nursing home). Bereavement counseling maximum of $250.

Nov 12 2021 08:13:42 am

Hospital Services

Daily hospital room and board at most common

semiprivate rate; eligible expenses for an intensive care

unit; inpatient use of an operating, treatment, or recovery

room; outpatient use of an operating, treatment, or

recovery room for surgery; services and supplies, including

drugs and medicines, which are routinely provided in the

hospital to persons for use only while they are inpatients;

emergency treatment of an injury or illness. Covered

expenses for use of the emergency room are subject to an

additional $500 deductible for each emergency room visit

for an illness unless the covered person is directly

admitted to the hospital for further treatment of that illness.

Hospital does not include a nursing or convalescent home

or an extended care facility.

Medical Supplies

• Dressings and other necessary medical supplies.

• Cost and administration of an anesthetic or oxygen.

Outpatient Surgery

Surgery in a doctor’s office or at an outpatient surgical

facility, including services and supplies.

Physician Fees

• Professional fees of doctors, medical practitioners,

and surgeons.

• Assistant surgeon fee limited to 16% of eligible expenses of

the procedure.

Prosthetics

Artificial eyes or larynx, breast prosthesis, orthotic and

prosthetic devices/services. Orthotic and prosthetic

devices/services limited to one device/service or

replacement every 3 years unless proven to be medically

necessary. If more than one device can meet covered

person’s functional needs, only the charge for the most

cost effective device will be considered a covered expense.

Reconstructive Surgery

• Reconstructive surgery incidental to or following surgery or

an injury that was covered under the certificate or is performed

to correct a birth defect in a child who has been a covered

person from its birth until the date surgery is performed.

• Reconstructive craniofacial surgery and related services for

a covered person of any age diagnosed as having a

craniofacial anomaly if the surgery is medically necessary to

improve functional impairment that results from the

craniofacial anomaly, as determined by a nationally approved

cleft-craniofacial team, approved by the American Cleft

Palate-Craniofacial Association in Chapel Hill, North Carolina.

Rehabilitation and Extended Care Facility (ECF)

To qualify for benefits, a Rehabilitation or Extended Care

Facility must be licensed by the state in which it operates.

Services or confinement must begin within 14 days of a

3-day or more hospital stay, for the same illness or injury.

Combined policy max of 60 days per person, per term for

both rehabilitation and ECF expenses. This benefit

excludes mental disorders or substance abuse.

Spine and Back Disorders

Limited to inpatient and surgical treatment.

Therapeutic Treatments

• Hemodialysis, processing, and administration of blood or

components (but not the cost of the actual blood or

components).

• Occupational therapy following a covered treatment for

traumatic hand injuries.

Transplant Expense Beneﬁt

The following transplants are covered the same as any

other illness

: cornea, artery or vein grafts, heart valve

grafts, prosthetic tissue and joint replacement, and

prosthetic lenses for cataracts.

For all other covered transplants, see the certificate for

“Listed Transplants” under Transplant Expense Benefits.

The covered person must be a good candidate, as

determined by us.

Medical Benefits

(insurance plans)

The following medical

benefits are provided using

network providers and are

subject to Plan Provisions,

Exclusions and/or Limitations,

the deductible, any

applicable copay or

coinsurance, and all policy

provisions (unless otherwise

stated). You will find complete

coverage details in the

certificate.

TERMS

4 of 9 TriTerm Medical Value Plans

THIS INFORMATION APPLIES TO FLORIDA TRITERM MEDICAL VALUE PLANS ONLY.

Nov 12 2021 08:13:42 am

Transplant Expense Beneﬁt, continued

The transplant must not be experimental or investigational.

Covered expenses for “Listed Transplants” are limited to 2

during a 36 month policy maximum duration, per person.

GRIC has arranged for certain hospitals around the country

(“Centers of Excellence” or COE) to perform specified

transplant services. At a designated COE, covered

expenses include the acquisition cost and transportation

and lodging limited to $5,000 per transplant. If COE not

used: Limit of 1 transplant per 36 month policy maximum

duration, per person, limited to max benefits of $100,000;

acquisition, transportation and lodging not covered.

No beneﬁts payable for:

• Search and testing in order to locate a suitable donor.

• A prophylactic bone marrow harvest and peripheral blood

stem cell collection when no “listed transplant” occurs.

• Animal-to-human transplants.

• Artificial or mechanical devices designed to replace a

human organ temporarily or permanently.

• Procurement or transportation of the organ or tissue, unless

expressly provided in this provision.

• Keeping a donor alive for the transplant operation.

• A live donor where the live donor is receiving a transplanted

organ to replace the donated organ.

• A transplant under study in an ongoing Phase I or II clinical

trial as set forth in the USFDA regulation.

Additional Beneﬁts

• Diagnosis of and treatment of autism spectrum disorders,

including evidence-based treatments.

• Outpatient applied behavior analysis for the treatment of

autism spectrum disorders up to a maximum of $50,000

per policy term, per covered person.

• Colorectal cancer examinations and laboratory tests in

accordance with the published American Cancer Society

guidelines.

• One digital rectal examination and one prostate specific

antigen test per policy term per covered person for

screening for the early detection of prostate cancer (exempt

from the deductible.)

• Medically necessary care and treatment of loss or impairment

of speech and hearing, including communicative disorders.

• Treatment of medical disorders requiring specialized

nutrients or formulas, including treatment with medical

foods, regardless of whether the delivery method is enteral

or oral.

• Routine in-hospital newborn infant care expenses provided

while an inpatient within first five days following covered

person’s birth or before the mother ceases to be an

inpatient, whichever occurs first.

• Medically necessary gastric pacemaker.

• Telemedicine services to the same extent that those

services provided would otherwise be covered expenses

under the certificate, including facility fee to originating site.

Combined reimbursement to the originating site and distant

site limited to the covered expense for the service when

provided in person.

• General anesthesia and services incurred at a hospital or

outpatient surgical facility for necessary dental care for an

eligible child: less than 8 years old with a significantly

complex dental condition or development disability for

which treatment in a dental office would be ineffective; or

who has one or more medical conditions that create a

significant or undue risk if the necessary dental care was

not performed in a hospital or outpatient surgical center.

• Medically necessary services and treatment for cleft lip and

palate for an eligible child under age 18.

• Diagnostic or surgical procedures involving bones or joints

of the jaw and facial region, if under accepted medical

standards, the procedure or surgery is medically necessary

to treat conditions caused by congenital or developmental

deformity, disease, or injury.

Medical Benefits

(insurance plans)

The following medical

benefits are provided using

network providers and are

subject to Plan Provisions,

Exclusions and/or Limitations,

the deductible, any

applicable copay or

coinsurance, and all policy

provisions (unless otherwise

stated). You will find complete

coverage details in the

certificate.

TERMS

5 of 9 TriTerm Medical Value Plans

THIS INFORMATION APPLIES TO FLORIDA TRITERM MEDICAL VALUE PLANS ONLY.

Nov 12 2021 08:13:42 am

TERMS

Other Information

(insurance plans)

This is only a general

outline of the benefits,

provisions and exclusions.

It is not an insurance

contract, nor part of the

insurance

certificate

. You

will find complete details in

the

certificate

6 of 9 TriTerm Medical Value Plans

THIS INFORMATION APPLIES TO FLORIDA TRITERM MEDICAL VALUE PLANS ONLY.

Exclusions and/or Limitations

Benefits will not be paid for services or supplies that are

not administered or ordered by a doctor and medically

necessary to the diagnosis or treatment of an illness or

injury, as defined in the certificate, or, where applicable,

covered under the Preventive Care Expense Benefits

provision.

No beneﬁts are payable for expenses:

• For a preexisting condition — A condition for which

medical advice, diagnosis, care, treatment, any diagnostic

procedure(s), or further evaluation was recommended or

received within the 24 months immediately prior to the date

the covered person became insured under the certificate;

or a condition that had manifested itself in a manner that

would have caused an ordinarily prudent person to seek

medical advice, diagnosis, care, or treatment within the 12

months immediately prior to the date the covered person

became insured under the certificate; or a pregnancy existing

on the effective date of coverage.

NOTE: Even if you have had prior GRIC coverage and your

preexisting conditions were covered under that plan, they

will not be covered under this plan for the first 12 months

of coverage.

• That would not have been charged if you did not have

insurance.

• Imposed on you by a provider (including a hospital) that are

actually the responsibility of the provider to pay.

• For services performed by an immediate family member.

• That are not identified and included as covered expenses

under the

certificate

or in excess of the eligible expenses.

• For services or supplies that are provided prior to the

effective date or after the termination date of the coverage.

• For outpatient treatment of spine and back disorders.

• For outpatient prescription drugs.

• For weight modification or surgical treatment of obesity,

including wiring of the teeth and all forms of intestinal

bypass surgery.

• For breast reduction or augmentation, except as provided

for in

certificate

• For drugs, treatment, or procedures that promote

conception, including but not limited to artificial

insemination or treatment for infertility or impotency.

• For sterilization or reversals of sterilization.

• For fetal reduction surgery or abortion (unless life of mother

would be endangered).

• For treatment of malocclusions, disorders of the

temporomandibular joint (TMJ) or craniomandibular

disorders, except as provided for by the

certificate

• For modification of the physical body in order to improve

psychological, mental, or emotional well-being, such as

sex-change surgery.

• Not specifically provided for in the

certificate

, including

telephone consultations, failure to keep an appointment,

television expenses, or telephone expenses.

• For marriage, family, or child counseling.

• For standby availability of a medical practitioner when no

treatment is rendered.

• For hospital room and board and nursing services if admitted

on a Friday or Saturday, unless for an emergency, or for

medically necessary surgery that is scheduled for the next day.

• For dental expenses, including braces and oral surgery,

except as provided for in the

certificate

• For cosmetic treatment.

• For diagnosis or treatment of learning disabilities, attitudinal

disorders, or disciplinary problems, except as provided for

the certificate

• For diagnosis or treatment of nicotine addiction.

• For surrogate parenting.

• For treatments of hyperhidrosis (excessive sweating).

Certificate Details

Nov 12 2021 08:13:42 am

TERMS

Other Information

(insurance plans)

This is only a general

outline of the benefits,

provisions and exclusions.

It is not an insurance

contract, nor part of the

insurance

certificate

. You

will find complete details in

the

certificate

7 of 9 TriTerm Medical Value Plans

THIS INFORMATION APPLIES TO FLORIDA TRITERM MEDICAL VALUE PLANS ONLY.

General Exclusions, continued

No beneﬁts are payable for expenses:

• For charges related to, or in preparation for, tissue or organ

transplants, except as expressly provided for under Transplant

Expense Benefits in the certificate.

• For injuries from participation in professional or

semi-professional sports or athletic activities for financial

gain, as determined by GRIC.

• For high-dose chemotherapy prior to, in conjunction with, or

supported by ABMT/BMT, except as specifically provided

under the Transplant Expense Benefits provision in the

certificate.

• For eye refractive surgery, when the primary purpose is to

correct nearsightedness, farsightedness, or astigmatism.

• While confined for rehabilitation, custodial care, educational

care, or nursing services, except as provided for in the

certificate

• For eyeglasses, contact lenses, hearing aids, eye refraction,

visual therapy, or any exam or fitting related to these

devices, except as provided for in the

certificate

• Due to pregnancy (except complications), except as

provided in the

certificate

• For any expenses, including for diagnostic testing incurred

while confined primarily for well-baby care, except as

provided in the

certificate

• For treatment of mental disorders, or court-ordered

treatment for substance abuse.

• For preventive care or prophylactic care, including routine

physical examinations, premarital examinations, and

educational programs, except as provided in the

certificate

• Incurred outside of the U.S., except for emergency treatment.

• Resulting from declared or undeclared war; intentionally

self-inflicted bodily harm (whether sane or insane); or

participation in a riot or felony (whether or not charged).

• For or related to durable medical equipment or for its fitting,

implantation, adjustment or removal or for complications

therefrom, except as provided for in the

certificate

• For alternative treatments, except as specifically covered by

the

certificate

, including: acupressure, acupuncture,

aromatherapy, hypnotism, massage therapy, rolfing, and

other alternative treatments defined by the Office of

Alternative Medicine of the National Institutes of Health.

• Resulting from or during employment for wage or profit,

if covered or required to be covered by workers’ compensation

insurance under state or federal law. If you entered into a

settlement that waives your right to recover future medical

benefits under a workers’ compensation law or insurance

plan, this exclusion will still apply.

• Resulting from intoxication, as defined by state law where

the illness or injury occurred, or while under the influence of

illegal narcotics or controlled substances, unless

administered or prescribed by a doctor.

• For joint replacement, unless related to an injury covered by

the certificate.

• For injuries sustained during or due to participating,

instructing, demonstrating, guiding, or accompanying

others in any of the following: sports (professional, or semi-

professional, or intercollegiate), parachute jumping, hang-

gliding, racing or speed testing any motorized vehicle or

conveyance, scuba/skin diving (when diving 60 or more feet

in depth), skydiving, bungee jumping, or rodeo sports.

• For injuries sustained during or due to participating,

instructing, demonstrating, guiding, or accompanying

others in any of the following if the covered person is paid

to participate or to instruct: operating or riding on a

motorcycle, racing or speed testing any non-motorized

vehicle or conveyance, horseback riding, rock or mountain

climbing, or skiing.

• For injuries sustained while performing the duties of an

aircraft crew member, including giving or receiving training

on an aircraft.

• For vocational or recreational therapy, vocational

rehabilitation, or occupational therapy, except as provided

for in the certificate.

Nov 12 2021 08:13:42 am

TERMS

Other Information

(insurance plans)

This is only a general

outline of the benefits,

provisions and exclusions.

It is not an insurance

contract, nor part of the

insurance

certificate

. You

will find complete details in

the

certificate

8 of 9 TriTerm Medical Value Plans

THIS INFORMATION APPLIES TO FLORIDA TRITERM MEDICAL VALUE PLANS ONLY.

General Exclusions, continued

No beneﬁts are payable for expenses:

• Resulting from experimental or investigational treatments,

or unproven services.

• Expenses incurred by a covered person for the treatment of

tonsils, adenoids, middle ear disorders, hemorrhoids,

hernia, or any disorders of the reproductive organs will not

be covered during the covered person’s first 6 months of

coverage under the policy. This exclusion will not apply if

the treatment is provided on an emergency basis.

Optional Supplemental Accident Beneﬁt for

TriTerm Medical Plans Form SA-S-1899RG-GRI and state variations

Reduce or eliminate your out-of-pocket exposure for an

accident-related injury for additional premium. Supplemental

Accident benefit matches your deductible, paying for treat-

ment of an unexpected injury within 90 days of an accident.

The benefit maximum amount ($2,500, $5,000, $7,500,

$10,000, $12,500, or $15,000) is per accident, per covered

person.

Application Fee

Nonrefundable $40 application fee required.

Coordination of Beneﬁts (including Medicare)

If after coverage is issued, a covered person becomes

insured under another health plan or Medicare, benefits

will be determined under the Coordination of Benefits

(COB) clause.

COB allows two or more plans to work together so the total

amount of all benefits is never more than 100% of covered

expenses. COB also takes into account medical coverage

under auto insurance contracts. To determine which plan is

primary, refer to “order of benefits” in the certificate.

Dependents

For purposes of this coverage, eligible dependents are

your lawful spouse and eligible children. Eligible child must

be under age 31 and unmarried. A child that is unmarried

and remains chiefly dependent on you or your spouse for

support and maintenance due to mental or physical

disability will be considered an eligible child under the

policy/certificate regardless of age. The disabled child’s

coverage will not terminate due to age. The dependent may

remain covered for the duration of the coverage term.

Eﬀective Date

Expenses for injuries and illnesses are eligible for

coverage as of your plan’s eﬀective date. Your certiﬁcate

will take eﬀect on the later of:

• The requested effective date on your application; or

• The 5th day after the date received by GRIC,* but only if the

following conditions are satisfied:

- A. Your application and the appropriate premium payment

are actually received by us within 15 days of your

signing;**

- B. Your application is properly completed and unaltered;

- C. Your application is approved after review by GRIC.

- D. You are a resident of a state in which the

certificate

form can be issued; and

- E. If the application is submitted by an agent or broker,

the agent or broker is properly licensed and appointed

to submit applications to GRIC.

* If mailed and not postmarked by the U.S. Postal Service or if the

postmark is not legible, the effective date will be the later of: (1) the

date you requested; or (2) the 5th day after the date received by GRIC.

If the application is sent by any electronic means including fax, your

coverage will take effect on the later of: (1) the requested effective date;

or (2) the 5th day after the date received by GRIC.

** Your account will be immediately charged.

Eligibility

At time of application, the primary insured must be a

minimum of 19 years of age.

Eligible Expense

An eligible expense means a covered expense as follows:

• For Network Providers: The contracted fee for the provider.

• For Non-Network Providers: As defined in the

certificate

Nov 12 2021 08:13:42 am

TERMS

Other Information

(insurance plans)

This is only a general

outline of the benefits,

provisions and exclusions.

It is not an insurance

contract, nor part of the

insurance

certificate

. You

will find complete details in

the

certificate

9 of 9 TriTerm Medical Value Plans

THIS INFORMATION APPLIES TO FLORIDA TRITERM MEDICAL VALUE PLANS ONLY.

Emergency

“Emergency” means an unforeseen or sudden medical

condition manifesting itself by acute signs or symptoms

which could reasonably result in death or serious disability

if medical attention is not provided within 24 hours.

Reduced Non-Network Beneﬁts

These plans pay reduced non-network benefits.

Using non-network providers will cost you more due to a

non-network penalty - see below.

For non-emergency care

received from Non-Network Providers you pay: (a) all

charges above what is considered an eligible expense; (b) a

penalty of 25% of the eligible expense, which does not count

toward the deductible; and (c) a deductible amount equal to 2

times the network deductible. There is no out-of-pocket

maximum for non-network providers. Your actual out-of-

pocket costs may be more than the stated coinsurance

because the

bill from a non-network provider may not be

used to calculate what we pay and what you pay.

Non-Renewable

TriTerm Medical is issued for a specific period of time.

We may cancel coverage if there is fraud or material

misrepresentation made by or with the knowledge of a

covered person in filing a claim for benefits. Coverage will

remain in force until the termination date shown in your

certificate. We will notify you in advance of any changes in

coverage or benefits, unless the policy terminates earlier

for any reason stated in the Termination section.

Premium

The premium amount is expected to change for each

term.

Rating Factors

The plan, age and sex of covered persons, type and level

of benefits, tobacco use status, underwriting class status,

time the certificate has been in force, and place of

residence on the premium due date are some of the

factors used in determining your premium rates. From time

to time, we may change the rate table used. Each

premium will be based on the rate table in effect on that

premium’s due date. At least 31 days’ notice of any plan to

take an action or make a change, permitted by the

premium provision in the certificate, will be mailed to you

at your last address as shown in our records. We will make

no change in your premium solely because of claims

made under the certificate or a change in a covered

person’s health.

Termination

The certificate will terminate on the earliest of:

• The date all covered persons under the certificate move

out of the state where the certificate was issued.

• The primary insured’s death. If the

certificate

includes

dependents, it may be continued after the primary

insured’s death by a spouse, if a covered person;

otherwise, by the youngest child who is a covered person.

• Nonpayment of premiums when due.

• The termination date shown on the Data Page of the

certificate

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

certificate

• The date of the primary insured’s 65th birthday.

• The date you accept any contribution from your employer

for any portion of the premium, or the date you and your

employer treat the plan as employer-provided insurance for

any purpose, including tax purposes.

45746iFL-G-0121

Nov 12 2021 08:13:42 am

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