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HOORAY HEALTH

ASSURANCE PLANSOVERVIEW OF HOORAY HEALTH ASSURANCE PLANS FOR

LARGE GROUPS

This proposal describes both insurance and non-insurance benefits and services. Unless otherwise noted, insurance is underwritten by AXIS Insurance Company. This proposal is not a contract of insurance. This proposal provides only brief descriptions of the coverage available. The policies contain reductions, limitations, exclusions and termination provisions. The policies contain the full details of the plan including effective dates, benefits, limitations, exclusions and termination provisions. If there is a difference between this proposal and the policy, the policy language will govern. Policies will be available to you upon enrollment. The policy is governed by the laws in the state in which it is delivered. Certain terms or provisions may be different if required by the laws of that state. If you accept the terms of this proposal, coverage is subject to the underwriting companies’ determination that trade or economic sanctions or regulations do not prohibit us from binding coverage. Ternian Insurance Group reserves the right to extend or withdraw this proposal at any time by providing written notice to the requestor of this proposal. Not for individual solicitation. This proposal is valid for 90 days unless extended in writing.

Ternian Insurance Group, a subsidiary of AXIS Insurance Company and a leading provider of innovative benefit solutions that meet these types of needs, offers a benefits package precisely designed to help provide affordable first-dollar benefits, flexible coverage options and financial protection for employers and their workers.

The information and products provided in this document should not be construed as providing tax advice. Any questions regarding tax and compliance should be directed to a tax professional or attorney.

HH103110

www.hoorayhealthcare.com1.866.7.(HOORAY)HOORAY HEALTH 2

*Hooray Health in-network providers only. THE SERVICES DESCRIBED ARE NOT INSURANCE AND ARE NOT PROVIDED BY AXIS INSURANCE COMPANY.**ACA compliant MEC benefit and administration is self-funded and not provided by AXIS Insurance Company.

Plan Benefit OverviewHooray Health Assurance Plans are limited-benefit medical plans that pay a fixed dollar amount for covered expenses.

Basic plans with low costs and no annual deductible

Our basic plans were designed to cover your everyday medical needs. That is how we can

start our plans at just $99/month for an employee.

Dedicated and exclusiveprovider network

You won’t have to worry about finding an in-network provider to accept your plan, because we have over 2,500 easy to access retail clinics

and urgent cares in 45 states.*

Low copays and nounexpected bills

Everyone has received an unexpected bill that caused a financial burden. Not with Hooray Health! A $25 copay takes care of your in-network retail clinic or urgent care visits.*

Mobile app for Apple and Android phones

Download the Hooray Health mobile app to easily find in-network providers, connect

to a concierge or find the lowest price prescriptions near you.*

Pharmacy Prescription Discount

Shop smarter with the Hooray Health’s mobile app where you can compare

discounted prescription prices at pharmacy locations nearest you.*

Guaranteed acceptanceand quick coverage

With Hooray Health you can rest easy knowing with guaranteed acceptance,

you and your family can receive coverage and see an in-network retail clinic or urgent

care providers next day.

Connect and consult with a telemedicine doctor

Doctors can be hard to reach, illnesses can occur in the middle of the night, and

sometimes you just have a question. You have access to board-certified doctors 24/7.*

Access to medical concierge 24/7

You have access to our medicalconcierge to help you find in-network

providers or provide telephonictriage and consult for you.*


Plan HighlightsOUTPATIENT RETAIL CLINIC & URGENT CARE BENEFITSPays a limited fixed dollar amount for the following medical expenses resulting from medically necessary treatment, accidental injury or sickness of a covered member.

SUPPLEMENTAL IN-HOSPITAL PLAN

NON-INSURANCE HOORAY HEALTH BENEFITS

Retail Clinic and Urgent Care Visits Benefit is payable for visits to a retail clinic and urgent care.

Wellness Visit Benefit is payable for an annual routine health visit for covered persons.

Diagnostic, Laboratory and X-Ray Benefit is payable for x-rays, laboratory and other diagnostic tests ordered or performed by a physician in a contracted retail clinic or urgent care.

Accident Benefit Benefit is payable for covered outpatient expenses that occur during a covered accident period.

Hospital Confinement Benefit Benefit is payable for a maximum number of days per policy period, for hospital confinement.

ICU Benefit Benefit is payable for a maximum number of days per policy period, for hospital confinement in an ICU.

Surgery Benefit is payable for operating and recovery room, surgical charges, medical services and supplies when surgery is performed.

Anesthesia BenefitBenefit is payable for anesthesia administration in connection with a covered surgical procedure.

Telemedicine Benefits*Have access to our medical concierge and telemedicine doctors 24/7.

Prescription Discount Card* Unlimited access to discounts for all policyholders with top 10 contracted retail pharmacies.

*THE SERVICES DESCRIBED ABOVE ARE NOT INSURANCE AND ARE NOT PROVIDED BY AXIS INSURANCE COMPANY.

Supplemental In-Hospital Plan (Inpatient)(2) Plus Plan

Day 1 hospital confinement benefit amount per day $2,000 per day x 1 day

Days 2 + hospital confinement benefit amount per day $1,000 thereafter

Maximum benefit 5 days per year

ICU benefit amount per day $1,000 per day x 5 days

Surgery benefit amount (incl. maternity) per day $1,500 per day x 1 day

Anesthesia benefit amount per day $375 per day x 1 day

Accident maximum benefit amount per year up to: $10,000

Benefit % payable 100% U&C

Retail Clinic and Urgent Care Plan (Outpatient)(1) Basic Plan

WELLNESS

Annual wellness or athletic physical benefit amount per day $125 per day x 1 day

LEVEL ONE

Physician office visit plus lab work or prescription when required $125 after $25 copay

LEVEL TWO

Physician office visit plus Level One services plus x-rays, hydration procedure or injectable therapy when required $175 after $25 copay

Maximum visits per year 5 per year

ACCIDENT BENEFIT(1)

Maximim benefit amount per year up to: $5,000 per year

Benefit % payable 100% U&C

PRESCRIPTION BENEFIT

Discount Rx Card Included

TELEMEDICINE BENEFIT

Telemedicine doctor and medical concierge $0 consult; unlimited visits

Plus Add-on Rate

Employee Only +$60.00Employee + Spouse +$130.00Employee + Child(ren) +$130.00Employee + Family +$230.00

Plus Plan Monthly Rate

Employee Only $159.00Employee + Spouse $279.00Employee + Child(ren) $269.00Employee + Family $459.00

*There is a $25 copay for level one and two visits and accidents only. Copay does not apply to wellness benefit. **THE SERVICES DESCRIBED ARE NOT INSURANCE AND ARE NOT PROVIDED BY AXIS INSURANCE COMPANY.(1)The Fixed Hospital Indemnity, Outpatient Accident-Only, Critical Illness Benefit and Accidental Death and Dismemberment are underwritten by AXIS Insurance Company. (2)Groups in NM, NY, FL, WV do not have the inpatient accident benefit. Rates remain the same. (3)No balance billing for covered services received at Hooray Health’s in-network Retail Clinic and Urgent Care. Notice: LIMITED BENEFIT PLANS ARE INSURANCE PRODUCTS WITH REDUCED BENEFITS AND ARE NOT INTENDED TO BE AN ALTERNATIVE TO OR INTEGRATED WITH COMPREHENSIVE COVERAGE. FURTHER, THIS INSURANCE DOES NOT COORDINATE WITH ANY OTHER INSURANCE PLAN. IT DOES NOT PROVIDE MAJOR MEDICAL OR COMPREHENSIVE MEDICAL COVERAGE AND IS NOT DESIGNED TO REPLACE MAJOR MEDICAL INSURANCE. THIS INSURANCE IS NOT MINIMUM ESSENTIAL BENEFITS AS SET FORTH UNDER THE PATIENT PROTECTION AND AFFORDABLE CARE ACT. IF YOU DON’T HAVE MINIMUM ESSENTIAL COVERAGE, YOU MAY OWE ADDITIONAL PAYMENT WITH YOUR TAXES.

Coverage is subject to exclusions and limitations, and may not be available in all US states and jurisdictions. Product availability and plan design features, including eligibility requirements, descriptions of benefits, exclusions or limitation may vary depending on local country or US state laws. Full terms and conditions of coverage, including effective dates of coverage, benefits, limitations, and exclusions, are set forth in the policy.


Discounts for In-hospital services received at FirstHealth network hospitals.

Supplemental In-hospital Plan must be purchased with Retail Clinic and Urgent Care Plan.

Basic Plan Monthly Rates

Employee Only $99.00Employee + Spouse $149.00Employee + Child(ren) $139.00Employee + Family $229.00

Plan Summary


Hooray Health Member Support

Never worry about finding the right number to call when you need help or have questions about your plan. We are always here for you.

Availability: 24/7/365Phone: 1866.746.6729

Hooray Health Medical Concierge

Our medical concierge team is available for you to call 24/7 when you have any health related questions and need triage support.


Telemedicine - MyTelemedicine

Discount Pharmacy - GeniusRx Powered by ScriptSave

Doctors can be hard to reach, illnesses can occur in the middle of the night, and sometimes you just have a question. In all of those circumstances - and many more - MyTelemedicine is a convenient and affordable solution. As a member you will receive access to a national network of U.S. board-certified doctors who are available to treat many of your medical issues.


ScriptSave® WellRx is the smart and trusted resource that makes prescription medicines more affordable and easier to manage, because ScriptSave WellRx cares about helping people stay healthy. ScriptSave WellRx is accepted nationwide at more than 62,000 pharmacies. Simply present your ScriptSave WellRx card at any of the thousands of participating pharmacies nationwide to receive your instant savings.

Phone: 1800.407.8156 Website: www.wellrx.com/geniusrx/2281

THE SERVICES DESCRIBED ABOVE ARE NOT INSURANCE AND ARE NOT PROVIDED BY AXIS INSURANCE COMPANY.

Hooray Health members will have access to non-insurance benefits that save them time and money on their healthcare. These non-insurance benefits include time-saving medical concierge and telemedicine services, as well as discounted dental, vision, and prescription drug programs. When members have questions regarding their plan and benefits, Hooray Health’s knowledgeable member support team is always available to assist them.

Hooray Health Benefits Non-Insurance


Dental & Vision Benefits

DENTAL PLAN No deductibles; Reimburses 100% of usual amounts listed. Dental $2,000 Dental $3,500

Maximum Plan Year Limit $2,000.00 $3,500.00

Periodontics lifetime maximum $1,000.00 $1,750.00

Orthodontics lifetime maximum $1,000.00 $2,000.00

TYPE 1: Preventative & Diagnostic

Oral exams, including prophalaxis $43.00 $75.00

Bitewings, per film $6.00 $11.00

X-ray, panoramic or cephalometric $43.00 $75.00

Sealants/ topical fluoride $13.00 $23.00

Space maintainers $129.00 $226.00

TYPE 2: Major Restorative

Crowns, bridges and dentures $216.00 $250.00

Pre-fabricated crowns $72.00 $126.00

Crown build-up procedures $57.00 $100.00

TYPE 3: Minor Restorative

Fillings $50.00 $88.00

Crowns, bridges and denture repair $28.00 $49.00

Relining or rebasing dentures $72.00 $126.00

TYPE 4: Endodontics

Root canals, apicoectomies $230.00 $250.00

Rootamputations $115.00 $201.00

Therapeutic pulpotomy, retrograde, fillings, apexification, hemisection $57.00 $100.00

TYPE 5: Periodontics

Lifetime Maximum $1,000.00 $1,750.00

Tissue grafts or bone surgery $115.00 $201.00

Gingivectomy (per quadrant) $72.00 $126.00

Gingivectomy (per tooth) $43.00 $75.00

Periodontal scaling, periodontal splinting, root planning, gingival curettage (per quadrant) $28.00 $49.00

TYPE 6: Oral Surgery

Surgeries Level 1 (example: removal of exostosis) $144.00 $250.00

Surgeries Level 2 (example: removal of impacted tooth) $79.00 $138.00

Surgeries Level 3 (example: simple extraction) $43.00 $75.00

TYPE 7: General Anesthesia and IV

IV, first half hour general, each additional 1/4 hour general $86.00 $151.00

TYPE 8: Orthodontia

Per course of treatment (Lifetime Maximum) $1,000.00 $2,000.00

Type 1 through 7: subject to annual maximum $2,000.00 $3,500.00

Type 2, 5, 6, 8: subject to 12 month waiting period

Vision Indemnity Benefits

Examination benefit/ Plan Year $35.00 $35.00

Materials benefit every two plan years $75.00 $75.00

MONTHLY RATES

Employee Only $33.33 $58.83

Employee + Spouse $53.33 $102.43

Employee + Child(ren) $54.99 $96.57

Employee + Family $89.99 $158.03



Terms & Qualifications

Pre-existing ConditionLimitation

Supplemental In-Hospital Plan:6 Month Treatment Period/ 12 Month Limitation Period on Hospital Confinement and Surgery Benefits only

Continuation of Coverage When Employment Ends - Continuation of coverage provision in policy

Issue Ages- Employee/Spouse: 18-64 (All benefits terminate at age 65)- Dependent Child: to 26- For Critical Illness benefit, covered person must be under age 65

Coordination of Benefits None

Rate Guarantee 1 Year

Rate ContingencyRates are based upon demographic and company information provided in proposal request. Any deviation may require recalculation.

Situs State Policy will be issued in the situs state of client


For hospital confinement or surgery benefits on supplemental in-hospital plan: 6 Month Treatment Period/ 12 Month Limitation Period

Pre-existing condition limitation The Insurance Company will not pay Hospital Confinement Benefits for any Pre-existing Condition. A “Pre-existing Condition” means a disease or physical condition for which the Employee received medical treatment and/or advice, during the treatment period shown above before his or her most recent effective date of insurance. The Pre-existing Condition Limitation will apply to any added benefits or increase in benefits. It will not apply after the Limitation Period shown above.


Pre-Existing Condition Limitation Limitations & Exclusions


Under the Group Hospital Indemnity Policy, AXIS Insurance Company will not pay benefits for any loss, injury or sickness that is caused by, or results from:

• Intentionally self-inflicted injury, suicide or any attempt while sane or insane;

• Commission or attempt to commit a felony or an assault; • Commission of or active participation in a riot or

insurrection; • Declared or undeclared war or act of war; • Release, whether or not accidental, or by any person

unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;

• An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;

• Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency;

• Flight in, boarding or alighting from an Aircraft except as: - a fare-paying passenger on a regularly scheduled commercial or charter airline; - a passenger in a non-scheduled, private Aircraft used for pleasure purposes with no commercial intent during rthe flight;

• Travel in any Aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the Policyholder, if the Aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year;

• Bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding;

• Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;

• The Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officer’s report, or similar items will be considered proof of the Insured Person’s intoxication;

• An Accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless: (a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver’s education instructor;

• Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Physician unless specifically provided herein;

• Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration;

• Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration;

• Repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses;

• Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed;

• Mental and nervous disorders; • Elective surgery or cosmetic surgery, except for

reconstructive surgery needed as the result of a Covered Injury or Covered Sickness;

• Experimental or Investigational drugs, services, supplies. For the purposes of this exclusion, “Experimental or Investigational” means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II, or III). The covered service will also be considered Experimental or Investigational if the Insured Person is required to sign a consent form that indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, that is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered Experimental or investigational. A drug, device or biological product is considered Experimental or Investigational if it does not have FDA approval or approval under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption;

• Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications;

• Sexual reassignment surgery, sexual transformation surgery, sexual transgendering surgery;

• Services related to sterilization, reversal of a vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a Covered Injury or Covered Sickness;

• Treatment or services provided by a private duty nurse; • Organ or tissue transplants and related services; • Personal comfort or convenience items; • Rest or custodial cures; • Hearing aids. • An Injury or Sickness for which the Insured Person is paid

benefits under any Workers’ Compensation or occupational disease law or under any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident.

In addition, benefits will not be paid for services or treatment rendered by any person who is:

• employed or retained by the Policyholder; Subscriber; • living in the Insured Person’s household; • an Immediate Family Member of either the Insured Person

or the Insured Person’s Spouse; • the Insured Person.


Under the Accident Medical Expense Policy, AXIS Insurance Company will not pay benefits for any loss or Injury that is caused by, results from, or is contributed to by:

• Intentionally self-inflicted injury, suicide or any attempt while sane or insane;

• Commission or attempt to commit a felony or an assault;

• Commission of or active participation in a riot or insurrection;

• Declared or undeclared war or act of war; • An injury or sickness that occurs while on active duty

service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;

• Flight in, boarding or alighting from an Aircraft except as a fare-paying passenger on a regularly scheduled commercial or charter airline;

• Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;

• Medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice;

• The Insured Person’s intoxication; The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officers report, or similar items will be considered proof of the Insured Person’s intoxication;

• Aggravation or re-injury of a prior injury the Insured Person suffered prior to His Coverage Effective Date, unless the Company receives a written medical release from the Insured Person’s Physician;

• Sickness, disease or any bacterial infection, except one that results from an Accidental cut or wound, or pyogenic infections that result from accidental ingestion of contaminated substances;

• Release, whether or not accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;

• Travel in any Aircraft owned, leased or controlled by the policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the policyholder if the Aircraft may be used as the policyholder wishes for more than 10 straight days, or more than 15 days in any year.

In addition, benefits will not be paid for services or treatment rendered by any person who is:

• employed or retained by the Policyholder; • living in the Insured Person’s household;

• an Immediate Family Member of either the Insured Person or the Insured Person’s spouse;

• the Insured Person.

In addition to the above Exclusions, under the Accident Medical Expense Policy, AXIS Insurance Company will not pay for any loss, treatment or services resulting from or contributed to by:

• Treatment by persons employed or retained by the Policyholder, or by any Immediate Family or member of the Insured Person’s household.

• Treatment of sickness, disease or infections except pyogenic infections or bacterial infections that result from the accidental ingestion of contaminated substances;

• Treatment of hernia, Osgood-Schlatter’s Disease, osteochondritis, appendicitis; osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness; detached retina unless caused by a Covered Accident;

• Mental disorder or psychological or psychiatric care or treatment whether or not caused by a Covered Accident;

• Pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions;

• Mental and nervous disorders; • Damage to or loss of dentures or bridges, or damage to

existing orthodontic equipment; • Expenses incurred for treatment of temporomandibular

or craniomandibular joint dysfunction and associated myofacial disorders;

• Injury covered by Workers’ Compensation, Employer’s Liability Laws or similar occupational benefits, including any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident, or while engaging in activity for monetary gain from sources other than the Policyholder.

• All surgery including cosmetic and elective;• Any elective treatment, health treatment, or examination,

including any service, treatment or supplies that: (a) are deemed by us to be experimental; and (b) are not recognized and generally accepted medical practices in the United States;

• Eyeglasses, contact lenses, hearing aids, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices;

• Expenses payable by any automobile insurance policy without regard to fault;

• Conditions that are not caused by a Covered Accident; Any treatment, service or supply not specifically covered by the Policy; or

• Injuries paid under medical payment coverage or no-fault coverage contained in an automobile insurance policy or liability insurance policy.

Under the Dental Policy, benefits will not be paid for the following:

• For services and supplies not listed in the Schedule of Benefits or not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.

• For cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons.

• For services related to, performed in conjunction with, or resulting from a non-covered procedure.


• For charges in excess of the Usual and Customary rate. • For any treatment program which began prior to the date

the Insured Person is covered under the Policy. • For crowns, inlays and onlays on teeth that can be restored

by direct placement materials. • For the replacement of crowns, bridges, dentures, inlays or

onlays that can be restored to normal function. • For the replacement of crowns, bridges, inlays, onlays or

prosthetic appliance within 5 years from the date of last placement.

• For service or supplies payable under any medical expense potion of an auto or no-fault plan.

• For any condition paid under any Worker’s Compensation Act or similar law.

• For services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence or insurance.

• During any Waiting Period the Company requires. When the Insured Person voluntarily ends this insurance without a qualifying event and re-enrolls at a later date, the Waiting Period is 2 years and begins on the date coverage first ended.

• For services that are applied toward the satisfaction of a Deductible, if any.

• For services subject to a Waiting Period that were incurred during the Waiting Period.

• For charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services.

• For Hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, Hospital confinement.

• For drugs or the dispensing of drugs. • For oral hygiene instruction; plaque control; acid etch;

prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).

• For implants; myofunctional therapy; athletic mouth guards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia.

• For orthodontia, unless included within the Schedule of Benefits.

• For services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage on Our Plan. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits.

• For composite, resin, or white fillings on posterior primary teeth. Benefits will be reduced to that of an amalgam or silver filling.

• For the replacement of a filling within 24 months of placement, unless for specific health reasons.

• For the replacement of retainers. • For sealants not applied to permanent bicuspid or molar;

applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth.

• For lab fees for higher metals or porcelain crowns,bridges, inlays, or onlays.

Vision Benefits will not be paid for: • Broken or lost or stolen lenses contact or frames. • Medical or surgical treatment of the eye. • Services or materials which are payable under any

Workers’ Compensation Act or similar law or public program other than Medicaid.

• Services or materials rendered by a provider other than an Ophthalmologist, Optometrist, or Optician acting within the scope of their license.

• Services rendered after the date an Insured Person ceases to be covered under the Policy, except when vision material ordered before coverage ended are delivered and the services rendered to Insured Person(s) within 31 days of such order.

• Services rendered or material ordered before the date coverage began for a Insured Person under the Policy.

• Regardless of Optical Necessity, benefits are not available more frequently than that which is specified in the Schedule of Benefits

The insurance coverage provided herein may be considered a welfare benefit plan pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”). If ERISA applies the plan sponsor has certain responsibilities. Please consult with your legal or tax counsel for guidance as to whether ERISA would apply to this coverage and the responsibilities of a plan sponsor.


This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit AXIS Insurance Company from providing insurance, including, but not limited to, the payment of claims.

Payment of claims under any insurance policy issued shall only be made in full compliance with all United States economic or trade and sanction laws or regulation, including, but not limited to, sanctions, laws and regulations administered and enforced by the U.S. Treasury Department’s Office of Foreign Assets Control (“OFAC”).

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