TransChoice® Plus Group Limited Benefit Hospital and Medical Indemnity Insurance Policy

Underwritten by Transamerica Life Insurance Company, Home Office, Cedar Rapids, IA

Plan not available in Washington State, New York, Connecticut or New Hampshire

Window World Benefit Plans

Choices..Options...Convenience...
Transamerica Life Insurance Company LogoText Box: TransChoice® Plus** is designed to help meet the needs of employees who are not offered traditional major medical insurance. This policy provides valuable benefits that can help pay for certain health care expenses, you can cover your eligible family members as well as yourself*** and you can choose from four different plan options to meet your families specific needs. No physical exam or health questions are required for coverage and the ease of payroll deductions makes paying for the premiums convenient. Text Box: Enhanced Plan Design Highlights No Pre-Existing Condition Limitation Outpatient Physician Office Visit Indemnity Benefit Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit Daily In-Hospital Indemnity Benefit Surgical and Anesthesia Indemnity Benefit Off-the-Job Accidental Injury Benefit Wellness Indemnity Benefit Prescription Drug Indemnity Benefit Employee Discount Card offered by New Benefits Ltd. PPO Network Provided by: Key Benefit Administrators through Beechstreet Network Group Term Life Insurance Policy (with an Accidental Death and Dismemberment Doctor and PatientText Box: *TransChoice® Plus is a group voluntary limited benefit medical and hospital indemnity insurance policy underwritten by Transamerica Life Insurance Company, Home Office: Cedar Rapids, IA. This is a brief description of coverage. Please refer to the policy language on this site and policy materials for detailed benefit descriptions, limitations and exclusions. **Coverage is also available for an eligible spouse (as defined by governing state law) and your eligible dependent children. Family coverage includes the insured employee, his or her spouse, and eligible dependent children. Employee plus Spouse coverage includes the insured employee and his/her eligible spouse. Employee plus Child(ren) includes the insured employee and his/her eligible dependent child(ren).

*Pays actual charges as the amount paid by or on behalf of the covered person, and accepted by the provider as payment in full for services provided.

†Rates assuming premiums are current and will continue to be remitted in advance of the effective date.
Text Box: TransChoice® Plus Policy Benefit Plan Details TransChoice Plus is a limited benefit medical and hospital insurance policy that pays benefits to help cover basic medical expenses. Coverage is subject to certain conditions, limitations and exclusions, which are detailed in the Group Master Policy, Certificate and Riders, together these constitute the legal contract. If there is a conflict between what is described in this brochure and the contract, the contact will govern. Outpatient Physician Office Visit Indemnity Benefit: This benefit pays the amount shown on the benefit page per physician’s office visit as a result of a covered sickness or accident. Benefits are payable for a maximum of six visits per calendar year for you and your spouse each and a maximum of 6 (sixe) visits per year for all children combined. Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit: This benefit pays the amount shown on the benefit page per testing day for tests performed for the purpose of diagnosis of a covered sickness or accident, as indicated by symptoms that would suggest the covered sickness or injury had occurred. The benefit is limited to four days of testing per calendar year per covered person and is not payable while he/she is confined in a hospital (i.e. it applies to outpatient services only). Daily In-Hospital Indemnity Benefit: When a covered person is confined in a hospital as a result of a covered sickness or accident, this benefit pays the benefit amount for each day over 23 hours the covered person is confined in a hospital, up to a maximum of 30 days per confinement. Surgical and Anesthesia Indemnity Benefit: When a covered person undergoes a surgical procedure listed in the Schedule of Surgical Indemnity Benefits in the certificate as a result of a covered sickness or accident, the policy pays the benefit amount shown in the Schedule based on the plan level selected. The anesthesia benefit is 20% of the surgical benefit amount. If two or more procedures are performed through the same incision or operative field, the benefit paid will be for only the procedure that has the larger benefit. If more than one procedure is performed, but each through a separate incision or in a separate operative field, the amount payable will be the specified amount for the primary procedure plus 50% of the amount payable for all other surgical procedures performed. Off-the-Job Accidental Injury Benefit: This benefit pays actual charges of expenses up to the amount shown on the benefit page for each covered accident (maximum of five covered accidents per covered person per calendar year) for x-rays used to diagnose an accidental injury and for treatment of a covered accident by a physician in the physician’s office, clinic, urgent care facility, or hospital emergency room. Treatment must be received within 72 hours of the accident for benefits to be payable. In addition, if you or your covered dependents require ambulance transportation to a hospital or emergency center for injuries sustained in an accident, benefits will be provided in the amount of $350 per covered person, with a maximum of three trips per calendar year per family. Prescription Drug Indemnity Benefit: This benefit pays the amount shown on the benefit page per prescription when you and your covered dependents incur expenses for prescription drugs prescribed by a physician as a result of a covered sickness or accident. The benefit pays for up to 12 prescriptions per calendar year for you and your spouse each and 12 prescriptions per year for all children combined. (one per covered person per month). By presenting your Caremark prescription drug discount card to one of Caremark’s 55,000 participating providers, you can receive a discount of at least 14% off the retail pharmacy price of brand-name drugs and up to 60% for generic drugs. The discount card will be included in the fulfillment package that you receive from KBA. You will continue to receive the discount even after your TransChoice prescription drug benefit has been used for the year. Wellness Indemnity Benefit: This benefit will pay the amount shown on the benefit page for each covered person who undergoes the following; physical examinations, mammograms, pap smears, immunizations, flexible sigmoidoscopy, prostate-specific antigen tests, and blood screenings. The benefit is payable only once each calendar year for each covered person. Services must be under the supervision or recommended by a physician and a charge must be incurred. Ambulance Indemnity Benefit: This benefit pays per trip in an ambulance. This benefit allows a maximum of 3 trips per covered person per calendar year with a lifetime maximum of 6 trips. Treatment must be received within 72 hours of the accident or onset of sickness, and must be provided by a licensed ambulance company for benefits to be payable. Limitations and Exclusions: No benefits will be payable as the result of: Suicide or any attempt thereof, while sane or insane; Any intentionally self-inflicted injury or sickness; Rest care or rehabilitative care and treatment; Immunization shots and routine examinations such as physical examinations, mammograms, pap smears, flexible sigmoidoscopy, prostate-specific antigen tests and blood screenings unless the Wellness Benefit is included; Routine newborn care, including routine nursery charges; The treatment of mental illness; functional or organic nervous disorder, regardless of cause, alcohol abuse, and drug use, unless such drugs were taken on the advice of a physician and taken as prescribed. In such circumstances and with respect to payment of the Daily In-Hospital Indemnity Benefit, benefits will be limited to no more than 10 days in any calendar year; Participation in a riot, civil commotion, civil disobedience, or unlawful assembly; Committing, or attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation; Participation in an organized contest of speed, parachuting, parasailing, bungee jumping, or hand gliding; Air travel, except as a fare-paying passenger on a commercial airline on a regularly scheduled route, or as a passenger for transportation only and not as a pilot or crew member; Any accident caused by the participation in any activity or even, including the operation of a vehicle, while under the influence or a controlled substance (unless administered by a physician or taken according to the physician’s instructions) or while intoxicated (intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred); Any procedure or treatment to change physical characteristics to those of the opposite sex and other treatment related to sex change; The reversal of tubal ligation and vasectomies; Artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications, or physician’s services, unless required by law; Any loss uncured while on active duty status in the armed forces (if the insured notifies the administrator of such active duty, they will refund any premiums paid for any period for which no coverage is provided as a result of this exception); Accidents or sicknesses arising out of and in the course of any occupation for compensation, wage or profit or expenses which are payable under Occupational Disease Law or similar law, whether or not application for such benefits has been made; Pre-existing conditions during the first 12 months after the effective date; Air or ground ambulance transportation (unless the Ambulance Benefit has been included); Routine eye examinations or fitting of eye glasses; Hearing aids or fitting of hearing aids; Dental examinations or dental care other than expenses resulting from an accident; Care or treatment of an accident or sickness not specifically provided for in the plan Any surgical procedure not specifically listed in the Schedule of Surgical Indemnity Benefits; With respect to the Off-the-Job Accidental Injury Benefit only, charges that the covered person is not legally required to pay, or charges which would not have been made if this coverage had not existed; or Treatment of an accident or sickness made necessary by or arising from war, declared or undeclared, or any act of war. Non-Insurance Benefits: Employee Discount Card This discount card is provided by New Benefits, LTD. It offers employees access to a discount Vision Plan, a Nurses Hotline, Counseling Services and benefits for Hearing Aids. This is not an insurance plan. The discount Vision Plan through the Coast to Coast network allows the employee to receive discounts of 20% to 60% on eyeglasses, non-prescription sunglasses, contact lenses (including disposables) and frames from over 10,000 independent retail optical locations nationwide. Providers include independent practitioners, regional chains, department store opticals, and the largest chains in the U.S. Some of these providers are LensCrafters, Pearle Vision, Sears Optical and JC Penney Optical (among others).* The Nurses Hotline allows access to experienced registered nurses 24 hours a day, 7 days a week, 365 days a year. These hotline nurses are an immediate, reliable and caring source of health information, education and support. Services provided by this plan include: * General information on all types of health concerns * Information on non-medical support groups * Information based on physician-approved guidelines * Answers about medication usage and interaction * Translation services for non-English speaking callers * Full time medical director on staff The Counseling Services benefit allows the employee to speak with a counselor 24 hours a day, 7 days a week regarding any personal problems they may be facing. In addition, if the employee is referred to one of the 27,000 counseling providers nationwide, they will receive discounts of 25% to 30% off the normal billing charges from those providers.* * Discounts on professional services are not available where prohibited by law. The Hearing Aid benefit provides savings of up to 15% off the retail cost on over 70 models of hearing aids, and a free hearing test when utilizing one of the 1,200 participating Beltone® locations nationwide. Or, the employees can realize savings of up to 50% off suggested retail price on over 90 models of hearing aids in over 1,000 locations nationwide.* Information on how to access the benefits of the Employee Discount card will be included in the fulfillment package that each insured employee receives from KBA. Prescription Drug Discount Card Includes an option of utilizing a prescription drug discount plan through Caremark. By presenting his or her discount card to one of Caremark’s 55,000 participating providers, an insured can receive a discount of at least 14% off the retail pharmacy price for brand name drugs and up to 60% for generic drugs. The insured will continue to receive the discount even after his or her TransChoice benefit has been completely used. PPO Network Benefit - offered by KBA Access to over 525,000 healthcare professionals, 3,800 hospitals and more than 66,000 ancillary care facilities in every state contract directly to participate in the Multiplan Network. This means that no matter where you live, work, and seek healthcare, you have access to the largest independent primary PPO in the nation. The PPO discounts continue to apply to the member’s medical bills even after the TransChoice benefits have been exhausted. Information on ac­cessing either of these networks will be included in the fulfillment package that each insured employee receives from KBA Group Term Life Insurance Policy with Accidental Death and Dismemberment (AD&D): Form Series CP100200 and CC100200 This policy pays the benefit amount shown on the benefit page upon the death of the insured, subject to any limitations/ exclusions. All eligible children in each family will be covered for the same amount. The AD&D coverage amount will match the amount of group term life insurance. Under the AD&D Rider, when a covered accident results in any of the following losses, benefits are paid for the following specified percentages of the coverage amount subject to any limitations and exclusions; Exclusions - Group Term Life Policy We will not pay a death benefit if an insured dies by suicide, while sane or insane, within two years of the date his/her insurance starts. If the insured or his/her spouse dies by suicide, we will refund the premiums paid for the insurance (if a dependent child dies by suicide, we will refund the premiums paid for the dependent children’s insurance only if there are no surviving insured dependent children). If any death benefit is increased, this suicide exclusion starts anew, but will apply only to the amount of the increase. Rider Form Series CR101100AD&D coverage is not available to dependent children Only one such amount will be paid as a result of a single covered accident

TransChoice® Plus Plan Benefits

Bronze

Silver

Gold

Platinum

Daily In-Hospital Indemnity Benefit  Pays per day over 23 hours (max of 30 days per confinement)

$100

$300

$600

$1,000

Surgical and Anesthesia Indemnity Benefit Pays benefit shown in Surgical Schedule up to max amount; pays additional 20% for Anesthesia

$1,000 Schedule

$1,000 Schedule

$2,500 Schedule

$5,000 Schedule

Outpatient Physician Office Visit Indemnity Benefit  Pays per visit up to 6 visits per calendar year per covered patient

$70

$70

$80

$80

Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit Pays up to 4 days of testing per calendar year, per covered person

$100

$100

$150

$200

Off-the-Job Accidental Injury Benefit  Pays actual charges* of up to a maximum per covered accident (5 covered accidents per year)

N/A

$500

$500

$700

Wellness Indemnity Benefit  Pays 1 visit per calendar year per insured over 2 years of age; 2 visits per year for children 12-24 months

$50

$100

$200

$200

Ambulance Indemnity Benefit Pays per trip in an ambulance, 3 trips per calendar year per covered person; lifetime maximum of 6 trips

$200

$200

$350

$350

Prescription Drug Indemnity Benefit  Pays per prescription for up to 12 prescriptions per person per calendar year

$25

$30

$40

$50

Group Term Life Insurance with Accidental Death and Dismemberment AD&D -AD&D not available to dependent children

Employee

Spouse

Child(ren)

$10,000

$5,000

$2,500

$10,000

$5,000

$2,500

$10,000

$5,000

$2,500

$10,000

$5,000

$2,500

Non Insurance Benefits

Employee Discount Card—Offered by New Benefits, LTD  Provides access to a discount Vision plan, nurse hotline, counseling services, and discounts on hearing aids

Included

PPO Network—Beechstreet—Offered by Key Benefit Administrators (KBA)  You and your covered dependents will receive contracted discounts from the normal fees charged by network physicians, hospitals, and outpatient x-ray and laboratory providers.  1-800-432-1776  www.beechstreet.com

Included

Weekly Premiums†

Bronze

Silver

Gold

Platinum

Employee

$16.45

$22.16

$32.48

$44.40

Employee + Spouse

$27.33

$37.96

$57.39

$79.92

Employee + Child(ren)

$27.94

$38.43

$58.60

$80.02

Family

$38.90

$54.37

$83.73

$115.86