Plan Benefits and Underwriting Guidelines Summary

Plan Benefits and
Underwriting Guidelines

dental
medical
vision
life
disability

Table of Contents

PPO Dental and IndemnityPlus Plans 4
PPO Dental Plan Summary - National 4
IndemnityPlus Dental Plan Summary - National 5
PPO Dental Plan Summary - Utah 6
IndemnityPlus Dental Plan Summary - Utah 7
Dental Networks 8
The Fine Print 8
Exclusions 9
HDHP Medical Plans 10
HSA-Compatible High Deductible Health Plan Summary 10
The Fine Print 11
Exclusions 11
Vision PPO and Indemnity Plans 12
Vision PPO Plan Summary 12
Vision Indemnity Plan Summary 12
The Fine Print 13
Access Vision Exclusions 14
Vision PPO Exclusions 14
Group Term Life Plans 15
Group Term Life Plan Summary 15
The Fine Print 16
Short Term Disability 17
Short Term Disability Plan Summary 17
The Fine Print 18

PPO Dental and IndemnityPlus Plans
Group Sizes 2 or More

PPO Dental Plan Summary - National
Available in AZ, CA, DC, FL, IL, IN, MD, MI, MO, NE, NV, OH, TX AND PA.

Texas reimbursement is based on Maximum Allowable Charge (MAC) only. Out-of-Network for Texas is paid as In-Network.
MAC is available in AZ, CA, NV and TX only. UCR is available in all states except Texas.

Plan Design PPO Dental
High Plan Mid Plan Basic Plan Value Plan
Out-of- Out-of- Out-of- Out-of-
Benefits In- Network In- Network In- Network In- Network
Network (Does not Network (Does not Network (Does not Network (Does not
apply to TX) apply to TX) apply to TX) apply to TX)

$2,500 $2,000 $2,000 $1,500 $1,500 $1,500 $1,500 $1,500
$2,000 $1,500 $1,500 $1,000 $1,000 $1,000 $1,000 $1,000
Calendar Year Maximum
$1,500 $1,000 $1,000 $1,000 $500 $500 $500 $500
$1,000 $1,000
$0, $25, $50, $75 or $100
Calendar Year Deductible (3 per family max)
(Waived on Preventive Services.)

Class I: Preventive Services – Routine oral exam,
cleanings, fluoride treatment for children, bitewing 100% 100% 100% 80% 100% 80% 100% 80%
x-rays, panoramic/full mouth x-rays, sealants

Class II: Basic Services – Fillings (amalgam,
porcelain & plastic), anterior & posterior composites,
anesthesia (general or IV sedation), emergency 90% 80% 80% 80% 80% 50% 50% 20%
palliative treatment, space maintainers for children,
limited oral exam, pathology, oral surgery

Class III: Major Services – Crowns & gold fillings,
inlays, onlays and pontics, fixed bridges, implants, 60% 50% 50% 50% 0% 0% 0% 0%
complete and partial dentures

Endodontics Class II or Class III
Periodontics Class II or Class III
12 month waiting period applies to major
Waiting Periods and orthodontic services None
(Waived for qualifying groups.)

Special Dental Accident Benefit $1,000 maximum per accident to sound, natural teeth
UCR at 80th or 90th Percentile or MAC
Out-of-Network Reimbursement
(MAC available in Arizona, California and Nevada. Texas is MAC only and is paid as in-network.)

Orthodontics (optional) 50%
$1,000 Lifetime / $500 Calendar Year
Child Only Orthodontic Benefit Option
(Dependent children through age 18)
Maximum or $1,500 Lifetime / $750 Calendar
Year Maximum Not offered
Adult/Child Orthodontia Benefit Option $1,000 Lifetime / $500 Calendar Year Maximum
Child Good Vision Benefit Covers 50% of UCR for an eye exam once
(Included with orthodontia) every 12 months for children through 18

Child Orthodontia is available for groups with 5 or more employees enrolling. Adult Orthodontia is available for employer-sponsored groups with 25 or more employees enrolling.

4 www.bestlife.com | 800.237.8543

IndemnityPlus Dental Plan Summary - National
Available in AK, AL, AR, AZ, CA, CO, DC, FL, GA, HI, ID, IL, IN, KS, KY, LA, MD, MI, MO, MS, MT, NC, ND, NE, NM, NV, OH, OK, OR, PA, SC, SD, TN,
TX, VA, WA and WY.

MAC is available in AZ, CA and NV.

Plan Design IndemnityPlus
Benefits High Plan Mid Plan Basic Plan Value Plan
$2,500 $2,000 $1,500 $1,500
$2,000 $1,500 $1,000 $1,000
Calendar Year Maximum
$1,500 $1,200 $500 $500
$1,000 $1,000
Calendar Year Deductible $0, $25, $50, $75 or $100
(3 per family max) (Waived on Preventive Services.)

Class I: Preventive Services – Routine oral exam,
cleanings, fluoride treatment for children, bitewing 100% 100% 100% 100%
x-rays, panoramic/full mouth x-rays, sealants

Class II: Basic Services – Fillings (amalgam,
porcelain & plastic), anterior & posterior composites,
anesthesia (general or IV sedation), emergency 90% 80% 80% 50%
palliative treatment, space maintainers for children,
limited oral exam, pathology, oral surgery

Class III: Major Services – Crowns & gold fillings,
inlays, onlays and pontics, fixed bridges, implants, 60% 50% 0% 0%
complete and partial dentures

12 month waiting period applies to major and
Waiting Periods orthodontic services None

UCR at 80th or 90th Percentile or MAC
Out-of-Network Reimbursement
(MAC available in Arizona, California and Nevada)

$1,000 Lifetime / $500 Calendar Year
Maximum or $1,500 Lifetime / $750 Calendar
Year Maximum Not offered
Adult/Child Orthodontia Benefit Option $1,000 Lifetime / $500 Calendar Year Maximum
Child Good Vision Benefit Covers 50% of UCR for an eye exam once
(Included with orthodontia) every 12 months for children through 18

Child Orthodontia is available for groups with 5 or more employees enrolling. Adult Orthodontia is available for employer-sponsored groups with 25 or more employees enrolling.

www.bestlife.com | 800.237.8543 5

PPO Dental Plan Summary - Utah
Available in UT only.

Plan Design Dental PPO Plans
Premium Plan Classic Plan Basic Plan Value Plan
Benefits In- Out-of- In- Out-of- In- Out-of- In- Out-of-
Network Network Network Network Network Network Network Network

$1,500 $1,500 $1,500 $1,500 $1,500 $1,500 $1,500 $1,500
Calendar Year Maximum $1,500 $1,000 $1,500 $1,000 $1,000 $1,000 $1,000 $1,000
$1,000 $1,000 $1,000 $1,000 $500 $500 $500 $500
Individual Calendar Year Deductible $0, $25, $50, $75 or $100

Lifetime Deductible Option $100 Lifetime Deductible in lieu of a Calendar Year Deductible
Class I: Preventive Services - Routine
oral exam, cleanings, fluoride treatment for
children, bitewing x-rays, panoramic/full
100% 100% 100% 80% 100% 80% 100% 80%
mouth x-rays, sealants

Class II: Basic Services - Fillings (amalgam,
porcelain & plastic), anterior & posterior
composites, anesthesia (general or IV
sedation), emergency palliative treatment,
90% 80% 80% 60% 80% 50% 50% 20%
space maintainers for children, limited oral
exam, pathology, oral surgery

Class III: Major Services - Crowns &
gold fillings, inlays, onlays & pontics, fixed
bridges, implants, complete & partial
60% 50% 50% 50% 0% 0% 0% 0%
dentures

Oral Surgery Class II or Class III
12 month waiting period applies to major
Waiting Periods and orthodontic services None


Out-of-Network Reimbursement UCR at 80th, 90th Percentile or MAC


$1,000 Lifetime / $500 Calendar Year Maximum
or $1,500 Lifetime / $750 Calendar Year
Maximum

$1,000 Lifetime / $500 Calendar Year Maximum Not offered
Adult/Child Orthodontia Benefit Option or $1,500 Lifetime / $750 Calendar Year
Maximum

Child Good Vision Benefit Covers 50% of UCR for an eye exam once every
(Included with orthodontia) 12 months for children through 18

Child Orthodontia is available for groups with 5 or more employees enrolling. Adult Orthodontia is available for employer-contributory groups with 25 or more employees enrolling.


IndemnityPlus Dental Plan Summary - Utah
Available in UT only.

Plan Design Dental Indemnity Plans
Benefits Premium Plan Classic Plan Basic Plan Value Plan

$1,500 $1,500 $1,500 $1,500
Calendar Year Maximum $1,000 $1,000 $1,000 $1,000
$500 $500

Individual Calendar Year Deductible $0, $25, $50, $75 or $100

Lifetime Deductible Option $100 Lifetime Deductible in lieu of a Calendar Year Deductible
Class I: Preventive Services - Routine
oral exam, cleanings, fluoride treatment for
children, bitewing x-rays, panoramic/full
100% 100% 100% 100%
mouth x-rays, sealants

Class II: Basic Services - Fillings (amalgam,
porcelain & plastic), anterior & posterior
composites, anesthesia (general or IV
sedation), emergency palliative treatment,
90% 80% 80% 50%
space maintainers for children, limited oral
exam, pathology, oral surgery

Class III: Major Services - Crowns &
gold fillings, inlays, onlays & pontics, fixed
bridges, implants, complete & partial
60% 50% 0% 0%
dentures

Oral Surgery Class II or Class III
12 month waiting period applies to major and
Waiting Periods orthodontic services None


Out-of-Network Reimbursement UCR at 80th, 90th Percentile or MAC


$1,000 Lifetime / $500 Calendar Year Maximum
or $1,500 Lifetime / $750 Calendar Year
Maximum

$1,000 Lifetime / $500 Calendar Year Maximum Not offered
Adult/Child Orthodontia Benefit Option or $1,500 Lifetime / $750 Calendar Year
Maximum

Child Good Vision Benefit Covers 50% of UCR for an eye exam once every
(Included with orthodontia) 12 months for children through 18

Child Orthodontia is available for groups with 5 or more employees enrolling. Adult Orthodontia is available for employer-contributory groups with 25 or more employees enrolling.


Dental Networks Usual, Customary and Reasonable
Claims payments are based on the usual, customary and reasonable (UCR) charge
for covered dental services and supplies. UCR is determined by the fee commonly
The BEST Life dental plans offer access to national and charged specifically for the severity and nature of the treatment within the
regional PPO networks. dentist’s particular geographic area. In-network claims are paid by the UCR fees
listed in the preferred provider fee schedule. Out-of-network claims payments are
based either on the UCR or on a fee level that is within the same range of fees
Network States of Coverage Products/Plans customarily charged for the services or supplies in the geographic area
concerned.
DenteMax National PPO & Indemnity
Diversified Dental Maximum Allowable Charge (MAC)
NV PPO & Indemnity On plans with the MAC option, bases claims payments are based on the fees
Services (DDS)
listed in the preferred provider fee schedule, or on a set fee level based on what
First Dental Health is customarily charged for dental services or supplies in the geographic area. For
CA PPO & Indemnity
(FDH) in-network claims, preferred providers have agreed to accept payment based on
the preferred provider fee schedule as payment in full. Any amounts over the
Maverest Dental
IN PPO & Indemnity maximum allowable charge (MAC) for out-of-network claims will be the
Alliance responsibility of the patient.
Total Dental
AZ*, UT PPO & Indemnity Advance Notice of Dental Treatment
Administrators (TDA)
Any course of treatment a provider estimates to be in excess of $500 must be
CONNECTION D.C., FL , MD, MO, NE, reported to the company for predetermination prior to the treatment being
PPO Plans Only
Dental PA & TX rendered. A predetermination is an estimate of how benefits will be processed.
*Network available for PPO plans only. Extension of Dental Benefits
We will continue to pay dental benefits for 30 days following the termination
date of the employee or dependent coverage if the expenses incurred would have

The Fine Print been eligible for payment had coverage remained in effect; and (1) the impression
for a prosthetic device or modification had been taken before termination and
delivered and installed within 30 days following the termination of coverage; or
Employee Effective Date (2) in the treatment of root canal therapy, where the pulp chamber was opened
before termination.
An employee’s coverage will take effect:
ƒƒ the date the group’s coverage takes effect if the employee’s enrollment
On Termination of Coverage
card is received within 31 days of that date and if there are no waiting periods Employee and dependent coverage will terminate on the earliest of the following
to satisfy. events:
ƒƒ the first day of the calendar month following the date the waiting period
On 1. The last day of the month in which active employment ceases, unless the
is met. The employee’s enrollment card must be received within 31 days after employee is on leave of absence, temporary layoff or total disability and the
satisfying the waiting period. If an employee is not working full-time on the employer decides to continue paying for coverage.
date he or she would otherwise become covered, the employee will not be
2. The last day of the month in which the employee and/or dependent ceases
eligible for coverage until he or she returns to active work.
to be eligible for insurance.
New employee hires can join the plan the first of the month after the date of hire,
3. The date the employer ceases to be a participating employer.
if elected by the employer on the employer application.
4. The day before the due date of any premium that remains unpaid at the end
Dependent Eligibility of the grace period.
Eligible dependents include spouse and dependent children. The definition of 5. The date the policy terminates.
dependent may vary by state. Refer to the certificate of insurance or your sales 6. The date the number of insured employees of a participating employer falls
representative for details. below two.

Dependent Effective Date
An eligible dependent’s insurance will take effect on the later of the following:
ƒƒ an eligible employee enrolls their eligible dependents at the time of the
If
employee’s initial enrollment, then the dependent effective date is the same
as the employee’s effective date.
ƒƒ after the eligible employee’s initial enrollment, the employee acquires an
If
eligible dependent, then the acquired dependent effective date is the first day
of the calendar month following the dependent enrollment date provided the
enrollment is made within 31 days of the dependent initial eligibility date.
Late Entrants To The Plan
If an employee or dependent enrolls for coverage 31 days or more after becoming
eligible, he or she will be considered a late entrant and only eligible for:
ƒƒPreventive services during the first 12 months of continuous coverage.
ƒƒPreventive services and 50% of Basic services not to exceed a maximum of
$500 during the second 12 months of continuous coverage.
ƒƒMajor services when the employee or dependent is no longer a late entrant.


Exclusions 26. The extraction of immature erupting third molars and non-pathologic,
asymptomatic third molar extractions.
27. Expenses for gross debridement allowed one time at the beginning of the
No payments will be made for and covered dental expenses do not include: periodontal treatment plan prior to pocket depth charting.
1. Treatment by someone other than a doctor of medical dentistry or a doctor 28. Surgical procedures incidental to orthodontic treatment, including but not
of dental surgery, except where performed by a licensed hygienist under the limited to, extraction of teeth solely for orthodontic reasons, exposure of
direction of a doctor of medical dentistry or a doctor of dental surgery. impacted teeth, correction of micrognathia or macrognathia or repair of
2. Expenses incurred while on active duty with any military, naval or air force of cleft palate.
any country or international organization. 29. Any service or procedure not commonly found within the scope of practice
3. An appliance used to repair or replace missing teeth, or modification of an by a licensed dentist. Such procedures are identified within the current CDT
appliance, where an impression was made before the patient was covered; a codes.
crown, bridge or other lab fabricated restorations for which the tooth was 30. Temporary services are considered an integral part of the final services rather
prepared before the patient was covered; root canal therapy if the pulp than a separate service and are therefore not eligible for benefits.
chamber was opened before the patient was covered. 31. X-rays are considered an integral part of the endodontic procedure rather
4. Pulp capping, if in conjunction with the installation of inlays, onlays or than a separate service and are therefore not eligible for benefits.
crowns, fillings or other lab fabricated restorations; including but not limited 32. Expenses incurred for a core buildup will only be considered in conjunction
to inlays, onlays and crowns, preventative tests and examinations diagnostic with a crown.
casts and oral cancer screenings, and expenses incurred for sedative fillings, 33. Chemotherapeutic agents and any other experimental procedures.
including charges for prescribed drugs, pre‑medication or analgesia.
34. Expenses incurred for veneers and related procedures.
5. Replacement of a lost or stolen or discarded prosthetic device.
6. Dental services and supplies which are given primarily for cosmetic reasons
including alteration or extraction of functional natural teeth for the purpose
of changing appearance and replacement of restorations previously
performed for cosmetic reasons.
7. The initial installation of a prosthetic device (a fixed bridge, implant, or
denture), including crowns and inlays which form abutments, to replace
teeth missing before coverage under the policy, except when it also replaces
a tooth that is extracted while covered unless such installation commences
after remained continuously covered under this plan for at least three years
immediately prior to the date such installation commences.
8. Expenses incurred for orthodontic treatment and orthodontia type procedures
unless such procedures are covered under an orthodontic rider.
9. Expenses incurred as a result of participating in a riot or insurrection or the
commission of a felony.
10. Charges in excess of usual, reasonable and customary charges or in excess of
the calendar year maximum amount stated in the schedule of dental benefits
section of this plan, or in excess of the preferred provider fee schedule.
11. Services and supplies not reasonably necessary, or not otherwise specifically
listed as an eligible expense.
12. Charges for service provided for temporomandibular joint dysfunction (TMJ),
expenses incurred for congenital or developmental malformations.
13. Services and supplies covered under any workers’ compensation act or similar
law, expenses incurred due to treatment rendered by the employer.
14. Services and supplies performed outside of the U.S.
15. Implants, implant services and implant supported prosthetics are not covered
for patients under the age of 16.
16. Any services or supplies for correction or alteration of occlusion, or any
occlusal adjustments, expenses incurred for night guards or any other
appliances for the correction of harmful habits.
17. Expenses for safe fees (gloves, masks, surgical scrubs and sterilization).
18. Expenses incurred due to treatment rendered by a family member. For the
purpose of this limitation, family member includes, but is not limited to, the
insured’s lawful spouse, child, parent, step-parent, grandparent, brother,
sister, cousin or in-law.
19. Expenses for services for which the insured would not legally have to pay if
there were no insurance.
20. Services not completed on or before the date of termination must be
completed within 30-days of the termination date, unless such services are
covered under the extension of dental benefits.
21. If the insured or any dependents transfer from the care of one dentist to
another dentist during the course of treatment, or if more than one dentist
renders services for one dental procedure, the amount liable is only for the
amount it would have been had one dentist rendered the services.
22. Expenses that are applied toward satisfaction of a deductible, if any.
23. For all procedures that are begun prior to your effective date but not
completed.
24. Adjustment, repairs or relines of prostheses for a period of one year from
initial placement if the prostheses were paid for under this plan.
25. If multiple endodontic treatments are necessary on the same tooth within a
period of one year, the allowance will be made for only one procedure.


HDHP Medical Plans
Group Sizes 2-50

HSA-Compatible High Deductible Health Plan Summary
Available in AZ, GA, ID, IL, IN, MO, MT, NV, OH, OK, TN, TX and UT.

In-Network Out-of-Network
Preventive Office Visits (includes annual routine physical exam,
screenings and immunizations, prostate and colorectal cancer screening/ 100% 100%
testing, flu shot, pap smear and mammogram)
Baby/Child Wellness Visits (includes exams, screenings,
100% 100%
immunizations and vaccinations, lab and X-ray through age 17)
Physician Office Visit - Professional Fee (includes Lab and X-ray
Deductible, then Coinsurance Deductible, then Coinsurance
when performed by Physician on the same day of visit)
Physician Office Visit, Other than Professional Fee Deductible, then Coinsurance Deductible, then Coinsurance
Lab and X-ray Services Deductible, then Coinsurance Deductible, then Coinsurance
Emergency Ambulance Services Deductible, then Coinsurance Deductible, then Coinsurance
Hospital Charges Deductible, then Coinsurance Deductible, then Coinsurance
Emergency Room Deductible, then Coinsurance Deductible, then In-network Coinsurance
Urgent Care (facility or clinic) Deductible, then Coinsurance Deductible, then Coinsurance
Outpatient Surgery (facility or hospital) Deductible, then Coinsurance Deductible, then Coinsurance
CVS Caremark Prescription Coverage Deductible, then Coinsurance Deductible, then Coinsurance
These services are subject to change upon notification of the United States Department of Health and Human Services.

Our high deductible health plans are HSA-compatible. Contributions to an HSA are tax deductible and employer contributions
are not counted as taxable income. Account withdrawals also are not taxed when used for qualifying medical expenses.
Meanwhile, the money remaining in the account at the end of the year belongs to the member and is rolled over to the next
year. Even if the member changes jobs, the account stays with that individual.
Check current HSA limits at www.treasury.gov/resource-center.

Health Solutions - High Deductible Health Plans

Individual Calendar Year Deductible ‰‰
$2,500 ‰‰
$4,000
(2 member family max) ‰‰
$3,000 ‰‰
$5,000

Family Deductible Aggregate Aggregate

Individual Out-of- Individual Out-of-
Coinsurance Coinsurance
Pocket Max Pocket Max
Coinsurance Levels and Out-of-
Pocket Maximum1
‰‰ In / 80% Out
100% $0 In / $2K Out ‰‰ In / 80% Out
100% $0 In / $2K Out
(2 member family max)
‰‰ In / 70% Out
90% $500 In / $3K Out ‰‰ In / 70% Out
90% $500 In / $3K Out

‰‰ In / 60% Out
80% $1K In / $4K Out

Prescription Coverage Discount Card, costs will be applied to deductible, then coinsurance

As any other illness or sickness (optional for groups of 2-14; mandatory for groups with 15+ may vary by state)
Maternity
q Yes q No
1
Deductible does not apply to out-of-pocket maximum.


The Fine Print Exclusions
Business Eligibility The following is a summary list of services and supplies that are not generally
covered. Please note that the certificate of insurance may contain exceptions to
Applications from all industries will be reviewed for eligibility. Some businesses or
this list based on state mandates or the plan design purchased and should be
industries may be subject to special rates, based on the hazards associated with
consulted.
certain industries. Any special rates applied because of industry or health
conditions are applied in accordance with the small group laws of your state. For Unless provided by endorsement or specifically included as a covered service, the
specific details, please refer to the medical underwriting guidelines. following are not covered:

Employee Eligibility ƒƒAcupuncture, unless used in lieu of anesthesia.
Eligible employees are defined as: ƒƒAdministration of drugs.
ƒƒ injury or illness that occurs in the course of or during participation in a
An
ƒƒFull-time. criminal activity or riot, or that is self-inflicted, including attempted suicide.
ƒƒActive employees working at least 30 hours a week (may vary by state). ƒƒBreast reduction.
ƒƒWho are paid a salary or earnings from which federal, state and Social Security ƒƒChelation therapy services or supplies.
taxes are withheld (may vary by state).
ƒƒComplications arising out of services or supplies or injuries or illnesses not
ƒƒPartners and owners working 30 hours a week or more are also eligible for covered.
coverage (may vary by state).
ƒƒCosmetic services or supplies.
There must be an employer-employee relationship in a bona-fide, full-time ƒƒCourt order services or supplies.
business pursuit. 1099 individuals are not eligible unless permitted by the state. ƒƒDental care.
States permitting 1099 individuals include ID, IL, MO, NV, TN, TX and UT.
ƒƒDurable medical equipment charges not specifically named as a covered
Dependent Eligibility service.
Eligible dependents include spouses and dependent children. Dependent children ƒƒEligible expenses in excess of Medicare RBRVS fee schedule or usual and
are eligible for coverage until they reach 26, which may be extended under customary.
certain circumstances according to your state law. The definition of dependent ƒƒEmployer provided services or supplies.
may vary by state. Refer to the certificate of insurance or your sales representative ƒƒInjury or illness arising out of employment for wage or profit, or service or
for details. supply required as a prerequisite to or as a part of employment.
ƒƒExpenses where payment is not required, due to coverage by other insurance,
Out-of-Network Charges except Medicaid, or which would not have been billed if no insurance coverage
Covered expenses incurred for out-of-network services where in-network or were in place.
wraparound network benefits do not apply are limited to: the limited fee
ƒƒExpenses incurred before the effective date of coverage under the Policy or
schedule, or if no schedule exists for the services, the average cost of service
after coverage under the Policy terminates, regardless of the date of the injury
based on the RBRVS. Benefit payables are subject to the plan deductibles and
or illness.
coinsurance percentages. The covered person is responsible for any uncovered
out-of-pocket expenses. ƒƒExperimental or investigational services or supplies.
ƒƒFoot care services in connection with corns, calluses, fallen arches, weak feet,
Review Program foot strain, symptomatic foot complaints or other foot care, including
The following covered services will require a review before a member receives orthopedic, orthoses, shoe or orthotics.
them: ƒƒGovernment facility services or supplies, unless there is a legal obligation to
pay.
ƒƒ inpatient admissions.
All
ƒƒGrowth hormones.
ƒƒEmergency admissions. Must obtain review within 24 hours, or as soon as
possible, after the admission. ƒƒServices or supplies provided in preparation of or for a gender change.
ƒƒNon-emergency inpatient admissions. Must obtain review at least 5 days ƒƒHearing impairment or loss.
before the admission date. ƒƒHospital admission room and board charges for diagnostic or evaluation
ƒƒExtended stay review for continued stays after a review is obtained for an procedures.
inpatient admission and member is admitted as an inpatient. Must obtain ƒƒInfertility services, including impotence, erectile dysfunction and fertilization.
review before original admission period expires. ƒƒServices or supplies provided by a member of the employee’s family or a
ƒƒ any outpatient surgery procedures, MRIs, CAT scans, PET Scans, nuclear
For person residing in the employee’s residence.
imaging and transplants. Must obtain review at least 5 days prior to scheduled ƒƒInjury or illness that occurs during active service in any armed forces or
procedure. auxiliary units.
ƒƒ any outpatient procedures requiring review. Must obtain review at least 5
For ƒƒInjuries or Illnesses arising out of any war, declared or undeclared, or act of
days prior to scheduled procedure. war or terrorism.
Failure to obtain a required review for a procedure could result in a reduction of ƒƒLearning disability or impairment services.
benefits and additional financial responsibility to the member. ƒƒNon-covered services.
ƒƒNon-covered expenses for transportation.
Pre-existing Conditions ƒƒNon-medically necessary services or supplies.
A pre-existing condition is a condition, other than pregnancy, for which a provider
ƒƒOver the counter supplies, except diabetic supplies.
recommended or provided medical advice, diagnosis, care or treatment within
the six month period prior to the effective date. Expenses incurred for pre-existing ƒƒServices or supplies for the care of a pre-existing condition.
conditions are not considered eligible until coverage has been in effect for 12 ƒƒPrivate duty nursing services, except for covered home health care services.
consecutive months or 18 months for a late enrollee. The pre-existing condition ƒƒReversal of sterilization.
exclusion period will be reduced by the number of days under credible coverage
ƒƒUnbundled charges.
without a 63-day break, immediately prior to their effective date. The period of
continuous coverage shall not include any waiting period. The exclusionary time ƒƒUvulopalatopharyngoplasty.
periods, prior treatment periods, time periods between prior coverage and new ƒƒVeterans Administration hospital services or supplies for armed service
coverage, and credit for qualifying prior coverage may vary according to the connected disabilities.
applicable laws of the employer’s state. ƒƒVision impairment or loss services or supplies.
ƒƒTreatment for addiction to tobacco, alcohol, drugs or any addictive
substances.


Vision PPO and Indemnity Plans

Vision PPO Plan Summary
Available in AK, AL, AR, AZ, CA, CO, DC, FL, GA, HI, ID, IL, IN, KS, KY, LA, MD, MI, MO, MS, MT, NC, ND, NE, NM, NV, OH, OK, OR, PA, SC, SD, TN, TX, UT VA, WA and WY.

Option 1 Option 2
In-Network Out-of-Network In-Network Out-of-Network
Annual Eye Exam $10 copay Up to $42 Annual Eye Exam $10 copay Up to $42
Fit and Follow-up Exams Covered in full Up to $40 Fit and Follow-up Exams Up to $55 copay No benefit
$130 allowance, $130 allowance,
Frames 20% off amount over Up to $65 Frames 20% off amount over Up to $65
allowance allowance
Lenses Lenses
Single $10 copay Up to $35 Single $25 copay Up to $35
Bifocal $10 copay Up to $40 Bifocal $25 copay Up to $40
Trifocal $10 copay Up to $65 Trifocal $25 copay Up to $65
Progressive $75 copay Up to $40 Progressive $90 copay Up to $40
$75 copay, $90 copay,
Premium Progressive Up to $40 Premium Progressive Up to $40
20% off amount over 20% off amount over
allowance allowance
Contacts Contacts
Elective - Conventional 15% off amount over Up to $104 Elective - Conventional 15% off amount over Up to $104
allowance allowance
Elective - Disposable $130 allowance Up to $104 Elective - Disposable $130 allowance Up to $104
Medically Necessary Covered in full Up to $200 Medically Necessary Covered in full Up to $200
Lens Options Lens Options
UV Coating $15 copay No benefit UV Coating $15 copay No benefit
Tine - Solid and Gradient $15 copay No benefit Tine - Solid and Gradient $15 copay No benefit
Scratch-resistant $15 copay No benefit Scratch-resistant $15 copay No benefit
Polycarbonate $40 copay No benefit Polycarbonate $40 copay No benefit
Anti-reflective $45 copay No benefit Anti-reflective $45 copay No benefit
Other add-ons and Other add-ons and
services
20% off amount No benefit services
20% off amount No benefit
Lenses or Contacts 12 Lenses or Contacts 12 Lenses or Contacts 12 Lenses or Contacts 12
Frequencies in Months Frequencies in Months
Frames 12 or 24 Frames 12 or 24 Frames 12 or 24 Frames 12 or 24

Vision Indemnity Plan Summary
Available in AK, AL, AR, AZ, CA, CO, DC, FL, GA, HI, ID, IL, IN, KS, KY, LA, MD, MI, MO, MS, MT, NC, ND, NE, NM, NV, OH, OK, OR, PA, SC, SD, TN, TX, UT VA, WA and WY.

Option 1 Option 2
Frequency Options Frequency Options
Plan Benefit Plan Benefit
A B C D A B C D
Yearly Deductible Options $0, $10 or $25 Yearly Deductible Options $0, $10 or $25
Annual Eye Exam $60 Allowance 12 12 12 12 Annual Eye Exam $60 Allowance 12 12 12 12
Frames $80 Allowance 12 24 24 24 Frames $100 Allowance 12 24 24 24
Lenses Lenses
Single $35 Allowance Single $45 Allowance
12 12 12 24 12 12 12 24
Bifocal $55 Allowance Bifocal $65 Allowance
Trifocal $65 Allowance Trifocal $75 Allowance
Contacts Contacts
Elective $125 Allowance 12 12 24 24 Elective $125 Allowance 12 12 24 24
Medically Necessary $200 Allowance 12 12 24 24 Medically Necessary $200 Allowance 12 12 24 24


EyeMed Discount
EyeMed Vision Care® discount program includes discounts
The Fine Print
off of exams, eyeglasses, progressive lenses, UV coating, Employee Eligibility
tints, polycarbonates, contacts and laser vision correction. Eligibility is based on, but not limited to the following:

QualSight® LASIK ƒƒThere must be an employee-employer relationship.
ƒƒ central office and a regular place of business where the maintenance of
A
Members are automatically eligible to access the QualSight payroll and insurance is performed.
LASIK network for discounts of 40-50% off the national ƒƒ eligible employees must be full-time and working at least 30 hours per
All
average charge for laser eye surgery. week.
The following employees are generally not eligible:
ƒƒPart-time, seasonal, retired or pensioned employees, leased, consultants,
employees covered under collective bargaining agreements and employees
Option 3 who are paid as 1099 employees.
In-Network Out-of-Network ƒƒDirectors or stockholders who do not work full-time or at least 30 hours per
week in the business.
Annual Eye Exam $10 copay Up to $42
Employee Effective Date
Fit and Follow-up Exams Up to $55 copay No benefit
Insurance will take effect on the later of:
$100 allowance,
Frames 20% off amount over Up to $50 ƒƒ date the employer group becomes effective if initial enrollment cards are
The
allowance received within 31 days of this date.
Lenses ƒƒThe first day of the next calendar month following the date a full-time
employee completes the waiting period as elected by the employer an
Single $25 copay Up to $35 enrollment card must be received within 31 days of this day.
Bifocal $25 copay Up to $40 ƒƒ first of the month after the date of hire, if this option is elected by the
The
Trifocal $25 copay Up to $65 employer on the master application.
Progressive $90 copay Up to $40 Dependent Eligibility
$90 copay, Eligible dependents include spouse and dependent children. The definition of
$120 allowance, dependent may vary by state. Refer to the certificate of insurance or your sales
Premium Progressive Up to $40
20% off amount over representative for details.
allowance
Contacts Dependent Effective Date
Dependent insurance will take effect on the later of:
$115 allowance,
Elective - Conventional 15% off amount over Up to $92 ƒƒ date the insurance is effective if the enrollment card is received within 31
The
allowance days of that date.
Elective - Disposable $115 allowance Up to $92 ƒƒ first day of the next calendar month following the date the employee
The
Medically Necessary Covered in full Up to $200 enrolled his or her dependents, provided the enrollment is made within 31
days of the dependents first becoming eligible (must be provided in writing).
Lens Options
UV Coating $15 copay No benefit Late Entrants to the Plan
If an employee or a dependent enrolls for coverage 31 days or more after
Tine - Solid and Gradient $15 copay No benefit
becoming eligible, he or she will be considered a late entrant and eligible for no
Scratch-resistant $15 copay No benefit more than $75 of vision care benefits during the first 12 months of continuous
Polycarbonate $40 copay No benefit coverage.
Anti-reflective $45 copay No benefit
Coordination of Benefits
Other add-ons and
services
20% off amount No benefit Benefits will be coordinated with the benefits of any other group vision plan to
which the individual is entitled.
Lenses or Contacts 12 Lenses or Contacts 12
Frequencies in Months
Frames 12 or 24 Frames 12 or 24 Termination of Coverage
Employee and dependent coverage will terminate on the earliest of the following
events:
1. The last day of the month in which active employment ceases, unless the
employee is on leave of absence, temporary layoff or total disability and the
employer decides to continue paying for coverage.
Option 3 2. The last day of the month in which the employee and/or dependent ceases
to be eligible for insurance.
Frequency Options
Plan Benefit 3. The date the employer ceases to be a Participating Employer.
A B C D 4. The day before the due date of any premium that remains unpaid at the end
Yearly Deductible Options $0, $10 or $25 of the grace period.
Annual Eye Exam $60 Allowance 12 12 12 12 5. The date the policy terminates.
Frames $115 Allowance 12 24 24 24 6. The date the number of insured employees of a Participating Employer falls
Lenses
below five.

Single $55 Allowance
12 12 12 24
Bifocal $75 Allowance
Trifocal $85 Allowance
Contacts
Elective $125 Allowance 12 12 24 24
Medically Necessary $200 Allowance 12 12 24 24


Underwriting Information Vision PPO Exclusions
Participation Requirements To be entitled to benefits for lenses and visual analysis, lenses must be prescribed
and visual analysis must be performed by a legally qualified ophthalmologist,
On groups where the employer pays 100% of the employee and/or dependent
optometrist or physician acting within the scope of his or her license.
premiums, 100% of all employees/dependents must participate. (Waived if other
lines of coverage are purchased.) No benefit shall be payable except as otherwise provided herein or on account
of:
Employer-sponsored: For 5 or more lives, 60% participation of eligible
employees for employees with other group vision coverage, a refusal card must 1. Services for which no charge is made or for which the insured is not required
be completed. These employees will not be counted toward the participation to pay or any eye examination furnished by or paid under or for any
requirement. government, federal or state, dominion or provincial, or any political
subdivisions thereof, or any glasses or frames for which the insured has been
Voluntary: For 5 or more lives, 20% participation of eligible employees
or may be reimbursed under any group hospitalization or medical expense
reimbursement insurance plan, to the extent of any such payment or
Contribution Requirements
reimbursement.
Employer-sponsored: 50% and above for EEs and 0% and above for
2. Charges for services due to occupational accidents or sickness covered by
Dependents
workers’ compensation.
Voluntary: Less than 50% of EE premium 3. More than one pair of lenses, frames, contact lenses or examination per
person per benefit period.
Underwriting Rights Reserved
4. Cosmetic lens enhancements such as tints, ultraviolet coating, scratch coating
The insurance company reserves the right to require additional information before or anti-reflection coating.
acting on an individual’s or group’s request for coverage. The insurance company
5. Safety glasses or goggles.
reserves the right to decline any particular case or applicant regardless of size.
Approval of all enrollment and employee eligibility requirements must be met 6. Services performed by an optometrist, ophthalmologist or physician beyond
before insurance can be put in force. the scope of their applicable licenses.
7. Services incurred as a result of sickness or injury.
8. Special procedures such as orthoptics, vision training or subnormal vision
aids.
Access Vision Exclusions 9. Plain or prescription sunglasses or other special purpose vision aids.
10. Medical or surgical treatment of eyes.
To be entitled to benefits for lenses and visual analysis, lenses must be prescribed 11. Replacement of lost or broken lenses and/or frames.
and visual analysis must be performed by a legally qualified ophthalmologist or
12. Duplicate glasses or frames.
legally qualified optometrist.
13. Services or materials not specifically listed in the schedule of vision benefits.
No payments will be made for and covered vision expenses do not include:
14. Care, including prescribed medications, that would be deemed an eligible
ƒƒServices for which no charge is made or for which the insured is not required expense under major medical or other insurance program.
to pay, or any eye examination furnished by or paid for by any government. 15. Any services performed prior to the effective date, or after the coverage
This includes glasses or frames for which the individual has been reimbursed termination date.
under any group hospitalization or medical reimbursement insurance plan. 16. Services not recommended by a provider or which are not required for
ƒƒCharges due to occupational accidents or sickness covered by workers’ necessary care and treatment, or which do not have uniform professional
compensation. endorsement.
ƒƒCosmetic lens enhancements such as tints, UV coating, scratch coating or 17. Services performed by a member of the patient’s immediate family, or a
anti-reflective coating. person who resides in the patient’s home.
ƒƒSafety glasses or goggles. 18. Charges for failure to keep a scheduled appointment, or for completion of
ƒƒServices performed by an optometrist or ophthalmologist beyond the scope claim forms.
of their applicable licenses. 19. Orthoptic or vision training, subnormal vision aids and any associated
ƒƒServices incurred as a result of sickness or injury. supplemental testing.
ƒƒSpecial procedures such as orthoptics, vision training or subnormal vision 20. Aniseikonic lenses.
aids. 21. Medical and/or surgical treatment of the eye, eyes or supporting structure.
ƒƒPlain or prescription sunglasses or other special purpose vision aids. 22. Non-prescription lenses and non-prescription sunglasses.
ƒƒMedical or surgical treatment of eyes. 23. Two pair of glasses in lieu of bifocals.
ƒƒReplacement of lost or broken frames and lenses. 24. Comprehensive eye exams not performed by either an optometrist,
ƒƒDuplicate glasses or frames. ophthalmologist or a physician acting within the scope of his or her license.
ƒƒServices or materials not specifically listed in the schedule of vision care 25. Lenses that are not prescribed by either an optometrist, ophthalmogist or
benefits. physician acting within the scope of his or her license.
ƒƒCare (including prescribed medication) that would be deemed an eligible
expense under major medical or other insurance programs, including workers’
compensation.
ƒƒAny service performed prior to the effective date or after the coverage
termination date.
ƒƒServices not recommended by a provider or which are not required for
necessary care and treatment; or which do not have uniform professional
endorsement.
ƒƒServices performed by a member of the patient’s immediate family, or a
person who resides in the patient’s home.
ƒƒCharges for failure to keep a scheduled appointment or for completion of
claim forms.


Group Term Life Plans

Group Term Life Plan Summary
Available in AK, AL, AR, AZ, CA, CO, DC, FL, GA, HI, ID, IL, IN, KS, KY, LA, MD, MI, MO, MS, MT, NC, ND, NE, NM, NV, OH, OK, OR, PA, SC, SD, TN, TX,
UT, VA, WA and WY.

BEST Life Gold BEST Life Silver BEST Life Bronze
(Employer-contributory) (Voluntary) (Employer-contributory)
Employer
Contribution
25% minimum Not applicable 25% minimum

Flat schedules up to $100,000 2-9: $10,000 or $15,000
Class Schedules 10+: Increments of $10,000 to $500,000,
Basic Life
Schedules Salaried Schedules not to exceed 5 times employee salary $10,000, $15,000, $20,000 or $25,000
Additional amounts available with Additional amounts available with
Evidence of Insurability Evidence of Insurability

2-9: $15,000
Upwards of $75,000, based on 2-4: $15,000
Guarantee Issue 10+: Upwards of $75,000 based on
participation and group size 5-9: $25,000
participation and group size

Non-contributory: 100% Non-contributory: 100%
Participation Not Applicable
Contributory: 75% minimum Contributory: 75% minimum

Waiver of Premium Provision to Age 60 Waiver of Premium Provision to Age 60
Accelerated Death Benefit 75% to Accelerated Death Benefit 75% to Waiver of Premium Provision to Age 60
Plan Features
$250,000 max $250,000 max Conversion
Conversion Conversion

65 - 35% 65 - 35% 65 - 35%
Age Reductions 70 - 50% 70 - 50% 70 - 50%
(From original 75 - 65% 75 - 65% 75 - 65%
amount) 80 - 80% 80 - 80% 80 - 80%
85 - 90% 85 - 90% 85 - 90%

Spouse: increments of $5,000, up to
Spouse: $5,000 or $10,000 $10,000 or 50% of employee coverage, Spouse: $10,000
Dependent
Children ages 6 months to 25: not to exceed $50,000 Children ages 6 months to 25:
Basic Life
Coverage increments of $1,000 up to $5,000 Children ages 6 months to 25: increments of $1,000 up to $5,000
Children 14 days to 6 months: $1,000 increments of $1,000 up to $5,000 Children 14 days to 6 months: $1,000
Children 14 days to 6 months: $1,000
AD&D Option Includes Seat Belt & Air Bag Benefit Includes Seat Belt & Air Bag Benefit
(For employees Available on basic and supplemental
only) Available on basic and supplemental Available on basic and supplemental

Accelerated Allows up to 75% or a maximum of $250,000 of life insurance benefits to be paid prior to the death of the participant.
Death Benefit Available for 10+ only

Supplemental / Voluntary Life for
employee and dependents
The following available to groups of
50+ only:
Critical Illness Supplemental / Voluntary Life for Supplemental / Voluntary Life for
Other Options
employee and dependents employee and dependents
Cancer Care
Day Care Benefit
Repatriation of Remains Benefit
Exposure and Disappearance

Disclaimer: Life insurance applications submitted in conjunction with a BEST Life medical plan application are subject to evidence of insurability.


The Fine Print Ineligible Industries for 2-9
SIC Description
1011-1500 Mining
Employee Effective Date
2111-2141 Tobacco products
Insurance coverage will take effect on the later of:
2411-2429 Logging and sawmills
ƒƒ date the employer becomes a participating employer if the employee’s
The 2431 Millwork
enrollment card is received within 31 days after that date.
2892 Explosives
ƒƒ first day of the next calendar month following the date the waiting period
The
3111 Leather tanning and finishing
elected by the participating employer is completed. The employee’s enrollment
card must be received within 31 days after satisfying the waiting period. If an 3292 Asbestos products
employee is not working full-time for the firm on the date he or she would 4111-4216 Local and interurban passenger transit
otherwise become covered, the employee will not be covered until he or she 4512-4581 Aviation and related services
returns to full-time work. 491-497 Electric, gas, water, etc.
ƒƒ first day of the next calendar month following the date evidence of
The 5992 Florists
insurability is approved, if required. Evidence of insurability will be required if
7231 Beauty shop
the enrollment card is received more than 31 days after first becoming eligible
or if applying for Supplemental Life Insurance coverage. 7241 Barber shops
7381 Detective and armored car services
Dependent Coverage
7382 Security systems services
Eligible dependents include spouse and unmarried dependent children.
Dependent children are covered until age 20, extended through age 25 if they are 7542 Car washes
full-time students. The definition of dependent may vary by state. Refer to the 7922-7929 Amusement and recreation
certificate of insurance or your sales representative for details. 7948 Racing, including track operations
8059 Drug and alcohol treatment centers
Dependent Effective Date
8111 Legal services
Dependent coverage will take effect on the later of:
8611-8651 Membership organizations/associations
ƒƒThe date the employee’s insurance is effective if the enrollment card is 8811 Private households
received within 31 days after that date.
9233-9229 Correctional institutions, fire protection, public order and
ƒƒ first day of the next calendar year month following the date the employee
The safety, n.e.c.
enrolled, in writing, his or her dependents for insurance, provided the
enrollment is made within 31 days of the dependents first becoming eligible.
ƒƒThe first of the month following the date the dependent evidence of Ineligible Industries for 10+
insurability is approved, if required. Evidence of insurability will be required if SIC Description
the dependent enrollment card is received more than 31 days after first 1011-1500 Mining
becoming eligible.
2111-2141 Tobacco products
Late Entrants To The Plan 2411-2429 Logging and sawmills
If an employee or dependent enrolls for coverage 31 days or more after becoming 2892 Explosives
eligible, he or she will be considered a late entrant. The employee or dependent
3111 Leather tanning and finishing
must complete and submit evidence of insurability.
4512-4581 Aviation and related services
Termination of Coverage 7381 Detective and armored car services
Group Term Life benefits will terminate on the earliest of the following dates: 7922-7929 Amusement and recreation
ƒƒ last day of the month in which the employee ceases active employment,
The 7948 Racing, including track operations
unless the employee is on leave of absence, temporary layoff, injured or sick. 8059 Drug and alcohol treatment centers
The employer may continue insurance by paying the required premiums, but 8611-8651 Membership organizations/associations
not beyond the following limits. 8811 Private households
-- months approved leave of absence.
Three 9233-9229 Correctional institutions, fire protection, public order and
-- Temporary layoff, the end of the month following the month in which safety, n.e.c.
the layoff occurred.
-- months of approved leave due to a disease or injury.
Three
AD&D Exclusions
ƒƒ last day of the month in which employee ceases to be in an eligible
The
class. No amount will be payable for loss caused or contributed to by:
ƒƒ date of the expiration of the period for which the last required premium
The ƒƒSuicide, or any attempt thereof, while sane or insane.
payment was due and not paid. ƒƒDrugs, poison, gas or fumes voluntarily taken, absorbed or inhaled which are
ƒƒ date the policy terminates.
The not administered on the advice of a physician.
Conversion Privilege ƒƒBodily or mental infirmity or disease in any form, or medical or surgical
treatment therefore.
Conversion privilege to individual policy is available without evidence of
insurability if an employee has been covered under the policy continuously for ƒƒBacterial infection, other than infection occurring simultaneously with or
five years. The individual policy will be issued only if application is made and first through an accidental cut or wound.
premium is paid within 31 days after the termination of insurance. See schedule ƒƒCommission of any crime.
of benefits for complete information. ƒƒRiot, insurrection or war, declared or undeclared.
For more information, please refer to the group term life underwriting ƒƒService in the military, naval or air forces of any country at war, declared or
guidelines. undeclared.
ƒƒTravel or flight in any kind of aircraft including falling or otherwise descending
from or with any aircraft in flight, while participating in aviation training in
any aircraft, or as a pilot, officer or other member of the crew of any
aircraft.
ƒƒBodily injury resulting from intoxication or from the voluntary use of narcotics
which are not administered on the advice of a physician.


Plan Benefits and Underwriting Guidelines Summary

Plan Benefits and Underwriting Guidelines Summary

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