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This is only a summary.

Ifyouwantmoredetailaboutyourcoverageandcosts,youcangetthecompletetermsintheplandocumentat
www.assurantselffunded.com orbycalling1-888-292-0272.
Important Questions Answers Why this Matters:
What is the overall
deductible?
Participating providers $1,500.00person/$3,000.00family
Non-Participatingproviders $3,000.00person/$6,000.00family
Doesntapplytonetworkpreventivecareandprescriptions.
Co-paymentsdonotapplytothedeductible.
Youmustpayallthecostuptothedeductibleamount
beforethisplanbeginstopayforcoveredservicesyouuse.
Checkyourplandocumenttoseewhenthedeductiblestarts
over(usually,butnotalways,January1
st
).Seethechart
startingonpage2forhowmuchyoupayforcoveredservices
afteryoumeetthedeductible.
Are there other
deductibles for specific
services?
No.
Youdonthavetomeetdeductiblesforspecificservices,but
seethechartstartingonpage2forothercostsforservicesthis
plancovers.
Is there an
outofpocket limit on
my expenses?
Yes.
Participatingproviders$2,000.00person/$4,000.00family
Non-participatingproviders$4,000.00person/$8,000.00family
Theout-of-pocket limitisthemostyoucouldpayduringa
coverageperiod(usuallyoneyear)foryourshareofthecostof
coveredservices.Thislimithelpsyouplanforhealthcare
expenses.
What is not included in
the outofpocket limit?
Premiums,balance-billedcharges,non-compliancepenalties,
servicesinexcessofPlanmaximumsorlimits
Co-payments,deductibles, accessfees,&healthcare
thisplandoesntcover.
Eventhoughyoupaytheseexpenses,theydontcounttoward
theoutofpocket limit.
Is there an overall
annual limit on what the
plan pays?
No.
Thechartstartingonpage2describesanylimitsonwhatthe
planwillpayforspecificcoveredservices,suchasofficevisits.
Does this plan use a
network of providers?
Yes.Seewww.assurantselffunded.comforalistof
participatingproviders.
Ifyouuseanin-networkdoctororotherhealthcare
provider,thisplanwillpaysomeorallofthecostofcovered
services.Beaware,yourin-networkdoctororhospitalmay
useanout-of-networkproviderforsomeservices.Plans
usethetermin-network, preferred,orparticipatingfor
providersintheirnetwork.Seethechartstartingonpage2
forhowthisplanpaysdifferentkindsofproviders.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
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Do I need a referral to
see a specialist?
No.Youdontneedareferraltoseeaspecialist
Youcanseethespecialistyouchosewithoutpermission
fromthisplan.
Are there services this
plan doesnt cover?
Yes.
Someoftheservicesthisplandoesntcoverarelistedonpage
4.Seeyourplandocumentforadditionalinformationabout
excluded services.
Co-payments arefixeddollaramounts(forexample,$15)youpayforcoveredhealthcare,usuallywhenyoureceivetheservice.
Co-insurance isyourshareofthecostsofacoveredservice,calculatedasapercentoftheallowed amount fortheservice.Forexample,ifthe
plansallowed amountforanovernighthospitalstayis$1,000,yourco-insurancepaymentof20%wouldbe$200.Thismaychangeifyou
haventmetyourdeductible.
Theamounttheplanpaysforcoveredservicesisbasedontheallowed amount.Ifanout-of-network provider chargesmorethanthe
allowed amount,youmayhavetopaythedifference.Forexample,ifanout-of-networkhospitalcharges$1,500foranovernightstayandthe
allowed amountis$1,000,youmayhavetopaythe$500difference.(Thisiscalledbalance billing.)
Thisplanmayencourageyoutouseparticipatingproviders bychargingyoulowerdeductibles,co-paymentsandco-insuranceamounts.
Common
Medical Event
Service You May Need
Your Cost if you use an
Limitations & Exceptions
In-Network
Provider
Out-of-Network
Provider
If you visit a health care
providers office or
clinic
Primarycarevisittotreataninjuryor
illness
$35.00co-pay/visit 40%co-insurance
Deductible doesnotapplytonetwork
officevisit.Officesurgery
co-insuranceapplies
Specialistvisit $50.00co-pay/visit 40%co-insurance
Deductible doesnotapplytonetwork
officevisit.Officesurgery
co-insuranceapplies
Otherpractitionerofficevisit 20%co-insurance 40%co-insurance Nocoverageforacupuncture.
Preventivecare/screening/immunization Nocharge 40%co-insurance None.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
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Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
Common
Medical Event
Service You May Need
Your Cost if you use an
Limitations & Exceptions
In-Network
Provider
Out-of-Network
Provider
If you have a test
Diagnostictest(x-ray,bloodwork)
Nochargefor
Outpatient;
20%co-insurance
Inpatient
40%co-insurance
EKG,ultrasoundandallergytesting,
deductible&co-insurance
applies.
Imaging(CT/PETscans,MRIs) 20%co-insurance 40%co-insurance None.
If you need drugs to
treat your illness or
condition
Moreinformationabout
prescription drug
coverage isavailableat
www.caremark.com
Genericdrugs
$15.00co-pay
(retail),$45.00
co-pay(mail-order)
$15.00co-pay
(retail),
(nocoverage
mail-order)
Coversupto30daysupply(retail);31-90
daysupply(mailorder)
PreferredBranddrugs
$45.00co-pay
(retail),$135.00
co-pay(mail-order)
$135.00co-pay
(retail),(no
coverage
mail-order)
Coversupto30daysupply(retail);31-90
daysupply(mailorder)
Non-preferredbranddrugs
$60.00co-pay
(retail),$180.00
co-pay(mail-order)
$180.00co-pay
(retail),(no
coverage
mail-order)
Coversupto30daysupply(retail);31-90
daysupply(mailorder)
Specialtydrugs 20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyisno
coverage.
If you have outpatient
surgery
Facilityfee(e.g.,ambulatorysurgery
center)
20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesup
to$1,000.
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Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
Common
Medical Event
Service You May Need
Your Cost if you use an
Limitations & Exceptions
In-Network
Provider
Out-of-Network
Provider
Physician/surgeonfees
20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesup
to$1,000.
If you need immediate
medical attention
Emergencyroomservices
$100.00accessfeethen20%
co-insurance.
Non-emergencyuseofanemergency
roomwillresultina30%reductionin
coveredcharges
Emergencymedicaltransportation 20%co-insurance 40%co-insurance None.
Urgentcare
$50.00co-pay/visit 40%co-insurance
Deductible doesnotapplytonetwork
officevisit.Officesurgery
co-insuranceapplies
If you have a hospital
stay
Facilityfee(e.g.,hospitalroom) 20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesupto
$1,000.
Physician/surgeonfee 20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesupto
$1,000.
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioralhealthoutpatient
services
20%co-insurance 40%co-insurance None
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Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
Common
Medical Event
Service You May Need
Your Cost if you use an
Limitations & Exceptions
In-Network
Provider
Out-of-Network
Provider
Mental/Behavioralhealthinpatient
services
20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesupto
$1,000.Limitedto30daysperyear.
Inpatientmaximumsforsubstanceabuse
andmental/behavioralhealthare
combined.
Substanceusedisorderoutpatient
services
20% co-insurance 40% co-insurance None
Substanceusedisorderinpatient
services
20% co-insurance 40% co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesupto
$1,000.Limitedto30daysperyear.
Inpatientmaximumsforsubstanceabuse
andmental/behavioralhealthare
combined.
If you are pregnant Prenatalandpostnatalcare 20%co-insurance 40%co-insurance None.
Deliveryandallinpatientservices 20%co-insurance 40%co-insurance None.
If you need help
recovering or have other
special health needs
Homehealthcare 20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesupto
$1,000.Limitedto50visitsperyear.
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Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
Common
Medical Event
Service You May Need
Your Cost if you use an
Limitations & Exceptions
In-Network
Provider
Out-of-Network
Provider
Rehabilitationservices
$50.00co-pay/visit
&20%co-insurance
forotherservices
40%co-insurance
Pre-authrequiredforinpatient.Inpatient
limitedto90daysperyear.Pre-authfor
outpatientneedediftreatmentwill
exceed12visitsorwilllastlongerthan
30days.Pre-authpenaltyis30%
reductionincoveredchargesupto
$1,000.
Habilitationservices
$50.00co-pay/visit
&20%co-insurance
forotherservices
40%co-insurance
Pre-authrequiredforinpatient.Inpatient
limitedto90daysperyear.Pre-authfor
outpatientneedediftreatmentwill
exceed12visitsorwilllastlongerthan
30days.Pre-authpenaltyis30%
reductionincoveredchargesupto
$1,000.
Skillednursingcare 20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesupto
$1,000.Limitedto31daysperyear.
Durablemedicalequipment 20%co-insurance 40%co-insurance
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesupto
$1,000.Limitedto$50,000lifetime.
Hospiceservice Nocharge Nocharge
Pre-authrequired.Pre-authpenaltyis
30%reductionincoveredchargesupto
$1,000.
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Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
Common
Medical Event
Service You May Need
Your Cost if you use an
Limitations & Exceptions
In-Network
Provider
Out-of-Network
Provider
If your child needs
dental or eye care
Eyeexam Notcovered
Glasses Notcovered
Dentalcheck-up
Not covered
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Excluded Services & Other Covered Services:
Chiropracticcare
Your Rights to Continue Coverage:
Ifyou losecoverage underthe plan,then, dependingupon thecircumstances, Federaland Statelaws mayprovide protectionsthat allowyou tokeep healthcoverage.
Anysuch rightsmay belimited induration andwill requireyou topay apremium, whichmay besignificantly higherthan thepremium youpay whilecovered underthe
plan.Otherlimitationsonyourrightstocontinuecoveragemayalsoapply.
For more information on your rights to continue coverage, contact the plan at 1-888-292-0272. You may also contact your state insurance department, the U.S.
Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at
1-877-267-2323x61565orwww.cciio.cms.gov.
Your Grievance and Appeals Rights:
Ifyouhaveacomplaintoraredissatisfiedwithadenialofcoverageforclaimsunderyourplan,youmaybeableto appealorfileagrievance.Forquestionsabout
yourrights,thisnotice,orassistance,youcancontact:theplanat1-888-292-0272.YoucanalsocontacttheDepartmentofLaborsEmployeeBenefitsSecurity
Administrationat1-866-444-EBSA(3272)orwww.dol.gov/ebsa/healthreform.
Toseeexamplesofhowthisplanmightcovercostsforasamplemedicalsituation,seethenextpage.
Acupuncture
BariatricSurgery
CosmeticSurgery
DentalCare(Adult)
Hearingaids
Other Covered Services (This isnt a complete list. Check your plan document for other covered services and your costs for these services.)
Services Your Plan Does NOT Cover (This isnt a complete list. Check your plan document for other excluded services.)
Infertilitytreatment
Long-termcare
MostcoverageprovidedoutsidetheUnited
States.
Non-emergencycarewhentravelingoutside
theU.S.
Private-dutyNursing
Routineeyecare(Adult)(exceptfortreatment
ofdiabetes)
Routinefootcare(exceptfortreatmentof
diabetes)
Weightlossprograms
Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
8 of 10
Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
About these Coverage
Examples:
Theseexamplesshowhowthisplanmightcover
medicalcareingivensituations.Usethese
examplestosee,ingeneral,howmuchfinancial
protectionasamplepatientmightgetiftheyare
coveredunderdifferentplans.
nAmount owed to providers:$7,540
nPlan pays$5,180
nPatient pays$2,360
Sample care costs:
Hospitalcharges(mother) $2,700
Routineobstetriccare $2,100
Hospitalcharges(baby) $900
Anesthesia $900
Laboratorytests $500
Prescriptions $200
Radiology $200
Vaccines,otherpreventive $40
Total $7,540

Patient pays:
Deductibles $1,500
Co-pays $60
Co-insurance $600
Limitsorexclusions $200
Total $2,360
nAmount owed to providers:$5,400
nPlan pays$4,020
nPatient pays$1,380
Sample care costs:
Prescriptions $2,900
MedicalEquipmentandSupplies $1,300
OfficeVisitsandProcedures $700
Education $300
Laboratorytests $100
Vaccines,otherpreventive $100
Total $5,400

Patient pays:
Deductibles $0
Co-pays $1,300
Co-insurance $0
Limitsorexclusions $80
Total $1,380
This is
not a cost
estimator.
Dontusetheseexamplesto
estimateyouractualcosts
underthisplan.Theactual
careyoureceivewillbe
differentfromtheseexamples,
andthecostofthatcarewill
alsobedifferent.
Seethenextpagefor
importantinformationabout
theseexamples.
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
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Questions and answers about the Coverage Examples:
What are some of the assumptions
behind the Coverage Examples?
Costsdontincludepremiums.
Samplecarecostsarebasedonnational
averagessuppliedbytheU.S.Departmentof
HealthandHumanServices,andarentspecific
toaparticulargeographicareaorhealthplan.
Thepatientsconditionwasnotanexcludedor
preexistingcondition.
Allservicesandtreatmentsstartedandendedin
thesamecoverageperiod.
Therearenoothermedicalexpensesforany
membercoveredunderthisplan.
Out-of-pocketexpensesarebasedonlyon
treatingtheconditionintheexample.
Thepatientreceivedallcarefromin-network
providers.Ifthepatienthadreceivedcare
fromout-of-networkproviders,costswould
havebeenhigher.
What does a Coverage Example
show?
Foreachtreatmentsituation,theCoverageExample
helpsyouseehowdeductibles,co-payments,
andco-insurancecanaddup.Italsohelpsyou
seewhatexpensesmightbeleftuptoyoutopay
becausetheserviceortreatmentisntcoveredor
paymentislimited.
Does the Coverage Example
predict my own care needs?
No.Treatmentsshownarejustexamples.The
careyouwouldreceiveforthisconditioncouldbe
differentbasedonyourdoctorsadvice,yourage,
howseriousyourconditionis,andmanyother
factors.
Does the Coverage Example
predict my future expenses?
No.CoverageExamplesarenotcostestimators.
Youcantusetheexamplestoestimatecostsfor
anactualcondition.Theyareforcomparative
purposesonly.Yourowncostswillbedifferent
dependingonthecareyoureceive,thepricesyour
providers charge,andthereimbursementyour
healthplanallows.
Can I use Coverage Examples to
compare plans?
Yes.WhenyoulookattheSummaryofBenefits
andCoverageforotherplans,youllfindthesame
CoverageExamples.Whenyoucompareplans,
checkthePatientPaysboxineachexample.The
smallerthatnumber,themorecoveragetheplan
provides.
Are there other costs I should
consider when comparing plans?
Yes.Animportantcostisthepremium you
pay.Generally,theloweryourpremium,the
moreyoullpayinout-of-pocketcosts,suchas
co-payments,deductibles,and
co-insurance.Youshouldalsoconsider
contributionstoaccountssuchashealthsavings
accounts(HSAs),flexiblespending
arrangements(FSAs)orhealthreimbursement
accounts(HRAs)thathelpyoupayout-of-pocket
expenses.
Questions:Call1-888-292-0272orgotowww.assurantselffunded.com.
Ifyouarentclearaboutanyoftheboldedtermsusedinthisform,seetheGlossary.YoucanviewtheGlossary
atwww.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf orcall1-888-292-0272torequestacopy.
PROMATRIX CORP: Plan 1 CoveragePeriod:07/15/201307/14/2014
SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatitCosts Coveragefor:Individual/Family|PlanType:PPO
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