DESCRIPTION OF BENEFIT

• The program will reimburse you $75.00 per Doctor's Office visit.

• The reimbursement will be paid for up to 10 visits per benefit year for sickness visits.

• The program will reimburse you no matter what doctor you choose, even out of network doctors. However, when you call Member Services before setting your appointment and choose to select a Participating Provider, you will also have access to the doctor's contracted reduced rates -- this will help you get the best value for your health care dollar.

Outpatient Physician Benefit: Pays $75 for treatment of a covered sickness or injury by a physician in the physician's office, clinic, urgent care facility or emergency room. The maximum number of visits is 10 per calendar year per family, 5 per calendar year for all covered dependent children combined and 5 per calendar year per covered adult except for dependent children. This benefit is not payable for routine health examinations or immunizations for covered persons aged 6 and older, for visits for mental or nervous disorders or for visits by a surgeon while confined to a hospital.

Eligibility and Effective Dates: This insured benefit is effective on the first day of the month following the date your completed application for Membership is received and processed. Coverage for Legal Dependents you acquire after your coverage is effective will be effective on the date that your application for the additional dependent is approved except that coverage for adopted children, newborn children, foster children and children in your custody by a court order is effective for 31 days from the date of birth, date of adoption or placement. To continue coverage beyond 31 days for these children, you must provide notice of such children. For purposes of this benefit: an otherwise Legal Dependent child must also reside in your home for more than 6 months a year and chiefly rely on you for support and maintenance to be covered; and legal dependent includes a child past the age of 19 (25 if a full time student) who has a handicapped condition which renders the child incapable of self-sustaining employment and who is chiefly dependent on you or other care providers for lifetime care and supervision because of a handicapped condition that occurred before such age.

Exclusions and Limitations: Benefits will not be paid for charges or loss caused by, or resulting from, any of the following: suicide or any intentionally self-inflicted injury; any drug, narcotic, gas or fumes, or chemical substance voluntarily taken, administered, absorbed or inhaled unless prescribed by, and taken according to the directions of, a doctor (accidental ingestion of a poisonous substance is not excluded.); commission, or attempt to commit, a felony; participation in a riot or insurrection; driving under the influence of a controlled substance, unless administered on the advice of a doctor; driving while intoxicated as determined by the laws in the jurisdiction of the geographical area where the loss occurs; declared or undeclared war or act of war; nuclear reaction or the release of nuclear energy. However, this exclusion will not apply if the loss is sustained within 180 days of the initial incident and: the loss was caused by fire, heat, explosion or other physical trauma which was a result of the release of nuclear energy; and the covered person was within a 25-mile radius of the site of the release either: at the time of the release; or within 24-hours of the start of the release; or occurs while he is in the state where this plan was issued; or treatment of mental or nervous disorders, or alcohol or substance abuse.