Midmed

A C C I D E N T
D I S A B I L I T Y
L I F E I N S U R A N C E
C R I T I C A L I L L N E S S
H O S P I T A L I N D E M N I T Y
Limited Benefit Medical Insurance Plan
The MidMed Group Limited Benefit Medical Insurance Plan,
underwritten by Continental American Insurance Company, is designed to provide
more coverage than most other limited benefit plan choices. It offers many of the same features of a comprehensive insurance plan and industry leading American Health Data Institute Wellness Services at an affordable cost.
SPECIAL FEATURES
• Compassionate, High-Tech Personalized Wellness Services According to Statistics:
• Co-Pays for Physician Office Visits and Routine Physicals • Includes Chronic Disease Management Program ELIGIBILITY
Employees & Spouses (ages 18-64) and dependent children under age 19 (or under age 25 if a full-time student).
Medical Benefits And How They Work
DEDUCTIBLES
Deductible applies to all expenses except Physician Office visits Network Physician/Specialist Office Visit set for your plan and the In and Out-of Network co-pays as shown in the benefit (Co-Pay does not apply to other services rendered in the PLAN MAXIMUMS Maximum amount shown in Benefits Description for Annual and
DeNavas-Walt, C.B. Proctor, and J.
Smith. Income, Poverty, and Health Insurance Coverage in the UnitedStates: 2007. U.S. Census Bureau.,August 2008.
C O N T I N E N T A L A M E R I C A N I N S U R A N C E C O M P A N Y
Annual Plan Maximum • $50,000
Lifetime Plan Maximum • $150,000
Calendar Year Deductible • $1,500
Outpatient Expense Benefits
In-Network
Out-of-Network
Other Services Provided During Office Visits Inpatient Expense Benefits
In-Network
Out-of-Network
The percentages shown are paid for eligible expenses AFTER you pay the deductible unless otherwise noted. *Expenses are subject
to reasonable and customary limits.
Outpatient Prescription Drugs • Underwritten by Fidelity Security Life Insurance Company
The Plan includes a separate Co-pay plan for outpatient prescription drugs purchased at participating pharmacies.TheCatalystRx plan, underwritten by Fidelity Security Life Insurance Company, utilizes a generic formulary with a preferreddrug list.The formulary is a list of all products available at one co-pay level or another.The preferred drug list containsgeneric products available at lower co-pay levels. Please refer to the Certificate of Insurance for a complete list of exclu-sions and limitations.
Annual Maximum Rx Benefit- $750 per insured Prescription Drug Card
www.caicworksite.com
Private duty nursing; 17. An Injury sustained while the Insured is legally Pre-admission certification prior to eligible inpatient hospitalization or intoxicated or under the influence of alcohol as defined by the jurisdic- Dispensing Limits and Authorized Refills - Retail: the lesser of a 30- surgery by the covered individual within 48 hours is required. This is not tion where the Accident occurred; 18. Charges made to treat a day supply or specified unit doses. Mail order not available.
a guarantee of benefits. Failure to pre-certify will result in benefit reduc- Sickness or Injury sustained while flying as a pilot or crew member; 19.
Voluntary sterilization procedure or the reversal of a sterilization proce- Rx Plan Underwritten by Fidelity Security Life Insurance Company dure; 20. Weight control services including surgical procedures, medical Policy Form Number M-9031. Some provisions, benefits, exclusions or treatments, weight control/loss programs, food supplements, exercise limitations may vary by state. Not available in all states.
A “reasonable and customary charge” is the charge typically made by programs or equipment; 21. Intentionally self inflicted injury or action physicians or suppliers of medical services, medicines and supplies with- unless the result of a medical condition;22. War (declared or undeclared) This is only a summary of the Continental American MidMed Limited or military conflicts, participation in an insurrection or riot, civil commo- Benefit Medical Insurance & Fidelity Security Life CatalystRx Prescription tion or state of belligerence. 23. Services and supplies not medically nec- Drug Plan; all benefits are subject to the terms, conditions, state man- essary, recommended or approved by a physician for the diagnosis, care dated benefits, exclusions and limitations of the master group policies.
Expenses incurred for treatment of Pre-Existing Conditions are not cov- or treatment of any Disease or Injury; 24. Charges made for: manipula- ered for the first 12 months following an Insured’s Effective Date of cov- tive (adjustive) treatment; or treatment of any condition caused by or Some provisions, benefits, exclusions or limitations may vary by
erage under the Group Policy. This limitation will not apply if: a)The indi- related to biomechanical or nerve conduction disorders of the spine; 25.
state. Not available in all states.
vidual seeking coverage under the Group Policy has an aggregate of 12 Prescription drugs and medicines prescribed by a physician on an outpa- months of Creditable Coverage and becomes eligible and applies for cov- tient basis; 26. Charges in excess of the Recognized Charge, based on the This Plan is not Comprehensive Major Medical Coverage or
erage, Credit will be given for the time the individual was covered under 90th percentile of the Medicode Medical Data Research Tables; 27.
designed as a substitute for Comprehensive Major Medical
prior Creditable Coverage that is not separated by a break in coverage of Charges for any treatment received while in a skilled nursing facility; 28.
Coverage. This is a limited medical plan that provides for limit-
Charges for any treatment for Home Health Care, except as covered ed coverage with a reduced annual and lifetime limit. The limi-
individual accepted and used up COBRA continuation of coverage or sim- under maternity: 29.Transportation charges, including ambulatory serv- tations are disclosed in the policy and certificate which are
ilar state coverage if it was offered to him or her.
ices; 30. Charges for biofeedback; 31. Any treatment received under hos- made available at the time of enrollment. Applicable to policy
pice care; 32. Elective or voluntary abortions except in the case of rape, form series CAI1000.
A newborn child, a child placed for adoption, or a newly adopted child incest or congenital deformities; 33. Charges for Prosthetics and/or under the age 18 who begins dependent coverage hereunder within 30 orthotics; 34. Charges for Temporomandibular Joint Disorder (TMJ).
days of birth, placement for adoption, or adoption (or who has creditablecoverage from birth, placement for adoption, or adoption without a sig- nificant break in coverage) shall not be considered to have any pre-exist- Prescription Drug benefits are not payable for the following items FOR CLAIMS AND CUSTOMER SERVICE CALL TOLL FREE:
except as set forth above: 1. all over-the-counter products and med-ications unless shown under the definition of Prescription Drug. This 1-800-308-6457
Pre-existing condition means a physical or mental condition, regardless includes, but is not limited to, electrolyte replacement, infant formu- of the cause of the condition, for which medical advice, las, miscellaneous nutritional supplements and all other over-the- diagnosis, care, or treatment was recommended or received within the 6 counter products and medications; 2. blood glucose meters; insulin month period prior to the enrollment date. Genetic information shall not injecting devices; 3. Depo-Provera; levonorgestrel; condoms, contra- be treated as a pre-existing condition in the absence of a diagnosis of the ceptive sponges and spermicides; sexual dysfunction drugs; 4. biolog- UNDERWRITTEN BY:
condition related to the genetic information. In order to be taken into icals (including allergy tests); blood products; growth hormones; account, the medical advice, diagnosis, care or treatment must have hemophiliac factors; MS injectables; immunizations; all other injecta- been recommended or received from an individual licensed or similarly bles unless shown under the definition of Prescription Drug; 5.
authorized to provide such services under state law and who operates Aerochamber, Aerochamber with Mask; Peak Flow Meter; all other within the scope of practice authorized by the state law.
medical supplies and durable medical equipment unless shown underthe definition of Prescription Drug; 6. liquid nutritional supplements; CREDIT FOR PRIOR COVERAGE: An insured whose coverage under prior pediatric Legend Drug vitamins; prenatal Legend Drug vitamins; pre- Creditable Coverage ended not more than 63 days before the Insured’s scribed versions of Vitamins A, D, K, B12, Folic Acid and Niacin used in Effective Date under the Group Policy, will have any applicable Pre- treatment versus as a dietary supplement; all other Legend Drug vita- 2801 DEVINE STREET
Existing Condition limitation reduced by the total number of days the mins and nutritional supplements; 7. Anorexiants; any cosmetic drugs COLUMBIA, SC 29205
Insured was covered by such coverage. If there was a break in Creditable including, but not limited to, Renova, skin pigmentation preps; any Coverage of more than 63 days, the Company will credit only the days of drugs or products used for the treatment of baldness; topical dental such coverage after the break. The Insured must provide proof of prior fluorides; 8. refills in excess of that specified by the prescribing Physician; or refills dispensed after one year from the original date ofthe prescription; 9. all newly marketed pharmaceuticals or currently EXCLUSIONS AND LIMITATIONS – The following are not Eligible Expenses marketed pharmaceuticals with a new FDA approved indication for a and will not be covered under the Group Policy: 1. Injury arising out of or period of one year from such FDA approval for its intended indication; in the course of employment, or activity for wage or profit, or which is 10. any drug labeled “Caution - Limited by Federal Law for compensable under Worker’s Compensation or Occupational Disease Act Investigational Use” or experimental drugs; 11. any drug that the FDA FOR MORE INFORMATION CONTACT:
or Law. 2. Experimental or investigational services, drugs, or supplies has determined to be contraindicated for the specific treatment; 12.
A KING AGENCY
except to the extent required by law; 3. Educational testing or training drugs needed due to conditions caused, directly or indirectly, by an related to learning disabilities or developmental delays; 4. Custodial care Insured Person taking part in a riot or other civil disorder; or the 5005 W. 81ST PLACE
or personal items; 5. Any expense incurred before the Insured’s Effective Insured Person taking part in the commission of a felony; 13. drugs Date of coverage under the Policy or after the coverage termination date; needed due to conditions caused, directly or indirectly, by declared or SUITE 400
6. Eye surgery to correct refractive errors; 7.Therapy, supplies or counsel- undeclared war or an act of war; or drugs dispensed to an Insured ing for sexual dysfunctions; 8. Performance, or lifestyle enhancement Person while on active duty in any Armed Forces; 14. any expenses WESTMINSTER, CO 80031
drugs or supplies; 9. Artificial insemination, in vitro fertilization, or related to the administration of any drug; 15. needles or syringes embryo transfer or any related procedures except where required by law; unless shown under the definition of Prescription Drug; 16. drugs or 303-487-1016
10. Routine physical, vision, or hearing exams, immunizations, or other medicines taken while in or administered by a hospital or any other preventative services or supplies, except to the extent that coverage is health care facility or office; 17. drugs covered under Workers’ specifically provided under the Group Policy. 11. Dental care except for Compensation, Medicare, Medicaid or other Governmental program; Injury to sound, natural teeth; 12. Elective Surgery;13. Cosmetic Surgery 18. drugs, medicines or products that are not Medically Necessary; 19.
other than Reconstructive Surgery incidental to or following surgery Brand Name Prescription Drugs; 20. Diaphragms; Erectile dysfunction resulting from trauma, infection, or other Diseases of the involved part; Legend Drugs, unless specifically listed in the definition of or Reconstructive Surgery because of a congenital Disease or anomaly; or Prescription Drug; Infertility Legend Drugs; 21. Epi-Pen, Epi-Pen Jr., according to the requirements of the Women’s Health and Cancer Rights Ana-Kit, Ana-Guard; Glucagon-auto injection; Imitrex-auto injection; Act. 14. Speech therapy except as otherwise specifically covered under or 22. smoking deterrents, Legend or over-the-counter.
the Group Policy; 15. Inpatient or outpatient treatment of alcoholism,drug abuse, and mental illnesses; except where required by law; 16.

Source: http://kingandi.us/assets/MidMed-AKA-071509.pdf