Invitation to Tender for Group Health Insurance Contract

Taipei Economic and Cultural Representative Office

in the United States

Invitation to Tender for Group Health Insurance Contract

  1. Procurement Object

Group health insurance service contract (the Contract)for Taipei Economic and Cultural Representative Office in the United States (“TECRO”) and its subsidiary offices (“TECO”) except for TECO in Honolulu.

  1. Insured Persons
  1. TECRO/TECO full time employees and their dependents, which include spouse, eligible child and parents. Eligible child” means minors; physically or mentally disabled sons or daughters without earning capacity; and unmarried sons or daughters under the age of 26 and still in school.
  2. Total accounts of TECRO/TECO current group health insurance as of September 30, 2018:
  1. Employee only: 176 accounts (176 persons);
  2. Employee plus spouse or child(ren): 83 accounts(166 persons); AND
  3. Family: 139 accounts (509 persons).
  1. A quoted total price in a tender must be based on the accounts listed above and it must also contain monthly premium for each type of accounts.
  1. Contract Dates
  1. 01/01/2019-12/31/2019 (US calendar day)
  2. TECRO has the option to renew the Contract for 1 year (01/01/2020-12/31/2020) provided that:
  1. TECRO is satisfied with the performance of the coverage under the Contract; AND
  2. The renewed Contract Price is agreed by both sides before October 15, 2019 after negotiation of the renewal.
  1. Procurement Budget:
  1. 2019: US$ 3,953,586.24.
  1. The maximum premium for monthly rate for an employee only account shall be no higher than US$ 392.77.
  2. The maximum monthly premium for an employee plus spouse or child(ren) account and a family account shall be calculated based on the carriers formula for the calculation of the maximum premium for the employee only account.
  1. 2020: US$ US$ 3,953,586.24.
  1. Provided that TECRO decides to renew the Contract for the year of 2020.
  2. 2019 maximum monthly premium aforesaid applies to 2020.
  1. Any quoted total price of tender that is over the procurement budget will not be considered.
  1. Health Insurance Carrier/Broker
  1. Basic requirements: the Contract reaches the threshold for large procurement under the Government Procurement Act (the “Act) of ROC (Taiwan). To comply with the Act, TECRO will review basic requirements for a health insurance carrier/broker (“carrier/broker”) before evaluating its tender. A prospective carrier/broker shall submit documents to prove that:
  1. It is licensed to provide health insurance service in the United States; AND
  2. It has had at least one group health insurance contract with foreign embassies/consulates within the last 5 years.
  1. A carrier may permit no more than one broker to submit its tender to TECRO on behalf of the carrier. A broker must submit no more than one tender to TECRO on behalf of the carrier. This does not preclude industry practices of business contacts and insurance proposal quotes between carriers and brokers before they formally submit tenders to TECRO.
  1. Procurement Procedure
  1. The procurement of the Contract adopts “The Most Advantageous Tender” rule pursuant to subparagraph 9 of paragraph 1 of Article 22 of the Act.
  2. TECRO will form a selection committee (“the Committee”) of 7 persons to review tenders submitted by carriers/brokers.
  3. TECRO will review the basic requirements listed in Paragraph V. above to determine whether a carrier/broker is qualified to submit its tender to TECRO. Qualified carries/brokers must make presentations to and take questions from the Committee on the date designated by TECRO.
  4. The Committee will evaluate each carrier/brokers tender in accordance with the selection criteria listed in Paragraph VIII below. The total evaluation score is 100 points and an “ordinal ranking” method will be adopted by turning the scores of all carriers/brokers into the ranking for each member of the Committee. The rankings of the same carrier/broker among the Committee members will be combined and the one with lowest figure will be the first priority carrier/broker for price negotiation. If two or more carriers/brokers have the same lowest figure, the Committee will choose the lowest quoted price to start the negotiation.
  5. TECRO may award the Contract to the 1st priority carrier/broker provided that the quoted total price in its tender is below the procurement budget listed in Paragraph IV. above and that TECRO accepts the quoted total price. If the quoted total price is below the procurement budget but TECRO is not satisfied with the price, TECRO will negotiate the final price with the 1st priority carrier/broker before awarding the Contract. If TECRO cannot reach an agreement with the 1st priority carrier/broker on the final price, TECRO will move to the 2nd priority carrier/broker and negotiate the final price for its tender, and so on. TECRO will only negotiate with any qualified carriers/brokers one time on the final price of its tender for the year of 2019.
  6. TECRO may award the Contract in its’ sole discretion.
  7. TECRO does not have a contractual relationship with any carriers/brokers until TECRO signs the Contract.
  1. Benefit Requirements
  1. Please see benefit requirements in the Addendum.
  2. The benefit summary of the tender submitted to TECRO must be a PPO medical program. A comparison between the benefit requirements in the Addendum and the tender’s benefit summary must be submitted for the Committee’s review.
  3. The Committee will evaluate the insurance carrier/broker’s tender and benefit summary in accordance with selection criteria in Paragraph VIII below to determine which tender has the priority for price negotiation.
  4. Parents living in the same household of TECRO/TECO eligible employees may enroll in the group health insurance plan in separate account. Diplomatic employees parents living in Taiwan may also enroll in the plan if they come to the United States for a short family visit.
  5. Prevention of medical fraud

No employees or dependents may enroll in the group health insurance plan if their main purpose of coming to the United States or joining this plan is to seek medical treatment. The insurance carrier/broker must inform TECRO of the aforesaid or other serious medical fraud cases it discovers.

  1. Selection Standard
  1. Selection Criteria

    Evaluation items

    Sub-evaluation items

    Score Distribution

    Professional Service Team Human resources

    15

    Number of in-network medical providers
    Service Quality Procedure of enrollment and claims

    15

    Customer service for claims and medical advice
    Broker Services
    Capability of Group Health Insurance Foreign embassies/consulates clients

    10

    Fortune 500 companies clients
    Completeness of proposal

    5

    Benefit summary

    15

    Quoted Price Premium Calculation

    40

    Premium Reasonableness
    Reward(credit back)
    Total Score

    100

  2. Any tender with a total score of less than 70 will not be considered further.
  1. Submission of Tender:
  1. Please contact TECRO personnel officer to request information of tender preparation.

Telephone number: 202-895-1840

Email: personnel.tecro@mofa.gov.tw

  1. Submission of tender is strictly limited to regular mail, courier service or personal delivery. Electric transmission of tender WILL NOT be accepted.
  2. The tender must be sealed and received by TECRO not later than 05:00pm on October 29, 2018 (ET). Please address the tender as follows:

Administrative Division (Group Health Insurance Tender)

Taipei Economic and Cultural Representative Office in the United States

4201 Wisconsin Avenue, N.W.

Washington, DC 20016

  1. Tenders received after the deadline WILL NOT be considered.
  2. A tender must contain following documents:
  1. Group health insurance service proposal

The proposal must contain the information required in this invitation to tender.

  1. One copy of draft contract.
  2. Statement of the tender (form provided by TECRO).
  3. Price list of the tender (form provided by TECRO).
  4. A carrier/broker’s basic requirement documents listed in Paragraph V. above.
  1. TECRO will hold a meeting in its office to open sealed tenders it received at 10:00am on the next business day of the submission deadline.
  1. Enrollment Procedure and Efffectivemess of Coverage
  1. The coverage of diplomatic employees and their dependents shall become effective upon their arrivals at the port of entries in the United States if they decide to enroll in the plan.
  2. The coverage of eligible locally-hired employees and their dependents (parents not included with some exceptions) shall become effective 90 days after the commencement of employment with TECRO/TECO if they choose to enroll in the plan
  1. Premium Payment Period

TECRO will pay insurance premium in a 3-month period and will adjust its payment according to new enrollments and withdraws.

Addendum

Benefit Requirements for TECRO Group Health Insurance Contract

OVERVIEW MATRIX

Limits Outside the U.S.

Limits In Network, U.S.

Limits Out-of-Network, U.S.

MEDICAL EXPENSES

Deductible

Any deductible paid for one column will be applied towards the deductible in another column.

$350 per Insured Person per Policy Year and limited to $700 per Family per Policy Year

$350 per Insured Person per Policy Year and limited to $700 per Family per Policy Year

$700 per Insured Person per Policy Year and limited to $1,400 per Family per Policy Year

Payment Level One

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 85% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee.

Payment Level Two

Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Negotiated Rate.

Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Coinsurance Maximum

Any Coinsurance paid for one column will be applied towards the Coinsurance in another column.

$4,700 per Insured Person per Policy Year and limited to $9,400 per Family per Policy Year

$2,250 per Insured Person per Policy Year and limited to $4,500 per Family per Policy Year

$4,700 per Insured Person per Policy Year and limited to $9,400 per Family per Policy Year

REPATRIATION OF REMAINS

Maximum Benefit up to $25,000

BEDSIDE VISIT

Up to a maximum benefit of $2,500 for the cost of one economy round-trip air fare ticket to, and the hotel accommodations in, the place of the Hospital Confinement for one (1) person

SCHEDULE OF BENEFITS

(Subject to Maximums, Coinsurance, and Deductibles in Overview Matrix)

Benefits

Outside the U.S.

In Network, U.S.

Out-of-Network, U.S.

Preventive Care Services – Deductible is not applicable

For Dependent Children (Birth to Age 19)

100% of the Usual and Customary Fee

100% of the Negotiated Rate

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of Reasonable Charges. After the Coinsurance Maximum is satisfied, the Insurer will pay 100% of Reasonable Charges.

For Adults (Age 20 and Older)

100% of the Usual and Customary Fee

100% of the Negotiated Rate

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of Reasonable Charges. After the Coinsurance Maximum is satisfied, the Insurer will pay 100% of Reasonable Charges.

Services Provided by a Physician or Provider – Copayments and Deductible apply if applicable unless specifically stated

Physician Office Visits

Deductible does not apply. Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Deductible does not apply. After a $20 Copayment, the Insurer will pay 100% of the Negotiated Rate.

Deductible does not apply. After a $40 Copayment, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Surgical Care

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Benefits

Outside the U.S.

In Network, U.S.

Out-of-Network, U.S.

Medical Care

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Emergency Care

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Other Physician services

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Annual Physical Examination/Health screening for services not covered by Preventative Care

Maximum of $500 and limited to one per Policy Year.

Deductible does not apply. Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Deductible does not apply. 85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Deductible does not apply. Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Services and Supplies Provided by a Hospital – Copayments and Deductible apply if applicable, unless specifically stated

Benefits

Outside the U.S.

In Network, U.S.

Out-of-Network, U.S.

Inpatient Hospital Care

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Outpatient Hospital Care

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Emergency Care

(Note 1)

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Other Services and Special Conditions – Copayments and Deductible apply if applicable, unless specifically stated

Ambulance Transportation

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Benefits

Outside the U.S.

In Network, U.S.

Out-of-Network, U.S.

Ambulatory Surgical Facility

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Dental Care for an Accidental Injury

100% of Covered Expenses up to $1,000 per Policy Year maximum and limited to $200 per tooth

Maternity

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Mental Illnesses – Inpatient Treatment

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Serious Mental Illness – Outpatient Treatment

Deductible does not apply. Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Deductible does not apply. After a $20 Copayment, the Insurer will pay 100% of the Negotiated Rate.

Deductible does not apply. After a $40 Copayment, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Benefits

Outside the U.S.

In Network, U.S.

Out-of-Network, U.S.

Mental Illness – Outpatient Treatment

Deductible does not apply. Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Deductible does not apply. After a $20 Copayment, the Insurer will pay 100% of the Negotiated Rate.

Deductible does not apply. After a $40 Copayment, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Substance Abuse rehabilitation- Inpatient Treatment

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the

Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the

Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Substance Abuse rehabilitation – Outpatient Treatment

Deductible does not apply. Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Deductible does not apply. After a $20 Copayment, the Insurer will pay 100% of the Negotiated Rate.

Deductible does not apply. After a $40 Copayment, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Chiropractic Care

As many as 20 visits per Policy Year

Deductible does not apply. Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Deductible does not apply. After a $20 Copayment, the Insurer will pay 100% of the Negotiated Rate.

Deductible does not apply. After a $40 Copayment, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Benefits

Outside the U.S.

In Network, U.S.

Out-of-Network, U.S.

Physical/Occupational/Speech Therapy/Medicine and Other Specified Therapies

As many as 30 visits per Policy Year

Deductible does not apply. Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Deductible does not apply. After a $20 Copayment, the Insurer will pay 100% of the Negotiated Rate.

Deductible does not apply. After a $40 Copayment, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Infusion Therapy/Radiation Therapy/Chemotherapy

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Human Organ Transplants

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Home Health Care

Up to a maximum of 120 visits per Policy Year

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Benefits

Outside the U.S.

In Network, U.S.

Out-of-Network, U.S.

Skilled Nursing Facilities

Up to a maximum of 60 days per Policy Year

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Hospice

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

85% of the Negotiated Rate, until the Coinsurance Maximum is satisfied, then the Insurer will pay 100% of the Negotiated Rate.

Until the Coinsurance Maximum is satisfied, the Insurer will pay 60% of the Usual and Customary Fee. Once the Coinsurance Maximum is satisfied the Insurer will pay 100% of the Usual and Customary Fee.

Pharmacy Benefits

Pharmacy – Outside the US Maximum 180 day supply

the Copayment stated below

1.

Prescription Drugs

All except a 40% Copayment per Prescription, per 30 day supply

2.

Injectables

All except a 30% Copayment per Prescription, per 30 day supply

Pharmacy – Inside the US Maximum 180 day supply

the Copayment stated below

1.

Generic Drugs

All except a $15 Copayment per prescription, per 30 day supply

2.

Brand name Drugs

All except a $30 Copayment per prescription, per 30 day supply

3.

Injectables

All except a 30% Copayment per Prescription, per 30 day supply

Hearing Services

No Deductible. 100% of Covered Expenses per Policy Year up to a maximum of $500 for Hearing Services that are not the result of an Injury or Illness. In addition, for a Covered Person who is a Dependent Child under age 24, 100% of Covered Expenses up to a maximum of $1,000 per Hearing Aid every three years.

Vision Care

No Deductible. 100% of Covered Expenses per Policy Year up to a maximum of $250 for Vision Care that is not the result of an Injury or Illness.

Note 1: If an Insured Person requires emergency treatment of an Injury or Sickness and incurs covered expenses at a non-Preferred Provider, Covered Medical Expenses for the Emergency Medical Care rendered during the course of the emergency will be treated as if they had been incurred at a Preferred Provider.