The Network Advantage

Quality Care at Significant Savings

Access to the right doctors can be the most important part of your health care.

Our network gives you:

Access to an extensive network of doctors, X-ray and lab facilities, hospitals, and other ancillary providers.*
Quality care at reduced costs because these providers have agreed to lower fees for covered expenses.

• Lower premiums — savings of up to 30% or more over the same plans without a network. Please note: Covered expenses for nonemergency care received from a provider outside your network are:

Subject to eligible expense limits;
Reduced by 25%;
Subject to an additional deductible amount equal to the calendar-year deductible.

For Services of Non-Network Providers: Your actual out-of-pocket expenses for covered expenses may exceed the stated coinsurance percentage because actual provider charges may not be used to determine insurer and member payment obligations.

Sample savings with our network:

(Services provided February-March 2010)**

*UnitedHealthcare Choice Plus network, available in most areas. LabCorp is the preferred laboratory services provider for UnitedHealthcare networks. Network availability may vary by state, and a specific health-care provider’s contract status can change at any time. Therefore, before you receive care, it is recommended that you verify with the health-care provider’s office that they are still contracted with your chosen network.

**All these services received from network providers in ZIP Code 336--. Your actual savings may be more or less than this illustration and will vary by several factors.

To find or view network providers for any network, visit www.goldenrule.com

Convenient Doctor Office Copay Benefits

Designed for individuals and families, Copay Select^SMis more like traditional employer plans with a copayment for routine health-care expenses. When you use a network doctor for an office visit, we pay 100% of history and exam fees after a $35 copay. Office visits outside your network are covered subject to the applicable deductible and your chosen coinsurance.

**Prescription Drug* Card Benefits**

Tier 1 drugs — $15 copay, no deductible.
Tier 2 drugs — $35 copay.
Tier 3 drugs — $65 copay.
Tier 4 drugs — you pay 25% coinsurance.

Tier 2-4 drugs have a combined $500 deductible per person, per calendar year.

Comprehensive Coverage for Inpatient and Outpatient Medical Expenses

• Covered inpatient and outpatient expenses are reimbursed after your chosen coinsurance and the deductible.

Note: Copay Select^SMis not available in Alaska.

*We have a preferred drug list, which changes periodically. Tier status for a prescription drug may be determined by accessing your prescription drug benefits via our Web site 6 or by calling the telephone number on your identification card. The tier to which a prescription drug is assigned may change as detailed in your policy/certificate.

Deductible Choices You pay: $1,000, $1,500, $2,500, $3,500, $5,000, $7,500 or (maximum 2 per family, per calendar year) $10,000

Choice of Coverage

With our High Deductible Plans, you select the level of coverage that makes you most comfortable. The higher the deductible, the lower your premiums. And you’re keeping more of your money and taking responsibility for covering minor or routine health-care expenses, if they come up.

Lowest Premium Plan

Saver 80^SMis our lowest premium plan. This plan provides coverage for hospital confinements, surgical procedures in or out of the hospital (but not in the doctor’s office), and the more costly outpatient expenses, such as CAT scans and MRIs.

Simple to Use

Golden Rule’s top-selling High Deductible Plan — Plan 100®. It pays 100% of covered expenses once you meet your calendar-year deductible. Your benefits are not complicated with multiple copays or coinsurance.

Deductible Choices You pay: $1,500, $2,500, $5,000, You pay: $1,500, $2,500, $5,000, You pay: $1,000, $1,500, $2,500, (maximum 2 per family, per calendar year) $7,500 or $10,000 $7,500 or $10,000 $5,000, $7,500 or $10,000

HSA Plans Offer Quality Coverage, Savings

HSA Plans simply combine a lower-cost, high deductible health insurance plan and a tax-favored savings account.

Lower Premiums, Tax-Advantaged Savings, and an Attractive Interest Rate*

High deductible plans typically cost a lot less than many copay or traditional plans. This means lower premiums for you. You can then take the premium savings and place it into your health savings account.

You get a tax deduction on the money you put in your HSA.
Your dollars can grow tax-deferred.
You spend the savings tax-free to help pay your deductible or for qualified medical care (including prescriptions, vision, or dental care).
What you don’t use in your account will continue to accumulate year after year. Then, if you ever need it for health-care expenses, the money will be there.
With Golden Rule’s HSA custodian, you’ll also earn interest on your savings, beginning with the first dollar deposited.

Bottom line — HSAs can help make health insurance more affordable.

Traditional Insurance High Deductible Insurance Premium Savings $ Premium $ Premium $ Put Into HSA

*See HSA insert for important information.

Deductible Choices You pay: Single — $1,250, $2,500, $3,000, $3,500 or $5,000 You pay: Single — $1,250, $2,500, $3,000, $3,500 or $5,000 (per family deductible, per calendar year) Family — $2,500, $5,000, $6,000, $7,000 or $10,000 Family — $2,500, $5,000, $6,000, $7,000 or $10,000

About Your HSA

We have chosen OptumHealth Bank, Member FDIC, a leading administrator of health savings accounts (HSA), as our financial institution. Your HSA funds are deposited at OptumHealth Bank in a custodial account. OptumHealth Bank will service your account and send information directly to you about your HSA.

You will receive your new OptumHealth Bank Health Savings Account Debit MasterCard® and PIN in separate mailings. Once you activate your card, you can use it at:

Any point-of-service location (such as a doctor’s office or pharmacy) that accepts MasterCard® debit cards.
Any ATM displaying the MasterCard® brand mark. ($1.50 per transaction OptumHealth Bank fee. In addition, the bank/ATM you use to withdraw funds may charge you its own fee (variable by bank) for the transaction.)

You can also access your HSA funds through:

Online bill payment at www.OptumHealthBank.com
Checks, if you choose to purchase them.

HSA deposits are set up on the same payment plan as premiums for Golden Rule health insurance coverage. Lump-sum deposits are also accepted by OptumHealth Bank; however, you must continue to deposit the $25 monthly minimum with your premium payment. OptumHealth Bank will provide online monthly statements detailing your account balance and activity. If you prefer to have statements mailed to your home, simply notify OptumHealth Bank. You can opt out of electronic statements at its website (www.OptumHealthBank.com), call customer service to do so, or send your request to P.O. Box 271629, Salt Lake City, UT 84127-1629.

Account Information by Phone or Online

With an OptumHealth Bank HSA, your account information is available, day or night, through:

Toll-free customer service — representatives are available to assist you Monday through Friday, 8
a.m. to 8 p.m. Eastern time, at (866) 234-8913.

Interactive voice response for self-service, 24/7.
www.OptumHealthBank.com

You can:

Make contributions to your HSA.
Pay bills online.
Check current balance.
See how much interest has been paid.
Transfer funds.
Check last five (5) account transactions (deposits and/or withdrawals).
Activate the Health Savings Account card.
Report the card lost or stolen.
Set or reset password.
View frequently asked questions.
View monthly statements.

HSA Management by OptumHealth Bank

Who is responsible for my HSA?

As custodian, OptumHealth Bank is responsible for your HSA funds. OptumHealth Bank’s deposits are insured by the Federal Deposit Insurance Corporation (FDIC).

Please be aware that the money market and mutual fund investment options are NOT guaranteed by OptumHealth Bank, are NOT FDIC-insured, and may lose value. We encourage you to read the prospectus of each fund carefully before investing and seek the advice of an investment professional you trust.

You will receive a OptumHealth Bank Health Savings Account Debit MasterCard® from OptumHealth Bank shortly after your qualified medical coverage becomes effective. HSA withdrawals can be made by simply using your Health Savings Account card at any point-of-service location (such as a doctor’s office or pharmacy) that accepts MasterCard® debit cards.

If you prefer, you can purchase the qualified health insurance coverage from Golden Rule and set up your savings account with another qualified custodian.

Health Savings Accounts (HSA) — Summary of the Law

Eligibility — Those covered under an qualified high deductible health plan, and not covered by other health insurance (except for vision or dental or other limited coverage) or enrolled in Medicare, and who may not be claimed as a dependent on another person’s tax return

HSA Contributions — 100% tax-deductible from gross income

Qualified Medical Withdrawals — Tax-free

Interest Earned — Tax-deferred; if used for qualified medical expenses, tax-free

Nonmedical Withdrawals — Income tax + penalty tax (10% in 2010, 20% in 2011 for those under age 65); income tax only (for age 65 and over)

Death, Disability — Income tax only — no penalty; If the spouse is listed as a beneficiary, the spouse can have the HSA transferred to their name — assume the HSA — no tax issue

Deductible and out-of-pocket maximums may be adjusted annually based on changes in the Consumer Price Index. This is only a brief summary of the applicable federal law. Consult your tax advisor for more details of the law.

Health savings accounts (HSAs) are individual accounts offered by OptumHealth Bank^SM, Member FDIC, and are subject to eligibility and restrictions, including but not limited to restrictions on distributions for qualified medical expenses set forth in section 213(d) of the Internal Revenue Code. This communication is not intended as legal or tax advice. Please contact a competent legal or tax professional for personal advice on eligibility, tax treatment, and restrictions. Federal and state laws and regulations are subject to change.

*As of 2/1/10, subject to change at any time without notice.

**The $3 monthly maintenance fee is waived when the Average Balance exceeds $5,000.

Optional Benefits

Further customize your health insurance coverage to meet your specific needs.

Benefits to Enhance Your Health Plan

Add more benefits to your plan for an additional premium.

$25 Office Visit Copay

Reduce the doctor office visit copay from $35 to $25. Available with Copay Select^SM.

Prescription Drug — $200 Deductible

Reduce the combined per person, per calendar-year deductible for tier 2-4 drugs from $500 to $200. Available with Copay Select^SM.

**Prescription Drug* — Copay Card**

With this benefit, you pay:

Tier 1 drugs — $15 copay, no deductible.
Tier 2 drugs — $35 copay.
Tier 3 drugs — $65 copay.

• Tier 4 drugs — you pay 25% coinsurance. Tier 2-4 drugs have a combined $500 deductible per person, per calendar year. If you purchase name-brand when generic is available, you pay your

generic copay plus the additional cost above the generic price. Available with Plan 100® and Plan 80^SM.

Term Life Benefit

You may choose an optional term life insurance benefit for you and/or your spouse who is also a covered person under the health plan. You and/or your spouse must be age 18 or older. The term life benefit expires when a covered person reaches age 65.

You select one of three benefit amounts. You may select different amounts for you and your spouse.

Accidental Death Benefit

This benefit provides $50,000 in coverage in the event of an accidental death for you and/or your spouse who is also a covered person under the health plan. You and/or your spouse must be age 18 or older. The accidental death benefit expires when a covered person reaches age 65. It may be purchased with or without the term life benefit.

Motorcyclists are not eligible for this benefit.

Mental Disorders and Substance Abuse

This benefit covers expenses for the diagnosis and treatment of mental disorders and substance abuse like any other illness. Charges are subject to your plan’s deductible, coinsurance, or copayment amounts.

Not available with Saver 80^SMexcept in AR. Not available in DC, NC, OH, TX, and WI.

Benefits to Reduce Premium

Adjust your plan benefits for a lower premium.

4-Dr. Office Visit Copay

For the first 4 network doctor office visits per person, per calendar year you pay a $35 copay, no deductible or coinsurance. For the fifth visit, and thereafter, you pay your deductible, then coinsurance.

Available with Copay Select^SMand cannot be combined with the $25 Office Visit Copay optional benefit.

Prescription Drug — Discount Card Only

You may obtain prescription drugs at an average savings of 20-25%. Discounts vary by pharmacy, geographic area, and drug. A discount-only card is provided. This discount program (card) is not insurance. By choosing this option, you are replacing the prescription drug insurance on your plan with a discount-only card.

Not available with Saver 80^SM.

Benefit Amounts: $50,000 $100,000 $150,000 _{Prescription Drug — Generic Only}You pay a $15 copay for generic drugs, no deductible. Name-brand prescription drugs are not covered. Available with Copay Select^SM. Not available in TX.

*We have a preferred drug list, which changes periodically. Tier status for a prescription drug may be determined by accessing your prescription drug benefits via our Web site or 12 by calling the telephone number on your identification card. The tier to which a prescription drug is assigned may change as detailed in your policy/certificate.

You may choose an optional Supplemental Accident benefit to reduce your out-of-pocket expenses for unexpected injuries.

Select a maximum benefit amount: $500, $1,000, $2,500, $5,000, or $10,000, per accident, per covered person.
Helps cover your deductible or other out-of- pocket medical expenses (before the health insurance starts paying covered expenses).
Expenses must be eligible for payment under the health insurance and incurred within 90 days of an injury.*
Any benefit amount paid by the Supplemental Accident benefit will first be credited to the deductible and coinsurance of the health insurance.*
Any remaining benefit payment will be made either to your health care provider under your assignment of benefits, or to you if you have already paid your provider.
Additional premium is required for the optional Supplemental Accident benefit rider.
Exclusions and limitations of the health plan apply to this optional benefit, see product brochure for details.

Consult a tax advisor regarding whether our HSA plan with the optional Supplemental Accident qualifies for favorable HSA (account) tax treatment.

*Saverplans: This rider will cover some expenses not otherwise covered under a Saverplan. This type of expense will not be credited toward deductible or coinsurance.

**Examples are as of 07/27/09, are for illustration purposes only, and assume all expenses are covered. All these services received from network providers in ZIP Codes 495--and 110--. Your actual savings may be more or less than this illustration and will vary by several factors.

Golden Rule Insurance Company, a UnitedHealthcare company, is the underwriter and administrator of these plans marketed under the UnitedHealthOne brand.

Keep an eye on your family’s vision health by adding our optional Vision Benefit rider to your health plan today. Our extensive vision care network today includes about 24,000 private practice and retail chain providers.* We’ll help keep your family seeing clearly, so you can focus on savings!

We’re here to help you.

Use www.myuhcvision.com/goldenruleto find a provider in your area, access your plan information, see your claim status, find general vision information, and more.

UnitedHealthcare Vision Benefit Rider

You may use a non-network provider, but by staying in-network you are eligible to receive better discounts:

Eye exam — $10 copay – once every 12 months.
Frames — $25 copay – once every 24 months.
Lenses — $25 copay – once every 12 months.
Contacts in lieu of glasses — $25 copay – once every 12 months.

*Network availability may vary by state, and a specific vision care provider’s contract status can change at any time. Therefore, before you receive care, it is recommended that you verify with the vision care provider that he or she is still contracted with the network.

Policy Form SA-S-1356R UnitedHealthOne is a brand name used for products underwritten by Golden Rule Insurance Company. This product is administered by Spectera, Inc. Additional premium is required. Availability varies by state. Please see the corresponding health product brochure and important information on the back of this page.

Covered Expenses

Subject to all policy provisions, the following vision expenses are covered:

Comprehensive eye examinations. Benefits are limited to 1 exam per 12 months.

Prescription eyewear. Benefits are limited to 1 pair of prescription single vision lenses per 12 months and 1 pair of frames per 24 months:

Spectacle lenses as prescribed by an ophthalmologist or optometrist; frames and their fitting and subsequent adjustments to maintain comfort and efficiency; or
Elective contact lenses that are in lieu of prescription spectacle lenses and frames; and
Medically necessary contact lenses and professional services when prescribed or received following cataract surgery or to correct extreme visual acuity problems that cannot be corrected with spectacle lenses.

Please Note: This vision benefit program is designed to cover vision needs rather than cosmetic extras. Cosmetic extras include: blended lenses, oversize lenses, photochromic lenses, tinted lenses except pink #1 or #2, progressive multifocal lenses, coating of a lens or lenses, laminating of a lens or lenses, frames that cost more than the plan allowance, cosmetic lenses, optional cosmetic processes, and UV (ultraviolet) protected lenses.

If you or your covered dependent select a cosmetic extra, the plan will pay the medically necessary costs of the allowed lenses and you or your covered dependent will be responsible for the additional cost of the cosmetic extra.

Definitions

Comprehensive eye examinationmeans an examination by an ophthalmologist or optometrist to determine the health of the eye, including glaucoma tests and refractive examinations to measure the eye for corrective lenses.

Medically necessarymeans a comprehensive eye examination or prescription eyewear that is necessary and appropriate to determine the health of the eye or correct visual acuity. This determination will be made by us based on our consultation with an appropriate licensed ophthalmologist or optometrist. A comprehensive eye examination or prescription eyewear will not be considered medically necessary if: (A) it is provided only as a convenience to the covered person or provider;
(B) it is not appropriate for the covered person’s diagnosis or symptoms; or (C) it exceeds (in scope, duration, or intensity) that level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment to the covered person.

Vision benefit preferred provideris an ophthalmologist or optometrist who has contracted with the vision benefit network and is licensed and otherwise qualified to practice vision care and/or provide vision care materials.
Vision benefit non-preferred provideris any ophthalmologist, optometrist, optician, or other licensed and qualified vision care provider who has not contracted with the vision benefit network to provide vision care services and/or vision care materials.

List of CO Counties with No Participating UHC Vision Providers Archuleta, Baca, Bent, Cheyenne, Clear Creek, Conejos, Costilla, Crowley, Custer, Dolores, Gilpin, Grand, Gunnison, Hinsdale, Huerfano, Jackson, Kiowa, Kit Carson, Lake, Mineral, Moffat, Ouray, Park, Pitkin, Rio Grande, Routt, Saguache, San Juan, San Miguel, Sedgwick, Summit, Teller, Washington, and Yuma.

How the Vision Program Works

Copayment, deductible amounts and coinsurance may differ when services are rendered and billed directly by a:

A. Vision benefit preferred provider; or

B. Vision benefit non-preferred provider.

We have a contract with a vision benefit network. Vision benefit preferred providers agree to discount their service fees. You or your covered dependents pay any applicable copayments, deductible amount or coinsurance. Vision benefit preferred providers then agree to accept our benefit payment as payment in full for covered expenses.

We do not have a contract with vision benefit non-preferred providers. You or your covered dependent must pay any applicable copayments, deductible amount or coinsurance. After satisfaction of applicable copayments, deductible amount or coinsurance benefits are limited up to the applicable allowance amount.

When the amount of actual charges exceeds the allowance amount, the vision benefit non-network providers may bill you or your covered dependent for the excess amount.

Exclusions and Limitations:

No benefits are payable for the following vision expenses:

Orthoptics or vision therapy training and any associated supplemental testing;
Plano lenses (a lens with no prescription on it);
Replacement of lenses and frames furnished under this plan which are lost or broken except at the normal intervals when services are otherwise available;
Medical or surgical treatment of the eyes;
Any eye examination or any corrective eyewear, required by an employer as a condition of employment;
Corrective vision treatment of an experimental or investigative nature;
Corrective surgical procedures such as, but not limited to, Radial Keratotomy (RK) and Photo-refractive Keratectomy (PRK);
Elective contact lenses if prescription spectacle lenses and frames are received in any 12 month period;
Prescription spectacle lenses and frames if elective contact lenses are received in any 24 month period;
Eyewear except prescription eyewear;
Charges that exceed the allowance amount; and
Services or treatments that are already excluded in the General Exclusions and Limitations section of the certificate or policy.

Discounts on Laser Eye Surgery

An alliance with the Laser Vision Network of America allows our policyholders access to substantial discounts on laser eye surgery procedures from highly reputable providers throughout the U.S. Laser eye surgery is a noncovered expense.

Covered Expenses

Subject to all policy provisions, the following expenses are covered. To be considered for reimbursement, expenses must qualify as covered expenses and are subject to eligible expense limits unless you use a network provider. Please review the detailed plan information on pages 15-18 and the state variations on pages 19-21.

All Plans

Preventive Care Expense Benefits

Benefits include coverage for the following (depending on the covered (B) For immunizations - Those of the Advisory Committee on person’s age): Immunization Practices of the Centers for Disease Control and

Routine vaccines for diseases ^Prevention;
_{Flu and pneumonia shots}(C) For preventive care and screenings for infants, children and adolescents - Those of the Health Resources and Services

Routine physical exams, including well-baby and well-child doctor _{Administration; an_d}visits
(D) For preventive care and screenings for women - Those of the

Screening for high blood pressure, cholesterol, diabetes
Health Resources and Services Administration that are not

Screening for detection of breast and other cancers through ^{included in section (A)^.}mammogram, pap smear, prostate cancer screening and colorectal As new recommendations and guidelines are issued, those services will screening be considered covered expenses when required by the United States

_{Preventive Care benefits are exempt from your plan deductible,}Secretary of Health and Human Services, but not earlier than one year coinsurance and copayments when services are provided by a network ^{after the recommendation or guideline is issued.}provider. Preventive health services must be appropriate for the covered person and follow these recommendations and guidelines:

(A) In general - Those of the U.S. Preventive Services Task Force that have an A or B rating;

Copay Select^SM, Plan 100®, Plan 80^SM, HSA 100®, and HSA 70^SM

Medical Expense Benefits

Daily hospital* room and board and nursing services at the most • Charges for operating, treatment, or recovery room for surgery.
^{common semiprivate rate^.}• Dental expenses due to an injury which damages natural teeth if

Charges for intensive care unit. expenses are incurred within six months.
Hospital emergency room treatment of an injury or illness (subject • Surgical treatment of TMJ disorders (see General Limitations on to an additional $100 copay each time the emergency room is page 17).

^{used for an illness not resulting in confinement — does not apply}• Cost and administration of anesthetic, oxygen, and other gases.

to HSA Plans).

• Radiation therapy or chemotherapy.

Services and supplies, including drugs and medicines, which are routinely provided by the hospital to persons for use while they • Prescription drugs.
^{are inpatients^.}• Hemodialysis, processing, and administration of blood and

Professional fees of doctors and surgeons (but not for standby components.
^{availability)^.}• Artificial eyes, larynx, breast prosthesis, or basic artificial limbs

Dressings, sutures, casts, or other necessary medical supplies. (but not replacements).
Professional fees for outpatient services of licensed physical • Surgery in a doctor’s office or at an outpatient surgical facility, therapists. including services and supplies.
Diagnostic testing using radiologic, ultrasonographic, or • Occupational therapy following a covered treatment for traumatic laboratory services in or out of the hospital. hand injuries.
Local ground ambulance service to the nearest hospital for necessary emergency care. Air ambulance, within U.S., if For information on additional plan provisions, including Transplant requested by police or medical authorities at the site of Expense Benefit, Notification Requirements, Preexisting Conditions, emergency. Limited Exclusion for AIDS or HIV-related Disease, General Exclusions,

General Limitations, and Other Plan Provisions, read pages 15-18.

*Hospital does not include a nursing home or convalescent home or an extended care facility. 13

Covered Expenses (continued)

Saver 80^SM

Inpatient Expense Benefits

Daily hospital* room and board and nursing services at the most common semiprivate rate.
Charges for intensive care unit.
Drugs, medicines, dressings, sutures, casts, or other necessary medical supplies.
Artificial limbs, eyes, larynx, or breast prosthesis (but not replacements).
Professional fees of doctors and surgeons (but not for standby availability).
Hemodialysis, processing, and administration of blood or components.
Charges for an operating, treatment, or recovery room for surgery.
Cost and administration of an anesthetic, oxygen, or other gases.
Radiation therapy or chemotherapy and diagnostic tests using radiologic, ultrasonographic, or laboratory services.
Local ground ambulance service to the nearest hospital for necessary emergency care. Air ambulance, within U.S., if requested by police or medical authorities at the site of the emergency.

Outpatient Expense Benefits

Charges for outpatient surgery in an outpatient surgical facility, including the fee from the primary surgeon, the assistant surgeon, and/or administration of anesthetic (surgery performed in the doctor’s office is not covered).
Hemodialysis, radiation, and chemotherapy.
Prescription drugs to protect against organ rejection in transplant cases.
Hospital emergency room treatment of an injury or illness (subject to an additional $500 copay each time the emergency room is used not resulting in confinement).
CAT scans and MRI testing.
Diagnostic testing related to, and performed within 14 days prior to, surgery or inpatient confinement.

Important note about Saver 80^SM:

Premiums for Saver 80^SMare significantly less because coverage is not provided for most outpatient services. Outpatient expenses not specifically listed in the policy are not covered. Please review the Saver ^SMInpatient and Outpatient Expense Benefits.

Some expenses not covered under Saver 80^SMinclude:

Outpatient doctor office visit fees (except preventive), diagnostic testing, prescription drugs, and other outpatient medical services not specifically listed under the Inpatient, Outpatient, or Transplant Expense Benefits;
Outpatient professional fees of licensed physical therapists, durable medical equipment, and medical supplies, except those covered under the Home Health Care Expense Benefits;
Expenses incurred for Spine and back disorders.
Outpatient surgery expenses for a surgery performed in a doctor’s

office. For information on additional plan provisions, including Transplant Expense Benefit, Notification Requirements, Preexisting Conditions, Limited Exclusion for AIDS or HIV-related Disease, General Exclusions, General Limitations, and Other Plan Provisions, read pages 15-18.

*Hospital does not include a nursing home or convalescent home or an extended care facility.

Provisions That Apply to All Plans

This brochure is only a general outline of the coverage provisions. It is not an insurance contract, nor part of the insurance policy or certificate. You’ll find complete coverage details in the policy and certificates. In most cases, coverage will be determined by the master policy issued in Illinois and subject to Illinois law.

The following conditions are eligible for bone marrow transplant

Deductible Credit

It can help you reduce your future out-of-pocket expenses. If you ^{coverage^:}don’t meet your per-person calendar-year network deductible, the Allogenic bone marrow transplants (BMT) for treatment of: Hodgkin’s Deductible Credit applies to next year’s network deductible. lymphoma or non-Hodgkin’s lymphoma, severe aplastic anemia, acute

lymphocytic and nonlymphocytic leukemia, chronic myelogenous

leukemia, severe combined immunodeficiency, Stage III or IV ^{Each qualified covered person*}neuroblastoma, myelodysplastic syndrome, Wiskott-Aldrich syndrome, ^{not meeting the plan’s chosen Receives this credit for the}thalassemia major, multiple myeloma, Fanconi’s anemia, malignant ^{network deductible** for: next calendar year:}histiocytic disorders, and juvenile myelomonocytic leukemia.

1 year 20% of chosen network deductible _{2 consecutive years 40% of chosen network deductible}Autologous bone marrow transplants (ABMT) for treatment of: _{3 or more consecutive years 50% of chosen network deductible}Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, acute lymphocytic and nonlymphocyctic leukemia, multiple myeloma, testicular cancer,

Stage III or IV neuroblastoma, pediatric Ewing’s sarcoma and related ^{With a Health Savings Account plan (HSA 100® and HSA 70}^SM^{), the}primitive neuroectodermal tumors, Wilms’ tumor, rhabdomyosarcoma, deductible credit will never reduce the deductible below the minimum _{medulloblastoma, astrocytoma, and glioma.}

required by law to maintain tax-qualified status of the insurance plan. The minimum for 2011 is $1,200 for singles and $2,400 for families. With the optional Continuity rider, deductible credit is only received Notification Requirements

when a covered person is “active.” You must notify us by phone on or before the day a covered person:

• Begins the fourth day of an inpatient hospitalization; or

^{Transplant Expense Benefi^t}• Is evaluated for an organ or tissue transplant.

The following types of transplants are eligible for coverage under

_{the Medical Benefits provision_:}Failure to comply with Notification Requirements will result in a 20% reduction in benefits, to a maximum of $1,000.

Cornea transplants, artery or vein grafts, heart valve grafts, and _{prosthetic tissue replacement, including joint replacements and}If it is impossible for you to notify us due to emergency inpatient hospital _{implantable prosthetic lenses, in connection with cataracts.}admission, you must contact us as soon as reasonably possible.

_{Transplants eligible for coverage under the Transplant Expense}Our receipt of notification does not guarantee either payment of _{Benefit are:}benefits or the amount of benefits. Eligibility for and payment of benefits are subject to all terms and conditions of the policy. You may

Heart, lung, heart and lung, kidney, liver, and bone marrow transplants. _{contact Golden Rule for further review if coverage for a health-care}

Golden Rule has arranged for certain hospitals around the country service is denied, reduced, or terminated. (referred to as our “Centers of Excellence”) to perform specified transplant services. If you use one of our “Centers of Excellence,” the specified transplant will be considered the same as any other illness Rehabilitation and Extended Care and will include a transportation and lodging incentive (for a family _{Facility (ECF) Benefit}member) of up to $5,000. Otherwise, the acquisition cost for the organ _{or bone marrow will not be covered, and covered expenses related to}Rehabilitation and Extended Care (ECF) expenses are covered if they begin _{the transplant will be limited to $100,000 and one transplant in a}within 14 days of a 3-day or more hospital stay, for the same illness or injury. _{12-month period.}There is a combined calendar-year maximum of 30 days for both

Rehabilitation and ECF expenses.

To qualify as a covered expense under the Transplant Expense Benefit, the covered person must be a good candidate, and the transplant must not be experimental or investigational. In considering these issues, we _{Home Health Care Expense Benefit}consult doctors with expertise in the type of transplant proposed.

To qualify for benefits, home health care must be provided through a licensed home health-care agency.

Subject to deductible and coinsurance, covered expenses for home health aide services are limited to seven visits per week and a lifetime maximum of 365 visits. Registered nurse services are limited to a lifetime maximum of 1,000 hours. Intermittent private-duty RN services (up to 4 hours each) limited to $75 per visit, and deemed to be 2 hours applied to the lifetime maximum.

*Must be a covered person and in active status for six consecutive months. **For family HSA plans, when combined per family deductible is not met. 15

Provisions That Apply to All Plans (continued)

Hospice Care

To qualify for benefits, a Hospice Care program for a terminally ill covered person must be licensed by the state in which it operates. Benefits for inpatient care in a hospice are subject to deductible and coinsurance and limited to 180 days in a covered person’s lifetime. Covered expenses for room and board are limited to the most common semiprivate room rate of the hospital or nursing home with which the hospice is associated. Bereavement counseling maximum of $250.

Preexisting Conditions

This does not apply to covered persons under age 19. Preexisting conditions will not be covered during the first 12 months after an individual becomes a covered person. This exclusion will not apply to conditions that are: (a) fully disclosed to Golden Rule in the

individual’s application; and (b) not excluded or limited by our underwriters. A preexisting condition is an injury or illness: (a) for which a covered

person received medical advice or treatment within 24 months prior to the applicable effective date for coverage of the illness or injury; or (b) which manifested symptoms which would cause an ordinarily prudent person to seek diagnosis or treatment within 12 months prior to the applicable effective date for coverage of the illness or injury.

Limited Exclusion for AIDS or HIV-Related Disease

AIDS or HIV-related disease are treated the same as any other illness unless the onset of AIDS or HIV-related disease is: (a) diagnosed before the coverage has been in force for one year; or (b) first manifested before the coverage has been in force for one year. If diagnosed or first manifested before coverage has been in force for one year, AIDS or HIV-related disease claims will never be covered. Details of this limited exclusion are set forth in the policy and certificates.

General Exclusions

No benefits are payable for expenses which:

Are due to pregnancy (except for complications of pregnancy) or routine newborn care.
Are for routine or preventive care unless provided for in the policy.
Are incurred while confined primarily for custodial, rehabilitative, or educational care or nursing services.
Result from or in the course of employment for wage or profit, if the covered person is insured, or is required to be insured, by workers’ compensation insurance pursuant to applicable state or federal law. If you enter into a settlement that waives a covered person’s right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply.

Are in relation to, or incurred in conjunction with, experimental or investigational treatment.
Are for unproven services.
Are for dental expenses or oral surgery, eyeglasses, contacts, eye refraction, hearing aids, or any examination or fitting related to these.
Are for modification of the physical body, including breast reduction or augmentation.
Are incurred for cosmetic or aesthetic reasons, such as weight modification or surgical treatment of obesity.
Would not have been charged in the absence of insurance.
Are for eye surgery to correct nearsightedness, farsightedness, or astigmatism.
Result from war, intentionally self-inflicted bodily harm (whether sane or insane), or participation in a felony (whether or not charged).
Are for treatment of temporomandibular joint disorders, except as may be provided for under covered expenses.
Are incurred for animal-to-human organ transplants, artificial or mechanical organs, procurement or transportation of the organ or tissue, or the cost of keeping a donor alive.
Are for diagnosis or treatment of mental disorders and substance abuse — inpatient and outpatient (unless optional coverage is selected).
Are incurred for marriage, family, or child counseling.
Are for recreational or vocational therapy or rehabilitation.
Are incurred for services performed by an immediate family member.
Are not specifically provided for in the policy.
Are incurred while your certificate is not in force.
Are for any drug treatment or procedure that promotes conception.
Are for any procedure that prevents conception or childbirth.
Result from intoxication, as defined by applicable state law in the state where the illness occurred, or under the influence of illegal narcotics or controlled substances unless administered or prescribed by a doctor.
Are for or related to surrogate parenting.
Are for or related to treatment of hyperhidrosis (excessive sweating).
Are for fetal reduction surgery.

Provisions That Apply to All Plans (continued)

• Are for alternative treatments, except as specifically identified as _{Continued Eligibility Requirements}

covered expenses under the policy/certificate, including: A covered person’s eligibility will cease on the earlier of the date a

acupressure, acupuncture, aromatherapy, hypnotism, massage _{covered person_:}therapy, rolfing, and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National • Ceases to be a dependent; or

^{Institutes of Health.}• Becomes insured under an individual plan providing medical or Benefits will not be paid for services or supplies that are not medically hospital, surgical, or medical services or benefits. (This does not necessary to the diagnosis or treatment of an illness or injury, as apply to stand-alone cancer, ICU, or accident-only policies.) defined in the policy.

Dependents ^{General Limitations}For purposes of this coverage, eligible dependents are your lawful

Expenses incurred by a covered person for treatment of tonsils, spouse and eligible children. Eligible children must be under 26 years adenoids, middle ear disorders, hemorrhoids, hernia, or any of age at time of application. disorders of the reproductive organs (except cancer) are not covered during the covered person’s first six months of coverage under the policy. This provision will not apply if treatment is Effective Date
provided on an “emergency” basis. Unless we agree to an earlier date, the effective date will be the later

_{Covered expenses will not include more than what was}of: (a) the requested effective date, or (b) 30 days after the application
_{determined to be the eligible expense for a service or supply.}is received by Golden Rule. Both injuries and illnesses will have the same effective date.

Transplants eligible for coverage under the Transplant Expense _{Plans issued with an effective date less than 30 days after the}
^{Benefit are limited to two transplants in a 10-year period.}application received date will include a 14-day wait for illness

Charges for an assistant surgeon are limited to 20% of the coverage. primary surgeon’s covered fee.
Covered expenses for surgical treatment of TMJ, excluding tooth Eligible Expense extractions, are limited to $10,000 per covered person. Eligible expense means a covered expense as determined below:

Covered outpatient expenses relating to diagnosis or treatment of _{• For Network Providers (excluding Transplant Benefits): th_e}any spine or back disorders are limited to 15 visits per person, per _{contracted fee with that provider_.}calendar year. CAT scans and MRI tests are not subject to this
_{limitation_.}• For Non-Network Providers

Covered expenses are limited to no more than a 34-day supply for ^{-When a covered expense is received as a result of an}_{any one outpatient prescription drug order or refill.}emergency or as otherwise approved by us, the eligible expense
is the lesser of the billed charge or the amount negotiated with

When using an in-network physician or facility, non-covered _{the provider.}

expenses may not be eligible for a network provider discount. -Except as provided above (excluding Transplant Benefits), the fee charged by the provider for the services; or the fee that has

_{Conditions Prior to Legal Actio_n}been negotiated with the provider; or the fee established by us

To help resolve disputes before litigation, the policy requires that you ^{by comparing rates from one or more regional or national}provide us with written notice of intent to sue as a condition prior to ^{databases or schedules for the same or similar services from a}legal action. This notice must identify the source of the disagreement, ^{geographical area determined by us; or 110% of the fee Medicare}including all relevant facts and information supporting your position. ^{allows for the same or similar services provided in the same}Unless prohibited by law, any action for extra-contractual or punitive ^{geographical area; or a fee schedule that we develop.}damages is waived if the contract claims at issue are paid or the disagreement is resolved or corrected within 30 days of the written notice.

Provisions That Apply to All Plans (continued)

Emergency Underwriting

A medical condition manifesting itself by acute symptoms of sufficient Coverage will not be issued as a supplement to other health plans that you severity (including severe pain) such that a prudent layperson, who may have at the time of application. Plans are subject to health possesses an average knowledge of health and medicine, could reasonably underwriting. If you provide incorrect or incomplete information on your expect the absence of immediate medical attention to result in: insurance application your coverage may be voided or claims denied.

-Placing the health of the covered person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in MISSTATEMENT OF TOBACCO USE:

serious jeopardy; The answer to the question concerning tobacco use on the application is -Serious impairment to bodily functions; or material (legally important) to correct underwriting. If a covered person _{-Serious dysfunction of any bodily organ or part.}misstates their tobacco use when applying for coverage, we have the right to cancel coverage, subject to the Recissions clause under Uniform

Provisions. Coordination of Benefits (including Medicare)

If, after coverage is issued, a covered person becomes insured under a group plan or Medicare, benefits will be determined under the Coordination of Benefits (COB) clause. COB allows two or more plans to work together so that the total amount of all benefits will never be more than 100% of covered expenses. COB also takes into account medical coverage under auto insurance contracts.

Premium

We may adjust the premium rates from time to time. Premium rates are set by class, and you will not be singled out for a premium change regardless of your health. The policy plan, age and sex of covered persons, type and level of benefits, time the certificate has been in force, and your place of residence are factors that may be used in setting rate classes. Premiums will increase the longer you are insured.

Renewability

You may renew coverage by paying the premium as it comes due. We may decline renewal only:

For failure to pay premium; or
If we decline to renew all certificates just like yours issued to everyone in the state where you are then living.

Termination of a Covered Person

A covered person’s coverage will terminate on the date that person no longer meets the eligibility requirements or if the covered person commits fraud or intentional misrepresentation.

State Variations

Please review the information provided below, which summarizes the major variations in coverage by state from these described in this brochure.

Alabama District of Columbia Iowa

There are no state variations. • Portability plans (guarantee issue without • The spine and back limitation does not apply. Alaska preexisting conditions exclusions) are available • The preexisting conditions 12-month waiting
Copay Select^SMis not available in this state. to eligible applicants. Review the application period may be reduced for persons covered by
Formulas necessary for the treatment of for insurance for details. qualifying prior coverage. phenylketonuria are covered the same as any • The exclusion of expenses incurred as a result • The limited exclusion for AIDS does not apply. other illness. of the covered person being intoxicated or Maryland
Reasonable and customary charges apply in under the influence of narcotics does not • The limited exclusion for AIDS does not apply. place of eligible expense limits. ^apply.• A “preexisting condition” means an injury or

• The limited exclusion for AIDs does not apply. illness for which medical advice, diagnosis,

Arizona

The references to 24 and 12 months in the • The policy provides coverage for mental disorders care or treatment was recommended or _{definition of a preexisting condition are}and substance abuse as required by applicable received within the 12 months immediately _{changed to 6 months.}state law. Specific details are included in the preceding the applicable effective date the
The limited exclusion for AIDS does not apply. ^{certificate at issue.}covered person became insured under the
Portability plans (you may be eligible for a Florida policy/certificate.

portability plan if statements 1-6 all apply to • A child will continue to be eligible after age 26 • Waiver of preexisting conditions limitation: you). if the child is unmarried and under age 30. The preexisting condition limitation shall not

I do not have any health insurance • Portability plans (guarantee issue without apply to a newborn child covered under coverage. preexisting conditions exclusions) are available creditable coverage within 30 days of birth

_{I have been insured for the last 18 months}to eligible applicants. Review the application providing there has been no subsequent lapse of coverage of 63 days or greater.
or more with no lapse in coverage of more ^{for insurance for details^.}_{than 63 days.}Illinois • Covered persons with prior health coverage

My most recent coverage was under a • A child will continue to be eligible after age 26 (creditable) may have the preexisting group health plan, a government plan, or a if the child: is unmarried and under age 30; is condition waiting period of this plan reduced. church plan. an Illinois resident; served in active or reserve The creditable coverage must be in force
My most recent coverage was not branches of the U.S. Armed Forces, and within 63 days prior to the effective date of

_{terminated due to nonpayment of}received other than a dishonorable discharge. the new health plan. The 12-month _{premiums, fraud, or intentional}_Indianapreexisting condition waiting period will be

misrepresentations. • The limited exclusion for AIDS does not apply. ^{reduced by the same number of months that}

_{I am not eligible for any coverage under a}_{• The preexisting conditions reference to}prior creditable coverage was continuously in _{group health plan, Medicare, or Medicaid.}_{treatment within 24 months prior to the}force. No lapse in prior coverage can be greater
I accepted and exhausted any group applicable effective date is changed to ^{than 63 days^.}continuation of coverage (including COBRA) 12 months. This 12-month waiting period may ^Michigaⁿ

that was offered me. _{be reduced for persons previously covered by}• The reference to 24 months in the definition of _{If you are eligible and want to apply, talk to}_{small employer group coverage.}a preexisting condition is changed to 6 months. _{your broker or contact us.}• Provider Network Continuity of

_{Arkansa_s}Treatment: If your provider leaves the

The exclusion for TMJ disorders does not apply. ^{network while you are receiving treatment for}
_{Optional Arkansas Hearing Aids Rider (not}an “injury or illness,” your first subsequent

visit will be covered as if your provider were ^{available with HSA plans.) removes the}still in the network, and we will notify you

general exclusion for hearing aids or any _{that the provider is no longer a networ_k}examination or fitting related to hearing aids.

provider so that you may choose a new

Covered expenses for hearing aids shall be _{network provider_.}exempt from any deductible amount,

• Grievance Procedure Information Phone

copayment, and coinsurance, with a

_{maximum three-year benefit per covere_d}Number: (800) 657-8205. Upon request, we

_{person of $1,400 per ear_.}will provide you with the telephone number for the Michigan Department of Consumer and Industry Services.

• Expenses incurred for diagnosis and treatment of pain are covered expenses the same as any other illness or injury.

State Variations (continued)

Mississippi • The limited exclusion for AIDS does not apply. Tennessee

• The references to 24 and 12 months in the • Nonemergency care provided out-of-network • Portability plans (guarantee issue without definition of a preexisting condition are will be: reduced by 25% of the in-network preexisting conditions exclusions) are available changed to 6 months. benefit paid rather than 25% of the covered to eligible applicants. Review the application

Quality Assurance Program Summary expense. (Still subject to eligible expense for insurance for details.

If you select a UnitedHealthcare network, limits; and an additional deductible amount Texas UnitedHealthcare will administer its Quality _{equal to the per person, calendar-year}Improvement Program to improve your health-care _deductible.)^{• Treatment of TMJ disorders is covered the}

experience. Components of the program include: ^{same as any other illness.}

^{^•}^{Send medical claims to:}• Formulas necessary for the treatment of

Providing Clinical Profile reports on key clinical Golden Rule Insurance Company _{phenylketonuria are covered the same as any}measures to your physician or other health-7440 Woodland Dr. _{other illness.}
^{care providers so he or she can deliver better}^{Indianapolis, IN 46278-1720}• If a designated “Center of Excellence” is not ^{quality medical care to you and your family;}Ohio used for a listed transplant, covered expenses

^{Public accountability through the}• The policy provides coverage for mental disorders will be reduced by 25%.
^{accreditation process and reporting to}^{and substance abuse as required by applicable}• A preexisting condition is an injury or illness ^{regulatory agencies;}state law. Specific details are included in the _{for which the covered person received medical}

Credentialing the physician and provider _{certificate at issue.}_{advice or treatment within the 12 months}
^{network; an^d}• The limited exclusion for AIDS does not apply. immediately preceding the effective date of

^{Reporting on, and improving performance on,}• State of Ohio Basic and Standard portability coverage. ^{clinical measures and measures of customer}plans (guarantee issue without preexisting • The limited exclusion for AIDS does not apply.
^{satisfaction.}conditions exclusions) are available to eligible _{• Eligible children will also include your}^Missouriapplicants. grandchild (under 26) who is your dependent

The limited exclusion for AIDS does not apply. • A child will continue to be eligible until age 28 for federal income tax purposes at time of

The exclusion for intentionally self-inflicted if unmarried. _application.
^{bodily harm does not apply if the intentionally}Oklahoma • The policy provides coverage for mental disorders ^{self-inflicted bodily harm resulted from a}• The spine and back limitation does not apply. and substance abuse as required by applicable ^{suicide attempt while insane.}• The preexisting conditions 12-month waiting state law. Specific details are included in the

The exclusion for suicide while insane in the _{period may be reduced for persons covered by}_{certificate at issue.}optional term life insurance and accidental _{qualifying prior coverage.}
• Medically necessary is a defined term and ^{death benefits does not apply.}Pennsylvania means that a service, medicine, or supply is

^{Notification requirements do not apply.}• Formulas or nutritional supplements for PKU necessary and appropriate for the treatment North Carolina and other metabolic disorders are covered and of an illness or injury as determined by Golden
Nonsurgical treatment of TMJ is provided, up are not subject to the deductible. Rule based on factors stated in the policy. to a lifetime maximum of $3,500. • The Coordination of Benefits provision also

South Carolina

The lifetime maximum for surgical treatment _{• The preexisting conditions reference to}takes into account personal injury protection of TMJ does not apply. _{treatment within 24 months prior to the}coverage, whether provided under a group or
Portability plans (guarantee issue without applicable effective date is changed to individual contract. preexisting conditions exclusions) are available 12 months. This 12-month waiting period may • Notification requirements do not apply. to eligible applicants. Review the application be reduced for persons covered by qualifying • The 14-day waiting period for the coverage of for insurance for details. prior coverage. illnesses does not apply.

Occupational injuries or illnesses are not • The limited exclusion for AIDS does not apply.
covered expenses if paid under the North Carolina Workers’ Compensation Act.

The preexisting conditions reference to treatment within 24 months prior to the applicable effective date is changed to 12 months. This 12-month waiting period may be reduced for persons covered by qualifying prior coverage.

State Variations (continued)

Virginia

Work-related injuries are covered unless benefits are payable by Workers’ Compensation.
Coordination of Benefits: If, after Golden Rule coverage is issued, a person becomes insured under (an)other group plan(s), benefits of the plans will be determined under the Coordination of Benefits (COB) clause. One plan will be determined to pay primary based on COB rules described in the policy/certificate. Some of the rules which usually result in a plan paying primary include: not having an appropriate COB clause; covering a person as other than a dependent; with regard to a dependent covered under both parents’ plans, the plan issued to the parent with the earlier date of birth or determined to be primary under the terms of a court decree or determinations based on custody; covering the person as an active employee/dependent of an active employee; or which plan has provided coverage longer.
Portability plans (guarantee issue without preexisting conditions exclusions) are available to eligible applicants. Review the application for insurance for details.

West Virginia

The exclusion of TMJ disorders does not apply.
Portability plans (guarantee issue without preexisting conditions exclusions) are available to eligible applicants. Review the application for insurance for details.

Wisconsin

The limited exclusion for AIDS does not apply.
The spine and back limitation does not apply.
The policy provides coverage for mental disorders and substance abuse as required by applicable state law. Specific details are included in the certificate at issue.
Limited coverage for nonsurgical treatment of TMJ disorders is provided.
Covered expenses for home health aide services are limited to 40 visits in a 12-month period.
Eligible children must be under 27 years of age at time of application. If age 26 at time of application, must also be unmarried.

• For Organ Procurement Purposes. We may use or disclose information • You have the right to a paper copy of this notice. You may ask for a

NOTICE OF INFORMATION PRACTICES

_{THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE}for procurement, banking or transplantation of organs, eyes or tissue. copy of this notice at any time. Even if you have agreed to receive this notice _{USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS}• To Correctional Institutions or Law Enforcement Officials if you are an electronically, you are still entitled to a paper copy of this notice upon _{INFORMATION. PLEASE REVIEW IT CAREFULLY.}inmate of a correctional institution or under the custody of a law enforcement request. In addition, you may obtain a copy of this notice at our websites,

official, but only if necessary (1) for the institution to provide you with health www.eAMS.comor www.goldenrule.com.^{We (including our affiliates listed at the end of this notice) are required by law}care; (2) to protect your health and safety or the health and safety of others; or • In New Mexico, you have the right to be considered a protected person. A to protect the privacy of your health information. We are also required to send _{(3) for the safety and security of the correctional institution.}

_{you this notice, which explains how we may use information about you an_d}“protected person” is a victim of domestic abuse who also is either: (1) an _{when we can give out or “disclose” that information to others. You also have}• To Business Associates that perform functions on our behalf or provide us applicant for insurance with us: (2) a person who is or may be covered by our _{rights regarding your health information that are described in this notice.}with services if the information is necessary for such functions or services. insurance; or (3) someone who has a claim for benefits under our insurance. _{The terms “information” or “health information” in this notice include any}Our business associates are required, under contract with us, to protect the Exercising Your Rights privacy of your information and are not allowed to use or disclose any • Contacting your Health Plan. If you have any questions about this notice information we maintain that reasonably can be used to identify you and that _{information other than as specified in our contract. As of 2/17/10, our}relates to your physical or mental health or condition, the provision of health _{business associates are also directly subject to federal privacy laws.}^{or want to exercise any of your rights, call the phone number on your ID card.}

care to you, or the payment for such health care. • Filing a Complaint. If you believe your privacy rights have been violated, We have the right to change our privacy practices. If we do, we will provide the ^{^•^{For Data Breach Notification Purposes.}We may use your contact}^{you may file a complaint with us at the following address:}information to provide legally-required notices of unauthorized acquisition, _{• Privacy Officer, Golden Rule Insurance Company, 7440 Woodland Drive,}

revised notice to you within 60 days by direct mail or post it on our websites _{access, or disclosure of your health information.}

Indianapolis, IN 47278-1719

^{^{located at}^{www.goldenrule.com}^or^www.eams.co^m}• Additional Restrictions on Use and Disclosure. Certain federal and state _{_•_{You may also notify the Secretary of the U.S. Department of Health}}

How We Use or Disclose Information

laws may require special privacy protections that restrict the use and disclosure _{_{and Human Services of your complaint.}We will not take any action}^{^{We must}use and disclose your health information to provide information:}of certain health information, including highly confidential information about _{against you for filing a complaint.}

To you or someone who has the legal right to act for you (your personal you. “Highly confidential information” may include confidential information representative); and under federal laws governing alcohol and drug abuse information and genetic ^{Fair Credit Reporting Act Notice}
To the Secretary of the Department of Health and Human Services, if information as well as state laws that often protect the following types of In some cases, we may ask a consumer-reporting agency to compile a

_{necessary, to make sure your privacy is protected.}information: HIV/AIDS; mental health; genetic tests; alcohol and drug abuse; consumer report, including potentially an investigative consumer report, about _{_{We have the right to}use and disclose health information to pay for your}sexually transmitted diseases and reproductive health information; and child or you. If we request an investigative consumer report, we will notify you promptly with the name and address of the agency that will furnish the report.

health care and operate our business. For example, we may use your health ^{adult abuse or neglect, including sexual assault.}

_{information_:}_{_{If none of the above reasons applies,}_{then we must get your written}}You may request in writing to be interviewed as part of the investigation. The

_{_{For Payment}of premiums due us and to process claims for health-care}_{_{authorization to use or disclose your health information.}If a use or}agency may retain a copy of the report. The agency may disclose it to other
_{services you receive.}disclosure of health information is prohibited or materially limited by other ^{persons as allowed by the federal Fair Credit Reporting Act.}applicable law, it is our intent to meet the requirements of the more stringent We may disclose information solely about our transactions or experiences with

^{^{For Treatment.}We may disclose health information to your physicians or}law. In some states, your authorization may also be required for disclosure of you to our affiliates. ^{hospitals to help them provide medical care to you.}your health information. Authorization is required for the use and disclosure of Medical Information Bureau
^{^{For Health-Care Operations.}}We may use or disclose health information psychotherapy notes or for marketing. In many states, your authorization may In conjunction with our membership in MIB, Inc., formerly known as Medical^{as necessary to operate and manage our business and to help manage your}be required in order for us to disclose your highly confidential health Information Bureau (MIB), we or our reinsurers may make a report of your personal^{health-care coverage. For example, we might conduct or arrange for medical}information. Once you give us authorization to release your health information, information to MIB. MIB is a nonprofit organization of life and health insurance

^{review, legal services, and auditing functions, including fraud and abuse}we cannot guarantee that the person to whom the information is provided will companies that operates an information exchange on behalf of its members.

^{detection or compliance programs. We may use your health information for}^{not disclose the information. You may take back or “revoke” your written}If you submit an application or claim for benefits to another MIB member

^{underwriting purposes; however, we are prohibited by law from using or}authorization, except if we have already acted based on your authorization. To _{company for life or health insurance coverage, the MIB, upon request, will}

^{disclosing genetic information for underwriting purposes.}^{revoke an authorization, contact the phone number listed on your ID card.}supply such company with information regarding you that it has in its file.

^•^{To Provide Information on Health Related Programs or Products}^{What Are Your Right^s}If you question the accuracy of information in the MIB’s file, you may seek a

such as alternative medical treatments and programs or about health-related _{The following are your rights with respect to your health information.}

_{products and services}. correction in accordance with the procedures set forth in the federal Fair Credit

_{_{To Plan Sponsors.}If your coverage is through an employer group health}• You have the right to ask to restrict uses or disclosures of your information Reporting Act. Contact MIB at: MIB, Inc., 50 Braintree Hill Ste. 400, Braintree, _{plan, we may share summary health information and enrollment and}for treatment, payment, or health-care operations and to ask to restrict MA 02184-8734, (866) 692-6901, www.mib.comor (TTY) (866) 346-3642. _{disenrollment information with the plan sponsor. In addition, we may share}disclosures to family members or to others who are involved in your health FINANCIAL INFORMATION PRIVACY NOTICE
other health information with the plan sponsor for plan administration if the ^{care or payment for your health care. We may also have policies on dependent}We (including our affiliates listed at the end of this notice) are committed to plan sponsor agrees to special restriction on its use and disclosure of the ^{^{access that may authorize certain restrictions.}^{Please note that while we}}maintaining the confidentiality of your personal financial information. For the information. ^{will try to honor your request and will permit requests consistent}purposes of this notice, “personal financial information” means information,

_{_{For Appointment Reminders.}We may use healthinformation to contact you}^{with its policies, we are not required to agree to any restriction.}other than health information, about an insured or an applicant for health-care

_{for appointment reminders with providers who provide medical care to you.}• You have the right to request that a provider not send health coverage that identifies the individual, is not generally publicly available and isinformation to us in certain circumstances if the health information collected from the individual or is obtained in connection with providing ^{^{We may}use or disclose your health information for the following purposes}concerns a health-care item or service for which you have paid the provider health-care coverage to the individual.

under limited circumstances: _{out of pocket in full.}

_{_{As Required by Law.}We may disclose information when required by law.}_{_•_{You have the right to ask to receive confidential communications}of}We collect personal financial information about you from the following sources:
• Information we receive from you on applications or other forms, such as

To Persons Involved With Your Care. We may use or disclose your health information in a different manner or at a different place (for example, by _{name, address, age and social security number; and}^{information to a person involved in your care, such as a family member,}^{sending information to a P.O. Box instead of your home address). We will}• Information about your transactions with us, our affiliates or others, such as
when you are incapacitated or in an emergency, or when permitted by law. accommodate reasonable requests where a disclosure of all or part of your _{premium payment history.}

For Public Health Activities such as reporting disease outbreaks. health information otherwise could endanger you. We will accept verbal

_{_{For Reporting Victims of Abuse, Neglect or Domestic Violence}to}requests to receive confidential communications, but request to modify or We do not disclose personal financial information about our insureds or former government authorities, including a social service or protective service ^{cancel a previous confidential communication request must be made in}^{insureds to any third party, except as required or permitted by law.}
_{agency_.}writing. Mail your request to the address listed below. We restrict access to personal financial information about you to employees,

_{_{For Health Oversight Activities}such as governmental audits and fraud}• You have the right to see and obtain a copy of health information that affiliates and service providers who are involved in administering your health-
_{and abuse investigations.}may be used to make decisions about you such as claims and case or medical care coverage or providing services to you. We maintain physical, electronic and management records. You also may receive a summary of this health procedural safeguards that comply with federal standards to guard your

^{^{For Judicial or Administrative Proceedings}such as in response to a}information. You must make a written request to inspect and copy your personal financial information. ^{court order, search warrant or subpoena.}health information. In certain limited circumstances, we may deny your Send written requests to access, correct, amend or delete
For Law Enforcement Purposes such as providing limited information to _{_{request to inspect and copy your health information.}_{information to:}}locate a missing person. • You have the right to ask to amend information we maintain about • Privacy Officer, Golden Rule Insurance Company, 7440 Woodland Drive,
^{^{To Avoid a Serious Threat to Health or Safety}by, for example,}you if you believe the health information about you is wrong or incomplete. Indianapolis, IN 47278-1719 ^{disclosing information to public health agencies.}We will notify you within 30 days if we deny your request and provide a We may disclose personal financial information to financial institutions which
^{^{For Specialized Government Functions}such as military and veteran}reason for our decision. If we deny your request, you may have a statement perform services for us. These services may include marketing our products or

activities, national security and intelligence activities, and the protective of your disagreement added to your health information. We will notify you in _{services or joint marketing of financial products or services.}

services for the President and others. writing of any amendments we make at your request. We will provide

_{_{For Workers Compensation}including disclosures required by state}_{updates to all parties that have received information from us within the past}The Notice of Information Practices , effective November 2010, is provided on
behalf of American Medical Security Life Insurance Company; Golden Rule^{workers compensation laws of job-related injuries.}^{two years (seven years for support organizations).}Insurance Company; PacifiCare Life and Health Insurance Company; PacifiCare

For Research Purposes such as research related to the prevention of • You have the right to receive an accounting of certain disclosures of Life Assurance Company, UnitedHealthcare Insurance Company, All Savers disease or disability, if the research study meets all privacy law requirements. your information made by us during the six years prior to your request. This Insurance Company; and All Savers Life Insurance Company of California.
_{_{To Provide Information Regarding Decedents.}We may disclose}accounting will not include disclosures of information: (i) made prior to April

To obtain an authorization to release your personal information to another information to a coroner or medical examiner to identify a deceased person, ^{14, 2003; (ii) for treatment, payment, and health-care operations purposes;}party, please go to appropriate website listed at the bottom of the page. determine a cause of death, or as authorized by law. We may also disclose ^{(iii) to you or pursuant to your authorization; and (iv) to correctiona^l}_{information to funeral directors as necessary to carry out their duties.}institutions or law enforcement officials; and (v) that federal law does not

require us to provide an accounting.

33638-X-1110 Products are either underwritten or administered by: American Medical Security Life Insurance Company, PacifiCare Life and Health Insurance Company, PacifiCare Life Assurance Company, UnitedHealthcare Insurance Company, www.eAMS.com, or All Savers Insurance Company, All Savers Life Insurance Company of California, and/or Golden Rule Insurance Company, www.goldenrule.com

CONDITIONS PRIOR TO COVERAGE (APPLICABLE WITH OR NOTICE TO APPLICANT REGARDING REPLACEMENT OF WITHOUT THE CONDITIONAL RECEIPT) ACCIDENT AND SICkNESS INSURANCE

Subject to the limitations shown below, insurance will become If you intend to lapse or otherwise terminate existing insurance effective if the following conditions are met: and replace it with a new plan from Golden Rule, you should be aware of and seriously consider certain factors that may affect

The application is completed in full and is _{your coverage under the new plan.}unconditionally accepted and approved by Golden Rule
_{Insurance Company (Golden Rule)_.}1. Full coverage will be provided under the new plan for

The person _{is a member of the Federation of American}preexisting health conditions: (a) that are fully disclosed _{Consumers and Travelers.}in your application; and (b) for which coverage is not
A_{ll medical examinations, if required, have been}excluded or limited by name or specific description. _{satisfactorily completed.}Other health conditions that you now have may not be
The persons proposed for _{insurance must be, on the}immediately or fully covered under the new plan. This could result in a claim for benefits being denied,

effective date for injuries, not less than a standard risk _{reduced, or delayed under the new plan, whereas a}acceptable to Golden Rule according to its regular _{similar claim might have been payable under your}underwriting rules and standards for the exact plan and _{present plan.}amount of insurance applied for.

2. If after due consideration, you still wish to terminate

The first full premium, according to the mode of _{your present insurance and replace it with new}premium payment chosen, has been paid on or prior to _{coverage, be certain to truthfully and completely}the effective date for injuries, and any check is honored _{answer all questions on the application concerning your}on first presentation for payment. _{medical and health history.}
The certificate is: (a) issued by Golden Rule exactly as applied for within 45 days from date of application; (b) ^{3. You may wish to secure the advice of your present}

_{delivered to the proposed insured; and (c) accepted by}insurer or its agent regarding the proposed replacement of or addition to your present plan. You should be ^{the proposed insured.}certain that you understand all the relevant factors

Definitions:

involved in replacing or adding to your present

1. “Satisfactorily completed” means that no adverse medical coverage. conditions or abnormal findings have been detected 4. Finally, we recommend that you not terminate your which would lead Golden Rule to decline issuing the present plan until you are certain that your application certificate or to issue a specially ridered certificate. for the new plan has been accepted by Golden Rule.

Limitation:

If, for any reason, Golden Rule declines to issue a certificate or A COPY OF YOUR AUTHORIzATION FOR ELECTRONIC FUNDS issues a certificate other than a standard certificate as applied _{TRANSFER (EFT)}for, Golden Rule shall incur no liability under this receipt except to return any premium amount received. Interest will not be ^{I (we) hereby authorize FACT or Golden Rule to}

_{paid on premium refunds_.}initiate debit entries to the account indicated below. I also authorize the named depository to debit the same to such account.

I agree this authorization will remain in effect until you actually receive written notification of its termination from me.

In Tennessee and Texas, drafts may only be scheduled on 1) the premium due date; or 2) up to 10 days after the due date.

A COPY OF YOUR AUTHORIzATION TO OBTAIN AND DISCLOSE HEALTH INFORMATION

I authorize Golden Rule Insurance Company’s Insurance Administration and Claims Departments to obtain health information that they need to underwrite or verify my application for insurance. Any health-care provider, consumer-reporting agency, MIB, Inc., formerly known as Medical Information Bureau (MIB), or insurance company having any information as to a diagnosis, the treatment, or prognosis of any physical or mental conditions about my family or me is authorized to give it to Golden Rule’s Insurance Administration and Claims Departments. This includes information related to substance use or abuse.

I understand any existing or future requests I have made or may make to restrict my protected health information do not and will not apply to this authorization, unless I revoke this authorization.

Golden Rule may release this information about my family or me to the MIB or any member company for the purposes described in Golden Rule’s Notice of Information Practices.

I (we) have received Golden Rule’s Notice of Information Practices. This authorization shall remain valid for 30 months from the date below.

I (we) understand the following:

A photocopy of this authorization is as valid as the original;
I (we) or my (our) authorized representative may obtain a copy of this authorization by writing to Golden Rule;
I (we) may request revocation of this authorization as described in Golden Rule’s Notice of Information Practices;
Golden Rule may condition enrollment in its health plan or eligibility for benefits on my (our) refusal to sign this authorization;
The information that is used or disclosed in accordance with this authorization may be redisclosed by the receiving entity and may no longer be protected by federal or state privacy laws regulating health insurers.

I have retained a copy of this authorization.

36228-0709

Failure to include all material medical information, correct information regarding the tobacco use of any applicant, or information concerning other health plans may cause the Company to deny a future claim and to void your coverage as though it has never been in force. After you have completed the application and before you sign it, reread it carefully. Be certain that all information has been properly recorded.

Why Choose Us for Health Insurance?

UnitedHealthcare

UnitedHealthOne

Experience and Expertise

Our Goal: Your Satisfaction

Which Plan Best Fits Your Needs?

A Variety of Plans to Choose From

The Network Advantage

Quality Care at Significant Savings

Our network gives you:

Convenient Doctor Office Copay Benefits

Prescription Drug* Card Benefits

Comprehensive Coverage for Inpatient and Outpatient Medical Expenses

Choice of Coverage

Lowest Premium Plan

Simple to Use

HSA Plans Offer Quality Coverage, Savings

Lower Premiums, Tax-Advantaged Savings, and an Attractive Interest Rate*

Bottom line — HSAs can help make health insurance more affordable.

About Your HSA

Account Information by Phone or Online

With an OptumHealth Bank HSA, your account information is available, day or night, through:

You can:

HSA Management by OptumHealth Bank

Who is responsible for my HSA?

Health Savings Accounts (HSA) — Summary of the Law

Optional Benefits

Benefits to Enhance Your Health Plan

$25 Office Visit Copay

Prescription Drug — $200 Deductible

Prescription Drug* — Copay Card

Term Life Benefit

Accidental Death Benefit

Mental Disorders and Substance Abuse

Benefits to Reduce Premium

4-Dr. Office Visit Copay

Prescription Drug — Discount Card Only

We’re here to help you.

UnitedHealthcare Vision Benefit Rider

Covered Expenses

Definitions

How the Vision Program Works

Exclusions and Limitations:

Discounts on Laser Eye Surgery

Covered Expenses

Preventive Care Expense Benefits

Medical Expense Benefits

Covered Expenses (continued)

Inpatient Expense Benefits

Outpatient Expense Benefits

Important note about Saver 80SM:

Provisions That Apply to All Plans

Deductible Credit

when a covered person is “active.” You must notify us by phone on or before the day a covered person:

Transplant Expense Benefit • Is evaluated for an organ or tissue transplant.

The following types of transplants are eligible for coverage under

Provisions That Apply to All Plans (continued)

Hospice Care

Preexisting Conditions

Limited Exclusion for AIDS or HIV-Related Disease

General Exclusions

Provisions That Apply to All Plans (continued)

Dependents General Limitations For purposes of this coverage, eligible dependents are your lawful

Conditions Prior to Legal Action been negotiated with the provider; or the fee established by us

Provisions That Apply to All Plans (continued)

Emergency Underwriting

Provisions. Coordination of Benefits (including Medicare)

Premium

Renewability

Termination of a Covered Person

State Variations

Alabama District of Columbia Iowa

Arizona

State Variations (continued)

State Variations (continued)

Virginia

West Virginia

Wisconsin

NOTICE OF INFORMATION PRACTICES

located at www.goldenrule.comor www.eams.com • Additional Restrictions on Use and Disclosure. Certain federal and state • You may also notify the Secretary of the U.S. Department of Health

**Prescription Drug* Card Benefits**

**Prescription Drug* — Copay Card**

Important note about Saver 80^SM:

^{Transplant Expense Benefi^t}• Is evaluated for an organ or tissue transplant.

Dependents ^{General Limitations}For purposes of this coverage, eligible dependents are your lawful

_{Conditions Prior to Legal Actio_n}been negotiated with the provider; or the fee established by us

^{^{located at}^{www.goldenrule.com}^or^www.eams.co^m}• Additional Restrictions on Use and Disclosure. Certain federal and state _{_•_{You may also notify the Secretary of the U.S. Department of Health}}