Limited Medical Indemnity Benefit Plans

Prepared for:

Form #USAPLMB-112310

SECTION 1 Overview of the Plans

SECTION 2 Limited Medical Indemnity Insurance Benefits Limited Medical Indemnity Insurance Benefits

Limitations and Exclusions

SECTION 3 Rx Benefits Insured Generic Rx

You are eligible to receive the following benefits by becoming a member of the American Advantage Association.

SECTION 1 Overview of the Plans

Limited Insurance Benefits 250 Plan 250 Plus Plan 500 Plan 1000 Plan

See page 7 for monthly premium rates. Maternity: Excluded | Pre-existing Conditions: 12/12 applied to Hospital, Surgery and related Anesthesia only

Physician’s Office Visit Benefit (30 day waiting period for sickness)

$80.00 per visit Max 3 visits per covered person per policy year

$90.00 per visit Max 3 visits per covered person per policy year

$90.00 per visit Max 5 visits per covered person per policy year

$90.00 per visit Max 5 visits per covered person per policy year

Wellness Physician’s Office Visit Benefit (30 day waiting period for sickness)

$90.00 per visit Max 1 visit per covered person per policy year

$90.00 per visit Max 1 visit per covered person per policy year

$90.00 per visit Max 1 visit per covered person per policy year

$90.00 per visit Max 1 visit per covered person per policy year

Emergency Room Benefit NA$50.00 per visit

Max 3 visit per covered person per policy year

$100.00 per visit Max 3 visit per covered person per policy year

$200.00 per visit Max 3 visit per covered person per policy year

Lab and X-ray Benefit NA$50.00 per visit

Max 3 tests per covered person per policy year

$100.00 per visit Max 3 tests per covered person per policy year

$150.00 per visit Max 3 tests per covered person per policy year

Hospital Admission Benefit

NA$500.00

1 payment per covered person per policy year

$1,000.00 1 payment per covered person per policy year

$1,000.00 1 payment per covered person per policy year

Hospital Confinement Daily Benefit

$250.00 Max 30 days per covered

person per policy year

$250.00 Max 30 days per covered

person per policy year

$500.00 Max 30 days per covered

person per policy year

$1,000.00 Max 30 days per covered

person per policy year

ICU Confinement Daily Benefit

$250.00 Max 15 days per covered

person per policy year

$250.00 Max 15 days per covered

person per policy year

$500.00 Max 15 days per covered

person per policy year

$1,000.00 Max 15 days per covered

person per policy year

Surgery Benefit (See pages 8-11 for surgical schedule)

NASee pages 8-11 for surgical schedule

Max 1 surgery per policy year

See pages 8-11 for surgical schedule

Max 1 surgery per policy year

See pages 8-11 for surgical schedule

Max 1 surgery per policy year

Anesthesia Benefit (See pages 8-11 for surgical schedule)

NASee pages 8-11 for surgical schedule Scheduled Benefit

See pages 8-11 for surgical schedule Scheduled Benefit

See pages 8-11 for surgical schedule Scheduled Benefit

Skilled Nursing Benefit NA NA NA $100.00 Max 10 visits

Ambulance NA NA $150.00 1 trip per policy year

$250.00 1 trip per policy year

IP Mental Health NA NA NA $100.00 Max 10 visits

OP Mental Health NA NA NA $100.00 Max 5 visits

Total Monthly Fees* 250 Plan 250 Plus Plan 500 Plan 1000 PlanIndividual $115.43 $155.82 $201.86 $272.21

Member / Spouse $171.37 $253.54 $349.45 $496.02

Member / Children $160.62 $233.74 $320.06 $451.98

Family $212.27 $324.31 $456.66 $658.93

The Limited Medical Indemnity Insurance Benefits listed below are underwritten by United States Fire Insurance Company, rated “A” by AM Best 2010.

These limited medical indemnity insurance benefits are underwritten by United States Fire Insurance Company, rated “A” by AM Best 2010, and are subject to the terms, definitions, conditions, exclusions and limitations of the group policy. Coverage is not provided for loss due to a pre-existing condition for 12 months from the Covered Person’s effective membership date. Coverage is not provided for members age 65 or over. Coverage will terminate at the end of the monthly billing cycle prior to turning age 65. 12 month Pre-existing Condition Limitations only apply to Hospital, ICU/CCU Surgery and Anesthesia. 30 day waiting period for sickness applies. Changes to coverage underwritten by United States Fire Insurance Company can only be made if the change is the result of a qualifying life event. A qualifying life event means marriage, divorce, the death of your spouse, or the birth or adoption of a child. If coverage is cancelled, persons may not re-enroll in coverage with United States Fire Insurance Company until six-months after their termination date. Benefits are not available in AK, AR, CT, KS, LA, ME, MD, MA, MT, NH, NJ, NY, NC, OR, RI, VT, & WA. MEMBERS CAN BE ENROLLED ONLY ONCE. DUPLICATE OR MULTIPLE MEMBERSHIPS, INCLUDING LIMITED MEDICAL INDEMNITY INSURANCE UNDERWRITTEN BY UNITED STATES FIRE INSURANCE COMPANY, IS NOT ALLOWED. THIS IS NOT BASIC HEALTH INSURANCE OR MAJOR MEDICAL COVERAGE AND IS NOT DESIGNED AS A SUBSTITUTE FOR BASIC HEALTH INSURANCE OR MAJOR MEDICAL COVERAGE.

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The non-insured benefits listed below are provided through the American Advantage Association.

Please see USAdvantagePlans Premier Plus booklet for more information on the association benefits.

*Total monthly fees may vary depending on your state of residence. Total monthly fees include association membership fee, insurance premium rates, and marketing and administration fees.

Association Membership Benefits 250 Plan 250 Plus Plan 500 Plan 1000 PlanMonthly Fee for Association Membership $49.95 $49.95 $49.95 $49.95

SHOPPING & ENTERTAINMENT BENEFITS

Discount Shopping and Entertainment 3 3 3 3Price Protection - Low Price Guarantee 3 3 3 3Extended Service Protection 3 3 3 3Online Comparison Shopping 3 3 3 3Warranty Registration 3 3 3 3TRAVEL BENEFITS

Full Service Travel Agency 3 3 3 3Travel Insurance Benefits 3 3 3 3HEALTH & WELLNESS

MyEWellness 3 3 3 3Discount Prescription Benefit 3 3 3 3VIP Health & Wellness 3 3 3 3AUTO BENEFITS

Roadside Assistance Services 3 3 3 3Auto Deductible Reimbursement Benefit 3 3 3 3HOME BENEFITS

Home Deductible Reimbursement 3 3 3 3Home Emergency Medical Expense Benefit 3 3 3 3Emergency Cash (Loss of Use Coverage) 3 3 3 3Rent or Mortgage Reimbursement 3 3 3 3Emergency Lodging 3 3 3 3Early Mortgage Pay-Off Plan 3 3 3 3LEGAL AND FINANCIAL BENEFITS

Family Legal Plan Benefits 3 3 3 3Tax Preparation & Advice Services 3 3 3 3Lost or Stolen Credit Card Assistance 3 3 3 3Identity Theft Restoration 3 3 3 3Identity Theft Insurance Benefits 3 3 3 3DISCOUNT MEDICAL BENEFITS

Consult a Doctor™ 3 3 3 3Aetna Discount Dental Services 3 3 3 3Coast to Coast Vision™ Discount 3 3 3 34-Tier Rx Benefit 3 3 3 3Lab and Imaging Services 3 3 3 3

Insured Generic RX 250 Plan 250 Plus Plan 500 Plan 1000 PlanSee page 10 for monthly premium rates.

Insured Generic Rx NA$250.00 monthly max

$10 Co-Pay / $50 Deductible

$250.00 monthly max $10 Co-Pay /

$50 Deductible

$250.00 monthly max $10 Co-Pay /

$50 Deductible

The Insured Generic Rx Benefit listed below is underwritten by Companion Life Insurance Company.

SECTION 2 Limited Medical Indemnity Insurance Benefits

Limited Medical Indemnity Insurance Benefits

Physician’s Office Visit Benefit Benefits are paid if a covered person visits a doctor’s office for medically necessary treatment or care of an injury or sickness covered under the policy. 30 day waiting period for sickness applies.

Wellness Physician’s Office Visit Benefit Benefits are paid if a covered person visits a doctor’s office for medically necessary wellness care covered under the policy. 30 day waiting period for sickness applies.

ER Benefit If a Covered Person requires Medically Necessary treatment by a Doctor in a Hospital emergency room for a Medical Emergency due to an Injury or Sickness, coverage is provided for treatment, services and supplies. Benefits are paid an indemnity amount depending on plan selected.

Lab and X-ray Benefit Benefits are paid for x-rays and laboratory testing including Pap test, colorectal screening, prostate cancer screening, mammography and bone density screening. Benefits are paid an indemnity amount depending on plan selected.

Hospital Admission Benefit Benefits are paid as a Hospital Admission Benefit as shown on the Certificate Schedule if any Covered Person incurs charges and is admitted to a Hospital as the result of injuries received in a Covered Accident or Covered Sickness while this coverage is in force. Pays an indemnity benefit depending on plan selected. This benefit is paid in addition to hospital, semi-private room, or intensive care or cardiac care unit. One admission benefit per covered person per policy year.

Hospital Confinement Daily Benefit Benefits are paid if a covered person is confined as an inpatient in a hospital because of a covered injury or sickness. Pays an indemnity benefit depending on plan selected.

ICU Confinement Daily Benefit Benefit is paid in addition to the Hospital Confinement Room benefit described above. For purposes of this benefit, “Period of Confinement” means one continuous ICU or CCU confinements, or two or more separate ICU or CCU confinements for the same or a related cause that are each separated by less than 72- hours. Pays an indemnity benefit depending on plan selected.

Surgery Benefit When surgery for a Covered Person is performed in an Outpatient Surgery Facility or while Confined to a Hospital, coverage is provided for the use of the operating and recovery room, including the Doctor’s charges for performing surgery. Benefits are also provided for medical services and supplies used in the performance of the surgery. Pays a scheduled surgical benefit per covered person per policy year with an Annual Maximum depending on plan selected. Please see pages 8-11 for surgical schedule.

Anesthesia Benefit Anesthesia Benefits are paid if a covered person undergoes medically necessary surgery at the direction of a doctor for a covered injury or sickness. Benefits are paid at 25% of the paid surgical benefit depending on plan selected. Benefit paid for anesthesia services for pre-operative screening and the administration of anesthesia during a surgical procedure whether performed as an inpatient or on an outpatient basis. Please see pages 8-11 for surgical schedule.

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Skilled Nursing Benefit (1000 plan only) Benefits are provided at $100 per day for a maximum of 10 days per covered person per policy year for room and board while a Covered Person is Confined as a registered bed-patient in the facility. Such Confinement must start within 14 days after the end of a covered Hospital Confinement of at least 3 continuous days and be ordered by a Doctor to recover from an Injury or Sickness that caused the prior Hospital Confinement.

Ambulance Benefits are paid when a Covered Person requires the services of a licensed professional ambulance company for transportation to or from a Hospital (or other facility licensed and qualified to provide proper care).

IP Mental Health (1000 plan only) Benefits are provided at $100 per day for a maximum of 10 days per covered person per policy year while a Covered Person is confined in a Hospital for the treatment and care of Mental or Nervous Disorder and the stay is prescribed by a Doctor as Medically Necessary for the Covered Person’s condition.

OP Mental Health (1000 plan only) Benefits are provided at $100 per day for a maximum of 5 days per covered person per policy year while a Covered Person is confined in a Rehabilitation Facility for the treatment and care of Mental or Nervous Disorder and the stay is prescribed by a Doctor as Medically Necessary for the Covered Person’s condition.

These limited medical indemnity insurance benefits are underwritten by United States Fire Insurance Company, rated “A” by AM Best 2010, and are subject to the terms, definitions, conditions, exclusions and limitations of the group policy. Coverage is not provided for loss due to a pre-existing condition for 12 months from the Covered Person’s effective membership date. Coverage is not provided for members age 65 or over. Coverage will terminate at the end of the monthly billing cycle prior to turning age 65. 12 month Pre-existing Condition Limitations only apply to Hospital, ICU/CCU Surgery and Anesthesia. 30 day waiting period for sickness applies. Changes to coverage underwritten by United States Fire Insurance Company can only be made if the change is the result of a qualifying life event. A qualifying life event means marriage, divorce, the death of your spouse, or the birth or adoption of a child. If coverage is cancelled, persons may not re-enroll in coverage with United States Fire Insurance Company until six-months after their termination date. Benefits are not available in AK, AR, CT, KS, LA, ME, MD, MA, MT, NH, NJ, NY, NC, OR, RI, VT, & WA. MEMBERS CAN BE ENROLLED ONLY ONCE. DUPLICATE OR MULTIPLE MEMBERSHIPS, INCLUDING LIMITED MEDICAL INDEMNITY INSURANCE UNDERWRITTEN BY UNITED STATES FIRE INSURANCE COMPANY, IS NOT ALLOWED. THIS IS NOT BASIC HEALTH INSURANCE OR MAJOR MEDICAL COVERAGE AND IS NOT DESIGNED AS A SUBSTITUTE FOR BASIC HEALTH INSURANCE OR MAJOR MEDICAL COVERAGE.

The insurance premium is the premium rate charged for the insurance coverage underwritten by United States Fire Insurance Company and offered through your membership in the American Advantage Association. The insurance premium rates for the following memberships are:

Plan: 250 Plan 250 Plus Plan 500 Plan 1,000 Plan

Individual $48.55 $72.50 $115.78 $181.91

Member/Spouse $101.14 $151.05 $241.20 $378.98

Member/Children $91.03 $135.94 $217.08 $341.08

Family $139.58 $208.45 $322.86 $522.99

Insurance premium rates may vary depending on your state of residence.

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1000 Plan 500 Plan 250 Plus Plan

SURGICAL PROCEDURE Surgical Reimbursement

Anesthesia Reimbursement

Surgical Reimbursement

Anesthesia Reimbursement

Surgical Reimbursement

Anesthesia Reimbursement

$10,000 25% $5,000 25% $2,500 25%

ABDOMEN

Appendectomy $2,500 $625 $1,250 $313 $625 $156

Removal of gallbladder $5,000 $1,250 $2,500 $625 $1,250 $313

Total Gastrectomy $8,500 $2,125 $4,250 $1,063 $2,125 $531

Gastrotomy $2,500 $625 $1,250 $313 $625 $156

Laparotomy, exploratory $2,500 $625 $1,250 $313 $625 $156

AMPUTATION

Amputation of upper arm $2,500 $625 $1,250 $313 $625 $156

Amputation of finger/thumb $2,500 $625 $1,250 $313 $625 $156

Amputation of leg at hip $5,000 $1,250 $2,500 $625 $1,250 $313

Amputation of lower leg $5,000 $1,250 $2,500 $625 $1,250 $313

Amputation of toe $2,500 $625 $1,250 $313 $625 $156

BREAST

Removal of breast $2,500 $625 $1,250 $313 $625 $156

Removal of breast lesion $2,500 $625 $1,250 $313 $625 $156

Breast reconstruction $5,000 $1,250 $2,500 $625 $1,250 $313

CHEST

Exploratory Thoracotomy $5,000 $1,250 $2,500 $625 $1,250 $313

Bronchoscopy (esophagoscopy)

$1,000 $250 $500 $125 $250 $63

Esophagectomy $8,500 $2,125 $4,250 $1,063 $2,125 $531

Lung, removal of or portion of (Lobectomy)

$5,000 $1,250 $2,500 $625 $1,250 $313

Valvotomy or commissurotomy, closed

$5,000 $1,250 $2,500 $625 $1,250 $313

Aortic, Mitral, or Tricuspid Val-vuloplasty, open with bypass

$8,500 $2,125 $4,250 $1,063 $2,125 $531

Tetralogy of Fallot with Bypass $8,500 $2,125 $4,250 $1,063 $2,125 $531

Double valve procedure replacement and or repair

$8,500 $2,125 $4,250 $1,063 $2,125 $531

DISLOCATION, REDUCTION OF

Treat ankle dislocation $1,000 $250 $500 $125 $250 $63

Treat clavicle dislocation $1,000 $250 $500 $125 $250 $63

Treat elbow dislocation $1,000 $250 $500 $125 $250 $63

Treat hip dislocation $1,000 $250 $500 $125 $250 $63

Reset dislocated jaw $2,500 $625 $1,250 $313 $625 $156

Treat shoulder dislocation $1,000 $250 $500 $125 $250 $63

Treat wrist dislocation $2,500 $625 $1,250 $313 $625 $156

Treat knee dislocation $5,000 $1,250 $2,500 $625 $1,250 $313

If a surgical procedure can not be located on this list, you need to contact the administrator to determine the appropriate dollar reimbursement.

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1000 Plan 500 Plan 250 Plus Plan

SURGICAL PROCEDURE Surgical Reimbursement

Anesthesia Reimbursement

Surgical Reimbursement

Anesthesia Reimbursement

Surgical Reimbursement

Anesthesia Reimbursement

$10,000 25% $5,000 25% $2,500 25%

ARTHROTOMY

Ankle arthroscopy/surgery $2,500 $625 $1,250 $313 $625 $156

Elbow arthroscopy/surgery $2,500 $625 $1,250 $313 $625 $156

Hip arthroscopy/surgery $2,500 $625 $1,250 $313 $625 $156

Knee arthroscopy/surgery $5,000 $1,250 $2,500 $625 $1,250 $313

Shoulder arthroscopy/surgery $5,000 $1,250 $2,500 $625 $1,250 $313

EAR, NOSE, THROAT

Fenestration $5,000 $1,250 $2,500 $625 $1,250 $313

Mastoidectomy-single $5,000 $1,250 $2,500 $625 $1,250 $313

Extensive mastoid surgery $5,000 $1,250 $2,500 $625 $1,250 $313

Adnoidectomy (independent procedure)

$1,000 $250 $500 $125 $250 $63

Sinusotomy, frontal, external simple (Trephine)

$2,500 $625 $1,250 $313 $625 $156

Submucous resection of na-sal septum (septectomy)

$2,500 $625 $1,250 $313 $625 $156

Laryngectomy, without neck dissection

$2,500 $625 $1,250 $313 $625 $156

Tonsillectomy, with or without adenoidectomy-under age 18

$1,000 $250 $500 $125 $250 $63

Tonsillectomy, with or without adenoidectomy-18 and over

$1,000 $250 $500 $125 $250 $63

Tracheotomy (independent procedure)

$1,000 $250 $500 $125 $250 $63

EYE

Cataract, operation for intracapsular, extracapsular unilateral

$5,000 $1,250 $2,500 $625 $1,250 $313

Repair detached retina $5,000 $1,250 $2,500 $625 $1,250 $313

Removal of eye $5,000 $1,250 $2,500 $625 $1,250 $313

FRACTURE, TREATMENT OF

Treatment of ankle fracture $1,000 $250 $500 $125 $250 $63

Treat finger fracture, each $1,000 $250 $500 $125 $250 $63

Treatment of nose fracture $1,000 $250 $500 $125 $250 $63

Treat fracture radius & ulna $1,000 $250 $500 $125 $250 $63

Treatment of fibula fracture $2,500 $625 $1,250 $313 $625 $156

GENITO_URINARY TRACT

Cervix amputation (cervicectomy)

$1,000 $250 $500 $125 $250 $63

Circumcision Newborn Clamp

$1,000 $250 $500 $125 $250 $63

Dilation & Curettage (non-Puerperal)

$1,000 $250 $500 $125 $250 $63

Partial hysterectomy $5,000 $1,250 $2,500 $625 $1,250 $313

Total hysterectomy $5,000 $1,250 $2,500 $625 $1,250 $313

Vaginal hysterectomy $5,000 $1,250 $2,500 $625 $1,250 $313

Kidney -Nephropexy $5,000 $1,250 $2,500 $625 $1,250 $313

1000 Plan 500 Plan 250 Plus Plan

SURGICAL PROCEDURE Surgical Reimbursement

Anesthesia Reimbursement

Surgical Reimbursement

Anesthesia Reimbursement

Surgical Reimbursement

Anesthesia Reimbursement

$10,000 25% $5,000 25% $2,500 25%

GENITO_URINARY TRACT

Kidney transplant, unilateral or bilateral, recipient with nephrectomy

$8,500 $2,125 $4,250 $1,063 $2,125 $531

Ureterotomy $2,500 $625 $1,250 $313 $625 $156

Cystotomy $2,500 $625 $1,250 $313 $625 $156

Prostate, removal of (Prostatectomy)

$2,500 $625 $1,250 $313 $625 $156

Surgical exposure, prostate $5,000 $1,250 $2,500 $625 $1,250 $313

Extensive prostate surgery $5,000 $1,250 $2,500 $625 $1,250 $313

Removal of epididymis $2,500 $625 $1,250 $313 $625 $156

Cyctocele, operation for anterior colporrhaphy

$2,500 $625 $1,250 $313 $625 $156

Rectocele operation for posterior colporrhaphy

$1,000 $250 $500 $125 $250 $63

Rectocele and cystocele A&P colporrhaphy

$2,500 $625 $1,250 $313 $625 $156

GOITRE

Adenoma or benign tumor of thyroid excecion

$2,500 $625 $1,250 $313 $625 $156

Thyroidectomy $5,000 $1,250 $2,500 $625 $1,250 $313

HERNIA

Repair Inguinal-unilateral $1,000 $250 $500 $125 $250 $63

Repair Umbilical-under age 5 $2,500 $625 $1,250 $313 $625 $156

Repair Umbilical-over age 5 $2,500 $625 $1,250 $313 $625 $156

Repair Ventral (incisional) $2,500 $625 $1,250 $313 $625 $156

Repair Femoral $2,500 $625 $1,250 $313 $625 $156

Repair Epigastric $1,000 $250 $500 $125 $250 $63

LIGAMENTS AND TENDONS

Revise lower leg tendons $2,500 $625 $1,250 $313 $625 $156

Repair hand tendon $2,500 $625 $1,250 $313 $625 $156

Repair finger/hand tendon $5,000 $1,250 $2,500 $625 $1,250 $313

Transplant hand tendon $5,000 $1,250 $2,500 $625 $1,250 $313

OBSTETRICAL

Removel of placenta and/or immediate or early repair of pereneum and/or cervix

$5,000 $1,250 $2,500 $625 $1,250 $313

Cesarean Section, complete procedure including delivery

$5,000 $1,250 $2,500 $625 $1,250 $313

Cesarean Section and Hyster-ectomy, total or subtotal

$2,500 $625 $1,250 $313 $625 $156

Ectopic (tubal, extra-uterine) pregnancy

$5,000 $1,250 $2,500 $625 $1,250 $313

Miscarriage, including dilation and curettage

$1,000 $250 $500 $125 $250 $63

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1000 Plan 500 Plan 250 Plus Plan

SURGICAL PROCEDURE Surgical Reimbursement

Anesthesia Reimbursement

Surgical Reimbursement

Anesthesia Reimbursement

Surgical Reimbursement

Anesthesia Reimbursement

PILONIDAL CYST OR SINUS

Removal of pilonidal lesion $1,000 $250 $500 $125 $250 $63

Drainage of pilonidal cyst $1,000 $250 $500 $125 $250 $63

$10,000 25% $5,000 25% $2,500 25%

RECTUM

Fissure (Fissurectomy) cutting operation for (Independent Procedure)

$1,000 $250 $500 $125 $250 $63

Incise external hemorrhoid $1,000 $250 $500 $125 $250 $63

Destruction of hemorrhoids $1,000 $250 $500 $125 $250 $63

Hemorrhoidectomy and Fistulotomy or Fistulectomy

$2,500 $625 $1,250 $313 $625 $156

Papillectomy, single tag (in-dependent procedure)

$1,000 $250 $500 $125 $250 $63

SKULL

Osteoplastic craniotomy (other than operation for brain tumor)

$8,500 $2,125 $4,250 $1,063 $2,125 $531

Trephine $2,500 $625 $1,250 $313 $625 $156

Hemispherectomy $8,500 $2,125 $4,250 $1,063 $2,125 $531

SPINE OR SPINAL CORD

Laminectomy $1,000 $250 $500 $125 $250 $63

Spinal cord tumor operation $5,000 $1,250 $2,500 $625 $1,250 $313

TUMOR

Remove tumor of arm/elbow $5,000 $1,250 $2,500 $625 $1,250 $313

Remove tumor, neck/chest $2,500 $625 $1,250 $313 $625 $156

VARICOSE VEINS

Revision of leg vein $1,000 $250 $500 $125 $250 $63

TRANSPLANT & PARTIAL ORGAN REMOVAL

Lung Transplant $10,000 $2,500 $5,000 $1,250 $2,500 $625

Lung Transplant with bypass $10,000 $2,500 $5,000 $1,250 $2,500 $625

Heart and Lung Transplant $10,000 $2,500 $5,000 $1,250 $2,500 $625

Liver Transplant $10,000 $2,500 $5,000 $1,250 $2,500 $625

Liver - partial removal $10,000 $2,500 $5,000 $1,250 $2,500 $625

Pancreas - partial removal $10,000 $2,500 $5,000 $1,250 $2,500 $625

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*For surgical procedures not listed, the benefit amount will be determined based on a percentage of a fixed relative value scale. The percentage used will be the same percentage as used in determining the benefit amount for the listed procedures.

Limitations and Exclusions

United States Fire Insurance Company Limited Medical Indemnity Insurance Benefits Limitations and Exclusions

Benefits will not be paid for charges or loss caused by, or resulting from, any of the following:

1. Suicide or any intentionally self-inflicted Injury;

2. Any drug, narcotic, gas or fumes, or chemical substance voluntarily taken, administered, absorbed or inhaled unless prescribed by, and taken according to the directions of, a Doctor (accidental ingestion of a poisonous substance is not excluded.).

3. Commission, or attempt to commit, a felony;

4. Participation in a riot or insurrection;

5. Driving under the influence of a controlled substance, unless administered on the advice of a Doctor;

6. Driving while Intoxicated. “Intoxicated” will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs.

7. Declared or undeclared war or act of war;

8. Nuclear reaction or the release of nuclear energy. However, this exclusion will not apply if the loss is sustained within 180-days of the initial incident and:

9. The loss was caused by fire, heat, explosion or other physical trauma which was a result of the release of nuclear energy; and

10. The Covered Person was within a 25-mile radius of the site of the release either: a. At the time of the release; or b. Within 24-hours of the start of the release; or c. Occurs while he is in the issue state of this Certificate;

11. Routine health checkups or immunizations for Covered Person aged 6 and older; expenses for allergies, allergy serum or allergy testing, unless specifically provided for in this Certificate;

12. Surgery to correct vision or hearing; eyeglasses, contact lenses and hearing aids, braces, appliances, or examinations or prescriptions therefore,

13. Dental care, x-rays, or treatment other than Injury to sound, natural teeth and gums resulting from an accidental Injury and rendered within 6-months of the Injury;

14. Spinal manipulations and manual manipulative treatment or therapy;

15. Rest cures or custodial care, or treatment of sleep disorders;

16. Treatment, services or supplies received outside of the U.S. except for acute Sickness or Injury sustained during the first 30-days of travel outside the U.S.;

17. Any drug, treatment, or procedure that either promotes or prevents conception or childbirth regardless of what the drug, treatment, or procedure was originally prescribed or intended for;

18. Blood or Blood plasma, except for charges by a Hospital for the processing or administration of blood;

19. Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy;

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20. Cosmetic surgery. This Exclusion does not apply to reconstructive surgery: a. On an injured part of the body following trauma, infection or other disease of the involved part; b. Of a congenital disease or anomaly of a covered dependent newborn or adopted infant; or c. On a non-diseased breast to restore and achieve symmetry between two breasts following a covered Mastectomy;

21. The repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; dentures, partial dentures, braces or fixed or removable bridges;

22. Treatment or removal of warts, moles, boils, skin blemishes or birthmarks, bunions, acne, corns, calluses, the cutting and trimming of toenails, care for flat feet, fallen arches or chronic foot strain;

23. Personal items such as television, telephone, lotions, shampoos, extra beds, meals for guests, take home items, or other items for comfort and convenience;

24. Treatment of Mental or Nervous Disorders, or alcohol or substance abuse, unless specifically provided for under this Certificate;

25. Prescription medicines, unless specifically provided for under this Certificate;

26. Any Injury that is caused by flight or travel in, or upon: a. An aircraft or other, craft designed for navigation above or beyond the earth’s atmosphere except as a fare-paying passenger; b. An ultra light, hang-gliding, parachuting or bungi-cord jumping; c. A snowmobile; d. Any two or three wheeled motor vehicle; e. Any off-road motorized vehicle not requiring licensing as a motor vehicle; f. Any watercraft or other craft designed for water use above or beneath the water, except as a fare-paying passenger;

27. Any accidental Injury where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator’s license;

28. Services, treatment or loss: a. Rendered in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay; b. Payable by any automobile insurance policy without regard to fault. (Does not apply in any state where prohibited); c. Which a Covered Person would not have to pay if he did not have insurance; d. Provided by a Doctor, Nurse or any other person who is employed or retained by a Covered Person or who is a member of a Covered Person’s Immediate Family; e. Covered by state or federal worker’s compensation, employers liability, occupational disease law, or similar laws; f. Injury or Sickness sustained while on active duty in the armed forces of any country. This does not include Reserve or

29. National Guard duty for training. Upon receipt of proof of service, we will refund, any unearned premium paid on a pro rata basis;

30. Hemorrhoids, tonsils, adenoids, middle ear disorders, any disease or disorder of the reproductive organs unless the loss is incurred at least 6-months after the Covered Person becomes insured under this Certificate;

31. Elective treatment or surgery and treatment, procedures, products or services that are experimental or investigative. “Experimental or Investigative” means a drug, device or medical treatment or procedure that: a. Cannot lawfully be marketed without approval of the United States Food and Drug Administration and approval for marketing has not been given at the time of being furnished; b. Has Reliable Evidence indicating it is the subject of ongoing clinical trials or is under study to determine its maximum tolerated dose, toxicity, safety, efficacy, or its efficacy as compared with the standard means of treatments or diagnosis; or c. Has Reliable Evidence indicating that the consensus of opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, efficacy, or its efficacy as compared with the standard means of treatment or diagnosis. “Reliable Evidence” means (i) published reports and articles in authoritative medical and scientific literature; (ii) the written protocol(s) of the treating facility or the protocols of another facility studying substantially the same drug, device, medical treatment or procedure; or (iii) the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

13Please note that exclusions vary by state.

14

SECTION 3 Rx Benefits

Insured Generic Rx

Retail Services • $10 co-pay for covered outpatient generic drugs when prescriptions are filled at participating pharmacies • $50 annual deductible per family member • $250 monthly maximum benefit per insured person, $500 monthly maximum per family • Co-pay applies to each 30 day supply • Over 58,000 participating pharmacies • Up to 25% off brand medications

Mail Order Services • $30 co-pay for covered outpatient generic drugs when filled through our mail order service, maximum supply of 90 days • Purchases are applied toward the annual deductible and monthly maximum*

This benefit is provided to Members by a group policy issued to American Advantage Association by Companion Life Insurance Company. All benefits provided by this insurance are subject to the terms, definitions, conditions, exclusions and limitations of the group policy. A brief list of exclusions includes the following: injectables, experimental drugs, vitamins, infertility, cosmetic drugs and brand name drugs. Please refer to the Description of Coverage for a complete list of exclusions and limitations. Coverage becomes effective on the date provided in your membership materials.

*BRAND PURCHASES CANNOT BE APPLIED TO THE DEDUCTIBLE.

THIS BENEFIT IS NOT AVAILABLE IN CA, CT, GA, HI, ME, MD, MN, NV, NJ, NM, NY, OR, SD, TN, VT, & WA. MEMBERS IN THESE STATES WILL RECEIVE THE 4-TIER RX BENEFIT.

The Insured Generic Rx premium rates for the following memberships are:

Plan: 250 Plan 250 Plus Plan 500 Plan 1,000 Plan

Individual NA $14.02 $14.02 $14.02

Member/Spouse NA $27.33 $27.33 $27.33

Member/Children NA $23.83 $23.83 $23.83

Family NA $36.45 $36.45 $36.45

Benefits are provided through your membership in the American Advantage Association.