DSA PROPOSED INSURANCE PLAN

INSURANCE CARRIER:                                                                   FAIRMONT INSURANCE

THIRD PARTY CLAIM ADMINISTRATOR (TPA):             HOMELAND4ONE

ENROLLMENT & MONTHLY BILLING ADMINISTRATOR:       CSS (Richard Tani)

ELIGIBILITY FOR INSURANCE:                             Must be a DSA/IMSA member in good standing
Enroll as Individual or Group with employees (full or part time) or independent contractors Open enrollment (no physical exam required, no pre-existing condition limitation)

TYPE OF PLAN:                                                        MEDICAL, SURGICAL & ACCIDENT EXPENSE BENEFIT (coverage & rates may vary for some states)  PRESCRIPTION DRUG DISCOUNT CARD (NBRX) Dental, Vision, Critical Illness, Disability, Life coverage may purchased as an additional option

PLAN LIMITS: 
Maximum payment of $250,000 per year and $1,000,000 lifetime, for all eligible medical expenses, regardless of plan selected

PLAN A PREMIUMS:  SINGLE $168  COUPLE $279  FAMILY $369

PLAN A BENEFITS:

Inpatient Hospital:                                                                 Emergency Room:                                         Physician Office Visits:
First day $500, all others $400 per day                                               $2,000                                                               $50
No more than 30 days per year per insured                               Must be due to an accident                               No more than 5 per year per insured                   
ICU/CCU additional $500 per day
30 day waiting period after enrollment

Surgical Fees:                                                                        Anesthesia Fees:                                           Outpatient Lab & Xray:
$500                                                                                                     $125                                                                $50
No more than 1 per year                                                                                                                                   No more than 5 per year
                       
NBRX Discount Card for Prescription Drugs:
Tier 1 = insured pays $10 to pharmacy
Tier 2 = insured pays $20 to pharmacy
Tier 3 = insured pays $40 to pharmacy
Unlisted drugs = insured pays pharmacy the NBRX negotiated discounted rate for that drug                                          

PLAN B PREMIUMS:  SINGLE $228  COUPLE $405  FAMILY $544

PLAN B BENEFITS:

Inpatient Hospital:                                                                 Emergency Room:                                         Physician Office Visits:
$1,000 per day                                                                                       $5,000                                                             $75
No more than 30 days per year per insured                               Must be due to an accident                               No more than 5 per year per insured                   
ICU/CCU additional $1,000 per day
30 day waiting period after enrollment

Surgical Fees:                                                                        Anesthesia Fees:                                           Outpatient Lab & Xray:
$1,000                                                                                                    $250                                                                $75
No more than 1 per year                                                                                                                                   No more than 5 per year
                       
NBRX Discount Card for Prescription Drugs:
Tier 1 = insured pays $10 to pharmacy
Tier 2 = insured pays $20 to pharmacy
Tier 3 = insured pays $40 to pharmacy
Unlisted drugs = insured pays pharmacy the NBRX negotiated discounted rate for that drug