BlueCare Comprehensive Outline of Coverage

							 BlueCare Comprehensive                                                                         Outline of Coverage
 Group name: SAMPLE                                                                         Group number:
 Effective date: 1/1/10                         Renewal date: 1/1/11                         Dependent/Student age limitation: 19/23 end of year


Benefits                                                                                                                      Insured Responsibility
     -Benefit Period                                                                                                                Calendar year
     -Deductible (Maximum 3 separate deductibles/family)                                                                                 $250
     -Coinsurance (Insured responsibility)                                                                           20% of allowable charge1 contracting provider; 30%
                                                                                                                       of allowable charge1 non-contracting provider
     -Coinsurance maximum (Maximum 3 separate coinsurance maximums/family)                                                              $1,250
     -Lifetime maximum                                                                                                                 Unlimited
     -Precertification penalty                                                                                                           $500

Preventive Care Services
     -Childhood immunizations (not subject to deductible)                                                                                    20%
     -Routine gynecological exams (one pelvic and breast examination and one pap smear for all                                               20%
       females annually, not subject to deductible)
     -Screening mammograms (not subject to deductible)                                                                                       20%
     -Routine colorectal cancer/prostate cancer screening (not subject to deductible)                                                        20%

Emergency Services
     -Ambulance services, emergency transport (not subject to deductible)                                                                    20%
     -Ambulance services, non-emergency transport                                                                                     20% after deductible
     -Outpatient emergency/accident care (not subject to deductible)                                                                           20%

Inpatient Services
     -Inpatient hospital services, including maternity (unlimited days)                                                               20% after deductible
     -Skilled nursing care (60 days per benefit period)                                                                               20% after deductible

Outpatient Servcies
     -Diagnostic services (lab tests, X-rays, etc.)                                                                                   20% after deductible
     -Occupational therapy (12 visits per benefit period)                                                                             20% after deductible
     -Physical therapy (20 visits per benefit period)                                                                                 20% after deductible
     -Speech therapy (12 visits per benefit period)                                                                                   20% after deductible
     -Cardiac rehabilitation (36 visits per benefit period)                                                                           20% after deductible
     -Pulmonary and respiratory therapy (18 visits per benefit period per therapy)                                                    20% after deductible
     -Radiation, chemotherapy, dialysis                                                                                               20% after deductible

Other Servcies
     -Chiropractic manipulative benefits (20 visits per benefit period; limited to ages 13 and up)                                   20% after deductible
     -Durable medical equipment/prosthetics/orthotics                                                                                20% after deductible
                                                                                                                                $5,000 maximum per benefit period
     -Home health care services (unlimited visits)                                                                                   20% after deductible
     -Hospice (180-day maximum per lifetime)                                                                                         20% after deductible
     -Physician office visits (unlimited visits)                                                                                     20% after deductible
     -Surgical services                                                                                                              20% after deductible
     -Voluntary sterilization                                                                                                        20% after deductible

Mental Health
     -Inpatient services (unlimited days)                                                                                             20% after deductible
     -Outpatient services (unlimited visits)                                                                                          20% after deductible

Substance Abuse
     -Outpatient services (unlimited visits)                                                                                          20% after deductible
     -Detoxification (unlimited days)                                                                                                 20% after deductible
     -Inpatient non-hospital residential treatment (30 days per benefit period; 30 outpatient visits may be                           20% after deductible
       exchanged for 15 additional inpatient non-hospital residential days)

Prescription Drugs
       -Deductible/Maximum                                                                                                                 None/None
       -Retail, 30-day supply                                                                                                            $0/$10/$20/$35
       -Mail order program (up to a 90-day supply)                                                                                       $0/$20/$40/$105
       -Oral contraceptives                                                                                                                  Covered
 1
  The allowable charge is established by a provider agreement or is the billed amount, whichever is less, and will be accepted by the contracting provider as payment in full for
 covered services less any deductibles, coinsurance, copayments, and amounts exceeding any benefit maximums. For a non-contracting provider, the allowable charge is the same
 amount First Priority Life would pay to a contracting provider.
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 This BlueCare Comprehensive Outline of Coverage is an abridged overview of the benefits covered by First Priority Life Insurance Company . This highlights general features
 and is not intended to be a substitute for the terms, provisions, limitations and conditions imposed by the controlling policy. Since benefits are reviewed annually and are often
 modified, if there is a condition that you are treated for on a regular basis, be sure to inquire about your specific coverage needs. 1/10             Form No. FP-17-CMM-O/C