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					            SUMMARY PLAN DESCRIPTION
                                                                                                     MEDICAL IDENTIFICATION CARD
                                                                                                The MEGA Life and Health Insurance Company
                                                                                                  Limited-Benefit Sickness and Accident Plan




                                                                                                                          ID
                                                                                           For Customer Service or Benefits Info Call: (877) 209-7098
                                                                                           Primary Insured’s Name:
                                                                                           ID Number:
                                                                                           Policy #ST-0100-1629




                                                                                                                        O
                                                                                           Group Name: Payless ShoeSource

 Underwritten by The MEGA Life and Health Insurance Company
                      for the associates of
                                                                                                       V
                                                                                           Group #T2014 Process online as MSC or ScriptSave
                                                                                           Envoy Bin #005522 NDC Bin #006053
                                                                                                                                           www.starbridgechoices.com

                                                                                           Customer Care (866) 225-3554 Pharmacist Assistance (800) 404-1031
                                                                                           The ScriptSave Program is Discount Only - Not Insurance




                                                                                                     MEDICAL IDENTIFICATION CARD
                                                                                                The MEGA Life and Health Insurance Company
              Please Find the Enclosed:                                                           Limited-Benefit Sickness and Accident Plan




                                                                                                                          ID
                                                                                           For Customer Service or Benefits Info Call: (877) 209-7098
              • ID Cards                                                                   Primary Insured’s Name:
              • Claim ID Form                                                              ID Number:
                                                                                           Policy #ST-0100-1629
              • Beneficiary Form


                                                                                                                        O
                                                                                           Group Name: Payless ShoeSource

              Please Complete the Following:
              • Detach ID Cards
              • Fill out Beneficiary Card
                and return to:
              Star HRG • P.O. Box 55270 • Phoenix, AZ 85078-5270
              THIS DOCUMENT IS REQUIRED BY, AND SUBJECT TO,
                                                                                                       V
                                                                                           Group #T2014 Process online as MSC or ScriptSave
                                                                                           Envoy Bin #005522 NDC Bin #006053
                                                                                                                                           www.starbridgechoices.com

                                                                                           Customer Care (866) 225-3554 Pharmacist Assistance (800) 404-1031
                                                                                           The ScriptSave Program is Discount Only - Not Insurance



              DEPARTMENT OF LABOR LAWS RELATED TO ERISA.


      CONFIRMATION OF COVERAGE FOR:                                                                  DENTAL/VISION IDENTIFICATION CARD
                                                                                                   The MEGA Life and Health Insurance Company




                                                                                                                          ID
                                                                                           For Customer Service or Benefits Info Call: (877) 209-7098
                                                                                           Primary Insured’s Name:
                                                                                           ID Number:
                                                                                           Dental Policy #ST-0100-1629




                                                                                                                        O
                                                                                           Group Name: Payless ShoeSource




                                                                                                       V
                                                                                           www.starbridgechoices.com
                                                                                           Vision One Eyecare Program Plan #35118
                                                                                           For location and customer service call: (800) 424-1155
                                                                                           For contact lens replacement call: (800) 987-LENS, dept. 701-1
                                                                                           Present this card to any participating optical center to obtain discounts on your eye
                                                                                           examination and eye-wear needs. See brochure for details. Your benefit is honored at
                                                                                           thousands of locations including most Sears, JCPenney and Target optical departments.




                                                                                                    DENTAL/VISION IDENTIFICATION CARD
                                                                                                  The MEGA Life and Health Insurance Company




                                                                                                                          ID
                                                                                           For Customer Service or Benefits Info Call: (877) 209-7098
              If this information is not correct, please call:                             Primary Insured’s Name:

                1-877-209-7098
                                                                                           ID Number:
                                                                                           Dental Policy #ST-0100-1629




                                                                                                                        O
                                                                                           Group Name: Payless ShoeSource




                                                                                                       V
This document is intended to confirm enrollment and to authorize your employer to          www.starbridgechoices.com
deduct or reduce your pay for any contributions required by the plan.This Summary          Vision One Eyecare Program Plan #35118
Plan Description is a brief summary of the Starbridge Choices Plan.You may be eligible     For location and customer service call: (800) 424-1155
                                                                                           For contact lens replacement call: (800) 987-LENS, dept. 701-1
for additional benefits that are required by your state. The insurance certificate, the    Present this card to any participating optical center to obtain discounts on your eye
group master policy, and state specific variations, are the official documents governing   examination and eye-wear needs. See brochure for details. Your benefit is honored at
                                                                                           thousands of locations including most Sears, JCPenney and Target optical departments.
the provisions of this plan. For a copy, please contact your employer.
SBC_101B                                                                       012706
                                                                                    This is a partial listing of Participating Pharmacies under the
For benefits or eligibility information go to www.StarbridgeChoices.com             ScriptSave Select program and is subject to change. Many other
                          Medical Claims and Inquiries to                           pharmacy chains and local independent pharmacies also accept
             Star HRG, PO Box 55270, Phoenix, AZ 85078-5270
                                                                                    your card. Maintenance prescriptions are available through mail
                                      Batch Payor ID# 59225                         order. If you have any questions, please call the ScriptSave Select
     Your coverage allows you to see the licensed physician of your choice;         Customer Assistance Call Center at 1-866-225-3554.
              however, to help make your benefit dollars go further,
 providers in the following networks may offer discounts on outpatient services.



               AK, AZ, CA, CO, CT, D.C.,                         AL, AR, DE, IA,                            Participating Pharmacies
               FL, GA, ID, IL, IN, KS, MA,                       HI, KY, LA, MS,                              Partial List Subject to Change
               MD, ME, MI, MN, MO, NC,                           MT, NE, PA,TN,
               ND, NH, NJ, NM, NV, NY,                           TX, UT,VA, WA,
               OH, OK, OR, RI, SC, SD,VT                         WI, WV, WY                  ScriptSave Select Customer Assistance
To identify participating providers, log on to www.coalitionamerica.com PIN #3729
                          or call 1-800-878-7896 PIN #3729                                               1-866-225-3554


                                                                                    A&P                   Genovese                             Piggly Wiggly
                                                                                    ACME                  Gerbes                               Pharmacy Plus
                                                                                    Albertsons            Giant Eagle                          Price Chopper*
For benefits or eligibility information go to www.StarbridgeChoices.com
                          Medical Claims and Inquiries to                           Arrow                 Giant Food Stores                    Price Wise
             Star HRG, PO Box 55270, Phoenix, AZ 85078-5270                         Aurora                Hannaford                            Publix
                                       Batch Payor ID# 59225                        Bashas’               Harmon’s                             Rainbow Foods
     Your coverage allows you to see the licensed physician of your choice;         Bi-Lo                 Harris Teeter                        Raley’s
              however, to help make your benefit dollars go further,
 providers in the following networks may offer discounts on outpatient services.    Bi-Mart               Harvest Foods                        Randall’s
                                                                                    Big Bear              Heartland                            Rite Aid
                                                                                    Brooks                H.E.B.                               Safeway
               AK, AZ, CA, CO, CT, D.C.,
               FL, GA, ID, IL, IN, KS, MA,
                                                                 AL, AR, DE, IA,
                                                                 HI, KY, LA, MS,
                                                                                    Brookshire            Hy-Vee                               Sav-A-Center
               MD, ME, MI, MN, MO, NC,
               ND, NH, NJ, NM, NV, NY,
                                                                 MT, NE, PA,TN,
                                                                 TX, UT,VA, WA,
                                                                                    Brookshire Bros.      Ingles                               Savon Drug
               OH, OK, OR, RI, SC, SD,VT                         WI, WV, WY         Bruno’s               Jewel-Osco                           Schnucks
To identify participating providers, log on to www.coalitionamerica.com PIN #3729
                          or call 1-800-878-7896 PIN #3729                          CareMax/Valu-Rite     Keltsch                              Seaway
                                                                                    Copps                 Kerr Drugs                           Sedanos
                                                                                    Cub Foods             King Soopers                         Shaw’s Supermarket
                                                                                    CVS                   Kinney Drugs                         ShopKo
                                                                                    Dillons               Kmart                                Smith’s Food & Drug
                                                                                    Discount Drug Mart    Kohl’s                               Snyders
For benefits or eligibility information go to www.StarbridgeChoices.com
                           Dental Claims and Inquiries to                           Dominick’s            Kroger                               Stop & Shop
             Star HRG, PO Box 55270, Phoenix, AZ 85078-5270                         Drug Emporium         Longs Drug Stores                    Super D Drugs
                                                                                    Drug Fair             Marsh Drugs                          Target
                                      Batch Payor ID# 59225
                                                                                    Drug Warehouse        Maxi Drug                            Tom Thumb
                                                                                    Duane Reade           Maxor                                Tops Pharmacy
                                                                                    Eagle                 Mays Drug Stores                     Ukrop’s
                                                                                    Eckerd                Medicap                              United Supermarkets
                                                                                    Fagen Pharmacy        Medicine Shoppe-                     USA Drug
                                                                                    Farm Fresh              (Kash ‘n Karry or                  Vons
                                                                                    Farmer Jack             Food Lion only)                    Waldbaum’s
                                                                                    Food City             Medistat                             Walgreens
                                                                                    Food World            Meijer                               Wal-Mart
                                                                                    Fred’s                NeighborCare                         Weis Markets
                                                                                    Fred Meyer            Osco Drug                            Winn Dixie
                                                                                    Fruth’s               Pamida                                 *KS & MO Only
For benefits or eligibility information go to www.StarbridgeChoices.com
                                                                                    Fry’s                 Pathmark
                           Dental Claims and Inquiries to
             Star HRG, PO Box 55270, Phoenix, AZ 85078-5270

                                      Batch Payor ID# 59225




                                                                                    VDSPD_SBC_Hi_514                                                    012706 v19
                                     Important Notice Regarding Your Benefits

                                                  Payless Shoesource, Inc.
                                               3231 SE Sixth Street • Topeka, KS 66607

Who is eligible?
All part-time associates and their dependents are eligible. All full-time associates who are in the six month waiting
period for the company’s major medical plan and their dependents are eligible.

When does my Starbridge Choices coverage begin?
Your coverage will begin the first pay period following your hire date or date of status change.




  If you have Medicare or will become eligible for Medicare in the next 12 months, a new Federal law gives
  you more choices about your prescription drug coverage, starting in 2006.The prescription drug coverage
  offered in this program is NOT expected to pay out as much as the standard Medicare prescription drug
  coverage. As a result, if you do not enroll in Medicare Part D prescription drug coverage
  when you are first eligible, you may have to pay a higher premium for Medicare Part D
  when you do enroll. If you need more information regarding Medicare Part D, please contact your
  employer for their Medicare Part D notice.


BENEFICIARY CARD                                                                                                                                       Cut Here
        Please fill out and mail this BENEFICIARY DESIGNATION NOTIFICATION in a stamped envelope to:
                                   Star HRG • P.O. Box 55270 • Phoenix, AZ 85078-5270

1. YOUR NAME ________________________________________                       4. BENEFICIARY_________________________________________
                                                                               Name of person who will receive benefit in the case of your accidental death.
2. SOCIAL SECURITY # ___ ___ ___ - ___ ___ - ___ ___ ___ ___
                                                                            5. YOUR BENEFICIARY’S ADDRESS
3. YOUR ADDRESS                                                             ADDRESS________________________________________________________________

STREET _________________________________________________________________    STREET _________________________________________________________________

CITY ____________________________________________________________________   STATE _____________________________________________ZIP __________________

STATE _____________________________________________ZIP __________________
                                                                            5. AUTHORIZATION
                                                                               By signing below I confirm that I have named my beneficiary

                                                                            _________________________________________________________
Payless Shoesource, Inc., Group #1629                                                        SIGNATURE                                                 DATE
                                                  Your Plan Information

Plan Name:                                            Starbridge Choices Sickness and Accident Plan and
                                                      Starbridge Choices Dental/Vision Plan

Plan ID Numbers:                                      EIN: 48-0674097                      PN: 551

Policy Number:                                        ST-0100-1629
                                                      ST-0140-1629

Plan Administrator/Sponsor:                           Payless Shoesource, Inc.
                                                      3231 SE Sixth Street
                                                      Topeka, KS 66607

Type of Administration:                               Insurer Administration

Program Administrator:                                Star HRG
                                                      2222 West Dunlap Avenue, Suite 350
                                                      Phoenix, AZ 85021-2866

Agent for Service of
Legal Process:                                        Star HRG
                                                      2222 West Dunlap Avenue, Suite 350
                                                      Phoenix, AZ 85021-2866

Claims Administrator:                                 Star HRG
                                                      P.O. Box 55270
                                                      Phoenix, AZ 85078-5270         (877) 209-7098

Sources and Methods of
Contributions to the Plan:                            Associate contribution through payroll deductions

Funding:                                              This Plan is underwritten by The MEGA Life and Health
                                                      Insurance Company, Oklahoma City, OK 73114

Date of the Plan’s Fiscal Year:                       January 1 - December 31


Although the Company presently intends to continue this Plan, it reserves the right to amend or terminate the Plan at its sole
discretion at any time.
                                                Frequently Asked Questions

Is Starbridge Choices a “Major Medical plan?”                                  What do I have to do to make sure my spouse receives
No, Starbridge Choices is not a major medical plan. Starbridge                 the Accidental Death Benefit if I were to pass away?
Choices offers limited-benefit coverage for the most common                    Fill out the Beneficiary Card on the “Important Notice Regarding
every day illnesses and off-the-job accidents–at an affordable price.          Your Benefits” page, naming your spouse (or whomever you
                                                                               would like to receive the benefit) as the beneficiary, and return it
Who is eligible?                                                               to Star HRG promptly. This will assure that your accidental death
The eligibility requirements appear on the “Important Notice                   claim is processed quickly. After your death, your beneficiary
Regarding Your Benefits” page, at the front of this booklet.                   should contact Star HRG’s Call Center. The Call Center will walk
                                                                               your beneficiary through the process of submitting the claim for
When does my Starbridge Choices coverage begin?                                accidental death benefits.
Your coverage begins when you are eligible as described on the
“Important Notice Regarding Your Benefits” page, at the front of               Does Starbridge Choices pay for routine exams?
this booklet.                                                                  No, Starbridge Choices is a sickness and off-the-job accident policy
                                                                               and does not cover routine physicals or exams. However, Starbridge
What kind of medical benefits are covered under this                           Choices does cover the laboratory fees for the following screening
plan? (Please see Medical Benefits pages for plan limits.)                     procedures: PAP smear (Cervical cancer screening) and PSA blood
Bills from unexpected sickness and off-the-job accidents:                      test (Prostate cancer screening). Starbridge Choices also covers the
                                                                               facility and reading charges for one routine annual mammogram
  •   Doctor office visits                                                     ordered by your provider. Charges for any other routine exams are
  •   Hospital services                                                        excluded under the policy unless required by state mandate.
  •   Lab and x-ray expenses
  •   Prescription drug expenses (Depending on the coverage                    I have a medical condition. How does that affect my
      level you chose)                                                         Starbridge Choices coverage?
                                                                               Did you recently have other group insurance? If so, ask your prior
Do I pay for everything up front?                                              insurance carrier for a Certificate of Creditable Coverage and
Starbridge Choices is easy to use because most providers bill us               submit it with your first claim to Starbridge Choices.This Certificate
directly. Occasionally some providers may ask you to pay for your              may reduce or eliminate the Pre-Existing Condition Limitation on
services up front. It is up to your individual provider. Prescriptions         your policy. Submitting the Certificate with your first claim will also
must be paid for up front and submitted by you for reimbursement.              speed up claim processing. If you did not have prior group
(Depending on the coverage level you chose.)                                   insurance, you may be subject to the Pre-Existing Condition
                                                                               Limitation Clause. Please read that section in this booklet carefully
What is the difference between the Prescription Discount                       and call us if we can help explain it further.
and the Prescription Benefit and how do they work?
If you have a prescription discount, you can use one of the more than          If you still have questions regarding your coverage or how to best
50,000 pharmacies in our prescription network, and you will always             use your Starbridge Choices benefits, please call the toll-free
receive a discount on the purchase price of your brand name or                 number located on the front of this booklet.
generic prescriptions (discounts may vary from retailer to retailer.)

You may also be eligible for the Prescription Benefit that reimburses
up to 100% of your prescription costs once your Per Prescription
Deductible has been met, until the plan has paid the Maximum Per
Coverage Year Amount listed in the Benefits Table. (Depending on               PRIVACY POLICY
the coverage level you chose.)                                                 We know that your privacy is important to you and we protect the
                                                                               confidentiality of your nonpublic personal information. We do not
My wife is pregnant. How does Starbridge Choices pay                           disclose any nonpublic personal information about our customers or
for maternity services?                                                        former customers to anyone, except as permitted or required by law.
The pre-natal, labor, delivery and post-delivery care charges for              We maintain appropriate physical, electronic and procedural safeguards
her pregnancy are billed by the doctor as a package.Your doctor                to ensure the security of your nonpublic personal information. A
will bill Starbridge Choices for these charges after the birth of              detailed copy of our privacy policy is located in this booklet.
your baby. The Star HRG Claims department will review the bill
for the packaged benefits after your baby is born.

Please note that the initial office visit, pregnancy test, lab work, and
ultrasound services can be submitted to Star HRG’s Claims
Department when the services are rendered.You do not need to
wait until your baby is born to submit these charges.

                                                                           1
                                           Frequently Asked Questions                               Continued

What is an “Open Enrollment Period?”                                               if the child is enrolled full-time in an accredited school or college.
An “Open Enrollment Period” is a specific number of days each                      Coverage will continue for any child who reaches the age limit and
year during which you and your dependents may enroll or make                       is both totally incapable of self-sustaining employment due to
changes to your coverage under this plan.                                          physical or mental handicap and is chiefly dependent on the Insured
                                                                                   for support and maintenance.Your dependents’ coverage will begin
What is a coverage year?                                                           on the same day your coverage begins, provided your dependents
Coverage Year - is a consecutive 12-month period or part thereof                   were enrolled when you enrolled and their premium has been paid.
beginning on an insured’s effective date of coverage and ending on
the insured’s certificate anniversary date (i.e., the anniversary of the           If I, or any of my dependents, do not enroll within 31days
insured’s effective date), subject to the termination provisions. On               of becoming eligible, may we enroll at a later date?
the insured’s certificate anniversary date, a new coverage year will               Enrollment in the plan for you, and your dependents, will only be
begin for each insured who still meets the eligibility requirements.               permitted as a “Qualified Family Status Change” or during an
A new deductible will need to be satisfied each new coverage year.                 “Open Enrollment Period” or if you did not enroll because you
                                                                                   had other health coverage and that other coverage has ended (but
When does my coverage end?                                                         you must enroll in this plan within 31 days from the date your other
When Starbridge Choices Coverage Ends: Your insurance will                         coverage ends). Qualified family status changes include:
terminate on the earliest of:                                                      • Marriage, divorce or legal separation
1. The date ending the last period for which You made any                          • Death of a spouse or child
   required premium contribution;                                                  • Birth or adoption of a child or eligibility under the terms of a
2. The date You enter the armed forces* of any country;                               Qualified Medical Child Support Order (QMCSO). You can
3. The date You are no longer a member of a class eligible for insurance;             request from the Program Administrator a free copy of the
4. With respect to a coverage,the date on which that coverage is canceled;            plan’s QMCSO procedures.
5. The date the policy is terminated or                                            • Loss of eligibility for a dependent (such as a child’s marriage)
6. The date your Employer ceases to provide this plan.                             • Gain or loss of your spouse’s coverage
                                                                                   • A change between part-time and full-time employment by you
The insurance of a covered Dependent will terminate on the
earliest of:                                                                          or your spouse.
1. The date Your insurance terminates;                                             • Become, or acquired, a dependent due to birth, adoption, or
2. The date he enters the armed forces* of any country; or                            placement for adoption in the Insured’s home.
3. The date he ceases to be a Dependent..
                                                                                   You have 31 days from the date of the family status change to make
                                                                                   new coverage elections. The coverage change must be consistent
May I obtain coverage for my dependents?1.                                         with the qualified family status change.
Yes, you may purchase coverage for yourself or yourself and eligible
dependents.The plan will provide the coverage as described above                   1.
                                                                                     This provision or limitation varies by state. Please contact the
for each of your eligible dependents whom you cover under this                     Starbridge Choices Call Center for additional information.
plan.Your eligible dependents are your spouse and your unmarried
dependent children under 19 years of age.The age limit is up to 25                 *Membership in the reserves is not deemed entry into the armed forces

                                                                 Filing a Claim
Filing your medical claim can be handled in 2 different ways:                      You can file a dental claim
                                                                                   All dental offices have a supply of the “Universal Dental Claim Form”
1. Have your doctor file the medical claim                                         that can be mailed directly to Star HRG (the claims payor) by your
                                                                                   Dentist at: Star HRG, P.O. Box 55270, Phoenix, AZ. 85078-5270.
During your office or hospital visit, confirm that your doctor will submit
an itemized bill to Star HRG’s Claims Department for processing.The                This claim form will be accepted by your Starbridge Choices Dental
doctor’s office can forward your itemized bills directly to our Claims             Plan as proof of claim. The Starbridge Choices Dental Plan allows
                            .O.
Department at Star HRG, P Box 55270, Phoenix, AZ. 85078-5270. If                   you complete freedom to obtain care from the Dentist of your
your doctor needs more information about how to file your claims with              choice. If your Dentist does not file insurance forms for you, please
Star HRG, please ask them to call the toll-free number on your ID card.            make certain that they give you a completed “Universal Dental
                                                                                   Claim Form” to submit to Star HRG, for reimbursement.
2. You can file a medical claim
                                                                                   Starbridge Choices cannot accept faxes or photocopies.
Filing a claim is easy. If you have been treated by a provider and have paid
for the services, please make sure you complete the following steps:
                                                                                   The policy requires your claim be filed within 90 days of
    • Fill-out the enclosed Claim Identification Form
                                                                                   the date of service.
    • Attach your original itemized medical receipts to the form, and
    • Mail to Star HRG’s Claims Department at:                                     Claim Timeline
           Star HRG                                                                The Claims Administrator will decide your claim within 30 days (or, if
           P.O. Box 55270                                                          extra time is needed, within 45 days) after your claim is received (or the
           Phoenix, AZ 85078-5270                                                  timeframe required by applicable state mandate).You will be notified in
Please be sure to keep a photocopy of everything you mail to Star HRG.             writing during the initial 30-day period if extra time is needed.1.

                                                                               2
                                            Medical Benefits Chart

                                                                           Level 1         Level 2       Level 3
Illness
      Physician Office Visit Co-Pay*
                  Per Visit                                                   $20              $20         $20
      Outpatient Basic Medical Expense Benefit
                  Amount Per Year                                            $1,000          $1,500      $2,000
                  Paid at                                                     80%             80%         80%
                  Deductible Per Year                                         $50             $50         $50
      Non-Emergency Care in Emergency Room*
                  Amount Per Year                                             $500            $500        $500
                  Paid at                                                     50%             50%         50%
                  Deductible Per Year                                         $100            $100        $100
      In-Hospital Medical Expense Benefit
           Daily In-Hospital Benefit
                  Amount Per Year                                           $10,000         $25,000      $50,000
                  Paid at                                                    100%            100%         100%
                  Maximum Amount Per Day                                     $100            $250         $500
                  Maximum Number of Days                                      100             100          100
           Supplemental In-Hospital Surgery
                  Amount Per Year                                             N/A            $3,000      $5,000
                  Maximum Per Occurrence                                      N/A            $1,500      $2,500
                  Maximum Occurrences Per Year                                N/A               2           2
           Supplemental Maternity Benefit
                  Maximum Per Occurrence                                      N/A            $1,500      $2,500
Wellness
      Preventive Care Benefit*†
           Cervical Cancer Screening/Prostate Cancer Screening/Mammogram
                  Paid at                                                     80%             80%         80%
                  Maximum Occurrence Per Year Per Procedure                    1               1           1
Injury
      Accident Medical Benefit
                 Amount Per Year                                             $2,500          $5,000      $7,500
                 Paid at                                                      80%             80%         80%
                 Maximum Per Occurrence                                      $2,500          $2,500      $2,500
                 Deductible Per Occurrence                                    $50             $50         $50
                 Maximum Occurrences Per Year                                   1               2           3
      Accidental Death Benefit
                 Amount Paid                                                $10,000         $15,000      $20,000
Prescriptions
      Prescription Discount
                  Name Brand or Generic                                     Discount        Discount     Discount
      Prescription Benefit*
                  Deductible - Generic                                        N/A              $15         $15
                  Deductible - Brand                                          N/A              $25         $25
                  Maximum Amount Per Year                                     N/A             $300        $600
Employee Assistance
      EAP / NurseLine                                                          Yes             Yes         Yes

*The paid benefit amount will count toward the outpatient basic medical expense coverage year maximum.
†
  This benefit amount may be higher if required by law.
The benefits above are provided by policy form SHR-POL-01 and SHR-POL-02.




                                                            3
    Each Associate and Each Insured Family Member Receive the Following Benefits

Physician Office Visit                                                        inpatient medical expenses incurred for injuries due to a covered
Each insured person is responsible for the Physician Office Visit Co-         accident. After each insured person meets the Per Occurrence
Pay listed in the Benefits Table. The plan will pay 100% of the               Deductible, the plan will pay 80% of the usual and customary
remaining service charge made by the physician up to the usual and            amount for each covered expense, until it has paid the Maximum
customary amount. In addition, Related Charges in connection with             Amount per Occurrence listed in the Benefits Table. The benefit
the office visit are paid at 80% once the individual insured coverage         provides coverage for the number of occurrences per coverage
year deductible is met. Related Charges include, but are not limited          year, as listed in the Benefits Table.This supplemental coverage is for
to the following: Injections, laboratory, pathology, radiology,               accidents only and does not cover sickness.
diagnostic testing and venipuncture. Any Physician Office Visit
benefit amount, whether paid to the insured or physician, will count          Accidental Death Benefit
towards the Basic Medical Expense Maximum Benefit per Coverage                If bodily injuries result in the death of a covered person within 365
Year.                                                                         days from the date of a covered accident (unless otherwise
                                                                              stipulated by law), the beneficiary will be paid the Accidental Death
Basic Medical Expense Benefit                                                 Benefit Amount listed in the Benefits Table.
Each insured person will receive coverage for outpatient medical
expenses incurred for covered sicknesses or maternity. Once the               Prescription Discount
individual insured coverage year deductible is satisfied, the plan will       You are automatically enrolled in ScriptSave Select, a national
pay 80% of the remaining expenses up to the usual and customary               network of over 50,000 pharmacies that offers savings on your
amount for each covered expense.This will continue until the Basic            prescriptions.You will save an average of 21% on brand name and
Medical Expense Maximum Benefit per Coverage Year is reached                  generic prescription drugs. This program is for everyone in the
(listed in the Benefits Table).                                               household regardless of age, and there are no limits or caps on
                                                                              usage. For more information, see the ScriptSave Select page located
Non-Emergency Care in Emergency Room                                          in this booklet.
The plan reimburses covered outpatient medical expenses incurred
for non-emergency care received in an Emergency Room (ER)                     Prescription Reimbursement Benefit
subject to the following limits: After a $100 Deductible per                  In addition to the Prescription Discount benefit, the plan will
occurrence, the plan will reimburse 50% of all covered expenses up            reimburse 100% of the outpatient prescription charge, after the Per
to $500 during the 12-month coverage year. Please remember that               Prescription Deductible has been met. This will continue until the
the $500 applies to the Basic Medical Expense Maximum Benefit                 plan has paid the Maximum per Coverage Year Amount listed in the
per Coverage Year. Once you have maximized the $500 non-                      Benefits Table. The reimbursement amount paid will count toward
emergency care in the ER coverage year limit, no additional non-              the Basic Medical Expense Maximum Benefit per Coverage Year.
emergency care provided in the ER will be paid under the plan.                The Prescription Reimbursement benefit is not available with the
                                                                              Level 1 Plan.
In-Hospital Medical Expense Benefit
(payable after Basic Medical Expense Benefit is exhausted)                    Wellness
Each insured person will receive coverage for medical expenses                Preventive Care Benefit
incurred for covered sickness, when confined in a hospital and                Once per Coverage Year, the plan will pay 80% of the laboratory
incurring a room and board charge (Pregnancy is considered a                  fees for the following screening procedures: PAP smear (Cervical
sickness). The plan will pay 100% of the covered inpatient medical            cancer screening) and PSA blood test (Prostate cancer screening).
expenses up to the Per Day Amount listed in the Benefits Table for            The plan also covers 80% of the facility and reading charges for one
the Maximum Number of Days per Coverage Year.                                 annual routine mammogram ordered by your provider. Charges for
                                                                              any other routine exams are excluded under the policy unless
Supplemental In-Hospital Surgical & Maternity Benefit                         required by state mandate. The paid benefit amount will count
(payable after Basic Medical Expense Benefit is exhausted)                    toward the Basic Medical Expense Maximum Benefit per Coverage
In addition to the In-Hospital Medical Expense Benefit, each insured          Year.
person will also receive coverage for additional inpatient medical
expenses incurred for surgery due to a covered sickness, and for              Employee Assistance
inpatient medical expenses incurred due to maternity.To be eligible,
the insured person must be confined in a hospital and incur a room            EAP/NurseLine
and board charge.The plan will pay 100% of the covered inpatient              You and your family have access to Care24, a trusted source of
medical expenses for surgery and maternity up to the Maximum                  information and support for health, emotional and personal
per Occurrence Amount listed in the Benefits Table. The                       challenges. By calling the Care24 toll-free number, you have
Supplemental In-Hospital Surgical and Maternity Benefit is not                unlimited access to speak with a registered nurse, legal and financial
available with the Level 1 Plan.                                              professionals, counselors, community resources, an audio health
                                                                              information library, access to dependent care and other specialists
Supplemental Accident Medical Benefit                                         that can help you with guidance and counseling over the phone.
(payable after Basic Medical Expense Benefit is exhausted)                    Care24 is available 24/7 and provides you confidential, face-to-face
Each insured person will receive coverage for outpatient and                  counseling appointments to help you maintain a balance between
                                                                              work, family and other personal responsibilities.

                                                                          4
                                          Medical Plan Coverage Descriptions

This plan is a sickness and off-the-job accident insurance plan designed       What rules govern my medical expenses?
to help pay basic and essential medical expenses while you are                 In order to be covered, your medical expense must:
covered by the plan. Additionally, participants are provided accidental          • Be administered and ordered by a physician;
death coverage. This plan is provided under a group insurance                    • Be medically necessary for the diagnosis and treatment of the
contract issued by The MEGA Life and Health Insurance Company.                      sickness or injury; and,
                                                                                 • Not be excluded by this plan.
What is an Accidental Injury?
To qualify, an injury must occur while covered under the plan. An              What qualifies as an inpatient (hospitalization) expense?
Accidental Injury is a non-work-related bodily injury that is sudden,          To qualify as an inpatient (hospitalization) expense, the expense
unexpected, and unforeseen, resulting from an identifiable event               must be the result of a hospital stay for which the hospital bill
producing objective symptoms of an injury. Only charges incurred               includes at least one day of in-patient room and board charges,
within 90-days of the accident will be eligible.                               excluding observation and recovery rooms.

                                                        1.                     What is emergency care?
What is a Pre-Existing Condition limitation?                                   “EMERGENCY CARE” means medical care and treatment provided
Pre-Existing Conditions are not covered under the Starbridge                   after the sudden onset of a medical condition manifesting itself by
Choices medical plans. A Pre-Existing Condition is any condition for           acute symptoms, including severe pain, which are severe enough that
which you have been medically diagnosed, treated by, sought advice             the lack of immediate medical attention could reasonably be
from, or consulted with, a physician during the 6 months before                expected to result in any of the following:
becoming insured under this plan. This provision will not apply to              1. The patient’s health would be placed in serious jeopardy;
any expenses incurred as the result of a pre-existing condition or              2. Bodily function would be seriously impaired;
any related condition after the end of a continuous period of 6                 3. There would be serious dysfunction of a bodily organ or part.
months of coverage under the policy during which no expense is
incurred, no diagnosis or treatment or advice is received, and a               What is an occurrence?
Physician has not been consulted, or 12 months of continuous                   An occurrence is a period of Sickness. An occurrence is deemed
coverage.The pre-existing condition limitation above does not                  to have ended when 60 consecutive days have passed during which
apply to newborn or adopted children, nor to any pregnancy. Any                the Insured Person:
pre-existing condition limitation can be reduced by the period of               1. Received no medical treatment, services, or supplies for a
time you were previously insured for the condition, provided you                    sickness or injury; and
were validly insured under a prior plan with creditable coverage                2. Neither took any medication, nor had any medication
immediately prior to being insured under this plan, and became                      prescribed, for a sickness or injury.
insured under this plan within 63 days of termination of your prior
plan. You have the right to request a certificate of creditable                How does the plan pay for maternity services?
coverage from a prior health plan, and can request assistance from             The pre-natal, labor, delivery and after care charges for your
the Program Administrator to obtain that certificate.                          pregnancy are billed by the doctor as a package. The majority of
                                                                               these charges are related to your labor and delivery. As such, the
What medical expenses are covered under this plan?                             charges can only be considered after the delivery of your baby.
                                                                               Please submit your initial office visit, pregnancy test, lab work, and
   • Doctor bills            • Lab and x-ray expenses                          ultrasound services upon receipt.These services can be processed
   • Hospital bills          • Prescription drug expenses                      prior to delivery.
                             (Depending upon coverage selected.)
                                                                               May I obtain medical coverage for my newborn or
“Usual Charge” means the fee regularly charged and received                    adopted child?1.
for a given service by the health care provider.                               Newborn children (born while insured is covered under the policy)
                                                                               are covered from birth to 31 days for injury and sickness, including
                                                                               care and treatment for congenital defects, birth abnormality and
“Customary Charge” means a charge that does not exceed the                     prematurity. After 31 days, a child will be covered only if we receive
general level of charges being made by providers of similar training           a “Special Enrollee” application and payment of premium.
and experience when furnishing customary treatment for a similar
                                                                               You may cover your adopted child as a dependent. The effective
sickness, condition or injury.The locality where the charge is incurred
                                                                               date of coverage will be the earlier of the date of placement for the
will also be considered.The term “locality” means a county or such
                                                                               purpose of adoption, or the date on which you assume legal
greater area as is necessary to establish a representative cross section
                                                                               obligation for total or partial support of the child.
of providers regularly furnishing the type of treatment, services or
supplies for which the charge was made.
                                                                               1.
                                                                                 This provision or limitation varies by state. Please contact the
                                                                               Starbridge Choices Call Center for additional information

                                                                           5
                                 Medical Plan Coverage Descriptions Continued

What will not be covered under this medical plan? 1.                         What should my beneficiary do in the event of my
Coverage is not provided for services, supplies or equipment for             accidental death?
which a charge is not customarily made in the absence of insurance.          Your beneficiary should contact the Star HRG Call Center for
No coverage is provided for loss caused by or resulting from:                instructions on filing a claim.
1. Injury or Sickness arising out of or in the course of
    employment; or which is compensable under any Workers’                   What happens if I can’t file my claim within 90 days of
    Compensation or Occupational Disease Act or Law;                         the date of service?
2. Declared or undeclared war; or act of war;                                The policy requires that you file your claim within 90 days of the
3. Expenses which are not ordered or under the written                       date of service. If this is not reasonably possible, you will be allowed
    direction of a Physician;                                                to submit your claim as soon as it is reasonably possible to do so,
4. Cosmetic surgery.This does not apply to:                                  along with the reason for the delay. Your benefits will not be
    a. Reconstructive surgery incidental to or following surgery             affected if your claim, and any additional requested information
        resulting from trauma, infection, or other diseases of the           needed to process your claim, is received in our office within one
        involved part; or                                                    year from the date of service. If you were legally incapacitated and
    b. Reconstructive surgery because of a congenital disease or             unable to file your claim within one year from the date of service,
        anomaly of a covered Dependent newborn or adopted                    please submit your claims along with the necessary documentation
        infant; or                                                           to our claims office, asking for a special review.
    c. Reconstructive surgery on a non-diseased breast to restore
        and achieve symmetry between two breasts following a                 How do I appeal a claim that has been denied?
        mastectomy.                                                          Any denial of a claim for benefits will be provided by the Claims
5. Hearing examinations or hearing aids;                                     Administrator and consist of a written explanation which will
6. Vision services and supplies related to eye refractions or eye            include (i) the specific reasons for the denial, (ii) reference to the
    examinations, eyeglasses or contact lenses or prescriptions or           pertinent plan provisions upon which the denial is based, (iii) a
    fitting of eyeglasses other than for a disease process, and radial       description of any additional information you might be required to
    keratotomy, keratomileusis or excimer laser photo refractive             provide and explanation of why it is needed, and (iv) an explanation
    keratectomy or similar type procedures or services;                      of the Plan’s claim review procedure. You, your beneficiary (when
7. Charges made by a health care provider if such provider is a              an appropriate claimant), or a duly authorized representative may
    member of the Covered Person’s Immediate Family or is living             appeal any denial of a claim for benefits by filing a written request
    with the Covered Person;                                                 for a full and fair review to the Program Administrator. In
8. Any period of Custodial Care confinement in a Hospital or                 connection with such a request, documents pertinent to the
    Skilled Nursing Facility;                                                administration of the Plan may be reviewed, and comments and
9. Charges for Home Health Care Services, unless provided in                 issues outlining the basis of the appeal may be submitted in writing.
    lieu of a Hospital confinement.                                          You may have representation throughout the review procedure. A
10. The Covered Person’s commission of a felony;                             request for a review must be filed by 180 days after receipt of the
11. Charges in connection with manipulations of the                          written notice of denial of a claim. All information that you submit
    musculoskeletal system, which includes manipulation of the               will be considered, even if you did not provide it when your claim
    muscles, joints, soft tissue, bone, spine, as well as traction and       was first decided.The full and fair review will be held and a decision
    massage and applications of heat and cold;                               rendered by the Program Administrator, no later than 60 days after
12. The treatment of mental or nervous disorders, alcoholism, or             receipt of the request for review.The decision after your review will
                                                                    1.
    any form of substance abuse, except as specifically provided;            be in writing and will include specific reasons for the decision as
13. Intentionally self-inflicted Injury or suicide attempt while sane        well as specific references to the pertinent plan provisions on which
    or insane;                                                               the decision is based.You will have the right to bring a legal action,
14. Dental care and treatment, except that required by Injury and            and the notice will tell you this.
    rendered within 6 months of the Injury;
15. Treatment which is determined to be Experimental or
                                                                             1.
    Investigational.                                                              This provision or limitation varies by state. Please contact the
16. With respect to accidental death:                                             Starbridge Choices Call Center for additional information.
    a. Declared or undeclared war, or any act of war;
    b. Death as a result of suicide within 2 years from the Covered
        Person's effective date of coverage ;
    c. Medical or surgical treatment of Sickness or Disease; or
    d. Flight in any kind of aircraft, except while riding as a
        passenger on a regularly scheduled flight of a commercial
        airline.



                                                                         6
                            ScriptSave Select Prescription Drug Savings Program

                                                                                                        1-866-225-3554
                                                                                               www.scriptsaveselect.com
You and your family are automatically enrolled in the ScriptSave                    Examples of Some Commonly Prescribed Drugs
Select prescription drug savings program. This national network                                        Generic drugs noted in bold
includes over 50,000 pharmacies made up of independent as well
as major chain, supermarket and retail pharmacies across the                              Non-Steroidal Anti-Inflammatory Agents
United States. The ScriptSave Select program is most likely
                                                                              Ibuprofen 600 mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .Tier             1
accepted at the neighborhood pharmacy you currently use.
                                                                              Ibuprofen 800 mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .Tier             2
The ScriptSave Select program also offers these valuable benefits:            Naproxen 500 mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .Tier              2
  • An average of more than 21% savings on both brand name                    Celebrex 200 mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tier       4
    and generic prescriptions                                                 Naproxen sodium 550 mg . . . . . . . . . . . . . . . . . . . . . . . . .Tier                4
  • There are no limits or caps on usage                                                        Based on a 30-day supply
  • No enrollment or paperwork to complete
  • Savings are for everyone in the household regardless of age                                                     Penicillins

Find a Participating Pharmacy                                                 Amoxil 500 mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . .Tier             1
The program provides an online Pharmacy Locator feature that will             Amoxicillin 500 mg capsule . . . . . . . . . . . . . . . . . . . . . . .Tier                1
assist you in quickly locating a convenient pharmacy. Log-in with             Amoxicillin 875 mg tablet . . . . . . . . . . . . . . . . . . . . . . . . .Tier             2
your Group #T2014 at www.scriptsaveselect.com and enter a zip                 Penicillin VK 500 mg tablet . . . . . . . . . . . . . . . . . . . . . . . .Tier             2
code to receive a list of all participating pharmacies within that zip        Amox TR-K CLV 875-125 mg tablet . . . . . . . . . . . .Tier                                 4
code.                                                                                           Based on a 10-day supply

Plan Your Prescription Purchases                                                                                Cardiac Drugs
You can plan your prescription purchases before you go to the
                                                                              Atenolol 50 mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tier         1
pharmacy. It is easy to understand the pricing for your prescriptions
                                                                              Metoprolol 50 mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .Tier             1
with these 4 simple pricing tiers:
                                                                              Lisinopril 20 mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tier         3
  Tier 1: Includes drugs that are $10 or less
                                                                              Norvasc 5 mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tier   3
  Tier 2: Includes drugs between $10.01 and $20
                                                                              Toprol XL 50 mg tablet SA . . . . . . . . . . . . . . . . . . . . . . . . . . .Tier         3
  Tier 3: Includes drugs between $20.01 and $50
                                                                                                 Based on a 30-day supply
  Tier 4: Includes all drugs over $50
To see which pricing level your prescription will be in, use the online       This material is not intended as a recommendation or endorsement of any
Drug Price Tier Look-Up tool. Simply enter the name of your                   drug or product. Placement of a drug in a particular tier or category is
                                                                              solely for the purpose of illustrating possible prices associated with
prescription and a table will show which pricing tier your
                                                                              particular drugs. Such placement shall not constitute a recommendation,
prescription is in.You will also see names of other prescriptions you
                                                                              endorsement, or ranking of any drugs or products. The listing of drugs in
can consider to save you money. You will need to talk to your                 particular tiers, and the prices for each drug and for each tier, are subject
doctor to see if any of the lower cost prescriptions are right for            to change without notice. The information herein is not intended as any
you.                                                                          medical, health or drug related advice, nor to replace the advice of your
                                                                              doctor or other health care professional.
The tiered system allows you, in partnership with your healthcare
provider, to make empowered choices regarding your pharmacy                   The ScriptSave Select Prescription Drug Savings Program is
spending.                                                                     not an insurance policy and does not provide insurance
                                                                              coverage. Discounts are available exclusively through
Please note that prescription prices will vary from pharmacy to
                                                                              participating pharmacies.
pharmacy and are subject to change.The pricing tiers shown on the
website are based on the most recent information available and
may change based on when you actually fill your prescription at the
pharmacy. With ScriptSave Select, you will pay the lowest available
price on that day at that pharmacy location.




                                                                          7
                                         Dental Coverage and Plan Descriptions

Each associate and each insured family member receives the                          1. Injury arising out of or in the course of employment; or which
following benefits:                                                                    is compensable under any Workers’ Compensation or
                                                                                       Occupational Disease Act or Law;
Preventive And Basic Dental Expense Reimbursement                                   2. Declared or undeclared war; or act of war;
The Starbridge Choices Dental Assistance Plan reimburses each                       3. Intentionally self-inflicted Injury or suicide attempt while sane
insured person for expenses incurred for many of the most                              or insane;
common Preventive and Basic dental procedures. Starbridge                           4. A service furnished a Covered Person for:
Choices will pay up to the Maximum Covered Charge for each                             a. Cosmetic purposes, unless needed as a result of Injury. Facing
covered procedure after each insured person meets a per coverage                          on crowns, or pontics, posterior to the second bicuspid shall
year deductible. An insured may go to any licensed dentist.                               always be considered cosmetic;
                                                                                       b. Dental care of a congenital or developmental malformation,
Reimbursement Amount For Covered Dental Procedures                                        unless benefits for Orthodontic services are specifically provided
Below is a list of covered dental procedures and amounts. As a                            in the Benefit Specifications;
suggestion, prior to any dental work, please ask your                               5. Replacement of lost or stolen appliances;
dentist to define the procedures, to determine                                      6. Appliances, restorations, or procedures for the purpose of altering
beforehand whether what you are having done is covered.                                vertical dimension, restoring or maintaining occlusion, splinting,or
This plan is a dental insurance plan designed to help pay basic and                    replacing tooth structure lost as a result of abrasion or attrition, or
essential dental expenses while you are covered by the plan. This                      treatment of disturbances of the temporomandibular joint;
plan is provided under a group insurance contract issued by The                     7. A service not furnished by a Dentist, except:
MEGA Life and Health Insurance Company.                                                a. That performed by a licensed dental hygienist under a
                                                                                          Dentist’s supervision; and
Dental Coverage Plan Descriptions                                                      b. X-rays ordered by a Dentist.

What dental expenses will be covered under this plan?                               If you chose the Dental/Vision package, you are enrolled in the
If an Insured Person incurs expenses for a service on the “List of                  Vision One Network which is honored at more than 6,500
Covered Dental Procedures,” such charges are covered to the                         locations nationally. You’ll save on all eyecare needs including: eye
extent that they do not exceed the Maximum Covered Charge in                        exams, frames, lenses and contacts.You’ll save up to 60% on frames
the schedule below.                                                                 and lenses and up to $10 on eye examinations.

What will not be covered under this plan?1.
                                                                                    1.
Coverage is not provided for services or supplies for which a                         This provision or limitation varies by state. Please contact the
charge is not customarily made in the absence of insurance.                         Starbridge Choices Call Center for additional information.
No coverage is provided for loss caused by or resulting from:

                           Reimbursement Amount for Covered Dental Procedures
 $25 per person annual deductible
       Maximum Covered Charge                                Maximum Covered Charge                                     Maximum Covered Charge

           ORAL EXAMINATION                              AMALGAM RESTORATION FOR                                D7250     Removal Residual Tooth Roots          $30
 D0120     Periodic Oral Exam*                 $17         PRIMARY/PERMANENT TEETH                              D7510     Incision & Drainage of Abscess        $45
 D0140     Limited Oral Exam/Problem Focused   $27   D2140    Amalgam Filling - 1 Surface                $35    D9220     General Anesthesia                    $52
 D0150     Comprehensive Oral Exam †           $27   D2150    Amalgam Filling - 2 Surfaces               $45
 D9110     Emergency - Palliative Treatment    $38   D2160    Amalgam Filling - 3 Surfaces               $56                   PERIODONTICS
                                                     D2161    Amalgam Filling - 4 or more Surfaces       $64    D4341     Scaling and Root Planing, Per Quadrant $72
         X-RAY AND PATHOLOGY                                                                                    D4355     Full Mouth Debridement to Enable
 D0210    Entire Dental Series (Intraoral)                   SYNTHETIC RESTORATIONS                                       Comprehensive Periodontal Evaluation $50
          Including Bitewings**                $40   D2330     Composite Resin - 1 Surface               $42    D4910     Periodontal Maintenance                $53
 D0220    Single Film - Initial                 $7   D2331     Composite Resin - 2 Surfaces              $55
 D0230    Single Film - Each Additional         $7   D2332     Composite Resin - 3 Surfaces              $67                   ENDODONTICS
 D0240    Intra-Oral Occlusal Film**           $10   D2335     Composite Resin - 4 or more Surfaces      $69             (excluding final restoration)
 D0250    Extraoral - First Film               $11   D2390     Composite Resin Crown, Anterior           $77    D3220      Therapeutic Pulpotomy                $20
 D0260    Extraoral - Each Additional           $9   D2391     Composite Resin - 1 Surface Posterior     $50    D3310      Root Canal - Anterior               $125
 D0270    Bitewing Film, One*                   $8   D2392     Composite Resin - 2 Surfaces Posterior    $68    D3320      Root Canal - Bicuspid               $135
 D0272    Bitewing Films, Two*                 $12   D2393     Composite Resin - 3 Surfaces Posterior    $85    D3330      Root Canal - Molar                  $140
 D0274    Bitewing Films, Four*                $17
                                                                       EXTRACTIONS                                                FOOTNOTES
     PROPHYLAXIS AND FLUORIDE                        D7140       Extraction-Erupted tooth or exposed root $39   *  Limited to once every 6 months
 D1110  Prophylaxis for age 14 and over*       $30   D7220       Removal Impacted Tooth-Soft Tissue       $45   †
                                                                                                                   Limited to once every 12 months
 D1120  Prophylaxis for age under 14*          $20   D7230       Removal Impacted Tooth-Partially Bony $70      ** Limited to once every 3 years
 D1203  Topical Applic of Fluoride, Child*     $12   D7240       Removal Impacted Tooth-Completely Bony $85
 D1204  Topical Applic of Fluoride, Adult*     $12   D7241       Removal Impacted Tooth-Completely Bony
 D1351  Sealant, Per Tooth                     $16               w/Unusual Surgical Complications         $85

                                                                                8
                                 Discount Vision Plan Coverage and Descriptions

The Vision One Eyecare Program                                                      Vision One Eyecare Benefits
Save up to 60% on all your eyecare needs.                                                                                              Vision One Typical
The Vision One Eyecare Program offers you and your family immediate                                                                       Cost    Savings
savings on all your eyecare needs including: eye exams, frames, lenses and
                                                                                    FRAMES*
contacts. Save up to 58% on frames, 40% on bifocals, and 20% on contact
                                                                                    Priced up to $60.00 retail                               $25           58%
lenses.                                                                             Priced from $61.00 to $80.00 retail                      $35           56%
                                                                                    Priced from $81.00 to $100.00 retail                     $45           55%
Thousands of locations nationwide.                                                  Priced from $101.00 and over                             65%           35%
Vision One is honored at thousands of locations nationwide. You'll find             35% discount from regular retail prices
providers conveniently located in stores you know and trust like Sears,
JCPenney,Target, participating Pearle Vision Centers1., and many others. For
                                                                                    LENSES (uncoated plastic)
                                                                                    Single Vision                                           $30            39%
your convenience, evening and weekend hours are available and many
                                                                                    Bifocal                                                 $50            52%
locations accept credit cards.
                                                                                    Trifocal                                                $60            50%
To find a location near you, call 1-800-424-1155, or go online to                   Lenticular                                              $100           50%
www.colemanagedvision.com and use plan number 35118.                                LENS OPTIONS (add to lens prices above)
                                                                                    Standard-Progressive (no-line bifocals)                  $50           33%
Save $5 or $10 on eye examinations.                                                 Polycarbonate                                            $30           40%
Licensed independent Doctors of Optometry maintain practices at most                Scratch Resistant Coating                                $12           40%
Vision One locations to provide complete eye examinations and                       Ultraviolet Coating                                      $12           40%
prescription(s). In addition, participating Vision One doctors have agreed          Solid or Gradient Tint                                   $08           33%
to discount their normal spectacle exam fees by $5 and their normal                 Photochromic                                             $30           25%
contact lens fees by $10. However, if you would rather have an                      Anti-Reflective Coating                                  $35           30%
examination elsewhere, you can still bring us your prescription and we will         EYE EXAMINATIONS**
gladly fill it, just as your doctor ordered, at discounted Vision One Prices.       Spectacle – $5 off normal fee
                                                                                    Contact – $10 off normal fee
Easy to use.                                                                        CONTACT LENSES (two ways to save)                                   20%
Simply visit a participating provider of your choice and present your Vision             1.   Visit our convenient nationwide locations and save 20% discount
One identification card which verifies your eligibility. Discounted Vision                    from regular retail prices (10% discount on disposables).
One prices are automatically calculated. There are no claim forms to file                2.   Use the Vision One Contact Lens Replacement Program for
and no waiting for reimbursements. And, your family can use your Vision                       additional convenience.
One benefits as often as it wants.There is no limit to your savings.

     For More Information Call Vision One At                                        ITEMS NOT LISTED ABOVE
                                                                                    20% Discount from regular retail prices

             1-800-424-1155                                                              * At certain locations frame pricing is only available on the Cole supplied
                                                                                              frames (approximately 270 clearly designated frames).
         Weekdays 9-9, Saturdays 9-5 Eastern Time                                        ** Eye examinations are provided by licensed independent Doctors of
1.                                                                                            Optometry located in or adjacent to most participating optical
  Some Pearle Vision Centers are franchisees and do not participate.
                                                                                              departments or by Ophthalmologists affiliated with PrimeSight. Be
Please call 1-800-804-4384 to verify participation.
                                                                                              sure to call the Doctor of Optometry or Ophthalmology in
                                                                                              advance to make an appointment and to verify participation in the
       The Vision One Eyecare Program is not insurance.                                       exam discount program.

                                                                                    Vision One Mail Order Contact Lens
                                                                                    Replacement Program
                                                                                    The Vision One Program now offers you and your family members a
                                                                                    convenient and economical alternative to purchasing replacement contact
                                                                                    lenses. With The Vision One Contact Lens Replacement Program you can
                                                                                    buy the exact brand name contact lenses your doctor prescribes through
                                                                                    the mail2....for less.Vision One carries all types and brands of contact lenses
                                                                                    with an inventory of over 120,000 lenses. We’re certain to have your
                                                                                    prescription in stock.
                                                                                    To use the Vision One Contact Lens Replacement Program, simply obtain
                                                                                    your prescription from your Vision One licensed independent Doctor of
                                                                                    Optometry, Ophthalmologist affiliated with PrimeSight, or another doctor
                                                                                    of your choice, and call our toll-free number 1-800-987-LENS, Dept.
                                                                                    701-1. Customer Service representatives will assist you with pricing and
                                                                                    ordering information.
                                                                                    2.
                                                                                     The mail order contact lens replacement program benefit does not apply
                                                                                    where prohibited by state law.

                                                                                9
                                                     Important Information

CONTINUATION COVERAGE RIGHTS UNDER                                             • The parent-employee’s employment ends for any reason other
COBRA                                                                            than his or her gross misconduct;
You are receiving this notice because you have recently become                 • The parent-employee becomes entitled to Medicare benefits
covered or renewed your coverage under a group health plan (the                  (Part A, Part B, or both);
Plan). This notice contains important information about your right             • The parents become divorced or legally separated; or
to COBRA continuation coverage, which is a temporary extension                 • The child stops being eligible for coverage under the plan as a
of medical and/or dental coverage under the Plan. This notice                    “dependent child.”
generally explains COBRA continuation coverage, when it may
become available to you and your family, and what you need to do               Note that your employer’s withdrawal from the Plan will not
to protect the right to receive it.                                            constitute a qualifying event. This means that even if you and/or
                                                                               your covered dependents lose Plan coverage because your
The right to COBRA continuation coverage was created by a                      employer withdrew from this plan (or stopped making
federal law, the Consolidated Omnibus Budget Reconciliation Act                contributions to the Plan), you and your dependents will not be
of 1985 (COBRA). COBRA continuation coverage can become                        eligible for COBRA continuation coverage.
available to you when you would otherwise lose your group health
coverage. It can also become available to other members of your                When is COBRA Coverage Available?
family who are covered under the Plan when they would otherwise                The Plan will offer COBRA continuation coverage to qualified
lose their group health coverage. For additional information about             beneficiaries only after the Program Administrator has been
your rights and obligations under the Plan and under federal law,              notified that a qualifying event has occurred. When the qualifying
you should review the Plan’s Summary Plan Description or contact               event is the end of employment or reduction of hours of
the Program Administrator.                                                     employment, death of the employee, or the employee’s becoming
                                                                               entitled to Medicare benefits (under Part A, Part B, or both), the
What is COBRA Continuation Coverage?                                           employer must notify the Program Administrator of the qualifying
COBRA continuation coverage is a continuation of Plan coverage                 event.
when coverage would otherwise end because of a life event known
as a “qualifying event.” Specific qualifying events are listed later in        You may elect COBRA if you are covered under the plan on the
this notice. After a qualifying event, COBRA continuation coverage             day prior to a qualifying event and would otherwise lose coverage
must be offered to each person who is a “qualified beneficiary.”You,           as a result of that event. If, however, you are the spouse or
your spouse, and your dependent children could become qualified                dependent child of an employee and the employee drops your
beneficiaries if coverage under the Plan is lost because of the                coverage in anticipation of a divorce, legal separation or annulment
qualifying event. Under the Plan, qualified beneficiaries who elect            (such as at open enrollment), you may still be entitled to elect
COBRA continuation coverage must pay for COBRA continuation                    COBRA following the date of the divorce, legal separation or
coverage.                                                                      annulment. The Program Administrator must determine that the
If you are an employee, you will become a qualified beneficiary if             employee dropped your coverage in anticipation of the qualifying
you lose your coverage under the Plan because either one of the                event. In this case, COBRA coverage would be offered only from
following qualifying events happens:                                           the date of the qualifying event. COBRA coverage would not be
• Your hours of employment are reduced, or                                     available from the date coverage was dropped to the date of the
• Your employment ends for any reason other than your gross                    qualifying event.
   misconduct.
                                                                               You Must Give Notice of Some Qualifying Events
If you are the spouse of an employee, you will become a qualified              For the other qualifying events (divorce or legal separation of
beneficiary if you lose your coverage under the Plan because any of            the employee and spouse or a dependent child’s losing eligibility
the following qualifying events happens:                                       for coverage as a dependent child), you must notify the Program
• Your spouse dies;                                                            Administrator, in writing, within 60 days after the qualifying
• Your spouse’s hours of employment are reduced;                               event occurs. To receive the form for reporting a qualifying
• Your spouse’s employment ends for any reason other than his or               event change, you must contact the Program Administrator for a
   her gross misconduct;                                                       qualifying event form. The completed form, along with any required
• Your spouse becomes entitled to Medicare benefits (under Part                documentation, must be received by the Program Administrator
   A, Part B, or both); or                                                     within 60 days of the qualifying event.
• You become divorced or legally separated from your spouse.
                                                                               How is COBRA Coverage Provided?
Your dependent children will become qualified beneficiaries if they            Once the Program Administrator receives notice that a qualifying
lose coverage under the Plan because any of the following                      event has occurred, COBRA continuation coverage will be offered
qualifying events happens:                                                     to each of the qualified beneficiaries. Each qualified beneficiary will
• The parent-employee dies;                                                    have an independent right to elect COBRA continuation coverage.
• The parent-employee’s hours of employment are reduced;                       Covered employees may elect COBRA continuation coverage on

                                                                          10
                                            Important Information                      Continued

behalf of their spouses, and parents may elect COBRA continuation            the second qualifying event is properly given to the Plan. This
coverage on behalf of their children. COBRA continuation                     extension may be available to the spouse and any dependent
coverage is a temporary continuation of coverage. When the                   children receiving continuation coverage if the employee or former
qualifying event is the death of the employee, the employee                  employee dies, becomes entitled to Medicare benefits (under Part
becoming entitled to Medicare benefits (under Part A, Part B, or             A, Part B, or both), or gets divorced or legally separated, or if the
both), your divorce or legal separation, or a dependent child losing         dependent child stops being eligible under the Plan as a dependent
eligibility as a dependent child, COBRA continuation coverage lasts          child, but only if the event would have caused the spouse or
for up to a total of 36 months from the date of the qualifying event.        dependent child to lose coverage under the Plan had the first
When the qualifying event is the end of employment or reduction              qualifying event not occurred. You must provide this notice, in
of the employee’s hours of employment, and the employee became               writing, to the Program Administrator within 60 days after the
entitled to Medicare benefits less than 18 months before the                 qualifying event occurs. To receive the form for requesting an
qualifying event, COBRA continuation coverage for qualified                  extension, you must contact the Program Administrator for a
beneficiaries, other than the employee, lasts until 36 months after          qualifying event form, complete the form, and return it with the
the date of Medicare entitlement. For example, if a covered                  appropriate documentation, as requested on the form.
employee becomes entitled to Medicare 8 months before the date
on which his employment terminates, COBRA continuation                       How can you elect COBRA continuation coverage?
coverage for his spouse and children can last up to 36 months after          Upon receipt of notice of the qualifying event, the Program
the date of Medicare entitlement, which is equal to 28 months after          Administrator generally has 14 days to provide each qualified
the date of the qualifying event (36 months minus 8 months).                 beneficiary with a COBRA election notice. You or your eligible
Otherwise, when the qualifying event is the end of employment or             family member(s) have 60 days after the date coverage is lost or
reduction of the employee’s hours of employment, COBRA                       the date the election notice is sent, if later, to submit a completed
continuation coverage generally lasts for only up to a total of 18           election form to the Program Administrator. Failure to timely
months from the date of the qualifying event. There are two ways             submit a completed election form will result in loss of your (and
in which this 18-month period of COBRA continuation coverage                 your family’s) rights to COBRA continuation coverage. To elect
can be extended.                                                             continuation coverage, you must complete an election form and
                                                                             furnish it according to the directions on the form. Each qualified
Disability extension of 18-month period of continuation                      beneficiary has a separate right to elect continuation coverage. For
coverage                                                                     example, the employee’s spouse may elect continuation coverage
If you or anyone in your family covered under the Plan is                    even if the employee does not. Continuation coverage may be
determined by the Social Security Administration (“SSA”) to be               elected for only one, several, or for all dependent children who are
disabled and you notify the Program Administrator in a timely                qualified beneficiaries. A parent may elect to continue coverage on
fashion, you and your entire family may be entitled to receive up to         behalf of any dependent children. The employee or the employee’s
an additional 11 months of COBRA continuation coverage, for a                spouse can elect continuation coverage on behalf of all of the
total maximum of 29 months from the date of the qualifying event             qualified beneficiaries. In considering whether to elect continuation
. The disability would have to have started at some time before the          coverage, you should take into account that a failure to continue
60th day of COBRA continuation coverage and must last at least               your group health coverage will affect your future rights under
until the end of the 18-month period of continuation coverage. You           federal law. First, you can lose the right to avoid having
must provide this notice, in writing, to the Program Administrator           pre-existing condition exclusions applied to you by other group
within 60 days after the later of: the date qualifying event occurs          health plans if you have more than a 63-day gap in health coverage,
and the date of the Social Security Administration disability                and election of continuation coverage may help you not have such
determination. To receive the form for requesting a disability               a gap. Second, you will lose the guaranteed right to purchase
extension, you must contact the Program Administrator for a                  individual health insurance policies that do not impose such
qualifying event form, complete the form, and return it with the             pre-existing condition exclusions if you do not get continuation
appropriate documentation, as requested on the form. If the                  coverage for the maximum time available to you. Finally, you should
qualified beneficiary is determined by SSA to no longer be disabled,         take into account that you have special enrollment rights under
you must notify the Program Administrator by filling out and                 federal law. You have the right to request special enrollment in
submitting the form required by the Program Administrator within             another group health plan for which you are otherwise eligible
30 days after SSA’s determination.                                           (such as a plan sponsored by your spouse’s employer) within 30
                                                                             days after your group health coverage ends because of the
Second qualifying event extension of 18-month period of                      qualifying event listed above. You will also have the same special
continuation coverage                                                        enrollment right at the end of continuation coverage if you get
If your family experiences another qualifying event while receiving          continuation coverage for the maximum time available to you.
18 months of COBRA continuation coverage, the spouse and
dependent children in your family can get up to 18 additional                How much does COBRA continuation coverage cost?
months of COBRA continuation coverage, for a maximum of 36                   Each qualified beneficiary will be required to pay the entire cost of
months from the date of the original qualifying event, if notice of          continuation coverage. The amount a qualified beneficiary may be

                                                                        11
                                             Important Information                       Continued

required to pay may not exceed 102 percent of the cost to the                 All payments for continuation coverage should be sent
group health plan (including both employer and employee                       to: Star HRG – P.O. Box 37218 Phoenix, Arizona 85069
contributions) for coverage of a similarly situated plan participant
or beneficiary who is not receiving continuation coverage. The                Termination of COBRA Coverage
required payment for each continuation coverage period for each               Continuation coverage will be terminated before the end of the
option is described in this notice.                                           maximum period if:
                                                                              • any required premium is not paid in full on time,
When and how must payment for COBRA continuation                              • a qualified beneficiary becomes covered, after electing
coverage be made?                                                               continuation coverage, under another group health plan that
First payment for continuation coverage                                         does not impose any pre-existing condition exclusion for a
If you elect continuation coverage, you do not have to send any                 pre-existing condition of the qualified beneficiary (if the plan does
payment with the election form. However, you must make your                     apply an exclusion or limitation for a pre-existing condition,
first payment for continuation coverage not later than 45 days after            COBRA continuation coverage will terminate at the end of the
the date of your election. (This is the date the election notice is             pre-existing condition exclusion or limitation period),
post-marked, if mailed.) If you do not make your first payment for            • a qualified beneficiary becomes enrolled in Medicare benefits
continuation coverage in full not later than 45 days after the date             (under Part A, Part B, or both) after electing continuation
of your election, you will lose all continuation coverage rights under          coverage, or
the Plan. You are responsible for making sure that the amount of              • your employer ceases to provide any group health plan for its
your first payment is correct. You may contact the Program                      employees.
Administrator to confirm the correct amount of your first payment.
                                                                              Continuation coverage may also be terminated for any reason the
Periodic payments for continuation coverage                                   Plan would terminate coverage of a participant or beneficiary not
After you make your first payment for continuation coverage, you              receiving continuation coverage (such as fraud).
will be required to make periodic payments for each subsequent
coverage period. The amount due for each coverage period for                  If You Have Questions
each qualified beneficiary is shown in the election notice. The               Questions concerning your Plan or your COBRA continuation
periodic payments can be made on a monthly basis. Under the                   coverage rights should be addressed to the contact or contacts
Plan, each of these periodic payments for continuation coverage is            identified below. For more information about your rights under
due on the specified day of the month for that coverage period. If            ERISA, including COBRA, the Health Insurance Portability and
you make a periodic payment on or before the first day of the                 Accountability Act (HIPAA), and other laws affecting group health
coverage period to which it applies, your coverage under the Plan             plans, contact the nearest Regional or District Office of the U.S.
will continue for that coverage period without any break. The Plan            Department of Labor’s Employee Benefits Security Administration
will not send periodic notices of payments due for these coverage             (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa.
periods.                                                                      (Addresses and phone numbers of Regional and District EBSA
                                                                              Offices are available through EBSA’s website.)
Grace periods for periodic payments
Although periodic payments are due on the dates shown above,                  Keep Your Plan Informed of Address Changes
you will be given a grace period of 30 days after the first day of the        In order to protect your family’s rights, you should keep the
coverage period to make each periodic payment. Your continuation              Program Administrator informed of any changes in the addresses of
coverage will be provided for each coverage period as long as                 family members. You should also keep a copy, for your records, of
payment for that coverage period is made before the end of the                any notices you send to the Program Administrator.
grace period for that payment. However, if you pay a periodic
payment later than the first day of the coverage period to which it           Program Administrator Information
applies, but before the end of the grace period for the coverage              If you have any questions, please contact us at Star HRG -
period, your coverage under the Plan will be suspended as of the              P.O. Box 55270, Phoenix, Arizona 85078 or call
first day of the coverage period and then retroactively reinstated            1-800-308-5948.
(going back to the first day of the coverage period) when the
periodic payment is received. This means that any claim you                   Statement of ERISA Rights
submit for benefits while your coverage is suspended may be                   As a participant in the plan, you are entitled to certain rights and
denied and may have to be resubmitted once your coverage is                   protections under the Employee Retirements Income Security Act
reinstated.                                                                   of 1974 (“ERISA”). ERISA provides that all plan participants shall be
                                                                              entitled to:
If you fail to make a periodic payment before the end of the grace            1. Examine, without charge, at the Program Administrator’s office
period for that coverage period, you will lose all rights to                     and at other specified locations, such as worksites and union halls,
continuation coverage under the Plan.                                            all documents governing the plan, including insurance contracts


                                                                         12
                                             Important Information                        Continued

   and collective bargaining agreements, and a copy of the latest                part, you may file suit in a state or Federal court. In addition, if
   annual report (Form 5500 Series) filed by the plan with the U.S.              you disagree with the plan’s decision or lack thereof concerning
   Department of Labor and available at the Public Disclosure                    the qualified status of a medical child support order, you may file
   Room of the Employee Benefits Security Administration.                        suit in Federal court. If it should happen that plan fiduciaries
2. Obtain upon written request to the Program Administrator,                     misuse the plans money, or if you are discriminated against for
   copies of documents governing the operation of the plan,                      asserting your rights, you may seek assistance from the U.S.
   including insurance contracts and collective bargaining                       Department of Labor, or you may file suite in a Federal court.
   agreements, and copies of the latest annual report (Form 5500                 The court will decide who should pay court costs and legal fees.
   Series) and updated summary plan description.The administrator                If you are successful, the court may order the person you have
   may make a reasonable charge for the copies.                                  sued to pay these costs and fees. If you lose, the court may
3. Receive a summary of the plan’s annual financial report.The plan              order you to pay these costs and fees, for example, if it finds your
   administrator is required by law to furnish each participant with             claim is frivolous
   a copy of this summary annual report if the plan is required to
   file an annual report.if it files an annual report, the Plan                If you have any questions about this statement or about your rights
   Administrator is required by law to furnish each plan participant           under ERISA, or if you need assistance in obtaining documents from the
   with a copy of this summary annual report.                                  Program Administrator, you should contact the nearest office of the
4. Continue health care coverage (for the participant or the                   Employee Benefits Security Administration, U.S. Department of Labor,
   participants spouse or dependents) if there is a loss of coverage           listed in your telephone directory or the Division of Technical Assistance
   under the plan as a result of a qualifying event.The participant may        and Inquiries, Employee Benefits Security Administration, U.S.
   have to pay for such coverage. Participants should review this              Department of Labor, 200 Constitution Avenue N.W.,Washington, D.C.
   summary plan description and the documents governing the plan               20210.You may also obtain certain publications about your rights and
   on the rules governing their COBRA continuation coverage rights.            responsibilities under ERISA by calling the publications hotline of the
5. Receive a reduction or elimination of exclusionary periods of               Employee Benefits Security Administration.
   coverage for preexisting conditions if there is creditable
   coverage from another plan. Participants should be provided a
   certificate of creditable coverage, free of charge, from their
   group health plan or health insurance issuer when they lose
   coverage under the plan, when they become entitled to elect
   COBRA continuation coverage, when their COBRA                                             IMPORTANT MASTECTOMY NOTICE
                                                                                           Reconstructive Surgery After Mastectomies
   continuation coverage ceases, if they request it before losing              Effective October 21, 1998, Congress enacted the Women’s
   coverage, or if they request it up to 24 months after losing                Health and Cancer Rights Act. The Act stipulates that any health
   coverage. Without evidence of creditable coverage, participants             plan that provides medical benefits for a mastectomy must also
   may be subject to a preexisting condition exclusion for 12                  provide coverage for breast reconstruction if you choose to
   months after enrollment. In addition to creating rights for plan            receive it. Specifically, any patient who is covered for mastectomy
                                                                               is also covered for:
   participants, ERISA imposes duties upon the people who are                  1. Reconstruction of the breast on which the mastectomy was
   responsible for the operation of the employee benefit plan. The                performed;
   people who operate your plan, called “fiduciaries” of the plan,             2. Reconstruction of the other breast to achieve symmetry;
   have a duty to do so prudently and in the interest of you and               3. Prostheses and physical complications of all stages of
   other plan participants and beneficiaries. No one, including your              mastectomy including lymphedema.
                                                                               This Act does not change the benefit limits or deductible of
   employer, your union, or any other person, may fire you or                  the Starbridge Choices Plan.
   otherwise discriminate against you in any way to prevent you
   from obtaining a (pension, welfare) benefit or exercising your              NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT
                                                                                                             (NMHPA)
   rights under ERISA. If your claim for a benefit is denied or                                  Special Rights Upon Childbirth
   ignored, in whole or in part, you have a right to know why this             Group health plans and health insurance Issuers generally may
   was done, to obtain copies of documents relating to the decision            not, under Federal law, restrict benefits for any hospital length of
   without charge, and to appeal any denial, all within certain time           stay in connection with childbirth for the mother or newborn
   schedules. Under ERISA, there are steps you can take to enforce             child to less than 48 hours following a vaginal delivery, or less than
                                                                               96 hours following a cesarean section. However, Federal law
   the above rights. For instance, if you request a copy of plan               generally does not prohibit the mother’s or newborn’s attending
   documents or the latest annual report from the plan and do not              provider, after consulting with the mother, from discharging the
   receive them within 30 days, you may file suit in a Federal court.          mother or her newborn earlier than 48 hours (or 96 hours as
   In such a case, the court may require the Program Administrator             applicable). In any case, plans and issuers may not, under Federal
   to provide the materials and pay you up to $110 a day until you             law, require that a provider obtain authorization from the plan or
                                                                               the issuer for prescribing a length of stay not in excess of 48
   receive the materials, unless the materials were not sent because           hours (or 96 hours).
   of reasons beyond the control of the administrator. If you have             This Act does not change the benefit limits or deductible of the Starbridge
   a claim for benefits which is denied or ignored, in whole or in             Choices Plan.


                                                                          13
                                    UICI/Star HRG Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION                                       contract;
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW                                       • placing an insurance contract for reinsurance of our insurance risks;
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE                                    • claims adjudication;
REVIEW IT CAREFULLY.                                                              • disclosures to medical consultants to determine the medical
                                                                                    necessity of treatment recommended by your physician;
If you have any questions about this Notice, please contact our                   • policy administration, underwriting and premium rating;
Privacy Office by calling 602-956-4200 or writing to Attn: Privacy                • eligibility determinations;
Office, Star HRG, P.O. Box 55270, Phoenix, AZ 85078-5270.                         • detection and investigation of fraud and other unlawful conduct;
WHO WILL FOLLOW THIS NOTICE.                                                      • recovery of overpayments;
This Notice of Privacy Practices describes the practices of UICI and              • conduct of grievances and appeals programs; and
the following companies that are affiliated with UICI: The MEGA Life              • disclosures to PPO networks for purposes of repricing claims.
and Health Insurance Company, Mid-West National Life Insurance                    We may use or disclose your medical information as necessary to
Company of Tennessee, The Chesapeake Life Insurance Company                       provide you with information about other health-related products or
and Star HRG (collectively, “UICI”).                                              services that are included in your insurance benefits, including
                                                                                  communications about replacement of, or enhancements to, an
OUR COMMITMENT TO YOUR PRIVACY                                                    insurance policy. For example, your name and address may be used to
We understand that medical information about you and your health                  send you a newsletter about our organization and your insurance
is personal and we are committed to protecting that information. We               benefits. You may contact our Privacy Office to opt-out of receiving
create a record of your benefits, eligibility status and claims history.We        such materials. We will not disclose your medical information to third
need this record to provide you with quality health care benefits and             parties for marketing purposes without your written authorization.
to comply with certain legal requirements. Hospitals, physicians and
other health care providers providing health care services to you may             As Required By Law
have different policies or notices regarding their uses and disclosures           We will disclose medical information about you when required to do
of your medical information.                                                      so by federal, state or local law. We must also share your medical
                                                                                  information with the Secretary of the Department of Health and
This Notice will tell you about the ways in which we may use and                  Human Services to investigate or determine our compliance with
disclose medical information about you.This Notice will also describe             federal privacy laws.
your rights and certain obligations we have regarding the use and
disclosure of medical information.                                                To Avert a Serious Threat to Health or Safety
                                                                                  We may use and disclose medical information about you when
We are required by law to:                                                        necessary to prevent a serious threat to your health and safety or to
                                                                                  the health and safety of the public or another person. Any disclosure,
• make sure that medical information that identifies you is kept private;         however, would only be to someone able to help prevent the threat.
• give you this Notice of our legal duties and privacy practices with
  respect to medical information about you; and                                   Special Situations
• follow the terms of the Notice that is currently in effect.                     We also may use or disclose your protected health information in the
                                                                                  following special situations without your authorization.These situations
                                                                                  include:
HOW WE MAY USE / DISCLOSE MEDICAL INFORMATION
ABOUT YOU                                                                         • Health Oversight
UICI will not disclose your medical information to anyone, except with            We may disclose protected health information to a health oversight
your authorization or as otherwise permitted or required by law. For              agency for activities authorized by law, such as audits, investigations and
some activities, we must have your written authorization to use or                inspections. Health oversight agencies include government agencies
disclose your medical information. However, the law permits us to use             that oversee health plan administration, state insurance regulatory
or disclose your medical information for the following purposes                   authorities and certain other government regulatory programs.
without your authorization:
                                                                                  • Public Health Risks
Payment                                                                           We may disclose medical information about you for public health
We may use and disclose your medical information in order to pay                  activities.These activities may include (1) the prevention or control of
for your medical benefits under our health insurance policy. These                disease, injury or disability and (2) notifying people of recalls of
activities may include making a determination of eligibility or coverage          products they may be using.
for insurance benefits, reviewing services provided to you to                     • Lawsuits and Disputes
determine medical necessity, and undertaking utilization review or                If you are involved in a lawsuit or a dispute, we may disclose medical
case management activities with respect to your claims. For example,              information about you in response to a court or administrative order.
we may use and disclosure your medical information to pay your                    We may also disclose medical information about you in response to a
claims or process your premium payments.                                          subpoena, discovery request or other lawful process by someone else
Health Care Operations                                                            involved in the dispute, but only if efforts have been made to tell you
We may use or disclose medical information about you for our insurance            about the request (which may include written notice to you) or to
operations.These uses and disclosures are necessary to run the insurance          obtain an order protecting the information requested.
company and make sure that our beneficiaries receive quality benefits and         • Law Enforcement
customer service. Here are some examples of the ways that we use your             We may release medical information if asked to do so by a law
medical information for our health care operations:                               enforcement official: (1) in response to a court order, subpoena,
• creation, renewal, replacement or maintenance of your insurance                 warrant, summons or similar process; (2) to identify or locate a

                                                                             14
                             UICI/Star HRG Notice of Privacy Practices                                           Continued

suspect, fugitive, material witness or missing person; (3) about the                You may have the right to have your medical information
victim of a crime if, under certain limited circumstances, we are unable            amended.
to obtain the person’s agreement; (4) about a death we believe may                  You may request that we amend your medical information that is
be the result of criminal conduct; or (5) in emergency circumstances                incorrect or incomplete for as long as we maintain the information. In
to report a crime, the location of the crime or victims, or the identity,           certain cases, we may deny your request for amendment. If we deny your
description or location of the person who committed the crime.                      request for amendment, you have the right to file a statement of
                                                                                    disagreement with us and we may prepare a rebuttal to your statement
• For Specific Government Functions                                                 and provide you with a copy of such rebuttal. Any statement of
We may disclose your medical information for the following specific                 disagreement will become a permanent part of our records.To request
government functions: (1) health information of military personnel, as              an amendment, you must send a written request, along with the reason
required by military authorities; (2) health information of inmates, to a           for the request, to our Privacy Office.
correctional institution or law enforcement official; and (3) for national
security reasons.                                                                   You have the right to receive an accounting of certain
                                                                                    disclosures of your medical information.
• Workers’ Compensation                                                             You have a right to receive an accounting of disclosures of your
We may disclose your protected health information as authorized to                  medical information we have made after April 14, 2003 for purposes
comply with workers’ compensation laws and other similar legally                    other than disclosures (1) for our treatment, payment or health care
established programs.                                                               operations, (2) to you or based upon your authorization and (3) for
                                                                                    certain government functions. To request an accounting, you must
YOUR RIGHTS                                                                         submit a written request to our Privacy Office. You must specify the
The following is a statement of your rights with respect to your                    time period, which may not be longer than six years.
medical information and a brief description of how you may exercise
these rights.                                                                       You have the right to a paper copy of this Notice.
                                                                                    You have the right to obtain a paper copy of this Notice from us upon
You have the right to inspect and copy your medical information.                    request, even if you have agreed to accept this Notice electronically.To
You may inspect and obtain a copy of medical information about you                  obtain a paper copy of this Notice, please contact our Privacy Office.
for as long as we maintain the medical information. We may charge
you a fee for the costs of copying, mailing or other supplies that are              CHANGES TO THIS NOTICE
necessary to grant your request. You have the right to choose to                    We reserve the right to change this Notice. We reserve the right to
obtain a summary instead of a copy of your medical information.                     make the revised Notice effective for the medical information we
Under federal law, however, you may not inspect or copy                             already have about you as well as any information we receive in the
psychotherapy notes or information compiled in reasonable                           future. We will post a copy of the current Notice on the Star HRG
anticipation of, or for use in a civil, criminal or administrative action or        (Starbridge Choices) website at www.starbridgechoices.com. The
proceeding. In some circumstances, you may have the right to have our               Notice will contain on the main page, under the Privacy link.
decision to deny you access to your medical information reviewed.
Please contact our Privacy Office if you have any questions about                   COMPLAINTS
access to your medical information.                                                 You may contact us or the Secretary of the United States Department
                                                                                    of Health and Human Services if you believe your privacy rights have
You have the right to request a restriction on the use and                          been violated.To file a complaint with UICI, contact our Privacy Office.
disclosure of your medical information.                                             All complaints must be submitted in writing. No retaliatory actions will
You have the right to request restrictions on certain uses and                      be taken against you for filing a complaint.
disclosures of your medical information. We are not required to agree
to a restriction that you request. If we do agree to a requested                    OTHER USES OF MEDICAL INFORMATION
restriction, we will put the agreement in writing and follow it, except in          Other uses and disclosures of medical information not covered by this
emergency situations. We cannot agree to limit uses or disclosures of               Notice or the laws that apply to us will be made only with your
information that are required by law.You may request a restriction by               authorization. If you provide us with permission to use or disclose
writing to or telephoning our Privacy Office.                                       medical information about you by signing a written authorization, you
                                                                                    may revoke that permission, in writing, at any time. If you revoke your
You have the right to request to receive confidential                               permission, we will no longer use or disclose medical information about
communications from us by alternative means or at an                                you for the reasons covered by your written authorization. You
alternative location.                                                               understand that we are unable to take back any disclosures we have
You may request that any and all confidential communications regarding              already made with your permission.
your medical information be sent by alternative means or to an
alternative location. For example, you may request that we contact you              You may contact our Privacy Office by calling 602-956-4200 or
only in writing or at a different residence or post office box. We will             writing to Attn: Privacy Office, Star HRG, P.O. Box 55270,
accommodate reasonable requests. We may, however, condition such                    Phoenix, AZ 85078-5270.
accommodation on your agreeing to permanent communications at the
alternative location or by the alternative means.We will not request an
explanation from you as to the basis for the request. Please make any
such requests in writing to our Privacy Office.




                                                                               15
                                      Claim Identification Form

We can’t process claims we can’t identify. To help us identify your claim faster, you must complete this
Claim Identification Form. Please follow the instructions below.
         1. Complete This Claim Identification Form (Claim ID Forms may be photocopied).
         2. Attach original bills (bills may NOT be photocopied).
         3. Attach copy of “Certificate of Creditable Coverage” from your prior insurer with your 1st claim.
         4. Mail to the address below. (Facsimile documents CANNOT be accepted.)
                   Please submit your claim within 90 days of the date of service.
                                                      Star HRG
                        A Division of The MEGA Life and Health Insurance Company
                                                  P. O. Box 55270
                                              Phoenix, AZ 85078-5270
                                                  (877) 209-7098

Associate Name                                                      Social Security Number

Home Address                                                        Associate Birth Date

City & State                                    Zip                 Telephone No.

Name of Employer                                                    Has Employment Terminated?
                                                                       Yes             No
City & State                                                         If Yes, Date

Patient Name (if other than Associate)                               Male           Female

Patient Relationship to Associate              Patient Birth Date   Is Patient Married?
                                                                       Yes            No
Nature of Sickness, Injury, Diagnosis or Medical Visit



I authorize the release for the use by Star HRG and/or The MEGA Life and Health Insurance Company, of
any medical or other information needed in processing this claim. A photocopy of this authorization shall be
valid as the original.
This authorization is valid for the term of the policy or contract under which a claim has been
submitted.

Signed (Associate, All Claims) X _____________________________Date ________________________

Patient or Parent (if minor) X _______________________________Date ________________________

Any person who knowingly (with intent to injure, defraud, or deceive the insurance company) files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
crime and maybe subject to fines and confinement in prison.

I certify that each of the statements made as part of this claim are complete and true to the best of my
knowledge and belief.

Associate Signature ____________________________________________________________________
        Payless Shoesource, Inc.
3231 SE Sixth Street • Topeka, KS 66607




                                          INSURANCE DOCUMENTS ENCLOSED

				
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