Attachment_4_-_SPD_Revised.docx

TABLE OF CONTENTS

Special Message for RSNF Personnel in the United States 1

Introduction 3

About the Medical Plan 3

Plan Eligibility 3

Adding Dependent Coverage 4

Extending Plan Coverage 4

Extraordinary Inclusion 5

Medical Identification Card 6

The Paid Prescription Card 8

The Reimbursement Claim Form 10

Sponsor (RSNF Member) Responsibilities 12

Responsibilities of (Company Name) 14

Schedule of Benefits

A. Major Medical 16

B. Exclusions to Major Medical Program 19

C. Prescription Drugs 20

D. Exclusions to Prescription Drug Program 20

E. Dental Services 21

F. Exclusions and Limitations to Dental Services 21

G. Orthodontic Services 23

H. Exclusions and Limitations to Orthodontic Services 24

I. Eye Care Services 24

J. Exclusions to Eye Care Services 25

Appendices:

A: Glossary of Terms 26

B: Reimbursement Claim Form 27

C: Extraordinary Inclusion Form 28

Special Message for RSNF Personnel in the United States

On (date) procedures for medical services for RSNF personnel and their dependents changed. It is very important that you take the time to read the material provided in this booklet to understand the new system. A failure to do this may result in an interruption of your medical care.

Each RSNF sponsor and the adult members (age 10 or more) of his family are issued a Medical Identification (ID) Card. These cards are effective from the commencement of the training period or 1 January of each year, whichever is later, through 31 December of the following year, or the end of your training period, whichever date is earlier. You must be careful to safeguard these cards. You will be unable to receive care without them.

Medical ID cards must be presented each time you visit a doctor or dentist for care. You must also have in your possession some other form of identification that bears your photograph (passport, driver's license, U.S. Government ID card). When children (less than age 10) require care they must be accompanied by a parent with a Medical ID card and the additional form of identification. Your Medical ID card may not be loaned or used by any other person. Sponsors must ensure that no one except the members of their immediate family (who are listed on the Invitational Travel Orders, ITOs) receive care with their family cards. Violation of this restriction will result in the loss of all RSNF paid care.

Each family will also receive a Paid Prescription card to be used to obtain drugs ordered by your doctor or dentist. This card will be accepted by most pharmacies. This card will ONLY pay for prescription generic drugs.

IF YOU LOSE ANY MEDICAL ID CARD OR YOUR PAID PRESCRIPTION CARD YOU MUST NOTIFY (COMPANY NAME) AND/OR NETSAFA IMMEDIATELY.

Most doctors and dentists will provide services to you and your family members and send bills to the notify (Company Name) for payment. They are not required to do this. Some may require you to pay at the time of the visit. If you are not willing to pay at the time of the visit make sure the doctor agrees in advance to bill the (Company Name).

If your doctor or dentist will not agree to bill (Company Name) for the services he provides to you, and you are unable to find another physician, you should obtain an estimate of the fees he will charge. This estimate should be sent by mail or fax to the (Company Name) with your request to determine if the fees are customary. If you fail to do this you may pay too much. You will only be reimbursed to the limit of what is determined to be customary for the services received.

You may also be required to pay for prescriptions if the drugstore you select will not accept your prescription card.

In order to be repaid in cases where you have paid for services you must complete a Reimbursement Claim Form (copies of this form are provided with the enrollment package and another is bound into this booklet as Appendix B) and mail it with ALL receipts to the (Company Name) at the address on the form. You should keep a copy of every claim form you submit for payment, together with copies of all receipts.

Any bills or other correspondence you receive concerning medical services provided to you should be promptly forwarded to the (Company Name) at the address on your Medical ID card. Failure to forward this kind of material may delay payment of bills on your behalf and could result in the later denial of credit while you remain in the United States.

INTRODUCTION

ABOUT THE MEDICAL PLAN

The Naval Education and Training Security Assistance Field Activity (NETSAFA), in Pensacola, Florida, has coordinated the award to (Company Name), of Medical Administrator contract (contract #). The purpose of this contract is the management of medical services required by Royal Saudi Naval Forces (RSNF) personnel and their dependents while stationed in the United States. As implementation of this contract continues, it is intended that there be no interruption of member medical services.

This Summary Plan Description (SPD) cancels and replaces the (Previous SDP information), and is effective upon receipt. This SPD is provided to assist you in understanding procedures so that no unintended interruption of medical services occurs. IT IS VERY IMPORTANT THAT YOU TAKE THE TIME TO REVIEW THIS DOCUMENT SO THAT YOU UNDERSTAND WHAT SERVICES ARE COVERED AND WHAT YOUR RESPONSIBILITIES ARE IN USING THIS SERVICE. It is also important that you inform your spouse and any other adult dependents of their responsibilities in this program.

PLAN ELIGIBILITY

1. Eligibility: A sponsor and his dependents become eligible for coverage on the first day of scheduled training as defined by NETSAFA and shown on the individual sponsor's ITO. This plan covers medical and dental services for the sponsor and accompanying family members only within the United States and Canada. The plan also covers emergency medical and dental services for eligible persons enroute to or from the United States in all countries except the Kingdom of Saudi Arabia.

2. Effective Date: The effective date of coverage for sponsors and dependents is the first day of scheduled training as defined by NETSAFA and shown on the ITO. This date is also shown on the Medical ID card ("Effective Date"). Payment for services received before the "Effective Date" will be the responsibility of the sponsor.

3. Expiration Date: Sponsor and all dependent coverage and benefits under this plan automatically end on the expiration date ("Expiration or Termination Date") shown on the Medical ID card. This date is normally 10 days after completion of last training. Payment for services, prescriptions, and supplies received after the "Expiration or Termination Date" is the responsibility of the sponsor.

4. Eligible Dependents: In order to be eligible for benefits under this Medical Plan accompanying dependents' full names and dates of birth must be listed as such on the sponsor's ITO. Eligible dependents include the following:

ADDING DEPENDENT COVERAGE

1. In cases where coverage is required for a dependent whose name does not appear on the ITO, the sponsor must apply in writing to ADANA for his/her addition. This application should be made through the assigned Training Liaison Team or directly to ADANA providing the following information:

a. Dependent's full name as shown in passport or Certificate of Birth for children born in the United States.

b. Date of dependent's birth.

c. Date dependent became/becomes eligible for coverage.

2. After information is provided, the sponsor’s ITO will be amended with dependent’s information and eligibility will be established.

EXTENDING PLAN COVERAGE

1. Should a need arise to extend coverage under the Plan it is the sponsor's responsibility to bring this need to the attention of the International Military Student Officer (IMSO) at the location where he is assigned for training. When pipeline changes are made by NETSAFA appropriate modifications are also made to the sponsor's ITO. These actions should result in the automatic generation of new Medical Plan ID cards that reflect current dates. It can occur, because of emergent, late changes, that new ID cards are not prepared and delivered before the (“Expiration or Termination Date") on original cards. If a sponsor is aware that he will remain in a training status beyond the (“Expiration or Termination Date") on his ID card he should advise the Training Liaison Team, when assigned, or the IMSO at least a week before coverage ends.

2. Personnel whose extended pipelines will increase their stays in the United States less than 60 days may not necessarily be provided new ID cards but, in this case, it is particularly important that the change to eligibility dates be reflected in the membership list held by (Company Name).

TREATMENT AT A MILITARY TRAINING FACILITY (MTF)

1. Treatment at MTF’s are allowed on a case by case basis and will only be provided the facility has the capacity to provide care.

2. FOR MTF VISITS ONLY:

Send invoices to:

Navy: Commanding Officer (Code N-8) Naval Education and Training Security Assistance Field Activity 250 Dallas Street, Suite B, Pensacola, FL 32508-5269 Invoices must be accompanied by a complete ITO.

EXTRAORDINARY INCLUSION

1. When requested by the ADANA, RSNF personnel whose total period of assignment, as described by the ITO, is less than 60 days, will be added to the plan membership by Extraordinary Inclusion. A copy of the Extraordinary Inclusion letter (a sample of which may be found in Appendix C) will be provided by the ADANA to each individual whose name is added to the medical membership plan in this fashion. This copy will serve the member and his dependents in place of the regular Medical Plan ID card that will not be issued. Persons added to the plan by Extraordinary Inclusion will not be issued Paid Prescription cards but can expect to pay out-of-pocket for prescriptions and related supplies at the time of delivery.

2. In cases where payment for services or supplies is demanded by the provider on delivery, the sponsor will be required to complete a Reimbursement Claim Form (Appendix B) and submit the form to the (Company Name) for repayment. A copy of this claim form is also included as an enclosure to the Extraordinary Inclusion letter and additional copies can be made by the sponsor as required. Read the instructions for submitting the Reimbursement Claim Form in the section of this description that follows.

3. All reimbursements for temporary members will be automatically forwarded to ADANA for further distribution to sponsors.

MEDICAL IDENTIFICATION CARD

Each sponsor and eligible dependent 10 years and older will receive a medical identification card. This card must be presented to the medical service provider on each visit. The card will be validated on the initial visit to a new provider by another form of identification (driver's license, passport, U.S. DOD ID card) which includes a photograph. The personal information on this card is the basis of your eligibility for membership in the RSNF Medical Plan and it is vitally important that it be correct in every detail.

Take the time when you receive your family's ID cards to make sure that all data is correct in accordance with the following specifications:

1. This is the full name of the bearer of the ID card, the sponsor or the eligible dependent.

2. This is the RSNF member's name. The names on lines 1 and 2 must be spelled exactly as they appear in the individual's passport.

3. The sponsor's Case Number from his ITO.

4. The sponsor's Work Control Number (WCN) from his ITO.

5. The earliest date the bearer is eligible under the plan.

6. The last date the bearer is eligible under the plan.

The loss of any family ID card should be reported promptly to the IMSO, NETSAFA, the TLT, or ADANA.

HOSPITAL ADMISSION PRE-CERTIFICATION IS

REQUIRED. CALL: 1-800-682-6065

MEMBERS NAME:

SPONSORS NAME:

CASE/WORK CONTROL NUMBER (WCN):

EFF DATE: EXP DATE:

IDENTITY MUST BE VALIDATED TO PROVIDERS BY A PHOTO IDENTIFICATION CARD SUCH AS A U.S. DOD ID CARD, PASSPORT OR A DRIVER'S LICENSE.

Front

Membership validation, claims and inquiries concerning plan BILLING INFORMATION:

Payment of plan benefits for the sponsor identified by this card, as well as his authorized dependents, is guaranteed by the Government of Saudi Arabia to the limit of customary charges in the geographic area where provided. Contract administration services only are provided by (Company Name) through a contract with the U.S. Navy, and neither shall be held liable for costs associated with the delivery of plan services. Patient's name and sponsor's name with CASE/WCN must appear on all billing statements as they appear on this card. Failure to submit the correct information will result in return to provider. Billing statements will not be honored unless received by (Company Name) within one year of date of service.

Benefits

Back

THE PAID PRESCRIPTION DRUG CARD

Each sponsor will receive a single prescription drug card for use by his family in obtaining drugs and supplies authorized under the Plan and prescribed by an authorized provider. There will be no charge to members for drugs and supplies delivered under this Plan. When using this card to obtain drugs and supplies under the Plan, you or your dependents must be prepared to identify yourselves by presenting your Medical ID card.

The Paid Prescription card carries two items of personal information to be validated:

1. Work Control Number (WCN) from the sponsor's ITO.

2. The sponsor's name, spelled exactly as it appears in the passport.

You must promptly report the loss of your Paid Prescription card to one of the following parties: the IMSO, NETSAFA, the TLT, or ADANA.

CASE:

SPONSORS NAME

FRONT

TERMS AND CONDITIONS

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THE REIMBURSEMENT CLAIM FORM

1. Each sponsor will receive several copies of the Reimbursement Claim Form with the initial delivery of his Medical Plan materials. Keep one of these forms blank so that you can make additional copies.

2. The Reimbursement Claim Form is to be completed and mailed to (Company Name), by the sponsor in cases where the sponsor had to make payment to a provider out-of-pocket. Only the costs of services and supplies that are eligible under this plan will be reimbursed. When submitting a reimbursement claim the sponsor must insure that a valid, complete address is provided to which the payment can be mailed. Reimbursement checks should normally be mailed within two months so, if the sponsor expects to transfer to a new location soon, he should make arrangements to have his mail forwarded to the new station. The sponsor may wish to have his reimbursement payment sent to ADANA for forwarding. In this case the following address should be entered at line 5 of the Reimbursement Form:

c/o ADANA 2461 South Clark Street Suite 560 Arlington, VA 22227

3. Sponsors must be certain to attach appropriate receipts and/or copy of the original bill which gives the following information:

a. Date that service(s) or supplies were received.

b. Identification of the provider.

c. Specific service(s) or supplies provided.

d. An indication that the charges have been paid.

4. The sponsor should keep a copy of all material submitted with the claim form until the reimbursement is received from the healthcare administrator.

ROYAL SAUDI NAVAL FORCES (RSNF) MEDICAL

REIMBURSEMENT CLAIM FORM

If you have paid for medical, dental or prescription charges as a member of the Health Plan you must complete the following information and send it to:

(Insurance provider information) Sponsor Completes:

1. Name of Sponsor:

2. Case # &Work Control #:

Complete the following ONLY if charges are for dependents:

3. Name of Dependent:

4. Spouse or Child:

5. Date of Birth:

6. To support this claim you must include the provider’s statement of the Services for which you paid which should include applicable CPT/ADA Codes, date(s) of service, and evidence that the bill(s) has/have been paid (copy of cancelled check, credit card receipt, etc.). Failure to provide this documentation will result in the claim being returned to you and delay in payment being received.

7. Sponsor Address for payment return:

SPONSOR (RSNF MEMBER) RESPONSIBILITIES

1. General: The most important responsibility that the sponsor has in this Medical Plan is to learn what is in this SPD and how the plan is designed to operate. The plan is intended to provide very high quality medical, dental, and associated services support to RSNF members and their families while they are in the United States. Extensive arrangements have been made to make the plan as simple to use as possible, but just because it is so much simpler than plans that U.S. providers are used to, it may be difficult for some to understand. SPONSORS WHO EXPERIENCE THESE DIFFICULTIES SHOULD ENCOURAGE THE PROVIDER'S BUSINESS REPRESENTATIVES TO CALL (COMPANY NAME & PHONE NUMBER), FOR ANSWERS TO THEIR QUESTIONS.

2. Family Data: The sponsor must verify that the data which appears on his family's medical ID cards and the Paid Prescription card are exactly correct. Each name must appear on individual cards just as they do in individual passports. Errors in any of this data could result in an interruption in receiving services under the plan.

3. Outpatient Services: Services under this Plan are paid up to the maximum that is Reasonable and Customary (R&C) for the geographic area where the provider is located. If you are unsure, you should ask the provider prior to your visit if services will be covered. If you do not ask before services are received you may be charged more than the Plan will pay. In such cases the sponsor is required to pay whatever charges are above R&C. The provider can determine if his charges will be covered by the Plan by calling (Company Name), at the number shown on the Medical ID card.

4. In Patient (Hospital) Services: Except in emergency situations sponsors are required to obtain hospital pre-admission authorization. In some cases (determined by the Administrator) surgical second opinions may also be required. Notice of these requirements is printed on the Plan ID card together with the toll-free telephone number through which authorization is requested. Hospital Admissions personnel normally handle this procedure. Sponsors must ensure that Admissions Office personnel see your ID card and comply with the pre-admission requirement. Failure to do so may make the sponsor liable for hospital costs. RSNF supported patients are normally required to select a hospital facility which has entered into a special pricing agreement. If a request is received for admission to a hospital that does not honor this agreement, admission will be denied and information will be provided to guide the sponsor to the nearest authorized facility. In emergency situations the sponsor is required to ensure that the hospital advises the Administrator through the pre-admission (800) number within 48 hours that an emergency admission has occurred.

5. Billing: The Administrator will make no effort to process or pay bills received under the Plan if the patient or the RSNF sponsor cannot be identified as a member or if CASE/WCN data is incorrect. Bills received with these deficiencies will be returned to the provider without action. This policy is printed on the ID card. Sponsors should verify that ID card data has been correctly transcribed on all billing documents because delays in payment, for whatever reason, may result in a demand for sponsor payments on future visits.

6. Correspondence: Sponsors should take one of the following actions on all Medical Plan correspondence they receive directly from providers:

a. If the correspondence concerns a bill for services which is the responsibility of the sponsor he should take action to pay the bill as promptly as possible. These kinds of billing problems will not resolve themselves. Medical creditors in the United States are typically very determined and valid debts will be eventually brought to the attention of the RSNF if they are ignored.

b. If the correspondence concerns a bill which you believe has been paid by the Plan, or should have been paid by the Plan, or any other Plan associated matter which is not understood or is not a provider responsibility, it must be referred to the (Insurance Provider). Telephone calls concerning matters which are not sponsor responsibilities should likewise be referred to the (Insurance Provider) as follows:

(Insurance Provider) Telephone:

Telephone:

Facsimile:

(Company Name) can represent the interests of Plan members only if they are kept informed of issues with providers as those issues occur.

RESPONSIBILITIES OF THE HEALTHCARE ADMINISTRATOR

1. Role as Administrator. the healthcare administrator will act as the Administrator for the Royal Saudi Naval Forces Medical Plan. The following are the principal duties of the Administrator:

a. (Company Name) will receive bills for medical, dental, and related health services provided to Plan members. These bills will be screened to determine that the services provided are eligible under the Plan, that the amounts billed do not exceed R&C for the geographical area where provided, and make payments to providers accordingly.

b. (Company Name) will have responsibility for management of approval action for all types of pre-treatment plans developed by providers in accordance with the requirements of this Plan. Dental treatment plans, which require case-by-case approval will be analyzed by (Company Name), and forwarded, with appropriate recommendation, to ADANA. Orthodontic treatment plans will be handled as outlined in the Schedule of Benefits, Section G & H.

c. A Utilization Review (UR) manager will be contracted for by the (Insurance Provider). The UR manager will have responsibility for the validation of medical need in cases where inpatient care is ordered by an authorized health professional. The UR manager will determine the need for second opinion, the appropriateness of the planned length of hospital stay, and hospital status in a Preferred Provider Organization (PPO), all conditions for authorizing admission.

d. (Insurance Provider) will advise the sponsor (or NETSAFA if the sponsor cannot be contacted) in any case where admission is denied based on the above criteria. In these cases (Insurance Provider) will also provide the names of alternative hospital(s) if appropriate.

e. (Insurance Provider) will not mandate use of PPO physicians by members, but will restrict admission to hospitals, which are members of a qualified PPO, when reasonably available.

f. All inquiries regarding hospitalization should be directed to (Company Name).

g. (Company Name) will have sole responsibility for the performance of subcontractors it employs in executing the requirements of the Insurance Provider’s contract.

h. (Company Name) will maintain a membership data base in accordance with direction received from NETSAFA in order to be able to confirm to provider's membership inquiries. (Company Name) will also provide Medical Plan ID cards, Paid Prescription cards, Reimbursement Claim Forms, and SPD copies to NETSAFA for distribution to new members.

i. (Company Name) will automatically advise providers whose charges for services exceed R&C levels, providing appeal options should the provider not agree with the payment level. (Company Name) will also respond to subsequent inquiries made by providers or their agents who seek to make collections of any kind, if provided the appropriate correspondence.

j. (Company Name) will provide members with Explanation of Medical/Dental Benefits via web access.

SCHEDULE OF BENEFITS

In the service descriptions which follow for Major Medical, Prescription Drugs, Dental Services, Orthodontic Services, and Eye Care Services, examples of specific, common services for which benefits are provided under the plan are provided. For the purposes of benefit authorization, only those services listed as Exclusions or Limitations are not authorized. Final determination of plan coverage is the responsibility (Company Name).

A. MAJOR MEDICAL

All medically necessary charges up to the level defined as Usual and Customary or Reasonable (U&C, R&C, URC) for hospital and medical expenses, professional services, office visits, prescription drugs, medical supplies and other expenses detailed below:

1. Mental health care. All services

2. In-patient hospital care including:

a. Private room.

b. Operating, recovery, anesthesia, delivery, labor, intensive care, coronary care and cystoscopic rooms.

c. Nursery care for the newborn while mother is hospitalized for maternity care.

d. Meals, including special diets.

e. Drugs and medicines provided by the hospital, including intravenous solutions and injections.

f. Oxygen, and the equipment necessary for its administration, sterile tray service, dressings and plaster casts.

g. Blood plasma and blood expanders.

h. Physical therapy, occupational therapy and inhalation therapy (when furnished by and billed by the hospital).

i. Semi-private accommodations, when:

(1) No private room is available at the time of admission.

3. Outpatient hospital services in connection with accidental injuries, medical emergencies, outpatient surgery and dialysis.

4. Hospital and medical care in connection with an abortion, D&C, or full term delivery for female members who are victims of rape and become pregnant as a result of rape.

5. Insulin (including intravenous prescription drugs) and medicines listed in the official U.S. formularies.

6. Artificial limbs or eyes.

7. Casts, splints, trusses, braces and crutches.

8. Rental of a wheel chair or hospital type bed, iron lung or mechanical equipment for the treatment of respiratory paralysis.

9. Local professional ambulance service to a local hospital or beyond the local area to the nearest PPO facility equipped to handle the patient's condition.

10. Professional nursing care by a registered private duty nurse (R.N.) or a licensed practical nurse (L.P.N.). Benefits for private duty nursing skilled care are limited to a maximum of 2 hours per day for up to 50 days in a calendar year where required by patient's condition.

11. Services provided by a certified nurse midwife.

12. Treatment of cleft lip and/or cleft palate disorders.

13. Maternity care including prenatal and postnatal care and complications of pregnancy.

14. Eyeglasses or contact lenses required as a result of surgery, including cataract surgery (subject to limitations in cost described in Section I).

15. The administration of general anesthesia when rendered by a physician, other than the attending physician or his assistant, when given for a covered surgical or obstetrical procedure.

16. Surgery, which includes operations necessary for treatment of a disease, injury or ailment, usual pre-operative and post-operative services, endoscopic procedures (inserting tube to examine internal organs; typical examples - cystoscopy, proctoscopy, sigmoidoscopy), and treatment of fractured and dislocated bones.

17. Well-baby examinations as prescribed by the attending physician.

18. Benefits for diagnostic and laboratory treatment services will be paid wherever performed when they are related to a symptom of a disease or ailment or are part of a routine physical examination.

19. Allergy tests, injections and serum.

20. Dressing, medical supplies and sterile tray service.

21. Blood transfusions, blood processing and blood handling, the cost of unreplaced blood or blood plasma.

22. Cardiac Rehabilitation Program benefits for up to 90 visits during treatment plan rendered by an approved Cardiac Rehabilitation Program provider.

23. Benefits are limited to one annual general physical examination or well-woman examination, including related physician ordered tests. This policy will not limit children who change schools within a year and require new examinations as a condition of entry in the new school.

24. Services in the technical specialties of physical therapy, occupational therapy, chiropractic, licensed speech therapy and pathology, audiology, pain management, and podiatry are authorized subject to the following prerequisites. Approval by the Plan Administrator is required on a case-by-case basis prior to the commencement of treatment.

a. Referral for any of these services must be obtained from a medical doctor practicing within an area relevant to the illness or disability for which services are sought. Should services be required beyond a three-month period from their commencement, reevaluation and referral is required.

b. A treatment plan is required from the therapist or chiropractor detailing the frequency and length of therapy, and cost of planned services. Physical therapy and chiropractic services are limited in frequency to twice weekly sessions.

c. The Plan will accept no responsibility for coverage of services not approved by the Plan Administrator prior to the commencement of those services and in each case where continuation of services is required beyond the three-month anniversary.

d. Members or providers who require assistance in interpreting these requirements my contact the Plan Administrator.

B. EXCLUSIONS TO MAJOR MEDICAL PROGRAM

The services identified in this section are not included in the medical plan except under conditions described. Members who accept these services without previous, specific, case-by-case authorization by ADANA will be responsible for all associated fees including services, equipment, and associated drugs.

1. Any case for which benefits may be or could have been obtained in whole or in part, under any Federal or State Compensation Act or similar legislation.

2. Any case to the extent benefits are obtained or could have been obtained upon appropriate application under Medicare.

3. Charges in connection with an illness to the extent the member is entitled to payment from other sources.

4. Charges which would not have been incurred if the member had not been covered by this or similar coverage.

5. Dental services, eye refractions, eye glasses or hearing aids unless required because of accidental injury while the member is covered.

6. Services related to cosmetic or plastic surgery except for the correction of a condition resulting from an accidental injury, disease or surgery or for congenital anomalies or the correction of a condition for functional reasons.

7. Treatment for weight reduction unless prescribed by a medical doctor.

8. Services and supplies which are not FDA approved for the use prescribed.

9. Charges filed later than one year from the date the services were rendered.

10. Charges for reproductive and sexual disorders and defects, whether or not the consequence of disease, illness, or injury except as authorized by ADANA on a pre-certified, case-by-case basis.

11. Physician's home, office or hospital visits are limited to one visit per day unless warranted by the complexity of the patient's condition.

C. PRESCRIPTION DRUGS

1. All charges associated with the provision to group members of out-of-hospital drugs that by Federal law may not be dispensed without a prescription are covered.

2. There is to be no deductible charge for prescription drugs.

3. Covered drugs are those which, by Federal law, are required to bear the legend, "Caution: Federal law prohibits dispensing without prescription." Injectable insulin, is also a covered drug. Prescription orders for oral contraceptives are covered; however, they are limited to a 90-day supply.

D. EXCLUSIONS TO PRESCRIPTION DRUG PROGRAM

1. Drugs which do not by Federal law require a prescription order, except injectable insulin.

2. Drugs requiring a prescription by state, but not Federal law.

3. Supplies of any type even though such supplies may require a prescription order, including, but not limited to: contraceptive devices, therapeutic devices, artificial appliances, hypodermic needles, syringes (except in conjunction with the prescription of injectable insulin), or similar devices.

4. Any charge for the administration or injection of drugs or insulin.

5. The charge for more than a 34-day supply of medication, except that chronic ailment prescription drugs may be dispensed in supplies up to a maximum of 100-dose quantities.

6. The charge for any prescription refill in excess of the number specified by the physician or dentist, or any refill dispensed after one year from the date of the prescription order.

E.

DENTAL SERVICES

All charges up to those defined as URC for the following professional services and associated supplies and expenses:

1. Preventative Care:

a. Oral exams (once each six-month period)

b. Bitewings (once each six-month period)

c. Full Mouth Series or Panoramic (in lieu of Full Mouth) Full Mouth or Panoramic x-rays benefits will be provided once every 36 months

d. Prophylaxis (once each six-month period)

e. Fluoride and sealants (provided once each six-month period in conjunction with routine semiannual prophylaxis for patients under age 16)

2. Palliative emergency services (to alleviate pain). ADA Code 9110

F. EXCLUSIONS AND LIMITATIONS TO DENTAL SERVICES

The services identified in this section are not included in the dental plan, except under the conditions described. Members who accept these services without previous, case-by-case authorization by ADANA or his designated representative will be responsible for all associated fees including services, equipment, and associated drugs.

1. Space maintainers.

2. Diagnostic models.

3. Pulp vitality testing

4. Consultation service.

5. Restorative services - including amalgam (silver filling), composite and synthetic resin materials, silicate cement, and stainless steel crowns (deciduous teeth only). Fillings or restorations provided only once per calendar year for the same tooth surface.

6. Treatment of acute periodontic disease.

7. Simple repair of dentures and bridges - including repair of removable dentures, repair of broken facings, and recementation of crowns, bridges, facings and inlays.

8. General Anesthesia.

9. Oral surgery - limited to routine, simple and complex extractions; alveoplasties; frenulectomies; stomatoplasties; the incision and drainage of abscesses; and the removal of exostosis and hyperplastic tissue.

10. Therapeutic drug injection.

11. Pulpotomy (removal of tooth pulp) and pulp capping in conjunction with the provision of palliative and routine restorative services.

12. Endodontic services - including root canal therapy, apicoectomy (removal of root tip), and retrograde amalgam.

13. Crowns.

14. Crown build-ups to permanent teeth (One crown build up per tooth every five benefit periods).

15. Onlays and inlays (porcelain or gold restorations).

16. Removable prosthetics (full or partial dentures).

17. Other prosthetics.

18. Relining of dentures.

19. Fixed prosthesis (bridges).

20. Periodontic services - including gingival curettage (removal of growths or material from the gums), gingivoplasty (surgical modeling of the gingival margin and papillae), and osseous (bone) surgery.

21. Orthognathic surgery.

22. Benefits are limited to one initial oral examination per patient per dentist.

23. Benefits for supplementary bitewings are not provided more frequently than twice in a benefit period (calendar year).

24. Benefits for topical fluoride application are not provided more than twice during a benefit period and will be limited to participants under age 16 only.

25. Benefits are limited to prophylaxis when prophylaxis and gross scaling are rendered on the same date. (Gross scaling is considered as a component of prophylaxis).

G. ORTHODONTIC SERVICES

1. Orthodontics is the branch of dentistry concerned with the diagnosis and treatment of irregularities of the teeth and malocclusion. Orthodontic services (beyond diagnosis) are approved for payment only if prescribed by a treatment plan which is a written report prepared by the attending orthodontist showing the recommended treatment of a recognizable malocclusion which is subsequently approved in writing by the Plan Administrator prior to the commencement of billed services. Sponsors considering orthodontic treatment must obtain permission from ADANA or his designated representative to undertake the diagnosis phase prior to incurring any expense. Fully supported orthodontic treatment plans must be received by the Administrator no later than 60 days prior to training completion.

2. Orthodontic services available under this plan if prescribed and approved by the treatment plan include:

a. Diagnosis - This service includes models, photographs, cephalometric radiographs, x-rays and tracings, appropriate to development of the treatment plan. The Administrator will provide verbal approval for this service to be performed in response to the attending orthodontist's request which must include identification of the member to receive the service and a not-to-exceed cost estimate for the service.

b. Retention - This service follows active treatment and is designed to permanently preserve tooth and bite adjustments achieved.

3. Benefits available as the result of an approved treatment plan for orthodontic services are payable only as long as the sponsor is a member of the medical plan. Additionally:

a. Initial professional services under an approved treatment plan shall be deemed to have been rendered on the date actually performed.

b. Active and retention treatment visits shall be deemed to have been rendered on the first day of each month.

H. EXCLUSIONS AND LIMITATIONS TO ORTHODONTIC SERVICES

1. Benefits for orthodontic services shall be available only to dependents under the age of 23.

2. The maximum number of months for which benefits are provided for active or retention treatment may be reduced by the number of months such treatment has been received before the commencement of sponsor's plan eligibility.

4. If orthodontic services are terminated before completion, plan liability ceases with payment through the month of termination.

5. There will be no plan liability for the replacement and/or repair of any appliance which was initially furnished under an approved orthodontic services treatment plan.

I. EYE CARE SERVICES

1. The eye care program provides payments for regular professional eye care services including periodic eye examination and necessary corrective eyewear supplied by an Ophthalmologist or other Doctor of Medicine, an Optometrist or an Optician acting within the scope of his license.

2. The program will compensate an eye care provider for eye services rendered, in an amount not to exceed the schedule of allowances set forth:

a. Services:

(1) $100.00 - Eye Examination - An eye examination determines visual defects and ocular refractive deformities and deficiencies of the human eye, including refraction and prescription. A medical doctor or optometrist may perform such an examination.

(2) $120.00 - Comprehensive Medical Eye Examination - A Comprehensive Medical Eye Examination is an eye examination as defined above, and in addition is designed to diagnose diseases and abnormalities of the body which can be determined through examination of the eye. Only a medical doctor may perform such an examination.

(3) During each 24-month period a member is entitled to:

(a) One Eye Examination or one Comprehensive Medical Eye Examination for group members under the age of 50.Yearly examinations permitted for members over the age of 50.

(b) One pair of lenses and set of frames or one pair of contact lenses.

b. Supplies:

(1) $130.00 - Single Vision Lenses and frames

(2) $200.00 - Bifocal Lenses and frames

(3) $250.00 - Trifocal Lens and frames

J. EXCLUSIONS TO EYE CARE SERVICES

1. Medical or surgical treatment of the eyes (these services are covered under the major medical portion of the plan).

2. Any examinations, materials or services which are not listed herein as a covered service or supply.

3. Duplicate or spare eyeglasses, or any lenses or frames for duplicate or spare eyeglasses or to replace those which have been lost, stolen or broken.

4. Any lenses which do not require a prescription.

5. Safety glasses or safety goggles.

6. Visual field examinations.

7. Drugs or any other medication (except those used during the examination of the eye and which should be included in the examination charge).

8. Eye exercises including remedial reading exercises.

GLOSSARY OF TERMS

ADANA Assistant Defense Attaché for Naval Affairs

ADMINISTRATOR (Company Name)

BENEFIT PERIOD One Calendar Year

CASE CASE from which funds are being expended

COR Contracting Officer's Representative (NETSAFA)

EFF DATE Effective Date (Start date for coverage)

EXP DATE Expiration Date (End date for coverage)

DOS Date of Service

ID Identification

IMSO International Military Student Officer

ITO Invitational Travel Order

NETSAFA Naval Education and Training Security Assistance Field Activity

PPO Preferred Provider Organization

PROVIDER Doctor, Dentist, Hospital (Any Source of Services)

R&C Reasonable and Customary Cost (Also URC/U&C)

SPD Summary Plan Description

UR Utilization Review

WCN Worksheet Control Number

Appendix A

ROYAL SAUDI NAVAL FORCES (RSNF) MEDICAL

REIMBURSEMENT CLAIM FORM

If you have paid for medical, dental or prescription charges as a member of the Health Plan you must complete the following information and send it to:

Company Name and Information Sponsor Completes:

1. Name of Sponsor:

2. CASE # & WCN:

3. Name of Dependent:

4. Spouse or Child:

5. Date of Birth:

6. To support this claim you must include the provider’s statement of the Services for which you paid which should include applicable CPT/ADA Codes, date(s) of service, and evidence that the bill(s) has/have been paid (copy of cancelled check, credit card receipt, etc.). Failure to provide this documentation will result in the claim being returned to you and delay in payment being received.

Appendix B

To: Commanding Officer, Naval Education and Training Security Assistance Field Activity; Pensacola, FL

Subj: Extraordinary Inclusion in RSNF Medical Plan Membership

Ref: (a) Contract, Medical Administrator Services

Encl: (1) Reimbursement Claim Form

1. It is requested that the Royal Saudi Naval Forces member whose name appears below be included as a Sponsor under the provisions of the medical program described in reference (a). For the purposes of eligibility under the plan membership begins on the effective date shown and ends on the expiration date. No care of any kind from civilian providers is authorized outside of the period described. Dependents (if any) authorized care under this plan are individually listed.

Name (Last, First, MI) WCN

Dependents (Last, First, MI) DOB

Effective Date Expiration Date Case

2. Medical identification cards will not be issued to this member or his dependents. A copy of this letter together with a photo identification card will be used to validate benefit eligibility.

Appendix C

3. Payment of plan benefits for the sponsor identified by this card, as well as his authorized dependents, is guaranteed by the Government of Saudi Arabia to the limit of customary charges in the geographic area where provided. Contract administration services only are provided by the healthcare administrator through a contract with the U. S. Navy, and neither shall be held liable for costs associated with the deliver of plan services. Patient's name and sponsor's name with CASE# &WCN must appear on all billing statements as they appear on this card. Failure to submit the correct information will result in return to provider. BILLING STATEMENTS WILL NOT BE HONORED UNLESS RECEIVED BY THE (COMPANY NAME) WITHIN ONE YEAR OF THE DATE OF SERVICE.

4. Membership validation, claims, and inquiries concerning plan benefits should be made to:

(Insurance provider information)

5. Hospital admission pre-certification is required. Call:

6. Significant program limitations exist in the provision of dental and vision care services and supplies. Specifically, endodontic and prosthodontic services are not authorized except through written case-by-case approval by the ADANA. Vision care and services and supplies are limited to $100 for examinations ($120 for comprehensive examinations provided by a medical doctor) and the following maximum cost for lenses and frames

Services performed without appropriate approval or which incur cost beyond the limitations cited above will be the responsibility of the individual sponsor.

7. If this member requires prescription drugs during the period of his inclusion in the program, as defined in paragraph 1., he will be required to pay for them at the time of delivery. He can recover prescription and other plan authorized out-of-pocket expenses by completing a Reimbursement Claim Form (enclosure (1)) and forwarding it, together with supporting documentation, to the healthcare administrator address on the form.

Commodore Abdullah Al-Khwyter Royal Saudi Naval Forces Copy to:

RSNF Sponsor The healthcare administrator Appendix C

ROYAL SAUDI NAVAL FORCES (RSNF) MEDICAL

REIMBURSEMENT CLAIM FORM

If you have paid for medical, dental or prescription charges as a member of the Health Plan you must complete the following information and send it to:

The healthcare administrator Sponsor Completes:

1. Name of Sponsor:

2. CASE # & WCN:

3. Name of Dependent:

4. Spouse or Child:

5. Date of Birth:

6. To support this claim you must include the provider’s statement of the Services for which you paid which should include applicable CPT/ADA Codes, date(s) of service, and evidence that the bill(s) has/have been paid (copy of cancelled check, credit card receipt, etc.). Failure to provide this documentation will result in the claim being returned to you and delay in payment being received.

Appendix C

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