Golden Rule Health Insurance Company

Policy Forms C-006.3 or C-006.4

36168-0506

Why Choose Golden Rule?

Experience and Expertise
Golden Rule Insurance Company has been a leader in the individual health market for nearly 60 years. Serving individuals and families is our primary focus. Because we are dedicated to this market, we have developed a unique understanding of the health insurance needs of individuals and families. This knowledge is reflected throughout your experience with Golden Rule -- in our high quality products, our handling of claims, and our customer service.

Product Leadership
Golden Rule’s experience and expertise in the individual health market drive the development of plans that strive to make health coverage more affordable for more Americans. A recognized pioneer -- and one of the nation’s leading providers -- of Health Savings Account plans, Golden Rule continues to seek and embrace new ways to build plans with the benefits you need at prices you can afford.

Claims Satisfaction
At Golden Rule, we recognize the critical importance
of being responsive to the service needs of our customers. That’s why more than 94% of all health insurance claims are processed within 10 working days or less.* With Golden Rule, you can be confident that your claims will be promptly processed.

Preferred Network Discounts
With a Golden Rule insurance plan, you gain access to a quality network of health care professionals and facilities available in your area. Having access to our Preferred Networks can mean substantial discounts in what you pay for your health care. The combined buying power of networks on behalf of large numbers of customers can translate into significant savings for you, including covered out-of-pocket health care expenses incurred before you meet your deductible.

Strength in Numbers
Golden Rule is proud to be a member of the UnitedHealth Group family of businesses. As an innovative leader in the health and well-being industry, UnitedHealth Group currently serves nearly 55 million individuals nationwide, with products and services to help people achieve better health.

* Actual 2005 results

The Network Advantage

All Golden Rule health insurance plans include access to one of our Savings-Based Networks. Preferred Networks are also available, and offer significant premium discounts.

Savings-Based Networks
Savings-Based Networks are included with all plans and provide:

Access to a broad network of physicians and hospitals to help reduce your costs; and
Freedom to use non-network physicians and hospitals.

While you are free to use any health care professional, using a Savings-Based Network physician or hospital benefits you in the following ways:

You may pay less for services incurred before your deductible is met;
Network physicians and hospitals will not bill above the accepted network fee; and
Network physicians and hospitals will file your claim for you.

Preferred Networks
Available in most areas. A Preferred Network includes physicians, hospitals, and other health care providers that have agreed to provide quality health care at reduced costs.

Lower costs mean lower premiums. Most applicants choose one of our Preferred Networks to take advantage of these premium reductions.

In return for the premium reduction, you agree to use physicians, hospitals, and other health care providers in your Preferred Network.

If you are insured under a Preferred Network plan and receive non-emergency services outside your Preferred Network, covered expenses are:

Reduced by 25%; and
Subject to a separate deductible amount equal to the calendar-year deductible.

If you are under a Copay Plan (which requires Preferred Network), office visit expenses outside your network are not eligible for copay benefits.

Copay Plans

Who might benefit most from a Copay Select^SM plan?

Anyone who prefers the convenience of copay benefits for routine health care expenses.
Families with young children who have regularly scheduled doctor office visits.
Adults who want copay benefits for preventive care and prescription drugs.

How Health Savings Accounts (HSAs) Work Chart

How Copay Select^SM Works

Convenient doctor office copay benefits
When you use a Preferred Network doctor for an office visit, we pay 100% of history and exam fees after a $25 copay.

Adult and Child Preventive Care included
Preventive Care office visits are covered the same as other doctor office visits -- with copay benefits.

Prescription drug card benefits

Generic drugs -- $15 copay
Name brand drugs -- $100 per person per calendar year deductible, then:
- $30 copay for preferred brands
- $60 copay for non-preferred brands

Comprehensive Coverage for inpatient and outpatient medical expenses

Up to $3 million lifetime maximum benefit per covered person
Covered inpatient and outpatient expenses are reimbursed at 80% once the deductible has been met

Copay Saver^SM
The Copay Saver^SM plan provides the convenience of copays for doctor office visits (limited to 2 visits per person, per calendar year) for a lower monthly premium.

Copay Plans -- Benefit Highlights
-	Copay Select^SM	Copay Saver^SM
Design Basics
Network Type	Preferred Network Included
Calendar-Year Deductible Choices (maximum 2 per family, per calendar year)	$500, $1,000, $1,500, $2,500	$2,000
Coinsurance (per covered person, per calendar year)	80/20 to $10,000 then 100%	80/20 to $15,000 then 100%
Lifetime Maximum Benefit (per covered person)	$3 million	$3 million
Initial Rate Guarantee (subject to benefit and address changes)	12 months	12 months
Coverage percentages below are effective AFTER deductibles have been met unless otherwise indicated.
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room and Professional Fees of Doctors, Surgeons, Nurses	80%	80%
Other Covered Inpatient Services	80%	80%
Outpatient Expense Benefits
Surgeon, Assistant Surgeon, and Facility Fees	80%	80%
Hemodialysis, Radiation, Chemotherapy, and Organ Transplant Drugs	80%	80%
CAT Scans, MRIs	80%	80%
Outpatient X-ray and Lab (performed in the doctor's office or elsewhere)	80%	80% if performed within 14 days of surgery or confinement
Emergency Room Fees	80% -- additional $100 Copay for illness if not admitted	80% -- additional $500 Copay if not admitted
Other Covered Outpatient Expenses	80%	See Covered Expenses for details
Routine Health Benefits
Doctor Office Visit	For history and exam: $25 Copay, then 100% (not subject to deductible)	For history and exam: $35 Copay, then 100% (maximum 2 visits per person, per year) Other services: Not Covered
Mammography, Pap Smear, and PSA Testing	For history and exam: $25 Copay, then 100% For other services, performed in or out of doctor's office, including but not limited to, X-ray and Lab, subject to the deductible, then 80%	80%
Adult Preventive Care (age 19 or older)		Not Covered
Well Child Care/Immunizations (ages 0-18)		Not covered
Outpatient Prescription Drugs	Generic: $15 Copay Name Brand: $100 per person, calendar year deductible -- then $30 Copay for preferred, $60 Copay for non-preferred (If Generic is available, Name Brand reimbursed at Generic price)	Not Covered -- Preferred Price Card Included
Dental and Vision Discounts -- Programs Are Not Insurance	Discounts through FACT membership provided by Health Allies -- save up to 50% on dental and vision.
Optional Benefits	For a complete list, see Optional Benefits.
This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network. We recommend review of the more detailed plan information under Covered Expenses, Provisions That Apply To All Plans, and State Variations.

Health Savings Account (HSA) Plans

Who might benefit most from an HSA plan?

Anyone interested in more control over how their health care dollars are spent.
Families interested in one annual deductible per family.
Those interested in trading low deductible health insurance for a higher deductible plan to save money on monthly premiums and taxes.

How HSAs Work

HSA Plans offer quality coverage, savings
HSA Plans have two components: a lower cost, high deductible health insurance plan and a tax-favored savings account.

The money you save on premiums can be put into your tax-favored health savings account (HSA). You can withdraw the money to help pay your deductible or other qualified health care expenses. Once your deductible is met, the insurance plan starts paying for covered expenses.

Your unspent savings roll over year after year.

Lower premiums, tax-advantaged savings, and an attractive interest rate*
The money you save from reduced premiums can be put into your Health Savings Account -- tax deductible.

Your health savings grow tax-deferred, and can be withdrawn tax-free to help pay your deductible or for other qualified health care expenses like prescriptions, vision, or dental care.

What you don’t use will continue to accumulate year after year. Then, if you ever need it for health care expenses, the money will be there.

At Golden Rule, you’ll earn interest on your savings, beginning with the first dollar deposited.

* See HSA Insert for important information.

HSA Plans -- Benefit Highlights
-	HSA 100^®	HSA Saver^®
Design Basics
Network Type	Preferred or Savings Based Network
Calendar-Year Deductible Choices (one per family)	See HSA Insert	See HSA Insert
Coinsurance After Deductible	100%	100%
Lifetime Maximum Benefit (per covered person)	$3 million	$3 million
Initial Rate Guarantee (subject to benefit and address changes)	12 months	12 months
Coverage percentages below are effective AFTER deductibles have been met unless otherwise indicated.
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, and Professional Fees of Doctors, Surgeons, Nurses	100%	100%
Other Covered Inpatient Services	100%	100%
Outpatient Expense Benefits
Surgeon, Assistant Surgeon, and Facility Fees	100%	100%
Hemodialysis, Radiation, Chemotherapy, and Organ Transplant Drugs	100%	100%
CAT Scans, MRIs	100%	100%
Outpatient X-ray and Lab	100%	100% if performed within 14 days of surgery or confinement
Emergency Room Fees	100%	100% if admitted; if not admitted -- limited to $250/person/year
Other Covered Outpatient Expenses	100%	See Covered Expenses for details
Routine Health Benefits
Doctor Office Visit Fees	100%	Not Covered
Outpatient Prescription Drugs (Preferred Price Card included with all plans)	100%	Not Covered -- Preferred Price Card Included
Mammography, Pap Smear, and PSA Testing	100%	100%
Adult Preventive Care (Up to $500 annually for each adult age 19 or older; subject to 3-month waiting period)	100%	Not Covered
Childhood Immunizations (Up to $500 annually for ages 0-18; subject to 3-month waiting period)	100%	Not covered
Dental and Vision Discounts -- Programs Are Not Insurance	Discounts through Health Allies (benefit of FACT membership) -- save up to 50% on dental and vision.
Optional Benefits	For a complete list, see Optional Benefits.
This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network. We recommend review of the more detailed plan information under Covered Expenses, Provisions That Apply To All Plans, and State Variations.

About Your HSA

Account Information by Phone or On-line

We have chosen Exante Bank, a leading administrator of Health Savings Accounts, as our financial institution. Your HSA funds are deposited in a custodial account at Exante Bank. Exante Bank, member FDIC, will service your account and will send information directly to you about your HSA.

You will receive your new Health Savings Account Card^SM and a PIN mailer in separate mailings. Once you activate your card, you can use it at:

Any point-of-service location (such as a doctor’s office or pharmacy) that accepts MasterCard^® debit cards
Any ATM displaying the MasterCard brand mark ($1.50 per transaction. In addition to Exante’s fee, the bank/ATM you use to withdraw funds will charge you their own fee (variable by bank) for the transaction)

You can also access your HSA funds through:

On-line bill payment at ExanteBankHSA.com -- limit one transaction per business day
Checks, if you choose to purchase them

HSA Deposits are set up on the same payment plan as premiums for Golden Rule health insurance coverage. Lump-sum deposits are also accepted by Exante Bank; however, you must continue to deposit the $25 monthly minimum with your premium payment. Exante Bank will provide on-line monthly statements detailing your account balance and activity. If you prefer to have statements mailed to your home, simply notify Exante Bank. You can opt-out of electronic statements at ExanteBankHSA.com, call customer service to do so, or send your request to P.O. Box 271629, Salt Lake City, UT 84127-1629.

If you prefer, you can purchase the qualified health insurance coverage from Golden Rule and set up your savings account with another qualified custodian.

With an Exante Bank HSA, your account information is available, day or night, through:

Toll-free customer service -- representatives are available to assist you Monday through Friday, 9:00 a.m. to 7:00 p.m. Eastern time, at 1-866-234-8913
Interactive voice response for self service, 24/7
ExanteBankHSA.com

You can:

Make lump-sum contributions to your HSA
Pay bills on-line
Check current balance
See how much interest has been paid
Transfer funds
Check last five (5) account transactions (deposits and/or withdrawals)
Activate the Health Savings Account Card
Report the card lost or stolen
Set or reset password
View frequently asked questions
View monthly statements

Health Savings Accounts (HSAs) -- Summary of the Law

Eligibility -- Those covered under a qualified high deductible health plan, and not covered by other health insurance (except for vision or dental coverage) or enrolled in Medicare, and who may not be claimed as a dependent on another person's tax return

HSA Contributions -- 100% tax-deductible from gross income

Qualified Medical Withdrawals -- Tax-free

Interest Earned -- Tax-deferred; if used for qualified medical expenses, tax-free

Non-medical Withdrawals -- Income tax +10% penalty tax (under age 65); income tax only (for age 65 and over)

Death, Disability -- Income tax only -- no penalty

Deductible and out-of-pocket maximums may be adjusted annually based on changes in the Consumer Price Index.

This is only a brief summary of the applicable federal law. Consult your tax advisor for more details of the law.

Deductibles and Monthly Health Savings Account (HSA) Deposit Options
-	Singles					Families
Deductible	$1,050	$1,800	$2,700	$3,500*	$5,000*	$2,100	$3,650	$5,450	$7,500*	$10,000*
Plan out-of-pocket maximum	Equal to the deductible
Maximum monthly deposit (tax-deductible limit)**	$87.50	$150.00	$225.00	$225.00	$225.00	$175.00	$304.16	$454.16	$454.16	$454.16
Deductibles not available in Connecticut and Delaware. *Those individuals aged 55 and over may contribute an additional $700 for tax year 2007.

HSA Management by Exante Bank
Current Interest Credited	Access to Funds	One-Time Set-Up Fee	Monthly Maintenance	Minimum Monthly Deposit
5%*	Health Savings Account Card	$10	$3	$25

Exante Bank is an FDIC insured institution, and is responsible for the money in your Health Savings Account.

You will receive a Health Savings Account Card from Exante Bank shortly after your qualified medical coverage becomes effective. HSA Withdrawals can be made by simply using your Health Savings Account Card at any point-of-service location (such as a doctor’s office or pharmacy) that accepts MasterCard^® debit cards.

*As of 7/1/06, subject to change.

If you prefer, you can purchase the qualified health insurance coverage from Golden Rule and set up your savings account with another qualified custodian.

Optional Benefit from Golden Rule: HSA Hospital Indemnity Rider

The optional HSA Hospital Indemnity Rider is designed to help protect against major hospitalization expenses during the early months of coverage while cash accumulates in your savings account.

The HSA Hospital Indemnity Rider provides a lump-sum cash benefit on the third day of hospital confinement. This money can be used to help pay your deductible or for any other purpose.

The cash benefit amount depends on your deductible amount and decreases over time (see table).

The optional rider pays once, regardless of the number of hospitalizations, and there are no benefits under this rider if the hospitalization would not have been covered by the medical coverage. In addition, you only pay the premium amount once.

Hospital Indemnity Rider Cash Benefit
Month	Single Benefit	Family Benefit
1	$1,500	$3,200
2	$1,400	$2,950
3	$1,250	$2,700
4	$1,150	$2,450
5	$1,050	$2,225
6	$950	$2,000
7	$850	$1,775
8	$750	$1,550
9	$675	$1,325
10	$600	$1,125
11	$525	$925
12	$450	$725
13	$400	$550
14	$350	$400
15	$300	$250
16	-$0- 0	-$0-
One-Time Premium Amount For This Option	$40	$150

Note: HSA Hospital Indemnity Rider is not available for plans with $1,050 or $2,100 deductibles.

35572-0606

High Deductible Plans

Who might benefit most from a High Deductible plan?

Anyone willing to take responsibility for routine health care expenses in exchange for lower premiums.
Anyone seeking lower cost protection from unexpected accidents and illnesses.
Early retirees needing a bridge to Medicare.

How High Deductible Plans Work

Lower Premiums
With high deductible plans, you’re keeping more of your money and taking responsibility for covering minor or routine health care expenses -- if they come up. The higher the deductible, the lower your premiums.

Saver 80^SM is our lowest premium plan. This plan provides coverage for hospital confinements, surgical procedures in or out of the hospital, and the more costly outpatient expenses, such as CAT scans and MRIs.

Simple to use
Golden Rule’s top-selling high deductible plan -- Plan 100^® -- pays 100% of covered expenses once you meet your calendar-year deductible. Your benefits are not complicated with multiple copays or coinsurance.

Comprehensive Coverage

Up to $3 million lifetime maximum benefit per covered person
Up to $500 annually for adult preventive care or childhood immunizations (see chart below for details)
Add optional benefits to increase coverage (see optional benefits for details)

High Deductible Plans -- Benefit Highlights
-	Plan 100^®	Plan 80^SM	Saver 80^SM
Design Basics
Network Type	Preferred or Savings Based Network
Calendar-Year Deductible Choices (maximum 2 per family, per calendar year)	$2,500, $3,500, $5,000	$2,500, $3,500, $5,000	$500, $1,000, $1,500 $2,500, $3,500, $5,000
Coinsurance (per covered person, per calendar year)	100%	80/20 to $15,000 then 100%	80/20 to $15,000 then 100%
Lifetime Maximum Benefit (per covered person)	$3 million	$3 million	$3 million
Initial Rate Guarantee (subject to benefit and address changes)	12 months	12 months	12 months
Coverage percentages below are effective AFTER deductibles have been met unless otherwise indicated.
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, and Professional Fees of Doctors, Surgeons, Nurses	100%	80%	80%
Other Covered Inpatient Services	100%	80%	80%
Outpatient Expense Benefits
Surgeon, Assistant Surgeon, and Facility Fees	100%	80%	80%
Hemodialysis, Radiation, Chemotherapy, and Organ Transplant Drugs	100%	80%	80%
CAT Scans, MRIs	100%	80%	80%
Outpatient X-ray and Lab	100%	80%	80% if performed within 14 days of surgery or confinement
Emergency Room Fees	100% -- additional $100 Copay for illness if not admitted	80% -- additional $100 Copay for illness if not admitted	80% -- additional $500 Copay if not admitted
Other Covered Outpatient Expenses	100%	80%	See Covered Expenses for details
Routine Health Benefits
Doctor Office Visit Fees	100%	80%	Not Covered
Outpatient Prescription Drugs (Preferred Price Card included with all plans)	100%	80%	Not Covered -- Preferred Price Card Included
Mammography, Pap Smear, and PSA Testing	100%	80%	80%
Adult Preventive Care (Up to $500 annually for each adult 19 or older; subject to 3-month waiting period.)	100%	80%	Not Covered
Childhood Immunizations (Up to $500 annually for ages 0-18; subject to 3-month waiting period)	100%	80%	Not Covered
Dental and Vision Discounts --Programs Are Not Insurance	Discounts through Health Allies (benefit of FACT membership) -- save up to 50% on dental and vision.
Optional Benefits	For a complete list, see Optional Benefits.
This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network. We recommend review of the more detailed plan information under Covered Expenses, Provisions That Apply To All Plans, and State Variations.

Optional Benefits

Optional Benefits
Further customize your health insurance coverage to meet your specific needs.

Preventive Care Benefits Package
(Not available with Copay Select^SM Plan.)

This option is available with our Preferred Network health insurance plans. If elected, this option replaces preventive care benefits otherwise included within the plan. This package waives the deductible and provides 100% for the following covered expenses:

Preventive Care Benefits Package

Routine well child care visits through age 18
100% in network for covered services; deductible does not apply

Childhood immunizations
100% in network; deductible does not apply

Mammogram, Pap smear, and PSA test
100% in network for one of each test per calendar year; deductible does not apply

Adult preventive care age 19 and older
(12 month wait on adult preventive care)
$35 copay, then 100% in network -- limited to $300 per calendar year

Maternity Benefit
(Not available with HSA Plans; not available in AR, MD, or VA.)

This optional benefit helps cover the costs for routine pregnancy and delivery. You choose the maximum benefit amount -- $2,500 or $4,000. Payment is limited to 50% of the maximum benefit during the first year. After the first year, the plan will pay 100% of the maximum benefit. To be covered, pregnancy must begin while maternity benefits are in effect.

Benefit Amount	Year 1	Year 2 & On
$2,500	50%	100%
$4,000	50%	100%

Prescription Drug Card Benefit
(Not available with any Saver or HSA Plans or Copay Select^SM.)

With this benefit, you can purchase:

Generic prescription drugs for a $20 copay; and
Name-brand drugs for a $50 copay after a $250 calendar-year, per-person deductible.

IMPORTANT: If generic is available, name-brand