Coverage Disclaimer

COVERAGE INFORMATION
I understand if I pay any portion of my health insurance premiums using pretax dollars (Section 125) or my employer pays any portion of my health insurance premiums (Section 106) or provides reimbursement for uninsured medical expenses for me and my dependents (Section 162), I should answer "yes" to the question, "Do you, your employer or any of your Eligible Dependents intend to treat this health Benefit Plan as part of a plan or program under Section 162, Section 125 or Section 106 of the U.S. Internal Revenue Code?" (located in Section 3, Coverage Information).

BLUE SAVER BENEFIT PLAN
I understand the Blue Saver Benefit Plan is a high deductible health plan designed to comply with Section 223 of the U.S. Internal Revenue Code and is intended for use with a Health Savings Account. I also understand BCBSND does not provide tax, investment or legal advice. If I have questions about a Health Savings Account or the tax implications of the Blue Saver Benefit Plan, I should contact a qualified tax, investment or legal professional.

ELIGIBILITY REQUIREMENTS FOR PERSONAL CHOICE FOR STUDENTS
To be eligible for coverage under this Benefit Plan, the applicant must be a full-time student at an accredited post-secondary institution in North Dakota, or must be a resident of the state of North Dakota at an accredited post-secondary institution.

Coverage under this Benefit Plan terminates when the Subscriber ceases attending school and does not continue to pursue their education. If the Subscriber has not graduated or completed a defined course of study and has taken one academic term off (including the summer academic term) during an academic year, the Subscriber will remain eligible. However, the Subscriber under this Benefit Plan becomes ineligible for coverage if the Subscriber does not return to school on a full time basis for the first academic term immediately following a missed academic term (including the summer academic term.) Identical non student coverage may be continued through the Personal Choice Bank Depositor Program.

LIMITATIONS AND EXCLUSIONS
I understand Members are subject to limitations and exclusions outlined in the relevant Benefit Plan or policy.

Benefits are not available for any services, supplies or charges for the care or treatment received by me or any of my Eligible Dependents listed on this application for 365 days following the individual Member's effective date of coverage under the Benefit Plan for a condition, disease, illness or injury for which medical advice or treatment was received within the six-month period immediately preceding the individual Member's effective date of coverage under the Benefit Plan.

Benefits are not available for services received by me or any of my Eligible Dependents listed on this membership application for services received during the 365-day Waiting Period, beginning on the effective date of the individual Member's coverage for human organ and tissue transplants, tonsillectomies, adenoidectomies, typanostomies requiring the insertion of ventilating tubes, myringotomy without ventilating tubes, excision of cataracts, hysterectomies, sterilization procedures*, treatment of hernias, treatment of hemorrhoids, breast reduction surgery, surgical treatment of morbid obesity**, maternity delivery services (except for complications of pregnancy)***, postnatal care or the surgical treatment of gallbladder and the bile duct system.

The Waiting Period may be reduced by Qualifying Previous Coverage, if continuous until at least 63 days prior to the individual Member's effective date of coverage under the Benefit Plan.

Members under age 19 will not be subject to a waiting period.

* No coverage is available for sterilization procedures under the Basic Plan or Basic Conversion.

** No coverage is available for the treatment of morbid obesity under Personal Choice, Personal Choice for Students, Standard Plan, Basic Plan or Basic Conversion.

*** No coverage is available for maternity services under Personal Choice or Personal Choice for Students. Benefits will be available for services provided to treat complications caused by pregnancy.

No coverage is available for infertility services under Personal Choice, Personal Choice for Students, Standard Plan, Basic Plan or Basic Conversion.