Superior Plan Benefit Schedule

NATIONAL CASUALTY COMPANY Home Office: Madison, WI 53703-2783 A Stock Insurance Company Administrative Office: 8877 N. Gainey Center Dr., Scottsdale, AZ 85258 • 800-423-7675 DIRECT ALL INQUIRIES AND CLAIMS TO: DVM Insurance Agency: 1800 E. Imperial Highway, Suite 145 • Brea, CA 92821 • 800-540-2016 • 714-989-0555 VPI® SUPERIOR PLAN–COVERAGE FORM 1. INSURING CLAUSE In return for your payment of premium when due and your compliance with the provisions of this policy, we will pay your incurred policy benefits as listed under "Benefit Provisions." We will pay only those veterinary services expenses you incur during the policy term. Benefit payments are subject to all exclusions, limitations, and conditions of this insurance policy. 2. DEFINITIONS: We define words or phrases in your policy. We identify these terms with bold typeface. Congenital disorder Means an abnormality present at birth, whether apparent or not, that can cause illness or disease. See Section 8 for examples. Condition Means an illness, injury, or disease. All manifestations of clinical signs or symptoms of an illness, injury, or disease, regardless of the number of affected areas of your pet's body, constitute one condition. Curable Means capable of being cured. Cured Means resolution of a condition so that ongoing or intermittent treatment is not required and recurrences or complications are not expected. Hereditary disorder Means an abnormality transmitted by gene(s) from parent to offspring, whether apparent or not, that can cause illness or disease. Incident Means any condition that causes you to consult a veterinarian. Chronic or ongoing conditions, e.g. allergic dermatitis, will be considered one incident no matter how many times you consult a veterinarian. Pet Means the animal identified on the Declarations Page or Renewal Certificate of your policy. Plan E Means the Veterinary Pet Insurance Superior Plan. Pre-existing condition Means any condition that began or was contracted, manifested, or incurred before the effective date of this policy, whether or not the condition was discovered, diagnosed, or treated. Specialist Means a diplomate of a specialty board recognized by the American Veterinary Medical Association. Veterinarian Means a legally licensed veterinary practitioner. Veterinary services Means medical treatment provided by or under the direct supervision of a veterinarian. Void Means declaring during the policy term that your policy is not in force and has no effect. We or us Means the company providing this insurance. You or your Means the policyholder listed on the Declarations Page or Renewal Certificate of this insurance policy. 3. POLICY EFFECTIVE DATE Your policy will be in effect at the time and date shown on your Declarations Page or Renewal Certificate. For Plan E, the effective date will be not less than fourteen (14) calendar days after we accept and approve the application and the premium is paid to us. 4. BENEFIT PROVISIONS–PLAN E A. We will pay reasonable and necessary veterinary services expenses for your pet's condition that occurs and is treated during the policy term. To be eligible for payment, your pet’s condition must come within a primary diagnostic code listed on the Superior Plan Benefit Schedule. Each condition is eligible for payment under only one primary diagnostic code and any applicable secondary diagnostic code, per incident. B. The amount we will pay for any condition covered by this policy is determined by: (1) your veterinary services expenses, (2) the Benefit Schedule, and (3) your deductible. We will pay 90% of covered veterinary services expenses up to a maximum of 90% of the Benefit Schedule diagnostic code that applies to your pet's condition, less your deductible. C. Payments under this insurance policy are limited to a maximum of $4,500 per incident and a maximum of $14,000 for each policy term. VS-21 (4-07)

D.

If your pet has a condition requiring your primary veterinarian to refer your pet to another veterinarian who is a specialist, you will receive a second Benefit Schedule allowance for your pet's treatment by the specialist. This additional allowance applies once per incident and does not increase your policy's maximum benefit per incident or the maximum benefit for each policy term.

5. DEDUCTIBLE We specify your deductible on the Declarations Page or Renewal Certificate of your policy. Your deductible will apply once to each incident during the policy term. 6. CO-PAYMENT We specify your co-payment on the Declarations Page or Renewal Certificate of your policy. We will apply a co-payment to each claim. 7. ASSIGNMENT OR TRANSFER OF POLICY You may not assign this policy in whole or in part to any other person or for any other pet. 8. WHAT WE DO NOT COVER: EXCLUSIONS This policy will not pay for: A. Pre-existing conditions. A condition is not pre-existing if it was cured before the effective date of this insurance policy and there has not been a recurrence or manifestation of the condition for at least six (6) months. B. The conditions listed on the Declarations Page or Renewal Certificate of your policy. C. The diagnosis, medical management or surgical correction of anterior cruciate ligament (ACL) damage or rupture to your pet that occurs during the first 12 calendar months this policy is in effect. D. The following musculoskeletal disorders: (1) hip dysplasia, (2) elbow dysplasia, (3) osteochondritis dissecans, (4) aseptic necrosis of the femoral head, (5) cervical vertebral instability, and (6) patellar luxation. E. The following urinary tract disorders: (1) renal dysplasia, and (2) cystine urolithiasis. F. The following ocular disorders: (1) prolapsed gland of the 3rd eyelid, (2) everted, scrolled or inverted cartilage of the 3rd eyelid, (3) distichiasis, (4) ectopic cilia, (5) ectropion, (6) entropion, (7) primary glaucoma, (8) retinal dysplasia, (9) progressive retinal atrophy, (10) corneal dystrophy, including indolent ulcers in pets 6 years of age and older, and (11) cataracts of dogs 6 years of age and younger unless secondary to documented injury or diabetes mellitus. G. The following endocrine disorder: (1) sex hormone dermatosis and (2) growth hormone dermatosis. H. The following respiratory disorder: (1) collapsed trachea. I. The following multi-systemic disorder: (1) histocytosis (cutaneous, systemic or malignant). J. Diagnosis or treatment of any congenital disorder or any condition resulting from the congenital disorder. Examples of congenital conditions are blood clotting deficiencies, portosystemic shunts, urinary tract calculi secondary to metabolic defects, and congenital anatomical defects. This is not a complete list. K. Diagnosis or treatment of any hereditary disorder or any condition resulting from the hereditary disorder. You may obtain a list of conditions we regard as breed-specific hereditary disorders through our Web site, www.petinsurance.com or call us at 800-USA-PETS. L. Elective procedures or cosmetic surgeries including, but not limited to, tail docking, dewclaws, skin folds and nail trims. M. Expression of anal glands or anal sacculitis and removal of anal glands. N. Breeding, artificial insemination, or conditions related to pregnancy, including cesarean section, dystocia, or termination of pregnancy. O. Special diets, pet foods, vitamins, minerals and nutritional supplements, boarding or transport expenses, grooming costs and bathing–including medicated baths. P. Any disease preventable by vaccination. We will pay policy benefits if: (1) your pet was fully vaccinated for the disease and contracted the disease despite the prior vaccination, or (2) your pet was not vaccinated for the disease based on the protocol of your pet's veterinarian. Q. Diagnosis, treatment, training, or therapy for behavioral problems. R. Diagnosis of, or treatment for, internal or external parasites including, but not limited to, fleas, heartworms, and roundworms. We will not pay for preventive treatment or preventive diagnostics associated with internal or external parasites. S. Orthodontics, endodontics, or removal of deciduous teeth. T. Diagnostic test(s) or treatment(s) for conditions excluded or limited by this policy or tests or treatments for complications of conditions excluded or limited by this policy. U. Preventive treatment or diagnostics associated with preventive treatment. V . Routine examinations, vaccines, teeth cleaning or polishing. W. Spaying and neutering. VS-21 (4-07)

X. Y.

Any injury to the insured pet caused intentionally by you or anyone who lives in your household. Any condition caused directly or indirectly by war, terrorism, rebellion, insurrection, or any release of nuclear radiation or radioactive contamination, regardless of cause.

9. OTHER INSURANCE This insurance is excess over any other insurance whether collectable or not, that covers your pet. 10. TERMINATION OF INSURANCE A. The policy will lapse if you do not pay your premium when due. B. We may cancel your policy by mailing written notice to you at the address shown on the Declarations Page or Renewal Certificate of your policy ten (10) days before we cancel your policy. C. You may cancel your policy at any time by notifying us in writing. D. We will refund unearned premiums on a prorated basis if either you or we cancel your policy. 11. LIBERALIZATION If we revise this policy form and broaden your coverage without charge, you will receive the broader coverage as soon as we make the revision. 12. REVIEW You may request a review: (1) if we deny your claim in whole or in part, or (2) to ask that we remove an excluded condition listed on the Declarations Page or Renewal Certificate of your policy. Your request must be in writing. You must provide us with all medical records and any other supporting documentation upon our reasonable request. We will not review requests to remove any excluded condition unless the condition has been cured for at least six (6) months before the date of your request. All review decisions are final. 13. INSURED'S DUTIES A. You must submit all itemized receipts of treatment from a veterinarian with your fully completed and legible claim form. In all cancer treatment claims, you may be required to submit documentation of a test or tests showing that your pet was treated for a malignant condition. B. You agree to submit your pet to examination by a veterinarian selected by us, upon our request. C. You must reasonably protect your pet from aggravation of any condition. D. Upon payment of benefits, we will be subrogated to your rights of recovery from any other party. E . You agree to provide us with all veterinary records when we request them. 14. DECLARATIONS By accepting this policy, you agree that all the statements in your application and the declarations are true and that you have provided us with all material information about your pet's medical condition. You affirm that the policy and the Riders are the entire and only agreements between you and us. 15. FRAUD AND CONCEALMENT We will void your policy from its inception if we discover that you have misrepresented or omitted any material fact and we relied on your misrepresentation or omission in issuing this policy to you. We may deny your claim and void your policy if you conceal material information or make any material misrepresentation in your claim. 16. INSTALLMENT PAYMENT SERVICE CHARGE If you elect to pay your premium in installments, we will charge you the installment fee listed on the Declarations Page or Renewal Certificate of your policy, per each installment payment.

VS-21 (4-07)

Code Diagnosis

(Effective 4-07. Subject to change)

Large Intestine Disorders

Column A is the benefit limit for the Primary Diagnosis or Condition. This includes exam, injections, hospitalization, treatment, surgery.

1250 1251 1255 1256 1257 4011 8120

Column B is the benefit limit for the Primary Diagnostic Testing Maximums listed or the system the diagnosis is under. Specialized Diagnostic Test allowance as listed at the end of this schedule may also be eligible for coverage. Column C is the benefit limit for General Anesthesia as it relates to the primary diagnosis.

Column E is the benefit limit for the condition if it is treated as a Secondary Diagnosis or Condition, concurrently with the Primary Diagnosis or Condition.

Code Diagnosis

C (P olum All rima n A o w ry an Dia ce) gn osi s Co (Pr lum Tes ima n B ting ry D All iagn ow os an tic ce) Co (Pr lum All ima n C o w ry an Ane ce) st he sia C (Prolum Ra ima n D d i a ry C tion he *) mo the ra p Co y/ (Se lum All con n E ow da a n ry ce) Dia gn osi s

Column D is the benefit allowance limit for Chemotherapy and Radiation treatment as it relates to the Primary Diagnosis.

CARDIOVASCULAR SYSTEM (1100) 1101 1102 1103 1104 1105 1106 1107 1108 1109 1110 1111 1114 1115 1121 8110

Arrhythmia $159 Arterial Thromboembolism 370 Cardiomyopathy 216 Neoplasia heart & Pericardium-Surgical 430 Myocarditis-endocarditis 182 Pericardial effusion 380 Congestive heart failure 294 Valvular heart Disease 118 Neoplasia (Peripheral Vessels) 294 Cardiac Arrest 180 Cardiovascular Collapse (Shock) 204 Pacemaker 1400 hypertension 103 Syncope 159 Secondary Tests (Cardiovascular)** —

$315 315 315 315 315 315 315 315 315 315 315 315 315 315 —

$— $— $111 — — 259 — — 151 125 300/1200* 301 — — 127 79 — 266 — — 207 — — 78 79 300/1200* 206 — — 126 — — 143 210 — 980 — — 72 — — 111 — — 205

$395 143 181 1200 700 609 682

$236 236 236 236 236 236 236

$— $— $276 — — 100 79 — 126 125 — 840 125 300/1200* 497 — — 426 100 — 495

$231 884 524 381 —

$236 236 236 236 —

$— $— $162 125 — 619 100 300/1200* 367 89 — 267 — — 405

$140 936 136 324 1617 799 337 700 130 352 —

$236 236 236 236 236 236 236 236 236 236 —

$— $— $98 123 — 655 — — 85 120 — 227 140 — 1132 120 300/1200* 559 — — 236 100 — 195 — — 63 — — 246 — — 150

$378 83 205 1018 900 870 900 1200 478 478

$236 236 236 236 236 236 236 236 236 236

$— $— $265 — — 58 — — 85 109 — 713 125 — 630 110 300/1200* 609 125 630 125 — 840 95 — 239 95 — 239

DIGESTIVE SYSTEM (1200) Esophageal Disorders 1201 1202 1203 1205 1207 1208 1209

Acquired Achalasia esophagitis foreign Body endoscopy foreign Body-Surgical Neoplasia, esophagus-Surgical Megaesophagus-Medical Megaesophagus-Surgical

Abdominal Wall Disorders 1211 1212 1213 1214 1217

Peritonitis-Medical Peritonitis-Surgical Peritoneal Neoplasia-Surgical Trauma-herniation exploratory-Surgical

Stomach Disorders 1220 1221 1222 1223 1224 1225 1226 1227 1228 1230 1235

foreign Body-Medical foreign Body-Surgical gastritis gastric Dilatation-Medical gastric Torsion-Surgical Neoplasia, Stomach-Surgical gastric ulcer Pyloric Stenosis-Surgical Pyloric Stenosis-Medical hemorrhagic gastroenteritis P.e.g. Tube

Small Intestine Disorders 1240 1241 1242 1243 1244 1246 1247 1248 1249 4010

endotoxic Shock enteritis foreign Body-Medical foreign Body-Surgical intussusception-Surgical Neoplasia, Small intestine-Surgical Mesenteric Volvulus intestinal Resection iBD (Biopsy required) Lymphangiectasia, Acquired (Biopsy required)

Colitis Megacolon-Acquired-Medical Neoplasia, Large intestine-Surgical Rectal Polyps-Surgical/endoscopy Rectal Prolapse-Medical Constipation Secondary Tests (Digestive)**

C (P olum All rima n A o w ry an Dia ce) gn osi s Co (Pr lum Tes ima n B ting ry D All iagn ow os an tic ce) Co (Pr lum All ima n C o w ry an Ane ce ) st he si a C (Prolum n i m Ra a D d i a ry C tion he *) mo the ra p Co y/ (Se lum All con n E ow da a n ry ce ) D i a gn o si s

SUPERIOR PLAN BENEFIT SCHEDULE

$98 175 616 167 229 98 —

$236 236 236 236 236 236 —

$–– $— $ 69 –– — 122 125 300/1200* 368 95 — 89 74 — 160 — — 69 — — 154

$241 306 600 379 100 365 —

$152 152 152 152 152 152 —

$–– $— $169 100 — 189 110 — 420 95 300/1200* 256 79 — 52 95 300/1200* 256 — — 98

Pancreatitis $388 exocrine Pancreatic insufficiency 166 Pancreatic Abscess-Surgical 835 Secondary Tests (exocrine Pancreatic)** —

$205 205 205 —

$–– –– 100 —

$1000 245 1200 900 —

$196 196 196 196 —

$94 $— $394 –– — 172 125 — 394 125 300/1200* 630 — — 127

$225 279 665 789 860 — 225 —

$184 184 184 184 184 — 184 —

$74 $— $158 –– — 195 115 300/1200* 466 115 — 552 115 — 602 — — 105 74 — 158 — — 120

$141 154 275 97 73 163 116 107 — 275 —

$131 131 131 131 131 131 131 131 — 131 —

$74 74 95 74 –– 84 –– –– — 95 —

$— — — — — — — — — — —

$99 108 192 68 51 114 81 75 200 192 85

Acanthosis Nigricans $96 Acne 94 Atopic or Allergic Dermatitis 107 Dermatomycosis 100 Dermal Cyst 109 endocrine Alopecia 88 Pyoderma 108 Seborrhea 69 Lick granuloma 113 Neoplasia (Benign) 155 immune Mediated Skin Disease 202 eosinophilic ulcer or eosinophilic granuloma 127 Allergic Reaction 94 folliculitis 116 Mast Cell Tumor 350 Lipoma 126 histiocytoma 133 fibrosarcoma 399 hemangiopericytoma 561 feline fibrosarcoma 270 Paronychia 134 Cellulitis 94 Dermatophytosis 100 Miliary Dermatitis 88

$168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168 168

$–– –– –– –– 70 –– –– –– –– 80 –– –– –– –– 105 85 80 105 124 100 80 — — —

$— — — — — — — — — — — — — — 300/1200* — — 300/1200* 300/1200* 300/1200* — — — —

$48 66 64 70 76 62 76 48 79 105 141 89 66 81 245 88 93 279 393 135 94 66 70 62

Perineal Disorders 1262 1263 1264 1265 1266 4021 8126

Perianal fistula-Medical Perianal fistula-Surgical Perineal hernia-Surgical Perineal Neoplasia Perineal hygroma Anal Sac Neoplasia Secondary Tests (Perineal)**

Exocrine Pancreatic Disorders 1270 1271 1274 8127

$272 116 394 133

Gall Bladder Disorders 1280 1281 1282 1283 8128

Choleliths-Surgical Cholangitis Ruptured Bile Duct-Surgical Neoplasia, gall Bladder-Surgical Secondary Tests (gall Bladder)**

Hepatic Disorders 1290 1291 1292 1293 1294 1297 4040 8129

hepatitis Cirrhosis Neoplasia, hepatic-Surgical hepatic Abscess-Surgical Trauma-Surgical hepatic encephalopathy Lipidosis Secondary Tests (hepatic)**

DERMATOLOGY (1300) Wounds 1301 1302 1303 1304 1305 1306 1307 1308 1310 1312 8130

foreign Body Laceration or Bite Wound Lacerations (Multiple) Puncture Abrasion Abscess or granuloma Burn Seroma Skin graft Bite Wounds (Multiple) Secondary Tests (Wounds)**

Dermatoses 1320 1321 1322 1323 1324 1325 1326 1327 1328 1329 1331 1332 1333 1335 1336 1337 1342 1343 1344 1345 1346 1350 1352 1353

*Chemotherapy/radiation treatment(s) may be eligible for coverage at a rate of $300 per treatment up to a maximum of $1200. Proof of malignancy required. **System Secondary Test Benefits may only be used once for each incident.

VS-20 (4-07)

$— — — —

SuPeRioR PLAN BeNefiT SCheDuLe – PAge 1

1355 1356 1357 1358 1359 1361 1363 1364 8132

Calcinosis $116 Squamous Cell Carcinoma 350 Adenoma 126 Malignant Melanoma or Melanosarcoma 399 Plasmacytoma 399 Cutaneous hemangiosarcoma 561 onychomycosis 134 Liposarcoma (infiltrative) 350 Secondary Tests (Dermatoses)** —

$168 168 168 168 168 168 168 168 —

$— 105 85 105 105 124 80 105 —

$— 300/1200* — 300/1200* 300/1200* 300/1200* — 300/1200* —

$81 245 88 279 279 393 94 245 110

Upper Airway foreign Bodies Tonsillitis Laryngeal edema Trauma Neoplasia, upper Airway-Surgical Tonsillectomy Laryngitis Laryngeal Paralysis-Medical Laryngeal Paralysis-Surgical

$119 108 158 195 395 310 100 203 1200

$163 163 163 163 163 163 163 163 163

$80 $— — — — — 100 — 90 300/1200* 85 — — — 85 — 125 —

$83 76 111 136 276 184 70 142 840

$80 158 175 262 525

$163 163 163 163 163

$74 $— 74 — 95 — — 300/1200* 115 300/1200*

$56 94 122 142 352

$490 241 115 115 412 1060 1100 425 1400 945 682 360 95 292 1600 1600 — —

$163 163 163 163 163 163 163 163 163 163 163 163 163 163 163 163 — —

$95 $— $343 — — 169 — — 77 — — 77 89 — 288 135 300/1200* 742 135 — 404 — — 298 130 — 624 130 — 682 100 — 404 — — 252 — — 66 — 300/1200* 204 120 — 1120 120 — 1120 — — 150 — — 106

$136 136 136 136

$— $— 85 — 92 — 110 300/1200*

Trachea 1420 1423 1425 1427 1428

Tracheitis foreign Body-Surgical Trauma Neoplasia, Tracheal-Medical Neoplasia, Tracheal-Surgical

Thorax 1440 1441 1442 1443 1444 1445 1446 1447 1448 1449 1450 1451 1452 1453 1454 1455 1458 8140

Trauma Pulmonary edema Bronchitis Asthma Pleural effusion Neoplasia, Thorax-Surgical Diaphragmatic hernia-Surgical Pneumonia Lung Torsion-Surgical Pneumothorax foreign Body-Surgical Mediastinal Disease Tracheobronchitis Neoplasia, Thorax-Medical Pyothorax Chylothorax Chest tube Secondary Tests (Respiratory)**

REPRODUCTIVE SYSTEM (1500) Vaginal Disorders 1501 1504 1505 1506

Vaginitis Vaginal foreign Body-Surgical Trauma Neoplasia, Vaginal-Surgical

$100 131 194 340

$70 52 105 176

Uterine Disorders 1510 1511 1512 1513 1514

Metritis-Medical Pyometra-Surgical Prolapse-Surgical uterine Neoplasia ovarian Neoplasia

$175 574 273 210 210

$136 136 136 136 136

$— $— 110 — 90 — 90 300/1200* 90 300/1200*

$74 392 142 120 120

Mastitis Mastectomy-Partial Mastectomy-Radical Lumpectomy

$86 305 500 175

$136 136 136 136

$— $— 100 300/1200* 120 300/1200* 80 —

$74 214 350 122

$175 175 175 175

$136 136 136 136

$80 $300/1200* $122 80 — 122 80 — 122 80 — 122

$80 96 186 121 89

$136 136 136 136 136

$— $— 74 — 74 300/1200* 79 — — —

Testicular Disorders 1530 1531 1532 1535

Neoplasia, Testicular-Surgical orchitis Torsion-Surgical epididymitis

Disorders of the Penis & Prepuce 1540 1541 1542 1543 1544

Paraphimosis Trauma Neoplasia, Penis or Prepuce foreign Body-Surgical Balanoposthitis

1550 1551 1552 8150

Neoplasia, Prostrate-Surgical Prostatitis Medical Prostatitis-Surgical-Castration Secondary Tests (Reproductive)**

osi s C (Prolum Tes ima n B ting ry D All iagn ow os an tic ce) Co l (Pr um All ima n C o w ry an Ane ce ) st he si a Co (Pr lum Ra ima n D d i a ry C tion he *) mo the ra p C y/ (Seolum n c All on E ow da a n ry ce ) D i a gn o si s

$581 181 175 —

$136 136 136 —

CHEMICAL AND PHYSICAL DISORDERS (1600) 1601 1602 1603 1604 1605 1606 1607 1608 1609 1610 1611 1612 1613 1615 1617

Metaldehyde Strychnine ethylene glycol (Antifreeze) organophosphate (Carbamate) Rodenticide Toxicity household Chemicals Drug Reactions Toad Poisoning Plant Poisoning Walnut Poisoning Drug overdose Methylxanthine Alcohol Toxicity heavy Metals (Lead/Zinc) Drug Toxicity

$356 200 281 246 248 162 197 205 181 232 296 169 280 446 248

$147 147 147 147 147 147 147 147 147 147 147 147 147 147 147

$80 74 — — — — — — — — — 74 — — —

$— — — — — — — — — — — — — — —

$142 142 185 172 174 113 138 124 127 168 207 78 126 312 174

$102 588 163 304 120 310 132 189 — — 145 —

$147 147 147 147 147 147 147 147 — — 147 —

$— 90 — — — 74 — — — — — —

$— — — — — — — — — — — —

$71 260 92 213 84 105 89 130 400 89 85 96

$232 180 457 1200 383 1465 285 103 346 180 285

$173 173 173 173 173 173 173 173 173 173 173

$— $— $155 — — 126 110 300/1200* 320 156 — 840 95 — 268 120 — 821 — — 200 — — 72 — — 204 — — 126 — — 200

$668 102 760 595 157 81 125

$173 173 173 173 173 173 173

$110 $— $468 — — 68 110 — 532 110 300/1200* 416 74 — 110 — — 57 — — 88

$586 209 1100 572 —

$173 173 173 173 —

$105 $— $410 — — 146 120 — 770 90 300/1200* 400 — — 112

$123 89 468 240 102 324 181 440 320 178 385

$165 165 165 165 165 165 165 165 165 165 165

Physical Disorders 1650 1651 1652 1653 1654 1655 1656 1657 1658 1659 1661 8160

insect Bites & Stings Snakebite Near Drowning heat Stroke (hyperthermia) hypothermia frostbite electric Shock hypoglycemia Antivenom Dehydration Vaccine Reaction Secondary Tests (Chemical & Physical)**

URINARY SYSTEM (1700) Kidney 1701 1703 1706 1707 1709 1715 1716 1717 1718 1723 1724

Nephrolithiasis-Medical Nephrotic Syndrome Neoplasia, Renal-Surgical Biopsy Nephrectomy glomerulonephritis (Biopsy required) Kidney Transplant Chronic Renal failure hypertension Acute Renal failure uremia Pyelonephritis

Bladder 1801 1802 1803 1804 1805 1806 1809

urolithiasis-Surgical Cystitis Trauma (Ruptured Bladder) Neoplasia, Bladder feline Lower urinary Tract Disease urinary incontinence or Atony urolithiasis-Medical

$52 68 133 85 62

1901 1902 1903 1905 8170

urethrolithiasis-Surgical Trauma/urethritis Perineal urethrostomy Neoplasia, urethral Secondary Tests (urinary)**

INFECTIOUS DISEASES (2000) 2001 2002 2003 2005 2006 2007 2008 2009 2010 2013 2014

Papillomatosis Salmonellosis Parvovirus Canine Coronavirus feline upper Respiratory infection fiP hemobartonella (Mycoplasmosis) Panleukopenia Canine Distemper Brucellosis Leptospirosis


VS- 20 (4-07)

$105 $300/1200* $407 — — 127 80 — 122 — — 89

Urethra

Mammary Gland Disorders 1520 1521 1522 1526

Disorders of the Prostate

Poisoning

RESPIRATORY SYSTEM (1400) 1401 1402 1404 1405 1406 1407 1408 1409 1410

Code Diagnosis

C (P olum All rima n A o w ry an Dia ce) gn

osi s C (Prolum n i m Tes a B r ting y D All iagn ow os an tic ce) Co (Pr lum All ima n C o w ry an Ane ce) st he sia Co l (Pr um n i m Ra a D d i a ry C tion he *) mo the ra p Co y/ (Se lum All con n E ow da a n ry ce) Dia gn osi s


Code Diagnosis


$— — — — — — — — — — —

$— — — — — — — — — — —

$88 62 328 119 71 250 127 198 192 89 270

2015 2016 2017 2019 2020 2021 2022 2023 2024 2039 2040 2041 2042 2043 2044 2045 2046 2048 8200

Tetanus $430 Botulism 326 Valley fever/Coccidioidomycosis 278 feline Leukemia 354 fever of unknown origin 113 Rickettsia (ehrlichia) 210 Salmon Disease 210 Lyme Disease 87 Rocky Mountain Spotted fever 210 herpes Virus 165 Blastomycosis-Systemic Mycosis 278 histoplasmosis-Systemic Mycosis 278 Cryptococcosis-Systemic Mycosis 278 Bartonella 87 Clostridiosis 89 Tuberculosis 178 fiV 354 Canine influenza 240 Secondary Tests (infectious Diseases)** —

$165 165 165 165 165 165 165 165 165 165 165 165 165 165 165 165 165 165 —

$— — — — — — — — — — — — — — — — — — —

$— — — — — — — — — — — — — — — — — — —

$247 195 195 248 79 139 139 61 139 116 195 195 195 61 62 89 248 119 107

$199 91 105 67 121 480 116 377 685 146 192 506 1016 890 221 470 141 134 346 438 690 350 110 127 198 139 117 315 — 146 146 110 —

$105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 105 — 105 105 105 —

$85 $300/1200* $139 — — 64 — — 74 — — 47 — — 85 100 — 236 80 — 81 84 — 264 86 — 480 — — 102 — — 134 100 — 354 120 — 711 110 — 623 90 — 142 110 — 329 80 — 99 80 — 94 80 –– 242 100 — 307 100 — 310 110 300/1200* 276 — — 77 80 — 89 — — 139 — — 97 — — 82 85 — 178 — — 150 — — 102 — — 102 — — 77 — — 68

Coon Dog Paralysis $422 Degenerative Myelopathy 254 encephalitis-Meningitis 473 epilepsy 168 intervertebral Disc Disease-Medical 161 intervertebral Disc Disease (fenestration) 975 intervertebral Disc Disease (Laminectomy)1875 Trauma 290 Stroke 310 Neuritis (Peripheral Nerve) 188 Neoplasia, Brain or Spinal Cord-Medical 477 Cauda equina Syndrome-Surgical 1489 Diskospondylitis 225 Cauda equina Syndrome-Medical 225 fibrocartilagenous emboli 561 Vestibular Syndrome 283 Myasthenia gravis 796 Neoplasia, Brain or Spinal Cord-Surgical 1299 Progressive Ataxia 135 Degenerative encephalopathy 125 Craniotomy — Ambulation Device — horner’s Syndrome 283 Secondary Tests (Neurological)** —

$210 210 210 210 210 210 210 210 210 210 210 210 210 210 210 210 210 210 210 210 — — 210 —

$— $— $253 — — 178 — — 331 — — 81 — — 113 154 — 682 253 — 1312 90 — 203 — — 217 — — 132 — 300/1200* 334 126 — 893 80 — 158 80 — 158 90 — 268 — — 198 — — 168 201 300/1200* 909 — — 94 — — 88 — — 1312 — — 200 — — 198 — — 137

$79 79 79 79 79

$90 $— $188 — — 54 80 — 117 85 300/1200* 122 80 — 66

OPHTHALMOLOGY (2100) 2102 2105 2106 2107 2108 2109 2110 2111 2112 2114 2115 2116 2117 2118 2119 2120 2121 2122 2123 2126 2127 2129 2131 2132 2134 2135 2136 2137 2148 2156 2157 2158 8210

eyelid Neoplasia-Surgical Plugged Tear Duct Corneal edema Conjunctivitis Keratitis Sicca-Medical Keratitis Sicca-Surgical Corneal ulcer-Medical Corneal ulcer-Surgical Descemetocele-Surgical iritis Secondary glaucoma-Medical Secondary glaucoma-Surgical Cataracts-Surgical Lens Luxation-Surgical Retrobulbar Abscess iris Prolapse-Surgical foreign Body Meibomian Cyst Proptosed eye enucleation Keratectomy Neoplasia, ocular-Surgical Blepharitis Trauma Retinal Detachment-Medical Retinal Degeneration Cataract-Medical Retinal Detachment-Surgical Lens implant uveitis Retinitis episcleritis Secondary Tests (ophthalmic)**

NEUROLOGY (2200) 2202 2203 2204 2205 2206 2207 2208 2210 2211 2213 2215 2216 2217 2218 2220 2221 2222 2223 2227 2228 2235 2236 2240 8220

EAR (2300) 2301 2302 2303 2304 2305

Auricular hematoma Solar Dermatitis Trauma Neoplasia, Pinna-Surgical otitis externa

$268 116 167 175 109

2306 2307 2308 2309 2310 2311 2313 2314 2315 8230

otitis Media-Medical otitis Media-Surgical foreign Body Lateral ear Resection Ablation Neoplasia, ear Canal-Surgical hearing Aid otitis interna-Medical otitis interna-Surgical Secondary Tests (ear)**

osi s C (Prolum Tes ima n B ting ry D All iagn ow os an tic ce ) Co (Pr lum All ima n C o w ry A an ne ce ) st he si a C (Prolum Ra ima n D d i a ry C tion he *) mo the ra p Co l y/ (Se um All con n E ow da a n ry ce ) D i a gn o si s

Code Diagnosis


C (P olum All rima n A o w ry an Dia ce) gn osi s Co (Pr lum n i m Tes a B r ting y D All iagn ow os an tic ce) Co (Pr lum All ima n C o w ry an Ane ce) st he sia Co l (Pr um n i m Ra a D d i a ry C tion he *) mo the ra p Co y/ (Se lum All con n E ow da a n ry ce) Dia gn osi s

Code Diagnosis

$187 300 115 624 1056 300 310 187 300 —

$79 79 79 79 79 79 79 79 79 —

$103 103 137 135 481 —

$126 126 126 126 126 —

$74 $— 74 — 90 — 75 — 100 300/1200* — —

$72 72 96 94 337 82

$115 176 291 161 98 161 157 245 146 502 263 92 210 94 186 —

$126 126 126 126 126 126 126 126 126 126 126 126 126 126 126 —

$75 $— 85 — 90 300/1200* 80 — 75 — 75 — 75 — 75 — — — 110 — 95 — — — 89 — 75 — 80 — — —

$76 123 172 103 69 113 110 111 78 351 184 64 147 66 130 82

$113 430 614 247 —

$158 158 158 158 —

$— $— 95 — 120 300/1200* 86 — — —

$79 257 289 94 103

$110 1207 312 525 252 900 159 155 250 571 138 290 849 356 952 76 173 144 92 513 95 158 304 380 111 124 424 810 1100 195 400 880 411 92 —

$152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 —

$75 125 75 100 85 123 — — — 101 — 100 110 — 120 — — 75 — 100 — 80 75 90 75 — 97 120 120 — 95 141 100 — —

$77 845 218 176 176 630 111 92 175 400 97 203 594 249 488 53 121 101 64 359 66 111 213 266 78 87 297 567 770 108 315 616 288 64 98

NASAL CAVITY (2400) 2401 2402 2403 2404 2406 8240

Rhinitis Sinusitis foreign Bodies Trauma Neoplasia, Nasal or Sinus-Surgical Secondary Tests (Nasal)**

ORAL CAVITY (2500) 2502 2503 2504 2505 2506 2507 2508 2509 2510 2511 2512 2513 2514 2520 2521 8250

Tooth Abscess Carnassial Abscess/Canine Tooth Neoplasia, oral-Surgical Trauma foreign Body Tongue Laceration Retropharyngeal foreign Body Mandible Luxation ulcerative Stomatitis Root Canal oronasal fistula Periodontitis-Medical Periodontitis-Surgical feline odontoclastic Disease Benign oral Neoplasia Secondary Tests (oral)**

SALIVARY GLAND (2600) 2601 2602 2604 2605 8260

Sialocele-Medical Sialocele-Surgical Neoplasia, Salivary gland-Surgical Abscess Secondary Tests (Salivary)**

MUSCULOSKELETAL (2700) 2701 2702 2704 2705 2706 2708 2710 2711 2715 2716 2717 2720 2721 2722 2723 2724 2725 2726 2727 2728 2729 2731 2732 2733 2734 2735 2736 2737 2738 2739 2740 2741 2742 2777 8270

Cruciate Rupture-Medical (see policy) Cruciate Rupture-Surgical (see policy) Luxation, elbow-Closed Reduction Luxation, elbow-Surgical Luxation, hip-Closed Reduction Luxation, hip-Surgical Myositis osteoarthritis osteomyelitis-Medical osteomyelitis-Surgical Spondylosis Tendon Rupture (Cast) Tendon Rupture-Surgical osteogenic Sarcoma-Medical osteogenic Sarcoma-Surgical Sprain Bone Cyst-Medical foreign Body, foot Panosteitis Neoplasia, Muscle-Surgical Soft Tissue Trauma Dewclaw Amputation (Non-elective) Tail Amputation Toe Amputation Torn Nail hygroma-Medical hygroma-Surgical fore Leg Amputation Rear Leg Amputation Synovitis Shoulder Luxation-Surgical Neoplasia, Jaw-Surgical Bone fragment Joint-Surgical hypertrophic osteodystrophy Secondary Tests (Musculoskeletal)**


VS-20 (4-07)

$80 $— $131 85 — 210 80 — 80 100 — 437 151 — 739 90 300/1200* 210 89 — 226 80 — 131 85 — 210 — — 51


$— — — — — — — — — — — — — 300/1200* 300/1200* — — — — 300/1200* — — — — — — — — — — — 300/1200* — — —

FRACTURES (2800)

BLOOD DISORDERS (3000)

Skull, Jaw, Scapula, Rib, Patella Non-Surgical

Blood Cell Disorders

2801 Cage Rest 2802 Bandage 2803 Sling

$355 210 247

$225 225 225

$–– –– —

$— — —

$— 147 100

$487 598 774 640

$225 225 225 225

$90 100 110 94

$— — — —

$341 394 542 420

Surgical 2811 2812 2813 2814

Wire Pin(s) or K Wire Plate Kirshner Apparatus

$149 245 251

$225 225 225

$75 75 80

$— — —

$104 172 176

$797 1425 1325 1105 —

$225 225 225 225 —

$110 202 151 110 —

$— — — — —

$558 998 546 430 210

Surgical 2830 2831 2832 2833 2834

$692 210 139 366 240 442 385 362 409 — 378

$200 200 200 200 200 200 200 200 200 — 200

$— $— $484 — — 157 — — 97 74 — 256 — — 136 179 — 309 74 300/1200* 270 — — 253 74 — 200 — — 290 74 300/1200* 265

3032 3033 3034 8300

Thrombocytopenia/Platelet Disorder Drug induced Disorders DiC (Dissem intravascular Coag) Secondary Tests (Blood)**

$325 331 242 —

$200 200 200 —

$— — — —

$159 188 528 1400 —

$200 200 200 200 —

$74 $— 74 — 100 300/1200* 74 300/1200* — —

$807 807 — 154 801 —

$160 160 — 160 160 —

$166 240 264 —

$90 90 90 —

$79 — — —

$— — — —

$116 168 185 59

$— —

$— —

$— —

$— —

$74 80

$— — — —

$228 232 169 130

LYMPHATIC DISORDERS (3100)

iM Pin(s) Plate Kirshner Apparatus Radius Curvus Surgical Bone graft or TPLo Plate

Pelvis & Vertebrae Non-Surgical 2840 Cage Rest

2850 iM Pins/Wire/Screws 2851 Plate 2852 Kirshner Apparatus

$279

$225

$—

$—

$––

$700 1800 1190

$225 225 225

$103 130 100

$— — —

$490 704 609

Carpus, Metacarpus, Tarsus, Metatarsus, Phalanges Non-Surgical 2860 Bandage 2861 Cast or Splint

3101 3102 3103 3104 8310

Lymphadenitis Lymphnode hyperplasia Lymphosarcoma Thymoma-Surgical Secondary Tests (Lymphatic)**

$111 132 370 980 130

SPLEEN DISORDERS (3200)

Surgical

$117 209

$225 225

$— 75

$— —

$82 146

3201 3202 3203 3204 3205 8320

Splenic Rupture-Surgical Splenic Torsion-Surgical Splenectomy Splenomegaly-Medical Neoplasia, Spleen-Surgical Secondary Tests (Spleen)**

$120 $— $336 100 — 565 — — 623 — — 108 100 300/1200* 561 — — 104

IMMUNOLOGY (3300) 3302 3303 3304 8330

Systemic Lupus erythematosus Rheumatoid Arthritis Polyarthritis Secondary Tests (immune)**

SPECIAL PROCEDURES

Surgical 2870 Pins/Wires/Screws 2871 Plate Arthrodesis 8280 Secondary Tests (fractures)**

$956 1140 —

$225 225 —

$110 131 —

$— — —

$669 798 146

Adrenal 2902 Addison's Disease 2903 Neoplasia, Adrenal-Surgical

$416 746

$268 268

$— $— $225 110 300/1200* 522

$72 129 442 880

$268 268 268 268

$— $— — — 90 300/1200* 100 —

$300 193 614

$268 268 268

$— $— $210 — — 135 98 300/1200* 350

$300 797

$268 268

$— $— $210 100 300/1200* 558

$196 193 —

$268 268 —

$— — —

Thyroid hypothyroidism hyperthyroidism Neoplasia, Thyroid-Surgical hyperthyroidism (i-131)

1000 euthanasia 7000 Secondary Anesthesia Benefit***

***Secondary anesthesia benefits may be used for Specialized Diagnostic Tests when applicable.

SPECIALIZED DIAGNOSTIC TESTS****

ENDOCRINOLOGY (2900)

2920 2921 2922 2923

immune Mediated hemolytic Anemia heinz-Body Anemia Anemia of Chronic Disease Aplastic-hypoplastic Anemia Drug induced Anemia Myeloproliferative Disorders Leukemia Septicemia immune Mediated Neutropenia Transfusion Multiple Myeloma

Bleeding Disorders

Humerus, Femur, Radius, Ulna, Tibia Non-Surgical 2820 Bandage (Rbt Jones/Temporary) 2821 Splint 2822 Cast

3001 3003 3004 3005 3006 3007 3008 3009 3010 3011 3014

sis C (P olum Tesrima n B ting ry D All iagn ow os an tic ce) Co (Pr lum All ima n C o w ry an Ane ce ) st he si a Co (Pr lum Ra ima n D d i a ry C tion he *) mo the ra p Co l y/ (Se um n All con E ow da a n ry ce ) D i a gn o si s

Code Diagnosis

C (P olum All rima n A o w ry an Dia ce) gn o

osi s C (P olum Tesrima n B ting ry D All iagn ow os an tic ce) Co (Pr lum All ima n C o w ry an Ane ce) st he sia C (Prolum n i m Ra a D d i a ry C tion he *) mo the ra p Co y/ (Se lum All con n E ow da a n ry ce) Dia gn osi s


Code Diagnosis

$50 90 309 348

Allergen Test Contrast Radiographs CT Scan endoscopy MRi Scan Myelogram Nuclear imaging/Thyroid Scan Spinal Tap/Culture & Analysis ultrasound/echocardiogram

$135 150 800 150 800 135 300 90 150

****This allowance is in addition to the maximum Diagnostic Allowances as listed for each diagnosis. Maximum benefit for Specialized Diagnostic Tests is $1000 per incident.

Parathyroid 2940 hyperparathyroidism 2942 hypoparathyroidism 2943 Neoplasia, Parathyroid-Surgical

Pancreas (Endocrine) 2950 Diabetes Mellitus 2951 islet Cell Tumor-Surgical

Pituitary 2960 Diabetes insipidus 2961 Cushing's Disease 8290 Secondary Tests (endocrine)**

$— — —

$137 135 174


VS-20 (4-07)


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