COMPREHENSIVE MEDICAL BENEFIT PLAN SCHEDULE OF BENEFITS BENEFIT PLAN FORM NUMBER 40XX1499 R01/13. GROUP'S ANNIVERSARY DATE January 1st

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1 COMPREHENSIVE MEDICAL BENEFIT PLAN SCHEDULE OF BENEFITS BENEFIT PLAN FORM NUMBER 40XX1499 R01/13 GROUP NAME GALLIANO MARINE SERVICE, L.L.C. DIVISIONS American Energy Innovations, LLC La. Ship, North American Fabricators, North American Shipbuilding, Gulf Ship, Tampa Ship, C-Port, C-Port2, Martin Holdings, Clean Tank, C-Logistics, Fourchon Heavy Lift, HRH, American Custom Yacht. GROUP NUMBER ERC GROUP'S ANNIVERSARY DATE January 1st GROUP'S EFFECTIVE DATE January 1, 2013 Annual Maximum Deductible Amount* PPO Preferred Providers Individual Family All Other Providers Individual Family * Deductible amounts are not integrated. $5,000, per Member $ per Benefit Period $1, per Benefit Period $ per Benefit Period $1, per Benefit Period The Benefit Period Deductible Amount may not apply to the following: Preferred Providers performing eligible Preventive or Wellness Care. Coinsurance Group Member PPO Preferred Providers 80% 20% Participating Providers 70% 30% Non-Participating Providers 70% 30% Special Coinsurance* Group Member All Providers 50% 50% *C-PAP, humidifier rental for C-PAP machines and related equipment *Bone Mass Measurement Services Out-of-Pocket Amount* (Does not include the Deductible Amount. Services payable at 50/50 coinsurance do not accrue to the Out-of-Pocket and are not payable at 100%): PPO Preferred Providers Individual $1, Family $3, All Other Providers Individual $2, Family $5, * Out-of-Pocket amounts are not integrated. 40XX1501 R01/13

2 Physician s Office Visit Copayment*: All Providers *applies only to office visits and consultations $25.00 per visit When eligible services are performed by a Preferred Provider, the Benefit Period Deductible and Coinsurance percentage are waived. Eligible services performed by all other Providers are subject to the Benefit Period Deductible, Coinsurance percentage and applicable Physician s Office Copayment. Accidental Injury Benefit: Benefit Period Maximum $ per Member Expenses incurred in connection with any accidental bodily injury or sickness arising out of or in the course of employment, when compensable under any Workers Compensation or Occupational Disease Act or Law, and recoverable under an enforceable policy of insurance providing coverage with respect to those obligations ARE NOT ELIGIBLE EXPENSES UNDER THIS BENEFIT PLAN. Alcohol and/or Drug Abuse: Benefits are payable same as any other illness. Three (3) hours or more of therapy per day is considered intensive outpatient therapy and requires prior authorization. Chiropractic Services: Benefit Period Maximum $1, per Member Mental Health Benefits: Benefits are payable same as any other illness. Three hours or more of therapy per day is considered intensive outpatient therapy and requires prior authorization. Organ, Tissue, and Bone Marrow Transplant Benefits: Authorization is required prior to services being performed. Pregnancy Care: Maternity and/or Pregnancy Care Benefits are available under the Benefit Plan for Subscriber or Spouse only. Ultrasounds limited to three (3) per normal pregnancy. Additional ultrasounds are subject to Medical Necessity. Preventive or Wellness Care: Wellness includes routine physicals and related tests and mammograms. See Benefit Plan for more information. Private Duty Nursing Services (Outpatient services only): Benefits are payable same as any other illness. Skilled Nursing Facility: Benefits are limited to a maximum of ninety (90) days per Benefit Period for each Member. Sleep Studies Benefit: Lifetime Maximum Benefit Temporomandibular Joint (TMJ) Disorders: Lifetime Maximum Benefit $6, per Member $1, per Member 40XX1501 R01/13 2

3 Other Covered Services/Expense: One (1) Compression Stocking per Month per Member Two (2) Mastectomy bras per Benefit Period per Member Epidural Steroid Injections - limited to 3 per Benefit Period per Member The following diabetic supplies are excluded from medical coverage as they are payable under the Prescription Benefit: 1. Alcohol Wipes 2. Blood Glucose Test Strips 3. Lancets The following are excluded under this Benefit Plan as non-covered: 1. Replacement Batteries Authorization of Therapeutic/Treatment Vaccines Examples include, but are not limited to vaccines to treat the following conditions: Allergic Rhinitis Alzheimer s Disease Cancers Multiple Sclerosis Substance Addiction, if covered on this policy AUTHORIZATION OF SERVICES AND SUPPLIES Authorization of Inpatient and Emergency Admissions: Inpatient Admissions must be authorized. Refer to Authorization of Services and Supplies and if applicable Pregnancy Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions, for Concurrent Review of an Admission in progress, or other Covered Services and Supplies must be made to Blue Cross and Blue Shield of Louisiana by calling Authorization of Outpatient Services, Including Other Covered Services and Supplies: The following services and supplies require Authorization prior to the services being rendered or supplies being received. Substance Abuse treatment/services Bone growth stimulator CT Scans Day Rehabilitation Programs Durable Medical Equipment (greater than $300.00) Epidural Steroid Injections (only 3 per Benefit Period) Chemotherapy Treatments Custom Wheelchairs Home Health Care Hospice Care Hyperbarics Implantable Medical Devices over $ such as Implantable Defibrillator and Insulin Pump Injections paid under medical benefits (greater than $750.00) Mental Disorder treatment/services - Three (3) hours or more of therapy/services per day. M.R.I./M.R.A. Non-Emergency Air Ambulance Nuclear Cardiology 40XX1501 R01/13 3

4 Occupational Therapy Organ Transplant Evaluation PET/SPECT Scans Physical Therapy Private Duty Nursing Prosthetic Appliances Radiation Treatments Sleep Studies including C-PAP and related equipment Speech Therapy Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy If Authorization is not requested prior to a listed service being rendered or a listed supply being received, We will have the right to determine if the service or supply was Medically Necessary. If the service or supply was medically necessary, Benefits will be provided based on the participating status of the Provider of the service or supply. If a contracted Provider in Louisiana s Preferred Care (or PCare) Network fails to obtain a required Authorization, we will reduce his Benefit amount by 30% of the Allowable Charge. This penalty applies to all services and supplies requiring an Authorization, other than Inpatient charges. The Preferred Care Provider is responsible for all charges not covered and for the penalty amount. The Member remains responsible for his Copayment, Deductible amount and applicable Coinsurance percentage. If a service or supply was not Medically Necessary, the service or supply is not covered. PRE-EXISTING CONDITION EXCLUSION PERIOD The exclusion for a Pre-Existing Condition is applicable as stated in the Limitations and Exclusions article of the Benefit Plan. A Member may receive credit toward this exclusionary period for any time he served toward a Pre-Existing Condition Exclusion Period under his prior coverage. Refer to the Benefit Plan for complete information. ELIGIBILITY WAITING PERIOD Active Employees: Eligible Persons who have completed the waiting period required for his position. Coverage will then become effective on the first day of the month following the completion of the waiting period. Retirees: Eligible Persons who satisfy the eligibility requirements as specified by the Group and who are eligible to participate in the Group s health care Benefit Plan. GROUP DETERMINES THE ELIGIBILITY WAITING PERIOD AND/OR EFFECTIVE DATE OF COVERAGE FOR ALL ELIGIBLE EMPLOYEES, RETIREES AND THEIR DEPENDENTS. 40XX1501 R01/13 4

5 NOTICE Your group plan administrator and Blue Cross and Blue Shield of Louisiana believe this plan is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your plan administrator or to Blue Cross and Blue Shield of Louisiana at the telephone number on the back of your ID card. ERISA members may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or This website has a table summarizing which protections do and do not apply to grandfathered health plans. Members who are not on ERISA plans may contact the U.S. Department of Health and Human Services at 40XX1501 R01/13 5