PLAN DOCUMENT SUMMARY PLAN DESCRIPTION C.W. MATTHEWS CONTRACTING CO., INC. CWM EMPLOYEE BENEFIT TRUST

Transcription

1 PLAN DOCUMENT SUMMARY PLAN DESCRIPTION FOR C.W. MATTHEWS CONTRACTING CO., INC. CWM EMPLOYEE BENEFIT TRUST G PLAN EFFECTIVE DATE: May 1, 1984 RESTATEMENT DATE: June 1, 2014

2 NOTICE This is issued and effective on the dates shown, and replaces all booklets bearing an earlier date of issue. The provisions of this do not describe or create any right or status of employment of any employee of C.W. Matthews Contracting Co. Inc.

3 TABLE OF CONTENTS Page No. Privacy of Medical Information 1 Introduction 7 Medical Benefits 10 Prescription Drug Benefits 15 Routine Preventive Care 16 Definitions 21 When Coverage Begins 39 When Coverage Ends 43 Conversion Privilege 47 Eligible Charges 48 Exclusions and Limitations 52 Outpatient Surgery 59 Mandatory Second Surgical Opinion 61 Managed Care 65 Coordination of Benefits 67 Subrogation and Reimbursement 70 Filing a Claim for Benefits 75 Misc. Plan Provisions 91 ERISA 93 HIPPA Privacy 95

4 PRIVACY OF MEDICAL INFORMATION THIS PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION, made by C.W. Matthews Contracting Co., Inc. (the Company or the Plan Sponsor ) as of June 1, 2014, hereby amends and restates the CWM Employee Benefit Trust (the Plan ), which was originally adopted by the Company, effective May 1, Effective Date The is effective as of the date first set forth above, and each amendment is effective as of the date set forth therein. Adoption of the The Plan Sponsor, as the settlor of the Plan, hereby adopts this as the written description of the Plan. This represents both the and the Summary Plan Description, which is required by the Employee Retirement Income Security Act of 1974, 29 U.S.C. et seq. ( ERISA ). This amends and replaces any prior statement of the health care coverage contained in the Plan or any predecessor to the Plan. IN WITNESS WHEREOF, the Plan Sponsor has caused this to be executed. By: Name: Ray A. Rodriguez Date: June 1, 2014 Title: Division Vice President 1

5 PRIVACY OF MEDICAL INFORMATION We understand that your medical information is private, and we are committed to maintaining the privacy of your medical information. Effective on or after April 14, 2004, the Plan will follow the policies below to help ensure that your medical information remains private. Each time you submit a claim to the Plan for reimbursement, and each time you see a health care provider who is paid by the Plan, a record is created. The record may contain your medical information. In general, the Plan will only use or disclose your medical information without your authorization for the specific reasons detailed below. Except in limited circumstances, the amount of information used or disclosed will be limited to the minimum necessary to accomplish the intent of the use or disclosure. PERMITTED USES AND DISCLOSURES. The following categories describe different ways that the Plan may use or disclose your medical information. Not every use or disclosure in a category will be listed. However, all of the ways the Plan is permitted to use and disclose information will fall within one of the categories. Treatment. The Plan may use or disclose your medical information to facilitate medical treatment or services by providers. The Plan may disclose your medical information to providers, including doctors, nurses, technicians, pharmacists, medical students, or other hospital personnel who are involved in your care. For example, the Plan might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is contraindicative with prior prescriptions. Payment. The Plan may use and disclose your medical information to determine eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, the Plan may tell your health care provider about your medical history to determine whether a particular treatment is Experimental/Investigational, or Medically Necessary or to determine whether the Plan will cover the treatment. The Plan may also share medical information with a utilization review or pre-certification service provider. Likewise, the Plan may share medical information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments. Health Care Operations. The Plan may use and disclose your medical information for other Plan operations. These uses and disclosures are necessary to run the Plan. For example, the Plan may use medical information in connection with: conducting quality assessment and improvement activities; underwriting, premium rating, and other activities relating to Plan coverage; submitting claims for stop-loss (or excess loss) coverage; conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs; business planning and development such as cost management; and business management and general Plan administrative activities. Requirement by Law. The Plan will disclose your medical information when required to do so by federal, state, or local law. For example, the Plan may disclose medical information when required by a court order in a litigation proceeding such as a malpractice action. 2

6 PRIVACY OF MEDICAL INFORMATION Aversion of a Serious Threat to Health or Safety. The Plan may use or disclose your medical information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, the Plan may disclose your medical information in a proceeding regarding the licensure of a physician. Organ and Tissue Donation. If you are an organ donor, the Plan may release your medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Military and Veterans. If you are a member of the armed forces, the Plan may release your medical information as required by military command authorities. The Plan may also release medical information about foreign military personnel to the appropriate foreign military authority. Workers Compensation. The Plan may release your medical information for workers compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks. The Plan may disclose your medical information for public health activities. These activities generally include the following: to prevent or control disease, injury, or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or, to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities. The Plan may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or dispute, the Plan may disclose your medical information in response to a court or administrative order. The Plan may also disclose your medical information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement. The Plan may release your medical information if asked to do so by a law 3

7 PRIVACY OF MEDICAL INFORMATION enforcement official: in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness or missing person; if you are, or are suspected to be, the victim of a crime, under certain limited circumstances, and the Plan Administrator is unable to obtain your agreement; about a death the Plan Administrator believes may be the result of criminal conduct; about criminal conduct on the Company s premises; or, in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the crime or victims, or the identity, description, or location of the person who committed the crime. Department of Health and Human Services. The Plan will disclose your medical information to the U.S. Department of Health and Human Services when requested for purposes of determining the Plan s compliance with applicable regulations. Coroners, Medical Examiners, and Funeral Directors. The Plan may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. The Plan may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities. The Plan may release your medical information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, the Plan may release your medical information to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care; to protect your health and safety or the health and safety of others; or, for the safety and security of the correctional institution. DISCLOSURES TO THE COMPANY. The Plan will disclose medical information about you to the Company only upon receipt of a certification from the Company that the Company agrees: not to further use or disclose medical information about you other than as permitted or required by the Plan documents or as required by law; to ensure that any agents, including a subcontractor, to whom it provides medical information received from the Plan agree to the same restrictions and conditions that apply to the Company with respect to such information; not to use or disclose the medical information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Company; to report to the Plan any use or disclosure of the medical information that is inconsistent with the permitted uses and disclosures; to make its internal practices, books, and records relating to the use and disclosure of medical information received from the Plan available to the Department of Health and Human Services for purposes of determining whether the Plan is complying with 4

8 PRIVACY OF MEDICAL INFORMATION applicable regulations; if feasible, to return or destroy all medical information received from the Plan about you and retain no copies of the information when it is no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, to limit further uses or disclosures to those purposes that make such return or destruction infeasible; and, to ensure that there is adequate separation between the Plan and the Company (described below). ACCESS TO MEDICAL INFORMATION. The Plan will make your medical information available to you for inspection and copying upon your written request to the Plan Administrator. The Plan may charge a fee for the costs of copying, mailing or other supplies associated with your request. The Plan may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. AMENDMENT OF MEDICAL INFORMATION. If you feel that medical information the Plan has about you is incorrect or incomplete, you may ask the Plan to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan. Your request must be made in writing and submitted to the Plan Administrator. In addition, you must provide a reason that supports your request. The Plan Administrator may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, the Plan Administrator may deny your request if you ask the Plan Administrator to amend information that: is not part of the medical information kept by or for the Plan; was not created by the Plan, unless the person or entity that created the information is no longer available to make the amendment; is not part of the information which you would be permitted to inspect and copy; or, is accurate and complete. ACCOUNTING OF DISCLOSURES. If you wish to know to whom medical information about you has been disclosed for any purpose other than (1) treatment, payment, or health care operations, (2) pursuant to your written authorization, and (3) for certain other purposes, you may make a written request to the Plan Administrator. Your request must state a time period which may not be longer than six (6) years and may not include dates before April 14, Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a twelve (12) month period will be free. For additional lists, the Plan Administrator may charge you for the costs of providing the list. The Plan Administrator will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. The accounting will not include disclosure for the purposes of treatment, payment, or health care operations. In addition, the accounting will not include disclosures which you have authorized in writing. 5

9 PRIVACY OF MEDICAL INFORMATION SEPARATION BETWEEN THE PLAN AND THE COMPANY. Only employees of the Company who are involved in the day-to-day operation and administrative functions of the Plan will have access to your medical information. In general, this will only include individuals who work in the Company s Human Resources or Employee Benefits departments. These individuals will receive appropriate training regarding the Plan s privacy policies. In the event an individual fails to comply with the Plan s provisions regarding the protection of your medical information, the Company will take appropriate action in accordance with its established policy for failure to comply with the Plan s privacy provisions. OTHER USES OF MEDICAL INFORMATION. Any other uses and disclosures of medical information will be made only with your written authorization. If you provide the Plan authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, the Plan will no longer use or disclose medical information about you for the reasons covered by your written authorization. Please note that the Plan is unable to take back any disclosures it has already made with your authorization, and that the Plan is required to retain records of the care provided to you. COMPLAINT RESOLUTION PROCESS. If you are concerned that your privacy rights have been violated; or, disagree with a decision made regarding access to your health information; or, in response to a request you made to amend or restrict the use or disclosure of your health information; you may contact the privacy officer in writing at the address listed below. You may also submit a written complaint to the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Privacy Officer: Ray A. Rodriguez P.O. Drawer 970 Marietta, Georgia Fax No:

10 INTRODUCTION ( Company ) hereby establishes this welfare plan for the benefit of eligible employees and their dependents. The Plan provides benefits as described on the following pages of this. Funds for providing plan benefits are administered under a Trust Agreement established by the Plan Sponsor. Health medical benefits and Short Term Disability Indemnity benefits are self-funded. Life Insurance and Accidental Death & Dismemberment benefits are underwritten and provided by insurance carriers as selected by the Company. The cost of coverage is paid for by employee and employer contributions, as follows: a. for medical coverage, the cost is shared by employee and employer contributions; b. for Extended Life and Extended AD& D, the cost is paid entirely by employer contributions; c. for Supplemental Life Coverage, the cost is paid entirely by employee contributions; d. for Short Term Disability (STD) Coverage, the cost is shared by employee and employer contributions; e. for Basic Life and AD&D, the cost is shared by employee and employer contributions; f. employee contributions for medical coverage will be made on a pre-tax basis in compliance with Section 125 of the Internal Revenue Code as explained under the Section 125 tab in this book; and g. dependent life is provided all participants in the medical plan as part of the employer contribution, at no cost to the employee. The Company reserves the right to make adjustments to the levels of employee contributions. Employee contributions will be set at smoker and non-smoker rates for all coverages. In order to make contributions at the level of a non-smoker, the employee must attest to the fact that he and his covered family members DO NOT use tobacco in any form, including but not limited to smoking (cigarettes, cigars, pipes), chewing or dipping, or that he or such covered family member is actively involved in a smoking/nicotine cessation program. This is a reward, as a part of an over-all wellness program. If it is unreasonably difficult due to a medical condition for the employee to achieve the standards for the reward under this program, or if it is medically inadvisable for the employee to attempt to achieve the standards for the reward under this program, contact the Company and they will work with the employee to develop another way to qualify for the reward. Amendment or Termination - The continued maintenance of the Plan is completely voluntary on the part of the Company and neither its existence nor its continuation shall be construed as creating any contractual right to or obligation for its future continuation. While the Company intends to continue the Plan indefinitely, it reserves the right at any time and for any reason, in its sole and absolute discretion, through the procedure of an execution of a document by any officer who is authorized, to curtail benefits under, or otherwise amend or terminate the Plan or any portion thereof, including, without limitation, those portions of the Plan outlining the benefits provided or the classes of employees or dependents eligible for benefits under the Plan. Summary Plan Description - The Company will issue to each covered employee a Summary Plan Description (SPD). The SPD will state: 7

11 INTRODUCTION a. the benefits provided; b. to whom benefits will be paid; and c. limitations or requirements of the Plan that may apply to the covered person. The SPD and the are the same. General Plan Information Name of Plan: Plan Sponsor: Plan Administrator: (Named Fiduciary) CWM Employee Benefit Trust CWM Preferred Coverage Plan Option PPACA Mandated Minimum Coverage Plan Option P.O. Drawer 970 Marietta, Georgia P.O. Drawer 970 Marietta, Georgia Plan Sponsor ID No. (EIN): Source of Funding: Applicable Law: Self-Funded ERISA Plan Year: May 1 through April 30 Plan Number: 2001 Plan Type: Third Party Administrator: Participating Employer(s): Agent for Service of Process: Medical Prescription Drugs Short-Term Disability Integrity Benefit Network P.O. Box 4537 Marietta, GA Bright Star Energy, Inc. P.O. Drawer 970 Marietta, GA

12 INTRODUCTION Legal Entity; Service of Process The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the Plan Administrator. Not a Contract This and any amendments constitute the terms and provisions of coverage under this Plan. The shall not be deemed to constitute a contract of any type between the Company and any Participant or to be consideration for, or an inducement or condition of, the employment of any Employee. Nothing in this shall be deemed to give any Employee the right to be retained in the service of the Company or to interfere with the right of the Company to discharge any Employee at any time; provided, however, that the foregoing shall not be deemed to modify the provisions of any collective bargaining agreements which may be entered into by the Company with the bargaining representatives of any Employees. Mental Health Parity This plan complies with the Mental Health Parity and Addiction Equity Act of 2008, In accordance with this act, no benefits will be paid for an illness, including, but not limited to, a neurosis, psychoneurosis, psychopathy, psychosis, personality disorder, or any other illness, the layman s understanding of which is a mental or nervous disorder. Applicable Law The Plan shall be governed by ERISA and the regulations promulgated there under. Any assignee of a covered person under this Plan shall be treated as the covered person with respect to any claim or request for payment of expenses for medical services submitted to the Plan, the Plan Administrator, the Plan Sponsor, the Third Party Administrator or any agent or employee thereof. Any claims or causes of action asserted by any covered person or assignee shall be subject to ERISA, and no state law claims or causes of action shall be applicable with respect to any expenses related to the provision of health care services. Discretionary Authority The Plan Administrator shall have sole, full and final discretionary authority to interpret all Plan provisions, including the right to remedy possible ambiguities, inconsistencies and/or omissions in the Plan and related documents; to make determinations in regards to issues relating to eligibility for benefits; to decide disputes that may arise relative to a Plan Participants rights; and to determine all questions of fact and law arising under the Plan. 9

13 Maximum Benefits Per Covered Person MEDICAL BENEFITS Maximum Calendar Year Benefit while under this plan CWM Preferred Coverage Plan Unlimited-No Maximum PPACA Mandated Minimum Coverage Plan Unlimited-No Maximum *Exceptions to the Maximum Calendar Year Benefit are as follows:* Exceptions to the Maximum Calendar Year Benefit Maximum Benefit while covered under this plan for Hospice Care Maximum Calendar Year Benefit for Chiropractic treatments and services Maximum Per Accident Supplemental Accident Expense Benefit Maximum Calendar Year Benefit for Home Health Care Treatments Maximum Calendar Year Benefits for Skilled Nursing Facility Care CWM Preferred Coverage Plan PPACA Mandated Minimum Coverage Plan $10,000 $10,000 $1,000 $1,000 $400 $ Visits 120 Visits 60 Days 60 Days Hospital Room & Board Charges The maximum eligible daily charge for room and board will be the lesser of: a. the total charge made; or b. the hospital s average charge for a semi-private room. For hospitals equipped with private rooms only, the maximum eligible daily charges will be 90% of the private room charge. The maximum eligible daily Intensive Care Unit charge will be the lesser of: a. the actual charge made; or b. 3 times the hospital s average charge for a semi-private room; or c. 3 times the maximum eligible daily charge for a private room, when the hospitals equipped with private rooms only. Normal/Basic Deductible Amounts Per Calendar Year (See Deductible Provisions) Per Person Deductible CWM Preferred Coverage Plan $750/person; $1,500/family PPACA Mandated Minimum Coverage Plan $1,500/person; $3,000/family 10

14 The deductible is waived for eligible charges: MEDICAL BENEFITS a. for Pre-Admission Testing; b. made by physicians for second surgical opinions; c. for routine physical exams; d. for supplemental accident expense benefits; and e. for office visits at Preferred Provider Organizations/Network approved physicians. Separate In-Patient Hospital Expense Deductible CWM Preferred Coverage Plan $750 per confinement PPACA Mandated Minimum Coverage Plan $1,500 per confinement This deductible applies to each hospitalization incurred by a covered person, except for: Additional Penalty Deductibles a. a mother s confinement for the birth and delivery of a child; and b. a newborn child s initial confinement for routine newborn care. The following penalty deductibles will be assessed the covered person, in addition to any other deductibles: Hospitalization incurred without compliance with pre-certification program except for emergency services For surgery performed without a second opinion, when required by the plan CWM Preferred Coverage Plan $250 per admission PPACA Mandated Minimum Coverage Plan $500 per admission $250 per surgery $500 per surgery Primary Care Providers A current list of primary care providers is available at the Preferred Provider Organization s website at Each Participant has a free choice of any physician or surgeon, and the physician-patient relationship shall be maintained. The Participant, together with his or her Physician, is ultimately responsible for determining the appropriate course of medical treatment, regardless of whether the Plan will pay for all or a portion of the cost of such care. The PPO providers are merely independent contractors; neither the Plan nor the Plan Administrator make any warranty as to the quality of care that may be rendered by any PPO provider. Out-of-Pocket Maximum The out-of-pocket maximum is the most you could pay per covered person during a coverage 11

15 MEDICAL BENEFITS period (usually one year) for your share of the cost of covered services. The out-of-pocket limit does not include premiums, balance billed charges, cost containment penalties, copayments, amounts over usual, customary and reasonable, as well as ineligible amounts and health care this plan doesn t cover. In-Network Annual Out-of-Pocket Maximum(excluding deductibles and copays) Out-of-network Annual Out-of- Pocket Maximum(excluding deductibles and copays) CWM Preferred Coverage Plan PPACA Mandated Minimum Coverage Plan $4,500 per person $6,250 per person $9,000 per person $12,500 per person Benefit Percentages Pre-Admission Testing: (if performed w/in 72 hours of admission)** CWM Preferred PPACA Mandated Coverage Plan Minimum Coverage Plan 100% 100% Second Surgical Opinion (physician charges)** Non-PPO 50% 50% PPO 100% 60% Supplemental Accident Expense Benefit** Non-PPO 50% 50% PPO 100% 60% Routine Physical Exams** Non-PPO 60% 50% PPO 100% 60% **Deductible Waived for these benefits Hospital Charges at Facilities Non-PPO 50% 50% PPO 70% 60% Out-Patient Surgery Surgeon s Fees: Non-PPO 50% 50% PPO 70% 60% Other Charges: Non-PPO 50% 50% PPO 70% 60% Preventative Wellness 100% 100% Preventative services as defined by the U.S. Preventative Services Task Force for in-network services only! Ambulance Charges Non-PPO 50% 50% PPO 70% 60% 12

16 Anesthesia Assistant Surgeon Diagnostic X-rays or Lab Tests Alcohol and/or Substance Abuse Durable Medical Equipment Emergency Room Illness Non-PPO 50% 50% PPO 70% 60% Non-PPO 50% 50% PPO 70% 60% Non-PPO 50% 50% PPO 70% 60% Non-PPO Not Covered PPO Not Covered Non-PPO 50% 50% PPO 70% 60% MEDICAL BENEFITS Not Covered Not Covered Non-PPO $250 Co-pay then $250 Co-pay then 50% after 50% after deductible deductible PPO $250 Co-pay then $250 Co-pay then 60% after 70% after deductible deductible Emergency room co-pay waived if admitted to the hospital within 24 hours of emergency room visit. Home Health Care Non-PPO 50% 50% PPO 70% 60% Hospice Non-PPO 50% 50% PPO 70% 60% Hospital Non-PPO 50% 50% PPO 70% 60% Hospital charges subject to deductible. Maximum eligible charge is the average semi-private room rate if the hospital has private rooms only. Hospital Inpatient and Outpatient/ Outpatient Surgical Centers Non-PPO 50% 50% PPO 70% 60% Mental and Nervous Non-PPO Not Covered Not Covered PPO Not Covered Not Covered Occupational, Speech & Hearing Therapy Non-PPO 50% 50% PPO 70% 60% Organ Transplant Non-PPO 50% 50% PPO 70% 60% 13

17 Other Eligible Expenses Physical Therapy Non-PPO 50% 50% PPO 70% 60% MEDICAL BENEFITS Non-PPO 50% 50% PPO 70% 60% Surgery-In-patient Non-PPO 50% 50% PPO 70% 60% Subject to deductible, reasonable and customary guidelines, and multiple surgical procedure reduction. Surgery-Out-Patient Non-PPO 50% 50% PPO 70% 60% Subject to deductible, reasonable and customary guidelines, and multiple surgical procedure reduction. Prosthetics Non-PPO 50% 50% PPO 70% 60% Skilled Nursing Facility Non-PPO 50% 50% PPO 70% 60% Chiropractic Care & Spinal Manipulation Non-PPO 50% 50% PPO 50% 50% Chiropractic subject to deductible and $1,000 annual limit. Office Visit Co-Payments Primary Care Physician Expenses eligible under Co-pay are Professional Fee, injection fee, lab & x-ray performed at time of visit in physician office and billed by physician ONLY. Additional charges apply to deductible and coinsurance. Specialist Expenses eligible under Co-pay are Professional Fee, injection fee, lab & x-ray performed at time of visit in physician office and billed by physician ONLY. Additional charges apply to deductible and coinsurance. CWM Preferred Coverage Plan PPACA Mandated Minimum Coverage Plan $40.00 $60.00 $75.00 $ Emergency Room Illness* $ $ *Deductibles and normal plan charges still apply. Emergency room illness co-payment is waived if admitted to hospital within 24 hours of emergency room visit. 14

18 Prescription Drug Card Benefits MEDICAL BENEFITS Out-patient prescription drugs are provided through a designated drug plan program as follows: Out-Patient Prescription Drugs Deductibles CWM Preferred Coverage Plan $50.00 $ PPACA Mandated Minimum Coverage Plan Tier 1 -All Generic Drugs* $20.00 copayment per prescription *Deductible waived for Generic Prescriptions Tier 2 Brand Named Drugs $75.00 copayment per Prescription after deductible when generic equivalent is not available. $30.00 Copayment per prescription $ copayment per Prescription after deductible when generic equivalent is not available. When generic equivalent is available for a name brand medication the plan will only cover the generic equivalent cost. The employee will be required to cover the difference. All prescriptions filled through the mail order prescription program will require three (3) copays for all 90 day supplies of medication. Prescription Drugs & Medicine Dispensed by Hospital while hospitalized CWM Preferred Coverage Plan Prescription Drugs & Medicine Dispensed by Hospital while hospitalized Non-PPO 50% 40% PPO 70% 60% PPACA Mandated Minimum Coverage Plan Covered Drugs: Prescription oral contraceptive; non-injectable Federal Legend Drugs; State Restricted Drugs; insulin (including syringes and test strips). Prilosec OTC and omeprazole OTC will now be allowed under Tier 1 with a copayment for a 28 day supply. Chantix will be covered as a Tier 2 prescription. Chantix will be limited to one (1) course of treatment (90 days) per person. Excluded Drugs: Medications prescribed for the treatment of mental and nervous disorders; Contraceptives (other than oral); injectables (except insulin); vitamins and over the counter drugs; therapeutic devices or appliances; needles and syringes (other than for insulin injection); immunization agent, biological sera, blood or blood plasma; prescriptions refilled after one year from the physician s original order; fertility drugs; drugs used primarily to stimulate hair growth; smoking deterrent; retin-a; stadol; 15

19 MEDICAL BENEFITS impotency drugs; growth hormones; all over the counter medications; prescriptions dispensed to an eligible covered person while confined in a hospital, nursing home or other institution; and drugs or medicines which are Experimental/ Investigational (see EXCLUSIONS AND LIMITATIONS section of this Plan for further details). This is not a complete list of drugs that are excluded. Please contact the prescription drug service provider at the toll-free number on your drug card to determine specific drug coverage. Routine Preventive Care Benefit Routine Preventive Care Covered Charges under Medical Benefits are payable for routine Preventive Care as described herein, and in the Schedule of Benefits. Additional preventive care shall be provided as required by applicable law if provided by a Panel/Network/Participating Provider. Below is a listing of the current Preventive Services covered under the Affordable Care Act as of A current listing of required preventive care can be accessed at: Charges for Routine Well Adult Care. Routine well adult care is care by a Physician that is not for an Injury or Sickness. Charges for Routine Well Child Care. Routine well child care is routine care by a Physician that is not for an Injury or Sickness. Covered Preventive Services for Adults 1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked. 2. Alcohol Misuse screening and counseling. 3. Aspirin use for men and women of certain ages (available through the Prescription Drug Plan). 4. Blood Pressure screening for all adults. 5. Cholesterol screening for adults of certain ages or at higher risk. 6. Colorectal Cancer screening for adults over Depression screening for adults. 8. Type 2 Diabetes screening for adults with high blood pressure. 9. Diet counseling for adults at higher risk for chronic disease. 10. HIV screening for all adults at higher risk. 11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary: o o o o o Hepatitis A Hepatitis B Herpes Zoster Human Papillomavirus Influenza (Flu Shot) 16

20 o o o o o Measles, Mumps, Rubella Meningococcal Pneumococcal Tetanus, Diphtheria, Pertussis Varicella MEDICAL BENEFITS 12. Obesity screening and counseling for all adults. 13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk. 14. Tobacco Use screening for all adults and cessation interventions for tobacco users. 15. Syphilis screening for all adults at higher risk. Covered Preventive Services for Women, Including Pregnant Women The eight new prevention-related health services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, Anemia screening on a routine basis for pregnant women. 2. Bacteriuria urinary tract or other infection screening for pregnant women. 3. BRCA counseling about genetic testing for women at higher risk. 4. Breast Cancer Mammography screenings every 1 to 2 years for women over Breast Cancer Chemoprevention counseling for women at higher risk. 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women.* 7. Cervical Cancer screening for sexually active women. 8. Chlamydia Infection screening for younger women and other women at higher risk. 9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs.* 10. Domestic and interpersonal violence screening and counseling for all women.* 11. Folic Acid supplements for women who may become pregnant. 12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes.* 13. Gonorrhea screening for all women at higher risk. 14. Hepatitis B screening for pregnant women at their first prenatal visit. 15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women.* 16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older.* 17. Osteoporosis screening for women over age 60 depending on risk factors. 17

21 MEDICAL BENEFITS 18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk. 19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users. 20. Sexually Transmitted Infections (STI) counseling for sexually active women.* 21. Syphilis screening for all pregnant women or other women at increased risk. 22. Well-woman visits to obtain recommended preventive services for women under 65.* Covered Preventive Services for Children 1. Alcohol and Drug Use assessments for adolescents. 2. Autism screening for children at 18 and 24 months. 3. Behavioral assessments for children of all ages. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 4. Blood Pressure screening for children. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 5. Cervical Dysplasia screening for sexually active females. 6. Congenital Hypothyroidism screening for newborns. 7. Depression screening for adolescents. 8. Developmental screening for children under age 3, and surveillance throughout childhood. 9. Dyslipidemia screening for children at higher risk of lipid disorders. Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 10. Fluoride Chemoprevention supplements for children without fluoride in their water source. 11. Gonorrhea preventive medication for the eyes of all newborns. 12. Hearing screening for all newborns. 13. Height, Weight and Body Mass Index measurements for children. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 14. Hematocrit or Hemoglobin screening for children. 15. Hemoglobinopathies or sickle cell screening for newborns. 16. HIV screening for adolescents at higher risk. 17. Immunization vaccines for children from birth to age 18 doses, recommended ages, and recommended populations vary: o o o o o Diphtheria, Tetanus, Pertussis Haemophilus influenzae type b Hepatitis A Hepatitis B Human Papillomavirus 18

22 o o o o o o o Inactivated Poliovirus Influenza (Flu Shot) Measles, Mumps, Rubella Meningococcal Pneumococcal Rotavirus Varicella MEDICAL BENEFITS 18. Iron supplements for children ages 6 to 12 months at risk for anemia. 19. Lead screening for children at risk of exposure. 20. Medical History for all children throughout development. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 21. Obesity screening and counseling. 22. Oral Health risk assessment for young children. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. 23. Phenylketonuria (PKU) screening for this genetic disorder in newborns. 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk. 25. Tuberculin testing for children at higher risk of tuberculosis. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 26. Vision screening for all children. Women s Health and Cancer Rights Pursuant to the Women s Health and Cancer Rights Act of 1998, this plan provides benefits for Covered Persons for mastectomy-related services, including reconstructions and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from mastectomy (including lymphedema). For further details see subsection s of the ELIGIBLE CHARGES section of this Plan. Claims Audit In addition to the Plan s Medical Record Review process, the Plan Administrator may use its discretionary authority to utilize an independent bill review and/or claim audit program or service for a complete claim. While every claim may not be subject to a bill review or audit, the Plan Administrator has the sole discretionary authority for selection of claims subject to review or audit. The analysis will be employed to identify charges billed in error and/or charges that are not Usual and Customary and/or Medically Necessary and Reasonable, if any, and may include a patient medical billing records review and/or audit of the patient s medical charts and records. Upon completion of an analysis, a report will be submitted to the Plan Administrator or its agent to identify the charges deemed in excess of the Usual and Customary and Reasonable amounts or 19

23 other applicable provisions, as outlined in this. MEDICAL BENEFITS Despite the existence any agreement to the converse, the Plan Administrator has the discretionary authority to reduce any charge to a Usual and Customary and Reasonable charge, in accord with the terms of this. 20

24 DEFINITIONS As used in this Plan, the following words and phrases shall have the meanings indicated: Actively At Work or Active Employment shall mean performance by the Employee of all the regular duties of his or her occupation at an established business location of the Participating Employer, or at another location to which he or she may be required to travel to perform the duties of his or her employment. An Employee shall be deemed Actively at Work if the Employee is absent from work due to a health factor. In no event will an Employee be considered Actively at Work if he or she has effectively terminated employment. ADA shall mean the American Dental Association. Administrative Service Agent means the firm providing administrative services to the employer in connection with the operation of the Plan, such as maintaining current eligibility data, billing, processing and payment of claims and providing the employer with any other information deemed necessary. AHA shall mean the American Hospital Association. Allowable Expenses shall mean the Usual and Customary charge for any Medically Necessary, Reasonable eligible item of expense, at least a portion of which is covered under this Plan. When some Other Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered, in the amount that would be payable in accordance with the terms of the Plan, shall be deemed to be the benefit. Benefits payable under any Other Plan include the benefits that would have been payable had claim been duly made therefore. AMA shall mean the American Medical Association. Ambulatory Surgical Center shall mean any public or private State licensed and approved (whenever required by law) establishment with an organized medical staff of Physicians, with permanent facilities that are equipped and operated primarily for the purpose of performing Surgical Procedures, with continuous Physician services and registered professional nursing service whenever a patient is in the facility, and which does not provide service or other accommodations for patients to stay overnight. Assignment of Benefits shall mean an arrangement whereby the Plan Participant assigns their right to seek and receive payment of eligible Plan benefits, in strict accordance with the terms of this, to a Provider. If a provider accepts said arrangement, Providers rights to receive Plan benefits are equal to those of a Plan Participant, and are limited by the terms of this. A Provider that accepts this arrangement indicates acceptance of an Assignment of Benefits as consideration in full for services, supplies, and/or treatment rendered Assistance Eligible Individual shall mean any Qualified Beneficiary who elects COBRA continuation coverage, and has satisfied all of the following conditions: 21

25 DEFINITIONS 1. The qualifying event occurred at any time during the period that begins with September 1, 2008, and ends with May 31, 2010, and the Qualified Beneficiary was eligible for COBRA continuation coverage during this period; 2. The covered Employee or Qualified Beneficiary must elect COBRA or applicable state continuation coverage; 3. The qualifying event with respect to the COBRA continuation coverage consists of the involuntary termination of the covered Employee s employment and occurred during such period*; and 4. The covered Employee must have had a modified adjusted gross income of less than $145,000, if single, or $290,000, if married filing jointly, for each tax year in which the subsidy is received. Note that the available COBRA subsidy will be reduced for years in which the covered Employee s gross income exceeds $125,000 (or $250,000 for joint returns). *Important Note: If you experienced a reduction of hours during the period that begins with September 1, 2008 and ends with May 31, 2010, followed by an involuntary termination of employment on or after March 2, 2010 and by May 31, 2010, then your termination will constitute a qualifying event and you are entitled to a new election period for COBRA continuation coverage. Under the new election period, COBRA continuation coverage (but not the 18-month COBRA period) and the 15 months of subsidy would begin starting with the first period of coverage after the termination. Calendar Year means each period of time beginning on January 1 and ending on December 31. Child shall mean, in addition to the Employee s own blood descendant of the first degree or lawfully adopted Child, a Child placed with a covered Employee in anticipation of adoption, a covered Employee s Child who is an alternate recipient under a Qualified Medical Child Support Order as required by the federal Omnibus Budget Reconciliation Act of 1993, any stepchild or any other Child for whom the Employee has obtained legal guardianship. CHIP refers to the Children s Health Insurance Program or any provision or section thereof, which is herein specifically referred to, as such act, provision or section may be amended from time to time. CHIPRA refers to the Children s Health Insurance Program Reauthorization Act of 2009 or any provision or section thereof, which is herein specifically referred to, as such act. A Clean Claim is one that can be processed in accordance with the terms of this document without obtaining additional information from the service Provider or a third party. It is a claim which has no defect or impropriety. A defect or impropriety shall include a lack of required sustaining documentation as set forth and in accordance with this document, or a particular circumstance requiring special treatment which prevents timely payment as set forth in this document, and only as permitted by this document, from being made. A Clean Claim does not 22

26 DEFINITIONS include claims under investigation for fraud and abuse or claims under review for Medical Necessity and Reasonableness, or fees under review for Usual and Customariness, or any other matter that may prevent the charge(s) from being covered expenses in accordance with the terms of this document. Filing a Clean Claim. A Provider submits a Clean Claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements or revisions to data elements, attachments and additional elements, of which the Provider has knowledge. The Plan Administrator may require attachments or other information in addition to these standard forms (as noted elsewhere in this document and at other times prior to claim submittal) to ensure charges constitute covered expenses as defined by and in accordance with the terms of this document. The paper claim form or electronic file record must include all required data elements and must be complete, legible, and accurate. A claim will not be considered to be a Clean Claim if the Plan Participant has failed to submit required forms or additional information to the Plan as well. COBRA shall mean the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. Co-Insurance - means the percentage of an eligible charge that is paid by the Plan on behalf of the covered person. Company means or any affiliate which is participating in the Plan with the permission of Complications of Pregnancy means conditions requiring hospital confinement (when pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or caused by pregnancy. Co-Pay - means the amount which is required to be paid to a provider by a covered person at the time of service. Cosmetic Treatment means treatment performed for the purpose of improving appearance rather than for restoring bodily function necessary to correct deformities or accidental injury. Covered Expense means a Usual and Customary fee for a Reasonable, Medically Necessary service, treatment or supply, meant to improve a condition or participant s health, which is eligible for coverage in this Plan. Covered Expenses will be determined based upon all other Plan provisions. When more than one treatment option is available, and one option is no more effective than another, the Covered Expense is the least costly option that is no less effective than any other option. All treatment is subject to benefit payment maximums shown in the Summary of Benefits and as determined elsewhere in this document. 23

27 DEFINITIONS Covered Person means an employee or a dependent for whom the coverage provided by this Plan is in effect. A covered person may be covered under this Plan as an employee or as a dependent, but not both at the same time. Creditable Coverage shall mean coverage of an individual under any of the following: a group health plan, health insurance coverage, Medicare, Medicaid (other than coverage consisting solely of benefits under the program for distribution of pediatric vaccines), medical and dental care for members and certain former members of the Uniformed Services and their dependents, a medical care program of the Indian Health Service or a tribal organization, a State health benefits risk pool, a health plan offered under the Federal Employees Health Benefits Program, a public health plan, or a health benefit plan under Section 5(e) of the Peace Corps Act, or Title XXI of the Social Security Act (State Children s Health Insurance Program). To the extent that further clarification is needed with respect to the sources of Creditable Coverage listed in the prior sentence, please see the complete definition of Creditable Coverage that is set forth in 45 C.F.R (a). Deductible means the amount of eligible charges that a covered person must incur before benefits will be payable, as listed in the Schedule of Medical Benefits. Dependent shall mean one or more of the following person(s): 1. An Employee s lawfully married spouse possessing a marriage license who is not divorced from the Employee. [For purposes of this section, marriage or married means a legal union between one man and one woman as husband and wife]; 2. An Employee s Child who is less than 26 years of age; 3. An Employee s Child, regardless of age, who was continuously covered prior to attaining the limiting age under the bullets above, who is mentally or physically incapable of sustaining his or her own living. Such Child must have been mentally or physically incapable of earning his or her own living prior to attaining the limiting age under the bullets above. Written proof of such incapacity and dependency satisfactory to the Plan must be furnished and approved by the Plan within 31 days after the date the Child attains the limiting age under the bullets above. The Plan may require, at reasonable intervals, subsequent proof satisfactory to the Plan during the next two years after such date. After such two year period, the Plan may require such proof, but not more often than once each year. Dependent does not include any person who is a member of the armed forces of any Country or who is a resident of a Country outside the United States. The Plan reserves the right to require documentation, satisfactory to the Plan Administrator, which establishes a Dependent relationship. Durable Medical Equipment means equipment which is: a. able to withstand repeated use; 24