CONRAD INDUSTRIES, INC. S2489 NON GRANDFATHERED PLAN BENEFIT SHEET

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1 BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children to age 26 Filing Limit 12 months from date of service Mailing Address & PPO Company. PPO Co.: PPO CIGNA Physicians & Hospitals PPO & NonPPO: Mail claims to Cigna, P.O. Box , Chattanooga, TN Electronic Payer ID Certain Cigna Ancillary Providers are required to file claims to the Ancillary Vendor Network If members access a Third Party Network will have remit info as follows (and reflected on ID cards): Community Health Network Cigna Mt CHN P.O. Box 3018 Missoula, MT EDI# Mississippi Health Partners MHP Systems P.O. Box Jackson, MS EDI# Don t forget to get a copy of the Patient s ID Card for claim filing directions in order to expedite claims processing Pre Existing Does not apply Utilization Review: CIGNA Must precertify services prior to admission, Emergency admissions within 48 hours or first business day. Must precertify: Inpatient stays Equipment Home Health Private Duty Nursing Speech Therapy Penalty applies to IP hospital stay only. Penalty: Hospital Facility fee reduced to 50%. Page 1 of 6

2 ANNUAL MAXIMUM BENEFIT Unlimited DEDUCTIBLE, PER CALENDAR YEAR Deductibles are combined, that is, expenses applied toward the satisfaction of the PPO will be applied toward satisfaction of the Non PPO, and vice versa. Per Participant $750 Per Family $2,250 MAXIMUM OUT OF POCKET EXPENSES, PER CALENDAR YEAR Out of Pocket expense amounts are combined, that is, expenses applied toward the satisfaction of the PPO out of pocket amount will be applied toward satisfaction of the Non PPO out of pocket amount, and vice versa. Per Participant $3,250 $6,500 Per Family $6,500 $13,000 NOTE: The following charges do not apply toward the out of pocket expense amount and are never paid at 100%: N/A HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Common Accident Deductible applies; refer to plan document for details. Acupuncture Ambulance Bariatric Surgery Behavioral/Mental Health and Substance Use Disorders Inpatient Includes Residential Treatment In addition to the PPO network, charges for services provided through the Interface EAP network ( ) will be considered PPO. Behavioral/Mental Health and Substance Use Disorders Outpatient Includes Partial Hospitalization In addition to the PPO network, charges for services provided through the Interface EAP network ( ) will be considered PPO. Blood Blood and blood derivatives that are not donated or replaced are covered. Chemotherapy & Radiation Therapy Chiropractic Treatment Clinical Trials (as defined by this Plan for cancer or other lifethreatening diseases or conditions) Includes coverage for routine patient costs associated with participation in approved Clinical Trials only. If one or more PPO providers are participating in a Clinical Trial, the Plan may require that the qualified individual participate in the Clinical Trial with the PPO provider. The Plan will cover Non PPO providers outside the state in which the qualified individual resides only if there is not a PPO provider conducting the same trial in state. Dental applicable service for Non Surgical Treatment of the Spine applicable service for This group does not have a dental plan. Page 2 of 6

3 Impacted Wisdom Teeth Diabetes Self management Training Diagnostic Testing (Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Diagnostic Testing (X ray, lab) Inpatient Diagnostic Testing (X ray, lab ) Outpatient Hospital Diagnostic Testing (X ray, lab) Stand Alone Facility Diagnostic Testing (X ray, lab) Office Durable Medical Equipment Requires approval for medical necessity. Emergency Services in an Emergency Room Extended Care/Skilled Nursing Facility (60 days Calendar Year maximum) Foot Conditions Physicians' services in connection with corns, calluses or toenails are excluded, unless the charges are for the partial or complete removal of the nail roots. Routine foot care and foot orthotics are not covered Gastric Bypass Hearing Aids Hearing Screening Home Health Care (60 visits Calendar Year maximum) Requires approval for medical necessity. Hospice Care (180 days Lifetime maximum) Covered under the medical plan only if the tooth is 100% impacted. Surgeon Benefit (Facility charges will follow facility ). 100% after $30 copay 50% after 50% after applicable service for Bariatric Surgery Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Hospital / Facility Inpatient Room and Board is limited to the semiprivate room rate, or if the Hospital has private rooms only, 90% of the lowest private room rate. ICU as billed Hospital / Facility Outpatient Infertility/Sterility Maternity Maternity related expenses for a dependent Child are not covered except as required by law for prenatal care. Prenatal care as required by federal law. care care Other eligible charges. Page 3 of 6

4 Newborn Care (routine inpatient) Physician 80%, no Facility Non Surgical Treatment of the Spine ($600 Calendar Year maximum) (OV & X ray included in the Calendar Year maximum) Obesity Organ Transplants Provider should notify Customer Contact Center prior to starting any transplant services, including initial evaluation. Case Management is strongly suggested. plan document for further limitations & exclusions. Orthotics / Prosthetics Foot orthotics are not covered Physician Services Inpatient Visits Physician Services Inpatient Surgeon Physician Services Outpatient Visits (services other than in a Physician's office) Physician Services Outpatient Surgeon (services other than in a Physician's office) Physician Services Office Visits Copay is per day and applies only to office visit charge, injections, supplies, X ray & lab services that are performed in the Physician s office and minor office surgery. All other eligible expenses rendered in the physician s office not covered under copay including allergy testing and allergy treatment. Physician Services In office Surgeon Prescription Drugs Inpatient Prescription Drugs Outpatient Preventive Care Preventive care benefit includes the following: physical exam, X ray & lab, immunizations, vision exam, gynecological exam, mammogram, pap smear, and prostatic testicular exam, and routine diagnostic testing including but not limited to colonoscopies. Breast pumps are limited to one per calendar year Services are also covered as recommended by the United States Preventive Services Task Force (USPSTF) and immunizations will be covered as recommended by the Centers for Disease Control (CDC). All services are limited to no more than once annually or as recommended by the USPSTF. Private Duty Nursing (Limited to Outpatient only and $10,000 Lifetime maximum) Requires approval for medical necessity. 80%, no 100% after $30 copay Deductible Physician Physician Services: Services: Office Office Visits Visits Hospital / Facility Inpatient Prescription Drug Benefits schedule and section 100%, no Page 4 of 6

5 Rehabilitation Services (Cardiac Rehab, Occupational, Physical, Speech and Vision Therapies) Provider must send letter of medical necessity and all applicable notes Cardiac rehab therapies limited to phase I & II Speech Therapy requires approval for medical necessity Sleep Disorder Covered only if medically necessary. Sleep Study Other eligible expenses Sterilization Vasectomy applicable service for applicable service for Female Sterilization as required by federal law Temporomandibular Joint Syndrome Care Care Urgent Care Facility (includes all covered charges billed by facility) 100% after $30 copay Vision Screening Wig After Chemotherapy Limited to one per lifetime ($500 Lifetime maximum) Care Page 5 of 6

6 PRESCRIPTION DRUG CARD OPTION Express Scripts/RX Benefits. scripts.com Paid by invoice. RxBIN: RxGRP: 35242RX Member: Pharmacy: Prescription Drug Card Options Copayment Benefit Percentage Retail Pharmacy Option (30 day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the Physician. $0 100% Generic drug $15 100% Formulary Brand Name drug $40 100% Non Formulary Brand Name drug $60 100% Mail Order Option (90 day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the Physician. $0 100% Generic drug $30 100% Formulary Brand Name drug $80 100% Non Formulary Brand Name drug $ % Page 6 of 6

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