Vectrus Systems Corporation OAP GLOBAL PLAN Benefits at a Glance Policy # 04804A Effective Date: January 1, 2015
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1 Vectrus Systems Corporation OAP GLOBAL PLAN Benefits at a Glance Policy # 04804A Effective Date: January 1, 2015 Vectrus Systems Corporation is offering Medical, Dental, Vision, EAP, Pharmacy, Medical Evacuation and Repatriation benefits to our employees through Cigna Global Health Benefits. This comprehensive international healthcare program allows our employees and their families to access quality healthcare anywhere in the world. The following pages provide a general overview of the plan design for our employees on international assignment. Medical Plan Eligibility Lifetime Maximum Calendar Year Deductible Per Individual Per Family Out of Pocket Maximum Per Individual Per Family Family members meet only their individual Outof-Pocket and then their claims will be covered at ; if the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at. Accumulation Combined Medical/Pharmacy Out-of-Pocket Maximum Coinsurance (The percentage of covered expenses the plan pays) Inpatient Hospital Services Facility Physician U.S In-Network U.S Out-of-Network (Outside of the U.S.) All active, full-time US Expatriate and Third Country National/Other Country National Employees of the employer and their dependents holding either a Green Card or US Authorized papers or employees as determined by the Client regularly working a minimum of 20 hours per week. Eligible populations: US expatriates TCN S (Third Country Nationals) Unlimited $1,500 $3,000 $4,000 $8,000 $3,000 $6,000 $8,000 16,000 Accumulation of Plan Deductible and Out-of-Pocket Maximums: Deductible and Out-of-Pocket Maximums will cross-accumulate between In-Network, Out-of-network and. All other plan maximums and service specific maximums (dollar and occurrence) will also crossaccumulate. The Out of Pocket (OOP) limits cross apply (Aggregate Family); OOP will exclude payments; exclude copay payments; exclude pharmacy copays; include pharmacy coinsurance payments; exclude Pre-Admission Certification/Continued Stay Review penalties. 80% 60% 80% after 80% after 60% after 60% after Outpatient Facility Services 80% after 60% after Hospital Emergency Room (refer to certificate for coverage and exclusions) $250 per visit copay, then 80% after $250 per visit copay, then 80% after
2 Medical Plan Infertility (Procedures directly related to diagnosis are covered. Treatment, prescription drugs, and/or other method to bypass, i.e. In-vitro, are not covered. Refer to the certificate for additional coverage and exclusions) (Outside of the U.S.) U.S In-Network U.S Out of Network 80% after 60% after Maternity Care Services 80% after 60% after Lab & Radiology Facility 80% after 60% after Short Term Rehabilitation (60-day maximum per calendar year for all therapies combined) Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab and Cognitive Therapy Prescription Drug Benefit 80% after 60% after Refer to the Prescription Drug Benefits schedule Refer to the Prescription Drug Benefits schedule TMJ ($1000 maximum per lifetime) 80% after 60% after Physician Services Physician s Office Visit Surgery performed in physician s office Allergy testing/treatment Mental Illness and Substance Abuse Inpatient Outpatient Skilled Nursing Facility (120-day maximum per calendar year combined) Home Health Care (120-day Maximum per calendar year) Chiropractic Services $50 per office visit copay 80% after 80% after 80% after 80% after 60% after 60% after 60% after 60% after 60% after 80% after 60% after 80% after 60% after (20-day maximum per calendar year) 80% not subject to 60% after (20-day maximum per calendar year) Hospice 80% after 60% after Diabetes Equipment & Supplies (Prescribed and recommended, in writing, by a physician. Equipment included: insulin pumps, blood glucose meters and strips, urine testing strips, insulin, syringes, lancets, alcohol swabs and pharmacological agents for controlling blood sugar) Hearing Exam: One every 36 month period Hardware: Up to $1,000 per hearing aid unit necessary for each hearing impaired ear every 3 years for Employees, Spouses and Dependent children to age 26 Autism Spectrum Disorders Coverage (Coverage for the screening, diagnosis and treatment of autism spectrum disorder and medications as prescribed by licensed providers) 80% after 60% after $50 per office visit copay 80% after 60% after 60% after 80% after 60% after
3 Medical Plan Family Planning: Women s Services Inpatient hospital facility Outpatient hospital facility Surgical services such as tubal ligation are covered (excluding reversals) Includes contraceptive devices as prescribed Family Planning: Men s Services Inpatient hospital facility Outpatient hospital facility Surgical services such as vasectomy are covered (excluding reversals) Women s Preventive Services Annual well-woman visits Gestational diabetes screening HPV DNA testing for women 30 years and older Sexually-transmitted infection counseling including HIV screening and counseling Domestic violence screening and counseling Breast-feeding equipment and supplies (Limited to one rental of one breast pump per birth as ordered or prescribed by a physician. Includes related supplies and counseling) (Out of U.S.) In-Network U.S. not subject to Out of Network U.S. 80% after 60% after Well Child Care Adult Preventive Care Immunizations For children birth to age 18 Includes diphtheria, hepatitis A, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, Haemophilus influenza B Travel Immunizations (For employee and dependents immunizations as required for travel) Papanicolaou Screening Test (One test per calendar year for females) Prostate Cancer Screening (One test per calendar year for males) Mammogram Ages 35-39: One baseline exam Ages 40-49: One exam every one or two years for asymptomatic women, but no sooner than two years after a women s baseline Age 50 & Over: One exam annually Any age: Whenever prescribed by a physician Lead Poisoning Screening (For children at or around 12 months and high-risk children under age 6) Colorectal Cancer Screening (Age 50 and older or any high-risk individual) not subject to not subject to not subject to not subject to not subject to not subject to not subject to not subject to not subject to not subject to not subject to
4 Medical Plan Dental Care (Accident) (Limited to a continuous course of treatment started within six months of accidental injury to sound natural teeth) (Out of U.S.) In-Network U.S. Out of Network U.S. 80% after 60% after Durable Medical Equipment 80% after 60% after External Prosthetic Appliances 80% after 60% after Smoking Cessation Products 80% after 60% after Pre-Admission Certification/ Continued Stay Review for Hospital Confinement Precertification for inpatient and outpatient services received in the U.S. is required. Network providers must call our toll-free number, to precertify services. The customer is responsible for ensuring that out-of-network providers precertify services. Failure to obtain precertification may affect out-of-pocket costs. This is a summary only and further details can be found in the insurance certificate Global Wellness Programs Pre-Assignment Assistance Program Health & Well-Being Assessment Cigna Global Health Benefits pre-assignment assistance is a unique clinical program that offers comprehensive case management, care coordination, inpatient management, evacuation assistance, and online expert second opinions for employees and dependents either in the U.S. or abroad. The tool can be accessed prior to or during assignment through Cigna's secure web portal, Employees that utilize the pre-assignment assistance program are more likely to have a successful assignment. The Health and Well-Being Assessment (HA) is a short, online assessment that is core to our wellness solutions and the first step to identifying personal health risks. Those who complete the HA receive a personalized health risk profile report. The HA is medically validated by the World Health Organization. Employee Assistance Program (IEAP) Level 3 EAP Assist & Work/Life Direct dial 24/7 immediate access to confidential services for behavioral issues. Services include telephonic triage for emergent and urgent referrals, crises intervention and referrals to community resources. Referrals for 5 face-to-face sessions with licensed behavioral professional. Includes work-life referrals for childcare, eldercare, legal and financial situations.
5 Prescription Drug Benefits Purchased Inside the United States Only Benefit Highlights Participating Pharmacy Non-Participating Pharmacy Retail Drugs The amount you pay for each 30 The amount you pay for each 30 Generic $15 40% not subject to plan Preferred Brand Name $50 40% not subject to plan Non Preferred Brand Name $90 40% not subject to plan Home Delivery Prescription Drugs The amount you pay for each 90 The amount you pay for each 90 Generic $45 U.S. In-network coverage only Preferred Brand Name $150 U.S. In-network coverage only Non Preferred Brand Name $270 U.S. In-network coverage only Emergency Medical Evacuation / Repatriation Emergency Evacuation Family Travel Arrangements Return of Dependent Children of covered expenses not subject to the for services approved by SOS Economy round-trip airfare to the place of hospitalization for one family member for hospitalizations in excess of 7 days One-way economy airfare to return dependent children to their country of residence Repatriation of Mortal Remains Return of Traveling Companion coverage In the event of hospitalization or evacuation, and a traveling companion s air ticket is no longer usable, one-way airfare paid at economy rates to return traveling companions to country of residence Vision Care (Outside the U.S.) U.S. In-Network U.S. Out-of-Network Eye Exams Limited to one exam each 12 month period not subject to plan plan Vision Hardware Lenses & Frames Limited to one pair of glasses or contact lenses per calendar year Maximum Every 24 months not subject to plan not subject to plan $500 $500 $500
6 Dental Plan - DENTAL BENEFITS ARE APPLICABLE ONLY IF DENTAL COVERAGE WAS ELECTED Calendar Year Maximum (for Class I, II, III) $1,000 Lifetime Maximum (for Class IV) $500 Calendar Year Deductible Class I Preventive Care For diagnostic and preventative services including: Oral Exam - 2 per person, per year Cleanings - 2 per person, per year Bitewing X-rays - 2 per person, per year Fluoride Applications - 1 per person, per year (Up to age 19) Sealants - 1 per person, per year Full Mouth X-rays - unlimited Panoramic X-rays - 1 per person, per 3 years $50 Individual / $150 Family not subject to Class II Class III This class does not have a specific maximum Basic Restorative For Basic Restorations, Endodontics, Periodontics, Prosthodontics Maintenance, Oral Surgery, Fillings, Root Canal, Periodontal Scaling and Root Planning and repair to Bridgework and Dentures This class does not have a specific maximum Major Restorative For Major Restorations, Dentures and Bridgework including Crowns 80% subject to 50% subject to This class does not have a specific maximum Class IV Orthodontia (for dependent children under age 19) 50% after plan The information herein is believed accurate as of the date of publication and is subject to change. This material is intended for informational purposes only and contains only a partial and general description of benefits. Please consult your policy/customer certificate for a complete description of coverage and exclusions. In the event of a conflict or discrepancy, the terms of the formal plan documents control. Please contact your Plan Administrator for a copy of the plan documents. Coverage and benefits are contingent upon the applicable policy terms and are available except where prohibited by applicable law. Copyright 2014 (Cigna Corporation) Publication Date 10/3/14 SCL-F
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-----------------None-------------------------------
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