2Page 2 of 11. Baker Hughes Incorporated. Benefits At A Glance International Plan Policy#: 05679B
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1 2Page 2 of 11 Baker Hughes Incorporated Policy#: 05679B
2 Baker Hughes, Inc. is offering Medical, Dental, Medical Evacuation and Repatriation benefits through Cigna Global Health Benefits to our employees. This comprehensive international healthcare program allows our employees and their families to access quality healthcare anywhere in the world. The following pages will provide a general overview of the plan designs for our employees on international assignment. PPO Network Deductible: Individual Family Maximum $0 $0 $250 $500 Plan Coinsurance Out of Pocket Limit: Individual Family Maximum (OOP Limits cross apply and exclude the ) Lifetime Maximum Physician Office Visit Services - General / Specialist Outpatient Laboratory and X-ray Services (including preadmission testing) $1,500 $3,000 $1,500 $3,000 $250 $500 60% of covered expenses $1,500 $3,000 Unlimited Unlimited Unlimited Inpatient Hospital Services Room and Board Inpatient Hospital Services Outpatient Hospital/Surgical Services The most common semiprivate room rate (private outside the US if there is no intermediate level between ward and private) The most common semiprivate room rate (private outside the US if there is no intermediate level between ward and private) The most common semiprivate room rate (private outside the US if there is no intermediate level between ward and private) Hospital Emergency Room (except if not a true emergency, then 60%) Page 2 of 11 Publication Date 12/5/2012
3 WELLNESS SERVICES Child Preventive Care (Birth to Age 18) for the following services: health history, physical examination, development assessments, anticipatory guidance, appropriate immunizations, and laboratory tests for the following services: health history, physical examination, development assessments, anticipatory guidance, appropriate immunizations, and laboratory tests for the following services: health history, physical examination, development assessments, anticipatory guidance, appropriate immunizations, and laboratory tests Adult Preventive Care (Age 18 and over) for charges made for or in connection with the overall health and well being including adult routine immunizations for charges made for or in connection with the overall health and well being including adult routine immunizations for charges made for or in connection with the overall health and well being including adult routine immunizations Travel Immunizations for Employee and Dependent immunizations required for travel are included 100% of covered for Employee and Dependent immunizations required for travel are included for Employee and Dependent immunizations required for travel are included Papanicolaou (Pap) Screening up to one test per calendar year for all eligible females 100% of covered up to one test per calendar year for all eligible females up to one test per calendar year for all eligible females Prostate Cancer Screening up to one test per calendar year for all eligible males 100% of covered up to one test per calendar year for all eligible males up to one test per calendar year for all eligible males Page 3 of 11 Publication Date 12/5/2012
4 Mammograms per the following schedule: 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 woman s baseline. Age 50 & Over: one exam annually Any Age: Whenever prescribed by a physician 100% of covered per the following schedule: 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 woman s baseline. Age 50 & Over: one exam annually Any Age: Whenever prescribed by a physician per the following schedule: 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 woman 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 old and children under age 6 who are considered to be at high risk 100% of covered for children at or around 12 months old and children under age 6 who are considered to be at high risk for children at or around 12 months old and children under age 6 who are considered to be at high risk Immunizations for children from birth through age 18 for immunization against diphtheria, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, haemophilus influenza B, and hepatitis A for children from birth through age 18 for immunization against diphtheria, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, haemophilus influenza B, and hepatitis A for children from birth through age 18 for immunization against diphtheria, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, haemophilus influenza B, and hepatitis A Colorectal Cancer Screening or persons age 50 and older or for any person deemed at high risk of colon cancer because of family history, ethnic or lifestyle background or persons age 50 and older or for any person deemed at high risk of colon cancer because of family history, ethnic or lifestyle background or persons age 50 and older or for any person deemed at high risk of colon cancer because of family history, ethnic or lifestyle background Page 4 of 11 Publication Date 12/5/2012
5 Developmental Screenings for charges for developmental screenings at nine, eighteen and thirty months which includes any developmental screening tool favorably mentioned by the American Academy of Pediatrics Committee on Children with Disabilities for charges for developmental screenings at nine, eighteen and thirty months which includes any developmental screening tool favorably mentioned by the American Academy of Pediatrics Committee on Children with Disabilities for charges for developmental screenings at nine, eighteen and thirty months which includes any developmental screening tool favorably mentioned by the American Academy of Pediatrics Committee on Children with Disabilities Vision Exams One eye exam every 12 consecutive months Vision Hardware On pair of frames or lenses per 12 consecutive months Hearing Exams One exam every 24 months PRESCRIPTION DRUGS Outside United States Inside United States (Co-pay does not apply toward OOP Maximum) Generic Brand - Formulary Brand Non Formulary In Network Participating Pharmacy Retail & Mail Order not subject to not subject to not subject to Out of Network Non-Participating Pharmacy Retail Only not subject to not subject to not subject to Page 5 of 11 Publication Date 12/5/2012
6 OBESITY/BARIATRIC SURGERY Coverage is provided subject to medical necessity and clinical guidelines. Members must contact Cigna prior to incurring such costs. Physician s Office Visit Inpatient Facility Outpatient Facility Physician s Services Lifetime Maximum $10,000 (applies to surgical procedure) $10,000 (applies to surgical procedure) $10,000 (applies to surgical procedure) Family Planning Physician Office Visit Vasectomy Tubal Ligation Abortion (Elective or Spontaneous) FAMILY PLANNING SERVICES, not subject to, (reversal not covered) not subject to (reversal not covered) Maternity Services Newborn Care Birthing Centers Nurse Midwife Infertility For diagnostic services only (reversal not covered) Page 6 of 11 Publication Date 12/5/2012
7 OTHER COVERED MEDICAL SERVICES Acupuncture Limited to 20 visits per calendar year 60% of covered Inpatient Mental Illness and Alcohol / Substance Abuse 60% of covered Outpatient Mental Illness and Alcohol / Substance Abuse 60% of covered Skilled Nursing Facility Limited to 120 days per calendar year.. 60% of covered Home Health Care Limited to 120 days per calendar year 60% of covered Hospice, 100% of covered expenses Page 7 of 11 Publication Date 12/5/2012
8 OTHER COVERED MEDICAL SERVICES Outpatient Short Term Rehabilitative Therapy Physical Outpatient Short Term Rehabilitative Therapy Cardiac Physio Pulmonary Cognitive Occupational Speech Combined maximum 30 visits per calendar year Infusion Therapy Dialysis Treatment Chiropractic Treatment Limited to a maximum of 30 days per calendar year Allergy Testing / Treatment Contraceptives Physician Office Visit Inpatient Facility Outpatient Facility Physician Services Page 8 of 11 Publication Date 12/5/2012
9 Physician Services For FDA approved prescription contraceptive drug/devices and for outpatient contraceptive services including consultations, exams, procedures and medical services related to the use of contraceptives. Diabetes Equipment and Supplies Dental Care limited to charges made for a continuous course of dental treatment started within six months of an injury to sound natural teeth limited to charges made for a continuous course of dental treatment started within six months of an injury to sound natural teeth limited to charges made for a continuous course of dental treatment started within six months of an injury to sound natural teeth TMJ services Calendar Year Maximum Benefit - $500 Page 9 of 11 Publication Date 12/5/2012
10 Preadmission Certification (PAC), Continued Stay Review (CSR), Surgical Precertification Case Management Pre-Assignment Assistance Program Cigna Pharmacy Management COST CONTAINMENT PROVISIONS Will apply with penalties for non-compliance for U.S. confinements. Penalties: $300 penalty applied to hospital in-patient charges for failure to pre-certify admission. Benefits are reduced 50% for any admission not certified or additional days not deemed medically necessary. A service provided through CareAllies, a Cigna company, which assists individuals with treatment needs that extend beyond the acute care setting. The goal is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a hospital or specialized facility. This service works with the patient, their family and the attending physician to determine appropriate treatment options which will best meet the patient s needs and keep costs manageable. Case managers will help coordinate the treatment program and arrange for necessary resources. Pre-Assignment Assistance Program - Cigna's Pre-Assignment Assistance is a unique clinical program that offers comprehensive case management, care coordination, inpatient management, evacuation assistance, and online expert second opinion's 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 Cigna Envoy. A service provided through Cigna Pharmacy Management, a Cigna company, which offers a managed pharmacy benefit plan for prescription drugs purchased in the United States at participating retail pharmacies. Mail order drugs will also be available via TelDrug, but can be shipped overseas to APO addresses only. Some limitations may apply. Page 10 of 11 Publication Date 12/5/2012
11 EVACUATION BENEFIT Emergency Evacuation Family Travel Arrangements Return of Dependent Children Repatriation of Mortal Remains Return of Traveling Companion ADDITIONAL SERVICE RIDERS for services approved by International SOS. Economy round-trip airfare to the place of hospitalization for one family member for hospitalizations in excess of 7days One-way Economy airfare to return dependent children to their country of residence In the event of hospitalization or evacuation, and a traveling companion s air ticket is no longer usable, one-way economy airfare will be provided to the original point of departure GROUP DENTAL INSURANCE Classes I, II, III Combined Calendar Year Maximum Calendar Year Deductible Individual Family Maximum Class I Preventive Care Class II Basic Restorative Class III Major Restorative Class IV Orthodontia (Limited to dependent children under age 19) Class V Implants $1,500 per person (waived for Class I) $0 $0 for Diagnostic and Preventive services including oral examination, diagnostic x-rays and periodontal maintenance for Basic Restorations, Endodontics, Periodontics, Prosthodontic Maintenance and Oral Surgery including Fillings, Root Canal, Periodontal Scaling and Root Planning and repair to Bridgework and Dentures 50% of covered expenses for Major Restorations, Dentures and bridgework including Crowns 50% of covered expenses up to a $1,500 lifetime maximum Not Covered Page 11 of 11 Publication Date 12/5/2012
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