L.B. Foster Company Medical Reimbursement Plan
EX-10.45 6 j0512301exv10w45.txt L.B. FOSTER COMPANY MEDICAL REIMBURSEMENT PLAN EXHIBIT 10.45 L.B. FOSTER COMPANY MEDICAL REIMBURSEMENT PLAN SUMMARY PLAN DESCRIPTION EFFECTIVE JANUARY 1, 2004 MEDICAL REIMBURSEMENT PLAN OF BENEFITS Maximum Yearly Benefit for Plan - MR1 $ 3,000 Maximum Yearly Benefit for Plan - MR2 $ 6,000 Maximum Lifetime Maximum for Substance Abuse $25,000
Medical Reimbursement Plans provide Benefits for covered services allowed, but not covered in their entirety by the Basic Medical and Dental Plans. Deductibles and Co-payments may be reimbursed by these Plans, up to the Usual, Reasonable and Customary Charge. Services for which coverage is limited by the Basic Plan, such as Orthodontics, may be reimbursed up to the Reasonable and Customary charge. Penalties for failure to Pre-notify or charges declined due to a Pre-Existing Condition are not allowable under these Plans, as well as charges above any limits set by the Medical Reimbursement Plans. Additionally, the Medical Reimbursement Plans contain provisions for vision care as listed in this schedule. SCHEDULE OF BENEFITS FOR MR1 & MR2 BENEFITS -------- BENEFIT PERCENTAGE: Medical Plan Pays 100% Covered Person Pays 0%
BENEFITS AND SERVICES PLAN PAYS COMMENTS --------------------- --------- -------- HOSPITAL BENEFIT Inpatient Hospital Services 100% of UCR Pre-notification required Benefit based on Semi- private room rate. Outpatient Hospital 100% of UCR Skilled Nursing Facility 100% of UCR Pre-notification required. Emergency Room 100% of UCR Non-emergency care is not covered. MENTAL HEALTH & SUBSTANCE ABUSE BENEFITS Inpatient Mental Health 100% of UCR Pre-notification required Treatment
BENEFITS AND SERVICES PLAN PAYS COMMENTS --------------------- --------- -------- Outpatient Mental Health 100% of UCR Treatment including Psychological Testing Inpatient Substance Abuse 100% of UCR Pre-notification required. Treatment Outpatient Substance 100% of UCR Limited to 50 paid visits per year. Abuse Treatment MISCELLANEOUS SERVICES AND SUPPLIES Home Health Care 100% of UCR Hospice Care 100% of UCR Pre-notification required. Inpatient Hospice Care 100% of UCR Outpatient Bereavement Counseling 100% of UCR Ambulance Service 100% of UCR Durable Medical 100% of UCR Equipment Other outpatient care 100% of UCR PROFESSIONAL SERVICES BENEFIT Physician's visits 100% of UCR - - Office Visit - - Inpatient Hospital Visit 100% of UCR or Consultation - - Allergy 100% of UCR - - Other Covered Injections 100% of UCR Second Surgical Opinion 100% of UCR If a second surgical opinion is required by Utilization Review but not obtained, the penalty will not be allowed under these Plans. Obstetrics & Newborn 100% of UCR Care
BENEFITS AND SERVICES PLAN PAYS COMMENTS --------------------- --------- -------- Surgical Services 100% of UCR Includes surgeon and facility. Pre-notification required for all In-patient and outpatient surgical procedures. Pre-notification not required for office surgery. Transplant Services 100% of UCR Donor/Procurement related to a transplant is NOT COVERED. Diagnostic Laboratory & X-ray 100% of UCR Expenses Supplemental Accident Benefit 100% of UCR REHABILITATION THERAPY Chiropractic Care 100% of UCR Limited to $500 per calendar year Acupuncture Treatment NOT COVERED Temporomandibular Joint Disorders NOT COVERED (TMJ) Chemotherapy 100% of UCR Radiation Therapy 100% of UCR Respiratory Therapy 100% of UCR Speech Therapy 100% of UCR Physical Therapy 100% of UCR Occupational Therapy 100% of UCR PREVENTIVE CARE Well Care - - Physical Exam 100% of UCR - - Other Well Services 100% of UCR Mammogram 100% of UCR GYN & Pap 100% of UCR
BENEFITS AND SERVICES PLAN PAYS COMMENTS --------------------- --------- -------- PSA testing 100% of UCR
Well Child Care includes reimbursement for the following services: office visits, physical examination, laboratory tests, x-rays, immunizations and cancer screenings. DENTAL BENEFITS Preventive Services 100% of UCR Basic Services 100% of UCR Major Services 100% of UCR Orthodontics 100% of UCR VISION BENEFITS Exams 100% of UCR Limited to 1 per 12 months. Glasses 100% of UCR Limited to 2 pair per 24 months. Frames 100% of UCR Limited to $75 per set. Contacts 100% of UCR Limited to 2 pair per 24 months or Disposable Contacts 100% of UCR Limited to $150 maximum PRESCRIPTION BENEFITS Retail or Mail Order Reimbursable after prescription Prescriptions 100% of UCR deductible has been met.
Benefits for this coverage may be increased if a prescription change occurs. Also, if a medical condition requires more frequent services, these Benefits may be increased to meet that requirement. Any such condition will have to be documented by a letter of Medical Necessity. EXCLUSIONS FOR MEDICAL REIMBURSEMENT PLANS (IN ADDITION TO THOSE OUTLINED IN THE GROUP INSURANCE PLAN MEDICAL EXCLUSIONS AND LIMITATIONS) MEDICAL EXCLUSIONS AMOUNTS over the Usual, Reasonable and Customary Charge; CHARGES ALREADY PAID by the L.B. Foster Company's basic medical and dental plans; CHARGES THAT ARE NOT COVERED in part by the L.B. Foster Company's medical and dental Plans, unless specifically stated in the Schedule of Benefits; PENALTIES accessed for non-compliance assessed with Utilization Review Requirements. VISION EXCLUSIONS NON-PRESCRIPTION EYE GLASSES; OVERSIZED LENSES, SPECIAL TINTING, SPECIAL POLISHING, SPECIAL LENS COATINGS; PRESCRIPTION EXCLUSIONS COVERED PRESCRIPTION DRUGS - Drugs prescribed by a physician that require a prescription by federal law unless otherwise excluded. - All compound medications containing at least one prescription ingredient in a therapeutic amount. - Insulin when prescribed by a physician; needles, syringes and diabetic supplies, i.e. blood test strips, lancets, alcohol swabs, diabetic meters. - Oral contraceptives - Immunosuppressants - Dermatological agents used to treat acne - Immune Response Modifiers, such as. Betaseron, Avonex and Copaxone and Rebif - Oral and injectable sexual dysfunction drugs LIMITS TO COVERED PRESCRIPTION DRUG BENEFIT The covered benefit for any one prescription will be limited to: - The quantity limits established by the plan - Refills only up to the time specified by a physician - Refills up to one year from the date of order by a physician - Certain prescription drugs require prior-authorization. A partial list is below: -All anabolic steriods -Drugs to treat Attention Deficit Hyperactivity Disorder or Narcolepsy -Remicade for treatment of Crohn's Disease -Infertility Drugs are limited to 7 cycles per lifetime; 30 days supply per prescription -Dermatological agents used to treat acne over the age of 25 -Xolair -Synagis -Lotronex; Zelnorm -Synvisc; Hylagan Limit to 2 cycles of injections per lifetime -Weight Loss medications (dx of morbid obesity) -Migraine Medications are limited to the manufacturer or FDA standard guidelines -Toradol;Stadol NS (quantity limits will apply) EXCLUDED PRESCRIPTION DRUGS - Over the Counter products that may be bought without a written prescription or their equivalents. This does not apply to injectable insulin, insulin syringes and needles and diabetic supplies, which are specifically included. - Devices of any type even though such devices may require a prescription. This includes (but not limited to) therapeutic devices or appliances such as Implantable insulin pumps and ancillary pump products. - Immunization Agents, biological serum, biological immune globulins and vaccines. - Implantable time-released medications. - Experimental or Investigational Drugs or drugs prescribed for experimental, Non-FDA approved, indications. - Drugs approved by the FDA for cosmetic use only, i.e. Renova - Compound chemical ingredients or combination of federal legend drugs in a Non FDA approved dosage form. - Nutritional Supplements except for metabolic conditions only. - Weight loss medications - Injectable arthritis medications: Enbrel, Kineret, Humira and Remicade - Influenza medications - Growth Hormones - Miscellaneous supplies, i.e. batteries, logbooks, adapters, videotapes - Hair reduction agents or hair replacement agents, i.e. Propecia or Vaniqa - Fluoride - Ceredase, Cerezyme - Xyrem - Pravigard - Sarafem - Blood Products and blood factor - Amieve and Raptiva - Any prescription that you are entitled to receive without charge from any Workers Compensation or similar law or municipal state or Federal program. - Charges for the administration of a drug by an attending physician - Charges for medication that is to be taken by or administered to you, in whole or part, while you are a patient in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital or nursing home. - Drugs for tobacco dependency. - Cosmetic drugs, even if ordered for non-cosmetic purposes. - Charges for giving or injecting drugs.
