Schedule of Benefits for Standard Major Medical Plan (Plan 207)
This document outlines the benefits provided under the Standard Major Medical Plan (Plan 207) for associates and their dependents. It details coverage limits, including a $750,000 individual lifetime maximum, and specifies that most medical services—such as hospitalization, surgery, physician visits, maternity, mental health, and preventative care—are covered at 100% with no deductibles or out-of-pocket maximums. The plan applies to both participating and non-participating providers. Some services, like health education and bereavement counseling, are not covered. Prescription drug benefits are only available with a drug card.
EXHIBIT 10.6
SCHEDULE OF BENEFITS
FOR STANDARD PLAN
Benefit Plan 207
| Major Medical Benefits (Associates and Dependents) | ||
| Individual Lifetime Maximum | $750,000 | |
| Maximum Hospital Daily Benefit | Semi Private | |
| Charge of semi-private room of which hospital has greatest number will be paid toward private room. | ||
| Number of Days per Confinement | Unlimited |
| Utilizing Participating Provider | Utilizing Non-Participating Provider | |||
| Deductible Amount Per Calendar Year | ||||
| Single | $0 | $0 | ||
| 2 Member Family | $0 | $0 | ||
| 3 or more Member Family | $0 | $0 | ||
| Percent of Company Participation after Deductible | 100% | 100% | ||
| Out-of-Pocket Maximum Per Calendar Year (Includes Deductible) | ||||
| Single | $0 | $0 | ||
| Family | $0 | $0 | ||
| Hospitalization | ||||
| Number of Inpatient Days | Unlimited 100% | Unlimited 100% | ||
| X-Ray, Lab and Miscellaneous Hospital Services in a: | ||||
| • Hospital (Inpatient and Outpatient) | ||||
| • Skilled Nursing Facility | ||||
| • Outpatient Surgery Facility | ||||
| Pre-Certification Required for All Inpatient Hospital Confinements | Required No Penalty for Non Certification | Required No Penalty for Non Certification | ||
| Surgery Services (Including Inpatient and Outpatient) | 100% | 100% |
| Second Surgical Opinion (Elective Non-Emergency Surgeries) | 100% | 100% | ||
| Physician Visits | ||||
| Hospital | 100% (No limit) | 100% (No limit) | ||
| Office | 100% | 100% | ||
| Radiation Therapy | 100% | 100% | ||
| Maternity (Includes coverage for dependent daughters) | 100% | 100% | ||
| Emergency Care | 100% | 100% | ||
| Mental Health and Alcoholism/Substance Abuse | ||||
| Inpatient/Transitional Treatment | 100% | 100% | ||
| Outpatient | 100% | 100% | ||
| Short Term Rehabilitation Therapy | ||||
| Physical | 100% | 100% | ||
| Occupational | 100% | 100% | ||
| Speech | 100% | 100% | ||
| Chiropractic Services | 100% | 100% | ||
| Preventative Care (Includes x-rays and lab tests in connection with exam) | 100% | 100% | ||
| Well Baby Care, including immunizations, the first 6 visits will not apply to the maximum (Birth to 6 years of age) | 100% | 100% | ||
| Routine Physical Exam (over age 6) | 100% | 100% | ||
| Pap Smears | 100% | 100% | ||
| Mammograms | 100% | 100% | ||
| Tuberculosis Testing (to age 19) | 100% | 100% | ||
| X-ray and Lab Tests | 100% | 100% | ||
| Allergy Care | 100% | 100% |
| Ambulance | 100% | 100% | ||
| Durable Medical Equipment | 100% | 100% | ||
| Oral Surgery | 100% | 100% | ||
| Vision Care Eye Exams (for illness or injury only) | 100% | 100% | ||
| Lenses | 100% | 100% | ||
| Frames | 100% | 100% | ||
| Contact Lenses | 100% | 100% | ||
| Hearing Exams | 100% | 100% | ||
| Health Education & Counseling | Not Covered | Not Covered | ||
| Hospice Care | ||||
| Impatient | 100% | 100% | ||
| Outpatient | 100% | 100% | ||
| Bereavement Counseling | Not Covered | Not Covered | ||
| Skilled Nursing Home | 100% | 100% | ||
| Home Health Care | 100% | 100% | ||
| Family Planing Elective Sterilization | 100% | 100% | ||
| Prescription Drugs | ||||
| Copay Waived with Drug Card | $0 Generic/Brand | No Benefit |
