·
|
Deductibles/Co-payments
|
| Amounts applied
toward Plan Choice “B” deductibles for covered participants for
medical or dental coverage. Co-payments that you make for covered plan
participants toward vision care or that are paid to the mail-order drug
program.
|
·
|
Co-Insurance
|
| Amounts are covered
health care expenses under the Benefits by Design Flexible Benefit
Programs, but are considered to be the patient’s share (20%) of
covered charges.
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·
|
COBRA
Premiums
|
| The Executive
Supplemental Health Plan will reimburse you for COBRA premiums you pay for
coverage under your prior employer’s plan or for your over-age
dependent(s) under the IT plan. For example, if you continue COBRA
coverage under your prior employer’s plan because the IT core plan
will not cover pre-existing conditions, you can submit proof of your COBRA
premium payments for reimbursement under the Executive Supplemental Health
Plan. Additionally, if you pay for COBRA coverage under the IT core plan
for a child who reaches the limiting age under the plan but continues to
be your dependent for tax purposes, you can submit proof of such COBRA
premium payments for reimbursement under the Executive Supplemental Health
Plan.
|
·
|
Above
Reasonable and Customary
|
| Reasonable and
Customary charges are determined by the health plan administrator and
represent nationwide statistics indicating a fee that is reasonable for
the diagnosis for procedure and is an amount at or below a level
customarily charged by 90% of providers of the same discipline and within
the same geographical location. Most providers’ fees are within a
range considered reasonable and customary. However, we recognize that some
providers do charge a premium for their services. This amount sometimes
exceeds the maximum benefit allowance. Amounts that exceed the reasonable
and customary maximum allowance are payable under your Executive
Supplemental Health Benefits.
|
·
|
Charges That
Exceed Core Plan Maximums (IT’s Your Choice Plan Option “B
”)
|
| The Benefits by
Design Flexible Benefit Programs contain plan features or benefits with
specific limitations or payment maximums. These include, but are not
limited to: annual maximums for dental care; lifetime maximums for
orthodontic procedures; per visit and number of visit limitations for home
health, treatment of spinal conditions, and outpatient mental
health/chemical dependency treatment. Annual and Lifetime Maximums also
apply to mental health/chemical dependency benefits. The vision plan also
limits the cost and timeframes for which you are eligible to receive
examinations, frames, lenses, and contact lenses (please refer to your
Summary Plan Description for a complete list of specific details). Covered
Plan participants’ submitted charges exceeding the Core Plan Annual
Maximums are payable under the Executive Supplemental Health Plan up to
your benefit maximum of 10% of your base salary or $10,000, whichever is
less.
|
·
|
Medically
Necessary Expenses which are not Covered under other
Plans
|
| The Executive
Supplemental Health Plan reimburses for expenses which are medically
necessary but are either not covered or are specifically excluded under
the IT Flexible Benefit Programs. However, the Executive Supplemental
Health Plan does not reimburse for expenses for pre-existing conditions
which are not covered under IT’s Core Plan(s). (See the first item
under “Charges Specifically Excluded” for further
details.)
|
| Expenses which
might appear to be reimbursable under the Executive Supplemental Health
Plan could be limited by IRS regulations which prohibit payment for
certain procedures, such as those which are purely cosmetic in nature.
Please contact Provident for a predetermination of benefits before
proceeding with any procedure not customarily covered under your Core
Plan.
|
| Expenses not
covered under the Core Plan but which are payable (subject to annual
maximum) under the Executive Supplemental Health Plan are illustrated
below:
|
·
|
Braille Books
and Magazines purchased for use by a visually impaired person covered
under your plan.
|
·
|
Car—Special
Design for a covered person with a physical impairment. Covered
expenses normally included the cost of special hand controls and other
special equipment installed in a car for the use of a person with a
disability.
|
·
|
Elective
Pregnancy Termination, which is not payable under the Core Plan for a
covered dependent child. Limited to one such procedure per calendar year
when performed within the first trimester. When performed for medical
reasons or under other certain conditions, these restrictions may not
apply. Contact Health International for further details on when these
restrictions may not apply.
|
·
|
Eye Care
—Expenses paid for examinations, frames, lenses, or contact
lenses that are for the primary purpose of correcting a visual impairment
of a covered person, and/or co-payments paid in conjunction with Vision
Care provided under your Core Plan.
|
·
|
Fertility
Treatment and Testing when services are performed for a covered
Executive or dependent spouse. Dependent children are not eligible for
this service.
|
·
|
Guide Dog or
Other Animal to be used by a visually or hearing impaired covered
person or any other covered person when the animal is specifically trained
to assist persons with the particular physical impairment or disability of
the individual.
|
·
|
Hearing
Appliances—the cost of hearing aids and batteries you buy to
operate them exceeding the maximums provided in the Core Plan of
coverage.
|
·
|
Improvements to
Rented Property occupied by a covered person with a disability, which
are made to provide accommodation to such disability.
|
·
|
Insurance
Premiums—amounts that you paid for Medicare Part B; paid to a
Health Maintenance Organization that is not part of an employer’s
cafeteria, flexible benefits, or other qualified 125 Plan; or paid as a
premium for COBRA continuation coverage under another employer’s plan
(for yourself or your dependent).
|
·
|
In Vitro
Fertilization when services are performed for a covered Executive or
dependent spouse. Dependent children are not eligible for this
benefit.
|
·
|
Laetrile
prescribed for a covered person by a doctor and purchased and used in
a location where the sale and use are legal.
|
·
|
Learning
Disabilities—tuition fees that you pay to a special school for a
covered child who has severe learning disabilities caused by mental or
physical impairment, including nervous disorders. Your doctor must
recommend that the child attend the school.
|
·
|
Legal Fees
paid in connection with authorizing mental treatment of a covered
person with a mental illness. If the fees include a guardianship or
management fee, you cannot include that amount as reimbursable or payable
expense.
|
·
|
Maternity
expenses for a covered dependent child. Covered charges include
obstetric care, labor and delivery, and associated hospitalization
expenses for childbirth. Nursery charges or any other expenses incurred
for injury or sickness of the newly born child of your dependent child are
charged which are specifically from payment. Complications of pregnancy
(such as an ectopic pregnancy) are charges which are covered for your
dependent child under your Core Plan.
|
·
|
Nursing or
Special Home for the Aged or Mentally Retarded if the expense is
incurred for a covered person and the primary reason for being there is to
get medical care or upon the recommendation of a psychiatrist, to help a
covered mentally retarded person adjust from living in a mental hospital
to community living.
|
·
|
Oral
Contraceptives prescribed by your doctor that are not purchased
through the mail-order program; or your co-payment for these drugs
purchased through the mail-order drug program; or your cost to purchase
oral contraceptives which are prescribed for a covered dependent
child.
|
·
|
Physical
Examinations for a covered person when such examination is for the
periodic screening of one’s health, not covered by another primary
payer of insurance benefits; and when such examination for the Executive
is not part of a Company Sponsored, Executive Physical Program. Physicals
required by the Company are paid through IT Corporation’s Health
& Safety Department.
|
·
|
Radial
Keratotomy procedures for a covered person to correct a visual
impairment of such an individual.
|
·
|
Telephone
Equipment or the Repair of Telephone Equipment that is used for a
covered hearing-impaired person to communicate over a regular
telephone.
|
·
|
Television
Equipment that displays the audio part of television programs as
subtitles for a covered hearing-impaired person.
|
·
|
Temporomandibular Joint Disorders (TMJ) treatment for a
covered person when expenses are not covered under your Core Plan and/or
the portion of expense exceeding the annual and/or lifetime maximums of
your Core Dental Plan or Orthodontic Benefit.
|
·
|
Transportation
Costs actually paid in connection with medical care of a covered
person. You may include: bus, taxi, plane fares, automobile expenses of
gas and oil, ambulance service, parking fees, and tolls. The following
costs cannot be included: transportation to or from work (even if the
condition of the covered person requires an unusual mode of
transportation), and costs incurred to travel to another city for care
when travel was for nonmedical reasons.
|
·
|
Well Baby Care
for your covered dependent child; to include the cost of check-ups and
immunizations not covered by your Core Plan when such treatment is for the
preventive treatment of childhood diseases and to monitor the ordinary
developmental process of your child.
|
·
|
Expenses for
pre-existing conditions which are not covered under IT’s Core
Plan(s). To obtain reimbursement for such expenses, you must continue
COBRA coverage under your prior employer’s plan. You can submit
evidence of COBRA premium payments for reimbursement under the Executive
Supplemental Health Plan.
|
·
|
Charges that have
not first been submitted for payment under your Core Benefit
Plan.
|
·
|
Expenses incurred
by a child of your covered dependent child, including nursery charges for
a well baby born while your dependent child is covered under your
plan.
|
·
|
Charges resulting
from benefit reductions when second surgical opinions or
pre-hospitalization review procedures as described in the Benefits by
Design Summary Plan Description are not followed.
|
·
|
Charges for
conditions that are sustained while on active military duty or rising out
of acts of war.
|
·
|
Charges that would
not be made if no plan existed, or charges that neither you nor any of
your dependents are required to pay.
|
·
|
Charges resulting
from work-related injury.
|
·
|
Charges resulting
from an injury caused by a third party when you fail to agree to
third-party subrogation.
|
·
|
Expenses for which
the covered person has or had the right to payment for the expense under:
(a) workers’ compensation or similar law; or (b) Medicare or other
plan established by law, except where the law does not permit such an
exclusion.
|
·
|
Charges for
services or supplies that are not necessary for the treatment, diagnosis,
or prevention of an injury, illness, or disease, or that are not
recommended and approved by the attending physician.
|
·
|
Expenses for
housekeeping or custodial care, except for that which qualifies under
hospice or home health care.
|
·
|
Expenses paid to
Christian Science Practitioners.
|
·
|
Expenses paid for
health club or other dues that are for your general health or to relieve
physical or mental discomfort that are not related to a particular medical
condition.
|
·
|
Expenses for
household help, even if recommended by a doctor, that does not provide
nursing-type services covered under home health care.
|
·
|
Expenses for
personal use items that are customarily or can be used for personal living
unless they are used primarily to prevent or alleviate a physical or
mental defect or illness.
|
·
|
Expenses for a
smoking cessation program that a covered person joins for the improvement
of general health. These expenses may be partially reimbursable, if
incurred by an IT Executive, under the IT Corporate Wellness program. See
a Human Resources Representative for details.
|
·
|
Expenses for a
weight loss program, even if prescribed by your doctor for a covered
person, when the treatment is for the betterment of your general health
and not to treat a specific illness or disease. These expenses may be
partially reimbursable, if incurred by an IT Executive, under the IT
Corporate Wellness program. See a Human Resources Representative for
details.
|
·
|
Expenses for
cosmetic surgery unless to repair: (1) birth defect; (2) damage caused by
a disfiguring disease; or (3) damage due to an accident that occurred
while you were covered for these benefits, provided the expense is also
incurred while so covered and eligible.
|
·
|
Expenses for
diapers or diaper service, unless they are needed to relieve the effects
of a particular disease.
|
·
|
IT Corporation
senior management determines that the covered Executive no longer meets
the eligibility criteria for participation in this program
|
·
|
The covered
Executive’s employment with IT Corporation or a subsidiary is
terminated
|
·
|
The Company elects
to discontinue this program and terminates the Executive Supplemental
Health Plan
|
·
|
The Executive is no
longer eligible to participate in the program
|
·
|
The covered
Executive dies
|
·
|
Divorce or legal
separation occurs
|
·
|
The spouse fails to
meet the eligibility requirements of the Core Plan
|
·
|
The plan is
terminated
|
·
|
The Executive is no
longer eligible to participate in the program
|
·
|
The covered
Executive dies
|
·
|
Divorce or legal
separation from spouse occurs (step-children only)
|
·
|
A step-child no
longer resides with the covered Executive or when any dependent child,
step-child or foster child ceases to be primarily dependent upon the
Executive for support
|
·
|
The dependent fails
to meet the eligibility requirements of the Core Plan, or reaches the plan
age limit and/or ceases to be enrolled as a student on a full-time basis
after reaching age 19
|
·
|
The plan is
terminated
|