SUMMARY PLAN DESCRIPTION Self-Funded THE HEALTH CARE PLAN OF C. A. LEWIS CONSTRUCTION COMPANY, INC. PLEASE READ THIS SUMMARY CAREFULLY! C. A. LEWIS CONSTRUCTION CO., INC. TO ALL EMPLOYEES: The Company’s success has been made possible by the efforts and loyalty of its personnel. The Company, in return, wishes to provide the best working conditions and benefits possible. Your health, welfare and security are of vital concern to the Company. Today everyone is aware that two of the largest problems facing our nation are the ever increasing cost of medical care and the large number of people who either have no health coverage or have inadequate coverage. While we all hope that we will all enjoy good health and long life, no one is immune to illness, accident or the tragedy of death. To protect the financial security of you and your family from these possibilities, the Company is happy to be able to provide you with this Employee Benefit Program. This Plan provides financial assistance to enable you to better meet unforeseen medical bills arising from an accident or an illness. Please review carefully the provisions of the program outlined in this Summary Plan Description. You should be aware of the coverage and security it provides. Keep this Summary Plan Description with your other valuable papers as it clearly indicates the benefits available during a time of emergency. This Summary Plan Description contains a summary in English of your Plan rights and benefits under your Group Health Plan. If you speak Spanish only and have difficulty understanding any part of this Summary Plan Description, contact Josie Longo at (336) 759-2013, ext. 1260. Office hours are from 8:00 a.m. to 5:00 p.m. (Eastern Time) Monday through Friday. Este Sumario de Beneficios contiene un Sumario de Beneficios en ingles de derechos del paciente y cobertura. Si es dificil entender cualquier parte de este Sumario de Beneficios, por favor ponerse en contacto con Josie Longo (336) 759-2013 Ext. 1260, durante las horas 8:00 - 5:00 del dia, los lunes a viernes. Thank you for your loyalty and efforts on behalf of the Company. With your assistance we can continue to provide a better place to work. May 1, 2003 C.A. Lewis Construction Co., Inc. TABLE OF CONTENTS Benefit Summary Managed Care Provisions M1 Schedule of Benefits S1 Explanation of Other Benefits O1 Preface Help Control Health Care Costs - Stay Fit!! 1 Special Alerts to Covered Persons 1 Certain ERISA Requirements 2 Statement of Rights 2 Claims Filing a Claim 3 Some Important Do’s and Don’ts 3 Claims Appeal Procedures 4 Notice of Benefit Determination 6 Appealing an Adverse Benefit Determination/Denied Claim 6 Other Items of Interest 9 Eligibility When Are You and Your Dependents Eligible? 10 Special Enrollment Rules 11 When Does Coverage Terminate? 13 Who May Be a Dependent? 13 Health Care Benefits How Are Plan Benefits Determined? 14 How Does the Deductible Amount Work? 14 What Is the Benefit Formula? 15 What Are the Maximum Plan Benefits? 15 What Are Covered Expenses? 15 What Are the Limitations and Exclusions? 16 What Charges May Be Reduced or Eliminated? 21 Are Some Expenses Paid in Full? 21 What Special Benefits Are Provided? 21 What About Pre-Existing Conditions? 23 How Does This Plan Coordinate with Other Plans? 24 Extension of Coverage Provisions 24 May You Convert Your Coverage? 24 Cost Containment Provisions Precertification of Hospital Days 25 Participant Audit Bonus 25 Subrogation Provision 26 Reasonable and Customary Guidelines 26 Ongoing Health Problem Participants 26 Second Surgical Opinions 27 COBRA Appendix i May 1, 2003 C.A. Lewis Construction Co., Inc. May 1, 2003 C.A. Lewis Construction Co., Inc. MedCost Preferred/MultiPlan IMPORTANT BENEFIT MODIFICATION FOR PREFERRED PROVIDER ORGANIZATION (PPO) This Health Care Plan contains a Preferred Provider Organization (PPO) known as MedCost Preferred. This PPO applies to hospitals and physicians and is applicable to all Covered Persons in North Carolina and South Carolina. For hospital services only outside North Carolina and South Carolina, this Plan also includes a PPO known as MultiPlan. Discounted charges are available from any Provider in the PPO. There is full freedom of choice by the Covered Person to use any Provider. The Providers in the network, however, have agreed to reduced charges which are usually lower than their standard charges. This results in lower out-of- pocket costs to the Covered Person and lower costs to C. A. Lewis Construction Co., Inc. by using such Providers. To encourage Covered Persons to use a Preferred Provider, Plan Benefits and Plan Copayment Rates are modified as follows: BASE PLAN SF 538 Hospitals - PPO Hospitals - Plan Copayment Rate 80%, After Deductible; Non-PPO Hospitals - Plan Copayment Rate 60%*, After Deductible; Physicians - PPO Primary Care Physician Office Visits - Plan Copayment Rate 100% After $25 Individual Copayment for services provided in any PPO Primary Care Physician’s office totaling $500 or less; for charges exceeding $500 and other PPO Primary Care Physician services, Plan Copayment Rate 80%, After Deductible; Individual Copayment does not apply to non-PPO Physician charges, Mental and Nervous Benefits or Chiropractic Care; PPO Specialist Physician Office Visits - Plan Copayment Rate 100% After $35 Individual Copayment for services provided in any PPO Specialist Physician’s office totaling $500 or less; for charges exceeding $500 and other PPO Specialist Physician services, Plan Copayment Rate 80%, After Deductible; Individual Copayment does not apply to non-PPO Physician charges, Mental and Nervous Benefits or Chiropractic Care; Non-PPO Physician Services - Plan Copayment Rate 60%*, After Deductible. MedCost Preferred/MultiPlan IMPORTANT BENEFIT MODIFICATION FOR PREFERRED PROVIDER ORGANIZATION (PPO) (Cont.) May 1, 2003 -M1- C.A. Lewis Construction Co., Inc. BUY UP PLAN SF 991 Hospitals - PPO Hospitals - Plan Copayment Rate 80%, After Deductible; Non-PPO Hospitals - Plan Copayment Rate 70%*, After Deductible; Physicians - PPO Primary Care Physician Office Visits - Plan Copayment Rate 100% After $15 Individual Copayment for services provided in any PPO Primary Care Physician’s office totaling $500 or less; for charges exceeding $500 and other PPO Primary Care Physician services, Plan Copayment Rate 80%, After Deductible; Individual Copayment does not apply to non-PPO Physician charges, Mental and Nervous Benefits or Chiropractic Care; PPO Specialist Physician Office Visits - Plan Copayment Rate 100% After $25 Individual Copayment for services provided in any PPO Specialist Physician’s office totaling $500 or less; for charges exceeding $500 and other PPO Specialist Physician services, Plan Copayment Rate 80%, After Deductible; Individual Copayment does not apply to non-PPO Physician charges, Mental and Nervous Benefits or Chiropractic Care; Non-PPO Physician Services - Plan Copayment Rate 70%*, After Deductible. INSTRUCTIONS FOR USING YOUR PPOs: The Participant should contact the PPO Sponsoring Organization to confirm the Provider’s current participation prior to incurring charges. For hospital and physician services in North Carolina and South Carolina, the PPO Sponsoring Organization is MedCost Preferred. Telephone: 1-800-824-7406, or on the internet at www.medcost.com For hospital services only outside North Carolina and South Carolina, the PPO Sponsoring Organization is MultiPlan. Telephone: 1-800-557-6794, or on the internet at www.multiplan.com MedCost Preferred/MultiPlan IMPORTANT BENEFIT MODIFICATION FOR PREFERRED PROVIDER ORGANIZATION (PPO) (Cont.) May 1, 2003 -M2- C.A. Lewis Construction Co., Inc. *The Plan Copayment Rate reduction will be waived if it can be shown that non-Preferred Provider care was needed either for practical or for medically necessary reasons, as determined by the Plan Supervisor. Some, but not all, of such reasons are: Emergency care required a non-Preferred Provider; No Preferred Provider was within fifty (50) miles of the residence of the Covered Person; Medically necessary care not available by a Preferred Provider; When services are provided by a non-PPO Provider without the prior knowledge of the Covered Person. All Plan Benefits are subject to the Schedule of Benefits, Limitations, Exclusions, and other provisions of this Plan including deductibles and out-of-pocket maximums, unless noted otherwise. Coverage for treatment of Pre-existing Conditions will be limited to a maximum payment of $1,000. See the Pre-existing Condition definition under “Certain Terms and Phrases” for further information. May 1, 2003 -M3- C.A. Lewis Construction Co., Inc. May 1, 2003 -M4- C.A. Lewis Construction Co., Inc. PLEASE READ YOUR SUMMARY PLAN DESCRIPTION CAREFULLY. Claim Filing Period Expenses must be submitted within 90 days of incurred date or they will not be paid. THE HEALTH CARE PLAN OF C. A. LEWIS CONSTRUCTION CO., INC. SCHEDULE OF BENEFITS MEDICAL BENEFITS Individual Lifetime Maximum Benefit $1,000,000 Deductibles Deductible Per Individual Base Plan - $750; Buy Up Plan - $400 Maximum Deductible Per Family Base Plan - $2,250; Buy Up Plan - $1,200 Deductibles Waived for Accidents Yes For treatment given within seventy-two (72) hours of accident. Deductible Carryover Period None Special Deductibles (These Deductibles are in addition to your Individual and Family Deductibles) Emergency Room Deductible $100 Waived for accidents or if admission follows immediately. Per Hospital Admission Deductible None Per Prescription Drug Deductible None See Page S5 for Additional Information Regarding Prescription Drug Benefits. Physician Individual Copayment SF 538 Base Plan PPO Primary Care Physicians - Plan Copayment Rate 100% after $25 Individual Copayment for services provided in any PPO Primary Care Physician’s office totaling $500 or less; for charges exceeding $500 and other PPO Primary Care Physician services, Plan Copayment Rate 80%, after deductible. PPO Specialist Physicians - Plan Copayment Rate 100% after $35 Individual Copayment for services provided in any PPO Specialist Physician’s office totaling $500 or less; for charges exceeding $500 and other PPO Specialist Physician services, Plan Copayment Rate 80%, after deductible. Non-PPO Physicians - Plan Copayment Rate 60%, after deductible. See Page M1 for additional PPO physician information. MEDICAL BENEFITS (Cont.) May 1, 2003 - S1 - C.A. Lewis Construction Co., Inc. Physician Individual Copayment SF 991 Buy Up Plan PPO Primary Care Physicians - Plan Copayment Rate 100% after $15 Individual Copayment for services provided in any PPO Primary Care Physician’s office totaling $500 or less; for charges exceeding $500 and other PPO Primary Care Physician services, Plan Copayment Rate 80%, after deductible. PPO Specialist Physicians - Plan Copayment Rate 100% after $25 Individual Copayment for services provided in any PPO Specialist Physician’s office totaling $500 or less; for charges exceeding $500 and other PPO Specialist Physician services, Plan Copayment Rate 80%, after deductible. Non-PPO Physicians - Plan Copayment Rate 70%, after deductible. See Page M2 for additional PPO physician information. Plan Copayment Rate SF 538 Base Plan PPO - 80%; Non-PPO - 60% SF 991 Buy Up Plan PPO - 80%; Non-PPO - 70% After Deductibles are applied to Covered Expenses, the Plan will apply the Plan Copayment Rate (the remainder is your copayment) to the remaining Covered Expenses until you reach your Out-of-Pocket Maximum; then the Plan pays 100% of Covered Expenses up to the applicable limit. The Plan Copayment Rate does not apply where other Copayment Rates are stated. Benefit Year Out-of-Pocket Maximum SF 538 Base Plan Individual (plus Deductible) $3,000 Family (plus Deductible) $6,000 SF 991 Buy Up Plan Individual (plus Deductible) $2,000 Family (plus Deductible) $4,000 The following do not count toward the Out-of-Pocket Maximums: Special deductibles as set out under Special Deductibles on Page S1; Physician and Prescription Drug Individual Copayments. Penalties or reductions in benefits due to failure to comply with cost containment provisions and PRECERT requirements. Expenses exceeding any Plan limits. Benefit modifications or reductions. Hospital Limitations Maximum Room and Board Average Semi-Private (ASP) All Private Room Hospital Reasonable and Customary Hospital Intensive Care Reasonable and Customary MEDICAL BENEFITS (Cont.) May 1, 2003 - S2 - C.A. Lewis Construction Co., Inc. Surgical Benefits Second Surgical Opinions Optional Benefits for Second Surgical Opinions 100%, Up to $100 Outpatient Surgery Benefits SF 538 Base Plan Physician Charges PPO - 80%; Non-PPO - 60%, After Deductible Facility Charges PPO - 80%; Non-PPO - 60%, After Deductible SF 991 Buy Up Plan Physician Charges PPO - 80%; Non-PPO - 70%, After Deductible Facility Charges PPO - 80%; Non-PPO - 70%, After Deductible Multiple Procedures and Assistant Surgeons Multiple procedures through the same incision will be allowed at 100% of the reasonable and customary charges for the most expensive procedure, 50% of the reasonable and customary charges for the second, and 25% of the reasonable and customary charges for the third and subsequent procedures, taking into consideration CPT codes that anticipate subsequent procedures. Assistant surgeon’s charges will be paid, not to exceed 20% of the reasonable and customary charges of the surgeon. Anesthesiology Benefits The Plan will pay the Usual, Reasonable and Customary amount toward charges of a licensed anesthesiologist or other qualified providers for services rendered in connection with a surgical operation. The benefit payable shall be based upon unit value plus time, according to the current American Society of Anesthesiologists Relative Value Guide and special modifiers (with updates). Certified Registered Nurse Anesthetist (CRNA) charges will be limited to a maximum of 25% of the surgical bill. If a licensed anesthesiologist and a CRNA are used during the same operative session, their combined charges will be limited to the maximum Usual, Reasonable and Customary allowance available to the licensed anesthesiologist. Pre-Admission Testing Benefit SF 538 Base Plan PPO - 80%; Non-PPO - 60%, After Deductible SF 991 Buy Up Plan PPO - 80%; Non-PPO - 70%, After Deductible Tests must be made within seventy-two (72) hours of scheduled admission. Skilled Nursing Care Required Hospitalization Period Three (3) Days Maximum Time from Hospital Discharge to Convalescent Admission Fourteen (14) Days Maximum Annual Benefit Days Thirty (30) Days Home Health Care Maximum Home Health Care Visits Per Benefit Year Thirty (30) Per Day One (1) Hospice Care Lifetime Maximum Benefit $10,000 MEDICAL BENEFITS (Cont.) Organ Transplants May 1, 2003 - S3 - C.A. Lewis Construction Co., Inc. Contact the Plan Supervisor for Written Details Prior to any Organ Transplant Evaluation. Your Plan has access to the LifeTrac Network that includes Designated Transplant Facilities. While you may prefer to select a transplant facility, utilizing a Designated Transplant Facility in the LifeTrac Network will result in the following enhanced benefits: Deductible: None Percentage payable: 100% The Plan Supervisor maintains a list of Designated Transplant Facilities. If you choose not to utilize a Designated Transplant Facility, benefits for covered services or supplies related to a covered organ transplant will be provided at the same level as any other condition or illness, subject to the Organ Transplant Limit and other Organ Transplant Benefits and Provisions of this Plan. TMJ Surgery and Related Temporomandibular Joint Dysfunction None Such Treatment is Not Covered. Supplemental Accident Benefit None Chiropractic Care Plan Copayment Rate SF 538 Base Plan PPO - 80%; Non-PPO - 60%, After Deductible SF 991 Buy Up Plan PPO - 80%; Non-PPO - 70%, After Deductible Maximum Allowed Charge Not Applicable Maximum Visits Per Benefit Year Not Applicable Maximum Benefit Per Benefit Year $600 Outpatient Physical Therapy Plan Copayment Rate 80%, After Deductible Maximum Visits Per Benefit Year Thirty (30) Maternity Benefits Maternity is covered as any other condition; it is not, however, subject to any pre-existing condition limitations. Newborns must be added to coverage according to Plan provisions, normally within thirty (30) days of birth. Routine Nursery Care is covered if newborn child is added according to Plan provisions. Birthing centers are covered. MEDICAL BENEFITS (Cont.) MENTAL AND NERVOUS DISORDERS (Includes Drug & Alcohol Abuse) Limitations to Psychiatric Treatment apply only to treatment for the conditions - not the May 1, 2003 - S4 - C.A. Lewis Construction Co., Inc. diagnosis. Psychiatric Treatment, not limited below, shall be covered as any other covered expense. Hospital Inpatient Plan Copayment Rate 80%, After Deductible Maximum Benefit Per Benefit Year Thirty (30) Days Outpatient Care (Therapy Only) Plan Copayment Rate 80%, After Deductible Maximum Benefit Per Benefit Year Ten (10) Visits Partial Hospitalization for Mental and Nervous Disorders Yes Partial hospitalizations (also known as day treatment programs) for mental and nervous disorders are covered by this Plan. A partial hospitalization (or day treatment program) is defined as a program consisting of at least six (6) hours of treatment programming or therapy per day in an approved facility. Benefits will be processed according to the Hospital Inpatient benefits for Mental & Nervous Disorders for this Plan as stated above. Partial hospitalizations (or day treatment programs) must be precertified. Failure to precertify such programs may result in a reduction of benefits. SCHEDULE OF OTHER BENEFITS PRESCRIPTION DRUGS Individual Copayment Amounts (Per 34 Day Supply) Preferred Brand - $25; Non-Preferred Brand - $35; Non-Brand - $15 The patient will be required to pay the difference in cost between the brand and non-brand, plus the non-brand co-pay: When a DOCTOR requires brand dispensing; If a PARTICIPANT chooses brand when non-brand is available; When the PHARMACY substitutes brand for non-brand; or If a non-brand is not available at the PHARMACY. The list of benefits contained in the Drug Card Plan Specifications, including all amendments, is incorporated herein by reference. For information regarding coverage for any particular medication and for a listing of those drugs included in the non-preferred category, please contact the Drug Card Administrator at the telephone number listed below. SCHEDULE OF OTHER BENEFITS (Cont.) PRESCRIPTION DRUGS (Cont.) Prescription Drug Card Administrator: Pharmacy Network National Corporation May 1, 2003 - S5 - C.A. Lewis Construction Co., Inc. 4000 Old Wake Forest Rd., Suite 101 Raleigh, NC 27609 1-800-331-7108 See Page O1 for further details concerning Prescription Drug Benefits. Mail Order Option None Prescription Card Data Program This Plan may participate in a prescription card data program and may receive compensation for its participation in such program. Any compensation received by the employer, Sponsor of this Plan, will remain the property of the employer and will not be distributed to Participants. IMMUNIZATIONS Immunizations for routine prevention of disease are covered except where otherwise allowed as part of pediatric care. ROUTINE CARE Maximum Benefit Per Benefit Year $500 (Charges over the Maximum Benefit are not covered) Plan Copayment Rate 100%, No Deductible Includes physician, x-ray and laboratory charges incurred in connection with a non-illness related physical examination. This includes, but is not limited to, charges for routine pap smears, gynecological exams, mammograms and Prostate Specific Antigen (PSA) tests. This benefit will be provided only for the covered employee and the covered spouse. PAP SMEARS, MAMMOGRAMS AND PROSTATE EXAMS Pap smear tests, mammograms and Prostate Specific Antigen (PSA) tests are covered expenses. Office visits associated with pap smear tests, mammograms and prostate exams are covered expenses. ROUTINE PEDIATRIC CARE Routine pediatric care to age six (6), including immunizations, is covered. SCHEDULE OF OTHER BENEFITS (Cont.) EXPERIMENTAL OR INVESTIGATIVE TREATMENT Experimental or Investigative Treatment is not covered. The term experimental or investigative means a drug, device, medical treatment or procedure that is determined by the Plan Supervisor to meet one or both of the following criteria in relation to the condition for which it is being dispensed or rendered: 1. The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug May 1, 2003 - S6 - C.A. Lewis Construction Co., Inc. Administration (FDA) and approval for marketing has not been given at the time the drug or device is furnished; or 2. Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials may be necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis. Reliable evidence includes, but is not limited to, published reports and articles in the authoritative medical and scientific literature; the written protocol(s) used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment or procedure; or written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure. COBRA CONTINUATION COVERAGE This continuation only applies to health coverage. See COBRA Appendix. PLAN FUNDING Are Participant Contributions Required?* Participant Dependent Benefit Funding Coverage Coverage SF 538 Base Plan Medical Self-Funded No Yes SF 991 Buy Up Plan Medical Self-Funded Yes Yes *The Amounts of the Participant contributions are calculated by the Employer. No health insurance issuer is responsible for the financing or administration of this Plan. MISCELLANEOUS Hearing Care Benefits, Dental Care Benefits, Vision Care Benefits and Short Term Disability Benefits are not provided under this Plan. Optional Dental Care Benefits are offered under a separate fully insured plan. CONVERSION OF MEDICAL BENEFITS Conversion is not offered. SCHEDULE OF COST CONTAINMENT PROVISIONS Precertification of Hospital Days* (Applies also to Partial Hospitalization for Mental and Nervous Disorders) Penalty for Not Certifying $150 Reduction for Days Not Certified Yes *Does not apply to Maternity stay of less than forty-eight (48) hours immediately following a normal vaginal May 1, 2003 - S7 - C.A. Lewis Construction Co., Inc. delivery, nor to less than ninety-six (96) hours immediately following a cesarean section for both the mother and the newborn child. Precertification of Urgent Claims is not required. Urgent admissions should be precertified within seventy-two (72) hours of admission by telephoning the number on your ACS Identification Card. See Precertification of Hospital Admissions under Cost Containment Provisions for additional information about Precertification. Pre-Authorization of Benefits Required The purpose of Pre-Authorization is to help control the costs of health care to the Participant and to the Plan. Pre-authorization of these benefits should not be interpreted to create a pre-service claim for the purposes of the claims procedures. Care involving dialysis, outpatient infusion therapy, home health care/visits, hospice, prosthetic devices, skilled nursing care, inpatient rehabilitation, outpatient pulmonary and cardiac rehabilitation, durable medical equipment (rental or purchase) costing five hundred ($500) dollars or more, or any renal or diabetic supplies must be pre-authorized by telephoning the number on your ACS Identification Card. Failure to pre-authorize such care will result in a retrospective review of services provided and may result in a determination that care was not medically necessary, was in excess of the usual, reasonable and customary charges or was not covered by the Plan. If such a determination is made, some or all of the billed amount may not be paid. Participant Audit Bonus Percent of Savings to Participant 50% Minimum - Maximum Limitation $100 - $500 Benefits Processing Guide Benefit Administration Manual Trilogy Claims Administration Handbook Reasonable and Customary Ingenix CERTAIN TERMS OR PHRASES Employer (and Plan Sponsor) mean: Employer Name: C. A. Lewis Construction Co., Inc. Address: 220 South Charles Boulevard P.O. Box 5064 City, State, Zip: Greenville, NC 27858 Greenville, NC 27835 EIN: 56-1494809 Tel: (252) 757-3536 Fax: (252) 757-1748 Participating Employers means Not Applicable. Plan Name means The Health Care Plan of C. A. Lewis Construction Co., Inc. CERTAIN TERMS OR PHRASES (Cont.) Plan Numbers for Administration Purposes are SF 538 and SF 991. ERISA Plan Number is 901. Effective Date of the Plan is March 1, 1995, restated May 1, 2003. Plan Supervisor means ACS Benefit Services, Inc. or its successor as may be appointed by the May 1, 2003 - S8 - C.A. Lewis Construction Co., Inc. Employer. Plan Administrator means the Employer, administering the Plan by contract through a third party administrator. Plan Administrator is also the Named Fiduciary and Agent of Legal Service of Process. The Plan Administrator has the final authority and responsibility to review and make final decisions on Plan matters such as benefit adjudication, eligibility for coverage determinations and construing terms. Benefit Processing Responsibility of the Plan Supervisor means the processing of all benefits through the appeals process. The Plan Administrator, however, is the adjudicator and record- keeper of last resort. Plan Coordinator means Ms. Cheryl Brown or a successor as shall be named by the Employer. Type of Plan means welfare plan providing health coverage. Plan Trustees mean none. Plan is not trusteed. Benefit Year means Calendar Year. Plan Year means the twelve (12) month period from March 1 to March 1. Employee means all full-time employees in Eligibility Class. Eligibility Class means all employees. Retirees are not covered. Eligibility Waiting Period means that period from the date of hire to the first day of the month coinciding with or following sixty (60) days continuous full-time service, actively-at-work. CERTAIN TERMS OR PHRASES (Cont.) Late Enrollment - This Plan allows Late Enrollment only during the period of March 1 through March 31 of each calendar year. Late Enrollment of the employee/parent of a Qualified Medical Child Support Order (QMCSO) Alternate Recipient is also allowed at the appropriate time if the Plan Sponsor requires or permits such employee/parent to enroll while the QMCSO is in effect. Such Late Enrollment permits otherwise-eligible employees or dependents to apply for coverage during the Late Enrollment Period. Such Late Enrollment does not waive the Pre- Existing Provisions. Such employee or dependent will be a Late Enrollee. Late Enrollees are subject to a post-coverage waiting period of eighteen (18) months for pre-existing conditions. May 1, 2003 - S9 - C.A. Lewis Construction Co., Inc. The Effective Date of coverage for such Late Enrollees who enroll during the Late Enrollment Period will be April 1. The effective date of coverage for an employee/parent of a QMCSO Alternate Recipient is the effective date of the QMCSO Alternate Recipient. Parent/Employee of a Qualified Medical Child Support Order Alternate Recipient is required to enroll in the Plan. Such Parent/Employee shall be a Late Enrollee unless Special Enrollment rules apply. The effective date of coverage for an employee/parent of a QMCSO Alternate Recipient is the effective date of the QMCSO Alternate Recipient. Late Enrollee means a person who fails for any reason to apply for coverage other than on the earliest date on which coverage can be effective, or other than under the Special Enrollment Rules. Late Enrollees are subject to a post-coverage waiting period of eighteen (18) months for pre-existing conditions. This provision does not apply if this Plan does not allow Late Enrollment. See Late Enrollment. Qualifying Hours means thirty (30) hours per week. Actively-at-Work means performing substantial and material activities of your job while working at least seventeen and one-half (17½) hours per week for the Employer. Claim Filing Period is ninety (90) days. Claims must be submitted within ninety (90) days of the incurred date or your claims will not be paid. Coordination of Benefits (COB) Percent means non-duplication of benefits. Under Non- Duplication of Benefits for eligible expenses, the Plan pays the difference between what the primary plan paid and what this Plan would have paid if it had been primary. Sometimes this calculation will result in no additional amount paid. For coordination of benefits for dependent children, the method of determining which plan is primary is the Birthday Rule. This means that the primary plan will be the plan of the parent whose birthday is the earliest in the calendar year. Re-Employment Period means six (6) months. Leave of Absence Period means three (3) months, but in the case of qualifying Family and Medical Leave, in no event will the Leave of Absence Period be less than that period mandated by the Federal Family and Medical Leave Act of 1993 and clarifying regulations and other pertinent federal laws and regulations. CERTAIN TERMS OR PHRASES (Cont.) Disability Extension Period means three (3) months. Basis of Non-Occupational Coverage means any occupational related injury or illness. Unmarried Child’s Eligibility Age means through age 18 (that is, to such child’s 19 th birthday); such eligibility is extended through age 24 (that is, to such child’s 25th birthday) if such Dependent Child is a full-time student in high school or an accredited school, college or university as listed in the most recent edition of The Directory of Higher Education. A child’s dependent status terminates upon his or her being employed full-time for wages, profit or gain. The Participant must notify the Plan Administrator within thirty (30) days of the date when a dependent child loses eligibility under this paragraph. May 1, 2003 - S10 - C.A. Lewis Construction Co., Inc. “Full-time” is the period of attendance which the accredited school, college or university considers full-time, as determined by the rules of the educational institution. Physically Handicapped and/or Mentally Retarded Dependent Children will be covered regardless of age if satisfactory proof of condition is provided and approved by the Plan Supervisor. To be eligible for coverage, a physically handicapped or mentally retarded child must be unmarried, incapable of self-support because of condition, and principally dependent upon the Participant for financial support. Proof of condition may be required once each year. Pre-Existing Condition means a condition which includes a sickness or injury (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received by the Covered Person (meaning you or a covered dependent), or the Covered Person has taken medicine or is under a health care provider’s orders to take medicine, within the six (6) month Pre- Coverage Period immediately preceding the Enrollment Date. Pregnancy and/or conception are not deemed to be pre-existing. In addition, genetic testing without a diagnosis is also not deemed to be pre-existing. A second surgical opinion is not deemed a consultation for pre-existing purposes. The pre-existing condition limitation may be waived up to the following Pre-existing Benefit Amount: $1,000. No benefits in excess of the Pre-existing Benefit Amount will be paid for pre-existing conditions until you or your covered dependent(s) have completed the Post-Coverage Waiting Period as follows: twelve (12) months for all Covered Persons, including Special Enrollees, except Late Enrollees; eighteen (18) months for Late Enrollees. The Pre-Coverage Period (look-back period) is the six (6) month period immediately preceding and ending on the Enrollment Date. The Enrollment Date is the first day of coverage, or if the Plan has an Eligibility Waiting Period, the first day of the waiting period. The Post-Coverage Waiting Period (look-forward period) is the twelve (12) month period immediately following the Enrollment Date, or in the case of a Late Enrollee, the eighteen (18) month period immediately following the Enrollment Date. CERTAIN TERMS OR PHRASES (Cont.) Exceptions to the Pre-Existing Condition Waiting Period Creditable Coverage - The length of any post coverage waiting period shall be reduced by the amount of coverage under an eligible health plan prior to enrollment in this Plan subsequent to any significant break in coverage of sixty-three (63) days or more, subject to the Alternative Method of calculation. See Credit for Periods of Previous Coverage. Example – If you are hired on January 1 and enroll in your plan, you will have a twelve (12) month waiting period for any pre-existing conditions, starting on January 1, whether or not the Plan has an Eligibility Waiting Period. Any time immediately before your hire date that you were covered by another eligible health plan is credited (subtracted) from the twelve (12) month pre-existing condition waiting period, so if you had been covered for a year before being hired, you will have no pre-existing condition waiting period in this Plan. If, during the year before being hired, you had coverage under an eligible health plan from January 1 through May 1, 2003 - S11 - C.A. Lewis Construction Co., Inc. June 30 and again from September 15 through December 31, you would receive credit for September 15 through December 31 only because the coverage you had before September 15 came before a sixty-three (63) day or longer break in coverage. Newborns - No Pre-existing Condition limitation will apply to a child who, as of the last day of the thirty (30) day period beginning with the date of birth, is properly enrolled in the Plan. Accordingly, if a newborn is enrolled in another health plan with creditable coverage within thirty (30) days after birth and subsequently enrolls in this Plan (without a Significant Break In Coverage), this Plan will not impose any Pre-existing Condition limitation. Child Who Is Adopted Or Placed For Adoption - No Pre-existing Condition limitation will apply to any child who is adopted or placed for adoption before attaining age eighteen (18) and who, as of the last day of the thirty (30) day period beginning on the date of the adoption or placement for adoption, is properly enrolled in the Plan. Accordingly, if an adopted child or a child who is placed for adoption is enrolled in another health plan with creditable coverage within thirty (30) days after adoption or placement for adoption and subsequently enrolls in this Plan without a Significant Break in Coverage, this Plan will not impose any Pre-existing Condition limitation. This rule does not apply to coverage before the date of such adoption or placement for adoption. Alternative Method This Plan has elected to use the Alternative Method of calculating creditable coverage (specific benefits are considered) as contained in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), to determine the amount of Creditable Coverage for the following benefit categories: 1) Mental health; 2) Substance abuse treatment; 3) Prescription drugs; 4) Dental Care; 5) Vision care. NOTE: Coverage under a reimbursement account or arrangement, such as a flexible spending arrangement, does not constitute coverage with any category. Enrollment Date The term Enrollment Date means the first day of coverage or, if there is a waiting period, the first day of the waiting period. CERTAIN TERMS OR PHRASES (Cont.) Significant Break in Coverage The term Significant Break in Coverage means a period of sixty-three (63) consecutive days during all of which the individual does not have any creditable coverage, except that neither a waiting period nor an affiliation period is taken into account in determining a Significant Break in Coverage. May 1, 2003 - S12 - C.A. Lewis Construction Co., Inc. ADDITIONAL EXTENSIONS, LIMITATIONS OR EXCLUSIONS OF COVERAGE 1) Smoking Cessation - Charges for smoking cessation treatment and products are covered at 100% on a one-time basis for employee and spouse up to a maximum of $500, not subject to deductible. 2) Birth Control Devices and Injections - Expenses for birth control devices and injections are covered. (For information regarding coverage of contraceptives under the prescription drug card, please contact the Drug Card Administrator at the telephone number listed on Page S5). 3) Impairment-Related Injuries (includes DWI [Driving While Impaired]) - An additional $2,500 deductible will apply if impairment due to alcohol and/or controlled substance was a contributing cause of the Participant’s or a covered dependent’s injuries. Benefits will apply if such person’s conduct was not a cause of the injuries. This provision does not change any exclusion or limitation of this Plan. 4) Safety Helmet Deductible - An additional $2,500 deductible will apply before any benefits are paid if you are injured while operating a motorcycle or a two-wheeled, three-wheeled, or four-wheeled all terrain motor vehicle without a safety helmet. 5) Additional Deductibles - An additional $1,000 deductible will apply if the Participant or a Covered Dependent is injured while participating in any of the following activities: Hang gliding, self-propelled vehicle racing, scuba diving, rock climbing or flying (excluding a common carrier). 6) Seatbelt Deductible - An additional $1,000 deductible will apply before any benefits are paid if the Participant or covered dependent is injured in an automobile accident while not wearing a seatbelt according to State Law. 7) Exhaustion of COBRA Coverage - This Plan will not require a person who has elected COBRA coverage in lieu of coverage under this Plan when coverage under this Plan was first available to exhaust such coverage in order to be eligible to enter this Plan as a Special Enrollee. 8) Loss of Eligibility - This Plan will allow loss of eligibility to mean loss of coverage under another group health plan as a result of a significant decrease in other plan benefits or a significant increase in premiums, as determined by the Plan Administrator. 9) Treatment of Developmental Disorders - Notwithstanding any provisions of this Plan to the contrary, treatment of developmental disorders is covered. 10) Special Enrollees - Notwithstanding any provisions of this Plan to the contrary, Special Enrollment shall include those situations where an employee or dependent has previously dropped coverage under this Plan to take other coverage and then re-enrolls in this Plan within thirty (30) days of loss of eligibility for other coverage. EXPLANATION OF OTHER BENEFITS May 1, 2003 - S13 - C.A. Lewis Construction Co., Inc. PRESCRIPTION DRUGS This Plan has an independent drug card administrator that supervises the retail and/or mail order prescription drug benefit. You are encouraged to use the prescription drug I.D. card which will be honored by many pharmacies. When such card is honored, you need pay only a cash amount at the pharmacy; the balance is paid by the Plan at 100%, subject to any annual maximums set out in the plan specifications. The Schedule of Benefits sets forth the Copayment Amounts for brand, non-brand and innovator prescription drugs. When such card is not honored, you should pay for the drugs in cash and file for reimbursement on a claim form (furnished by either your Plan Coordinator or by the Plan Supervisor). Such claim filing should include the covered drug bills and should be mailed to the Prescription Drug Card Administrator as set forth in the Schedule of Benefits. By accepting this booklet and prescription identification card, you agree to return the prescription identification card to your Employer upon your loss of coverage under this Plan. The Schedule of Benefits indicates whether or not the Plan offers a mail-order prescription drug option and the benefits and/or limitations provided. The usual rule is that supplies in excess of ninety (90) days are not covered. This benefit is suitable for maintenance medications. As indicated in the Schedule of Benefits, the Drug Card Administrator maintains a list of covered prescription and non-prescription medications and supplies that are covered under the drug card program. This list is subject to change during the Plan Year at the direction of the Plan Administrator. Such list of covered medications and supplies are incorporated into this Plan by reference. The standard and special wording of the health plan indicating definitions and covered and excluded charges and expenses do not apply to the drug card program. If a prescription drug, injectible, supply or device is not covered under the Prescription Drug Card Benefit, it generally is not covered under this Plan. However, a medically necessary drug, injectible, supply or device that is dispensed in a physician’s office or administered by or under the supervision of a licensed professional in an appropriate setting will be covered up to the average wholesale price in the most current edition of Red Book, plus twenty per cent (20%). (See Schedule of Benefits under PRESCRIPTION DRUGS).
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