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THE BOYD GROUP, INC.ELMHURST ILHealth Benefit Summary Plan Description7670-00-030060Revised 04-01-2017BENEFITS ADMINISTERED BY
Table of ContentsINTRODUCTION. 1PLAN INFORMATION . 2MEDICAL SCHEDULE OF BENEFITS . 4MEDICAL SCHEDULE OF BENEFITS . 11MEDICAL SCHEDULE OF BENEFITS . 16MEDICAL SCHEDULE OF BENEFITS . 21MEDICAL SCHEDULE OF BENEFITS . 27MEDICAL SCHEDULE OF BENEFITS . 33TRANSPLANT SCHEDULE OF BENEFITS . 38TRANSPLANT SCHEDULE OF BENEFITS . 39TRANSPLANT SCHEDULE OF BENEFITS . 40TRANSPLANT SCHEDULE OF BENEFITS . 41TRANSPLANT SCHEDULE OF BENEFITS . 42TRANSPLANT SCHEDULE OF BENEFITS . 43PRESCRIPTION SCHEDULE OF BENEFITS . 44PRESCRIPTION SCHEDULE OF BENEFITS . 45PRESCRIPTION SCHEDULE OF BENEFITS . 46PRESCRIPTION SCHEDULE OF BENEFITS . 47PRESCRIPTION SCHEDULE OF BENEFITS . 48PRESCRIPTION SCHEDULE OF BENEFITS . 49OUT-OF-POCKET EXPENSES AND MAXIMUMS . 50ELIGIBILITY AND ENROLLMENT . 52SPECIAL ENROLLMENT PROVISION . 56TERMINATION . 58COBRA CONTINUATION OF COVERAGE. 60UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 . 68PROVIDER NETWORK . 69
COVERED MEDICAL BENEFITS . 71COVERED MEDICAL BENEFITS . 81HOME HEALTH CARE BENEFITS . 93TRANSPLANT BENEFITS . 94TRANSPLANT BENEFITS . 97PRESCRIPTION DRUG BENEFITS . 100HEARING AID BENEFITS. 101MENTAL HEALTH BENEFITS . 102SUBSTANCE USE DISORDER AND CHEMICAL DEPENDENCY BENEFITS . 104CARE MANAGEMENT . 106COORDINATION OF BENEFITS . 109RIGHT OF SUBROGATION, REIMBURSEMENT, AND OFFSET . 113GENERAL EXCLUSIONS . 116GENERAL EXCLUSIONS . 123CLAIMS AND APPEAL PROCEDURES . 129FRAUD . 138OTHER FEDERAL PROVISIONS . 139HIPAA ADMINISTRATIVE SIMPLIFICATION MEDICAL PRIVACY AND SECURITY PROVISION . 141STATEMENT OF ERISA RIGHTS . 145PLAN AMENDMENT AND TERMINATION INFORMATION . 147GLOSSARY OF TERMS . 148
THE BOYD GROUP, INC.GROUP HEALTH BENEFIT PLANSUMMARY PLAN DESCRIPTIONINTRODUCTIONThe purpose of this document is to provide You and Your covered Dependents, if any, with summaryinformation on benefits available under this Plan as well as information on a Covered Person's rights andobligations under THE BOYD GROUP, INC. Health Benefit Plan (the "Plan"). As a valued Employee ofTHE BOYD GROUP, INC. , we are pleased to sponsor this Plan to provide benefits that can help meetYour health care needs. Please read this document carefully and contact Your Human Resources orPersonnel office if You have questions.THE BOYD GROUP, INC. is named the Plan Administrator for this Plan. The Plan Administrator hasretained the services of independent Third Party Administrators to process claims and handle other dutiesfor this self-funded Plan. The Third Party Administrators for this Plan are UMR, Inc. (hereinafter "UMR")for medical claims, and Caremark for pharmacy claims. The Third Party Administrators do not assumeliability for benefits payable under this Plan, as they are solely claims paying agents for the PlanAdministrator.The employer assumes the sole responsibility for funding the Plan benefits out of general assets;however, Employees help cover some of the costs of covered benefits through contributions, Deductibles,out-of-pocket, and Plan Participation amounts as described in the Schedule of Benefits. All claimpayments and reimbursements are paid out of the general assets of the employer and there is noseparate fund that is used to pay promised benefits. The Plan is intended to comply with and begoverned by the Employee Retirement Income Security Act of 1974 (ERISA) and its amendments.Some of the terms used in this document begin with a capital letter, even though the term normally wouldnot be capitalized. These terms have special meaning under the Plan. Most terms will be listed in theGlossary of Terms, but some terms are defined within the provision the term is used. Becoming familiarwith the terms defined in the Glossary will help to better understand the provisions of this Plan.Individuals covered under this Plan will be receiving an identification card to present to the providerwhenever services are received. On the back of this card are phone numbers to call in case of questionsor problems.This document summarizes the benefits and limitations of the Plan and will serve as the SPD and Plandocument. Therefore it will be referred to as both the Summary Plan Description (“SPD”) and Plandocument. It is being furnished to You in accordance with ERISA.This document becomes effective on April 1, 2011.10-01-2010-1-7670-00-030060
PLAN INFORMATIONPlan NameTHE BOYD GROUP, INC. GROUP BENEFIT PLANName And Address Of EmployerTHE BOYD GROUP, INC.400 W GRAND AVEELMHURST IL 60126Name, Address And Phone NumberOf Plan AdministratorTHE BOYD GROUP, INC.400 W GRAND AVEELMHURST IL 60126630-532-5776Named FiduciaryTHE BOYD GROUP, INC.Employer Identification NumberAssigned By The IRS51-0394062Plan Number Assigned By The Plan501Type Of Benefit Plan ProvidedSelf-funded Health & Welfare Plan providing group healthbenefits.Type Of AdministrationThe administration of the Plan is under the supervision ofthe Plan Administrator. The Plan is not financed by aninsurance company and benefits are not guaranteed by acontract of insurance. UMR provides administrativeservices such as claim payments for medical andpharmacy claims.Name And Address Of Agent ForService Of Legal ProcessTHE BOYD GROUP (U.S.) INC400 W GRAND AVEELMHURST IL 60126Services of legal process may also be made upon the PlanAdministrator.Funding Of The PlanEmployer and Employee ContributionsBenefits are provided by a benefit Plan maintained on aself-insured basis by Your employer.Benefit Plan Year(Applies to Benefit Plan(s) 017, 018,019, 020, 021, 022, 023)Benefits begin on April 1 and end on the following March31. For new Employees and Dependents, a Benefit PlanYear begins on the individual's Effective Date and runsthrough March 31 of the same Benefit Plan Year.Benefit Plan Year(Applies to Benefit Plan(s) 011)Benefits begin on January 1 and end on the followingDecember 31. For new Employees and Dependents, aBenefit Plan Year begins on the individual's Effective Dateand runs through December 31 of the same Benefit PlanYear.10-01-2010-2-7670-00-030060
ERISA And Other Federal ComplianceIt is intended that this Plan comply with all applicablerequirements of ERISA and other federal regulations. Inthe event of any conflict between this Plan and ERISA orother federal regulations, the provisions of ERISA and thefederal regulations will be deemed controlling, and anyconflicting part of this Plan will be deemed superseded tothe extent of the conflict.Discretionary AuthorityThe Plan Administrator will perform its duties as the PlanAdministrator and in its sole discretion, will determineappropriate courses of action in light of the reason andpurpose for which this Plan is established and maintained.In particular, the Plan Administrator will have full and solediscretionary authority to interpret all Plan documents,including this SPD, and make all interpretive and factualdeterminations as to whether any individual is entitled toreceive any benefit under the terms of this Plan. Anyconstruction of the terms of any Plan document and anydetermination of fact adopted by the Plan Administrator willbe final and legally binding on all parties, except that thePlan Administrator has delegated certain responsibilities tothe Third Party Administrators for this Plan. Anyinterpretation, determination or other action of the PlanAdministrator or the Third Party Administrators will besubject to review only if a court of proper jurisdictiondetermines its action is arbitrary or capricious or otherwisea clear abuse of discretion. Any review of a final decisionor action of the Plan Administrator or the Third PartyAdministrators will be based only on such evidencepresented to or considered by the Plan Administrator orthe Third Party Administrators at the time they made thedecision that is the subject of review. Accepting anybenefits or making any claim for benefits under this Planconstitutes agreement with and consent to any decisionsthat the Plan Administrator or the Third PartyAdministrators make, in their sole discretion, and further,means that the Covered Person consents to the limitedstandard and scope of review afforded under law.10-01-2010-3-7670-00-030060
MEDICAL SCHEDULE OF BENEFITSBenefit Plan(s) 011All health benefits shown on this Schedule of Benefits are subject to the following: Benefit maximums,Deductibles, Co-pays, Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-ofPocket Expenses section of this SPD for more details.Benefits are subject to all provisions of this Plan including any benefit determination based on anevaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and GeneralExclusions sections of this SPD for more details.Important: Prior authorization may be required before benefits will be considered for payment. Failure toobtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the CareManagement section of this SPD for a description of these services and prior authorization procedures.Notes: Refer to the Provider Network section for clarifications and possible exceptions to the In-Networkor Out-of-Network classifications.If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, that means that it isa combined Maximum Benefit for services that the Covered Person receives from all In-Network andOut-of-Network providers and facilities.Annual Deductible Per Calendar Year: Per Person Per FamilyPlan Participation Rate, Unless Otherwise StatedBelow: Paid By Plan After Satisfaction Of DeductibleAnnual Out-Of-Pocket Maximum:IN-NETWORKOUT-OF-NETWORK 0 0 300 600100%70% 1,000 2,000 2,000 4,000100%100%(Deductible Waived)100%(Deductible Waived)70%Note: Medical And Pharmacy Expenses AreSubject To The Same Out-Of-Pocket Maximum. Per Person Per FamilyAmbulance Transportation: Paid By PlanBreast Pumps: Paid By Plan After DeductibleContraceptive Methods And Counseling ApprovedBy The FDA:For Men: Paid By Plan After Deductible100%For Women: Paid By PlanDurable Medical Equipment: Paid By Plan After Deductible10-01-2010No Benefit100%100%-4-70%7670-00-030060
IN-NETWORKOUT-OF-NETWORKTrue Emergency Urgent Care: Co-pay Per Visit Paid By Plan 25100% 25100%(Deductible Waived)Non-True Emergency Urgent Care: Co-pay Per Visit Paid By Plan After Deductible 25100% 2570% 50 50100%100%(Deductible Waived) 50Not Applicable100%70%Emergency Services / Treatment:True Emergency Room / Emergency Physicians: Co-pay Per Visit(Waived If Admitted As Inpatient Within 24 Hours) Paid By PlanNon-True Emergency Room / EmergencyPhysicians: Co-pay Per Visit(Waived If Admitted As Inpatient Within 24 Hours) Paid By Plan After DeductibleExtended Care Facility Benefits Such As SkilledNursing, Convalescent Or Sub-Acute Facility: Co-pay Per Admission Maximum Days Per Calendar Year Paid By Plan After DeductibleGenetic Counseling And Genetic Testing (Pre AndPost Testing): Maximum Visits Per Calendar Year Paid By Plan After DeductibleHome Health Care Benefits: Maximum Visits Per Calendar Year IncludingOutpatient Private Duty Nursing Paid By Plan After Deductible 200 200120 Days100%70%3 Visits100%70%100 Visits100%70%Hospice Services: Paid By Plan After Deductible100%70%Bereavement Counseling: Paid By Plan After Deductible100%70%Respite Care: Paid By Plan After Deductible100%70%Note: A Home Health Care Visit Will Be ConsideredA Periodic Visit By Either A Nurse Or Therapist, AsThe Case May Be, Two (2) Hours Or Less Of HomeHealth Care Services.Hospice Care Benefits:10-01-2010-5-7670-00-030060
IN-NETWORKOUT-OF-NETWORKPre-Admission Testing: Paid By Plan After Deductible100%70%Inpatient Services Only: Co-pay Per Admission Paid By Plan After Deductible 200100% 20070%Inpatient Physician Charges Only: Paid By Plan After Deductible100%70%Outpatient Services / Outpatient PhysicianCharges: Paid By Plan After Deductible100%70%Outpatient Imaging Charges: Paid By Plan After Deductible100%70%Outpatient Lab And X-ray Charges: Paid By Plan After Deductible100%70%100%70%Hospital Services:Outpatient Surgery / Surgeon Charges: Paid By Plan After DeductibleManipulations: Co-pay Per Day Maximum Visits Per Calendar Year Paid By Plan After DeductibleMaternity: 10Not Applicable20 Visits100%70%Physician Office Services: Co-pay Per Visit Paid By Plan After Deductible 10100%Not Applicable70%Subsequent Prenatal Visit, Postnatal Visits AndPhysician’s Delivery Charges (i.e. Global MaternityFee): Paid By Plan After Deductible100%70% 10100%Not Applicable70%Physician’s Office Visits In Addition To The GlobalMaternity Fee When Performed By An OB/GYN OrSpecialist:Physician Office Services: Co-pay Per Visit Paid By Plan After DeductibleMental Health, Substance Use Disorder AndChemical Dependency Benefits:Inpatient Services / Physician Charges: Co-pay Per Admission Maximum Days Per Calendar Year Paid By Plan After Deductible100%70%Residential Treatment: Co-pay Per Admission Paid By Plan After Deductible 200100% 20070%10-01-2010 200 20030 Days-6-7670-00-030060
Partial Hospitalization: Paid By Plan After DeductibleIN-NETWORKOUT-OF-NETWORK100%70%Note: Two Days Of Partial Hospitalization WillReduce Inpatient Maximum By One Day.Outpatient Treatment: Co-pay Per Visit Maximum Visits Per Calendar Year Paid By Plan After DeductibleMorbid Obesity Treatment: Maximum Benefit Per Lifetime Paid By Plan After DeductibleNutritional Evaluation: Maximum Visits Per Calendar Year 10Not Applicable50 Visits100%70% 10,000100%70%3 VisitsPhysician Office Services:Included In Maximum Co-pay Per Visit Paid By Plan After Deductible 10100%Not Applicable70%100%70% 10100%Not Applicable70%100%70% 10100%Not Applicable70%Preventive / Routine Physical Exams AtAppropriate Ages: Paid By Plan After Deductible100%70%Immunizations: Paid By Plan After Deductible100%70%Preventive / Routine Diagnostic Tests, Lab AndX-rays At Appropriate Ages: Paid By Plan After Deductible100%70%Preventive / Routine Mammograms And BreastExams:From Age 35 To Age 70 Maximum Exams Per Calendar Year Paid By Plan100%Outpatient Facility: Paid By Plan After DeductiblePhysician Office Visit:Office Visit: Co-pay Per Visit Paid By Plan After DeductiblePhysician Office Services: Paid By Plan After DeductibleAllergy Injections: Co-pay Per Visit Paid By Plan After DeductiblePreventive / Routine Care Benefits. See GlossaryOf Terms For Definition. Benefits Include:From Age 1710-01-2010-7-1 Exam70%(Deductible Waived)7670-00-030060
IN-NETWORKOUT-OF-NETWORKPreventive / Routine Pelvic Exams And Pap Test: Maximum Exams Per Calendar Year Paid By Plan100%70%(Deductible Waived)Family Planning (Office Visits, Lab And RadiologyTests And Counseling): Paid By Plan After Deductible100%70%Preventive / Routine PSA Test And ProstateExams: Maximum Exams Per Calendar Year Paid By Plan100%70%(Deductible Waived)Preventive / Routine Screenings / Services AtAppropriate Ages And Gender: Paid By Plan After Deductible100%70%Preventive / Routine Colonoscopy, SigmoidoscopyAnd Similar Routine Surgical Procedures Done ForPreventive Reasons:From Age 50 (Unless Medical Necessity Is Met) Paid By Plan After Deductible100%70%100%(Deductible Waived)70%100%(Deductible Waived)70%Preventive / Routine Physical Exams: Paid By Plan100%70%(Deductible Waived)Immunizations: Paid By Plan100%70%(Deductible Waived)1 Exam1 ExamPreventive / Routine Counseling For Alcohol AndSubstance Use Disorder, Tobacco Use, Obesity,Diet And Nutrition: Paid By Plan After DeductibleIn Addition, The Following Preventive / RoutineServices Are Covered For Women: Gestational Diabetes Papillomavirus DNA Testing* Counseling For Sexually TransmittedInfections (Provided Annually)* Counseling For Human Immune-deficiencyVirus (Provided Annually)* Breastfeeding Support, Supplies AndCounseling Counseling For Interpersonal And DomesticViolence For Women (Provided Annually)* Paid By Plan After Deductible*These Services May Also Apply To Men.Preventive / Routine Care Benefits For ChildrenInclude:From Birth Through Age 1610-01-2010-8-7670-00-030060
IN-NETWORKOUT-OF-NETWORKPreventive / Routine Screenings At AppropriateAges: Paid By Plan100%70%(Deductible Waived)Preventive / Routine Autism Screenings:From Age 0 To 21 Paid By Plan100%70%(Deductible Waived)Preventive / Routine Diagnostic Tests, Lab AndX-rays: Paid By Plan100%70%(Deductible Waived)Preventive / Routine Oral Fluoride SupplementsPrescribed For Children Ages 6 Months To 5 YearsWhose Primary Water Source Is Deficient InFluoride: Paid By Plan After Deductible100%70%(Deductible Waived)100%70%100%70%100%(Deductible Waived)70%Private Duty Nursing:Included In Home Health Care Maximum Paid By Plan After DeductibleSterilizations:For Men: Paid By Plan After DeductibleFor Women: Paid By Plan After DeductibleTemporomandibular Joint Disorder Benefits: Maximum Benefit Per Lifetime 1,000Inpatient Facility: Co-pay Per Admission Maximum Days Per Calendar Year Paid By Plan After Deductible100%70%Office Visit: Co-pay Per Visit Paid By Plan After Deductible 10100%Not Applicable70%Outpatient Facility / Hospital Physician’s Services: Paid By Plan After Deductible100%70%10-01-2010 200 20030 Days-9-7670-00-030060
IN-NETWORKTherapy Services (Includes Physical Therapy,Occupational Therapy, Speech Therapy, CardiacPulmonary And Cognitive Therapy): Co-pay Per Visit Maximum Visits Per Calendar Year Paid By Plan After DeductibleNote: Physical Therapy/Occupational Therapy AndOther Rehabilitative Therapy Services Provided InThe Home Are NOT Subject To The Home HealthServices Benefit Limitation, But Are Subject To TheBenefit Limitations Described Above.Wigs, Toupees Or Hairpieces Related To CancerTreatment And Alopecia Areata: Maximum Benefit Per Lifetime Paid By Plan After DeductibleAll Other Covered Expenses: Paid By Plan After Deductible10-01-2010-10-OUT-OF-NETWORK 10Not Applicable30 Visits100%70% 500100%70%100%70%7670-00-030060
MEDICAL SCHEDULE OF BENEFITSBenefit Plan(s) 017, 018 – Bronze Alt PlanAll health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays,Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expenses andMaximums section of this SPD for more details.Benefits are subject to all provisions of this Plan including any benefit determination based on anevaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and GeneralExclusions sections of this SPD for more details.Important: Prior authorization may be required before benefits will be considered for payment. Failure toobtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the CareManagement section of this SPD for a description of these services and prior authorization procedures.Note: Refer to the Provider Network section for clarifications and possible exceptions to the in-network orout-of-network classifications.If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, it is a combinedMaximum Benefit for services that the Covered Person receives from all in-network and out-of-networkproviders and facilities.IN-NETWORKOUT-OF-NETWORK 4,500 9,000 5,000 10,00080%60% 6,000 12,000 12,000 24,00080%80%100%(Deductible Waived)60%80%60%100%(Deductible Waived)60%80%60%Annual Deductible Per Plan Year:Note: Medical And Pharmacy Expenses AreSubject To The Same Deductible. Single Coverage Family CoveragePlan Participation Rate, Unless Otherwise StatedBelow: Paid By Plan After Satisfaction Of DeductibleAnnual Out-Of-Pocket Maximum:Note: Medical And Pharmacy Expenses AreSubject To The Same Out-Of-Pocket Maximum. Single Coverage Family CoverageAmbulance Transportation: Paid By Plan After In-Network DeductibleBreast Pumps: Paid By Plan After DeductibleContraceptive Methods And ContraceptiveCounseling Approved By The FDA:For Men: Paid By Plan After DeductibleFor Women: Paid By Plan After DeductibleDurable Medical Equipment: Paid By Plan After Deductible10-01-2010-11-7670-00-030060
IN-NETWORKOUT-OF-NETWORK80%60%80%80%Emergency Services / Treatment:Urgent Care: Paid By Plan After DeductibleTrue Emergency Room / Emergency Physicians: Paid By Plan After In-Network DeductibleExtended Care Facility Benefits, Such As SkilledNursing, Convalescent, Or Subacute Facility: Maximum Days Per Plan Year Paid By Plan After DeductibleGender Assignment / Reassignment:Surgery: Maximum Benefit Per Lifetime Paid By Plan After Deductible120 Days80%60% 75,00080%60%80%60%Exams, Tests: Paid By Plan After Deductible80%60%Hearing Aids: Maximum Benefit Per Plan Year Paid By Plan After Deductible80%60%80%60%Counseling:Included In Maximum Paid By Plan After DeductibleHearing Services: 500Implantable Hearing Devices: Paid By Plan After DeductibleHome Health Care Benefits: Maximum Visits Per Plan Year Paid By Plan After Deductible120 Visits80%60%80%60%80%60%Inpatient Services / Inpatient Physician Charges;Room And Board Subject To The Payment OfSemi-private Room Rate Or Negotiated Room Rate: Paid By Plan After Deductible80%60%Outpatient Services / Outpatient PhysicianCharges: Paid By Plan After Deductible80%60%Note: A Home Health Care Visit Will Be ConsideredA Periodic Visit By A Nurse, Qualified Therapist, OrQualified Dietician, As The Case May Be, Or Up ToFour Hours Of Home Health Care Services.Hospice Care Benefits:Hospice Services: Paid By Plan After DeductibleBereavement Counseling: Paid By Plan After DeductibleHospital Services:10-01-2010-12-7670-00-030060
IN-NETWORKOUT-OF-NETWORKOutpatient Imaging Charges: Paid By Plan After Deductible80%60%Outpatient Lab And X-ray Charges: Paid By Plan After Deductible80%60%80%60%Outpatient Surgery / Surgeon Charges: Paid By Plan After DeductibleInfertility Treatment: Maximum Benefit Per Lifetime Paid By Plan After DeductibleManipulations: Maximum Visits Per Plan Year Paid By Plan After DeductibleMaternity: 15,00080%20 VisitsRoutine Prenatal Services: Paid By Plan After DeductibleNon-Routine Prenatal Services, Delivery, AndPostnatal Care: Paid By Plan After DeductibleMental Health, Substance Use Disorder, AndChemical Dependency Benefits: Paid By Plan After DeductiblePhysician Office Visit: Paid By Plan After DeductiblePhysician Office Services: Paid By Plan After DeductiblePreventive / Routine Care Benefits. See GlossaryOf Terms For Definition. Benefits Include:Preventive / Routine Physical Exams AtAppropriate Ages: Paid By Plan After DeductibleImmunizations: Paid By Plan After DeductiblePreventive / Routine Diagnostic Tests, Lab, AndX-rays At Appropriate Ages: Paid By Plan After DeductiblePreventive / Routine Mammograms And BreastExams: Maximum Exams Per Plan Year Paid By Plan After Deductible10-01-201060%-13-80%60%100%(Deductible Waived)60%80%60%80%60%80%60%80%60%100%(Deductible Waived)60%100%(Deductible Waived)60%100%(Deductible Waived)60%1 Exam100%(Deductible Waived)60%7670-00-030060
IN-NETWORKPreventive / Routine Pelvic Exams And Pap Tests: Maximum Exams Per Plan Year Paid By Plan After DeductiblePreventive / Routine PSA Test And ProstateExams: Maximum Exams Per Plan Year Paid By Plan After DeductiblePreventive / Routine Screenings / Services AtAppropriate Ages And Gender: Paid By Plan After DeductiblePreventive / Routine Autism Screenings:From Age 0 To 21 Paid By Plan After DeductiblePreventive / Routine Colonoscopies,Sigmoidoscopies, And Similar Routine SurgicalProcedures Performed For Preventive Reasons: Paid By Plan After DeductiblePreventive / Routine Hearing Exams: Paid By Plan After DeductiblePreventive / Routine Eye Exams And GlaucomaTesting: Maximum Exams Per Plan Year Paid By Plan After DeductibleEye Refractions: Maximum Exams Per Plan Year Paid By Plan After DeductiblePreventive / Routine Counseling For Alcohol OrSubstance Use Disorder, Tobacco Use, Obesity,Diet, And Nutrition: Maximum Exams Per Plan Year Paid By Plan After DeductiblePreventive / Routine Tobacco Addiction: Paid By Plan10-01-2010-14-OUT-OF-NETWORK1 Exam100%(Deductible Waived)60%1 Exam100%(Deductible Waived)60%100%(Deductible Waived)60%100%(Deductible Waived)60%100%(Deductible Waived)60%100%(Deductible Waived)60%1 Exam100%(Deductible Waived)60%1 Exam100%(Deductible Waived)60%Not Applicable100%(Deductible Waived)1 Exams60%100%(Deductible Waived)100%(Deductible Waived)7670-00-030060
Preventive / Routine Oral Fluoride SupplementsPrescribed For Children Ages 6 Months To 5 YearsWhose Primary Water Source Is Deficient InFluoride: Paid By Plan After DeductibleIn Addition, The Following Preventive / RoutineServices Are Covered For Women: Treatment For Gestational Diabetes Papillomavirus DNA Testing* Counseling For Sexually TransmittedInfections (Provided Annually)* Counseling For Human Immune-DeficiencyVirus (Provided Annually)* Breastfeeding Support, Supplies, AndCounseling Counseling For Interpersonal And DomesticViolence For Women (Provided Annually)* Paid By Plan After DeductibleIN-NETWORKOUT-OF-NETWORK100%(Deductible Waived)60%100%(Deductible Waived)60%80%60%100%(Deduc
THE BOYD GROUP, INC. ELMHURST IL Health Benefit Summary Plan Description 7670-00-030060 Revised 04-01-2017 . Funding Of The Plan Employer and Employee Contributions Benefits are provided by a benefit Plan maintained on a self-insured basis by Your employer. Benefit Plan Year (Applies to Benefit Plan(s) 017, 018,
