TYSON FOODS, INC. SUMMARY OF MEDICAL BENEFITS

 

This Plan includes benefits for preferred provider organization providers (hereinafter called In-Network Providers). Your identification card indicates which network of providers applies to your benefits under this Plan. It is important to use In-Network Providers in order to receive the maximum benefits available under the Plan.

 

Eligibility

 

Medical Benefits become available to eligible Tyson Team Members on the first day of the calendar month coinciding with or following completion of three (3) months of Full-time service.

 

Lifetime Maximum Benefits

 

Lifetime Maximum Benefit Per Individual                                                                                                  $1,000,000

(Includes All Other Maximums and Prescription Drug Amounts Paid by the Plan)

 

Substance Abuse Treatment (under the Premium Plan)                                                                                         $25,000

 

The word Lifetime refers to the period of time you or your eligible Dependents participate in this Plan or any other plan sponsored by Tyson Foods, Inc. or any affiliate.

 

Maximum Benefits (other than Lifetime)

 

Convalescent/Skilled Nursing Facility Services

Per Individual per Calendar Year                                                                                                            100 days

 

Calendar Year Deductible

 

Services provided by In-Network Providers:

Per Individual                                                                                                                                           $300

Per Family                                                                                                                                                $600

 

Services provided by Out-of-Network Providers:

Per Individual                                                                                                                                           $300

Per Family                                                                                                                                                $600

 

Copays

 

Primary care office visits and emergency room services are subject to a per visit Copay that must be paid by the covered person.

 

$100 per visit to a Hospital emergency department. This Copay is waived when admitted.

 

$20 per visit for Primary Care Office Visit exam charge when provided by a Physician that is an OB/GYN, a pediatrician, an internist, a family physician, physician assistant, or nurse practitioner.

 

Calendar Year Out-of-Pocket Maximum

 

The Out-of-Pocket Maximum can be met by payments of 20% Coinsurance and Deductible amounts for In-Network Provider services. It cannot be met by payments for non-covered services, any Coinsurance or Deductible amounts for Out-of-Network Provider services, or Copays.

 

Basic Plan

Services provided by In-Network Providers:

Per Individual                                                                                                                           $2,300

Per Family                                                                                                                                $4,600

Services provided by Out-of-Network Providers:                                                                                  No limit

 

Premium Plan

Services provided by In-Network Providers:

Per Individual                                                                                                                           $1,300

Per Family                                                                                                                                $2,600

Services provided by Out-of-Network Providers:                                                                                  No limit

 

Inpatient Hospital & Physician Services

 

In-Network Providers                                         Out-of-Network Providers

Medical/Surgical Care

Semi-private room

Medically Necessary Hospital services and supplies

After Deductible, Plan pays 80% of Network Fee Schedule

After Deductible, Plan pays 50% of Out-of-Network Fee Schedule

 

Failure to obtain pre-notification and pre-approval of an inpatient Hospital admission will result in a penalty of 50% up to a maximum of $1,000. Refer to the Medical Review section of this Plan.

Outpatient Hospital & Physician Services

 

                                                                                In-Network Providers                                         Out-of-Network Providers

Outpatient surgery, rehabilitation services

After Deductible, Plan pays 80% of Network Fee Schedule

After Deductible, Plan pays 50% of Out-of-Network Fee Schedule

 

Diagnostic Laboratory and X-ray Services

 

In-Network Providers                                         Out-of-Network Providers

X-ray and lab, including pre-admission testing

After Deductible, Plan pays 80% of Network Fee Schedule

After Deductible, Plan pays 50% of Out-of-Network Fee Schedule

 

Primary Care Office Visit

 

Also applies to the exam charge for covered Preventive Care Services refer to Preventive Care Services on the following page.

In-Network Providers                                         Out-of-Network Providers

Exam charge when rendered by OB/GYN, pediatrician, internist, family physician, physician assistant, or nurse practitioner

After $20 Copay, Plan pays 100%

After Deductible, Plan pays 50% of Out-of-Network Fee Schedule

 

Specialty Office Visit

 

Also applies to the exam charge for covered Preventive Care Services refer to Preventive Care Services below.

 

In-Network Providers                                         Out-of-Network Providers

Exam charge when rendered by specialty care providers

After Deductible, Plan pays 80% of Network Fee Schedule

After Deductible, Plan pays 50% of Out-of-Network Fee Schedule

 

Preventive Care Services

 

Services other than the exam charge (i.e., lab, x-ray and immunizations). Refer to Primary Care or Specialty Office Visit above for the applicable exam charge benefit.

 

Basic Plan

In-Network Providers                                         Out-of-Network Providers

Routine Physicals

Not a Covered Expense

Not a Covered Expense

Routine Mammograms

Not a Covered Expense

Not a Covered Expense

Well Child Exams

Not a Covered Expense

Not a Covered Expense

Well Child Immunizations

(Up to age 17)

After Deductible, Plan pays 80% of Network Fee Schedule

After Deductible, Plan pays 50% of Out-of-Network Fee Schedule

Routine Hearing Exams

Not a Covered Expense

Not a Covered Expense

 

Premium Plan

In-Network Providers                                         Out-of-Network Providers

Routine Physicals,

Routine Mammograms,

Well Child Exams,

Well Child Immunizations

(Up to age 17), and

Routine Hearing Exams

After Deductible, Plan pays 80% of Network Fee Schedule

After Deductible, Plan pays 50% of Out-of-Network Fee Schedule

 

Durable Medical Equipment and Supplies, Prosthetic and Orthotic Devices

 

In-Network Providers                                         Out-of-Network Providers

Durable Medical Equipment and supplies, prosthetic and orthotic devices which are related directly to the treatment of an Illness or Injury

After Deductible, Plan pays 80% of Network Fee Schedule

After Deductible, Plan pays 80% of Network Fee Schedule