EX-10.4 5 v51970exv10w4.htm EX-10.4 exv10w4
Exhibit 10.4
Northrop Grumman Executive Health Plan Matrix
           
 
  Plan Feature     Benefit  
 
Eligibility
    Employee + Spouse & Eligible Dependents  
 
Medical Plan
    Premium PPO Plan administered by Anthem Blue Cross Blue Shield  
 
   Coverage
    100% coverage, for all eligible plan expenses  
 
   Annual Deductible
    No annual deductible  
 
   Co-payment/Co-insurance
    No co-payment/No co-insurance  
 
   Preventive Care Coverage
    No limits as long as procedures fall under Anthem’s Guidelines  
 
Prescription Drug Coverage
    Covered under Medical Plan  
 
   Annual Deductible
    No annual deductible  
 
   Coverage — retail    
   30 — day supply
    100% coverage, when network pharmacy is utilized  
 
   Coverage — mail order    
   90 — day supply
    100% coverage, when network pharmacy is utilized  
 
Vision and Hearing Coverage
    $500 vision/ $500 per ear per plan year — per covered individual  
 
Acupuncture and Acupressure
    20 visits [combined] — per person, per plan year  
 
Chiropractic Care
    40 visits per benefit plan year  
 
Physical Therapy
    50 visits per benefit plan year (in and out-of-network combined)  
 
Speech Therapy
    50 visits per benefit plan year (in and out-of-network combined)  
 
Occupational Therapy
    50 visits per benefit plan year (in and out-of-network combined)  
 
Mental Health Coverage
Inpatient treatment must be pre-authorized by Value Options(800) 982-8161

Mental Health Maximums
    Mental health is 100% covered (in and out-of-network combined) Unlimited office visits (in and out-of-network)

Combined Lifetime Limits — included in $2 million per person Medical lifetime maximum
 
 
Health Plan Lifetime Maximums
    $2,000,000.00 per covered individual, including mental health benefits  
 
Dental Plan
    Premium PPO Plan administered by Delta Dental  
 
   Annual maximum
    $4,000 per person — per benefit plan year  
 
   Coverage
    100% coverage, for all eligible plan expenses up to annual maximum  
 
   Annual Deductible
    No annual deductible  
 
   Co-payment/Co-insurance
    No co-payment/No co-insurance  
 
 
       
 
Eligibility
    Employee  
 
Life Insurance Coverage
    Company-paid life insurance 3x Annual base salary up to a maximum of $2 million  
 
Accidental Death & Dismemberment (AD&D) Coverage
    Company-paid accidental death & dismemberment insurance — 6 x Annual base salary up to a maximum of $1 million  
 
Long-Term Disability (LTD)
    Company-paid basic LTD benefit of 75% of monthly base salary, up to a maximum monthly benefit of $25,000  
 
Executive Physicals
    $2,000/year allowance for executive physical — coverage under Perquisite Program (covers employee only)  
 
Effective 07/01/08