in the event of any discrepancy between this benefits ... annual enrollment guide with...in the...
TRANSCRIPT
In the event of any discrepancy between this Benefits Guide and the Summary PlanDescription (also known as the Employee Benefits Handbook), the information in the SummaryPlan Description will prevail.
Table of Contents
Eligibility & Life Events ................................................................................. 1
Medical, Prescription Drug, Dental and Vision Overview .......................................... 7
Medical Plan Chart.................................................................................... 9 Prescription Drug Chart ............................................................................. 12 Dental Plan Chart .................................................................................... 14 Vision Plan Chart ..................................................................................... 16
Wellness Program....................................................................................... 17
Spending & Savings Accounts ......................................................................... 19
Life & Security .......................................................................................... 20
Employee Assistance Program ........................................................................ 21
Retirement Savings Plan ............................................................................... 22
Pension Plans............................................................................................ 22
Retiree Benefits......................................................................................... 23
Financial Planning Services............................................................................ 24
Travel Guide............................................................................................. 25
2015 Benefit Monthly Rates ........................................................................... 26
Ceridian Self-Service User Guide ..................................................................... 28
Benefits Website........................................................................................ 31
Required Disclosures ................................................................................... 32
General Notice of COBRA Continuation Coverage Rights....................................... 32 Notice of Privacy Practices ......................................................................... 35 HIPAA Special Enrollment Rights Notice .......................................................... 38 Women's Health and Cancer Rights Act ........................................................... 39 Newborns' and Mothers' Health Protection Act .................................................. 39 Medicare Part D Disclosure / Notice of Creditable Coverage.................................. 40 Medicaid and the Children's Health Insurance Program (CHIP) ................................ 42
1
Eligibility & Life Events
Benefits Eligibility ChartIn general, this chart reflects the benefits for which you are eligible.
Benefit Plans
Full-Time(Working 20+
hours perweek)
Part-Time,Temporary and
Seasonal(Working lessthan 20 hours
per week)
Part-Time,Temporary and
Seasonal(Working 20+
hours perweek)
Medical Plan Yes No Yes
Wellness Plan Yes No Yes
Dental Plan Yes No Yes
Vision Plan Yes No Yes
Flexible Spending Accounts Yes No Yes
Long-Term Disability Yes No Yes
Long-Term Disability Buy-up Yes No Yes
Basic Life Insurance Yes No Yes
Basic Personal Accident Insurance Yes No Yes
Voluntary Personal AccidentInsurance
Yes No Yes
Group Universal Life Insurance(GUL)
Yes No Yes
Voluntary Personal AccidentInsurance
Yes No Yes
Employee Assistance Plan Yes Yes Yes
Financial Assistance Plan Yes Yes Yes
Retirement Savings Plan Yes Yes Yes
Pension * * *
Retiree Medical * * *
Retiree Dental * * *
*See the Employee Benefits Handbook for details on these plans eligibility requirements. These plans were closed to new entrants effective 1/1/08.
2
Dependent Eligibility
Spouse / Domestic PartnerYour spouse is the person to whom you are legally married under the law of the state in which you were married, even if you reside in a state whose laws do not recognize the validity of your marriage.
Your domestic partner is the person of the same or opposite sex with whom you have entered into a civil union or substantially similar legal relationship (other than a common law marriage) that is legally recognized under state law, or withrespect to whom all of the following requirements have been met:
Both of you are at least 18 years old, oflegal age, and mentally competent to enter into contracts, and have been so for at least six months.
You are each other’s sole domesticpartner, have been so for at least six months, with the intent to remain so indefinitely.
You reside together in the sameprincipal residence, have done so for at least six months prior to the date of the signed Affidavit, and intend to do so indefinitely.
You are emotionally committed to oneanother and share joint responsibilities for your common welfare and financial obligations, and have done so for at least six months.
Neither of you are legally married northe domestic partner of anyone else, nor have you been married or the domestic partner of anyone else within the last six months.
You are not related by blood to anextent that would prohibit marriage in the state in which you reside.
In order for your domestic partner to enroll in the Plan, you must either submit the certification or other documentation of your civil union or other similar legal relationship, or a signed, notarizedDomestic Partner Affidavit. You can
download the Affidavit from the Benefitswebsite at: www.ineosbenefits.com.If you wish to drop your Domestic Partnerfrom coverage, you and your Domestic Partner will need to complete another Affidavit requesting the change.
Child(ren)Your child includes:
Your natural child, stepchild, legallyadopted child (including a child placed for adoption), foster child, or child for whom you have legal guardianship, until the end of the month in which the child attains age 26;
Your spouse's or domestic partner'snatural child, stepchild, or legally adopted child (including a child placed for adoption), if the child is a tax dependent of the spouse or domestic partner;
A child who is covered by the Plan andis permanently and totally disabled at the time he or she turns 26. Such child can continue coverage if proof of disability is provided to the applicable benefits administrator before age 26.
Supporting Documentation RequirementsDocumentation supporting yourdependent's eligibility is required within 30 days of enrollment. Supporting documentation may include a marriage certificate, certificate of civil union, Domestic Partner Affidavit, birth certificate, legal guardianship papers, foster child documentation, etc. Please review the Life Events Chart for information regarding what supporting documentation is required when making changes to your coverage or to the coverage of your dependents.
MisrepresentationIf you misrepresent a dependent’seligibility to enroll in the INEOS plans or do not timely notify the Company when a dependent is no longer eligible under the INEOS plans, this will be considered fraud
3
and may result in disciplinary action up to and including termination of employment.
Additional Domestic Partner InformationIn general, domestic partner coverage is a taxable benefit under IRS Regulations. If your domestic partner qualifies as a dependent for income tax purposes, the domestic partner coverage is not taxable to the employee. In order to qualify as a dependent for income tax purposes the Internal Revenue Code requires that all of the following must be true for the applicable tax year:
The domestic partner’s principal placeof residence is the home of the employee and has been the full calendar year;
The domestic partner is a member ofthe employee’s household and has been the full calendar year;
The employee financially supports thedomestic partner to the degree required by the Internal Revenue Code;
At no time during the taxable year doesthe relationship between the employee and the domestic partner violate local law;
The domestic partner must not be a“qualifying child” of the employee or any other taxpayer; and
The domestic partner must be a U.S.citizen, a U.S. national, or a resident of the U.S., Canada, or Mexico.
You should consult with a tax advisor for assistance in determining whether or not your domestic partner qualifies as your dependent for income tax purposes and any questions you may have regarding your state specific taxation.
Defense of Marriage Act (DOMA)The Supreme Court has ruled the definition of marriage under Section 3 of the Defense of Marriage Act is unconstitutional. If youwere married in a State where same sex marriage is legal, you should enroll your partner as a “Spouse” and submit thecertificate of marriage to the Benefits Department. You should not enroll your spouse as a Domestic Partner.
4
Life Events Guide
When you have a qualifying life event outside of the annual Open Enrollment period and wish to make changes to your benefit plans, you may do so, however supporting documentation is required as proof of the event. The following charts show what documentation is required for the different life events and where the information will be housed (in your HR file or the Benefits Department).
All supporting documentation must be returned to your local HR Department within 30 days of the event date in orderfor your changes to be effective. Whenadding coverage, if HR is not notified of the Life Event and provided the supporting documentation within 30 days, you will have to wait until the next Open Enrollment to make your changes.
In the event one of your dependents is no longer eligible, notice must be given as soon as possible on or before the event date. Supporting documentation must be provided to HR prior to your request being processed. All changes will be processed as soon as possible upon receipt of notification and supporting documentation.
Rules for Changing CoverageMedical, Dental and Vision - You may adddependents to your coverage as well as yourself if you are currently not enrolled. You will not be able to change the plan previously elected, only the tier or coverage level. For instance, if you are enrolled in the 80% PPO Plan, you cannot change your election to the 90% PPO Plan due to the life event, only change the tier and add/delete dependents. You can initiate a coverage change through Ceridian Self Service as well as update dependent information.
Flexible Spending Accounts (including both health care and dependent care accounts) – You may increase your election when you add dependents to your existing coverage or enroll for the first time. You
are able to decrease your election when you remove dependents from your existing coverage. The same rules apply for traditional and limited purpose FSA accounts.
Health Savings Accounts – You may change your election at any time during the year even if you do not experience a life event. In order to enroll in a Health Savings Account you must be enrolled in the Account Based High Deductible medical plan. See the Health Savings Account section for details on how to enroll and make changes to your election.
Group Universal Life - You can enroll in or change your coverage amount at any time without a qualifying life event. Evidence of Insurability (EOI) may be required if you are increasing the coverage for yourself, your spouse or domestic partner.
Voluntary Personal Accident - You can enroll in or change your coverage amount at any time without a qualifying life event. Evidence of Insurability (EOI) is not required for this benefit.
Long Term Disability Buy-up – You can enroll or cancel your coverage amount at any time without a qualifying life event. Evidence of Insurability (EOI) may be required to secure this benefit.
Retirement Savings Plan – You can make changes to your contribution election and/or beneficiary information at any time.
Pension Plans – You can change your beneficiary information at any time.
How to Change your Coverage and/or Beneficiary DesignationsMedical, Dental, Vision and FlexibleSpending Accounts - You can initiate a coverage change through Ceridian Self Service by selecting and saving the relevant life event – birth or adoption of child, change of marital status, spouse eligibility, etc. HR will receive notification of your request and will approve it upon
5
receipt of the supporting documentation. Once the request is approved, you will have the option in Self Service to update your benefits. Beneficiary information is not housed in Self Service.
Health Savings Accounts – You can change your election through Ceridian Self Service at any time. If enrolling for the first time, see the HSA section for furtherinstructions.
Voluntary Benefits – You can initiate a coverage change directly with the Customer Service Representatives at CIGNA or online via the CIGNA Trusted Advisor website. Beneficiary information is not housed in Ceridian Self Service. Beneficiary changes are handled
electronically through CIGNA’s website. While reviewing your beneficiary information for voluntary benefits, be sure to also check your company provided Basic Life Insurance and Basic Personal Accident insurance beneficiary designations.
Retirement Savings Plan - You can review and/or update not only your contribution elections, but also your beneficiary information online at the T. Rowe Price website.
Pension Plans – You can review and/or update your beneficiary information by completing a Beneficiary Designation Form. The form can be found online via Towers Watson’s website.
Life Events –Lose Coverage
Supporting Documentation RequiredDocuments Housed
By:
Marriage(Enrolling in your spouse’s coverage)
Marriage Certificate or other documentation supporting the legal relationship
Human Resources
Divorce Divorce Decree(The full legal document is required)
BenefitsDepartment
Legal Separation Court documents Human Resources
End of a domestic partnership
Domestic Partner Affidavit Termination Form
Benefits Department
Dependent Child’s StatusChange(No longer an eligible dependent)
Copy of Birth Certificate(if not already on file)
Human Resources
Death of a Dependent Copy of the Death Certificate Human Resources
Loss of other coverage(Spouse, Domestic Partner and/or child)
HIPAA Certificate of Creditable Coverage reflecting the end date of coverage or proof of loss from an employer or government agency
Human Resources
Enrollment in the BP Retiree Medical Plan
BP Enrollment Confirmation Human Resources
6
Life Event –Gain Coverage
Supporting Documentation RequiredDocuments Housed
By:
Marriage(Enrolling spouse on your coverage)
Marriage Certificate or other documentation supporting the legal relationship
Human Resources
New Domestic Partnership
Domestic Partner Affidavit FormBenefits Department
Birth of a childBirth Certificate or Certificate from Hospital
Human Resources
Adoption Final court approved adoption papersBenefitsDepartment
Legal guardianship or custody of a child
Final court order or Medical Support Order from the State of Residence
Benefits Department
Employment related changes of a Spouse or Domestic Partner
HIPAA Certificate of Credible Coverage from a prior insurance company
Human Resources
Spouse or Domestic Partner’s annual enrollment
Copy of Open Enrollment information from the employer
Human Resources
Gain of other coverage(Spouse, Domestic Partner and/or child)
Confirmation of coverage with effective date from an employer or government agency
Human Resources
Dependent Child’s Status Change - Disability
Medical Plan - BCBS Disabled Dependent Form (provide the original to BCBS and a copy to HR)
Dental and Vision Plans - Physician’s letter or other documentation certifying the disability (provide the original to the vendor and a copy to HR)
Human Resources
7
Medical, Prescription Drug, Dental and Vision Overview
Medical PlansThe INEOS medical plans, administered byBlue Cross Blue Shield (BCBS) of Illinois, offer the advantage of a comprehensive, nationwide network of providers. By using network providers, you and the Company share in the savings of negotiated fees with hospitals, highly qualified doctors and other healthcare providers. Our plans provide the financial security of annual out-of-pocket limits coupled with unlimited lifetime benefits per person to protect you and your family.
Choose the plan that best meets your needs! You have the choice of three different plans: an 80% PPO Plan, 90% PPO Plan, and 85% Account Based Health Plan (ABHP). The 80% and 90% PPO Plans are traditional coinsurance plans whereas the 85% ABHP is a high deductible plan. The benefits covered and networks available under the plans are the same. See the Employee Benefits Handbook for specific information regarding coverage.
Along with the medical plans you have two tools to help you be a good health care consumer: the Integrated Provider Finder (IPF) and the Benefits Value Advisor. The Integrated Provider Finder is a web-based tool offered by BCBS that prioritizes service providers by cost, quality and outcomes.Here you can search for providers, procedures and facilities within a certain geographic region and obtain cost information BEFORE you have any services performed. You can access information and locate networkproviders via the internet at www.bcbsil.com.
The Benefits Value Advisor (BVA) is a concierge service which provides you with advisors armed and ready to assist you with navigating the healthcare system and finding quality, cost-effective providers and facilities. They can assist you with making appointments, help you understand your benefits, provide general information about any health condition you may have, assist you
with the pre-certification process, and inform you about available online educational tools.
To reach a BVA, simply call the customer service number on your ID card. Blue Cross Blue Shield’s BVA’s are available from 8:30 am to 6:00 pm CST, Monday through Friday at (888) 979-4516. Pre-certifications should be processed through the Blue Care Connection customer service representatives at (800) 826-8551.
Prescription Drug PlanBlue Cross Blue Shield, a leading name inprescription drug plans nationwide, allows you to access prescription drugs, helpful information and other related services through their Pharmacy Benefits Manager, Prime Therapeutics. A separate enrollment election is not required – when you enroll in coverage under one of the medical plans, you are automatically enrolled in the prescription drug plan.
Customer Service Representatives are available at (800) 423-1973, 24 hours a day, 7 days a week to answer your questions regarding your prescription drugs and/or order processing. To place an order for Specialty Drugs, you should have your doctor contact a customer service representative at (877) 627-MEDS (6337) or, they can fax your prescription to (877) 828-3939. You can access additional information via the internetat www.bcbsil.com.
State Health Exchange NoticeUnder PPACA, employers are required to provide a notice to employees about the state's health insurance exchanges. Youwill find the Notice after the Required Disclosures section of this guide.
Summary of Benefits and CoverageAlso under PPACA, group health plans arerequired to provide a Summary of Benefits and Coverage (SBC) that provides you with a concise document detailing, in plain language, simple and consistent information
8
about health plan benefits and coverage. The SBC will help you better understand the coverage you have and allow you to compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. When making your medical plan election, you should use these SBCs along with the information provided in the Medical section of this Benefits Guide. You will find the SBCs for each of the INEOS medical plans after the Required Disclosures section of this Guide.
Dental PlanThe INEOS dental plan combines the freedom to choose your dentist with the cost-savings advantage of network providers through one of the nation’s premier dental plan providers, Humana Dental. Help in locating network providers in your area is just a phone call away (800) 233-4013 or via the internet atwww.humanadental.com. Customer servicerepresentatives are available from 8:00 am through 6 pm, Monday through Friday regardless of your time zone.
Vision PlanThe INEOS Vision Plan is offered through VSP.With VSP doctors, you will enjoy quality and personalized care. Besides helping you see better, routine eye exams can detect symptoms of serious conditions such as glaucoma, cataracts and diabetes. Eye exams for children may discover problems that can hinder learning and development.
VSP network doctors are in medical offices and shopping centers – close to home and work. Most offer evening and weekend hours and accept walk-ins. New patients are always welcome. Here’s how you get started:
1. Choose a VSP doctor at www.vsp.com orcall (800) 877-7195.
2. Make an appointment and tell the doctoryou are a VSP member.
3. That’s it! No ID cards or filling out claimforms.
Dollar for dollar you get the best value from your VSP benefit when you visit a VSP network doctor. If you decide not to see a VSP doctor, copays still apply. You will also receive a lesser benefit and typically pay more out-of-pocket. At the time of your appointment, you are required to pay the provider in full. To receive reimbursement under the Plan, you will have to submit a claim to VSP. If you decide to see a provider not in the network, we suggest that you call VSP first.
Waiving CoverageIf you choose not to participate in the Medicaland/or Dental benefits offered, you will need to waive your coverage. When doing so, you will receive $100 per month for opting out of Medical and $8.33 per month for opting out of Dental. If you are an employee and a dependent (spouse or child) covered by another INEOS employee, you are exempt from receiving the opt-out credits.
9
Medic
al Pla
n C
hart
80%
PPO
Pla
n90%
PPO
Pla
n85%
ABH
PIn
-Netw
ork
Out-
of-
Netw
ork
In-N
etw
ork
Out-
of-
Netw
ork
In-N
etw
ork
Out-
of-
Netw
ork
Genera
l In
form
ati
on
Deduct
ible
(excl
udes
copays
)
$450/pers
on
$1,3
50/fa
mily
$900/pers
on
$2,7
00/fa
mily
$700/pers
on
$2,1
00/fa
mily
$1,4
00/pers
on
$4,2
00/fa
mily
$1,7
50/pers
on
$5,2
50/fa
mily
Out-
of-
pock
et
maxim
um
$2,0
00/pers
on
$4,0
00/fa
mily
(incl
udes
copays
, co
insu
rance
and
deduct
ible
)
$4,0
00/pers
on
$8,0
00/fa
mily
(incl
udes
copays
, co
insu
rance
and
deduct
ible
)
$2,0
00/pers
on
$4,0
00/fa
mily
(incl
udes
copays
, co
insu
rance
and
deduct
ible
)
$4,0
00/pers
on
$8,0
00/fa
mily
(incl
udes
copays
, co
insu
rance
&
deduct
ible
)
$2,5
00/pers
on
$7,5
00/fa
mily
(incl
udes
deduct
ible
, co
insu
rance
and R
x)
Lif
eti
me
maxim
um
benefi
tN
one
None
None
None
None
For
the
foll
ow
ing
treatm
ents
and
serv
ices,
the
medic
alpla
nopti
ons
pay:
Physi
cian
Off
ice
Vis
its
Pri
mary
care
off
ice v
isit
100% a
fter
$20
copay
60% a
fter
deduct
ible
100%
aft
er
$20
copay
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Speci
alist
off
ice v
isit
100% a
fter
$30
copay
60% a
fter
deduct
ible
100%
aft
er
$30
copay
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Mate
rnit
y se
rvic
es
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Lab a
nd X
-ray
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Pre
venta
tive
Care
(Routi
ne
Serv
ices
Only
)
Annual
phys
icals
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100%
65%
Well
-Wom
en
Pre
venta
tive
Care
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100%
65%
Routi
ne G
yneco
logic
al Exam
(1 e
xam
eve
ry c
ale
ndar
year
in a
ddit
ion t
o r
outi
ne p
hysi
cal)
Routi
ne B
reast
Exam
and/or
Mam
mogra
m
FD
A-a
ppro
ved c
ontr
ace
pti
on m
eth
ods
and c
ounse
ling
In
terp
ers
onal and d
om
est
ic v
iole
nce
scr
eenin
g &
co
unse
ling
Sc
reenin
g f
or
gest
ati
onal
dia
bete
s
Bre
ast
feedin
g s
upport
, su
pplies
and c
ounse
ling
C
ounse
ling f
or
sexuall
y tr
ansm
itte
d i
nfe
ctio
ns
H
IV s
creenin
g a
nd c
ounse
ling
H
PV t
est
ing f
or
wom
en a
t le
ast
30 y
ears
old
(D
NA)
Routi
ne
Dig
ital
Rect
al
Exam
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100%
65%
Routi
ne
Pro
state
Speci
fic
Anti
gen (
PSA
) te
sts
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
Routi
ne B
one D
ensi
ty T
est
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
10
80%
PPO
Pla
n90%
PPO
Pla
n85%
ABH
PIn
-Netw
ork
Out-
of-
Netw
ork
In-N
etw
ork
Out-
of-
Netw
ork
In-N
etw
ork
Out-
of-
Netw
ork
Colo
rect
al
Cance
rSc
reenin
g100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
Routi
ne C
olo
nosc
opy
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
Well
-Child C
are
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
Imm
uniz
ati
ons,
HPV
vacc
ine,
Shin
gle
s va
ccin
e100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
Smokin
g C
ess
ati
on
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
Obesi
ty S
creenin
g &
Counse
ling
100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
Routi
ne L
ab P
roce
dure
s100%
60% a
fter
deduct
ible
100%
70% a
fter
deduct
ible
100% 6
5%
Em
erg
ency S
erv
ices
Hosp
ital em
erg
ency
room
(appli
es
to f
aci
lity
charg
es
only
) th
e c
opay
is w
aiv
ed i
fadm
itte
d
80% a
fter
$100
copay
80%
aft
er
$100
copay
90% a
fter
$100
copay
90% a
fter
$100
copay
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Am
bula
nce
80% a
fter
deduct
ible
80% a
fter
deduct
ible
90% a
fter
deduct
ible
90% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Outp
ati
ent
Serv
ices
(serv
ices
pro
vid
ed
oth
er
than
ina
physi
cia
n’s
off
ice)
Outp
ati
ent
surg
ery
faci
lity
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Phys
icia
n/su
rgeon a
nd
rela
ted p
rofe
ssio
nal fe
es
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Lab a
nd X
-ray
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Radia
tion
thera
py/
chem
oth
era
py
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Inpati
ent
Hosp
ital
Serv
ices
Room
and b
oard
, fa
cility
serv
ices
and s
upplies
(incl
udes
menta
l healt
h/su
bst
ance
abuse
)
80% a
fter
deduct
ible
$100 c
opay
per
adm
issi
on a
pplies
60% a
fter
deduct
ible
$100 c
opay
per
adm
issi
on a
pplies
90% a
fter
deduct
ible
$100 c
opay
per
adm
issi
on a
pplies
70% a
fter
deduct
ible
$100 c
opay p
er
adm
issi
on a
pplies
85% a
fter
deduct
ible
65% a
fter
deduct
ible
11
80%
PPO
Pla
n90%
PPO
Pla
n85%
ABH
PIn
-Netw
ork
Out-
of-
Netw
ork
In-N
etw
ork
Out-
of-
Netw
ork
In-N
etw
ork
Out-
of-
Netw
ork
Phys
icia
n h
osp
ital
visi
ts,
surg
ery
and r
ela
ted
pro
fess
ional fe
es
(incl
udes
mate
rnit
y &
new
born
care
)
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Lab,
X-r
ay
and a
nest
hesi
a80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Outp
ati
ent
Care
Skille
d n
urs
ing f
aci
lity
(120 d
ays
per
pla
n y
ear)
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Hom
e h
ealt
h c
are
(120 v
isit
s per
pla
n y
ear)
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Hosp
ice c
are
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Pri
vate
duty
nurs
e(1
20 v
isit
s per
pla
n y
ear)
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Menta
lhealt
h/su
bst
ance
abuse
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Oth
er
Covere
dServ
ices
Chir
opra
ctic
care
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Heari
ng
Aid
Exam
,Fit
ting,
and D
evi
ce
$5,0
00 m
axim
um
per
pers
on
eve
ry36
month
s
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Ort
hoti
cs,
dura
ble
medic
al
equip
ment;
consu
mable
m
edic
al
supplies
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Pro
stheti
cappliances
&w
igs
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Infe
rtilit
y tr
eatm
ent
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Steri
liza
tion
(tubal
ligati
on
or
vase
ctom
y)80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
Phys
ical,
occ
upati
onal
&sp
eech t
hera
py)
90 v
isit
s per
thera
py p
er
year
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85% a
fter
deduct
ible
65% a
fter
deduct
ible
Card
iac
Rehabilit
ati
on
80% a
fter
deduct
ible
60% a
fter
deduct
ible
90% a
fter
deduct
ible
70% a
fter
deduct
ible
85%
aft
er
deduct
ible
65%
aft
er
deduct
ible
12
Prescription Drug Chart
80% & 90% PPO Plans 85% ABHP
Copay/Co-insurance
Retail(30 day supply)
Mail Service(90 day supply)
Retail or Mail Order
Generic $8 copay $20 copay 15% after deductible
Brand nameFormulary
20%maximum of $40 per Rx
15%maximum of $100 per Rx
15% after deductible
Brand nameNon-Formulary
30%maximum of $60 per Rx
25%maximum of $150 per Rx
15% after deductible
Out-Of-Pocket Maximum
$1,500/Person and $3,000/FamilyOPM separate from Medical
$2,500/Employee Only$7,500/All Other Tiers
OPM includes Medical
Out of Network benefits are paid at the same level as In Network Benefits.
Additional Prescription Drug Provisions
Prior AuthorizationUnder this part of the program, your physician will be required to obtain authorization through BlueCross and Blue Shield of Illinois in order for you to receive benefits for certain medications and drugcategories. A complete list of these drugs can be found on the BCBS website. Please allow up to 10business days for approval provided all information is complete and is received timely.
Prior AuthorizationCategory
Prescription Drugs within the Category
Acne Antibiotics Adoxa, Aldodox, Avidoxy, Avidoxy DK, Doryx (and generic equivalents),Doxycycline, Monodox, Nicazeldoxy, Oracea, Oraxyl, Vibramycin, Dynacin, Minocin, Minocin Kit, Solodyn (and generic equivalents), Morigidox Kit, Nutridox Kit, Ocudox Kit
Acne Topical Atralin, Avita, Retin-A, Retin-A Micro, Tretin-X, Tazorac, Ziana, Differin,Adapalene
Androgens/Anabolic Steroids Anadrol-50, Androderm, Androgel, Android, Androxy, danazol, First-Testosterone, Depo-Testosterone, Delatestryl, Methitest, Oxandrin, Striant, Testim, Testred, Fortesta, Axiron, Aveed, Vogelxo
Antifungal Agents Noxafil, VfendAttention DeficitHyperactivity Disorder (adults)
Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Dexedrine, Dextrostat,Focalin, Focalin XR, Intuniv, Liquadd, Methylin, Metadate CD, Metadate ER, Ritalin, Ritalin LA, Ritalin SR, Strattera, Vyvanse
Growth Hormones Egrifta, Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ,Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive
Hepatitis B & C Infergen, Pegasys, PegIntron, Incivek, Victrelis, Olysio, SovaldiNarcolepsy Nuvigil, ProvigilOral Fentanyl Actiq, Fentora, Onsolis, Abstral, Subsys, LazandaOncology Afinitor, Afinitor Disperz, Bosulif, Caprelsa, Cometriq, Erivedge, Gleevec,
Hexalen, Hycamtin, Gilotrif, Iclusig, Imbruvica, Inlyta, Jakafi, Lysodren, Mekinist, Matulane, Nexavar, Oforta, Pomalyst, Revlimid, Sprycel, Stivarga, Sutent, Sylatron, Tafinlar, Tarceva, Targretin, Tasigna, Temodar, Thalomid, Tretinoin, Tykerb, Votrient, Xalkori, Xeloda, Xtandi, Zelboraf, Zolinza, Zytiga
Pain Management Suboxone, Subutex, ZubsolvSpecial Kuvan, Arcalyst, Ampyra, Forteo, Aranesp, Epogen, Procrit, Juxtapid,
Kynamro, Gattex, Purpura, Adcirca, Revatio, Letairis, Tracleer, Kalydeco, H.P. Acthar Gel, Xenazine, Promacta, Signifor, Ravicti, Buphenyl, Opsumit, Xyrem
13
Step TherapyThe Step Therapy program is designed to encourage the initial use of alternative medications generally recognized as safe and effective which are also lower in cost. Under this program, in order to receive coverage the member may need to first try a proven, cost-effective medication before progressing to a more costly treatment, if necessary. After the member has a prescription history for a lower-cost medication, coverage will automatically be provided for a more costly medication included in the program. See the BCBS website for additional information.
Step Therapy Category Prescription Drugs within the CategoryAntidepressants Aplenzin, Celexa, Cymbalta, Effexor, Effexor XR, Forfivo XL, Fluoxetine 60 mg
tabs, Lexapro, Luvox CR, maprotiline, Oleptro, Paxil, Paxil CR, Pexeva,Pristiq, Prozac, Prozac Weekly, Remeron, Remeron SolTab, venlafaxine ER tabs, Viibryd, Viibryd Starter Kit, Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zoloft, Brintellix, Desvenlafaxine fumarate, Fetzima, Desvenlafaxine ER
Cholesterol (LipidManagement)
Advicor, Altoprev, Lescol, Lescol XL, Lipitor, Liptruzet, Livalo, Mevacor,Pravachol, Simcor, Vytorin, Zocor
Diabetes (GLP-1 ReceptorAgonsits)
Bydureon, Byetta, Victoza, Tanzeum
Gastroesophageal RefluxDisease (Proton Pump Inhibitors – PPI)
Aciphex, Dexilant, First-lansoprazole Suspension Kit, First-OmeprazoleSuspension Kit, Nexium, omeprazole/sodium bicarbonate, Prevacid, Prilosec, Protonix, Zegerid, Esomeprazole Strontium
Glucose Test Strips All non-formulary brand test strips and disks (formulary brands are Bayer andRoche brands)
Pain Management Celebrex, Duexis, VimovoInfertility Gonal F, Gonal F RFFIron Chelator FerriproxMultiple Sclerosis Aubagio, Avonex, Extavia, GilenyaRheumatoidArthritis/Psoriasis
Cimzia, Enbrel, Humira, Kineret, Orencia subcutaneous, Simponi, Xeljanz,Otezla, Actemra subcutaneous, Entyvio, Stelara
Specialty MedicationsSpecialty medications include those used in the treatment of complex medical conditions, such as hepatitis, hemophilia, multiple sclerosis, rheumatoid arthritis and other conditions requiring self-administered specialty medications. (See the BCBS website for a complete listing of specialty medications.) Through Prime Therapeutics, you can have your covered specialty medication delivered directly to you, if it is a self-administered drug, or to your doctor’s office. Since many specialty medications have unique shipping or handling requirements, all shipments are arranged with you through Prime Therapeutics. Medications are shipped in plain, secure, tamper-resistant packaging. To place an order, have your doctor call (877) 627-MEDS (6337) or fax your prescription to (877) 828-3939.
14
Dental Plan Chart
The chart below reflects the treatments and services covered under the Dental Plan.
General Information Humana Dental DPO Plan
Deductible In-Network Out-Of-Network
Individual $25 $25
Individual + One $50 $50
Family $75 $75
Plan Year Maximum $1,500 per person $1,500 per person
Lifetime Maximum Unlimited Unlimited
Orthodontia Maximum(Lifetime)
$1,750 per person $1,750 per person
The following services will be covered in and out of network for the category indicated:Diagnostic and Preventative 100%, no deductible
Covered Services Include: Oral Exams2 times in one calendar year
Sealants1 per tooth per lifetime
Full Mouth X-rays or Panorex X-ray1 time within 36 months
Space Maintainer
Bitewing X-ray2 times in one calendar year
Palliative (emergency) Treatment
Prophylaxis/Cleaning2 times in one calendar year
Oral Cancer ScreeningOver the age of 40
Fluoride1 time in one calendar year (no age limit)
Pulp vitality testing andbacteriological studies for determination of bacteriologic agents
Basic Restoration 85% after deductible
Covered Services Include: Fillings
(includes composite fillings onanterior and bicuspids)
Apexification/recalcification
Periodontal surgeryOnce per quadrant every 3 years; based on the date services areperformed
Tissue Conditioning
Periodontal Scaling/Root Planning1 time per quadrant within 3 years; based on the date services are performed
Occlusal Adjustments1 time per quadrant every 3 years; based on the date services are performed
Periodontal Maintenance2 times per year
Full mouth debridementOnly once per lifetime
Pulp CappingExcludes final restoration
Therapeutic pulpotomyExcludes final restoration
Fixed and removable appliancesfor correction of harmful habits
Re-cementation of inlays/onlays,veneers, crowns and bridges
Appliances for treating bruxism(grinding teeth), occlusal guards and night guardsReline and repair not covered
Application of desensitizingmedications where periodontal treatment has been performed
15
Basic Restoration (cont.) 85% after deductible
Oral surgery Local chemotherapeutic agents(Site Therapy)
Administration of generalanesthesia when medically necessary, in conjunction with covered oral surgical procedures
Drug injections done in conjunctionwith oral surgery
Stainless steel crowns Injections of therapeutic drugs,except oral surgery
Consultations Endodontics (root canals)
Extractions
Major Restoration 50% after deductible
Covered Services Include: Non-surgical treatment of TMJdisorders
Labial veneersno more than once per tooth in aperiod of 60 months
Core Buildup Repair of Implants
Cone beam imaging Diagnostic casts
Prosthodontic Posts and cores
Inlays and onlays1 time per 5 years
Crowns1 time per 5 years
Implant servicesincludes sinus augmentation and bone replacement and graft for ridgepreservation
Crown repair
Removable or fixed bridgework Bridge1 time per 5 years
Complete Denture1 time per 5 years
Partial denture1 time per 5 years
Relinings and rebasings of existingremovable dentures
Partial or complete denturerepairs/adjustments
Addition of teeth to a partialremovable denture
Orthodontia (no deductible)
16
Vision Plan ChartThe charts below reflect the treatments and services covered under the Vision Plan.
In-Network Providers Out-of-Network Providers
Service orMaterials
Copay Plan PaysService or Materials
CopayMaximumAmount Reimbursed
Eye Exam $10100% after
copayEye Exam $10
$45 aftercopay
Contact LensExam*
Up to$60
100% aftercopay
Contact LensExam*
Up to$60
$45 aftercopay
Elective ContactLenses
$0100% up to
$130Elective ContactLenses
$0 $105
Necessary ContactLenses
$25100% after
copayNecessary ContactLenses
$25$210 after
copayLenses – SingleVision
$25100% after
copayLenses - SingleVision
$25$30 after
copayLenses - LinedBifocal
$25100% after
copayLenses - LinedBifocal
$25$50 after
copayLenses - LinedTrifocal
$25100% after
copayLenses - LinedTrifocal
$25$65 after
copay
Lenses - Lenticular $25100% after
copayLenses - Lenticular $25
$100 aftercopay
Frames $25100% aftercopay, up to $130
Frames $25$70 after
copay
Low VisionSupplemental Testing
$0 100%Low VisionSupplemental Testing
$0 $125
Low VisionSupplemental Aids
$0 75%Low VisionSupplemental Aids
$0 75%
Diabetic Eye Exam $20100% after
copayDiabetic Eye Exam $20
$100 aftercopay
SpecialOphthalmological Services(Diabetic Eye Care)
$0 100%
SpecialOphthalmological Services(Diabetic Eye Care)
$0$120 per individual
service
*Copay based on network provider’s fee schedule.
17
Wellness Program
Healthy employees are an important elementof a strong organization. The Balanced LivingWellness Program is aimed at increasing employees’ awareness of their own personal health risks with the belief that annual testing and early detection will help greatly to mitigate future illness.
Who is EligibleIf you are enrolled in one of the INEOS Healthplans you are eligible. (Union employees areeligible to participate based on their Collective Bargaining Agreement.) You can be an active employee, on a Leave of Absence, or on Short-Term Disability. As long as you participate in an INEOS Health Plan, you are an eligible participant. Other dependents such as children and ex-spouses cannot participate.
How the Program WorksIf you choose to participate in the Program,you will receive a discount on your monthly medical premium if you accumulate 9,500 points during the Wellness Plan Year. If you cover a spouse or domestic partner under the medical program, they must also participate in order for you to receive the medical premium discount. This is an annual program that involves the completion of certain requirements every year. The Wellness Planyear runs from October 1st through September 30th of each year. The discount will be applied to the following calendar year. If you choose not to participate, you will pay a surcharge on your monthly premiums.
Participation is easy. All you need to do is complete the following:
Core Activities Have a routine annual physical or medical
visit (3,000 points) Have a blood screen to test cholesterol
and blood glucose levels (3,000 Points) Take the online health risk assessment
(3,000 points)
By completing the Core Activities you will accumulate a total of 9,000 points.
To achieve your 9,500 point goal, you can choose from Bonus Activities to accumulate additional points.
Bonus Activities Health Coaching – Talk with a Health
Coach and earn up to 100 points per call. The maximum number of points allowed for this activity is 500 or 5 calls.
Benefits Value Advisor – Talk with anAdvisor and earn up to 100 points per call. The maximum number of points allowed for this activity is 500 or 5 calls.
Keas Wellness Portal - Earn 500 points bycompleting activities of your choice on the Keas website at:https://play.keas.com/ineos.
Completing Program Requirements
Routine Annual Physical/Medical VisitThe wellness program will not define exactlywhat your doctor should check for your routine physical or during a medical visit. That is between you and your doctor. The aim is to have you visit a doctor once a year to have your health reviewed and items such as your blood pressure and heart rate checked. If you have completed the annual physical and appropriate lab work due to requirements from your job, you will not be required to do it again.
Blood ScreeningThe program requires that you have yourcholesterol (lipid panel) and blood sugars (blood glucose) checked annually. Your doctor may, however, request other lab tests based on your personal health.
Health Risk Assessment (HRA)An online HRA is used to provide a picture of your current health and quality of life, plus potential future health risks. The HRA asks questions to understand your individual lifestyle practices and behaviors related to health and wellness. It will also incorporate your blood screening values to produce a more accurate report of your current health status.
18
New Entrants to the Program
New and Rehired EmployeesAll newly hired and rehired employees will automatically receive the premium discount upon their initial enrollment with INEOS. Depending upon your hire date (or rehire date) the program requirements for future discounts will differ.
Employees Hired between January 1 and August 1
Assuming you enroll in an INEOS Health Plan upon hire, to receive the premium discount for the following year, you must complete the 3 core requirements (annual physical, blood work and HRA) bySeptember 30th. For subsequent years,the requirements are the same as all other employees.
Employees Hired On or After August 1 through December 31Since it may not be possible to complete the core and additional requirements before the wellness window closes on September 30th,you will not be required to do any wellness activities for the remainder of the year in which you were newly hired. For subsequent years, the requirements are the same as all other employees.
Life Events between January 1 and August 1 If you experience a Life Event before August1st and wish to enroll for the first time or add a spouse to coverage, you must complete the 3 core requirements (annual physical, bloodwork and HRA) by September 30th. Forsubsequent years, the requirements are the same as all other employees.
Life Events On or After August 1 through December 31If you experience a Life Event after August 1st
and wish to enroll for the first time or add a spouse to coverage, it may not be possible to complete the core and additional requirements before the wellness window closes on September 30. Thus, you will not be required to do any wellness activities for this year. For subsequent years, the
requirements are the same as all other employees.
Open EnrollmentIf you are an active employee that is not enrolled in an INEOS medical plan and wish to do so at open enrollment, you will automatically receive the premium discount upon enrollment. In future years, you will be required to complete the same criteria (core requirements and bonus activities) as all other employees.
How Your Medical Premiums Are Calculated
Active Employees (Currently Enrolled in Medical)When developing the annual medical rates, the Company will determine an 80%/20% cost sharing for the employer and employee medical plan premiums. If you complete the program’s requirements, the medical rate discount will then be applied to medical premiums, as follows:
The Employee Only and Employee +Children tiers will be reduced by $120 a year.
The Employee + Spouse and Employee +Family tiers will be reduced by $240 per year.
Conversely, if you choose not to participate a surcharge will apply. Medical rates will be increased above the 20% employee premium, as follows:
The Employee Only and Employee +Children tiers will be increased by $360 a year.
The Employee + Spouse and Employee +Family tiers will be increased by $720 per year.
The rate discount and surcharge will be evaluated each year and will be based on current participation levels of the program.
Please refer to the Employee Benefits Handbook for details regarding the Program.
19
Spending & Savings Accounts
The INEOS Flexible Benefits Plan is a smartand convenient way for you to stretch your paycheck and receive real tax savings. It affords you the opportunity to pay certain out-of-pocket medical, dental, vision and dependent care expenses with pre-tax money. The Plan allows you to reduce your salary via payroll deduction and use that amount to:
make contributions to a Health CareFlexible Spending Account (FSA);
make contributions to a Dependent CareFlexible Spending Account (FSA); and/or
make contributions to a Health SavingsAccount (HSA).
In other words, pay your eligible expenses with tax-free money!
If you are enrolled in the 80% and 90% PPOPlans, you are eligible to participate in the Health Care FSA. If you are enrolled in the85% ABHP, you are eligible to participate in the HSA and Limited Purpose FSA. A Health Savings Account works similarly to but is very different from a Health Care FSA. Detailed information can be found in the Employee Benefits Handbook under the Spending & Savings Account section. You can also contact CONEXIS, our FSA and HSA Administrator, if you have questions. CONEXIS Customer Service Representatives can be reached at (866) 279-8385. Additional information can also be found on the CONEXIS website athttps://Mybenefits.conexis.com.
Eligible ExpensesYou decide how to use your money and whento draw against your account. Examples ofqualifying expenses for the FSA and HSA accounts can be found in the Employee Benefits Handbook under the Spending & Savings Account section. You can also find a complete list of eligible expenses on the CONEXIS and/or IRS websites.
Contribution LimitsThe government sets limits on the amount ofmoney you can set aside to use for your FSA and/or HSA accounts. For 2015, the following limits apply:
Dependent Care FSA – maximum of $5,000 Health Care FSA – maximum of $2,500 Limited FSA – maximum of $2,500 Health Savings Account – maximum of
$3,350 for Employee Only coverage; maximum of $6,650 for all other coverage tiers. If you are age 55 or older you can contribute an additional $1,000.
Debit CardsWhen you have eligible expenses, you can payfor them with your benefit card. This cardoperates just like any credit transaction at merchants that accept Visa and can be used for Health Care expenses (the benefit card cannot be used for Dependent Care Spending Accounts). The money is taken directly out of your Flexible Spending Account (FSA) or Health Savings Account (HSA), thereby avoiding any cash flow issues. The CONEXIS Benefit Card is provided to participants free of charge. If you wish to have a card issued for your spouse, you may request an additional card by calling CONEXIS. Be sure to keep your receipts so you can substantiate the expense if needed.
If a provider or store does not accept payment by Visa or, if you don’t have your card with you at the time, you can pay for an eligible expense out of your own pocket and submit a paper claim for reimbursement.
Run out PeriodYou will have until March 31st to submit alleligible expenses for the plan year just completed. If you do not use the amounts in your Dependent Care FSA account by the end of the year, you will forfeit the balance. For Health Care FSA accounts, you can roll over up to $500 into the next year. HSAs allow all balances to rollover. There is no “use-it-or-lose-it” rule.
Analyze Your Costs CarefullyWhether it’s the Health Care Account,Dependent Care Account or Health SavingsAccount, you should carefully plan how much you will save each year. Expense worksheets can be found in the Employees BenefitsHandbook.
20
Life & Security
Basic Life Insurance PlanThe Company provides you with life insurancein the amount of 1 ½ times your base compensation up to a maximum of $1 million. Coverage is automatic and is fully paid by the Company. Upon attainment of age 65 your benefit may decrease.
If your Basic Life insurance amount is over $50,000, you will have to pay “imputed income”, which is income tax on the cost of the coverage for any amount over $50,000. The amount of tax is based on IRS tax tables and will be reported on your W-2 form each year.
To elect your beneficiaries for life insurance, you will need to access your account at CIGNA.
Group Universal Life Insurance Plan (GUL)In addition to your Company provided Basic Life Insurance, you have the opportunity to elect additional life insurance coverage foryourself, your spouse and your eligible children (up to age 25).
Coverage is available in amounts of 1 to 8 times your base annual salary, rounded to the next higher $10,000, if not already an even multiple. You may also apply for coverage to protect your spouse and children. For spousal coverage, you may apply for benefits in$10,000 increments up to a maximum of $250,000. You may also purchase coverage for your dependent child(ren) who are older than 14 days old up to age 25. For just one premium, you can insure all of your dependent children with a $25,000 policy.
Guarantee Issue Amounts for New HiresAs a new hire, you can receive 1 times yourbase annual salary in coverage up to the maximum of $300,000 (whichever is less) without completing any additional Evidence of Insurability (EOI) paperwork. Any amounts selected greater than $300,000 will require EOI and must be approved by CIGNA prior to coverage beginning.
For spousal coverage, EOI will not be required for amounts up to $30,000. Any applications for amounts from $30,000 up to $250,000 (plan maximum), will require EOI and must be approved by CIGNA prior to coverage commencing.
The GUL Program provides life insurance coverage at group rates and gives you the chance to build cash value through the program’s Cash Accumulation Fund. These options give you flexibility as you plan for your family’s future financial needs.
Personal Accident Insurance (PAI) PlanThe Company provides you with PersonalAccident Insurance equal to 1 ½ times your annual base pay, up to a maximum of $1 million in coverage. The plan pays a benefit if you die or are dismembered as the result of an accident. In the event of death, this benefit is payable in addition to any life insurance benefit. Enrollment in this coverage is automatic.
Voluntary Personal Accident Insurance (VPAI) PlanVPAI insurance coverage is available for youand your family at group rates. You canobtain coverage up to 6 times your annual base pay to a maximum of $1 million, if you suffer a loss due to an accident. You must be enrolled in the Plan in order to purchase coverage for your dependents. The maximum benefit for a spouse is $250,000; for children, the maximum benefit amount is $10,000.
You do not need to provide Evidence of Insurability to obtain this coverage. This coverage also applies while traveling for business or pleasure.
Long Term Disability Plan (LTD)The Company provides you with Long Term Disability insurance equal in the amount of60% of your monthly eligible compensation, if you are disabled beyond 26 weeks (6 months). The minimum LTD benefit is $100 per month. The maximum is $20,000 per month minus any offsetting benefits. Eligible earnings are defined as your annual base compensation, excluding over time, commissions and bonus.
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Buy-Up OptionThis plan offers you the opportunity to buy additional coverage up to 65% of your monthly eligible compensation. The cost of additional coverage is based on your age and eligible earnings per $100 of coverage. As you age and earnings change, your costs will be adjusted automatically.
For information on how to file a LTD claim, please reference the Employee Benefit Handbook.
How to Enroll, Make Changes to Voluntary Benefits and Elect BeneficiariesTo apply for, make changes to voluntary coverage (GUL, VPAI and LTD Buy-Up), and to elect beneficiaries for all of your life insurance policies, you may do so by calling CIGNA at (800) 828-3485 or via their websiteat: www.cignatrustedadvisor.com/ineos
To access your account through CIGNATrusted Advisor for the first time, click on the “My Account” link in the upper right hand corner, then click on “Register”, next read the terms and conditions and click “I Agree”.
To complete the registration process, enter your last 6 digits of your SSN and your date of birth. Once this information is confirmed, you will then be asked to create a username and password. If you have any technical difficulties or have any questions throughout the enrollment process, please contact CIGNA directly.
Employee Assistance Program
All employees have access to the Companyprovided Employee Assistance Plan (EAP) through CIGNA Behavioral Health. CIGNA’s EAP provides access to in-person behavioral health assistance, telephonic counseling and online tools.
The program offers covered employees and their families:
Access to telephonic counseling 24 hours aday, seven days a week and up to 3, free in-person sessions from CIGNA’s Masters and Ph.D.-level licensed behavioral health clinicians
Life event referrals and research Health Rewards discount program Personal Stress Navigator
To discover the full array of benefits that the Program has to offer, visit their website atwww.cignabehavioral.com or you can callCIGNA’s Customer Service Representatives(888) 371-1125. Our Employer ID is “ineos”.
There is no need to make an election for thiscoverage. The Company will automaticallyenroll you.
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Retirement Savings Plan
The INEOS Retirement Savings Plan is a 401(k)plan that lets you save up to 75% of your eligible pay towards retirement. You can elect to contribute on a before-tax, Roth or after-tax basis, or a combination, up to legal limits. Effective 1/1/2013, the Company matches pre-tax, catch-up and Roth contributions $1 for $1 up to 6%. All employees are eligible to receive a 3% company base contribution regardless of participation. Some employees may also be eligible for other company contributions called transition credits. Please see the Employee Benefits Handbook for details. The above mentioned provisions may not apply to all union employees.
All contributions and investment gains or losses are credited to your plan account. You choose how your savings are invested from a wide variety of investment options. You – not the Company – assume all the investment risk. That means your account will benefit from any investment gains and experience any investments losses as well. You have a variety of different investment options from which to choose, including a Self-Directed Brokerage account.
You have access to your account through the Plan’s loan provisions, and, under certain conditions, may withdraw a portion of your account while still working with the Company.
The Plan is intended to be a “qualified retirement plan” under Section 401(a) of the Internal Revenue Code and to meet the requirements of Code Section 401(k).
The Plan is administered by T. Rowe Price. Additional information can be obtained by calling T. Rowe Price at (800) 922-9945 or via their website at www.rps.troweprice.com.
Please refer to the Employee BenefitsHandbook at www.ineosbenefits.com foreligibility requirements and other plan details.
Pension Plans
As an active employee hired prior to1/1/2008, you may be eligible for benefits under a pension plan sponsored by INEOS. If you are eligible for a benefit, you will receive an annual pension statement along with other information each year. For further information regarding the pension plans, you should refer to the Employee Benefits Handbook.
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Retiree Benefits
As an active employee hired prior to1/1/2008, you may be eligible for retiree medical and/or dental benefits under the INEOS Retiree Welfare Plan.
Retiree Medical EligibilityThe plan’s eligibility requirements are age 55with 10 years of service at the time you leave the Company. Employees hired 1/1/2008 and thereafter will not be eligible for Retiree benefits.
If you were an INEOS USA employee at or beyond age 50 with 10 years of service upon the transition from BP on December 16, 2005, you will be eligible for retiree medical coverage from BP and not the INEOS Plan. Please contact the BP Benefits Center for more information.
To be eligible for Subsidized Medicare-Eligible coverage, that is coverage for the remainder of your life, you must be at least age 50 with 10 years of service on January 1, 2013. Once you enroll in Medicare, your INEOS retiree rate will be reduced to 1/3 of the pre-Medicare or pre-65 cost.
Retiree Dental EligibilityThe Plan’s eligibility requirements are age 55with 10 years of service at the time you retire. If you worked at one of the following INEOS Heritage Companies prior to 1/1/2008, you will be eligible for retiree dental:
ABS Melamines Phenol Oxide Styrolution – except Texas City
Employees hired 1/1/2008 and thereafter will not be eligible for Retiree Dental benefits. Also, employees from an INEOS USA heritage company are not eligible for this benefit.
Calculating Your Retiree MultiplierWhen you retire and enroll in the RetireeMedical Plan your monthly premium will be based upon your age at the time of
retirement. If you retire before age 62, youwill pay a higher premium or a multiple of the rate. INEOS subsidizes coverage for retirees and their spouses. Coverage for children and families are an option; however the retiree will pay the full cost of insurance for children.
The table below reflects the multipliers in effect for each age:
Age Multiplier62+ 1.061 1.260 1.459 1.658 1.857 2.056 2.255 2.4
For more information regarding the retiree rates, company cost share and company maximum contributions please reference the Retiree Benefits Guide found on the INEOS Benefits website.
How to Enroll for Retiree BenefitsAt the time of your retirement, you willreceive a retirement package from the Plan Administrator with your enrollment options and retiree medical and/or dental costs. This package will contain an enrollment form for you to complete and return to the Benefits Department. You will have 30 days within which to enroll. If you do not you’re your election in a timely manner, you will forfeit the ability to enroll in the future.
Paying For Your Retiree BenefitsOnce the Benefits Department has receivedyour enrollment form, you will begin receiving bills directly from CONEXIS, the Company’s Benefits Billing provider. You will receive monthly invoices and will be required to send your payment directly to CONEXIS for processing. You may view your accountonline via https://Mybenefits.conexis.com.You can also set up an ACH from your bank to CONEXIS to make your monthly payments. If you have questions regarding your bill or this process, contact CONEXIS at (877) 722-2667.
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Financial Planning Services
To help you with your retirement planning,INEOS provides access to two powerful financial planning resources – the EY Financial Planner Line® and the Ernst & Young Financial Planning Center. These resources are designed to help you make the best use of your benefit plans and plan for your financial future. Best of all, the services are free to you.
How The Program WorksYou get unlimited, toll-free telephone accessto experienced and credentialed financial planners who are educated in INEOS benefit plan offerings. When you call the EY Financial Planner Line®, you will be connected with a planner who offers confidential, objective and personalized financial planning guidance in a wide range of areas. Financial Planners are available at (866) 544-6299 from 8 am – 7 pm CST, Monday-Friday, except holidays.
You can also request personalized printed financial reports. Prepared by Ernst & Young financial planners, personalized reports are available to help you plan in specific areas of personal finance.
Useful resources can be accessed on the web. On the Ernst & Young Financial Planning Center website, you’ll find a wealth of informative articles, tips, financial calculators and videos.
For a personalized experience, employees can call E&Y at (866) 544-6299, or go tohttp://INEOS.eyfpc.com to register for thewebsite using Company Code: INEOS and set up an individual login id using your work email, date of birth and home zip code.
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Travel Guide
Questions regarding your benefit plans mayarise when traveling outside of the country, either for personal travel or business. Where do I go for treatment in the case of an emergency? How are my claims processed? Do I have to pay for services out of pocket? This section of the guide will help answer these questions.
Medical – Blue Cross Blue Shield (BCBS)While traveling out of the country, you haveaccess to the BCBS World Wide network of physicians and hospitals. Providers and hospitals that participate in this network can be found by accessing the BCBS website(www.bcbsil.com) and clicking on the “Find adoctor” link.
If you do not have access to a computer while traveling, you can call the Customer Service number on the back of your BCBS insurance card to help locate an in-network provider.
Dental – HumanaDentalHumana does not have an Internationalnetwork of providers. Typically payment willbe requested at the time services are rendered from the provider. For claims processing, submit a claim form to Humana with an itemized receipt for reimbursement. It is preferred to have the receipt in English and in US currency; however, if it is not, Humana will translate it for payment.
Vision - VSPWhile traveling outside of the United States,vision services will need to be paid out of pocket at the point of sale. VSP does not have an International network of providers. VSP will reimburse you based on the out of network benefit levels provided that a reimbursement form is completed with an itemized statement.
FSA & HSA – CONEXISThe CONEXIS Flexible Spending AccountBenefit Card cannot be used at the point of sale when traveling outside of the country. If you incur eligible expenses while traveling, a
claim form must be submitted to CONEXIS with a receipt for reimbursement.
CIGNA Secure TravelAn emergency can be much more difficult todeal with when you are traveling. In theevent that an unfortunate situation arises –injury, illness, death, theft, natural disaster, disease outbreak or terrorism – knowing that CIGNA Secure Travel is available to you can provide added peace of mind in unfamiliar surroundings. You can be on the other side of the world or only a couple of hours away from home and still get the help you need.
Available to employees, CIGNA Secure Travel provides emergency medical and travel services, as well as helpful pre-trip planning assistance, when travelling 100 miles or more away from home on company business or vacation. Toll-free customer service representatives are available 24 hours a day, 365 days a year. In an emergency, the Customer Service Center can even accept collect calls.
Health Care CoverageImagine that you require medical care while traveling on company business or you are onvacation in another country—a country where care may not be comparable to western medical standards. CIGNA Secure Travel can arrange and cover the cost of transportation to the nearest appropriate hospital or medical facility. This program will also provide up-front payment, often required when abroad, for medical services – saving you from having to pay expenses out-of-pocket at that time. And, in the event of a fatality, CIGNA will arrange and covert the cost of transporting remains back to the country of origin. CIGNA Secure Travel places no coverage limit on either of these services.
You may contact the Customer Service Representatives at CIGNA Secure Travel by calling (888) 226-4567 from the U.S. and Canada. From other locations call collect at (202) 331-7635. Or to reach them by fax, dial (202) 331-1528.
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2015 Benefit Monthly Rates
With Wellness DiscountEmployee
OnlyEmployee +
SpouseEmployee +
ChildrenEmployee +
Family80% PPO Plan $77.67 $139.34 $155.62 $226.5690% PPO Plan $126.67 $222.76 $241.86 $357.8785% ABHP $3.35 $8.73 $24.46 $88.32
With Wellness SurchargeEmployee
OnlyEmployee +
SpouseEmployee +
ChildrenEmployee +
Family80% PPO Plan $117.67 $219.34 $195.62 $306.5690% PPO Plan $166.67 $302.76 $281.86 $437.8785% ABHP $43.34 $88.73 $64.46 $168.33
EmployeeOnly
Employee +Spouse
Employee +Children
Employee +Family
Dental $10.18 $20.21 $20.30 $31.09Vision $8.67 $12.97 $13.88 $22.17
Group Universal Life(per $1,000 of Monthly Eligible Earnings)
Long-Term Disability Buy-Up Option
(per $100 of Monthly Eligible Earnings)
Age Bracket Smoker Non-Smoker Age Bracket 65% Buy-Up<25 $0.046 $0.039 18-39 $0.084
25 - 29 $0.053 $0.045 40-44 $0.12630 – 34 $0.058 $0.049 45-49 $0.18535 – 39 $0.063 $0.054 50-54 $0.21040 – 44 $0.100 $0.088 55-59 $0.16545 – 49 $0.150 $0.136 60-64 $0.12650 – 54 $0.230 $0.212 65-69 $0.08855 – 59 $0.430 $0.365 70+ $0.08860 – 64 $0.660 $0.59065 - 69 $1.152 $0.943
Voluntary Personal Accident Insurance(per $1,000 of coverage)
Coverage Level PremiumSingle $0.020Family $0.034
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2015 Domestic Partner Benefit Monthly Rates
With Wellness DiscountEmployee +
Domestic Partner
Employee +Dom.Part’sChildren
Employee +Dom.Part +
Family80% PPO Plan $61.66 $77.94 $148.8990% PPO Plan $96.09 $115.19 $231.2085% ABHP $5.38 $21.11 $84.98
With Wellness SurchargeEmployee +
Domestic Partner
Employee +Dom.Part’sChildren
Employee +Dom.Part +
Family80% PPO Plan $101.66 $77.94 $188.8990% PPO Plan $136.09 $115.19 $271.2085% ABHP $45.39 $21.12 $124.99
Employee +Domestic Partner
Employee +Dom.Part’sChildren
Employee +Dom.Part +
FamilyDental DPO $10.03 $10.13 $20.91Vision $4.30 $5.21 $13.50
Imputed IncomeWith Wellness Discount
Employee +Domestic Partner
Employee +Dom.Part’sChildren
Employee +Dom.Part +
Family80% PPO Plan $296.65 $311.77 $645.5590% PPO Plan $434.36 $460.76 $974.8085% ABHP $321.58 $334.49 $639.95
Imputed IncomeWith Wellness Surcharge
Employee +Domestic Partner
Employee +Dom.Part’sChildren
Employee +Dom.Part +
Family80% PPO Plan $256.65 $311.77 $605.5590% PPO Plan $394.36 $460.76 $934.8085% ABHP $281.57 $334.49 $599.94
Dental DPO $27.12 $27.38 $56.55
How are paycheck deductions calculated?The employee’s portion of the premium isdeducted on a pre-tax basis and, the domestic partner coverage is deducted on an after-tax basis.
How is the Imputed Income calculated?The Company paid portion of the cost is taxedin the form of imputed income. To properlytax the benefit, the imputed income amount is added to the paycheck as gross pay under the “Hours & Earnings” section so that taxes can be calculated and withdrawn for that
specific amount. The earnings description onthe paycheck is “Dom Prt Incom”. This sameamount is deducted from the paycheck under the “Deductions” section with the description “Dom Prt Incom”. The earnings and deduction amounts net to zero. The Imputed Income amount is the taxable amount for the benefit--this is not the cost of insurance.
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Ceridian Self-Service User Guide
How to Enroll and Make Changes to Your ElectionsThe Ceridian Self-Service Portal is an internetbased application that can be accessed from anywhere you have an internet connection--not only on the INEOS network. This portal should be used for the following benefits and payroll items:
electing benefits when you are newlyhired
adding or changing dependentinformation
changing benefits when you have aqualifying life event (such as marriage, divorce, birth of a child, etc.)
electing benefits during OpenEnrollment
viewing benefit statements changing your home address viewing or updating emergency
contacts viewing earnings statements viewing past W2 statements
Go to an Internet browser and enter this URL: https://sourceselfservice2.ceridian.com/ineosfluor. The Self-Service Login page willappear.
Login InstructionsEnter your assigned user name and password.(Your user name is your clock number. It is the last 5 digits of the ID number found on your paystub.) If you have never logged in before, your password will initially be the last 4 digits of your SSN. Next, click “Log In” or press the Enter key on the keyboard. Once you log on successfully, you will be asked to create a unique password. Passwords must be between 8-20 characters, contain at least one digit (0-9), contain at least one uppercase and one lowercase alphabetic character, may contain special characters (i.e. !@#%&*) and cannot contain your first or last name or ID.
If you require further assistance or need your password reset, please email the Ceridian Self-Service Administrator at:[email protected]
How to Add or Verify a DependentTo add dependent information, click on the“dependents” link under the Personal Information section on the Home Page. You must first add your dependents on this screen or they will not be available to select during your benefit election process.
To add a new dependent, click “Add”, to delete a dependent, click “delete” and to change a dependent’s information, click on their name. If you delete a dependent, they will not disappear from this view immediately as they may hold historical information on your record.
Please make sure to double check the “Gender” drop down menu as it defaults to “Female”. Also, please include date of birth and SSN of your dependents as this is required information for covering a dependent on your health plans. If you do not have the SSN initially, please come back later and update their record when it is available.
How to Complete Your Medical, Dental, and Vision EnrollmentsOn the Home screen, you should see anenrollment notice which will provide you with a deadline for completing your enrollment. Click on the link, “Please enroll now” to begin the enrollment process.
The first page will ask you to verify your list of dependents and your marital status. Please note that even if you are not including someone in your benefits at this time, they may show here if you have covered them in the past. It is not necessary to delete them again. Once you verify this information is accurate, click “Next”.
If it seems to take a long time to process, do not be alarmed. Please be patient as this page may take a few minutes to load.
The next screen shows a list of your currently enrolled benefit options along with your covered dependents. Next to each section is a blue button titled, “Change” which should be used to show all available benefit plans for enrollment. If you are enrolling at Open Enrollment, you may see a message that
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states you are no longer eligible for this plan along with a red lined box around the plan. This means that a new plan must be selected. Please click on the “Change” button and proceed with choosing a new plan.
You will notice that in each Benefit Plan section, there will be plans listed in two separate background shades. One set ofbenefits is for employees and the other is for Domestic Partners. If you are not enrolling a Domestic Partner, make sure that you do not choose these options. Instructions forenrolling or changing Domestic Partner coverage can be found below.
Once your selection has been made, you will be returned to the main election screen. If you are covering dependents on this plan, you will now see a new button titled, “Cover Dependents”. Please click on the button to advance to the next screen. Next, put a check mark next to your designated dependent(s) and click “Save” to complete your changes. Likewise, if you want to remove a dependent from being covered on a specific plan, de-select the check mark box next to their name.
Each enrollment is unique. If you chooseyour dependents on the medical plan, the system will not automatically know if you want these same dependents on your dental or vision plans.
If you are electing a plan that includes dependents (i.e. employee + spouse) and you do not complete the “Covered Dependents”section, you will get an error message when you try to save your enrollment.
How to Enroll or Change Domestic Partner CoverageAll employees are eligible to enroll Domestic Partners (same or opposite sex). If you are not enrolling a Domestic Partner, you may disregard these instructions.
Electing domestic partner coverage will require you to enroll in TWO benefit plans for each benefit option. For instance, two plans will be needed for medical, two for dental and two for vision. The reason for this set up
is to allow for a pre-tax deduction for the employee’s portion of the plan. The second plan designates the after-tax deduction for the domestic partner coverage.
The first plan will be titled as any other plan available; however, the tier or “coverage”will be specific to the domestic partner option. The second plan will have “Domestic Partner” attached to the end of the description for the plan. Therefore, you will have two plans that look like the below:
Plan #1: 80% PPO PlanPlan #2: 80% PPO Plan – Domestic Partner(or 90% PPO Plan, or 85% ABHP if you are selecting that plan)
Plan #1: Humana DentalPlan #2: Humana Dental – Domestic Partner
Plan#1: Vision PlanPlan#2: Vision Plan – Domestic Partner
Next, when selecting the two plans, you will also need to make sure the tier or “coverage”is the same for each plan you are choosing. The available coverage/tier options are:
Employee + Domestic PartnerEmployee + Dom.Part’s Children Employee + Dom.Part + Family
If you wish to cover other dependents, you will need to add them to the employee plans. Those are the plans without “Domestic Partner” at the end of the name.
How to Complete your Flexible Spending Account EnrollmentsFlexible Spending Accounts require that you re-elect your contributions on an annual basis. A Health Care FSA account is for you and your covered dependents health care expenses. A Limited FSA account is for dental and vision expenses only. A Dependent Care FSA account is for dependent care expenses such as day care or elder care services. Please note that a Dependent Care account is NOT for health care expenses for your dependents.
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You will see three choices for FSA accounts, one for the Health Care FSA, one for the Limited FSA and one for Dependent Care FSA. If you had either of these benefits in the prior year, the system will automatically default to your prior election. If you wish to keep the same election, click “Save.” Otherwise, click “Change” to make a new election. If you do not want to enroll for the next calendar year, deselect the check mark in the “Elect”column.
How to Complete your Health Savings Account Plan ElectionIf you have enrolled in the 85% ABHP, you will be eligible to enroll in the HSA plan. Before enrolling through Ceridian Self-Service, you must go to the Conexis website and submit an application for an account. You will then be notified by the Benefits Department once your application has been approved so that you can log into Self-Service to complete your elections. Once approved, go to the“Benefits” section of Self-Service and click on the “Health Savings Account Enrollment” link. Here you will be able to designate the dollaramount you want to contribute per pay check. You can change this amount as often as you like throughout the year.
Finalizing Your Elections in Ceridian Self-Service during Open EnrollmentOnce you are finished designating your elections for the next calendar year, you have several options available to finalize the enrollment process. You can:
Click on “Complete Enrollment” and all ofyour changes will be saved
Click on “Save Selections and Enroll Later”which will allow you to keep going back into the system and making changes.
Click on “Start Over” and all of yourchanges will be lost and you will be returned to the beginning of the enrollment process.
Click on “Cancel” and all of your changeswill be lost and you will be returned to the Home page.
After you have “Completed your Enrollment”you are given the option to print a Benefit
Confirmation Statement reflecting your new/changed elections. It is highly recommended that you print your statement at the time you have completed theenrollment process in order to keep record of your new elections.
If you do not choose to print the benefit confirmation statement at this time, you can access it from the Home page under the Benefits Section. There are two links under the Benefit Section, one which will reflect your “Current Benefits” and one that will show your new elections. The Benefits Summary will show your new elections. At the bottom of the Benefits Summary screen, there is a link that allows you to view your new elections. This link will take you back to the original confirmation you received after you completed the enrollment.
The “Current Benefits Statement” will only show your current year benefit elections as of the date you are accessing the website.
If you “Complete Enrollment” but later decide that you want to make a change to your election, you may still do so. On the Home Page you will see a link that states “Reset your benefits enrollment”. Keep in mind that if you reset your enrollment, this does not extend the due date for completing your elections. You will need to go back into the enrollment process and complete your elections within the designated time frame.
How to Complete your Life, PAI and LTD Insurance ElectionsCompany provided Life, PAI and LTD benefits do not require an election. You are automatically enrolled and can view your coverage when enrolling in other benefits. As a convenience to you, Group Universal Life, Voluntary Personal Accident Insurance and Long Term Disability benefits will also display on your Benefits Summary. See the Life & Security section of the guide for enrollment instructions.
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Benefits Website
Check out the INEOS Benefits Website atwww.ineosbenefits.com for more informationregarding all benefit plans and the Employee Benefits Handbook.
Since the website contains company-confidential information, you will need to register under your INEOS email address to use the site.
Registration is an easy 2-step process:
1. After clicking on the "Register" linkunder the Login button on the website you will need to complete a registration form that will be submitted to the Benefits Department for authorization. You will receive 2 emails, one thanking you for registering and another once your registration has been approved.
2. The second email will contain a linkfor you to set your personal access code (password). You will then be able to use the website from anycomputer connected to the internet.
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Required Disclosures
General Notice of COBRA Continuation Coverage Rights
IntroductionYou’re getting this notice because yourecently gained coverage under the INEOS Welfare Benefit Plan. This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description (also known as the Employees Benefit Handbook) or contact the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
What is COBRA Continuation Coverage?COBRA continuation coverage is acontinuation of Plan coverage when it would otherwise end because of a life event. This is also called a "qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you're an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
Your hours of employment are reduced, or Your employment ends for any reason
other than your gross misconduct.
If you're the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
Your spouse dies; Your spouse’s hours of employment are
reduced; Your spouse’s employment ends for any
reason other than his or her gross misconduct;
Your spouse becomes entitled to Medicarebenefits (under Part A, Part B, or both); or
You become divorced or legally separatedfrom your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:
The parent-employee dies; The parent-employee’s hours of
employment are reduced;
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The parent-employee’s employment endsfor any reason other than his or her gross misconduct;
The parent-employee becomes entitled toMedicare benefits (Part A, Part B, or both);
The parents become divorced or legallyseparated; or
The child stops being eligible for coverageunder the Plan as a “dependent child.”
When is COBRA Continuation Coverage Available?The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:
The end of employment or reduction ofhours of employment;
Death of the employee; Commencement of a proceeding in
bankruptcy with respect to the employer; or
The employee’s becoming entitled toMedicare benefits (under Part A, Part B, or both).
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to the employer's local HR representative.
The Plan Administrator may require you to fill out applicable forms at that time. If you do not provide this notice or follow the Plan Administrator's procedures, you or your dependents will not be entitled to COBRA continuation coverage.
How is COBRA Continuation Coverage Provided?Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified
beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lastsfor 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended. See below.
Disability Extension of 18-Month Period of COBRA Continuation CoverageIf you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.
In order to obtain this extended coverage, notice of the disability determination must be provided to the employer's local HR representative by the qualified beneficiary within 18 months of the qualifying event andwithin 60 days after the later of the date: (i) of the Social Security Administration's disability determination, (ii) of the qualifying event, (iii) the qualified beneficiary loses or would lose coverage due to the qualifying event, or (iv) on which the qualified beneficiary is informed of his or her obligation to provide notice (and you are hereby so informed through this Notice). The Plan Administrator may require you to fill out applicable forms at that time. If you do notprovide this notice or follow the PlanAdministrator's procedures, you or your
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dependents will not be entitled to anadditional period of COBRA continuationcoverage due to disability.
The qualified beneficiary is responsible for notifying the employer's local HR representative within 30 days after the later of the date: (i) of the determination that the disabled qualified beneficiary is no longer disabled or (ii) on which the qualified beneficiary is informed of his or her obligation to provide notice (and you are hereby so informed through this Notice)
Second Qualifying Event Extension of 18-Month Period of Continuation CoverageIf your family experiences another qualifyingevent during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, orboth); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extensionis only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
Are there other Coverage Options Besides COBRA Continuation Coverage?Yes. Instead of enrolling in COBRAcontinuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.”Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options atwww.healthcare.gov.
If You Have QuestionsQuestions concerning your Plan or your COBRAcontinuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visitwww.dol.gov/ebsa. (Addresses and phonenumbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visitwww.HealthCare.gov.
Keep Your Plan Informed of Address ChangesTo protect your family’s rights, let the PlanAdministrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Plan Administrator Contact Information
INEOS USA LLC2600 South Shore Boulevard, Suite 500 League, TX 77573(281) 535-4229
How to EnrollIf you and/or your dependents experience aqualifying event of which the Company has been given notice, you will receive a COBRA enrollment package from the COBRA Administrator.
You have 60 days within which to elect COBRA coverage. The 60 day period begins to run from the later of (i) the date you would lose coverage under the Plan due to the qualifying event, or (ii) the date on which the Plan Administrator or the COBRA Administrator notifies you that you have the option to elect COBRA coverage. Each qualified beneficiary has an independent right to elect COBRA coverage. You may elect COBRA coverage on
35
behalf of your spouse, and parents may elect COBRA coverage on behalf of their children.
Your and/or your dependents' coverage under the Plan is terminated the end of the month in which the qualifying event occurs. Your coverage will be retroactively reinstated if you elect COBRA coverage by timely completing and returning your COBRA enrollment package and your first COBRA payment. You may also elect COBRA online athttps://Mybenefits.conexis.com.
Please keep in mind that when you leave theCompany, your coverage is terminated. If you elect COBRA, your coverage will be reinstated as of the date of your severance, termination or retirement once your COBRA enrollment has been completed and your first payment is received. After 60 days to elect, you have 45 days to pay your initial premium.
COBRA CostsThe qualified beneficiary is responsible forpaying the COBRA premium. Premiums are102% of the total cost of the coverage, or 150% of the total cost of the coverage in the event of a disability. COBRA premiums will change each year.
How to Pay for COBRAThe COBRA Administrator will send youmonthly invoices for the amount owed based on the coverage you elected. You may view your account online athttps://Mybenefits.conexis.com. You canalso set up an ACH from your bank to the COBRA Administrator to make your monthly payments.
The initial premium payment, which is for the time period between the date of thequalifying event and the date you elected COBRA coverage, must be made within 45days after the date of your COBRA coverage election. Failure to pay this initial premium by the due date will result in cancellation of coverage retroactive to the date coverage would have terminated without a COBRA coverage election.
Thereafter, if you fail to send your payment to the COBRA Administrator within 30 days
of the due date, your COBRA coverage will be cancelled effective as of the due date.
Notice of Privacy Practices
This notice describes how medical informationabout you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your RightsWhen it comes to your health information,you have certain rights. This section explainsyour rights and some of our responsibilities to help you.
Get a copy of your health and claims recordsYou can ask to see or get a copy of yourhealth and claims records and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims recordsYou can ask us to correct your health andclaims records if you think they are incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communicationsYou can ask us to contact you in a specificway (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
Ask us to limit what we use or shareYou can ask us not to use or share certainhealth information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
Get a list of those with whom we’ve shared informationYou can ask for a list (accounting) of thetimes we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include
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all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy noticeYou can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for youIf you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violatedYou can complain if you feel we have violated your rights by contacting us using the above information. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or atwww.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing acomplaint.
Your ChoicesFor certain health information, you can tell usyour choices about what we share. If youhave a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, closefriends, or others involved in payment for your care
Share information in a disaster reliefsituation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Marketing purposes Sale of your information
Other Uses and Disclosures
How do we typically use or share your health information?We typically use or share your healthinformation in the following ways.
Help manage the health care treatment you receiveWe can use your health information and shareit with professionals who are treating you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organizationWe can use and disclose your information torun our organization and contact you when necessary.
We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Example: We use health information about you to develop better services for you.
Pay for your health servicesWe can use and disclose your healthinformation as we pay for your health services.
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Example: We share information about you with your dental plan to coordinate payment for your dental work.
Administer your planWe may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
How else can we use or share your health information?We are allowed or required to share yourinformation in other ways – usually in ways that contribute to the public good, such aspublic health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issuesWe can share health information about youfor certain situations such as:
Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or
domestic violence Preventing or reducing a serious threat to
anyone’s health or safety
Do researchWe can use or share your information forhealth research.
Comply with the lawWe will share information about you if stateor federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying withfederal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral directorWe can share health information about youwith organ procurement organizations. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requestsWe can use or share health information aboutyou:
For workers’ compensation claims For law enforcement purposes or with a law
enforcement official With health oversight agencies for activities
authorized by law For special government functions such as
military, national security, and presidential protective services
Respond to lawsuits and legal actionsWe can share health information about you inresponse to a court or administrative order, or in response to a subpoena.
Our Responsibilities We are required by law to maintain the
privacy and security of your protected health information.
We will let you know promptly if a breachoccurs that may have compromised the privacy or security of your information.
We must follow the duties and privacypractices described in this notice and give you a copy of it.
We will not use or share your informationother than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
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Changes to the Terms of This NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.
This Notice of Privacy Practices applies to the following organizations.This Notice of Privacy Practices applies to the INEOS Welfare Benefit Plan and the INEOS Retiree Welfare Benefit Plan, which include the benefits in the group health plans sponsored by INEOS USA LLC that pay for the cost of, or provide, medical, dental, vision, prescription drug, and medical flexible spending benefits. It does not apply to other benefits such as life insurance, disability benefits, or accidental death and dismemberment insurance. If you receive health benefits through an insurance company through the INEOS Welfare Benefit Plan or INEOS Retiree Welfare Benefit Plan, such as vision benefits, you may also receive a notice from the insurer. That notice will describe how the insurer will use your health information and provide your rights.
HIPAA Security Privacy Officer
Pete Train, Benefits Director INEOS USA LLC2600 South Shore Boulevard, Suite 500 League, TX 77573
Effective Date: January 1, 2015
For HIPAA security questions contact the HIPAA Security Privacy Officer.
HIPAA Privacy Officer
Carrie Stotts, Benefits Manager INEOS USA LLC3030 Warrenville Road, Suite 645 Lisle, IL 60532
Effective Date: January 1, 2015
For HIPAA Privacy questions contact the HIPAA Privacy Officer.
HIPAA Special Enrollment Rights NoticeIf you are declining enrollment for yourself or your dependent spouse or children in the INEOS Medical Plan because of other health insurance or group health plan coverage, you should know that you may be able to enroll yourself and your dependents in the Plan ifyou or your dependents lose eligibility for that other coverage (or if the other employer stops contributing toward the other coverage).However, you must request enrollment in the Plan within 30 days after your or your dependents' other coverage ends (or after the other employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents.However, you must request enrollment in the Plan within 30 days after the marriage, birth, adoption, or placement for adoption.
Lastly, if you and/or your dependents were eligible for coverage under the Plan but were not covered, and you and/or your dependents either: (1) lose coverage under a Medicaid plan or a state children's health plan because of a loss of eligibility, or (2) become eligible for premium assistance with respect to a Medicaid plan or a state children's health plan, you may elect coverage under the Plan if you request enrollment within 60 days after loss of such coverage or eligibility for premium assistance.
To request special enrollment or obtain more information, contact:
Pete Train, Benefits Director INEOS USA LLC2600 South Shore Boulevard, Suite 500 League, TX 77573
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Women's Health and Cancer Rights Act
The INEOS Medical Plan provides coverage for:
All stages of reconstruction of the breaston which the mastectomy has been
performed; Surgery and reconstruction of the other
breast to produce a symmetrical appearance; and Prostheses and physical complications of
mastectomy, including lymphedemas, in amanner determined in consultation with the attending physician and the patient.
Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.
For more information, contact your Plan Administrator:
Benefits Administration Committee INEOS USA LLC2600 South Shore Boulevard, Suite 500 League, TX 77573(281) 535-4229
Newborns' and Mothers' Health Protection Act
The INEOS Medical Plan generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
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Medicare Part D Disclosure / Notice of Creditable Coverage
Read and keep this Disclosure Notice if you or your dependents have or soon will be eligible for Medicare Coverage. If you or your dependents are not eligible for Medicare and will not become eligible for Medicare in the next twelve months, this Disclosure Notice does not apply to you.
Please read this notice carefully and keep it where you can find it. You will need it when you receive information from prescriptiondrug plan sponsors and Medicare concerning Medicare Part D prescription drug coverage.You will also need it if you decide not to buy Medicare Part D prescription drug coverage now, but buy it later. This notice has information about your current prescriptiondrug coverage under the INEOS Medical Plan and prescription drug coverage available for people with Medicare. It also explains theoptions you have for prescription drug coverage and can help you decide whether or not you want to enroll in the Medicare Part D prescription drug program. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Part D prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. If you or your dependents are not eligible for Medicare coverage, you are not eligible for the Part D prescription drug benefit and the information in this Notice does not apply to you.
Important Facts about Your Health Plan Coverage & Medicare Prescription Drug Coverage
1. Medicare prescription drug coveragebecame available in 2006 to everyone with Medicare. You can obtain this coverage if you join a Medicare Part D Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a
standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. INEOS has determined that theprescription drug coverage offered by the 80% PPO Plan and 90% PPO Plan are, on average for all plan participants, expected to pay out as much as the standard Part D coverage will pay. This coverage is considered "Creditable Coverage." This means that if you decide to keep your INEOS Medical Plan drug coverage and wait to enroll in a Medicare prescription drug plan, you will not have to pay a late enrollment penalty to Medicare if you later enroll in the Medicare prescription drug plan.
When Can You Join a Medicare Drug Plan?You can join a Medicare drug plan when you first become eligible for Medicare, and each year from October 15th through December 7th. This may mean that you may have to wait to join a Medicare prescription drug plan and that you may pay a higher premium if you join later. However, if you or your spouse leave employer coverage that is creditable (such as the INEOS Medical Plan) or if you otherwise lose other creditable coverage through no fault of your own, you and yourspouse may be eligible for a two (2) month "Special Enrollment Period" to sign up for a Medicare prescription drug plan after theemployer coverage ends, and without having to pay extra for your Medicare prescription drug coverage.
What Are My Choices?Your existing prescription drug coverage with the INEOS Medical Plan provides coverage that is, on average, at least as good as the standard Medicare prescription drug coverage. This means that you can keep your INEOS Medical Plan prescription drug coverage and not pay extra if you wait to enroll in Medicare drug coverage later (unless you have a gap in prescription drug coverage).
You may enroll in a Medicare prescription drug plan without losing your prescription
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drug coverage under the INEOS Medical Plan (unless you do not meet other eligibility requirements under the INEOS Medical Plan). This also applies to your covered dependents. Therefore, you may:
Keep the INEOS Medical Plan coverage anddelay your enrollment in a Medicare prescription drug plan without penalty;
Drop the INEOS Medical Plan coverage andenroll in a Medicare prescription drug plan (remember, if you drop the INEOS Medical Plan coverage, you will lose your medicalbenefits as well as your prescription drug coverage under the INEOS Medical Plan); or
Keep the INEOS Medical Plan coverage andenroll in a Medicare prescription drug plan.
When Will You Pay a Higher Premium (Penalty) to Join a Medicare Prescription Drug Plan?If you drop or lose your current coverageunder the INEOS Medical Plan and don’t join a Medicare prescription drug plan within 63 consecutive days after your current coverage ends, you may pay more (a penalty) to join a Medicare prescription drug plan later.
If you go 63 consecutive days or longer without creditable prescription drug coverage that is at least as good as Medicare's prescription drug coverage, your monthly premium for Part D coverage may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have "creditable coverage." For example, if you drop your INEOS Medical Plan coverage and go nineteen months without creditable coverage, your Part D premium will always be at least 19% higher than what most other people pay(i.e., the Medicare base beneficiary premium). You will have to pay this higher premium (a penalty) as long as you have Medicare coverage. You also may have to wait until the following October to enroll in Medicare Part D coverage that will be effective the next January 1. In other words, you most likely do not want to drop
your INEOS Medical Plan coverage until you are enrolled in the Medicare coverage.
You Need to Make A DecisionWhen you make your decision, you shouldalso compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Your decision will be a personal decision based on factors such as the medications you currently take, whether those medications are covered by the INEOS Medical Plan's prescription drug coverage or the Medicare prescription drug plan, whether your pharmacy is a part of the Medicare prescription drug plan, the premiums, deductibles, copays, and coinsurance you pay, and your income level.Most people will not need coverage under both the INEOS Medical Plan and a Medicare prescription drug plan.
You should also know that if you drop or lose your prescription drug coverage under the INEOS Medical Plan and you don't enroll in Medicare prescription drug coverage when your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later.
For More Information about This Notice or Your Current Prescription Drug Coverage
Contact the person listed below for furtherinformation or, you may call your local HR Representative.
NOTE: You’ll receive this notice each year. You will also receive this notice at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if the INEOS Medical Plan coverage changes. You may also request a copy of this notice at any time.
For More Information about Your Options Under Medicare Prescription Drug CoverageMore detailed information about Medicareplans that offer prescription drug coverage is in the “Medicare & You” handbook. You will get a copy of the handbook in the mail every
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year from Medicare. You may also be contacted directly by Medicare prescription drug plans.
For more information about Medicare prescription drug coverage:
Visit www.medicare.gov Call your State Health Insurance
Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.
Call (800) MEDICARE (800-633-4227). TTYusers should call (877) 486-2048.
For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available. For more information about this extra help, visit Social Security on the web atwww.socialsecurity.gov, or call them at(800) 772-1213 (TTY 1-800-325-0778).
Remember: Keep this CreditableCoverage notice. If you decide to joinone of the Medicare drug plans, you maybe required to provide a copy of thisnotice when you join to show whether ornot you have maintained creditablecoverage and, therefore, whether or notyou are required to pay a higher premium(a penalty).
Date: January 1, 2015
Contact:
Peter Train, Director of Benefits INEOS USA LLC2600 South Shore Blvd, Suite 500 League City, TX 77573(281) 535-4229
Medicaid and the Children's Health Insurance Program (CHIP)
If you or your children are eligible forMedicaid or CHIP and you're eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren't eligible for Medicaid or CHIP, you won't be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For moreinformation, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial(877) KIDS NOW or www.insurekidsnow.gov tofind out how to apply. If you qualify, ask yourstate if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren't already enrolled. This is called a "special enrollment" opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor atwww.askebsa.dol.gov or call (866) 444-EBSA(3272).
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To see if any other states have added a premium assistance program since January 31, 2014, or for more information on special enrollment rights, contact either:
U.S. Department of LaborEmployee Benefits Security Administrationwww.dol.gov/ebsa(866) 444-EBSA (3272)OMB Control Number 1210-0137 (expires 10/31/2016)
U.S. Department of Health & Human Services Centers for Medicare & Medicaid Serviceswww.cms.hhs.gov(877) 267-2323, Menu Option 4, Ext. 61565
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If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2014. Contact your State for more information on eligibility.
ALABAMA – Medicaid COLORADO – MedicaidWebsite: http://www.medicaid.alabama.govPhone: 1-855-692-5447
Medicaid Website: http://www.colorado.gov/Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943ALASKA – Medicaid
Website:http://health.hss.state.ak.us/dpa/programs/medicaid/Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529
ARIZONA – CHIP FLORIDA – Medicaid
Website: http://www.azahcccs.gov/applicantsPhone (Outside of Maricopa County): 1-877-764-5437Phone (Maricopa County): 602-417-5437
Website:https://www.flmedicaidtplrecovery.com/Phone: 1-877-357-3268GEORGIA – MedicaidWebsite: http://dch.georgia.gov/ - Click onPrograms, then Medicaid, then Health Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150IDAHO – Medicaid MONTANA – MedicaidMedicaid Website:http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssistance/tabid/1510/Default.aspxMedicaid Phone: 1-800-926-2588
Website:http://medicaidprovider.hhs.mt.gov/clientpages/clientindex.shtml Phone: 1-800-694-3084
INDIANA – Medicaid NEBRASKA – MedicaidWebsite: http://www.in.gov/fssaPhone: 1-800-889-9949
Website: www.ACCESSNebraska.ne.govPhone: 1-800-383-4278
IOWA – Medicaid NEVADA – MedicaidWebsite: www.dhs.state.ia.us/hipp/Phone: 1-888-346-9562
Medicaid Website: http://dwss.nv.gov/Medicaid Phone: 1-800-992-0900
KANSAS – MedicaidWebsite: http://www.kdheks.gov/hcf/Phone: 1-800-792-4884
KENTUCKY – Medicaid NEW HAMPSHIRE – MedicaidWebsite: http://chfs.ky.gov/dms/default.htmPhone: 1-800-635-2570
Website:http://www.dhhs.nh.gov/oii/documents/hippapp.pdfPhone: 603-271-5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIPWebsite: http://www.lahipp.dhh.louisiana.govPhone: 1-888-695-2447
Medicaid Website:http://www.state.nj.us/humanservices/dmahs/clients/medicaid/Medicaid Phone: 609-631-2392 CHIP Website:http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710
MAINE – MedicaidWebsite:http://www.maine.gov/dhhs/ofi/public-assistance/index.html
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Phone: 1-800-977-6740TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid
Website: http://www.mass.gov/MassHealthPhone: 1-800-462-1120
Website:http://www.nyhealth.gov/health_care/medicaid/Phone: 1-800-541-2831
MINNESOTA – Medicaid NORTH CAROLINA – MedicaidWebsite: http://www.dhs.state.mn.us/
Click on Health Care, then Medical AssistancePhone: 1-800-657-3629
Website: http://www.ncdhhs.gov/dmaPhone: 919-855-4100
MISSOURI – Medicaid NORTH DAKOTA – MedicaidWebsite:http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005
Website:http://www.nd.gov/dhs/services/medicalserv/medicaid/Phone: 1-800-755-2604
OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1-888-365-3742
Website: http://health.utah.gov/uppPhone: 1-866-435-7414
OREGON – Medicaid VERMONT– MedicaidWebsite: http://www.oregonhealthykids.govhttp://www.hijossaludablesoregon.govPhone: 1-800-699-9075
Website: http://www.greenmountaincare.org/Phone: 1-800-250-8427
PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIPWebsite: http://www.dpw.state.pa.us/hippPhone: 1-800-692-7462
Medicaid Website:http://www.dmas.virginia.gov/rcp-HIPP.htmMedicaid Phone: 1-800-432-5924CHIP Website: http://www.famis.org/CHIP Phone: 1-866-873-2647
RHODE ISLAND – Medicaid WASHINGTON – MedicaidWebsite: www.ohhs.ri.govPhone: 401-462-5300
Website:http://www.hca.wa.gov/medicaid/premiumpymt/ pages/index.aspxPhone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid
Website: http://www.scdhhs.govPhone: 1-888-549-0820
Website: www.dhhr.wv.gov/bms/Phone: 1-877-598-5820, HMS Third Party Liability
SOUTH DAKOTA - Medicaid WISCONSIN – MedicaidWebsite: http://dss.sd.govPhone: 1-888-828-0059
Website:http://www.badgercareplus.org/pubs/p-10095.htmPhone: 1-800-362-3002
TEXAS – Medicaid WYOMING – MedicaidWebsite: https://www.gethipptexas.com/Phone: 1-800-440-0493
Website:http://health.wyo.gov/healthcarefin/equalitycarePhone: 307-777-7531
PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered
to correspond to the Marketplace application.
3. Employer name
4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address
Here is some basic information about health coverage offered by this employer:
• As your employer, we offer a health plan to:
All employees. Eligible employees are:
Some employees. Eligible employees are:
• With respect to dependents:
We do offer coverage. Eligible dependents are:
We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended
to be affordable, based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium
discount through the Marketplace. The Marketplace will use your household income, along with other factors,
to determine whether you may be eligible for a premium discount. If, for example, your wages vary from
week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly
employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the
employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your
monthly premiums.
INEOS USA LLC 20-1981933
2600 South Shore Boulevard, Suite 500 281-535-4229
League City TX 77573
Peter M. Train, Director of Benefits and Payroll
✔
✔
✔
All employees scheduled to work 20 hours or more per week will be eligible to participate in the INEOSHealth Plans.
The employee's spouse or domestic partner; the employee's child (natural child, stepchild, legally adoptedchild placed for adoption, or foster child) until age 26; a spouse's or domestic partner's child if a taxdependent of the spouse or domestic partner; a child age 26 or older who is permanently and totally disabledand covered by the Plan prior to attaining age 26.
PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered
to correspond to the Marketplace application.
3. Employer name
4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address
Here is some basic information about health coverage offered by this employer:
• As your employer, we offer a health plan to:
All employees. Eligible employees are:
Some employees. Eligible employees are:
• With respect to dependents:
We do offer coverage. Eligible dependents are:
We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended
to be affordable, based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium
discount through the Marketplace. The Marketplace will use your household income, along with other factors,
to determine whether you may be eligible for a premium discount. If, for example, your wages vary from
week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly
employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the
employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your
monthly premiums.
INEOS USA LLC 20-1981933
2600 South Shore Boulevard, Suite 500 281-535-4229
League City TX 77573
Peter M. Train, Director of Benefits and Payroll
✔
✔
✔
All employees scheduled to work 20 hours or more per week will be eligible to participate in the INEOSHealth Plans.
The employee's spouse or domestic partner; the employee's child (natural child, stepchild, legally adoptedchild placed for adoption, or foster child) until age 26; a spouse's or domestic partner's child if a taxdependent of the spouse or domestic partner; a child age 26 or older who is permanently and totally disabledand covered by the Plan prior to attaining age 26.
1
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 80%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.bcb
sil.c
om o
r by
calli
ng 1
-888
-979
-451
6.
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy th
is M
atte
rs:
Wha
t is
the
over
all
dedu
ctib
le?
PPO
$4
50 P
erso
n/$1
,350
Fam
ily
Non
-PPO
$9
00 P
erso
n/$2
,700
Fam
ily
Doe
sn’t
appl
y to
cer
tain
pre
vent
ive
serv
ices
, pre
scrip
tions
, em
erge
ncy
room
se
rvic
es, o
r offi
ce c
opay
s.
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins t
o pa
y fo
r cov
ered
serv
ices y
ou u
se.
Chec
k yo
ur p
olicy
or p
lan d
ocum
ent t
o se
e w
hen
the
dedu
ctib
le st
arts
ove
r (us
ually
, but
not
alw
ays,
Janu
ary
1st).
See
the
char
t sta
rting
on
page
2 fo
r how
muc
h yo
u pa
y fo
r cov
ered
serv
ices
afte
r you
mee
t th
e de
duct
ible
.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
?
Yes
. $10
0 de
duct
ible
for h
ospi
tal
adm
issio
n.
Ther
e ar
e no
oth
er sp
ecifi
c de
duct
ible
s.
You
mus
t pay
all
of th
e co
sts f
or th
ese
serv
ices u
p to
the
spec
ific
dedu
ctib
le
amou
nt b
efor
e th
is pl
an b
egin
s to
pay
for t
hese
serv
ices
.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
?
Yes
. PPO
$2
,000
Per
son/
$4,0
00 F
amily
N
on-P
PO
$4,0
00 P
erso
n/$8
,000
Fam
ily
RX O
ut-o
f-Poc
ket E
xpen
se L
imit:
$1
,500
Indi
vidu
al/ $
3,00
0 Fa
mily
The
out-o
f-poc
ket l
imit
is th
e m
ost y
ou c
ould
pay
dur
ing
a co
vera
ge p
erio
d (u
suall
y on
e ye
ar) f
or y
our s
hare
of t
he c
ost o
f cov
ered
serv
ices.
Thi
s lim
it he
lps
you
plan
for h
ealth
car
e ex
pens
es.
Wha
t is
not i
nclu
ded
in
the
out–
of–p
ocke
t lim
it?
Pres
crip
tion
drug
s, pr
emiu
ms,
balan
ced-
bille
d ch
arge
s, an
d he
alth
care
this
plan
do
esn’
t cov
er.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t–of
–poc
ket
limit.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. Visi
t ww
w.b
cbsi
l.com
or c
all
1-88
8-97
9-45
16 fo
r a li
st o
f Par
ticip
atin
g pr
ovid
ers.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s plan
will
pay
som
e or
all
of th
e co
sts o
f cov
ered
serv
ices.
Be
awar
e, yo
ur in
-net
wor
k do
ctor
or h
ospi
tal
may
use
an
out-o
f-net
wor
k pr
ovid
er fo
r som
e se
rvice
s. P
lans u
se th
e te
rm in
-ne
twor
k, p
refe
rred
, or p
artic
ipat
ing
for p
rovi
ders
in th
eir n
etw
ork.
See
the
char
t st
artin
g on
pag
e 2
for h
ow th
is pl
an p
ays d
iffer
ent k
inds
of p
rovi
ders
.
Do
I nee
d a
refe
rral
to
see
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvic
es th
is pl
an d
oesn
’t co
ver a
re li
sted
on
page
5. S
ee y
our p
olic
y or
plan
doc
umen
t for
add
ition
al in
form
atio
n ab
out e
xclu
ded
serv
ices
.
2
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 80%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $1
5) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usua
lly w
hen
you
rece
ive
the
serv
ice.
C
oins
uran
ce is
your
shar
e of
the
cost
s of a
cov
ered
serv
ice,
calc
ulat
ed a
s a p
erce
nt o
f the
allo
wed
am
ount
for t
he se
rvic
e. Fo
r exa
mpl
e, if
the
plan
’s al
low
ed a
mou
nt fo
r an
over
nigh
t hos
pita
l sta
y is
$1,0
00, y
our c
oins
uran
ce p
aym
ent o
f 20%
wou
ld b
e $2
00.
This
may
cha
nge
if yo
u ha
ven’
t met
you
r ded
uctib
le.
Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-n
etw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffere
nce.
For e
xam
ple,
if an
out
-of-n
etw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
you
may
hav
e to
pay
the
$500
diff
eren
ce. (
This
is ca
lled
bala
nce
billi
ng.)
Th
is pl
an m
ay e
ncou
rage
you
to u
se P
PO p
rovi
ders
by
char
ging
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s. C
omm
on
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d Yo
ur C
ost I
f Yo
u U
se a
n
PPO
P
rovi
der
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
$20
copa
y/vi
sit
40%
coi
nsur
ance
Co
pay
appl
ies t
o of
fice
visit
onl
y.
Spec
ialist
visi
t $3
0 co
pay/
visit
40
% c
oins
uran
ce
Copa
y ap
plie
s to
offic
e vi
sit o
nly.
Oth
er p
ract
ition
er o
ffice
visi
t 20
% c
oins
uran
ce
40%
coi
nsur
ance
Li
mite
d to
chi
ropr
actic
and
os
teop
athi
c m
anip
ulat
ions
.
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
Char
ge
40%
coi
nsur
ance
---
none
---
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
20
% c
oins
uran
ce
40%
coi
nsur
ance
---
none
---
Imag
ing
(CT/
PET
scan
s, M
RIs)
20
% c
oins
uran
ce
40%
coi
nsur
ance
---
none
---
3
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 80%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
an
PP
O
Pro
vide
r
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
drug
s to
tre
at y
our i
llnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out p
resc
riptio
n dr
ug c
over
age
is av
ailab
le a
t w
ww
.bcb
sil.co
m.
Gen
eric
drug
s
$8 c
opay
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
$20
copa
y/
pres
crip
tion
for u
p to
a 9
0 da
y su
pply.
$8 c
opay
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
$20
copa
y/
pres
crip
tion
for u
p to
a 9
0 da
y su
pply.
Certa
in w
omen
’s pr
even
tativ
e se
rvice
s w
ill b
e co
vere
d w
ith n
o co
st to
the
mem
ber.
For a
full
list o
f the
se
pres
crip
tions
and
/or s
ervi
ces,
plea
se
cont
act C
usto
mer
Ser
vice
.
Form
ular
y br
and
drug
s
20%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
15%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
90
day
supp
ly.
20%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
15%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
90
day
supp
ly.
30 d
ay su
pply:
Max
$40
per
pr
escr
iptio
n; 9
0 da
y su
pply:
Max
$10
0 pe
r pre
scrip
tion.
Se
e ab
ove
(refe
r to
gene
ric).
Non
-For
mul
ary
bran
d dr
ugs
30%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
25%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
90
day
supp
ly.
30%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
25%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
90
day
supp
ly.
30 d
ay su
pply:
Max
$60
per
pr
escr
iptio
n; 9
0 da
y su
pply:
Max
$15
0 pe
r pre
scrip
tion.
Se
e ab
ove
(refe
r to
gene
ric).
Spec
ialty
dru
gs
$8 c
opay
/gen
eric
pres
crip
tion.
20
% c
oins
uran
ce/
Form
ular
y br
and
pres
crip
tion.
30
% c
oins
uran
ce/
Non
-For
mul
ary
bran
d pr
escr
iptio
n.
30 d
ay su
pply.
Not
Cov
ered
Form
ular
y br
and
$40
max
imum
N
on-F
orm
ular
y br
and
$60
max
imum
. Sp
ecial
ty re
tail
limite
d to
a 3
0 da
y su
pply
.
If y
ou h
ave
outp
atie
nt s
urge
ry
Faci
lity
fee
(e.g
., am
bulat
ory
surg
ery
cent
er)
20%
coi
nsur
ance
40
% c
oins
uran
ce
---no
ne---
Ph
ysic
ian/s
urge
on fe
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
4
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 80%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
an
PP
O
Pro
vide
r
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
imm
edia
te m
edic
al
atte
ntio
n
Em
erge
ncy
room
serv
ices
$1
00 c
opay
plu
s 20
% c
oins
uran
ce.
$100
cop
ay p
lus
20%
coi
nsur
ance
. Co
pay
waiv
ed if
adm
itted
.
Em
erge
ncy
med
ical
trans
porta
tion
20%
coi
nsur
ance
20
% c
oins
uran
ce
---no
ne---
U
rgen
t car
e 20
% c
oins
uran
ce
40%
coi
nsur
ance
---
none
---
If y
ou h
ave
a ho
spita
l sta
y
Faci
lity
fee
(e.g
., ho
spita
l roo
m)
$100
cop
ay p
lus
20%
coi
nsur
ance
$1
00 c
opay
plu
s 40
% c
oins
uran
ce
---no
ne---
Phys
ician
/sur
geon
fee
20%
coi
nsur
ance
40
% c
oins
uran
ce
---no
ne---
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al he
alth
outp
atien
t ser
vice
s 20
% c
oins
uran
ce
40%
coi
nsur
ance
---
none
---
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
$1
00 c
opay
plu
s 20
% c
oins
uran
ce
$100
cop
ay p
lus
40%
coi
nsur
ance
---
none
---
Subs
tanc
e us
e di
sord
er o
utpa
tient
serv
ices
20
% c
oins
uran
ce
40%
coi
nsur
ance
---
none
---
Subs
tanc
e us
e di
sord
er in
patie
nt se
rvic
es
$100
cop
ay p
lus
20%
coi
nsur
ance
$1
00 c
opay
plu
s 40
% c
oins
uran
ce
---no
ne---
If y
ou a
re p
regn
ant
Pren
atal
and
post
nata
l car
e $2
0 co
pay
40%
coi
nsur
ance
Co
pay
appl
ies t
o fir
st p
rena
tal v
isit
(per
pre
gnan
cy).
Del
iver
y an
d all
inpa
tient
serv
ices
$1
00 c
opay
plu
s 20
% c
oins
uran
ce
$100
cop
ay p
lus
40%
coi
nsur
ance
---
none
---
5
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 80%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
an
PP
O
Pro
vide
r
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
care
20
% c
oins
uran
ce
40%
coi
nsur
ance
Li
mite
d to
120
visi
ts p
er b
enef
it pe
riod.
Re
habi
litat
ion
serv
ices
20
% c
oins
uran
ce
40%
coi
nsur
ance
Li
mite
d to
90
visit
s per
ben
efit
perio
d.
Hab
ilita
tion
serv
ices
20
% c
oins
uran
ce
40%
coi
nsur
ance
Li
mite
d to
90
visit
s per
ben
efit
perio
d.
Skill
ed n
ursin
g ca
re
$100
cop
ay p
lus
20%
coi
nsur
ance
$1
00 c
opay
plu
s 40
% c
oins
uran
ce
Lim
ited
to 1
20 d
ays p
er b
enef
it pe
riod.
Dur
able
med
ical
equi
pmen
t 20
% c
oins
uran
ce
40%
coi
nsur
ance
Bene
fits a
re li
mite
d to
item
s use
d to
se
rve
a m
edic
al pu
rpos
e. D
ME
be
nefit
s are
pro
vide
d fo
r bot
h pu
rcha
se a
nd re
ntal
equi
pmen
t (up
to
the
purc
hase
pric
e).
Hos
pice
serv
ice
20%
coi
nsur
ance
40
% c
oins
uran
ce
---no
ne---
If y
our c
hild
nee
ds
dent
al o
r eye
car
e
Eye
exa
m
Not
Cov
ered
N
ot C
over
ed
---no
ne---
G
lasse
s N
ot C
over
ed
Not
Cov
ered
D
enta
l che
ck-u
p N
ot C
over
ed
Not
Cov
ered
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Se
rvic
es Y
our P
lan
Doe
s N
OT
Cov
er (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
exc
lude
d se
rvic
es.)
A
cupu
nctu
re
Co
smet
ic S
urge
ry
D
enta
l Car
e (A
dult)
Lo
ng T
erm
Car
e
Rout
ing
Eye
Car
e (A
dult)
Ro
utin
g Fo
ot C
are
(with
the
exce
ptio
n of
pe
rson
with
diag
nosis
of d
iabet
es)
W
eigh
t Los
s Pro
gram
O
ther
Cov
ered
Ser
vice
s (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
cov
ered
ser
vice
s an
d yo
ur c
osts
for t
hese
se
rvic
es.)
Ba
riatri
c Su
rger
y
Chiro
prac
tic C
are
H
earin
g A
id
In
ferti
lity
Trea
tmen
t
Mos
t cov
erag
e pr
ovid
ed o
utsid
e th
e U
nite
d St
ates
. See
ww
w.b
cbsil
.com
N
on-E
mer
genc
y Ca
re W
hen
Trav
elin
g O
utsid
e th
e U
.S
Pr
ivat
e D
uty
Nur
sing
(with
the
exce
ptio
n of
inpa
tient
priv
ate
duty
nur
sing)
6
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 80%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Your
Rig
hts
to C
ontin
ue C
over
age:
If
you
lose
cov
erag
e un
der t
he p
lan, t
hen,
dep
endi
ng u
pon
the
circ
umst
ance
s, Fe
dera
l and
Sta
te la
ws m
ay p
rovi
de p
rote
ctio
ns th
at a
llow
you
to k
eep
healt
h co
vera
ge. A
ny su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay
whi
le c
over
ed u
nder
the
plan
. Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e m
ay a
lso a
pply
. Fo
r mor
e in
form
atio
n on
you
r rig
hts t
o co
ntin
ue c
over
age,
cont
act t
he p
lan a
t 1-8
88-9
79-4
516.
You
may
also
con
tact
you
r sta
te in
sura
nce
depa
rtmen
t, th
e U
.S. D
epar
tmen
t of L
abor
, Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istra
tion
at 1
-866
-444
-327
2 or
ww
w.d
ol.g
ov/e
bsa,
or th
e U
.S. D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s at 1
-877
-267
-232
3 x6
1565
or w
ww
.cciio
.cms.g
ov.
Your
Grie
vanc
e an
d A
ppea
ls R
ight
s:
If y
ou h
ave
a co
mpl
aint o
r are
diss
atisf
ied
with
a d
enial
of c
over
age
for c
laim
s und
er y
our p
lan, y
ou m
ay b
e ab
le to
app
eal o
r file
a g
rieva
nce.
For
qu
estio
ns a
bout
you
r rig
hts,
this
notic
e, or
ass
istan
ce, y
ou c
an c
onta
ct B
lue
Cros
s and
Blu
e Sh
ield
of I
llino
is at
1-8
88-9
79-4
516
or v
isit w
ww
.bcb
sil.co
m, o
r co
ntac
t the
U.S
Dep
artm
ent o
f Lab
or's
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istra
tion
at 1
-866
-444
-EBS
A (3
272)
or v
isit w
ww
.dol
.gov
/ebs
a/he
althr
efor
m.
Add
ition
ally,
a co
nsum
er a
ssist
ance
pro
gram
can
help
you
file
you
r app
eal.
Cont
act t
he Il
linoi
s Dep
artm
ent o
f Ins
uran
ce a
t (87
7) 5
27-9
431
or v
isit
http
://i
nsur
ance
.illin
ois.g
ov.
Doe
s th
is C
over
age
Prov
ide
Min
imum
Ess
entia
l Cov
erag
e?
The
Affo
rdab
le C
are
Act
requ
ires m
ost p
eopl
e to
hav
e he
alth
care
cov
erag
e th
at q
ualif
ies a
s “m
inim
um e
ssen
tial c
over
age.”
Thi
s pl
an o
r pol
icy
does
pr
ovid
e m
inim
um e
ssen
tial c
over
age.
D
oes
this
Cov
erag
e M
eet t
he M
inim
um V
alue
Sta
ndar
d?
The
Affo
rdab
le C
are
Act
est
ablis
hes a
min
imum
valu
e st
anda
rd o
f ben
efits
of a
hea
lth p
lan. T
he m
inim
um v
alue
stan
dard
is 6
0% (a
ctua
rial v
alue)
. Thi
s he
alth
cov
erag
e do
es m
eet t
he m
inim
um v
alue
sta
ndar
d fo
r the
ben
efits
it p
rovi
des.
Lang
uage
Acc
ess
Serv
ices
: Sp
anish
(Esp
añol
): Pa
ra o
bten
er a
siste
ncia
en E
spañ
ol, l
lame
al 1-
888-
979-
4516
. Ta
galo
g (T
agalo
g): K
ung
kaila
ngan
nin
yo a
ng tu
long
sa T
agalo
g tu
maw
ag sa
1-88
8-97
9-45
16.
Chin
ese
(中文
): 如果需要中文的帮助,请拨打这个号码
1-88
8-97
9-45
16.
Nav
ajo (D
ine)
: Din
ek'eh
go sh
ika
at'o
hwol
nin
ising
o, k
wiij
igo
holn
e' 1-
888-
979-
4516
. ––
––––
––––
––––
––––
––––
To se
e exa
mples
of h
ow th
is pla
n mi
ght c
over
costs
for a
samp
le me
dical
situa
tion,
see th
e nex
t pag
e.–––
––––
––––
––––
––––
–––
7
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 80%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 C
over
age
Exa
mpl
es
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Hav
ing
a ba
by
(nor
mal
deliv
ery)
Man
agin
g ty
pe 2
dia
bete
s (ro
utin
e m
ainte
nanc
e of
a
wel
l-con
trolle
d co
nditi
on)
Abo
ut th
ese
Cov
erag
e Ex
ampl
es:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
cov
er
med
ical
care
in g
iven
situ
atio
ns. U
se th
ese
exam
ples
to se
e, in
gen
eral,
how
muc
h fin
ancia
l pr
otec
tion
a sa
mpl
e pa
tient
mig
ht g
et if
they
are
co
vere
d un
der d
iffer
ent p
lans.
A
mou
nt o
wed
to p
rovi
ders
: $7,
540
P
lan
pays
$5,
810
P
atie
nt p
ays
$1,7
30
Sa
mpl
e ca
re c
osts
: H
ospi
tal c
harg
es (m
othe
r) $2
,700
Ro
utin
e ob
stet
ric c
are
$2,1
00
Hos
pita
l cha
rges
(bab
y)
$900
A
nest
hesia
$9
00
Labo
rato
ry te
sts
$500
Pr
escr
iptio
ns
$200
Ra
diol
ogy
$200
V
acci
nes,
othe
r pre
vent
ive
$40
Tot
al
$7,5
40
Patie
nt p
ays:
D
educ
tibles
$4
50
Copa
ys
$30
Coin
sura
nce
$1,0
10
Lim
its o
r exc
lusio
ns
$150
T
otal
$1
,640
A
mou
nt o
wed
to p
rovi
ders
: $5,
400
P
lan
pays
$4,
120
P
atie
nt p
ays
$1,3
60
Sa
mpl
e ca
re c
osts
: Pr
escr
iptio
ns
$2,9
00
Med
ical
Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Offi
ce V
isits
and
Pro
cedu
res
$700
E
duca
tion
$300
La
bora
tory
test
s $1
00
Vac
cine
s, ot
her p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patie
nt p
ays:
D
educ
tibles
$4
50
Copa
ys
$510
Co
insu
ranc
e $2
40
Lim
its o
r exc
lusio
ns
$80
Tot
al
$1,2
80
Not
e: Th
ese
exam
ples
are
bas
ed o
n in
divi
dual
cove
rage
onl
y.
This
is
not a
cos
t es
timat
or.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
un
der t
his p
lan. T
he a
ctua
l ca
re y
ou re
ceiv
e w
ill b
e di
ffere
nt fr
om th
ese
exam
ples
, and
the
cost
of
that
car
e w
ill a
lso b
e di
ffere
nt.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
8
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 80%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 C
over
age
Exa
mpl
es
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Que
stio
ns a
nd a
nsw
ers
abou
t the
Cov
erag
e Ex
ampl
es:
Wha
t are
som
e of
the
assu
mpt
ions
beh
ind
the
Cov
erag
e Ex
ampl
es?
Co
sts d
on’t
incl
ude
prem
ium
s.
Sam
ple
care
cos
ts a
re b
ased
on
natio
nal
aver
ages
supp
lied
by th
e U
.S.
Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvice
s, an
d ar
en’t
spec
ific
to a
pa
rticu
lar g
eogr
aphi
c ar
ea o
r hea
lth p
lan.
Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clud
ed o
r pre
exist
ing
cond
ition
.
All
serv
ices
and
trea
tmen
ts st
arte
d an
d en
ded
in th
e sa
me
cove
rage
per
iod.
Ther
e ar
e no
oth
er m
edica
l exp
ense
s for
an
y m
embe
r cov
ered
und
er th
is pl
an.
O
ut-o
f-poc
ket e
xpen
ses a
re b
ased
onl
y on
trea
ting
the
cond
ition
in th
e ex
ampl
e.
The
patie
nt re
ceiv
ed a
ll ca
re fr
om in
-ne
twor
k pr
ovid
ers.
If th
e pa
tient
had
re
ceiv
ed c
are
from
out
-of-n
etw
ork
prov
ider
s, co
sts w
ould
hav
e be
en h
ighe
r.
Wha
t doe
s a
Cov
erag
e Ex
ampl
e sh
ow?
Fo
r eac
h tre
atm
ent s
ituat
ion,
the
Cove
rage
E
xam
ple
help
s you
see
how
ded
uctib
les,
copa
ymen
ts, a
nd c
oins
uran
ce c
an a
dd u
p. It
als
o he
lps y
ou se
e w
hat e
xpen
ses m
ight
be
left
up to
you
to p
ay b
ecau
se th
e se
rvic
e or
tre
atm
ent i
sn’t
cove
red
or p
aym
ent i
s lim
ited.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y ow
n ca
re n
eeds
?
N
o. T
reat
men
ts sh
own
are
just
exa
mpl
es.
The
care
you
wou
ld re
ceiv
e fo
r thi
s co
nditi
on c
ould
be
diffe
rent
bas
ed o
n yo
ur
doct
or’s
advi
ce, y
our a
ge, h
ow se
rious
you
r co
nditi
on is
, and
man
y ot
her f
acto
rs.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y fu
ture
exp
ense
s?
N
o. C
over
age
Exa
mpl
es a
re n
ot c
ost
estim
ator
s. Y
ou c
an’t
use
the
exam
ples
to
estim
ate
cost
s for
an
actu
al co
nditi
on. T
hey
are
for c
ompa
rativ
e pu
rpos
es o
nly.
You
r ow
n co
sts w
ill b
e di
ffere
nt d
epen
ding
on
the
care
you
rece
ive,
the
price
s you
r pr
ovid
ers
char
ge, a
nd th
e re
imbu
rsem
ent
your
hea
lth p
lan a
llow
s.
Can
I us
e C
over
age
Exam
ples
to
com
pare
pla
ns?
Y
es. W
hen
you
look
at t
he S
umm
ary
of
Bene
fits a
nd C
over
age
for o
ther
plan
s, yo
u’ll
find
the
sam
e Co
vera
ge E
xam
ples
. W
hen
you
com
pare
plan
s, ch
eck
the
“Pat
ient P
ays”
box
in e
ach
exam
ple.
The
small
er th
at n
umbe
r, th
e m
ore
cove
rage
th
e pl
an p
rovi
des.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Y
es. A
n im
porta
nt c
ost i
s the
pre
miu
m
you
pay.
Gen
erall
y, th
e lo
wer
you
r pr
emiu
m, t
he m
ore
you’
ll pa
y in
out
-of-
pock
et c
osts
, suc
h as
cop
aym
ents
, de
duct
ible
s, an
d co
insu
ranc
e. Y
ou
shou
ld a
lso c
onsid
er c
ontri
butio
ns to
ac
coun
ts su
ch a
s hea
lth sa
ving
s acc
ount
s (H
SAs)
, flex
ible
spen
ding
arr
ange
men
ts
(FSA
s) o
r hea
lth re
imbu
rsem
ent a
ccou
nts
(HRA
s) th
at h
elp y
ou p
ay o
ut-o
f-poc
ket
expe
nses
.
1
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.bcb
sil.c
om o
r by
calli
ng 1
-888
-979
-451
6.
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy th
is M
atte
rs:
Wha
t is
the
over
all
dedu
ctib
le?
PPO
$70
0 Pe
rson
/$2,
100F
amily
N
on-P
PO $
1,40
0 Pe
rson
/$4,
200
Fam
ily.
Doe
sn’t
appl
y to
cer
tain
pre
vent
ive
serv
ices
, pre
scrip
tions
, em
erge
ncy
room
se
rvic
es, o
r offi
ce c
opay
s.
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins t
o pa
y fo
r cov
ered
serv
ices y
ou u
se.
Chec
k yo
ur p
olicy
or p
lan d
ocum
ent t
o se
e w
hen
the
dedu
ctib
le st
arts
ove
r (us
ually
, but
not
alw
ays,
Janu
ary
1st).
See
the
char
t sta
rting
on
page
2 fo
r how
muc
h yo
u pa
y fo
r cov
ered
serv
ices
afte
r you
mee
t th
e de
duct
ible
.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
?
Yes
. $10
0 de
duct
ible
for
hosp
ital a
dmiss
ion.
Th
ere
are
no o
ther
spec
ific
dedu
ctib
les.
You
mus
t pay
all
of th
e co
sts f
or th
ese
serv
ices u
p to
the
spec
ific
dedu
ctib
le
amou
nt b
efor
e th
is pl
an b
egin
s to
pay
for t
hese
serv
ices.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
?
Yes
. PPO
$2,
000
Pers
on/$
4,00
0 Fa
mily
N
on-P
PO
$4,0
00 P
erso
n/$8
,000
Fam
ily
RX O
ut-o
f-Poc
ket E
xpen
se L
imit:
$1
,500
Indi
vidu
al/ $
3,00
0 Fa
mily
The
out-o
f-poc
ket l
imit
is th
e m
ost y
ou c
ould
pay
dur
ing
a co
vera
ge p
erio
d (u
suall
y on
e ye
ar) f
or y
our s
hare
of t
he c
ost o
f cov
ered
serv
ices
. Th
is lim
it he
lps
you
plan
for h
ealth
car
e ex
pens
es.
Wha
t is
not i
nclu
ded
in
the
out–
of–p
ocke
t lim
it?
Pres
crip
tion
drug
s, pr
emiu
ms,
balan
ced-
bille
d ch
arge
s, an
d he
alth
care
this
plan
do
esn’
t cov
er.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t–of
–poc
ket
limit.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. Visi
t ww
w.b
cbsi
l.com
or c
all
1-88
8-97
9-45
16 fo
r a li
st o
f Par
ticip
atin
g pr
ovid
ers.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s plan
will
pay
so
me
or a
ll of
the
cost
s of c
over
ed se
rvic
es.
Be a
war
e, yo
ur in
-net
wor
k do
ctor
or
hosp
ital m
ay u
se a
n ou
t-of-n
etw
ork
prov
ider
for s
ome
serv
ices
. Pl
ans u
se th
e te
rm in
-net
wor
k, p
refe
rred
, or p
artic
ipat
ing
for p
rovi
ders
in th
eir n
etw
ork.
See
th
e ch
art s
tarti
ng o
n pa
ge 2
for h
ow th
is pl
an p
ays d
iffer
ent k
inds
of p
rovi
ders
.
Do
I nee
d a
refe
rral
to
see
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvic
es th
is pl
an d
oesn
’t co
ver a
re li
sted
on p
age
5. S
ee y
our p
olic
y or
plan
doc
umen
t for
add
ition
al in
form
atio
n ab
out e
xclu
ded
serv
ices
.
2
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $1
5) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usua
lly w
hen
you
rece
ive
the
serv
ice.
Coi
nsur
ance
is yo
ur sh
are
of th
e co
sts o
f a c
over
ed se
rvic
e, ca
lculat
ed a
s a p
erce
nt o
f the
allo
wed
am
ount
for t
he se
rvic
e. Fo
r exa
mpl
e, if
the
plan
’s al
low
ed a
mou
nt fo
r an
over
nigh
t hos
pita
l sta
y is
$1,0
00, y
our c
oins
uran
ce p
aym
ent o
f 20%
wou
ld b
e $2
00.
This
may
cha
nge
if yo
u ha
ven’
t met
you
r ded
uctib
le.
Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-n
etw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffere
nce.
For e
xam
ple,
if an
out
-of-n
etw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
you
may
hav
e to
pay
the
$500
diff
eren
ce. (
This
is ca
lled
bala
nce
billi
ng.)
Th
is pl
an m
ay e
ncou
rage
you
to u
se P
PO p
rovi
ders
by
char
ging
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s. C
omm
on
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d Yo
ur C
ost I
f Yo
u U
se a
n
PPO
P
rovi
der
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
$20
copa
y/vi
sit
30%
coi
nsur
ance
Co
pay
appl
ies t
o of
fice
visit
onl
y.
Spec
ialist
visi
t $3
0 co
pay/
visit
30
% c
oins
uran
ce
Copa
y ap
plie
s to
offic
e vi
sit o
nly.
Oth
er p
ract
ition
er o
ffice
visi
t 10
% c
oins
uran
ce
30%
coi
nsur
ance
Li
mite
d to
Chi
ropr
actic
and
O
steo
path
ic m
anip
ulat
ions
.
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
Char
ge
30%
coi
nsur
ance
---
none
---
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
10
% c
oins
uran
ce
30%
coi
nsur
ance
---
none
---
Imag
ing
(CT/
PET
scan
s, M
RIs)
10
% c
oins
uran
ce
30%
coi
nsur
ance
2
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $1
5) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usua
lly w
hen
you
rece
ive
the
serv
ice.
Coi
nsur
ance
is yo
ur sh
are
of th
e co
sts o
f a c
over
ed se
rvic
e, ca
lculat
ed a
s a p
erce
nt o
f the
allo
wed
am
ount
for t
he se
rvic
e. Fo
r exa
mpl
e, if
the
plan
’s al
low
ed a
mou
nt fo
r an
over
nigh
t hos
pita
l sta
y is
$1,0
00, y
our c
oins
uran
ce p
aym
ent o
f 20%
wou
ld b
e $2
00.
This
may
cha
nge
if yo
u ha
ven’
t met
you
r ded
uctib
le.
Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-n
etw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffere
nce.
For e
xam
ple,
if an
out
-of-n
etw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
you
may
hav
e to
pay
the
$500
diff
eren
ce. (
This
is ca
lled
bala
nce
billi
ng.)
Th
is pl
an m
ay e
ncou
rage
you
to u
se P
PO p
rovi
ders
by
char
ging
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s. C
omm
on
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d Yo
ur C
ost I
f Yo
u U
se a
n
PPO
P
rovi
der
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
$20
copa
y/vi
sit
30%
coi
nsur
ance
Co
pay
appl
ies t
o of
fice
visit
onl
y.
Spec
ialist
visi
t $3
0 co
pay/
visit
30
% c
oins
uran
ce
Copa
y ap
plie
s to
offic
e vi
sit o
nly.
Oth
er p
ract
ition
er o
ffice
visi
t 10
% c
oins
uran
ce
30%
coi
nsur
ance
Li
mite
d to
Chi
ropr
actic
and
O
steo
path
ic m
anip
ulat
ions
.
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
Char
ge
30%
coi
nsur
ance
---
none
---
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
10
% c
oins
uran
ce
30%
coi
nsur
ance
---
none
---
Imag
ing
(CT/
PET
scan
s, M
RIs)
10
% c
oins
uran
ce
30%
coi
nsur
ance
3
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
an
PP
O
Pro
vide
r
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
drug
s to
tre
at y
our i
llnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out p
resc
riptio
n dr
ug c
over
age
is av
ailab
le a
t w
ww
.bcb
sil.co
m.
Gen
eric
drug
s
$8 c
opay
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
$20
copa
y/
pres
crip
tion
for u
p to
a 9
0 da
y su
pply.
$8 c
opay
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
$20
copa
y/
pres
crip
tion
for u
p to
a 9
0 da
y su
pply.
Certa
in w
omen
’s pr
even
tativ
e se
rvice
s w
ill b
e co
vere
d w
ith n
o co
st to
the
mem
ber.
For a
full
list o
f the
se
pres
crip
tions
and
/or s
ervi
ces,
plea
se
cont
act C
usto
mer
Ser
vice
.
Form
ular
y br
and
drug
s
20%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
15%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
90
day
supp
ly.
20%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
15%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
90
day
supp
ly.
30 d
ay su
pply:
Max
$40
per
pr
escr
iptio
n; 9
0 da
y su
pply:
Max
$10
0 pe
r pre
scrip
tion.
See
abov
e (re
fer t
o ge
neric
).
Non
-For
mul
ary
bran
d dr
ugs
30%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
25%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
90
day
supp
ly.
30%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
30
day
supp
ly.
25%
coi
nsur
ance
/ pr
escr
iptio
n fo
r up
to a
90
day
supp
ly..
30 d
ay su
pply:
Max
$60
per
pr
escr
iptio
n; 9
0 da
y su
pply:
Max
$15
0 pe
r pre
scrip
tion.
Se
e ab
ove
(refe
r to
gene
ric).
Spec
ialty
dru
gs
$8 c
opay
/gen
eric
pres
crip
tion.
20
% c
oins
uran
ce/
Form
ular
y br
and
pres
crip
tion.
30
% c
oins
uran
ce/
Non
-For
mul
ary
bran
d pr
escr
iptio
n.
30 d
ay su
pply.
Not
Cov
ered
Form
ular
y br
and
$40
max
imum
N
on-F
orm
ular
y br
and
$60
max
imum
. Sp
ecial
ty re
tail
limite
d to
a 3
0 da
y su
pply
.
4
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
an
PP
O
Pro
vide
r
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou h
ave
outp
atie
nt s
urge
ry
Faci
lity
fee
(e.g
., am
bulat
ory
surg
ery
cent
er)
10%
coi
nsur
ance
30
% c
oins
uran
ce
---no
ne---
Phys
ician
/sur
geon
fees
10
% c
oins
uran
ce
30%
coi
nsur
ance
---
none
---
If y
ou n
eed
imm
edia
te m
edic
al
atte
ntio
n
Em
erge
ncy
room
serv
ices
$1
00 c
opay
plu
s 10
% c
oins
uran
ce.
$100
cop
ay p
lus
10%
coi
nsur
ance
Co
pay
waiv
ed if
adm
itted
.
Em
erge
ncy
med
ical t
rans
porta
tion
10%
coi
nsur
ance
10
% c
oins
uran
ce
---no
ne---
U
rgen
t car
e 10
% c
oins
uran
ce
30%
coi
nsur
ance
---
none
---
If y
ou h
ave
a ho
spita
l sta
y Fa
cilit
y fe
e (e
.g.,
hosp
ital r
oom
) $1
00 c
opay
plu
s 10
% c
oins
uran
ce
$100
cop
ay p
lus
30%
coi
nsur
ance
---
none
---
Phys
ician
/sur
geon
fee
10%
coi
nsur
ance
30
% c
oins
uran
ce
---no
ne---
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al he
alth
outp
atien
t ser
vice
s 10
% c
oins
uran
ce
30%
coi
nsur
ance
---
none
---
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
$1
00 c
opay
plu
s 10
% c
oins
uran
ce
$100
cop
ay p
lus
30%
coi
nsur
ance
---
none
---
Subs
tanc
e us
e di
sord
er o
utpa
tient
serv
ices
10
% c
oins
uran
ce
30%
coi
nsur
ance
---
none
---
Subs
tanc
e us
e di
sord
er in
patie
nt se
rvic
es
$100
cop
ay p
lus
10%
coi
nsur
ance
$1
00 c
opay
plu
s 30
% c
oins
uran
ce
---no
ne---
If y
ou a
re p
regn
ant
Pren
atal
and
post
nata
l car
e $2
0 co
pay
30%
coi
nsur
ance
Co
pay
appl
ies t
o fir
st p
rena
tal v
isit
(per
pre
gnan
cy).
Del
iver
y an
d all
inpa
tient
serv
ices
$1
00 c
opay
plu
s 10
% c
oins
uran
ce
$100
cop
ay p
lus
30%
coi
nsur
ance
---
none
---
5
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
an
PP
O
Pro
vide
r
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
care
10
% c
oins
uran
ce
30%
coi
nsur
ance
Li
mite
d to
120
visi
ts p
er b
enef
it pe
riod.
Re
habi
litat
ion
serv
ices
10
% c
oins
uran
ce
30%
coi
nsur
ance
Li
mite
d to
90
visit
s per
ben
efit
perio
d.
Hab
ilita
tion
serv
ices
10
% c
oins
uran
ce
30%
coi
nsur
ance
Li
mite
d to
90
visit
s per
ben
efit
perio
d.
Skill
ed n
ursin
g ca
re
$100
cop
ay p
lus
10%
coi
nsur
ance
$1
00 c
opay
plu
s 30
% c
oins
uran
ce
Lim
ited
to a
120
day
s per
ben
efit
perio
d.
Dur
able
med
ical
equi
pmen
t 10
% c
oins
uran
ce
30%
coi
nsur
ance
Bene
fits a
re li
mite
d to
item
s use
d to
se
rve
a m
edic
al pu
rpos
e. D
ME
be
nefit
s are
pro
vide
d fo
r bot
h pu
rcha
se a
nd re
ntal
equi
pmen
t (up
to
the
purc
hase
pric
e).
Hos
pice
serv
ice
10%
coi
nsur
ance
30
% c
oins
uran
ce
---no
ne---
If y
our c
hild
nee
ds
dent
al o
r eye
car
e
Eye
exa
m
Not
Cov
ered
N
ot C
over
ed
---no
ne---
G
lasse
s N
ot C
over
ed
Not
Cov
ered
D
enta
l che
ck-u
p N
ot C
over
ed
Not
Cov
ered
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Se
rvic
es Y
our P
lan
Doe
s N
OT
Cov
er (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
exc
lude
d se
rvic
es.)
A
cupu
nctu
re
Co
smet
ic S
urge
ry
D
enta
l Car
e (A
dult)
Lo
ng T
erm
Car
e
Rout
ine
Eye
Car
e (A
dult)
Ro
utin
g Fo
ot C
are
(with
the
exce
ptio
n of
pe
rson
with
the
diag
nosis
of d
iabet
es)
W
eigh
t Los
s Pro
gram
O
ther
Cov
ered
Ser
vice
s (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
cov
ered
ser
vice
s an
d yo
ur c
osts
for t
hese
se
rvic
es.)
Ba
riatri
c Su
rger
y
Chiro
prac
tic C
are
H
earin
g A
ids
In
ferti
lity
Trea
tmen
t
Mos
t cov
erag
e pr
ovid
ed o
utsid
e th
e U
nite
d St
ates
. See
ww
w.b
cbsil
.com
N
on-E
mer
genc
y Ca
re W
hen
Trav
elin
g O
utsid
e th
e U
.S
Pr
ivat
e D
uty
Nur
sing
(with
the
exce
ptio
n of
inpa
tient
priv
ate
duty
nur
sing)
6
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Plan
Cov
ers &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Your
Rig
hts
to C
ontin
ue C
over
age:
If
you
lose
cov
erag
e un
der t
he p
lan, t
hen,
dep
endi
ng u
pon
the
circ
umst
ance
s, Fe
dera
l and
Sta
te la
ws m
ay p
rovi
de p
rote
ctio
ns th
at a
llow
you
to k
eep
healt
h co
vera
ge. A
ny su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay
whi
le c
over
ed u
nder
the
plan
. Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e m
ay a
lso a
pply
. Fo
r mor
e in
form
atio
n on
you
r rig
hts t
o co
ntin
ue c
over
age,
cont
act t
he p
lan a
t 1-8
88-9
79-4
516.
You
may
also
con
tact
you
r sta
te in
sura
nce
depa
rtmen
t, th
e U
.S. D
epar
tmen
t of L
abor
, Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istra
tion
at 1
-866
-444
-327
2 or
ww
w.d
ol.g
ov/e
bsa,
or th
e U
.S. D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s at 1
-877
-267
-232
3 x6
1565
or w
ww
.cciio
.cms.g
ov.
Your
Grie
vanc
e an
d A
ppea
ls R
ight
s:
If y
ou h
ave
a co
mpl
aint o
r are
diss
atisf
ied
with
a d
enial
of c
over
age
for c
laim
s und
er y
our p
lan, y
ou m
ay b
e ab
le to
app
eal o
r file
a g
rieva
nce.
For
qu
estio
ns a
bout
you
r rig
hts,
this
notic
e, or
ass
istan
ce, y
ou c
an c
onta
ct B
lue
Cros
s and
Blu
e Sh
ield
of I
llino
is at
1-8
88-9
79-4
516
or v
isit w
ww
.bcb
sil.co
m, o
r co
ntac
t the
U.S
Dep
artm
ent o
f Lab
or's
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istra
tion
at 1
-866
-444
-EBS
A (3
272)
or v
isit w
ww
.dol
.gov
/ebs
a/he
althr
efor
m.
Add
ition
ally,
a co
nsum
er a
ssist
ance
pro
gram
can
help
you
file
you
r app
eal.
Cont
act t
he Il
linoi
s Dep
artm
ent o
f Ins
uran
ce a
t (87
7) 5
27-9
431
or v
isit
http
://i
nsur
ance
.illin
ois.g
ov.
Doe
s th
is C
over
age
Prov
ide
Min
imum
Ess
entia
l Cov
erag
e?
The
Affo
rdab
le C
are
Act
requ
ires m
ost p
eopl
e to
hav
e he
alth
care
cov
erag
e th
at q
ualif
ies a
s “m
inim
um e
ssen
tial c
over
age.”
Thi
s pl
an o
r pol
icy
does
pr
ovid
e m
inim
um e
ssen
tial c
over
age.
D
oes
this
Cov
erag
e M
eet t
he M
inim
um V
alue
Sta
ndar
d?
The
Affo
rdab
le C
are
Act
est
ablis
hes a
min
imum
valu
e st
anda
rd o
f ben
efits
of a
hea
lth p
lan. T
he m
inim
um v
alue
stan
dard
is 6
0% (a
ctua
rial v
alue)
. Thi
s he
alth
cov
erag
e do
es m
eet t
he m
inim
um v
alue
sta
ndar
d fo
r the
ben
efits
it p
rovi
des.
Lang
uage
Acc
ess
Serv
ices
: Sp
anish
(Esp
añol
): Pa
ra o
bten
er a
siste
ncia
en E
spañ
ol, l
lame
al 1-
888-
979-
4516
. Ta
galo
g (T
agalo
g): K
ung
kaila
ngan
nin
yo a
ng tu
long
sa T
agalo
g tu
maw
ag sa
1-88
8-97
9-45
16.
Chin
ese
(中文
): 如果需要中文的帮助,请拨打这个号码
1-88
8-97
9-45
16.
Nav
ajo (D
ine)
: Din
ek'eh
go sh
ika
at'o
hwol
nin
ising
o, k
wiij
igo
holn
e' 1-
888-
979-
4516
. ––
––––
––––
––––
––––
––––
To se
e exa
mples
of h
ow th
is pla
n mi
ght c
over
costs
for a
samp
le me
dical
situa
tion,
see th
e nex
t pag
e.–––
––––
––––
––––
––––
–––
7
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 C
over
age
Exa
mpl
es
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Hav
ing
a ba
by
(nor
mal
deliv
ery)
Man
agin
g ty
pe 2
dia
bete
s (ro
utin
e m
ainte
nanc
e of
a
wel
l-con
trolle
d co
nditi
on)
Abo
ut th
ese
Cov
erag
e Ex
ampl
es:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
cov
er
med
ical
care
in g
iven
situ
atio
ns. U
se th
ese
exam
ples
to se
e, in
gen
eral,
how
muc
h fin
ancia
l pr
otec
tion
a sa
mpl
e pa
tient
mig
ht g
et if
they
are
co
vere
d un
der d
iffer
ent p
lans.
A
mou
nt o
wed
to p
rovi
ders
: $7,
540
P
lan
pays
$6,
150
P
atie
nt p
ays
$1,3
90
Sa
mpl
e ca
re c
osts
: H
ospi
tal c
harg
es (m
othe
r) $2
,700
Ro
utin
e ob
stet
ric c
are
$2,1
00
Hos
pita
l cha
rges
(bab
y)
$900
A
nest
hesia
$9
00
Labo
rato
ry te
sts
$500
Pr
escr
iptio
ns
$200
Ra
diol
ogy
$200
V
acci
nes,
othe
r pre
vent
ive
$40
Tot
al
$7,5
40
Patie
nt p
ays:
D
educ
tibles
$7
00
Copa
ys
$30
Coin
sura
nce
$510
Li
mits
or e
xclu
sions
$1
50
Tot
al
$1,3
90
A
mou
nt o
wed
to p
rovi
ders
: $5,
400
P
lan
pays
$4,
020
P
atie
nt p
ays
$1,3
80
Sa
mpl
e ca
re c
osts
: Pr
escr
iptio
ns
$2,9
00
Med
ical
Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Offi
ce V
isits
and
Pro
cedu
res
$700
E
duca
tion
$300
La
bora
tory
test
s $1
00
Vac
cine
s, ot
her p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patie
nt p
ays:
D
educ
tibles
$7
00
Copa
ys
$490
Co
insu
ranc
e $1
10
Lim
its o
r exc
lusio
ns
$80
Tot
al
$1,3
80
Not
e: Th
ese
exam
ples
are
bas
ed o
n in
divi
dual
cove
rage
onl
y.
This
is
not a
cos
t es
timat
or.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
un
der t
his p
lan. T
he a
ctua
l ca
re y
ou re
ceiv
e w
ill b
e di
ffere
nt fr
om th
ese
exam
ples
, and
the
cost
of
that
car
e w
ill a
lso b
e di
ffere
nt.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
8
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 90%
PPO
Med
ical
Pla
n C
over
age
Perio
d: 0
1/01
/201
5 - 1
2/31
/201
5 C
over
age
Exa
mpl
es
C
over
age
for:
Indi
vidu
al+Fa
mily
| P
lan
Typ
e: P
PO
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Que
stio
ns a
nd a
nsw
ers
abou
t the
Cov
erag
e Ex
ampl
es:
Wha
t are
som
e of
the
assu
mpt
ions
beh
ind
the
Cov
erag
e Ex
ampl
es?
Co
sts d
on’t
incl
ude
prem
ium
s.
Sam
ple
care
cos
ts a
re b
ased
on
natio
nal
aver
ages
supp
lied
by th
e U
.S.
Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvice
s, an
d ar
en’t
spec
ific
to a
pa
rticu
lar g
eogr
aphi
c ar
ea o
r hea
lth p
lan.
Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clud
ed o
r pre
exist
ing
cond
ition
.
All
serv
ices
and
trea
tmen
ts st
arte
d an
d en
ded
in th
e sa
me
cove
rage
per
iod.
Ther
e ar
e no
oth
er m
edica
l exp
ense
s for
an
y m
embe
r cov
ered
und
er th
is pl
an.
O
ut-o
f-poc
ket e
xpen
ses a
re b
ased
onl
y on
trea
ting
the
cond
ition
in th
e ex
ampl
e.
The
patie
nt re
ceiv
ed a
ll ca
re fr
om in
-ne
twor
k pr
ovid
ers.
If th
e pa
tient
had
re
ceiv
ed c
are
from
out
-of-n
etw
ork
prov
ider
s, co
sts w
ould
hav
e be
en h
ighe
r.
Wha
t doe
s a
Cov
erag
e Ex
ampl
e sh
ow?
Fo
r eac
h tre
atm
ent s
ituat
ion,
the
Cove
rage
E
xam
ple
help
s you
see
how
ded
uctib
les,
copa
ymen
ts, a
nd c
oins
uran
ce c
an a
dd u
p. It
als
o he
lps y
ou se
e w
hat e
xpen
ses m
ight
be
left
up to
you
to p
ay b
ecau
se th
e se
rvic
e or
tre
atm
ent i
sn’t
cove
red
or p
aym
ent i
s lim
ited.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y ow
n ca
re n
eeds
?
N
o. T
reat
men
ts sh
own
are
just
exa
mpl
es.
The
care
you
wou
ld re
ceiv
e fo
r thi
s co
nditi
on c
ould
be
diffe
rent
bas
ed o
n yo
ur
doct
or’s
advi
ce, y
our a
ge, h
ow se
rious
you
r co
nditi
on is
, and
man
y ot
her f
acto
rs.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y fu
ture
exp
ense
s?
N
o. C
over
age
Exa
mpl
es a
re n
ot c
ost
estim
ator
s. Y
ou c
an’t
use
the
exam
ples
to
estim
ate
cost
s for
an
actu
al co
nditi
on. T
hey
are
for c
ompa
rativ
e pu
rpos
es o
nly.
You
r ow
n co
sts w
ill b
e di
ffere
nt d
epen
ding
on
the
care
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
the
reim
burs
emen
t yo
ur h
ealth
plan
allo
ws.
Can
I us
e C
over
age
Exam
ples
to
com
pare
pla
ns?
Y
es. W
hen
you
look
at t
he S
umm
ary
of
Bene
fits a
nd C
over
age
for o
ther
plan
s, yo
u’ll
find
the
sam
e Co
vera
ge E
xam
ples
. W
hen
you
com
pare
plan
s, ch
eck
the
“Pat
ient P
ays”
box
in e
ach
exam
ple.
The
small
er th
at n
umbe
r, th
e m
ore
cove
rage
th
e pl
an p
rovi
des.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Y
es. A
n im
porta
nt c
ost i
s the
pre
miu
m
you
pay.
Gen
erall
y, th
e lo
wer
you
r pr
emiu
m, t
he m
ore
you’
ll pa
y in
out
-of-
pock
et c
osts
, suc
h as
cop
aym
ents
, de
duct
ible
s, an
d co
insu
ranc
e. Y
ou
shou
ld a
lso c
onsid
er c
ontri
butio
ns to
ac
coun
ts su
ch a
s hea
lth sa
ving
s acc
ount
s (H
SAs)
, flex
ible
spen
ding
arr
ange
men
ts
(FSA
s) o
r hea
lth re
imbu
rsem
ent a
ccou
nts
(HRA
s) th
at h
elp y
ou p
ay o
ut-o
f-poc
ket
expe
nses
.
1
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his P
lan C
over
s & W
hat i
t Cos
ts
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.bcb
sil.c
om o
r by
calli
ng 1
-888
-979
-451
6.
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy th
is M
atte
rs:
Wha
t is
the
over
all
dedu
ctib
le?
$1,7
50 P
erso
n/$5
,250
Fam
ily
PPO
& N
on-P
PO
Doe
sn’t
appl
y to
cer
tain
pre
vent
ive
serv
ices
, pre
scrip
tions
, em
erge
ncy
room
se
rvic
es, o
r offi
ce c
opay
s.
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins t
o pa
y fo
r cov
ered
serv
ices y
ou u
se.
Chec
k yo
ur p
olicy
or p
lan d
ocum
ent t
o se
e w
hen
the
dedu
ctib
le st
arts
ove
r (us
ually
, but
not
alw
ays,
Janu
ary
1st).
See
the
char
t sta
rting
on
page
2 fo
r how
muc
h yo
u pa
y fo
r cov
ered
serv
ices
afte
r you
mee
t th
e de
duct
ible
.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
? N
o.
You
mus
t pay
all
of th
e co
sts f
or th
ese
serv
ices u
p to
the
spec
ific
dedu
ctib
le
amou
nt b
efor
e th
is pl
an b
egin
s to
pay
for t
hese
serv
ices.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
? Y
es. $
2,50
0 Pe
rson
/$7,
500
Fam
ily
The
out-o
f-poc
ket l
imit
is th
e m
ost y
ou c
ould
pay
dur
ing
a co
vera
ge p
erio
d (u
suall
y on
e ye
ar) f
or y
our s
hare
of t
he c
ost o
f cov
ered
serv
ices
. Th
is lim
it he
lps
you
plan
for h
ealth
car
e ex
pens
es.
Wha
t is
not i
nclu
ded
in
the
out–
of–p
ocke
t lim
it?
Pres
crip
tion
drug
s, pr
emiu
ms,
balan
ced-
bille
d ch
arge
s, an
d he
alth
care
this
plan
do
esn’
t cov
er.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t–of
–poc
ket
limit.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. Visi
t ww
w.b
cbsi
l.com
or c
all 1
-88
8-97
9-45
16 fo
r a li
st o
f Par
ticip
atin
g pr
ovid
ers.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s plan
will
pay
som
e or
all
of th
e co
sts o
f cov
ered
serv
ices
. Be
aw
are,
your
in-n
etw
ork
doct
or o
r hos
pita
l m
ay u
se a
n ou
t-of-n
etw
ork
prov
ider
for s
ome
serv
ices.
Plan
s use
the
term
in-
netw
ork,
pre
ferr
ed, o
r par
ticip
atin
g fo
r pro
vide
rs in
their
net
wor
k. S
ee th
e ch
art
star
ting
on p
age
2 fo
r how
this
plan
pay
s diff
eren
t kin
ds o
f pro
vide
rs.
Do
I nee
d a
refe
rral
to
see
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvic
es th
is pl
an d
oesn
’t co
ver a
re li
sted
on p
age
5. S
ee y
our p
olic
y or
plan
doc
umen
t for
add
ition
al in
form
atio
n ab
out e
xclu
ded
serv
ices
.
1
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his P
lan C
over
s & W
hat i
t Cos
ts
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.bcb
sil.c
om o
r by
calli
ng 1
-888
-979
-451
6.
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy th
is M
atte
rs:
Wha
t is
the
over
all
dedu
ctib
le?
$1,7
50 P
erso
n/$5
,250
Fam
ily
PPO
& N
on-P
PO
Doe
sn’t
appl
y to
cer
tain
pre
vent
ive
serv
ices
, pre
scrip
tions
, em
erge
ncy
room
se
rvic
es, o
r offi
ce c
opay
s.
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins t
o pa
y fo
r cov
ered
serv
ices y
ou u
se.
Chec
k yo
ur p
olicy
or p
lan d
ocum
ent t
o se
e w
hen
the
dedu
ctib
le st
arts
ove
r (us
ually
, but
not
alw
ays,
Janu
ary
1st).
See
the
char
t sta
rting
on
page
2 fo
r how
muc
h yo
u pa
y fo
r cov
ered
serv
ices
afte
r you
mee
t th
e de
duct
ible
.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
? N
o.
You
mus
t pay
all
of th
e co
sts f
or th
ese
serv
ices u
p to
the
spec
ific
dedu
ctib
le
amou
nt b
efor
e th
is pl
an b
egin
s to
pay
for t
hese
serv
ices.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
? Y
es. $
2,50
0 Pe
rson
/$7,
500
Fam
ily
The
out-o
f-poc
ket l
imit
is th
e m
ost y
ou c
ould
pay
dur
ing
a co
vera
ge p
erio
d (u
suall
y on
e ye
ar) f
or y
our s
hare
of t
he c
ost o
f cov
ered
serv
ices
. Th
is lim
it he
lps
you
plan
for h
ealth
car
e ex
pens
es.
Wha
t is
not i
nclu
ded
in
the
out–
of–p
ocke
t lim
it?
Pres
crip
tion
drug
s, pr
emiu
ms,
balan
ced-
bille
d ch
arge
s, an
d he
alth
care
this
plan
do
esn’
t cov
er.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t–of
–poc
ket
limit.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. Visi
t ww
w.b
cbsi
l.com
or c
all 1
-88
8-97
9-45
16 fo
r a li
st o
f Par
ticip
atin
g pr
ovid
ers.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s plan
will
pay
som
e or
all
of th
e co
sts o
f cov
ered
serv
ices
. Be
aw
are,
your
in-n
etw
ork
doct
or o
r hos
pita
l m
ay u
se a
n ou
t-of-n
etw
ork
prov
ider
for s
ome
serv
ices.
Plan
s use
the
term
in-
netw
ork,
pre
ferr
ed, o
r par
ticip
atin
g fo
r pro
vide
rs in
their
net
wor
k. S
ee th
e ch
art
star
ting
on p
age
2 fo
r how
this
plan
pay
s diff
eren
t kin
ds o
f pro
vide
rs.
Do
I nee
d a
refe
rral
to
see
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvic
es th
is pl
an d
oesn
’t co
ver a
re li
sted
on p
age
5. S
ee y
our p
olic
y or
plan
doc
umen
t for
add
ition
al in
form
atio
n ab
out e
xclu
ded
serv
ices
.
2
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his P
lan C
over
s & W
hat i
t Cos
ts
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $1
5) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usua
lly w
hen
you
rece
ive
the
serv
ice.
Coi
nsur
ance
is yo
ur sh
are
of th
e co
sts o
f a c
over
ed se
rvic
e, ca
lculat
ed a
s a p
erce
nt o
f the
allo
wed
am
ount
for t
he se
rvic
e. Fo
r exa
mpl
e, if
the
plan
’s al
low
ed a
mou
nt fo
r an
over
nigh
t hos
pita
l sta
y is
$1,0
00, y
our c
oins
uran
ce p
aym
ent o
f 20%
wou
ld b
e $2
00.
This
may
cha
nge
if yo
u ha
ven’
t met
you
r ded
uctib
le.
Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-n
etw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffere
nce.
For e
xam
ple,
if an
out
-of-n
etw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
you
may
hav
e to
pay
the
$500
diff
eren
ce. (
This
is ca
lled
bala
nce
billi
ng.)
Th
is pl
an m
ay e
ncou
rage
you
to u
se P
PO p
rovi
ders
by
char
ging
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s. C
omm
on
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d Yo
ur C
ost I
f Yo
u U
se a
n
PPO
P
rovi
der
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
15%
coi
nsur
ance
35
% c
oins
uran
ce
---no
ne---
Spec
ialist
visi
t 15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Oth
er p
ract
ition
er o
ffice
visi
t 15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
Char
ge
35%
coi
nsur
ance
---
none
---
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Imag
ing
(CT/
PET
scan
s, M
RIs)
15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
2
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his P
lan C
over
s & W
hat i
t Cos
ts
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $1
5) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usua
lly w
hen
you
rece
ive
the
serv
ice.
Coi
nsur
ance
is yo
ur sh
are
of th
e co
sts o
f a c
over
ed se
rvic
e, ca
lculat
ed a
s a p
erce
nt o
f the
allo
wed
am
ount
for t
he se
rvic
e. Fo
r exa
mpl
e, if
the
plan
’s al
low
ed a
mou
nt fo
r an
over
nigh
t hos
pita
l sta
y is
$1,0
00, y
our c
oins
uran
ce p
aym
ent o
f 20%
wou
ld b
e $2
00.
This
may
cha
nge
if yo
u ha
ven’
t met
you
r ded
uctib
le.
Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-n
etw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffere
nce.
For e
xam
ple,
if an
out
-of-n
etw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
you
may
hav
e to
pay
the
$500
diff
eren
ce. (
This
is ca
lled
bala
nce
billi
ng.)
Th
is pl
an m
ay e
ncou
rage
you
to u
se P
PO p
rovi
ders
by
char
ging
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s. C
omm
on
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d Yo
ur C
ost I
f Yo
u U
se a
n
PPO
P
rovi
der
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
15%
coi
nsur
ance
35
% c
oins
uran
ce
---no
ne---
Spec
ialist
visi
t 15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Oth
er p
ract
ition
er o
ffice
visi
t 15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
Char
ge
35%
coi
nsur
ance
---
none
---
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Imag
ing
(CT/
PET
scan
s, M
RIs)
15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
3
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his P
lan C
over
s & W
hat i
t Cos
ts
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
an
PP
O
Pro
vide
r
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
drug
s to
tre
at y
our i
llnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out p
resc
riptio
n dr
ug c
over
age
is av
ailab
le a
t w
ww
.bcb
sil.co
m.
Gen
eric
drug
s 15
% c
oins
uran
ce
15%
coi
nsur
ance
Ce
rtain
wom
en’s
prev
enta
tive
serv
ices
will
be
cove
red
with
no
cost
to th
e m
embe
r. Fo
r a fu
ll lis
t of t
hese
pr
escr
iptio
ns a
nd/o
r ser
vice
s, pl
ease
co
ntac
t Cus
tom
er S
ervi
ce.
30 d
ay re
tail/
90 d
ay m
ail
Form
ular
y br
and
drug
s 15
% c
oins
uran
ce
15%
coi
nsur
ance
N
on-F
orm
ular
y br
and
drug
s 15
% c
oins
uran
ce
15%
coi
nsur
ance
Spec
ialty
dru
gs
Cove
red
Not
Cov
ered
If y
ou h
ave
outp
atie
nt s
urge
ry
Faci
lity
fee
(e.g
., am
bulat
ory
surg
ery
cent
er)
15%
coi
nsur
ance
35
% c
oins
uran
ce
---no
ne---
Ph
ysic
ian/s
urge
on fe
es
15%
coi
nsur
ance
35
% c
oins
uran
ce
If y
ou n
eed
imm
edia
te m
edic
al
atte
ntio
n
Em
erge
ncy
room
serv
ices
15
% c
oins
uran
ce
15%
coi
nsur
ance
---
none
---
Em
erge
ncy
med
ical t
rans
porta
tion
15%
coi
nsur
ance
15
% c
oins
uran
ce
---no
ne---
U
rgen
t car
e 15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
If y
ou h
ave
a ho
spita
l sta
y
Faci
lity
fee
(e.g
., ho
spita
l roo
m)
15%
coi
nsur
ance
35
% c
oins
uran
ce
---no
ne---
Phys
ician
/sur
geon
fee
15%
coi
nsur
ance
35
% c
oins
uran
ce
---no
ne---
4
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his P
lan C
over
s & W
hat i
t Cos
ts
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
an
PP
O
Pro
vide
r
Your
Cos
t If
You
Use
an
N
on-P
PO
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al he
alth
outp
atien
t ser
vice
s 15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Subs
tanc
e us
e di
sord
er o
utpa
tient
serv
ices
15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Subs
tanc
e us
e di
sord
er in
patie
nt se
rvic
es
15%
coi
nsur
ance
35
% c
oins
uran
ce
---no
ne---
If y
ou a
re p
regn
ant
Pren
atal
and
post
nata
l car
e 15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
Del
iver
y an
d all
inpa
tient
serv
ices
15
% c
oins
uran
ce
35%
coi
nsur
ance
---
none
---
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
care
15
% c
oins
uran
ce
35%
coi
nsur
ance
Li
mite
d to
120
visi
ts p
er b
enef
it pe
riod.
Re
habi
litat
ion
serv
ices
15
% c
oins
uran
ce
35%
coi
nsur
ance
Li
mite
d to
90
visit
s per
ben
efit
perio
d.
Hab
ilita
tion
serv
ices
15
% c
oins
uran
ce
35%
coi
nsur
ance
Li
mite
d to
90
visit
s per
ben
efit
perio
d.
Skill
ed n
ursin
g ca
re
15%
coi
nsur
ance
35
% c
oins
uran
ce
Lim
ited
to 1
20 d
ays p
er b
enef
it pe
riod.
Dur
able
med
ical
equi
pmen
t 15
% c
oins
uran
ce
35%
coi
nsur
ance
Bene
fits a
re li
mite
d to
item
s use
d to
se
rve
a m
edic
al pu
rpos
e. D
ME
be
nefit
s are
pro
vide
d fo
r bot
h pu
rcha
se a
nd re
ntal
equi
pmen
t (up
to
the
purc
hase
pric
e).
Hos
pice
serv
ice
15%
coi
nsur
ance
35
% c
oins
uran
ce
---no
ne---
If y
our c
hild
nee
ds
dent
al o
r eye
car
e
Eye
exa
m
Not
Cov
ered
N
ot C
over
ed
---no
ne---
G
lasse
s N
ot C
over
ed
Not
Cov
ered
D
enta
l che
ck-u
p N
ot C
over
ed
Not
Cov
ered
5
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his P
lan C
over
s & W
hat i
t Cos
ts
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Se
rvic
es Y
our P
lan
Doe
s N
OT
Cov
er (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
exc
lude
d se
rvic
es.)
A
cupu
nctu
re
Co
smet
ic S
urge
ry
D
enta
l Car
e (A
dult)
Lo
ng T
erm
Car
e
Rout
ing
Eye
Car
e (A
dult)
Ro
utin
g Fo
ot C
are
(with
the
exce
ptio
n of
pe
rson
with
diag
nosis
of d
iabet
es)
W
eigh
t Los
s Pro
gram
O
ther
Cov
ered
Ser
vice
s (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
cov
ered
ser
vice
s an
d yo
ur c
osts
for t
hese
se
rvic
es.)
Ba
riatri
c Su
rger
y
Chiro
prac
tic C
are
H
earin
g A
ids
In
ferti
lity
Trea
tmen
t
Mos
t cov
erag
e pr
ovid
ed o
utsid
e th
e U
nite
d St
ates
. See
ww
w.b
cbsil
.com
N
on-E
mer
genc
y Ca
re W
hen
Trav
elin
g O
utsid
e th
e U
.S
Pr
ivat
e D
uty
Nur
sing
(with
the
exce
ptio
n of
inpa
tient
priv
ate
duty
nur
sing)
Yo
ur R
ight
s to
Con
tinue
Cov
erag
e:
If y
ou lo
se c
over
age
unde
r the
plan
, the
n, d
epen
ding
upo
n th
e ci
rcum
stan
ces,
Fede
ral a
nd S
tate
law
s may
pro
vide
pro
tect
ions
that
allo
w y
ou to
kee
p he
alth
cove
rage
. Any
such
righ
ts m
ay b
e lim
ited
in d
urat
ion
and
will
requ
ire y
ou to
pay
a p
rem
ium
, whi
ch m
ay b
e sig
nific
antly
hig
her t
han
the
prem
ium
you
pay
w
hile
cov
ered
und
er th
e pl
an. O
ther
lim
itatio
ns o
n yo
ur ri
ghts
to c
ontin
ue c
over
age
may
also
app
ly.
For m
ore
info
rmat
ion
on y
our r
ight
s to
cont
inue
cov
erag
e, co
ntac
t the
plan
at 1
-888
-979
-451
6. Y
ou m
ay a
lso c
onta
ct y
our s
tate
insu
ranc
e de
partm
ent,
the
U.S
. Dep
artm
ent o
f Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, or
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd
Hum
an S
ervi
ces a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.cc
iio.cm
s.gov
. Yo
ur G
rieva
nce
and
App
eals
Rig
hts:
If
you
hav
e a
com
plain
t or a
re d
issat
isfie
d w
ith a
den
ial o
f cov
erag
e fo
r clai
ms u
nder
you
r plan
, you
may
be
able
to a
ppea
l or f
ile a
grie
vanc
e. F
or
ques
tions
abo
ut y
our r
ight
s, th
is no
tice,
or a
ssist
ance
, you
can
con
tact
Blu
e Cr
oss a
nd B
lue
Shie
ld o
f Illi
nois
at 1
-888
-979
-451
6 or
visi
t ww
w.b
cbsil
.com
, or
cont
act t
he U
.S D
epar
tmen
t of L
abor
's E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-E
BSA
(327
2) o
r visi
t ww
w.d
ol.g
ov/e
bsa/
healt
href
orm
. A
dditi
onall
y, a
cons
umer
ass
istan
ce p
rogr
am c
an h
elp y
ou fi
le y
our a
ppea
l. Co
ntac
t the
Illin
ois D
epar
tmen
t of I
nsur
ance
at (
877)
527
-943
1 or
visi
t ht
tp:/
/ins
uran
ce.il
linoi
s.gov
.
Doe
s th
is C
over
age
Prov
ide
Min
imum
Ess
entia
l Cov
erag
e?
The
Affo
rdab
le C
are
Act
requ
ires m
ost p
eopl
e to
hav
e he
alth
care
cov
erag
e th
at q
ualif
ies a
s “m
inim
um e
ssen
tial c
over
age.”
Thi
s pl
an o
r pol
icy
does
pr
ovid
e m
inim
um e
ssen
tial c
over
age.
6
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his P
lan C
over
s & W
hat i
t Cos
ts
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Doe
s th
is C
over
age
Mee
t the
Min
imum
Val
ue S
tand
ard?
Th
e A
fford
able
Car
e A
ct e
stab
lishe
s a m
inim
um v
alue
stan
dard
of b
enef
its o
f a h
ealth
plan
. The
min
imum
valu
e st
anda
rd is
60%
(act
uaria
l valu
e). T
his
heal
th c
over
age
does
mee
t the
min
imum
val
ue s
tand
ard
for t
he b
enef
its it
pro
vide
s.
Lang
uage
Acc
ess
Serv
ices
: Sp
anish
(Esp
añol
): Pa
ra o
bten
er a
siste
ncia
en E
spañ
ol, l
lame
al 1-
888-
979-
4516
. Ta
galo
g (T
agalo
g): K
ung
kaila
ngan
nin
yo a
ng tu
long
sa T
agalo
g tu
maw
ag sa
1-88
8-97
9-45
16.
Chin
ese
(中文
): 如果需要中文的帮助,请拨打这个号码
1-88
8-97
9-45
16.
Nav
ajo (D
ine)
: Din
ek'eh
go sh
ika
at'o
hwol
nin
ising
o, k
wiij
igo
holn
e' 1-
888-
979-
4516
. ––
––––
––––
––––
––––
––––
To se
e exa
mples
of h
ow th
is pla
n mi
ght c
over
costs
for a
samp
le me
dical
situa
tion,
see t
he n
ext p
age.–
––––
––––
––––
––––
––––
–
7
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Cov
erag
e E
xam
ples
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
Pla
n T
ype:
HSA
Que
stio
ns: C
all 1-
888-
979-
4516
or v
isit u
s at w
ww
.bcb
sil.c
om.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all 1
-855
-756
-444
8 to
requ
est a
cop
y.
Hav
ing
a ba
by
(nor
mal
deliv
ery)
Man
agin
g ty
pe 2
dia
bete
s (ro
utin
e m
ainte
nanc
e of
a
wel
l-con
trolle
d co
nditi
on)
Abo
ut th
ese
Cov
erag
e Ex
ampl
es:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
cov
er
med
ical
care
in g
iven
situ
atio
ns. U
se th
ese
exam
ples
to se
e, in
gen
eral,
how
muc
h fin
ancia
l pr
otec
tion
a sa
mpl
e pa
tient
mig
ht g
et if
they
are
co
vere
d un
der d
iffer
ent p
lans.
A
mou
nt o
wed
to p
rovi
ders
: $7,
540
P
lan
pays
$4,
890
P
atie
nt p
ays
$2,6
50
Sa
mpl
e ca
re c
osts
: H
ospi
tal c
harg
es (m
othe
r) $2
,700
Ro
utin
e ob
stet
ric c
are
$2,1
00
Hos
pita
l cha
rges
(bab
y)
$900
A
nest
hesia
$9
00
Labo
rato
ry te
sts
$500
Pr
escr
iptio
ns
$200
Ra
diol
ogy
$200
V
acci
nes,
othe
r pre
vent
ive
$40
Tot
al
$7,5
40
Patie
nt p
ays:
D
educ
tibles
$1
,750
Co
pays
$0
Co
insu
ranc
e $7
50
Lim
its o
r exc
lusio
ns
$150
T
otal
$2
,650
A
mou
nt o
wed
to p
rovi
ders
: $5,
400
P
lan
pays
$2,
890
P
atie
nt p
ays
$2,5
10
Sa
mpl
e ca
re c
osts
: Pr
escr
iptio
ns
$2,9
00
Med
ical
Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Offi
ce V
isits
and
Pro
cedu
res
$700
E
duca
tion
$300
La
bora
tory
test
s $1
00
Vac
cine
s, ot
her p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patie
nt p
ays:
D
educ
tibles
$1
,750
Co
pays
$4
70
Coin
sura
nce
$210
Li
mits
or e
xclu
sions
$8
0 T
otal
$2
,510
N
ote:
Thes
e ex
ampl
es a
re b
ased
on
indi
vidu
al co
vera
ge o
nly.
This
is
not a
cos
t es
timat
or.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
un
der t
his p
lan. T
he a
ctua
l ca
re y
ou re
ceiv
e w
ill b
e di
ffere
nt fr
om th
ese
exam
ples
, and
the
cost
of
that
car
e w
ill a
lso b
e di
ffere
nt.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
8
of 8
Ineo
s U
SA L
LC/S
tyro
lutio
n A
mer
ica
LLC
: 85%
AB
HP
Cov
erag
e Pe
riod:
01/
01/2
015
- 12/
31/2
015
Cov
erag
e E
xam
ples
Cov
erag
e fo
r: In
divi
dual+
Fam
ily |
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ns: C
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erlin
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is fo
rm, s
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e G
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ary.
You
can
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ssar
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y.pdf
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8 to
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est a
cop
y.
Que
stio
ns a
nd a
nsw
ers
abou
t the
Cov
erag
e Ex
ampl
es:
Wha
t are
som
e of
the
assu
mpt
ions
beh
ind
the
Cov
erag
e Ex
ampl
e s?
Co
sts d
on’t
incl
ude
prem
ium
s.
Sam
ple
care
cos
ts a
re b
ased
on
natio
nal
aver
ages
supp
lied
by th
e U
.S.
Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvice
s, an
d ar
en’t
spec
ific
to a
pa
rticu
lar g
eogr
aphi
c ar
ea o
r hea
lth p
lan.
Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clud
ed o
r pre
exist
ing
cond
ition
.
All
serv
ices
and
trea
tmen
ts st
arte
d an
d en
ded
in th
e sa
me
cove
rage
per
iod.
Ther
e ar
e no
oth
er m
edica
l exp
ense
s for
an
y m
embe
r cov
ered
und
er th
is pl
an.
O
ut-o
f-poc
ket e
xpen
ses a
re b
ased
onl
y on
trea
ting
the
cond
ition
in th
e ex
ampl
e.
The
patie
nt re
ceiv
ed a
ll ca
re fr
om in
-ne
twor
k pr
ovid
ers.
If th
e pa
tient
had
re
ceiv
ed c
are
from
out
-of-n
etw
ork
prov
ider
s, co
sts w
ould
hav
e be
en h
ighe
r.
Wha
t doe
s a
Cov
erag
e Ex
ampl
e sh
ow?
Fo
r eac
h tre
atm
ent s
ituat
ion,
the
Cove
rage
E
xam
ple
help
s you
see
how
ded
uctib
les,
copa
ymen
ts, a
nd c
oins
uran
ce c
an a
dd u
p. It
als
o he
lps y
ou se
e w
hat e
xpen
ses m
ight
be
left
up to
you
to p
ay b
ecau
se th
e se
rvic
e or
tre
atm
ent i
sn’t
cove
red
or p
aym
ent i
s lim
ited.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y ow
n ca
re n
eeds
?
N
o. T
reat
men
ts sh
own
are
just
exa
mpl
es.
The
care
you
wou
ld re
ceiv
e fo
r thi
s co
nditi
on c
ould
be
diffe
rent
bas
ed o
n yo
ur
doct
or’s
advi
ce, y
our a
ge, h
ow se
rious
you
r co
nditi
on is
, and
man
y ot
her f
acto
rs.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y fu
ture
exp
ense
s?
N
o. C
over
age
Exa
mpl
es a
re n
ot c
ost
estim
ator
s. Y
ou c
an’t
use
the
exam
ples
to
estim
ate
cost
s for
an
actu
al co
nditi
on. T
hey
are
for c
ompa
rativ
e pu
rpos
es o
nly.
You
r ow
n co
sts w
ill b
e di
ffere
nt d
epen
ding
on
the
care
you
rece
ive,
the
price
s you
r pr
ovid
ers
char
ge, a
nd th
e re
imbu
rsem
ent
your
hea
lth p
lan a
llow
s.
Can
I us
e C
over
age
Exam
ples
to
com
pare
pla
ns?
Y
es. W
hen
you
look
at t
he S
umm
ary
of
Bene
fits a
nd C
over
age
for o
ther
plan
s, yo
u’ll
find
the
sam
e Co
vera
ge E
xam
ples
. W
hen
you
com
pare
plan
s, ch
eck
the
“Pat
ient P
ays”
box
in e
ach
exam
ple.
The
small
er th
at n
umbe
r, th
e m
ore
cove
rage
th
e pl
an p
rovi
des.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Y
es. A
n im
porta
nt c
ost i
s the
pre
miu
m
you
pay.
Gen
erall
y, th
e lo
wer
you
r pr
emiu
m, t
he m
ore
you’
ll pa
y in
out
-of-
pock
et c
osts
, suc
h as
cop
aym
ents
, de
duct
ible
s, an
d co
insu
ranc
e. Y
ou
shou
ld a
lso c
onsid
er c
ontri
butio
ns to
ac
coun
ts su
ch a
s hea
lth sa
ving
s acc
ount
s (H
SAs)
, flex
ible
spen
ding
arr
ange
men
ts
(FSA
s) o
r hea
lth re
imbu
rsem
ent a
ccou
nts
(HRA
s) th
at h
elp y
ou p
ay o
ut-o
f-poc
ket
expe
nses
.
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