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Robert Bosch LLC

Bosch Choice Welfare Benefit Plan

Summary Plan Description

This Summary Plan Description (SPD) describes the Bosch Choice Welfare Benefit Plan (Plan) with benefits based on an April 1 – March 31 Plan Year. The

SPD effective date is April 1, 2015.

Bosch Choice April 2015 i

Your Welfare Benefit Plan Robert Bosch LLC (the Company) has established the Bosch Choice Welfare Benefit Plan (the Plan) for your benefit and the benefit of your family if you are an eligible associate of the Company. The SPD contains highlights of the benefit programs offered under the Plan (Benefit Programs), and is the first place you should turn when you have questions about the Plan or the benefits offered under the Plan. Additional details on the Benefit Programs are provided in official plan documents (which include the Plan Document, insurance contracts or policies, or the certificates for the insured Benefit Programs). If there is a discrepancy between the information in this SPD and the Plan Document, the Plan Document will govern. If there is a discrepancy between the information in the Plan Document and the insurance contracts or policies, the insurance contracts or policies will govern.

Receipt of this SPD does not guarantee eligibility to the Plan, Benefit Programs or Benefit Program options described in the SPD. See “Who Is Eligible” in the Participating in the Plan section for eligibility requirements.

If you cannot find the information you are looking for in this SPD, see Contact Information for important web addresses and phone numbers, or contact the Bosch Benefits Center with any questions you may have.

Contents See Page

Your Welfare Benefit Plan.................................................................................... i About This SPD ..................................................................................................1 Participating in the Plan ......................................................................................3 About the Benefit Programs................................................................................3 Who Is Eligible ....................................................................................................4 Dependent Coverage Details..............................................................................4 When You Can Enroll .........................................................................................7 When Coverage Begins ....................................................................................10 Your Cost ..........................................................................................................12 COBRA Continuation Coverage .......................................................................13 When You Have Coverage Elsewhere .............................................................20 Subrogation and Right of Recovery ..................................................................20 When Coverage Ends.......................................................................................24 Eligibility Claims ................................................................................................24 How to File an Eligibility Claim..........................................................................24 Decisions on Eligibility Claims ..........................................................................24 Appealing an Eligibility Claim............................................................................25 Healthcare Benefit Programs............................................................................27

Benefits-at-a-Glance ....................................................................................29 Participating in Healthcare Benefit Programs...............................................30

Who Is Eligible ..................................................................................................30 Medical Benefit Program..............................................................................31

Overview of the Medical Benefit Program.........................................................32 Health Savings Account....................................................................................34 Your Preventive Care Coverage .......................................................................36 Medical Review Program ..................................................................................37

Your Welfare Benefit Plan

ii April 2015 Bosch Choice

Comparison of Medical Benefit Options ........................................................... 39 CDHP Benefit Option Comparison ................................................................... 39 PPO Benefit Option Comparison ...................................................................... 44 Additional Information about Covered Care and Services................................ 49 Important Terms for Understanding Your Benefits ........................................... 52 Medical Expenses Not Covered ....................................................................... 55

Prescription Benefits .................................................................................... 58 Summary of Prescription Drug Benefits............................................................ 59

Dental Benefit Program................................................................................ 62 Summary of Dental Benefit Options ................................................................. 62 Covered Services ............................................................................................. 63 Dental Expenses Not Covered ......................................................................... 65

Vision Benefit Program ................................................................................ 67 Summary of Vision Benefits.............................................................................. 67 Vision Expenses Not Covered .......................................................................... 68

Employee Assistance Program.................................................................... 69 How to File Claims ....................................................................................... 70

Medical Claims ................................................................................................. 71 Prescription Drug Claims.................................................................................. 71 Dental Claims ................................................................................................... 72 Vision Claims.................................................................................................... 72 Decisions on Non-Medical Claims and Appeal Procedures ............................. 72 Medical and Prescription Drug Benefit Program Claim Filing and Appeals Procedures ......................................................................................... 73 Addresses for Claim Appeals ........................................................................... 85 Special Claim Rules for Advance Approval and Urgent Care Claims............... 85 Flexible Spending Account Benefit Programs .................................................. 87

Benefits-at-a-Glance .................................................................................... 89 Participating in FSAs.................................................................................... 91

How Your Accounts Work................................................................................. 91 Changing Contributions During the Year .......................................................... 92 How Much You Can Deposit............................................................................. 93 How Much Can Be Reimbursed ....................................................................... 94 Pre-Tax Contributions — Issues to Consider ................................................... 94 When Coverage Ends....................................................................................... 95

Healthcare FSA............................................................................................ 96 Whose Expenses Can Be Reimbursed ............................................................ 96 Eligible Healthcare Expenses ........................................................................... 96 Non-eligible Healthcare Expenses.................................................................... 98 Making Contributions during a FMLA Leave of Absence.................................. 99 COBRA Continuation Coverage for Healthcare FSAs.................................... 100

Dependent Day Care FSA ......................................................................... 101 Whose Expenses Can Be Reimbursed .......................................................... 101 Eligible Dependent Day Care Expenses......................................................... 101 Non-eligible Dependent Day Care Expenses ................................................. 102 Making Contributions during a Leave of Absence .......................................... 103 Federal Dependent Tax Credit ....................................................................... 103

Paying Yourself Back................................................................................. 104 Submitting Expenses...................................................................................... 104 Claim Decisions and Appeals ......................................................................... 105 Healthcare FSAs............................................................................................. 105 Dependent Day Care FSAs ............................................................................ 106


Bosch Choice April 2015 iii

Right of the Plan to Obtain Information...........................................................106 Insurance Benefit Programs ...........................................................................107

Benefits-at-a-Glance ..................................................................................109 Participating in the Insurance Benefit Programs ........................................111

When Coverage Begins ..................................................................................111 Your Cost ........................................................................................................112 Evidence of Insurability (EOI) .........................................................................113 Your Beneficiary..............................................................................................114 When Coverage Ends.....................................................................................114 Continuing Coverage ......................................................................................115 Portable Coverage and Conversion................................................................115

Life Insurance Benefit Program..................................................................117 Associate Life Insurance.................................................................................117 If Your Pay Changes During the Year.............................................................118 Maximum Benefit ............................................................................................118 Accelerated Benefit.........................................................................................118 Coverage at Age 70 and Older .......................................................................119 When Benefits Will Not Be Paid......................................................................119 Spouse Life Insurance ....................................................................................120 Child(ren) Life Insurance.................................................................................120

AD&D Insurance Benefit Program..............................................................121 Coverage for You............................................................................................121 Maximum Benefit ............................................................................................122 Coverage at Age 70 and Older .......................................................................122 Coverage for Your Dependents ......................................................................123 Covered Accidental Losses ............................................................................123 Benefit Payments............................................................................................124 Seatbelt and Airbag Benefits ..........................................................................124 When AD&D Benefits Are Not Paid ................................................................125

Business Travel Accident Insurance Benefit Program ...............................127 How to File Insurance Claims.....................................................................128

If Your Claim Is Denied ...................................................................................129 Disability Benefit Program...............................................................................131

Benefits-at-a-Glance ..................................................................................133 Participating in Disability Benefits ..............................................................134

Who Is Eligible ................................................................................................134 When Coverage Begins ..................................................................................134 Your Cost ........................................................................................................135 Changing Coverage during the Year ..............................................................135 Waiver of Long Term Disability Premium........................................................136 When Coverage Ends.....................................................................................136 Continuation of Other Benefits........................................................................136

Long Term Disability Insurance Benefit Program.......................................138 How Your LTD Benefits Work .........................................................................138 Recurring Disabilities and the Elimination Period ...........................................140 Rehabilitation Incentives .................................................................................140 Date Benefit Payments End............................................................................142 Maximum Benefit Period.................................................................................142 When Benefits Are Not Paid ...........................................................................143 Survivor Benefits.............................................................................................143 Coordination with Other Benefits ....................................................................143 Social Security Benefits ..................................................................................144


iv April 2015 Bosch Choice

How to File Claims.......................................................................................... 145 If Your Claim Is Denied................................................................................... 146 Administrative Information .............................................................................. 149 Leaves of Absence ......................................................................................... 149 Plan Information.............................................................................................. 151 Your Right to Benefits..................................................................................... 155 Non-assignment of Benefits............................................................................ 156 Affiliates and Subsidiaries Participating in the Plan........................................ 156 Contact Information ........................................................................................ 159

Bosch Choice April 2015 1

About This SPD The Employee Retirement Income Security Act of 1974 (ERISA) requires the Plan to maintain an SPD and provide a copy of the SPD to Plan participants. This SPD provides you with most of the information you need to know about the Benefit Programs offered under the Plan, and is divided into the following sections: Participating in the Plan provides general information about

who is eligible to participate in the Benefit Programs and enrolling for benefits.

Healthcare Benefit Programs includes more specific information about the Medical Benefit Program, including Health Savings Accounts (HSAs) and prescription drug coverage, Dental Benefit Program, Vision Benefit Program and Employee Assistance Program (EAP).

Flexible Spending Account (FSA) Benefit Programs provides details about the Healthcare FSA Benefit Program and Dependent Day Care FSA Benefit Program.

Insurance Benefit Programs describes the Life Insurance Benefit Program, Accidental Death and Dismemberment (AD&D) Insurance Benefit Program and Business Travel Accident Insurance Benefit Program offered to you and your eligible dependents.

Disability Benefit Program includes details about the Long Term Disability (LTD) Benefit Program that provides financial protection if you are unable to work because of an approved illness or injury.

Administrative Information provides general administrative information about the Plan.

Contact Information provides web addresses and phone numbers so you know who to contact to get information about your benefits.

Take time to read through this material carefully and share it with your family. If you have any questions about your benefits, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).

About This SPD

2 April 2015 Bosch Choice


Participating in the Plan This section provides an overview for participating in the Plan offered to eligible Bosch associates, such as elected and non-elected benefits, who is eligible, enrolling for benefits and when coverage begins and ends.

About the Benefit Programs The following list shows the Benefit Programs you may elect as an eligible associate, as well as those you will automatically receive from the Company.

Coverage You May Elect

Medical*

Dental

Vision

Health Savings Account

Healthcare FSA**

Dependent Day Care FSA**

Spouse Life Insurance

Child(ren) Life Insurance

Optional (i.e. additional or supplemental) Associate Life Insurance and Accidental Death and Dismemberment (AD&D) Insurance (dependent AD&D coverage or associate AD&D coverage)

Optional Long Term Disability (LTD) Insurance (increases your LTD benefit to 65% of eligible pay)

Coverage You’ll Receive Automatically

Basic Associate Life and AD&D Insurance

Basic LTD Insurance (provides coverage equal to 50% of your eligible pay)

Business Travel Accident Insurance

Short Term Disability (STD)***

Employee Assistance Program (EAP)

* When you enroll in medical benefits, you will receive prescription drug coverage automatically. Depending on the Medical Benefit Program option you elect, you may also be able to enroll in a Health Savings Account (HSA). HSAs are not available if you enroll in an HMO.

** You must re-enroll for these benefits each year.

*** Although mentioned in this SPD, STD coverage is not offered as a benefit program under the Plan nor is it covered by ERISA. Please contact Bosch HR Service at 855-922-5547 for further information on STD coverage.

Participating in the Plan


Who Is Eligible You are eligible to participate in the Plan if you are:

classified by the Company (or a participating affiliate or subsidiary of the Company), pursuant to its regular administrative practices, as a regular, full-time associate on the U.S. Payroll, and

regularly scheduled to work at least 30 hours a week.

You are not an eligible associate if you:

are a leased employee, nonresident alien who receives no U.S. earned income, or an associate covered under a welfare plan of a foreign affiliate;

are classified as an independent contractor, temporary associate or seasonal associate under the Company’s customary work classification practices (whether or not you are an employee or reclassified as an employee by the Internal Revenue Service, administrative agency or a court or competent jurisdiction);

are covered by a collective bargaining agreement, unless the collective bargaining agreement expressly provides that coverage under the Plan is provided to associates in the bargaining unit, and

waive participation in the Plan through any means, including an employment agreement.

Eligible Dependents

When you enroll in the Plan, you also may enroll your eligible dependents. Eligible dependents include your:

legal Spouse (including common-law spouses where recognized by the state) or Domestic Partner (see “Spouse Eligibility” and “Domestic Partner Coverage Details” below),

dependent children (natural or adopted) under the age of 26 for Medical, Dental, Vision, and Child(ren) Life Insurance coverage, and

children who must be provided healthcare coverage as required by a Qualified Medical Child Support order (QMCSO).

Dependent Coverage Details Spouse Coverage Details

If you elect coverage for yourself, you can also elect coverage for your Spouse. If you do not elect coverage for your eligible dependents when you enroll in the Plan, then they will not be eligible for coverage under the Plan until the next open enrollment period, or if you incur a life status event.

A Note about QMCSOs…

You may cover a child who qualifies as your dependent for the Healthcare Benefit Programs even if the child’s parent has the right to claim the child as a dependent for tax purposes under the terms of your divorce. See “Qualified Medical Child Support Orders (QMCSO)” in Healthcare Benefit Programs for details.



Domestic Partner Coverage Details

Bosch benefit plans extend medical, dental, vision and life insurance coverage to Domestic Partners and their dependent children. If you want to enroll a Domestic Partner and/or a Domestic Partner’s dependent child(ren), be sure to review the following coverage details. Your Domestic Partner may be the same or opposite sex. To be eligible for Bosch benefits, your relationship must meet all of these requirements:

be financially interdependent and jointly responsible for each other’s common welfare;

intend to remain in a committed relationship;

share the same permanent address;

not be closely related by blood so that legal marriage would otherwise be prohibited;

be at least age 18;

must not have been in a different Domestic Partner relationship or marriage within the last six months; and

current relationship has been in effect for at least six months.

If you enroll children of your Domestic Partner, they must satisfy all eligibility requirements of the Bosch health plan.

You will be asked to provide verification that your partner and any enrolled children of your Domestic Partner meet these requirements. This may include birth certificates, marriage licenses, tax returns or other proof of eligibility.

Dependent Child(ren) Coverage

Dependent children include any children who depend on you and are not employed on a regular, full-time basis. The term “children” includes:

natural children,

legally adopted children,

children who have been placed with you for adoption (see “Placement for Adoption”),

stepchildren,

children of your Domestic Partner,

foster children, and

children under your legal guardianship residing with you.

children age 19 or older who are physically or mentally incapable of earning a living and who were handicapped and enrolled in coverage before reaching age 19.

Children are not eligible to be covered as dependents under the Plan if they:

are eligible as associates of the Company, or

are in the military.

Placement for Adoption

Placement for adoption means that, in anticipation of a child’s adoption, the person with whom the child is being placed has the legal obligation for at least 50% of the child’s support.



Not Covered Under the Plan

Individuals are not eligible to be covered as dependents under the Plan if they:

are in the military,

are eligible for the Plan as associates of the Company or a participating company, or

are eligible for the Plan as retirees of the Company or a participating company.

Tax Implications

Under IRS rules, the value of benefits for Domestic Partners and their children generally is taxable. Benefits may be offered on a pre-tax basis only if your Domestic Partner and/or their children qualify as your “tax dependent” under the Internal Revenue Code, Section 152. To qualify as a tax dependent, they must:

reside with you;

receive over 50% of their support from you;

not be anyone’s qualifying child (for dependents, not be anyone else’s qualifying child); and

be a citizen or national of the U.S., or a resident of the U.S. or a country contiguous to the U.S.

If they do not meet these requirements, Bosch is required to record and apply taxes for the cost of those benefits as “imputed income” to you.

Most states follow the federal guidelines described here; however, at the present time, California, Illinois, Iowa, Massachusetts, New Jersey and Oregon follow different rules. See your tax advisor for further assistance on the taxability of benefits for Domestic Partners and/or their children.

Note: You will be asked to provide documentation that verifies your dependent’s eligibility to participate in the plan. This may include birth certificates, marriage licenses, tax returns or other proof of eligibility.

Coverage Options

When enrolling for benefits, there are four coverage options to choose from:

associate only,

associate and Spouse/Domestic Partner,

associate and child(ren), and

family (associate, Spouse/Domestic Partner and child[ren]).

You will be able to choose the level of coverage you want under the Medical, Dental, Vision, Life Insurance and AD&D Insurance Benefit Programs. However, to cover your Spouse/Domestic Partner or eligible dependents under the Benefit Programs, you must be enrolled in those Benefit Programs yourself.



You and Your Spouse/Domestic Partner Are Both Eligible for Coverage Under the Plan

If you are a Bosch associate eligible for coverage and have a Spouse/Domestic Partner who is also eligible for coverage under the Plan, please keep in mind the following limitations on coverage:

you may not elect Spouse Life/AD&D Insurance,

if a child is eligible for coverage under more than one associate, only one associate may cover the child, and

you may not be covered as both an associate and your Spouse’s/Domestic Partner’s dependent.

Qualified Medical Child Support Order

A child may be eligible for the Healthcare Benefit Program due to a Qualified Medical Child Support Order (QMCSO). If you receive an order for medical child support, please contact Bosch HR Service at 855-922-5547.

The Plan Administrator will honor an order that is a QMCSO, including a national medical support notice. The Plan Administrator has established written procedures for determining whether a Medical Child Support Order (MCSO) is a QMCSO and for administering the provision of benefits under the Plan pursuant to a valid QMCSO.

Note: The Plan Administrator has full discretionary authority to determine whether a MCSO is “qualified” within the meaning of ERISA and reserves the right, waivable at its discretion, to seek clarification with respect to the order from the court or administrative agency that issued the order, up to and including the right to seek a hearing before the court or agency.

When You Can Enroll Generally, you can enroll for the Benefit Programs available under the Plan:

during Annual Enrollment,

as a new hire, or

when you experience a change in status event.

As a new hire or during Annual Enrollment, you will receive a benefits packet that includes an enrollment guide and a personalized enrollment worksheet listing all of the Benefit Programs for which you can enroll.

See the specific Benefit Program sections for any eligibility requirements or enrollment processes that may be unique to those Benefit Programs.

Annual Enrollment

As a participant in the Plan, you can make new decisions about your health and welfare benefits once a year during the designated Annual Enrollment period (usually in February). Your new elections will become effective on April 1 and will remain in effect until you make a change at the next Annual Enrollment, unless you experience a change in status event during the year. Note: You need to reenroll in the Flexible Spending Account Benefit Programs at each Annual Enrollment to participate in one or both of the FSAs for the next Plan Year.

QMCSO Coverage…

You may cover a child who qualifies as your dependent under the Retiree Medical Benefit Program even if the child’s parent has the right to claim the child as a dependent for tax purposes under the terms of your divorce.

Keep in Mind

The Plan Year runs from April 1 to March 31 of the following year.



New Hire

You must enroll yourself and your eligible dependents within 31 days of the date on which your enrollment worksheet was “prepared,” as listed under the Associate Information section of the form. Your enrollment worksheet is part of the benefits packet you will receive in the mail shortly after you are hired. If you did not receive your packet call the Bosch Benefits Center.

If you do not make an affirmative election to enroll in or decline coverage within 31 days, you will automatically be enrolled in — and pay for — the default coverage shown in your enrollment materials. The cost of this coverage will be deducted from your paycheck on a pre-tax basis, and your next opportunity to change your coverage will be during the next Annual Enrollment period. Similarly, if you decline coverage during your initial enrollment period, you will not be able to enroll yourself or your dependents until the next Annual Enrollment period. The only exception to these rules is if you experience a change in status event as described in the “When Coverage Begins” on page 10 or are eligible for a special enrollment period as described under Special Enrollment Rights below.

Special Enrollment Rights

You and your eligible dependents may enroll in the Medical Benefit Program (which includes prescription drugs) under the following circumstances:

Individuals Losing Other Coverage

If you declined coverage under the Medical Benefit Program when it was first available because of other health coverage, and that coverage is later lost on account of:

exhaustion of COBRA continuation coverage,

lost eligibility for other coverage, or

termination of employer contributions towards the other coverage.

You and your eligible dependents may enroll in the Medical Benefit Program on or before the date that is 60 days after the date you lost that other coverage.

Lost eligibility for other coverage includes a loss of other health coverage as a result of your legal separation or divorce, domestic partnership ending, a dependent’s loss of dependent status, death, or termination of employment or reduction in number of hours of employment - or you no longer reside, live or work in the service area of a health maintenance organization or other medical option in which you participated.

Your enrollment will take effect on the date prior coverage is lost, as long as you request to enroll on or before the date that is 60 days after the loss of coverage.



New Eligible Dependents

If you initially declined enrollment for yourself or your eligible dependents and you later have a new eligible dependent because of marriage, domestic partnership, birth, adoption, or placement for adoption, you may enroll yourself and your new eligible dependents (including an eligible dependent Spouse/Domestic Partner if you have a new eligible dependent child) in the Medical Benefit Program, as long as you request enrollment on or before the date that is 60 days after the marriage, domestic partnership, birth, adoption, or placement for adoption.

For example, if you and your eligible dependent Spouse/Domestic Partner have a child, you may enroll yourself, your eligible dependent Spouse/Domestic Partner and your new child in the Medical and Vision Benefit Programs, even if you were not previously enrolled. You will not, however, be able to enroll existing eligible dependent children for whom coverage has been waived in the past and who are not currently covered under these Benefit Programs.

For birth, adoption, or placement for adoption, your participation or your eligible dependent’s participation will start as of the date of the birth, adoption, or placement for adoption, as long as you timely requested enrollment.

For marriage and domestic partnership, your participation or your eligible dependent’s participation will start as of the date of the marriage or as soon as all of the eligibility requirements of a domestic partnership are met, provided you request enrollment on or before the date that is 60 days after the marriage/domestic partnership begins. Domestic partnership requirements are explained in the Participating in the Plan section.

You will need to enroll your new eligible dependents on or before the date that is 60 days after the event by which they became your eligible dependent (for example, a new Spouse/Domestic Partner after your marriage/domestic partnership or your baby is born). If you do not add new eligible dependents within this 60-day period, you cannot enroll them until the next Annual Enrollment unless a change in status event occurs. You will need to provide proof of your dependent’s status as an eligible dependent.

Medicaid and CHIP

If you or your eligible dependent children are eligible for, but not enrolled in, the Medical Benefit Program and you or your eligible dependent children:

lose coverage under Medicaid or a State child health plan, or

become eligible for a premium assistance subsidy through Medicaid or CHIP.

You and your eligible dependent children may enroll in the Medical Benefit Program, as long as you request enrollment on or before the date that is 60 days after the loss of coverage or the date you or your eligible dependent children became eligible for the premium subsidy.

Your enrollment will take effect on the date prior coverage is lost, as long as you request to enroll on or before the date that is 60 days after the loss of coverage.

The 60-day periods described in this section are Special Enrollment Periods.



When Coverage Begins In addition to the Plan provisions explained under the Participating in the Plan section, the following rules also apply to the Healthcare Benefit Programs.

Active Employment

If you are absent from work on the day your coverage is scheduled to begin, or you do not begin working on the date scheduled, coverage generally will begin on the date you return to active employment.

For purposes of the Medical Benefit Program (which includes prescription drugs), however, if you are absent from work due to any health status (for example, you are sick or disabled), the Company will treat you as if you started active employment and coverage may begin under the Medical Benefit Program.

For the Dental and Vision Benefit Programs and EAP, if an eligible dependent is confined at home, in a hospital or elsewhere, or is not conducting normal daily activities on the date coverage is scheduled to begin, coverage for this dependent begins on the date confinement ends or normal activities resume.

Pre-existing Medical Conditions

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes rules for any pre-existing condition that you or your dependents may have. Under the Medical Benefit Program, there are no pre-existing condition limitations.

Change in Status Events

In general, you can change your current Plan enrollment elections during the plan year if you incur a Change in Status. If you decide to make a change to coverage due to a Change in Status event, you must change your benefit coverage within 60 days of the event.

You can make changes to your Health Savings Account contributions at any time.

In the event you decide to make a change under the terms of a Change in Status, you can make changes to all the Benefit Programs available under the Plan, except for the Flexible Spending Account Benefit Programs. See “Changing Contributions during the Year” in Flexible Spending Account Benefit Programs for the change in status events that apply for FSAs.

Each Benefit Program also may have additional requirements (such as evidence of insurability) for changing coverage during the Plan Year. See the “Changing Coverage during the Year” sections for specific Benefit Programs for details.

The following changes are considered Change in Status Events:

a legal marital status change including marriage, divorce, legal separation, annulment,

Domestic Partnership (beginning or ending),

birth, death, adoption, placement for adoption, or court ordered guardianship of a dependent child,



an eligible dependent’s status change (for example, your dependent is no longer eligible for coverage because of age),

employment status change that affects eligibility for current benefits for you or a dependent,

residence or worksite change that affect eligibility for current benefits for you or a dependent,

a change in coverage due to an election made by your Spouse/Domestic Partner or dependent under the Spouse’s/Domestic Partner’s or dependent’s employer’s benefit plan if:

the other employer’s plan has a different open enrollment period that relates to a period that is different from the Plan Year (April 1 – March 31) for this Plan (for example, your Spouse’s/Domestic Partner’s open enrollment period is in October and your Spouse/Domestic Partner changes coverage), or

the other employer’s plan allows an election change for a change in status event as provided under the cafeteria plan regulations.

a change in the availability of a benefit option or coverage (addition or removal) under the Plan’s Benefit Programs (for example, a new HMO or PPO option is added to the Medical Benefit Program), or

a significant increase or decrease in the cost of coverage during the Plan Year.

In addition to the change in status event listed above, you may change your benefit elections for the Healthcare Benefit Programs if:

a judgment, decree, or order, resulting from a divorce, legal separation, annulment, or change in legal custody (including a qualified medical child support order) is entered by a court of competent jurisdiction and it requires accident or health coverage for your child under this Plan or it requires another individual to provide the coverage for the child;

you or your eligible dependent becomes enrolled or loses coverage under Part A or Part B of Medicare or Medicaid (other than coverage solely with respect to the distribution of pediatric vaccines);

for the Medical Benefit Program only, you or your eligible dependent are eligible for a Special Enrollment Period (see the “Special Enrollment” section); or

you or your eligible dependent loses coverage under any group health coverage sponsored by a governmental or educational institution including:

a State children’s health insurance program (SCHIP);

a medical care program of an Indian Health Service or a tribal organization;

a State health benefits risk pool; or

a foreign government group health plan.



If you experience a change in status event as listed above, you have 60 days from the date of the event to access the Bosch Benefits Center website or call the Bosch Benefits Center and change your benefit elections. For contact information, see Contact Information.

The benefit change you request must be consistent with the change in status event. For example, if you have a baby, you can add your baby to your existing medical coverage or enroll for coverage; however, you may not cancel your medical benefits.

Note: The change in coverage will take effect as of the date of the event, even though you file your change request after the date of the event (but within 60 days of the event).

If you do not provide timely notice of the change in status event and complete a new election within the 60-day timeframe, you will not be able to change coverage until the next Annual Enrollment period, or until you have another change in status event, whichever occurs first.

Your Cost The Company pays a major portion of the cost of medical, dental and vision benefits. Your share of the cost will be paid automatically through payroll deductions on a Pre-Tax basis. If you elect vision benefits, you pay the entire cost for coverage on a Pre-Tax basis. The Company pays the entire cost of the EAP.

The cost of each option will depend on:

the Benefit Options and Benefit Programs you elect under the Plan (Medical, Dental and/or Vision),

the number of dependents you want to enroll (i.e., the coverage option you elect), and

your annual base pay, as defined below.

Your payroll deductions will begin as soon as administratively possible following receipt of your elections.

Under IRS rules, the value of benefits for domestic partners and their children generally is taxable. Benefits may be offered on a pre-tax basis only if your domestic partner and/or their children qualify as your “tax dependent” under the Internal Revenue Code, Section 152. See the Participating in the Plan section for more information.

Please review your paycheck after you enroll to make sure that the appropriate deductions or credits are being processed. If you have any questions, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).



Annual Base Pay

For full-time associates, your annual base pay is your regular base compensation excluding items such as bonuses and overtime as of the January 1st preceding the Plan Year.

For sales associates earning commission, any commission sales wages paid in the last 24-month period will be averaged and annualized for this period. The calculated annualized commission amount will then be added to your benefit salary affecting benefit coverage and contributions. This “look back” will be calculated each January 1st with the benefit commission wage used for the entire Plan Year.

Your annual base pay will be used to determine the percentage you contribute for your medical benefits.

COBRA Continuation Coverage Under certain circumstances you or your eligible dependents covered by any of the Healthcare Benefit Programs or the Healthcare FSA have the right, under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), to continue coverage under the Healthcare Benefit Programs. You and your covered dependents may also continue coverage under the Healthcare FSA with certain limitations. The rules explained in this section apply to the Healthcare Benefit Programs and Healthcare FSA. See the Flexible Spending Account Benefit Programs section for additional rules that apply to the Healthcare FSA.

COBRA coverage is available to you and to covered dependents when you or they would otherwise lose coverage under the Healthcare Benefit Programs. This section generally explains COBRA coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. COBRA coverage for the Plan is administered by the COBRA administrator listed in the Contact Information section.

You may have other options available to you when you lose coverage under the Healthcare Benefit Programs. 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 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 may of these options at www.healthcare.gov.

Qualifying Events

COBRA coverage is available if you are enrolled in the any of the Healthcare Benefit Programs and your coverage or your covered dependent’s coverage would otherwise end on account of a qualifying event. COBRA coverage is offered to each person who is a qualified beneficiary. A qualified beneficiary is someone who will lose coverage under a Healthcare Benefit Program because of a qualifying event.

Your HSA under COBRA

If you participate in one of the Bosch CDHP Benefit Options and have a Health Savings Account (HSA) through the Plan’s benefit provider, you can take your HSA with you when your Healthcare Benefit Program coverage ends. However, once your benefits end, the Company will not provide contributions to your HSA, even if you continue your medical coverage under COBRA. See the Health Benefits Program for more information.



You will become a qualified beneficiary if you will lose your coverage under the Healthcare Benefit Programs because either of the following qualifying events occurs:

your hours of work are reduced, or

your employment ends for any reason other than your gross misconduct.

Each of your covered dependents will become a qualified beneficiary if coverage under the Healthcare Benefit Programs will be lost because any of the following qualifying events occur:

your death,

your hours of work are reduced,

your employment ends for any reason other than your gross misconduct,

you become entitled to Medicare benefits (under Part A, Part B, or both) while enrolled in COBRA,

you become divorced or legally separated from your Spouse,

your domestic partnership ends, or

your child stops being eligible for coverage under the Healthcare Benefit Programs as an eligible dependent. (For this qualifying event, only the covered dependent child becomes a qualified beneficiary.)

The Plan offers COBRA coverage to qualified beneficiaries only after the Bosch Benefits Center has been notified that a qualifying event has occurred.

When the qualifying event is the termination of your employment, a reduction of your hours of employment, your death, the Bosch Benefits Center will notify the COBRA administrator of the qualifying event.

For the other qualifying events (e.g., divorce or legal separation, domestic partnership ending or a dependent child’s loss of eligibility for coverage as an eligible dependent), you or a qualified beneficiary, or a person acting on your or his or her behalf, must notify the Bosch Benefits Center within 60 days after the latest of:

the date of the qualifying event, or

the date on which you or a covered dependent loses (or would lose) coverage under the Healthcare Benefit Programs.

If you, a qualified beneficiary, or a person acting on your or his or her behalf, do not provide the notice to the Bosch Benefits Center within the time limit explained above, coverage under the Healthcare Benefit Programs cannot be continued.

After a qualifying event has occurred, the COBRA administrator, on behalf of the Plan Administrator, has 44 days from the date of the loss of coverage or the qualifying event, to provide you and your family members with a notice of your right to elect COBRA coverage.



Electing COBRA Continuation Coverage

If it is determined that you and each of your covered dependents qualify for COBRA coverage, each of you may individually decide whether or not to continue coverage. You and each of your covered dependents will have the right to elect the same coverage under the Healthcare Benefit Programs in which you were enrolled immediately before the qualifying event. Both you and your Spouse/Domestic Partner may elect COBRA coverage, or only one of you may choose it. Spouses/domestic partners may elect coverage for each other and parents may elect to continue coverage on behalf of their covered dependent children.

If you or a covered dependent wants to elect COBRA coverage, you must do so within 60 days of the date the notice of your right to elect COBRA coverage was sent by the COBRA administrator.

As long as you elected and you are covered by COBRA coverage during the Plan’s Annual Enrollment, you may make changes to your coverage under the Healthcare Benefit Programs during the Annual Enrollment, including adding new coverage or changing your Benefit Options under Medical, Dental and Vision Benefit Programs.

Premium Payments

COBRA coverage is at your expense or your covered dependent’s expense. The monthly cost of COBRA coverage will be included in the notice sent to you. The amount you must pay for COBRA coverage will not exceed 102 percent of the cost for this coverage to the Plan (including both the Company’s and your contributions) for a similarly situated participant or beneficiary who is not receiving COBRA coverage (or, in the case of an extension of COBRA coverage due to a disability, 150 percent of that cost). You will have to pay COBRA premiums on an After-Tax basis.

For coverage to continue, the first premium must be received by the date stated in the notice sent to you. Normally, this date will be 45 days after COBRA coverage is elected. Premiums for every following month of COBRA coverage must be paid monthly on or before the premium due date stated in the notice sent to you. There is a 30-day grace period for these monthly premiums. If they are not paid within 30 days after their due date, COBRA coverage will end as of the first day of that period of coverage and cannot be reinstated. If a partial premium payment is made that falls short of the current amount due by a minimal amount, you will be notified, and, if the shortfall is not paid within 30 days of the date the notice is received, COBRA coverage will end as of the first day of that monthly period of coverage.

Duration of Coverage

COBRA continuation coverage for you and/or your covered dependents will start on the date of the qualifying event and may continue until the earliest of the following:

18 months if your employment ends and/or your hours are reduced,

29 months if you or a covered dependent qualify for a disability extension (refer to “Disabled Individuals,” below),



for your covered dependents, 36 months in the event of your divorce or legal separation, domestic partnership ending, your death, or your becoming entitled to Medicare benefits (under Part A or Part B, or both), or your covered dependent child’s loss of dependency status,

the date on which a premium payment was due but not paid,

the date after the qualified beneficiary first becomes covered under another employer’s group health plan without an exclusion or limitation affecting coverage of his/her pre-existing condition, if any; provided the qualified beneficiary becomes covered after his/her election of COBRA continuation coverage,

the date the qualified beneficiary first becomes entitled to Medicare benefits (under Part A or Part B, or both); provided the qualified beneficiary becomes enrolled in Medicare benefits after his/her election of COBRA continuation coverage, or

the date the Company terminates all of its group health plans.

Newborns and Adopted Children

If you or your Spouse/Domestic Partner elect COBRA coverage, any child born to or adopted by you and your Spouse/Domestic Partner during the period of COBRA coverage will also be a qualified beneficiary, and be entitled to COBRA coverage for the maximum period of coverage available to any family member, as long as you notify the COBRA administrator within 60 days of the birth or adoption.

Second Qualifying Event

If COBRA coverage was elected by a covered dependent because your employment ended or your hours were reduced (including COBRA coverage during a disability extension period) and if, during the period of continuation coverage, another qualifying event occurs, the maximum period of COBRA coverage for the covered dependent is extended, upon proper notice to the COBRA administrator, for up to an additional 18 months (that means, to a maximum of 36 months from the date your employment ended or your hours were reduced).

This extension may be available to your covered dependents receiving COBRA coverage in the event of your death or divorce, domestic partnership ending or if your dependent child stops being an eligible dependent under the Healthcare Benefit Programs, but only if the event would have caused the covered dependent to lose coverage under the Healthcare Benefit Programs when a covered employee becomes entitled to Medicare after his/her termination of employment or reduction of hours. COBRA coverage will still end for any of the other reasons listed above, such as failure to pay premiums when due.

You or the covered dependent, or a person acting on your or his/her behalf, must notify the COBRA administrator in writing within 60 days after the latest of:

the date of the second qualifying event, or

the date on which the covered dependent would lose coverage under the Healthcare Benefit Programs as a result of the second qualifying event.



If you or the covered dependent, or a person acting on your or his/her behalf, do not provide the notice to the COBRA Administrator within the time limit explained above, the maximum period for COBRA continuation coverage will not be extended beyond the original 18-month coverage period.

Medicare-eligible Associates

If you become entitled to Medicare (Part A or B) while you are still employed by the Company (but no more than 18 months before the qualifying event) and you then lose your health coverage because of a qualifying event that is a termination or reduction in your hours of employment, you can elect to have both COBRA coverage and Medicare coverage at the same time.

After the qualifying event, your COBRA coverage will be secondary to Medicare with respect to services or supplies that are covered, or would be covered upon proper application, under Parts A or B of Medicare.

If you think you will need both Medicare and COBRA after your retirement, you should enroll in Medicare on or before the date on which you elect COBRA coverage. If you do not enroll in Medicare on or before the date on which you elect COBRA coverage, your COBRA benefits will end when your Medicare coverage begins. Your covered dependents, however, will remain eligible for COBRA coverage.

Covered Dependents of Medicare-eligible Associates

If you become entitled to Medicare (Part A or B) while you are still employed by the Company (but no more than 18 months before the qualifying event) and you then lose your health coverage because of a qualifying event that is a termination or reduction in your hours of employment, then your covered dependents may elect COBRA coverage for the balance of the 36-month period starting when you became entitled to Medicare, or 18 months from your later termination or reduction in hours of employment, whichever period is longer.

You or your covered dependents, or a person acting on your or their behalf must provide notice to the COBRA administrator of your entitlement to Medicare benefits (under Part A, Part B or both) within the time limit and in the manner described above for second qualifying events.

Disabled Individuals

When the qualifying event for COBRA coverage is your termination of employment or the reduction in your hours of employment, the 18-month period of COBRA coverage is extended by an additional 11 months (to a total of 29 months) if these two conditions are met:

the Social Security Administration determines that a qualified beneficiary (you or a covered dependent) is disabled, and that the date the qualified beneficiary’s disability began was either:

within the first 60 days of COBRA coverage (in the case of a child born to or placed for adoption with you and your Spouse/Domestic Partner, the 60-day period is measured from the date of birth or placement for adoption), or



before the qualifying event, and the Social Security Administration considers that the qualifying beneficiary remains disabled as of the date of the qualifying event,

you or a covered dependent, or a person acting on your or his/her behalf, provide written notice to the COBRA administrator of the Social Security Administration’s disability determination before the end of the original 18-month period of continuation coverage and within 60 days after the latest of:

the date of the disability determination by the Social Security Administration,

the date on which the qualifying event occurred,

the date on which you or a covered dependent loses (or would lose) coverage under the Healthcare Benefit Programs as a result of the qualifying event, or

the date on which you or a covered dependent are informed, through receipt of this document or an initial notice of COBRA coverage, of both your obligation to provide the notice of the qualifying event and the Plan’s procedures for providing such notice to the COBRA administrator.

If you or a covered dependent, or a person acting on your or his/her behalf, do not provide the notice to the COBRA administrator within the time limit explained above, the maximum period for continuation coverage will not be extended beyond the original 18-month coverage period.

Continuation coverage will still end for any of the other reasons listed above, such as failure to pay premiums when due. You, a covered dependent, or another person acting on your or his/her behalf, must notify the COBRA administrator within 30 days of the date you are finally determined not to be disabled under the Social Security Act, if such a determination is made. The 11-month disability extension of COBRA coverage will end on the first day of the month following the date the qualified beneficiary is determined not to be disabled.

Continuation coverage due to the initial employment-related qualifying event, or any subsequent qualifying event, may still be available if the maximum period for such continuation coverage has not expired as of the date a determination of “no longer disabled” is made. The cost of COBRA coverage for the 11-month disability extension will, however, increase after the 18th month of continuation coverage, unless coverage would continue in any event on account of a second qualifying event. The increase, if any, will not exceed 150 percent of the cost to the Plan, including both employer and associate contributions, for coverage of a similarly situated participant (as applicable) or beneficiary who is not receiving COBRA coverage.



Form of Notice to Human Resources and COBRA Administrator

When you or the covered dependent, or a person acting on your or his/her behalf, must notify Human Resources or the COBRA administrator, the notice must be in writing. The notice must include:

the name of the employee or former employee who is or was a Plan participant,

a description of the qualifying event or second qualifying event (if any),

the date of the qualifying event (and second qualifying event, if any),

the name(s), address(es) and Social Security number(s) of the covered dependents affected by the qualifying event, and

for a notice relating to a disabled individual, a copy of the Social Security Administration’s disability determination and the date of the determination.

The timely provision of the notice by one individual will satisfy the notice requirement on behalf of all related qualified beneficiaries with respect to the qualifying event.

Trade Act

If you should lose your job, and, as a consequence, you are eligible for trade adjustment assistance under the Trade Act of 2002, or if you are at least age 55 and receiving a pension benefit from the Pension Benefit Guaranty Corporation, you may be eligible to take a tax credit or get advance payment of up to 65 percent of your COBRA coverage premiums or other qualified health insurance. In certain circumstances, you may also be eligible for a second 60-day COBRA coverage election period. If you have questions about these Trade Act provisions, you may contact the Health Coverage Tax Credit Customer Contact Center toll-free at 866-628-4282 or 866-626-4282 (TTD/TTY). More information about the Trade Act is also available at www.doleta.gov/tradeact.

Questions about COBRA Continuation Coverage

If you are an active employee or a COBRA participant and you have questions about COBRA coverage, you may contact the COBRA administrator. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 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 in your area or visit its website at www.dol.gov/ebsa. Addresses and phone numbers of Regional and District Employee Benefits Security Administration offices are available through its website. For more information about the Health Insurance Marketplace, visit www.HealthCare.gov.

Keep the Plan Informed of Address Changes

In order to protect your family’s rights, you should keep your local Human Resources representative informed of any changes in the addresses of family members. You should also keep copies, for your records, of any notices you send to the COBRA administrator.



When You Have Coverage Elsewhere Coordination of Benefits (COB)

The Medical and Dental Benefit Programs coordinate their benefits with other group plans to reimburse you or your dependents up to the allowable payment from these plans. An allowable expense is any expense covered at least in part by a Medical and Dental Benefit Program.

Here is how the benefits are coordinated when a claim is made:

As an Associate Employed by the Company. The Medical or Dental Benefit Program is primary — it pays its benefit first without regard to any other plan.

For a Spouse/Domestic Partner Who Has Other Healthcare Insurance. The Medical or Dental Benefit Program is secondary — benefits from the Medical or Dental Benefit Programs will be adjusted so that the total benefit payable will not be greater than the maximum reimbursement under the Medical or Dental Benefit Program.

If You Have Children and You and Your Spouse/Domestic Partner Have Separate Medical Coverage. Bosch considers the plan of the parent whose birthday comes first in the year as the primary plan; the other plan is secondary.

Any legal requirements that vary from these rules will take precedence.

After a claim has been processed by the plan that is primary, it may be submitted to the secondary plan. The written explanation of benefits (EOB) from the primary plan must accompany the claim when it is sent to the secondary plan.

The Company has the right to obtain information from any other organization necessary to coordinate benefits. The Company also has the right to recover any amounts paid in excess of benefits payable by the Plan.

Coordination of Benefits does not apply to prescription drug expenses, vision benefits or any individual medical insurance you have purchased on your own. Coordination of benefits applies only to group benefit plans.

Subrogation and Right of Recovery When you are injured or become ill because of the actions of a responsible party (defined as a third party who is responsible for making any payment to you because of your injury, illness or condition), the Plan may cover your eligible medical, prescription drug or dental expenses. However, to receive coverage, you must notify the Plan of your illness or injury and identify the responsible party.

Note!

As used in this section, “you” refers to any person who is a covered person (that is, anyone on whose behalf the Plan pays or provides any medical or dental benefit, including but not limited to, the minor child or dependent of any Plan member or person entitled to receive any benefits from the Plan).



Terms to Know

Responsible Party. In addition to any party actually, possibly or potentially responsible for making a payment to you because of your injury, illness or condition, this term includes the responsible party’s liability insurer or any insurance coverage.

Insurance Coverage. This refers to any coverage providing medical expense coverage or liability coverage, including but not limited to, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, medical payments coverage, workers’ compensation coverage, no-fault automobile insurance coverage or any first party insurance coverage.

Subrogation

Immediately upon paying or providing any benefit under the Medical and Dental Benefit Programs, the Plan will be subrogated to (i.e., will stand in the place of) all rights of recovery you have against any responsible party with respect to any payment you receive from the responsible party because of your injury, illness, or condition, to the full extent of benefits provided or to be provided by the Plan.

Reimbursement

In addition, if you receive any payment from any responsible party or insurance coverage as a result of an injury, illness, or condition, the Plan has the right to recover from, and be reimbursed by, you for all amounts this Plan has paid and will pay as a result of that injury, illness, or condition. This includes payments from any insurance proceeds, settlement amounts, judgments, or amounts recovered in a lawsuit.

Reimbursement will be taken from such payment, up to and including the full amount you receive from any responsible party.

Constructive Trust

By accepting benefits from the Plan (whether benefits are paid to you or paid on your behalf to any provider), you agree that if you receive any payment from any responsible party as a result of an injury, illness, or condition, you will serve as a constructive trustee over the funds that constitute that payment. Failure to hold those funds in trust will be deemed a breach of your fiduciary duty to the Plan.

Lien Rights

Further, the Plan will automatically have a lien against the proceeds of your recovery and against future benefits due under the Plan (for benefits paid by the Plan for the treatment of your illness, injury, or condition or due to an act or omission of the responsible party).

The lien will attach as soon as any person or entity agrees to pay any money to you or on your behalf that could be subject to the Plan’s right of recovery. The lien will be imposed upon any recovery (whether by settlement, judgment, arbitration award or otherwise, including from any insurance coverage), related to treatment for any illness, injury, or condition for which the Plan paid benefits.



The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the Plan including, but not limited to, you, your representative or agent, the responsible party, the responsible party’s insurer, representative, or agent, and/or any other source possessing funds representing the amount of benefits paid by the Plan.

If you fail to repay the Plan from the proceeds of any recovery, the Plan Administrator may satisfy the lien by deducting the amount from future claims otherwise payable under the Plan. The Plan’s provisions concerning subrogation, equitable liens, and other equitable remedies are also intended to supersede the applicability of the federal common law doctrines commonly referred to as the “make whole” rule and the “common fund” rule.

First-Priority Claim

By accepting benefits (whether benefits are paid to you or paid on your behalf to any provider) from the Plan, you acknowledge that this Plan’s recovery rights are a first-priority claim against all responsible parties and are to be paid to the Plan before any other claim for your damages.

This Plan is entitled to full reimbursement on a first-dollar basis from any responsible party’s payments, even if payment to the Plan results in a recovery that is insufficient to make you “whole” or to compensate you in part or in whole for the damages sustained.

The Plan’s right to recover will not be limited by application of any statutory or common law “make whole” doctrine. The Plan also is not required to participate in or pay court costs or attorney fees to any attorney hired by you to pursue your damage claim.

Applicability to All Settlements and Judgments

The terms of this entire subrogation and right of recovery provision apply and the Plan is entitled to full recovery regardless of whether any liability for payment is admitted by any responsible party and regardless of whether the settlement or judgment you receive identifies the benefits the Plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses.

The Plan is entitled to recover from any and all settlements or judgments, regardless of the identity of the party from which recovery is obtained, even those designated as pain and suffering, non-economic damages, and/or general damages only.

Cooperation

You must fully cooperate with the Plan’s efforts to recover its benefits paid. Such cooperation includes, where requested, the filing of suit by you against the responsible party and the giving of testimony in any action filed by the Plan. It is your duty to notify the Plan within 30 days of the date when any notice is given to any party, including an insurance company or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to injury, illness, or condition sustained by you.



If you fail to take action against a responsible party to recover damages within one year or within 30 days after the Plan’s request, the Plan will be deemed to have acquired, by assignment or subrogation, a portion of your claim equal to the amounts the Plan has paid on your behalf. The Plan may thereafter commence proceedings directly against any responsible party.

The Plan will not be deemed to waive its rights to commence action against a third party if it fails to act after the expiration of one year nor will the Plan’s failure to act be deemed a waiver or discharge of the lien described above.

You and your agents must provide all information requested by the Plan, the claims administrator or its representative including, but not limited to, completing and submitting any applications or other forms or statements the Plan may reasonably request. Failure to provide this information may result in the termination of your health benefits, denial of payment of claims, treatment of prior claims as overpayments recoverable by offset against future plan benefits or the institution of court proceedings against you.

You must do nothing to prejudice the Plan’s subrogation or recovery interest or to prejudice the Plan’s ability to enforce the terms of this Plan provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the Plan.

You also must acknowledge that the Plan has the right to conduct an investigation regarding the injury, illness, or condition to identify any responsible party. The Plan reserves the right to notify a responsible party and his/her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys.

Interpretation In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its terms, the claims administrator for the applicable Healthcare Benefit Program has the sole authority and discretion to resolve all disputes regarding the interpretation of this provision.

Jurisdiction By accepting benefits from the Plan (whether benefits are paid to you or paid on your behalf to any provider), you agree that any court proceeding with respect to this provision may be brought in any court of competent jurisdiction as the Plan may elect.

By accepting benefits, you hereby submit to each jurisdiction, waiving whatever rights may correspond to you by reason of your present or future domicile.

In addition, the Plan has a right to recover benefits paid in error (e.g. benefits paid to an ineligible person), or benefits that were obtained through fraudulence, as determined by the claims administrator. Benefits may be recovered by either direct payment to the Plan by the person for whom the payments were made or from any other insurance company or organization through voluntary payments, legal action, or by an offset of future benefits equal to the amount of the overpayment.

The claims administrator may delegate these functions.



When Coverage Ends Except for the rights outlined under “COBRA Continuation Coverage” in the previous section, coverage for you and/or your dependents will end:

on the date your employment ends for any reason, including retirement,

if you are no longer eligible for the Plan,

if a dependent is no longer eligible (that is, no longer meets the definition of dependent under the Plan or a Benefit Program),

you are unable to provide proof of dependent eligibility documentation,

if you fail to pay required premiums, or

if the Plan, a Benefit Program or Benefit Program option is terminated, canceled or amended.

Eligibility Claims An “eligibility claim” is any written request for participation in the Plan or a Benefit Program or to change a coverage election that is made by you or your authorized representative. For example, eligibility claims include requests to enroll or drop coverage for yourself or your dependent, or a request to opt-out of coverage if you are automatically enrolled. An eligibility claim may occur if you believe a mistake was made during an initial or annual enrollment period, or if you mistakenly believed your dependent child was enrolled in the Plan.

How to File an Eligibility Claim You must submit eligibility claims in writing to the Robert Bosch LLC Corporate Benefits Department at the following address:

Robert Bosch LLC Corporate Benefits Department 2800 South 25thth Avenue Broadview, IL 60155

Decisions on Eligibility Claims If your eligibility claim is denied, you will be provided with written notice of the denial within 30 days after the date your eligibility claim is received by the Corporate Benefits Department. In some cases, it may take up to 15 extra days to review your eligibility claim; however, any extension will not go beyond 45 days from the date your eligibility claim was first received. If additional time is necessary, you will be notified by the end of the initial 30-day period of the reasons for the delay and an estimate of when your eligibility claim will be resolved.

Note

Any benefits continued under severance end on the last day of the month in which severance ends.



Appealing an Eligibility Claim If you receive notice that your eligibility claim is denied and you disagree with that decision, you must file an internal appeal by submitting your request for internal review to the Bosch Benefit Plans Committee at the following address within 180 days of receiving the eligibility claim denial:

Robert Bosch LLC Bosch Benefit Plans Committee 2800 South 25th Avenue Broadview, IL 60155

The Bosch Benefit Plans Committee will make its determination on your appeal and provide you with a notice of the determination within 60 days of the date the Committee receives your appeal. The decision by the Bosch Benefit Plans Committee will be final and binding on all parties. Eligibility claims are not eligible for external review.

If you are not satisfied with the results of the appeal, you may have the right to file a lawsuit under ERISA. However, you must file such a suit no more than 180 days after you are notified of the result of the appeal, and you may not file such a suit unless you have first complied with all of the claim and appeal procedures described above in a timely manner. See “Your Right to Benefits” in the Administrative Information section for more information about lawsuits under ERISA.


Healthcare Benefit Programs Robert Bosch LLC offers you and your dependents the following Healthcare Benefit Programs under the Bosch Choice Welfare Benefit Plan.

Medical Benefit Program. Under the Medical Benefit Program, you may choose to participate in a medical benefit option, which provides coverage for preventive care, hospital stays, emergency room care and mental health/chemical dependency treatment. Prescription drugs, both short-term and long-term medications, are also covered under these Benefit Options.

Dental Benefit Program. The Dental Benefit Program offers two dental Benefit Options that cover routine oral exams and cleanings, as well as basic and major services, such as oral surgery, root canal therapy, dentures and, for one of the dental options, orthodontia.

Vision Benefit Program. This coverage includes benefits for eye exams, glasses and contact lenses. Discounts for laser correction surgery and additional pairs of glasses are also available.

The benefits under the Vision Benefit Program are provided under (or pursuant to) an insurance contract issued to Bosch by the insurance carrier. This insurance contract controls over all other documents, including this SPD.

Employee Assistance Program. This Benefit Program provides assistance to you or your family with issues that threaten or disrupt your life at home or at work.

For More Information

Administrative details and procedures can be found in the Administrative Information section. If you have questions about the information in this SPD, you can Contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).

Healthcare Benefit Programs


In This Section See Page

Benefits-at-a-Glance ........................................................................................ 29 Participating in Healthcare Benefit Programs................................................... 30

Who Is Eligible ............................................................................................. 30 Medical Benefit Program .................................................................................. 31

Overview of the Medical Benefit Program ................................................... 32 Medical Review Program............................................................................. 37 Comparison of Medical Benefit Options ...................................................... 39 Additional Information about Covered Care and Services........................... 49 Important Terms for Understanding Your Benefits ...................................... 52 Medical Expenses Not Covered .................................................................. 55

Prescription Benefits ........................................................................................ 58 Dental Benefit Program .................................................................................... 62 Vision Benefit Program..................................................................................... 67 Employee Assistance Program ........................................................................ 69 How to File Claims ........................................................................................... 70



Benefits-at-a-Glance While we have made every effort to offer the same Benefit Options at all Company locations, your choices may vary based on where you live and your ability to access network providers. This section of the SPD covers the major features of the Healthcare Benefit Programs — the Medical Benefit Program (except for HMO Benefit Options), Dental Benefit Program, Vision Benefit Program and EAP — offered to eligible Bosch associates. It also discusses how to submit claims if necessary, as well as the claim denials and appeals processes for the Healthcare Benefit Programs.

The following chart shows the healthcare benefits you may elect as an eligible Bosch associate for yourself and your eligible dependents.

Note: Automotive Service Solutions associates are not eligible for the CDHP Benefit Options.

Medical Benefit Program*

Dental Benefit Program

Vision Benefit Program

As an Eligible Associate, You May Choose from These Benefit Options…

CDHP 80 Benefit Option

CDHP 90 Benefit Option

PPO — Basic Benefit Option

PPO — Plus Benefit Option

HMO Benefit Option (if available based on your location)

80% Preventive — Without Orthodontia Benefit Option

100% Preventive — With Orthodontia Benefit Option

Vision Service Plan (VSP)

* When you enroll in your medical benefits, you will receive prescription drug coverage automatically.

HMO Coverage

If an HMO is available to you based on where you live, please refer to the certificate published by the HMO for information about eligibility requirements under that HMO and a description of medical and vision benefits. The certificates for the HMOs are considered part of this SPD.



Participating in Healthcare Benefit Programs This section provides important information about the Healthcare Benefit Programs, including certain eligibility and enrollment rules specific to these Programs and how much coverage costs. It also explains other features of these Programs, such as what happens when coverage ends and how benefits are coordinated if you have coverage elsewhere.

Who Is Eligible You are eligible to participate in the Healthcare Benefit Programs if you satisfy the eligibility requirements listed in the Participating in the Plan section.


To participate in the HMO Benefit Options, you will need to also reside within the service area for the HMO and work at a location that offers the HMO as a benefit option under the Medical Benefit Program. Please contact HAP at 248-443-8160 for more information about the HMOs.

Eligible Dependents

When you enroll in the Healthcare Benefit Programs, you may also enroll your eligible dependents. See “Who Is Eligible” in the Participating in the Plan section for the dependent eligibility requirements and additional information on what happens if both you and your Spouse/Domestic Partner are eligible for the Plan.

Note: You will be asked to provide documentation that verifies your dependent’s eligibility to participate in the plan. This may include birth certificates, marriage licenses, tax returns or other proof of eligibility.

Coverage Options

You do not have to enroll in any other Benefit Programs to participate in the Healthcare Benefit Programs. You will be able to choose the level of coverage you want for medical, dental and vision coverage. For example, you can elect to enroll yourself, your Spouse/Domestic Partner and your child(ren) in medical benefits, but only yourself in dental benefits. However, to cover your Spouse/Domestic Partner or other eligible dependents under the Medical, Dental or Vision Benefit Programs, you must be enrolled in those Programs yourself.

See the Participating in the Plan section for information on what happens if you and your Spouse/Domestic Partner are both eligible for the Plan.



Medical Benefit Program The Medical Benefit Program provides broad, comprehensive protection to cover a wide range of medical providers, services and supplies. Depending on where you live, you may be able to elect one of the following Benefit Options:

Bosch CDHP 80 Benefit Option,

Bosch CDHP 90 Benefit Option,

Preferred Provider Organization (PPO) — Basic Benefit,

Preferred Provider Organization (PPO) — Plus Benefit Option, or

Health Maintenance Organization (HMO). Note: Automotive Service Solutions associates are not eligible for the CDHP Benefit Options.

To participate in the HMO Benefit Options, you will need to also reside within the service area for the HMO and work at a location that offers the HMO as a benefit option under the Medical Benefit Program. Please contact HAP at 248-443-8160 for more information about the HMOs.

The CDHP 80, CDHP 90, PPO Basic, and PPO Plus Benefit Options have a Medical Services Advisory (MSA) Program, including Advance Approval, to ensure that you are receiving the appropriate medical care in the most effective setting possible and that the services are covered. See “Medical Review Program” on page 37 for more information.

Important Reminder!

Keep in mind that the standards for coverage of medical expenses change from time to time. You will receive periodic notices of important changes or modifications to the Plan. However, all changes to covered benefits are binding, even without notice.

If you have any questions as to whether a particular medical procedure is covered under current standards, you should always check with the medical carrier before incurring the expense, even if the mandatory review program does not apply.

HMO Coverage

If you elect to enroll in an HMO, detailed information about special eligibility requirements, covered services and supplies, and claim filing procedures appears in the HMO certificates. Contact HAP at 248-443-8160 to obtain specific HMO plan information. The HMO certificates are considered to be part of this SPD.



An Important Note!

The Company reserves the right to amend, modify, suspend or terminate the Plan or any of the Benefit Programs, in whole or in part, at any time and for any reason by written action of the Retirement and Benefits Plans Committee. A decision to terminate, amend, or replace a Benefit Program may be due to changes in federal or state laws governing benefits; the requirements of the Internal Revenue Service or ERISA, or for any other reason. This may include the elimination of or decreases in benefits, changes in Medical Benefit Program networks and increase in your required contributions for coverage.

If You Have Questions

If you have any questions about this SPD or any provision of the Benefit Programs, contact the appropriate Benefit Program provider listed in the Contact Information section or call the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).

If You Need Help Understanding This Summary

This SPD contains a summary of your rights and benefits under the Plan. If you have difficulty understanding any part of the SPD, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).

Overview of the Medical Benefit Program This section describes the Benefit Options available to you under the Medical Benefit Program.

Consumer Driven Health Care Plans

A Consumer Driven Health Care Plan (CDHP) is a health plan designed to help associates take more responsibility for their personal health. CDHPs combine higher deductibles with preventive care covered at 100% and the option to set up and make Pre-Tax contributions to a Health Savings Account (HSA) to help pay for eligible expenses. For more details, see “Health Savings Account” on page 34.

As a Bosch associate, you may choose between two CDHPs:

Bosch CDHP 80 Benefit Option, or

Bosch CDHP 90 Benefit Option.


These Benefit Options have a maximum limit on the amount of out-of-pocket medical and prescription drug expenses that participants spend, which includes coinsurance, deductibles and flat dollar copayments. The deductible is the amount you must pay each year for healthcare expenses (including prescription drug expenses) before any benefits are payable under these Benefit Options. After the deductible has been met for the year, you will be responsible for coinsurance. Coinsurance is your share of the cost for eligible expenses.

Important

Because physicians and hospitals frequently change their affiliations with networks and organizations, printed directories become quickly outdated. To ensure that the provider you are going to receive treatment from is currently in-network, contact the Claims Administrator for your medical benefit option before each visit or hospital stay. For contact information, see the Contact Information section of this SPD.



While the CDHP 80 Benefit Option has a lower premium rate than the CDHP 90 Benefit Option, the deductible for the CDHP 80 Benefit Option is higher. In addition, the coinsurance percentage you will be responsible for under the CDHP 80 Benefit Option is more than you will be required to pay under the CDHP 90 Benefit Option.

A CDHP allows you to receive medical care and services from any physician or facility you choose, although your costs are generally lower if you use in-network providers. As a CDHP participant, you do not need to select a primary care physician, nor do you need referrals for a specialist. There are two types of providers:

In-Network Providers. BlueCross BlueShield (BCBS) network providers, including physicians and hospitals, that have agreed to become part of the network and provide care to members at a lower negotiated rate. Your out-of-pocket expenses will also be lower if you use in-network providers.

Out-of-Network Providers. Any provider not affiliated with BCBS is out-of-network. If you obtain care from an out-of-network provider, your benefit coverage may be lower. In addition, your cost for care and services may be higher than with an in-network provider.

Specific details of the two Plans are outlined in the “Comparison of Medical Benefit Options” on page 39. See “Prescription Benefits” beginning on page 58 for more information on how prescription drugs are covered under the CDHPs.

Preferred Provider Organization (PPO)

Like the CDHP, a PPO Plan allows you to receive medical care and services from any physician or facility you choose — although you benefit from negotiated rates when you use in-network providers. As a PPO participant, you do not need to select a primary care physician, nor do you need referrals for a specialist. There are two types of providers:

In-Network Providers. BlueCross BlueShield (BCBS) network providers, including physicians and hospitals, that have agreed to become part of the network and provide care to members at a lower negotiated rate. Your out-of-pocket expenses may also be lower if you use in-network providers.

Out-of-Network Providers. Any provider not affiliated with BCBS is out-of-network. If you obtain care from an out-of-network provider, your benefit coverage may be lower.

There are two PPO options offered by the Company:

PPO Basic Benefit Option, and

PPO Plus Benefit Option.

While the PPO Basic Benefit Option has a lower premium rate than the PPO Plus Benefit Option, the deductible for the PPO Basic Benefit Option is higher, as well as the amount you are expected to pay out of your own pocket (i.e., out-of-pocket maximum). In addition, the coinsurance percentage you will be responsible for under the PPO Basic Benefit Option is more than you will be required to pay under the PPO Plus Benefit Option.



Specific details about these benefits options are outlined in the “PPO Benefit Option Comparison” on page 44. See “Prescription Benefits” on page 58 for more information on how prescription drugs are covered under the PPO Benefit Options.

Health Maintenance Organization (HMO)

Depending on your location, you may have the option of enrolling in an HMO. With most HMOs, you must select a primary care physician (PCP) who will coordinate all of your medical care, including referrals to a specialist if necessary (this process varies by HMO).

All PCPs are considered “in-network” — they have agreed to become part of the organization for purposes of providing care to members at a lower negotiated rate. There is usually no out-of-network benefit coverage available, except in emergencies.

If your enrollment worksheet indicates that you have the option of enrolling in an HMO, visit the Bosch Benefits Center website for an HMO SBC containing detailed information.

Health Savings Account When you enroll in the CDHP 80 or CDHP 90 Benefit Option, you may contribute to a tax-advantaged Health Savings Account (HSA). An HSA is a savings account that belongs to you. It is designed to help you save for current and future healthcare expenses in a tax-free account.

You may make Pre-Tax payroll deductions for the HSA only if you enroll in either the CDHP 80 or CDHP 90 Benefit Option — and you are not covered by another plan that does not qualify as a high deductible health plan, such as Medicare Part A or B, a Spouse’s/Domestic Partner’s health plan or flexible spending account, or military coverage. HSAs offer the following features:

your contributions (up to certain limits), investment earnings (or losses) and qualified distributions are all exempt from federal income tax, FICA (Social Security and Medicare) tax, and state income taxes (for most states),

to remain tax-free, contributions must be used to pay for eligible healthcare expenses, as defined by the IRS (amounts used to pay other expenses are subject to regular income tax and, if you are under age 65, a 10% tax penalty), and

the dollars that remain in your account at the end of the year will roll over to the next year, making your account a convenient, easy way to save and invest to pay for future medical expenses. Even if you change jobs, or when you decide to retire, you can take your HSA with you.

If you enroll in one of the Bosch CDHP Benefit Options and open an HSA through the Plan’s benefit provider, you may automatically receive a Company contribution to your account on a quarterly basis, even if you don’t contribute yourself. In your enrollment materials, the Company will indicate the amount of the Company contribution. (You may choose to open a health savings account through your own financial institution and deduct your contributions on your tax return, but you will not receive the Company contribution.) The Company reserves the right to discontinue contributions at its discretion.

Save Your Receipts!

Whether for your own records or in the event of an IRS audit, it’s a good idea to keep your receipts for any healthcare expense you incur. This way, you can prove that you used your HSA to pay for eligible healthcare expenses, if necessary.

Keep in mind that if you use your funds for non-eligible expenses, you will need to claim this money on your tax return and pay both regular taxes as well as a tax penalty on this amount if you are under age 65.



HSAs are individually owned accounts (like IRAs) and are not part of a Company benefit plan. The HSA is not an ERISA plan, nor a benefit option under the Plan.

Your Spouse’s/Domestic Partner’s participation in a healthcare flexible spending account could disqualify you from establishing and making/receiving tax-favored contributions to a health savings account. For more information on health savings accounts, you may refer to IRS Publication 969 at www.irs.gov.

HSA Contributions

The annual calendar year maximum amount that can be contributed to an HSA is based on a statutory limit. In 2015, the statutory limits are:

$3,350 individual, and

$6,650 family.

Under the Company’s cafeteria plan, you may make contributions to the HSA that you set up with the Plan’s benefit provider on a Pre-Tax basis, up to the annual calendar year maximum (less any Company contributions), through payroll deductions. You may change your payroll deductions for the HSA at any time.

The Company may also make contributions to the HSA through the cafeteria plan. The Company reserves the right to discontinue contributions at any time at its discretion. Note: Once your benefits end, the Company will not provide contributions to your HSA even if you continue your medical coverage under COBRA.

All contributions to an HSA, regardless of source (your contributions or the Company’s contributions), count toward the annual maximum.

Where Your HSA Money Comes From

Bosch Contributions

If you enroll in one of the Bosch CDHP Benefit Options and open an HSA through the Plan’s benefit provider, BenefitWallet, you will automatically receive a Bosch contribution to your account on a quarterly basis, even if you don’t contribute yourself. (See “Health Savings Account” on page 34.) The Company reserves the right to discontinue contributions at its discretion.

Your Contributions

In addition to the contributions that the Company will make on your behalf, you can elect to make additional Pre-Tax or After-Tax contributions during the year, up to the calendar year maximum limit set by the IRS (less any Company contributions). (See “Health Savings Account” on page 34.)

Earnings

Your BenefitWallet HSA will earn interest annually, adding to your account balance. After your HSA account balance reaches a certain amount, you may select investment funds for your HSA.

HSA Catch Up Contributions

If you are age 55 or older and not enrolled in Medicare, you may make a $1,000 catch-up contribution, in addition to regular contributions, to your HSA.



Eligible Expenses

You can use your tax-advantaged HSA to help pay for qualified medical expenses (as defined by the IRS) for you and your family. See IRS Publications 502 and 969 at www.irs.gov for more information about qualified medical expenses and HSAs.

Qualified medical expenses include:

visits to the doctor for reasons other than preventive care (preventive care is 100% covered by Bosch),

prescription drugs, dental care, vision care, nursing care, psychiatric care and chiropractic care,

other medical expenses not covered by the Plan (but eligible according to IRS publications 502 and 969),

certain healthcare premiums while receiving unemployment compensation (i.e., under COBRA), and

if you are over age 65, Medicare Part B, C, and D premiums and deductibles; copays; and coinsurance under any part of Medicare (premiums for Medigap policies are not qualified medical expenses).

Withdrawals for non-medical expenses and medical insurance premiums are taxable and if you are under age 65, an additional 10% penalty applies. Consult your tax advisor for additional information.

Your Preventive Care Coverage Preventive care includes routine procedures and exams that focus on preventing disease and promoting health and well-being. The CDHP and PPO Benefit Options cover eligible preventive care services at 100%. This means that you will have no out-of-pocket expenses for these services.

Some common preventive care services are listed below. When you receive these services, the claims must be submitted by your healthcare provider as routine or preventive to ensure that you receive the full benefit for those services:

immunizations,

routine blood work (e.g., glucose, cholesterol, iron),

routine colorectal cancer screening,

routine diagnostic tests (e.g., EKG, bone density tests),

routine digital rectal exams,

routine gynecological exams,

routine mammograms,

routine pap smear tests,

routine prostate tests,

routine urinalysis,

well-baby care,



wellness exams, and

the following preventive care prescription drugs:

iron supplements for children age 6 to 12 months with increased risk of iron deficiency anemia,

folic acid for women age 18 to 45,

low dose aspirin (to prevent cardiovascular disease) for men age 45 to 79 and for women age 55 to 79, and

fluoride drops or tablets for children age 6 months to age 5.

In addition, all Bosch medical plans now cover the following women’s services at 100%, with no deductible. Some of these services are currently covered, and others feature new or expanded coverage:

Annual well-woman preventive care visits, including prenatal care (prenatal labs remain part of maternity coverage),

Gestational diabetes screening for symptomatic individuals at high risk of diabetes,

Human papillomavirus (HPV) DNA testing,

Counseling and screening for HIV and other sexually transmitted diseases,

All FDA-approved female contraceptive methods and sterilization procedures, including patient education and counseling (under the CDHP and PPO plans, this does not include brand-name contraceptives that have a generic equivalent),

Breastfeeding support, supplies and counseling, and

Interpersonal and domestic violence screening and counseling.

For more information about this coverage, call the Claims Administrator. See Contact Information for detailed contact information.

Medical Review Program Medical Services Advisory (MSA) Program

Unnecessary medical care and hospital stays, or stays that last longer than necessary, cause healthcare costs to increase. Sometimes, individuals are hospitalized for procedures that can be performed safely, effectively and more comfortably in an alternative setting, such as a hospital’s outpatient department or physician’s office.

The CDHP 80, CDHP 90, PPO Basic and PPO Plus Benefit Options require advance approval through the Medical Services Advisory (MSA) Program.

The MSA Program is supported by healthcare professionals, including registered nurses and physicians in a full range of medical specialties, who can help you:

determine the most appropriate and cost-effective way to meet your healthcare needs, and

meet the requirements of your medical coverage.



Your phone call to MSA starts the process working for you. From the time your doctor first recommends treatment until the treatment is completed, an MSA advisor will answer your questions and work with your physician when necessary to make sure you know how to get the most appropriate coverage available.

The MSA Program is available from 7:00 a.m. to 6:00 p.m. Central Time, Monday through Friday. You may leave a message with the answering service after hours or on weekends; an MSA advisor will call you back the next business day. For contact information, see the Contact Information section of this SPD.

Advance Approval

Advance approval, also referred to as Pre-Admission Certification (PAC) and Continued Stay Review (CSR), refers to the process used to certify medical necessity when you or your dependent requires care or services. You are responsible for receiving advance approval in the following situations.

Care or Services Timeframe

Inpatient Hospital Stays

Including maternity admissions and inpatient care for mental health or chemical dependency treatment

Scheduled, non-emergency At least 1 business day before admission

Non-scheduled, emergency Within 2 business days of an admission

Skilled Nursing Facility At least 1 business day before admission

Home Health Care At least 1 business day before receiving care

In-home Private Duty Nursing At least 1 business day before receiving care

Transplants At least 1 business day before the procedure

Failure to Receive Advance Approval

If you do not contact MSA when required, there will be a 50% reduction in benefits before the Plan pays benefits. In addition, expenses for treatment not considered medically necessary will not be covered.

If you need to continue a stay beyond the period certified, you must contact MSA before the original timeframe expires. If you do not contact MSA in this situation, benefits will be reduced by 50% for hospital treatment charges in excess of the number of days certified.

Maximum Penalty

The maximum cost you will be required to pay for failing to receive advance approval is $500. However, this amount does not include the cost of any treatment that is not medically necessary, nor will it be applied to your out-of-pocket maximum.

HMO Enrollment

If you are enrolled in an HMO, contact HAP at 248-443-8160 for detailed Plan information and review procedures.



Comparison of Medical Benefit Options While the medical Benefit Options provide broad protection, there are some differences between them. The following two charts compare the CDHP Benefit Options and the PPO Benefit Options side by side.

The CDHP Benefit Options cover in-network preventive care services at 100%. All other services and supplies, including prescription drugs and office visits, are subject to each Benefit Option’s annual deductible and coinsurance until you meet the annual out-of-pocket maximum.

For more information, see “Additional Information about Covered Care and Services” beginning on page 49 and “Important Terms for Understanding Your Benefits” beginning on page 52.


CDHP Benefit Option Comparison

CDHP 80 Benefit Option CDHP 90 Benefit Option

Plan Pays You Pay Plan Pays You Pay

Medical and Prescription Drug Coverage

Nothing until the deductible is met

Coinsurance (80% in-network or 60% out-of-network1)

100% of eligible expenses after the out-of-pocket maximum is met

100% until the deductible is met

Coinsurance until out-of-pocket maximum is met

Nothing for eligible expenses once out-of-pocket maximum is met







Preventive Care 100% $0 100% $0





Health Savings Account (HSA)

For Robert Bosch Tool Corporation Associates

The Company contributes:

$595 individual

$1,190 family

For All Others

If base pay is $50,000 or more, the company contributes:

$500 individual

$1,000 family

If base pay is less than $50,000, the Company contributes:

$595 individual

$1,190 family

These amounts are prorated on a quarterly basis

For the 2015 calendar year, you can make optional contributions directly to BenefitWallet. The total of your contributions and the Company contributions cannot exceed:

$3,350 individual

$6,650 family

You also can add an additional $1,000 if over age 55

For Robert Bosch Tool Corporation Associates

The Company contributes:

$595 individual

$1,190 family

For All Others

If base pay is $50,000 or more, the Company contributes:

$500 individual

$1,000 family

If base pay is less than $50,000, the Company contributes:

$595 individual

$1,190 family

These amounts are prorated on a quarterly basis

For the 2015 calendar year, you can make optional contributions directly to BenefitWallet. The total of your contributions and the Company contributions cannot exceed:

$3,350 individual

$6,650 family

You also can add an additional $1,000 if over age 55

Annual Deductible

The Company HSA contribution can reduce your annual deductible

$1,900 individual

$3,800 family

The Company HSA contribution can reduce your annual deductible

$1,300 individual

$2,600 family

Coinsurance1 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network





Annual Out-of-Pocket Maximum

(amounts include annual deductible and copays)

Please Note: Different out-of-pocket maximums apply for in-network and out-of-network services; however, charges for covered expenses are combined to reach each maximum amount. That means covered in-network expenses apply to your out-of-network out-of-pocket maximum, and vice versa.

Plan pays 100% of eligible expenses for the rest of the plan year once you reach this limit

In-Network

$2,500 individual

$5,000 family

Out-of-Network

$5,000 individual

$10,000 family

Plan pays 100% of eligible expenses for the rest of the plan year once you reach this limit

In-Network

$2,500 individual

$5,000 family

Out-of-Network

$5,000 individual

$10,000 family

Outpatient Doctor’s Office Visits

Treatment for illness/injury

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Allergy Treatments

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Diagnostic and Laboratory Testing

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Second Surgical Opinions

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network





Outpatient Preadmission Testing

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Hospital Services

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Emergency Room Visit

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Ambulance Services

(limited to R&C allowance)

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Urgent Care Facility

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Physical, Speech, Occupational Therapy

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Chiropractic Therapy

20 visit annual maximum per Plan Year

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Maternity

Prenatal and Postnatal Care

100% in-network

60% out-of-network

0% in-network

40% out-of-network

100% in-network

70% out-of-network

0% in-network

30% out-of-network

Delivery 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Family Planning 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network





Durable Medical Equipment

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

External Prosthetic Appliances

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Organ Transplants2

Heart, Lung, Heart/Lung, Liver, Pancreas, Pancreas/ Kidney

80% in-network

Not covered out-of-network

20% in-network

100% out-of-network

90% in-network


10% in-network

100% out-of-network

All Other Transplants

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

60% out-of-network

10% in-network

40% out-of-network

Dental Care3

Accidental injury to natural, sound teeth or removal of fully impacted wisdom teeth

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

TMJ

Excludes orthodontic care

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Outpatient Private Duty Nursing

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Skilled Nursing Facility and Rehabilitation

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Hospice Care

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network





Mental Health and Chemical Dependency

Inpatient care (no day limit)

Outpatient care (no visit limit)

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

1. See the definition of “Out-of-network” on page 54.

2. The human organ or tissue transplants listed are covered only when performed at a BCBS-approved program.

3. Dental care is limited to charges made for a continuous course of treatment started within six months of the injury to sound, natural teeth. The accident that caused damage to the sound, natural teeth must have been sustained while covered under the Medical Benefit Program.

PPO Benefit Option Comparison

PPO Basic PPO Plus


Medical Coverage Nothing until the deductible is met












Preventive Care 100% after $25 office visit copay (in-network)

60% (out-of-network)

40%, no deductible (out-of-network)

100% after $20 office visit copay (in-network)

70% (out-of-network)

30%, no deductible (out-of-network)

Health Savings Account (HSA)

HSA not available for PPO Options






PPO Basic PPO Plus


Annual Deductible

N/A In-Network $600

individual

$1,200 family

Out-of-Network $1,200

individual

$2,400 family

N/A In-Network $300

individual

$600 family

Out-of-Network $600

individual

$1,200 family

Coinsurance 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Annual Out-of-Pocket Maximum

(amounts include annual deductible, coinsurance and flat dollar copays)

Bosch pays 100% of eligible expenses for the rest of the plan year once you reach the limit shown to the right

In-Network $3,000

individual

$6,000 family


individual

$12,000 family

Bosch pays 100% of eligible expenses for the rest of the plan year once you reach the limit shown to the right

In-Network $1,500

individual

$3,000 Family


individual

$6,000 family

Outpatient Doctor’s Office Visits

Treatment for illness/injury

$25 copay in-network

60% out-of-network


40% out-of-network


70% out-of-network


30% out-of-network

Allergy Treatments

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network


Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Second Surgical Opinions

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network



PPO Basic PPO Plus


Outpatient Preadmission Testing

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Hospital Services

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Emergency Room Visit

Emergency 100% after

$100 copay (waived if admitted)

Emergency $100 copay

(waived if admitted)

Emergency 100% after

$100 copay (waived if admitted)

Emergency $100 copay

(waived if admitted)

Non-emergency 80% after


60% after $100 copay out-of-network










Ambulance Services

(limited to R&C allowance)

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Urgent Care Facility

80% after $50 copay in-network








Physical, Speech, Occupational Therapy

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Chiropractic Therapy

20 combined visits per Plan Year

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network



PPO Basic PPO Plus


Maternity

Prenatal and Postnatal Care

100% after $25 initial visit copay in-network

60% out-of-network

$25 initial visit copay in-network

40% out-of-network

100% after $20 initial visit copay in-network

70% out-of-network

$20 initial visit copay in-network

30% out-of-network

Delivery 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Family Planning 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network


80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network


80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Organ Transplants2

Heart, Lung, Heart/Lung, Liver, Pancreas, Pancreas/ Kidney

80% in-network


20% in-network


90% in-network


10% in-network


All Other Transplants

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

60% out-of-network

10% in-network

40% out-of-network

Dental Care3

Accidental injury to natural, sound teeth

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

TMJ

Excludes appliances and orthodontic care

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network



PPO Basic PPO Plus


Outpatient Private Duty Nursing

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Skilled Nursing Facility and Rehabilitation

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Hospice Care

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Mental Health and Chemical Dependency

Inpatient care (no day limit)

Outpatient care (no visit limit)

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

1. See the definition of “Out-of-network” on page 54.

2. The human organ or tissue transplants listed are covered only when performed at a BCBS-approved program.

3. Dental care is limited to charges made for a continuous course of treatment started within six months of the injury to sound, natural teeth. The accident that caused damage to the sound, natural teeth must have been sustained while covered under the Bosch Medical Benefit Program.



Additional Information about Covered Care and Services This section provides additional information about the covered care and services offered by the Plans. Services are subject to deductibles and coinsurance as noted in the “Comparison of Medical Benefit Options” table beginning on page 39.

Ambulance Service

Charges for a licensed ambulance service to or from the nearest hospital where the needed medical care and treatment can be provided.

Autism-Related Diagnoses

Charges for speech, physical and occupational therapy for autism-related diagnoses, including testing to determine such diagnoses.

Breast Reconstruction Following Mastectomy

The following services are covered for you and your dependents if required as a result of a mastectomy:

reconstruction of the breast on which the mastectomy has been performed,

surgery and reconstruction of the other breast to produce a symmetrical appearance, and

prostheses and treatment of physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes).


Includes x-rays, MRI (Magnetic Resonance Imaging), CAT (Computerized Axial Tomography), PET (Positron Emission Tomography) scans and laboratory procedures performed on an inpatient or outpatient basis.


Medical equipment used during a sickness or illness that can withstand repeated use and is appropriate for use in the home. Some examples include crutches, hospital beds, wheelchairs, respirators and dialysis machines.

Hygienic items, self-help equipment or items, or items that are primarily used for comfort or convenience are not considered covered supplies.


External prosthetic appliances include devices that replace appendages, as well as those that may treat a medical condition or alleviate symptoms (i.e., foot supports, custom-made shoes and braces, etc.). To be covered by a medical Plan, a physician must prescribe the appliance.

Replacements of appliances due to wear, tear, loss, theft or destruction are not covered by the Plan.

Women’s Health and Cancer Rights Act

Your Plan provides the benefits listed here as required by the Women’s Health and Cancer Rights Act of 1998. For more information, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).

Coverage for Wigs

If you are diagnosed with cancer or alopecia, wigs will also be covered, up to $750 each Plan Year.



Family Planning

Family planning includes:

office visits for infertility testing only; it does not cover counseling or any treatments, including in vitro fertilization, artificial insemination, GIFT, ZIFT, etc.,

inpatient and outpatient surgical sterilization procedures for vasectomy and tubal ligations (reversals are not covered by this Plan), and

contraceptive devices that are administered by a physician in the physician’s office (e.g., diaphragms and intrauterine devices).

Home Health Care

Home health care refers to skilled healthcare services that can be provided during visits of two hours or less. Home health care is covered when the patient requires skilled care, he or she is unable to obtain the required care as an ambulatory outpatient and confinement in a hospital or other healthcare facility is not required. Care includes necessary consumable medical supplies, home infusion therapy and durable medical equipment administered or used by a healthcare professional.

Hospice Care

Hospice care is a program of home and inpatient care for individuals who have a life expectancy of six months or less. Its aim is to provide care that meets the special needs of the patient and family during the final stages of a terminal illness. The program provides palliative and supportive medical, nursing and other health services through home or inpatient care during the illness. Hospice services can be provided by a hospital, skilled nursing facility, a home healthcare agency, hospice facility or any other licensed facility or agency under a hospice care program.

Hospice care does not cover expenses for services of a person who is a member of the patient’s family, for any period when you or your dependent is not under the care of a physician, for treatment other than for pain, or services or supplies that are primarily used to aid you or your dependent for daily living expenses.

Maternity Care

The Plan pays benefits for prenatal, delivery and postnatal care including exams, laboratory fees, delivery room and newborn nursery charges, as well as physician delivery fees or charges from a licensed midwife. The Plan, in compliance with federal law, provides that:

hospital stays will be covered for at least 48 hours following a normal vaginal delivery, or at least 96 hours following a cesarean section,

the attending physician does not need to obtain authorization from the Plan to provide the mother and newborn with this length of hospital stay, and

shorter hospital stays are permitted if the attending healthcare provider, in consultation with the mother, determines that this is the best course of action.

Fertility Drugs

For information about fertility drugs, see “Prescription Benefits” beginning on page 58.



Midwife Services

The Plan covers services of a midwife, as long as the individual is appropriately licensed, certified and working under the direct supervision of a physician acting within the scope of his or her license.

Organ Transplant

This benefit provides coverage for all human-to-human transplants that have advance approval, are medically appropriate and non-experimental. There are two categories of coverage:

Heart, lung, heart/lung, liver, pancreas or pancreas/kidney transplants must be performed in a BCBS-approved program in order to receive coverage.

All other organ and tissue transplants and organ transplants (e.g., cornea, kidney, bone marrow, heart valve, muscular skeletal and parathyroid transplants).

Note: If you are enrolled in the CDHP 80 or CDHP 90 Benefit Option, there is no out-of-network coverage for these transplant procedures.

Transplant services include:

compatibility testing,

medical, surgical and hospital services for the recipient,

procurement of an organ from a donor, and

transportation, lodging and food for a recipient, one companion and the donor (up to $10,000 each transplant) if the facility is more than 50 miles from the member’s residence.

For additional information, contact the Claims Administrator listed under the Contact Information section of this SPD.

Outpatient Hospital, Surgical and Facility Services

Includes benefits for surgery, radiation therapy, chemotherapy, shock therapy, renal dialysis treatments, diagnostic and cardiac rehabilitation services.

Residential Treatment Centers

A facility setting offering therapeutic intervention and special programming in a controlled environment which also offers a degree of security, supervision and structure and is licensed by the appropriate state and local authority to provide such service. It does not include halfway houses, supervised living, group homes, boarding houses or other facilities that provide primarily a supportive environment, even if counseling is provided in such facilities. Patients are medically monitored with 24 hour medical availability and 24 hour onsite nursing service for patients with Mental Illness and/or Substance Abuse disorders.

Who Is a Companion?

The term companion includes a Spouse/Domestic Partner, family member, the legal guardian of you or your dependent or any person not related to you who is actively involved as your caregiver. If a transplant is required for your minor child, expenses may be covered for two companions.



Routine Preventive Care

This benefit covers routine exams (including gynecological exams/Pap tests) and immunizations. Routine preventive care also covers non-diagnosed diagnostic and laboratory testing such as mammograms, various types of cancer screenings and bone density tests. For specific information on your benefits, as well as any limitations that may be applicable, contact the Claims Administrator listed under the Contact Information section of this SPD.

Skilled Nursing Facility

A skilled nursing facility is a licensed institution (other than a hospital) that provides physical rehabilitation, skilled nursing and medical care on an inpatient basis. The institution must maintain on the premises all facilities necessary for medical treatment, be under the supervision of a staff of physicians and provide nursing services.

TMJ (Temporomandibular Joint) Syndrome

TMJ Disorder is a condition of the joints linking the jawbone and skull, as well as muscles and other tissues related to that joint. Covered services for TMJ, Craniomandibular Joint Disorders and other conditions of the joints include surgical procedures and non-surgical care.

Important Terms for Understanding Your Benefits The terms defined in this section have significant meaning under the BCBS Plans. Other definitions appear in the appropriate sections.

Coinsurance

Once you meet the deductible, where applicable, your Benefit Option will pay a percentage of covered expenses for you and your family. For example, if the Plan pays 80% of an expense, you pay the remaining 20%. You are responsible for your portion of the coinsurance amount until you meet the out-of-pocket maximum.

Covered Expenses

To be covered by any of the Benefit Options, expenses must be recommended or approved by a physician and must be medically necessary for the care and treatment of an injury or sickness.

Deductible

The deductible, where it applies, is the portion of covered expenses you pay each year before your Benefit Option pays benefits. The deductible amount depends on the coverage option you select (i.e., associate only, associate and Spouse/Domestic Partner, associate and child(ren) or associate, Spouse/Domestic Partner and children) and whether you use in-network or out-of-network providers.

Once you have met your individual deductible, your Benefit Option pays its share of your covered charges for the rest of the Plan Year — and you will be responsible for your share of the covered charges.



For the CDHP Benefit Options, the family deductible must be satisfied before the Plan pays its share of the cost for any covered person’s eligible expenses. However, all eligible expenses incurred by you or your covered family members apply to the family deductible. Once the family deductible is met, the Plan will pay its share of covered charges for you or any of your covered family members for the rest of that Plan Year.

Experimental or Investigational

Technologies, supplies, treatments, procedures, drug therapies or devices are considered experimental or investigational if they are:

not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use,

the subject of review or approval by an institutional review board,

a part of an ongoing clinical trial, or

not demonstrated, through peer-reviewed literature, to be safe, effective and appropriate for the diagnosis or treatment of the injury or illness.

Family Coverage

Family coverage, for the purposes of the deductible, out-of-pocket maximum and HSA contributions, includes the following tiers:

associate and Spouse/Domestic Partner,

associate and child(ren), and

family (associate, Spouse/Domestic Partner and child[ren]).

Hospital

An institution licensed as a hospital that:

maintains on the premises all facilities necessary for providing inpatient medical and surgical treatment,

is supervised by a staff of physicians,

provides 24-hour nursing services by graduate registered nurses, and

is accredited as a hospital by the Joint Commission on the Accreditation of Hospitals.

A hospital does not include an institution that is primarily a place for rest, a place for the aged or a nursing home.

Lifetime Maximum

There is no limit to the amount of benefits you, or any of your covered dependents, can receive during a lifetime.



Medically Necessary

To be covered by the Plan, all healthcare supplies and services must be considered medically necessary. Medically necessary means that a specific medical, healthcare or hospital service is required for the treatment or management of a medical symptom or condition and that the service or care administered is the most efficient and economical service that can be provided safely. The Claims Administrator will be responsible for making a reasonable determination of medical necessity.

Out-of-network

Out-of-network providers can be contracted or noncontracted. Payment to noncontracted providers is based on Medicare reimbursement rates. Noncontracted providers can balance bill you for the difference between the Medicare reimbursement rate and the amount charged by the provider. Please ask your out-of-network provider if they are contracted with BCBSILor not.

Out-of-Pocket Maximum

As added protection for you, the Plan places a limit on how much you have to pay out of your own pocket for covered medical expenses each year. Once the limit is met, the Plan pays 100% of the remaining covered expenses for that Plan Year.

Please Note: Under the CDHP Benefit Options, different out-of-pocket maximums apply for in-network and out-of-network services; however, charges for covered expenses are combined to reach each maximum amount. That means covered in-network expenses apply to your out-of-network out-of-pocket maximum, and vice versa.

Regardless of your Benefit Option, the following expenses will not be applied toward your out-of-pocket limit and are not paid at 100% once the limit is reached:

expenses/penalties incurred for not receiving advance approval when required,

expenses not covered by the Benefit Option, or

expenses considered not medically necessary.

If you have associate only coverage under the PPO or Indemnity Benefit Options, the Plan will pay 100% of your eligible charges for the rest of the Plan Year once you meet the individual out-of-pocket maximum. If you have coverage for your spouse and/or child(ren), you or any combination of family members can meet the family out-of-pocket maximum. Once the family out-of-pocket maximum is met, the Plan pays 100% of covered charges for you and your covered family members for the rest of that Plan Year.

Under the CDHP Benefit Options, the family out-of-pocket maximum must be met before the Plan pays 100% of the cost for any eligible participant (required under HSA rules). However, any combination of deductible-eligible expenses incurred by family members may apply toward satisfaction of the family out-of-pocket maximum. Once the family out-of-pocket maximum is met, the Plan will pay 100% of covered charges for you or any of your covered family members for the rest of that Plan Year.



Primary Care Physician (PCP)

While you are encouraged to choose a primary care doctor who knows you and can coordinate your care, a PCP is not required if you enroll in the CDHP 80, CDHP 90, PPO Basic or PPO Plus Benefit Options. You will be required to select a PCP if you enroll in an HMO.

Physician

A physician is a medical practitioner who is:

licensed to prescribe and administer drugs or to perform surgery,

operating within the scope of his or her license, and

performing a service for which benefits are provided under this Plan (when performed by a physician).

Limited Benefits Will Be Paid When Non-Participating Providers Are Used

You should be aware that when you elect to utilize the services of a Non-Participating Provider for a Covered Service in non-emergency situations, benefit payments to such Non-Participating Provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy’s fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical area where the services are performed), or other method as defined by the plan. You can expect to pay more than the coinsurance amount defined under this coverage after the Plan has paid its required portion.

Non-Participating Providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill. Participating Providers have agreed to accept discounted payments for services with no additional billing to the member other than Coinsurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling the toll free telephone number on your identification card.

Single Coverage

Single coverage, for the purposes of the deductible, out-of-pocket maximum and HSA contributions, includes the following tier:

associate only or Spouse/Domestic Partner of associate only if associate loses eligibility before covered Spouse/Domestic Partner loses eligibility.

Medical Expenses Not Covered The Benefit Program will not pay benefits for the following medical expenses, even though they may be medically necessary:

charges for failure to keep an appointment or for completion of a claim form,

charges for which a person is not legally required to pay, for which you are not billed or for which you would not have been billed except that there was coverage under this Plan,

services not medically necessary, except for specifically outlined routine preventive care,



charges made by a hospital owned or operated by the U.S. government if the charges are directly related to a sickness or injury connected to a military service,

any injury resulting from, or in the course of, any employment for wage or profit,

any sickness covered by Worker’s Compensation or similar law,

reports, evaluations, examinations or hospitalizations not required for health reasons,

reversals of voluntary sterilizations and certain infertility services,

charges for or in connection with in vitro fertilization, artificial insemination or any other similar procedure,

amniocentesis, ultrasound or any other procedures requested solely for sex determination of the fetus, unless medically necessary to determine the existence of a sex-linked genetic disorder,

cosmetic surgery, except for the correction of congenital deformities or resulting from accidental injuries, scars, tumors or disease,

medical and surgical services intended primarily for the treatment or control of obesity which are not medically necessary,

replacement of external prostheses due to loss, theft or destruction,

transsexual surgery and related services,

acupuncture,

over-the-counter disposable or consumable medical supplies,

foot care for tired, weak or strained feet, including orthotics, the removal of calluses/corns and the trimming of nails (except for persons diagnosed with diabetes),

hearing exams or hearing aids,

eye exams and expenses associated with eye exercises,

eyeglasses or contact lenses (except for the first pair following cataract surgery),

surgical treatment for correction of refractive errors, including radial keratotomy, when eyeglasses or contact lenses may be worn,

expenses paid through a public program other than Medicaid,

wigs (except for hair loss as the result of cancer treatments or a diagnosis of alopecia),

speech therapy which is not restorative in nature,

experimental and/or investigational procedures,

charges made by any covered provider who is a member of your or your dependent’s family,

any injury or sickness that is due to war, declared or undeclared,



therapy undertaken to improve one’s general physical condition or to reduce potential health risk factors that is not medically necessary and is not expected to provide significant therapeutic improvement, including, but not limited to routine, long-term chiropractic care and rehabilitative services,

non-medical ancillary services, including vocational rehabilitation, behavioral training, employment counseling, driving safety and services, training or educational therapy for learning disabilities, developmental delays or mental retardation (this exclusion does not apply to speech, physical and occupational therapy for autism-related diagnoses and medical tests to determine diagnoses),

homemaker, chore or similar services and healthcare services primarily for rest, custodial or convalescent care,

elective abortions, unless the physician certifies in writing that the pregnancy would endanger the life of the mother or the expenses are incurred to treat medical complications caused by the abortion,

exercise and hygienic equipment,

over-the-counter drugs, diet pills, minoxidil or Retin-A, unless medically necessary,

educational testing or therapy,

smoking cessation drugs or patches except as covered under the Prescription Drug Benefits,

care and services incurred if a covered individual remains in the hospital when continued stay is not necessary,

services or supplies that are primarily to aid in daily living,

services resulting from the covered individual’s committing or attempting to commit a felony or from the covered individual’s engaging in an illegal occupation,

custodial care or services not intended primarily to treat a specific injury or sickness, or any education or training,

services performed by someone other than a licensed practitioner practicing within the scope of his or her license,

treatment of teeth/periodontalium under the medical Plan except for emergency dental work to stabilize natural sound teeth due to injury,

claims submitted after the time for submission has expired (see “How to File Claims” beginning on page 70),

dental implants, or

investigational services and supplies and all related services and supplies, except as may be provided under this benefit booklet for the cost of routine patient care associated with investigational cancer treatment if you are a qualified individual participating in a qualified clinical cancer trial, if those services or supplies would otherwise be covered under this benefit booklet if not provided in connection with a qualified cancer trial program.



Prescription Benefits If you enroll in the CDHP 80, CDHP 90, PPO Basic or PPO Plus Benefit Options, you are automatically eligible for prescription drug benefits. The prescription drug program is provided through Express Scripts.

Your coverage and share of the costs will vary depending on a number of factors, such as which medical benefit option you enroll in, whether services are received from a retail pharmacy or through the mail order service, and whether you receive generic or brand name drugs:

Under a CDHP Benefit Option. Prescription drugs are covered like any other covered expense, with deductibles and coinsurance amounts that apply to other eligible expenses. (You also can use your HSA to help pay for covered expenses.) See “Prescription Benefits” on page 58 for information about coverage under the CDHPs.

Under a PPO Benefit Option. Copays apply for generic drugs and minimum or maximum coinsurance amounts apply to brand name drugs. See the “Prescription Benefits” on page 58 charts below for information about coverage under the other Plans.

HMOs often require copays at the time the prescription is filled. Contact HAP for information about prescription drug benefits if you are enrolled in an HMO.

Regardless of your Benefit Option, you have two options for filling or refilling your prescriptions:

Retail Pharmacy. For immediate, short-term needs (a 30-day supply or less), or

Mail Order Service. With delivery directly to your home — for ongoing, long-term maintenance drugs (a 90-day supply or more).

To receive the greatest savings through a retail pharmacy, you must visit a participating pharmacy. If you choose a non-participating pharmacy, you must pay 100% of the prescription price and then submit a claim form, along with your original receipt, to Express Scripts for reimbursement. (See “How to File Claims” beginning on page 70 for more information.)

Note about HMO Coverage…

If you are enrolled in an HMO, contact HAP at 248-443-8160 for information about the prescription drug benefits offered and a copy of the HMO certificate.



Summary of Prescription Drug Benefits

Prescription Drug Benefits — CDHP 80 and CDHP 90 Benefit Options



Retail Pharmacy

(30-day supply)

Generic Nothing until the deductible is met

80% after deductible, in-network

60% after deductible, out-of-network

100% until deductible is met









Brand Name













Mail Order Service

(90-day supply)

Generic Nothing until the deductible is met
















Brand Name













Prescription Drug Benefits — PPO Basic and PPO Plus Benefit Options

Drug Type Retail Pharmacy (30-day supply)

Mail Order Service (90-day supply)

Generic $10 copay $20 copay

Brand Name 20% coinsurance

Minimum payment $25*

Maximum payment $50

20% coinsurance

Minimum payment $50*

Maximum payment $100 * If the total cost of a brand name prescription is less than the minimum payment limit, you will only be

responsible for the lesser amount.

Preventive Care Prescription Drugs

The following preventive care prescription drugs will be covered at 100%:

iron supplements for children from birth to 12 months with increased risk of iron deficiency anemia,

folic acid for women age 18 to 45,

aspirin for men age 45 to 79 and for women age 55 to 79, and

fluoride drops or tablets for children from birth to age 5,

Tamoxifen/Raloxifene/Soltamax for the prevention of invasive breast cancer for women at high risk per PPACA requirements (must be asymptomatic and greater than 34 years old as well as have no previous diagnoses of breast cancer),

smoking cessation: all FDA-approved products for adults age 18 and older (limit of 180-day supply within a 365 day period),

vitamin D: generic (up to age 65),

bowel preparation agents: ages 50 to 75 (limit 2 per year),

female contraceptives (up to age 50).



Important Terms

Brand Name

Brand-name drugs are manufactured by a drug company under a registered trademark. Medications are generally more expensive due to the research, development and marketing that is required for introducing a new drug to the public.

Retail

When a drug is purchased at retail, you will pay either the Express Scripts discounted price or the retail price of the drug, whichever is lower.

Generic

When a patent on a brand-name drug expires, the generic equivalent can be made by other manufacturers without the initial start-up costs. As a result, the medication can be made available to consumers, with the identical chemical composition of the brand name, at much lower costs.



Dental Benefit Program The dental benefits offered by the Dental Benefit Program are designed to encourage regular, preventive care that can help you avoid more extensive and costly care later. You can enroll for dental benefits even if you do not elect medical benefits. Dental care is offered through MetLife Dental. Your Dental Benefit Options include:

80% Preventive — Without Orthodontia, or

100% Preventive — With Orthodontia.

If you do not elect dental coverage when you are first eligible, you will only be able to elect 80% Preventive — Without Orthodontia during a future enrollment. After you have been covered for one Plan Year (April 1 through March 31), you may increase coverage to 100% Preventive — With Orthodontia.

If you elect to enroll for dental benefits, you have the freedom to choose your dentist. When you receive dental services, you may have to pay the bill and then file a claim for reimbursement. (See “How to File Claims” beginning on page 70 for more information.)

You can enroll for dental benefits even if you do not enroll in a Medical Benefit Program.

Summary of Dental Benefit Options The chart below highlights key features of your Dental Benefit Options.

Covered Care and Services 80% Preventive — Without Orthodontia

100% Preventive — With Orthodontia

Deductible

Individual (associate only) $50 $50

Family (associate plus Spouse/Domestic Partner, associate plus children, family)

$100 $100

Plan Year Maximum Benefit

Costs for preventive care are counted towards the maximum benefit

The Plan Year maximum benefit does not include orthodontia and TMJ lifetime maximums

$1,500/person $1,500/person

Preventive/Diagnostic Care 80%, after deductible is met

100%, no deductible

Basic/Restorative Care 80%, after deductible is met

80%, after deductible is met

Be a Smart Consumer!

Get a pre-treatment estimate so you are not surprised by an expensive bill for services you thought were covered.

Important R&C Note!

Reasonable and Customary (R&C) charges apply to all out-of-network dental expenses.



Covered Care and Services 80% Preventive — Without Orthodontia

100% Preventive — With Orthodontia

Major Care 50%, after deductible is met

50%, after deductible is met

Orthodontia Care Not covered 50%

$1,500 lifetime maximum

Temporomandibular Joint Syndrome (TMJ)

50%


50%


The cost for coverage, as well as preventive and orthodontia care, is what distinguishes the two Benefit Options.

Covered Services Under the Dental Benefit Options, covered dental expenses are the Reasonable and Customary charges for any dental treatment, care, service or supply provided or ordered by a dentist or dental hygienist that are necessary for the care of your or your dependents’ teeth. All care must be started and completed while you are covered under the Dental Benefit Option.

Contracted Rates and Reasonable and Customary (R&C) Cost

All in-network dental benefits are paid at the rates contracted by the Dental Benefits Program.

All out-of-network dental benefits are limited to the Reasonable and Customary cost of the care or services provided. This means that costs for services must be within the range of fees usually charged by dental providers for the same services in the same (or comparable) geographic area. If your expenses exceed Reasonable and Customary limits, you will have to pay the excess amount. That amount may not be applied toward your deductible.

Basic/Restorative Care

Either Plan will pay the Reasonable and Customary charges for the following services:

fillings,

extractions,

anesthetics,

periodontal treatment (disease of the gums) — including scaling and root planing,

endodontic treatment (pulp and root canal therapy) — including scaling and root planing,

osseous surgery,



denture adjustments and repairs,

oral surgery — including periodontal and wisdom teeth for both disease and functional problems, and

biteplates for Bruxism (teeth grinding) only.

Major Care

Either Plan will pay the Reasonable and Customary charges for these major and restorative services:

inlays and onlays — including repairs,

crowns — including repairs, and

dentures and bridgework — including replacement.

The Plan will not pay for the replacement of any prosthetic appliance, crown or bridge within five years of the last placement unless the replacement is required because of an accidental injury that occurs while you are covered by either Plan.

Orthodontic Care

Orthodontic care is provided to correct problems such as overbites and cross bites by straightening or repositioning teeth. These benefits are available only to participants enrolled in the 100% Preventive — With Orthodontia option. Orthodontic treatment is generally provided over a period of months or years. As a result, the Plan will pay orthodontic benefits in installments based on the expected number of months of treatment. It is important to receive a pre-treatment estimate (as outlined in this section) before orthodontic care begins so that you fully understand the costs associated with the care and services provided by your doctor.

Pre-treatment Estimate

It is in your best interest to receive a pre-treatment estimate before you receive extensive dental work (i.e., services estimated to cost $200 or more). Using a regular claim form, ask your dentist to write down the full description of the planned treatment he or she feels you need and the estimated costs, including diagnostic x-rays and other supporting records. The dentist will submit the form to the Claims Administrator before any treatment begins. The Claims Administrator will then provide you with a pre-treatment estimate — what services are covered and what alternative treatments are available.

By taking this step, you will be able to decide what treatment to receive based on your out-of-pocket costs associated with the care. If your dentist decides to change the treatment he or she initially submitted, a revised plan should be sent to the Claims Administrator before any treatment begins. If you do not receive a pre-treatment estimate, benefits will be determined at the time the claim is received.

Pre-Treatment Note

Receiving a pre-treatment estimate does not guarantee benefit payment.



Preventive Care

Either Plan will pay the Reasonable and Customary charges for the following services:

routine exam/cleaning — twice each plan year (April 1 to March 31),

fluoride treatments — for children under age 19, once each plan year,

space maintainers — for children under age 19 (only non-orthodontic care),

bitewing x-rays — twice each plan year,

full-mouth or panoramic x-rays — one complete set every three plan years,

sealants — for children under age 14, one treatment per posterior tooth every three plan years, and

emergency pain relief.

Temporomandibular Joint (TMJ) Syndrome

TMJ Syndrome is a condition of the joints linking the jawbone and skull, as well as muscles and other tissues related to that joint. Covered services include only non-surgical care and appliances up to a $1,000 lifetime maximum.

Dental Expenses Not Covered The Plans will not pay benefits for the following dental expenses, even though they may be medically necessary:

charges in excess of the allowable amount,

charges for failure to keep a visit or for completion of a claim form,

services not medically necessary, except for specifically outlined routine preventive care,

any service not listed in this summary as a covered expense,

initial installation of bridgework or dentures to replace teeth extracted before you or your covered family member joined the Plan,

treatment by someone other than a dentist or physician unless the service is performed under the supervision of a dentist (scaling or cleaning of teeth and topical fluoride treatments may be performed by a licensed dentist hygienist),

veneers or similar properties or crowns and pontics placed on or replacing teeth, other than the ten upper and lower anterior teeth,

prosthetic devices (including bridges and crowns) and their fitting that were ordered while you were a covered participant, but were installed or delivered more than two months after your coverage ended,

replacement of a lost, missing or stolen prosthetic device, services performed through a medical department, clinic or similar facility provided or maintained by the Company,

services and supplies that do not meet accepted standards of dental practice, including experimental procedures,



services or supplies received as a result of dental disease, defect or injury due to an act of war, either declared or undeclared,

duplicate prosthetic devices or any other duplicate appliance,

oral hygiene, dietary instruction or plaque-control programs,

implants,

services or supplies that are partly or wholly cosmetic or directed toward a cosmetic result, including charges for personalization of dentures,

periodontal splinting,

treatment of injury to teeth arising from employment or for which benefits are provided under any Worker’s Compensation or similar law,

services or supplies that you would otherwise not have to pay,

appliances, restorations or procedures to alter vertical dimension or restore occlusion,

any dental services if benefits or services for all or any part of the expenses are provided under a Bosch Choice Medical Plan for which you are enrolled,

replacement or repair of orthodontic appliances,

periodontal surgical expenses,

services performed by a relative,

claims submitted more than 12 months after the expense was incurred, or

treatment with nitrous oxide (laughing gas).



Vision Benefit Program Proper vision care is an essential part of good health. That is why the Company offers vision benefits to you and your eligible dependents. Vision care is offered through Vision Service Plan (VSP). Under the Vision Benefit Program, you can visit a VSP provider or obtain care from a non-network provider. However, you receive greater benefits if you use a VSP network provider. The Vision Benefit Program provides benefits for:

a regular eye exam once every 12 months,

glasses (lenses only) or contact lenses once every 12 months,

frames once every 24 months.

A Two-Year Decision

When you elect vision coverage, your participation must last for two Plan Years. If you disenroll after the first Plan Year, you will be unable to re-enroll for vision coverage for an additional two Plan Years.

Cost of Coverage

If you elect vision benefits, you pay the entire cost for coverage on a Pre-Tax basis, but at a lower negotiated group rate. If you elect not to have vision coverage, you can still reimburse your and your dependents’ vision-related expenses through the Healthcare HSA or FSA, described in the Flexible Spending Account Benefit Programs section of this SPD.

Summary of Vision Benefits The chart below highlights key features of the Vision Program.

In-Network Out-of-Network

Plan Procedures

Provider Restriction VSP providers Any provider

Responsibility for Filing Claims

VSP providers You pay for expenses up front and then submit an itemized bill (claims must be filed within six months of the service)

Care and Services

Eye Exams Once every 12 months

$10 copay Plan reimburses up to $30

Eyeglass Lenses* Once every 12 months

Single Vision Plan reimburses up to $20

Lined Bifocal Plan reimburses up to $30

Lined Trifocal

$20 copay for lenses and/or frames

Plan reimburses up to $40

Glasses or Contacts

To receive the full benefit, you must choose between glasses or contacts. For example, if you choose contacts, you will be eligible to receive the full benefit for glasses only after 24 months from the date of the contact purchase has passed.



In-Network Out-of-Network

Lens Options Standard

Progressive $55 copay

Premium Progressive

$95 – $105 copay

Custom Progressive

$150 –$175 copay


Frames* Once every 24 months

Plan pays up to $150 after $20 copay (Note: If you have an exam and also get frames, you only pay one $20 copay)


Elective Contact Lenses Once every 12 months

Lenses, Fitting and Evaluation

Plan pays up to $150 for lenses, fitting and evaluation


Additional Pairs of Prescription Glasses

20% discount Not covered

Laser Correction Surgery Including LASIK

In-network centers offer a 10% — 25% discount off their Usual and Customary fees or 5% off their best advertised price, whichever is lower

Not covered

* If you need lenses and frames, only one copay of $20 applies.

Vision Expenses Not Covered Vision benefits will not be paid for the following cosmetic options:

blended lenses,

photochromic or tinted lenses (other than Pink 1 or 2),

coated or laminated lenses,

a frame that costs more than the Plan allowance,

cosmetic lenses,

optional cosmetic processes, or

UV-protected lenses.

The following professional services or materials are not covered:

orthoptics or vision training and any associated supplemental testing,

plano lenses (non-prescription),

two pairs of glasses in lieu of bifocals,

lenses and frames furnished under this program which are lost or broken,

medical or surgical treatment of the eyes,

any eye exam or corrective eyewear required by an employer as a condition of employment,

low vision care, or

corrective vision services, treatments and materials of an experimental nature.



Employee Assistance Program You, your dependents and any members currently residing in your household can access the Bosch Employee Assistance Program (EAP), which is available at no cost to you. All associates and their families are eligible to use the EAP without having to elect medical coverage. The EAP can assist you or your family with issues that threaten or disrupt your life at home or at work. Examples of issues include stress, depression, parenting, eating disorders, grief, workplace, child/elder care, attention deficit disorder, marital/family, anxiety, drug, alcohol, domestic violence, relationships, legal disputes and financial troubles.

You can call the EAP to speak with a counselor about such issues. Up to eight sessions a year are available for problem assessment, diagnosis, referral and short-term problem resolution. Emergency service is available 24 hours a day.

In the event you are terminated from the Company and receive severance, the EAP benefit will be extended an additional 90 days from your last day of employment.

The EAP also provides referrals to local providers, along with articles and information about behavioral issues. For more information, contact the EAP as listed in the Contact Information section of this SPD.

All Conversations Are Confidential

When you call the EAP, you will speak with a specialist who will listen to your concerns and help you determine if a counselor within the EAP can assist you, or if you should be referred to another representative or provider for appropriate care. All conversations with an EAP specialist are confidential.



How to File Claims This section provides instructions on how to file a claim for healthcare expenses. Each of the Benefit Options and Benefit Programs has a Claims Administrator, appointed by the Plan Administrator, to process claims under that Benefit Program. The certificates issued by the insurance carriers may have additional claims requirements, so you should review those procedures as well. You can get claim forms for medical, prescription drug, dental and vision benefits on the Bosch Benefits Center website, in the “Health” tab under the “Forms” section. In addition, many of the Claims Administrators have websites from which the appropriate claim forms can be printed. If you have any questions about how to obtain or file a claim, contact the Bosch Benefits Center. You always have the right to file a formal claim if you are advised by any provider that any service you feel should be covered is not eligible, or if you have any other dispute over the coverage provided under the Plan. If you are advised that any service is not covered, you must file a formal claim within the appropriate time period for that Benefit Program.

If you are submitting a bill, you will be required to provide information such as:

your Social Security number,

the name of the patient,

the date and description of each service, including diagnosis,

the reason (illness or injury) for each charge,

an itemized copy of all charges, and

the name and address of the provider.

To be eligible for reimbursement:

all medical claims must be received by the end of the calendar year following the Plan Year in which the service was received (e.g., for the Plan Year beginning April 1, 2015, all claims must be received by December 31, 2016),

all member-submitted prescription drug claims must be received within 24 months of the date the service was received,

all dental claims must be received within 12 months of the date the service was received, and

all vision claims for non-VSP providers must be received within six months of the date service was received (e.g., if a service was received on July 1, 2015, all claims must be received by December 31, 2015).

You will be responsible for expenses not filed within these timeframes. If you have questions, contact the Bosch Benefits Center or the Claims Administrator. For contact information, see the Contact Information section of this SPD.



For the EAP, you do not need to file a specific claim for benefits. EAP benefits are automatically provided when you contact the EAP provider. If, for any reason, however, you believe that you have been improperly excluded from participation in the EAP, you may file a formal claim in writing to Robert Bosch LLC Corporate Benefits Department at the following address:

Robert Bosch LLC Corporate Benefits Department 2800 South 25th Avenue Broadview, IL 60155

Medical Claims If you receive supplies or services from in-network providers under a Medical Benefit Program, you do not have to file claims. However, please refer to the Schedule of Benefits or certificates for the HMO relating to filing claims under the HMO Benefit Options.

If you receive services from an out-of-network provider, you may need to complete and submit a claim form. Claims and bills must be submitted to BlueCross Blue Shield of Illinois. For address information, see the Contact Information section of this SPD.

Prescription Drug Claims

Retail

If you purchase a prescription from a participating Express Scripts pharmacy, you do not have to file a claim form. The Express Scripts pharmacy will file the claim for you.

For prescription drugs that are purchased from a non-participating pharmacy, or if your card or eligibility information is not available at the time the prescription is purchased, you will need to complete a claim form and submit it with your prescription drug receipt to:

Express Scripts, Inc. ATTN: Standard Accounts P.O. Box 66583 St. Louis, MO 63166-6583

Mail Order

To use the mail order program, send your prescription and payment to:

Express Scripts, Inc. P.O. Box 66566 St. Louis, MO 63166-6566



Dental Claims If you receive supplies or services from in-network providers under the Dental Benefit Program, you do not have to file claims. The provider will file the claim for you.

If you receive services from an out-of-network provider, you may need to complete and submit a claim form. Send claims to:

MetLife Dental Claims P.O. Box 981282 El Paso, TX 79998-1282 FAX: 859-389-6505

Vision Claims If you receive services or supplies from VSP providers, you do not have to file a claim form. The VSP provider will file the claim for you.

For non-VSP providers, send the itemized bill and claim form to:

Vision Service Plan P.O. Box 997105 Sacramento, CA 95899-7105

Decisions on Non-Medical Claims and Appeal Procedures For the non-Medical Benefit Options, such as the HMO Benefit Options and Vision Benefit Program, refer to the certificates issued by the insurance carrier for the appeal procedures.

In addition, the following applies for the Dental Benefit Program. If your claim for a benefit is denied in whole or in part, you will be notified by the Claims Administrator within 30 days of the date your claim was received. It will include:

the specific reasons for denial,

references to the Plan provisions on which the denial is based,

a description of any additional material or information that is needed to complete or support your claim and why it is needed, and

procedures for how you can appeal your claim.

In some cases, it may take up to 15 extra days to review your claim application; however, any extension will not go beyond 45 days from the date your claim was first received. If additional time is necessary, you will be notified by the end of the initial 30-day period of:

the reasons for the delay, and

an estimate of when your claim will be resolved.

If additional information is needed to process your claim, you will be given at least 45 days to provide that information. You also have the right to receive, on written request and without charge, copies of information relevant to your claim.

Note

If your dentist files claims for you, make sure that he or she has the current claim office address.



In some cases, you will receive an Explanation of Benefits (EOB) statement after receiving healthcare benefits even though you were not required to file a written claim. If the EOB indicates that any portion of the services you received were not covered, you should treat this as a denial of your claim. Your 180-day period to appeal the denial (as described below) begins when you receive the EOB, not when you are billed by the provider for the services that are not covered.

Appealing a Claim

You have 180 days from the date you receive the written denial of your claim to appeal. An appeal is a review by the Claims Administrator. The Claims Administrator may also designate the Claims Administrator or another party to review appeals. However, in any case, your appeal will not be reviewed by the same person (or their subordinate) who denied the claim in the first place. In addition, if a medical issue is involved, an independent medical opinion will be obtained.

Upon request and free of charge, you may review and receive copies of the documents, records, and other information relevant to your claim for benefits. You may also submit written comments, documents, records and other information relating to your claim to the Claims Administrator.

The review on your claims will take into account all comments, documents, records and other information submitted by you relating to your claim — even if such information was not submitted or considered in the initial decision of your claim.

The Claims Administrator has 60 days from the date it receives your appeal to respond. The decisions of the Claims Administrator are final and binding. However, if you are not satisfied with the results of the appeal, you may have the right to file a lawsuit under the Employee Retirement Income Security Act (ERISA). You must file such a suit no more than 180 days after you are notified of the result of the appeal and you may not file such a suit unless you have first complied with the claims and appeals procedures in a timely manner. See “Your Right to Benefits” in the Administrative Information section for more information about lawsuits under ERISA, including who is responsible for paying attorney’s fees.

Medical and Prescription Drug Benefit Program Claim Filing and Appeals Procedures In order to obtain your benefits under the Medical and Prescription Drug Benefit Programs, it is necessary for a claim to be filed with the Claims Administrator. To file a claim, for the Medical Benefit Program, usually all you will have to do is show your ID card to your hospital or physician (or other provider). They will file your claim for you. Remember however, it is your responsibility to ensure that the necessary claim information has been provided to the Claims Administrator.

Once the Claims Administrator receives your claim, it will be processed and the benefit payment will usually be sent directly to the hospital or physician. You will receive a statement telling you how your benefits were calculated. In some cases the claims administrator will send the payment directly to you or if applicable, in the case of a Qualified Medical Child Support Order, to the designated representative as it appears on the claims administrator’s records.

Note

Appeals relating to the CDHP 80 and CDHP 90 Benefit Options will be reviewed by BlueCross BlueShield of Illinois or Express Scripts, the Claims Administrators for those Benefit Options.



In certain situations, you will have to file your own claims. This is primarily true when you are receiving services or supplies from providers other than a hospital or physician. An example would be when you have had ambulance expenses.

To file your own claim, follow these instructions:

1. Complete a claim form. These are available from your Claims Administrator’s office.

2. Attach copies of all bills to be considered for benefits. These bills must include the provider’s name and address, the patient’s name, the diagnosis, the date of service and a description of the service and the claim charge.

3. For the Medical Benefit Program, mail the completed claim form with attachments to:

BlueCross BlueShield of Illinois P.O. Box 805107 Chicago, IL 60680-4112

In any case, claims must be received by the end of the calendar year following the Plan Year in which the service was received (e.g., for the Plan Year beginning April 1, 2014, all claims must be received by December 31, 2015).

Should you have any questions about filing claims, call the Claims Administrator’s office.

The Claims Administrator contact information contained in this section related to the Medical Benefit Program. For the address and phone numbers for submitting appeals under the Prescription Drug Benefit Program, refer to the Contact Information section.

Internal Claim Determinations and Appeals Process Initial Claim Determinations

The Claims Administrator will usually pay all claims within 30 days of receipt of all information required to process a claim. The Claims Administrator will usually notify you, your valid assignee or your authorized representative, when all information required to pay a claim within 30 days of the claim’s receipt has not been received. (For information regarding assigning benefits, see “Non-Assignment of Benefits” in the Administrative Information section of this SPD.) If you fail to follow the procedures for filing a pre-service claim, as defined below, you will be notified within 5 days (or within 24 hours in the case of a failure regarding an urgent care/expedited clinical claim, as defined below). Notification may be oral unless the claimant requests written notification.



If a Claim Is Denied or Not Paid in Full

If a claim for benefits is denied in whole or in part, you will receive a notice from the Claims Administrator within the following time limits:

1. For non-urgent pre-service claims, within 15 days after receipt of the claim by the Claims Administrator. A “pre-service claim” is any non-urgent request for benefits or for a determination, with respect to which the terms of the benefit plan condition receipt of the benefit on approval of the benefit in advance of obtaining medical care.

2. For post-service claims, within 30 days after receipt of the claim by the Claims Administrator. A “post-service claim” is a claim as defined above.

If the Claims Administrator determines that special circumstances require an extension of time for processing the claim, for non-urgent pre-service and post-service claims, the Claims Administrator shall notify you or your authorized representative in writing of the need for extension, the reason for the extension, and the expected date of decision within the initial period. In no event will such extension exceed 15 days from the end of such initial period. If an extension is necessary because additional information is needed from you, the notice of extension will also specifically describe the missing information, and you will have at least 45 days from receipt of the notice within which to provide the requested information.

If the claim for benefits is denied in whole or in part, you or your authorized representative will be notified in writing of the following:

The reasons for denial;

A reference to the benefit plan provisions on which the denial is based;

A description of additional information which may be necessary to perfect an appeal and an explanation of why such material is necessary;

Subject to privacy laws and other restrictions, if any, information sufficient to identify the claim involved including the date of service, health care provider, claim amount (if applicable), diagnosis, and a statement describing the availability, upon request, of the treatment and denial codes with their meanings and the standards used;

An explanation of the Claims Administrator’s internal review/appeals and external review processes (and how to initiate a review/appeal or external review) and a statement of your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on internal review/appeal;

The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits;



Any internal rule, guideline, protocol or other similar criterion relied on in the determination, and a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request;

An explanation of the scientific or clinical judgment relied on in the determination as applied to claimant’s medical circumstances, if the denial was based on medical necessity, experimental treatment or similar exclusion, or a statement that such explanation will be provided free of charge upon request; and

Contact information for applicable office of health insurance consumer assistance or ombudsman.

3. For benefit determinations relating to urgent care/expedited clinical claims (as defined below), such notice will be provided no later than 24 hours after the receipt of your claim for benefits, unless you fail to provide sufficient information. You will be notified of the missing information and will have no less than 48 hours to provide the information. A benefit determination will be made within 48 hours after the missing information is received. An urgent care/expedited claim decision may be provided orally, so long as written notice is furnished within 3 days of oral notification.

4. For benefit determinations relating to care that is being received at the same time as the determination, such notice will be provided no later than 24 hours after receipt of your claim for benefits involving urgent care/expedited clinical claims.

What Is a Urgent Care/Expedited Clinical Claim?

An “urgent care/expedited clinical claim” is any pre-service claim for benefits for medical care or treatment with respect to which the application of regular time periods for making health claim decisions could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function or, in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment.



Claim Appeal Procedures

If you have received an adverse benefit determination, you may have your claim reviewed on appeal. The Claims Administrator will review its decision in accordance with the procedures outlined below.

Claim Appeal Procedures — Definitions

An appeal of an adverse benefit determination may be filed by you or a person authorized to act on your behalf. In some circumstances, a health care provider may appeal on his/her own behalf. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative. To obtain an Authorized Representative Form, you or your representative may call the Claims Administrator at the number on the back of your ID card.

An “adverse benefit determination” means a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment for, a benefit resulting from the application of utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. If an ongoing course of treatment had been approved by the Claims Administrator or the Plan Administrator and the Claims Administrator or the Plan Administrator reduces or terminates such treatment (other than by amendment or termination of the Medical Benefit Program) before the end of the approved treatment period that is also an adverse benefit determination. A rescission of coverage is also an adverse benefit determination. A rescission does not include a termination of coverage for reasons related to nonpayment of premium.

In addition, an adverse benefit determination also includes an “adverse determination.” An “adverse determination” means a determination by the Claims Administrator or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered service has been reviewed and, based upon the information provided, does not meet the Claims Administrator’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. For purposes of this benefit program, we will refer to both an adverse determination and an adverse benefit determination as an adverse benefit determination, unless indicated otherwise.

A “final internal adverse benefit determination” means an adverse benefit determination that has been upheld by the Claims Administrator or the Plan Administrator at the completion of the Claims Administrator’s or the Plan Administrator’s internal review/appeal process.



Claim reviews are commonly referred to as “appeals.” Within 180 days after you receive notice of an adverse benefit determination, you may call or write to the Claims Administrator to request a claim review. The Claims Administrator will need to know the reasons why you do not agree with the adverse benefit determination. For the Medical Benefit Program, you may call 1-877-284-9302 or send your request to:

Claim Review Section Health Care Service Corporation P.O. Box 2401 Chicago, Illinois 60690

In support of your claim review, you have the option of presenting evidence and testimony to the Claims Administrator, by phone or in person at a location of the Claims Administrator’s choice. You and your authorized representative may ask to review your file and any relevant documents and may submit written issues, comments and additional medical information within 180 days after you receive notice of an adverse benefit determination or at any time during the claim review process.

The Claims Administrator will provide you or your authorized representative with any new or additional evidence or rationale and any other information and documents used in the denial or the review of your claim without regard to whether such information was considered in the initial determination. No deference will be given to the initial adverse benefit determination. Such new or additional evidence or rationale and information will be provided to you or your authorized representative sufficiently in advance of the date a final decision on appeal is made in order to give you a chance to respond. The appeal will be conducted by individuals associated with the Claims Administrator and/or by external advisors, but who were not involved in making the initial denial of your claim.

An appeal of an adverse benefit determination may be filed by you or a person authorized to act on your behalf. In some circumstances, a health care provider may appeal on his/her own behalf. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative. To obtain an Authorized Representative Form, you or your representative may call the Claims Administrator at the number on the back of your ID card.



Urgent Care/Expedited Clinical Appeals

If your appeal relates to an urgent care/expedited clinical claim, or health care services, including but not limited to, procedures or treatments ordered by a health care provider, the denial of which could significantly increase the risk to the claimant’s health, then you may be entitled to an appeal on an expedited basis. Before authorization of benefits for an ongoing course of treatment is terminated or reduced, the Claims Administrator will provide you with notice at least 24 hours before the previous benefits authorization ends and an opportunity to appeal. For the ongoing course of treatment, coverage will continue during the appeal process. Upon receipt of an urgent care/expedited pre-service or concurrent clinical appeal, the Claims Administrator will notify the party filing the appeal, as soon as possible, but no more than 24 hours after submission of the appeal, of all the information needed to review the appeal. Additional information must be submitted within 24 hours of request. The Claims Administrator will render a determination on the appeal within 24 hours after it receives the requested information.

Other Appeals

Upon receipt of a non-urgent pre-service appeal the Claims Administrator will render a determination of the appeal within 30 days after the appeal has been received by the Claims Administrator. For non-urgent post-service appeals, the claim administrator will render a determination of the appeal within 60 days after the appeal has been received by the Claims Administrator.

Notice of Appeal Determination

If your appeal is denied, the Claims Administrator will provide written notice of the determination.

The written notice will include:

The reasons for the determination, including the denial code and its meaning;

A reference to the benefit plan provisions on which the determination is based, or the contractual, administrative or protocol for the determination;

Subject to privacy laws and other restrictions, information sufficient to identify the claim involved, including the date of service, health care provider, claim amount (if applicable), and information about how to obtain diagnosis, treatment and denial codes with their meanings;

An explanation of any voluntary levels of review the Claims Administrator makes available, the Claims Administrator’s external review processes (and how to initiate an external review) and a statement of your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on external appeal;

The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits;

Any internal rule, guideline, protocol or other similar criterion relied on in the determination, or a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request;



An explanation of the scientific or clinical judgment relied on in the determination, or a statement that such explanation will be provided free of charge upon request;

A description of the standard that was used in denying the claim and a discussion of the decision; and

Contact information for the applicable office of health insurance consumer assistance or ombudsman.

If the decision is to continue to deny or partially deny your claim or you do not receive timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Your external review rights are described in “Independent External Review” on page 81.

If an appeal under the Medical Benefit Program is not resolved to your satisfaction, you may appeal the Claims Administrator’s decision to the Illinois Department of Insurance. The Illinois Department of Insurance will notify the Claims Administrator of the appeal. The Claims Administrator will have 21 days to respond to the Illinois Department of Insurance.

Some of the operations of the Medical Benefit Program Claims Administrator are regulated by the Illinois Department of Insurance. Filing an appeal does not prevent you from filing a complaint with the Illinois Department of Insurance or keep the Illinois Department of Insurance from investigating a complaint.

Court Review and Failure to Follow These Procedures

All decisions following a review by the Claims Administrator are final and binding for purposes of the Plan’s internal claim review procedures. If no review is sought, the decision of the Claims Administrator is final and binding upon the expiration of the time period for seeking internal review. If your claim is denied in whole or in part after all stages of the internal review procedures have been completed (except any voluntary levels of review), you have the right to seek to have your claim paid by filing a request for external review (if your claim is eligible), or a civil action in federal court, but you will not be able to do so unless you have completed all of the levels of the internal review process (except any voluntary levels) required under the Plan.

If your claim is eligible for external review and you wish to file a request for external review, you must do so within four months after you receive a final internal adverse benefit determination. If you do not follow and complete these procedures, your request may be ineligible for external review. If you wish to file your claim in court, you must do so within one year of the date of the final internal adverse benefit determination, or if later, within one year of the date of the final decision on external review. If you do not follow and complete these procedures, a review of your claim in court will be subject to dismissal for your failure to exhaust your claim and review rights under this Plan.



If You Need Assistance

If you have any questions about the claims procedures or the review procedure for the Medical Benefit Program, write or call the Claims Administrator’s headquarters at 1-800-538-8833. The Claims Administrator’s offices are open from 8:45 A.M. to 4:45 P.M., Monday through Friday.

Blue Cross and Blue Shield of Illinois 300 East Randolph Chicago, IL 60601

If you need assistance with the internal claims and appeals or the external review processes that are described below, you may contact the health insurance consumer assistance office or ombudsman. You may contact the Illinois ombudsman program at 1-877-527-9431, or call the number on the back of your ID card for contact information. In addition, for questions about your appeal rights or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272).

Independent External Review

For adverse benefit determination involving medical judgment or a rescission, you or your authorized representative (as described above) may make a request for an independent external review or expedited external review of an adverse benefit determination or final internal adverse benefit determination by an independent review organization (IRO).

Request for External Review

Within 4 months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination from the Claims Administrator, you or your authorized representative must file your request for standard (or “independent”) external review. If there is no corresponding date 4 months after the date of receipt of such a notice, then the request must be filed by the first day of the fifth month following the receipt of the notice. For example, if the date of receipt of the notice is October 30, because there is no February 30, the request must be filed by March 1. If the last filing date would fall on a Saturday, Sunday, or federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday, or federal holiday.

Preliminary Review

Within 5 business days following the date of receipt of the external review request, the Claims Administrator must complete a preliminary review of the request to determine whether your request is eligible for external review.

You will be notified within 1 business day after the preliminary review is completed if your request is eligible or if further information or documents are needed. You will have the remainder of the 4-month appeal period (or 48 hours following receipt of the notice), whichever is later, to perfect the appeal request. If your claim is not eligible for external review, the reasons it is ineligible will be outlined in the notice, and provide contact information for the Department of Labor’s Employee Benefits Security Administration (toll-free number 866-444-EBSA (3272).



Referral to Independent Review Organization

When an eligible request for external review is completed within the time period allowed, the Claims Administrator will assign the matter to an independent review organization (IRO).

Within 5 business days after the date of assignment of the IRO, the Claims Administrator must provide to the assigned IRO the documents and any information considered in making the adverse benefit determination or final internal adverse benefit determination. The IRO will then notify you of your acceptance for external review and your right to submit additional information to the IRA within 10 business days following your receipt of the notification.

Upon receipt of any information submitted by you or your authorized representative, the assigned IRO must within 1 business day forward the information to the Claims Administrator. Upon receipt of any such information, the Claims Administrator may reconsider its adverse benefit determination or final internal adverse benefit determination that is the subject of the external review.

If the Claims Administrator reverses its decision based on this information, the Claims Administrator will provide you and the IRO will notice of the reversal within 1 business day of making the determination. The IRO will then terminate the external review process.

If the Claims Administrator does not reverse this determination, the IRO will continue the external review process and provide you with written notice of the final external review decision.

Reversal of Plan’s Decision

Upon receipt of a notice of a final external review decision reversing the adverse benefit determination or final internal adverse benefit determination, the claim administrator immediately must provide coverage or payment (including immediately authorizing or immediately paying benefits) for the claim.

Expedited External Review

Request for Expedited External Review

The Claims Administrator must allow you or your authorized representative to make a request for an expedited external review with the Claims Administrator for claims that otherwise qualify for external review at the time you receive:

An adverse benefit determination if the adverse benefit determination involves a medical condition of the claimant for which the timeframe for completion of an expedited internal appeal under the interim final regulations would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal appeal; or



A final internal adverse benefit determination, if the claimant has a medical condition where the timeframe for completion of an independent external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, or if the final internal adverse benefit determination concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but have not been discharged from a facility.

Preliminary Review

Immediately upon receipt of the request for expedited external review, the Claims Administrator must determine whether the request qualifies for external review and provide you with notice.

Referral to Independent Review Organization

Upon a determination that a request is eligible for external review following the preliminary review, the Claims Administrator will assign an IRO. The Claims Administrator must provide or transmit all necessary documents and information considered in making the adverse benefit determination or final internal adverse benefit determination to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method.

The assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the information or documents described above under the procedures for standard review. In reaching a decision, the assigned IRO must review the claim de novo and is not bound by any decisions or conclusions reached during the Claims Administrator’s internal claims and appeals process.

Notice of Final External Review Decision

The IRO will provide notice of the final external review decision as expeditiously as your medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within 48 hours after the date of providing that notice, the assigned IRO must provide written confirmation of the decision to the Claims Administrator and you or your authorized representative.



Exhaustion

For standard internal review, you have the right to request external review once the internal review process has been completed and you have received the final internal adverse benefit determination. For expedited internal review, you may request external review simultaneously with the request for expedited internal review. The IRO will determine whether or not your request is appropriate for expedited external review or if the expedited internal review process must be completed before external review may be requested. You will be deemed to have exhausted the internal review process and may request external review if the Claims Administrator waives the internal review process or the Claims Administrator has failed to comply with the internal claims and appeals process. In the event you have been deemed to exhaust the internal review process due to the failure by the Claims Administrator to comply with the internal claims and appeals process, you also have the right to pursue any available remedies under 502(a) of ERISA or under state law. External review may not be requested for an adverse benefit determination involving a claim for benefits for a health care service that you have already received until the internal review process has been exhausted.

Inquiries and Complaints

For purposes of the Medical Benefit Program, an “inquiry” is a general request for information regarding claims, benefits, or membership.

A “complaint” is an expression of dissatisfaction by you either orally or in writing.

The Claims Administrator has a team available to assist you with inquiries and complaints. Issues may include, but are not limited to, the following:

claims, and

quality of care.

When your complaint relates to dissatisfaction with a claim denial (or partial denial), then you have the right to a claim review/appeal as described in the “Claim Appeal Procedures” on page 77.

To pursue an inquiry or a complaint, you may contact Customer Service at the number on the back of your ID card, or you may write to:

Blue Cross and Blue Shield of Illinois 300 East Randolph Chicago, IL 60601

When you contact Customer Service to pursue an inquiry or complaint, you will receive a written acknowledgement of your call or correspondence. You will receive a written response to your inquiry or complaint within 30 days of receipt by Customer Service. Sometimes the acknowledgement and the response will be combined. If the Claims Administrator needs more information, you will be contacted. If a response to your inquiry or complaint will be delayed due to the need for additional information, you will be contacted.

An appeal is an oral or written request for review of an adverse benefit determination (as defined below) or an adverse action by the Claims Administrator, its employees or a participating provider.



Addresses for Claim Appeals

Medical Benefit Program

See the “Medical and Prescription Drug Benefit Program Claim Filing and Appeals Procedures” section beginning on page 73 for addresses to use for the CDHP 80 and CDHP 90 Benefit Options.

Dental Benefit Program

An appeal, or any information regarding an appeal, for the Dental Benefit Options must be sent in writing within one year from the date of the initial claim decision to:

MetLife Dental Claims P.O. Box 981282 El Paso, TX 79998-1282 FAX: 859-389-6505

Please provide the details/reasons for appeal approval and include all supporting information and/or documentation. You can also contact MetLife Member Services, at 877-638-3379 to request an appeal registration.

Prescription Benefits

An appeal, or any information regarding an appeal, for the prescription drug benefit must be sent in writing to:

Express Scripts, Inc. ATTN: Pharmacy Appeals – JYC Mail Route BL 0390 6625 West 78th Street Bloomington, MN 55439

Fax: 877-852-4070

Special Claim Rules for Advance Approval and Urgent Care Claims The Plan provides special rules and specific timeframes for situations that require advance approval and urgent care, including the denial of any request. This section describes some scenarios in which special rules would be applied.

Advance Approval

Advance approval, as described under “Medical Review Program” on page 37, is required for all inpatient hospital stays, stays at a skilled nursing facility, home healthcare, in-home private duty nursing and transplants. As long as there is no urgent care required, the following rules will apply to advance approval:

The decision as to whether to approve the procedure will be made within 15 days after approval is requested. This period may be extended by an additional 15 days if the circumstances are beyond the control of the Plan Administrator and/or its representative. In this case, you will be notified of the reason for the extension before the end of the initial 15-day period. If additional information is needed to process the claim, you will be given at least 45 days to provide the information.



If the Plan decides that a course of care you are receiving should be terminated, you will be notified within sufficient time before treatment ends to allow you to appeal the decision to stop coverage.

If advance approval is denied, and you appeal the denial, the decision on review will be made within 30 days after your appeal is denied.

Urgent Care

Urgent care involves a situation where the failure to receive care would seriously jeopardize the life or health of the covered individual, including the ability to regain maximum function, or would subject the covered individual to severe pain that cannot be adequately managed without the treatment. In cases of urgent care, the following rules will apply:

Your request for advance approval of the procedure will be made as soon as possible, but no later than 72 hours after advance approval is requested. If additional information is needed, you will be notified within 24 hours and will have at least 48 hours to provide the information. The Plan will decide whether to approve the procedure within 48 hours after the additional information is provided (or within 48 hours from the time your period for providing information ends).

If you are receiving a course of treatment involving urgent care and need to extend the timeframe for which approval was received (for example, extending the period of a hospital stay), the Plan Administrator and/or its representative will respond to your application within 24 hours after it is submitted, provided it is submitted at least 24 hours before the approved period ends.

If advance approval of a procedure involving urgent care is denied, including an application to extend the course of treatment, and you appeal the denial, the decision on the appeal will be made within 72 hours after the appeal is filed.


Flexible Spending Account Benefit Programs The Flexible Spending Accounts (FSAs) offered under the Bosch Choice Welfare Benefit Plan help you save money by letting you set aside money on a Pre-Tax basis to pay for eligible expenses. There are two types of accounts:

Healthcare FSA. This FSA reimburses you for eligible out-of-pocket medical, dental and vision expenses. There are two types of Healthcare FSAs available to you — Traditional and Limited Purpose. If you have a Health Savings Account through the CDHP Medical Plan (see the Healthcare Benefit Programs section), you are only allowed to participate in a Limited Purpose Healthcare FSA.

Dependent Day Care FSA. This FSA helps reimburse you for out-of-pocket expenses related to the care of your dependents while you are working.


Administrative details and procedures can be found in the Administrative Information section. If you have questions about the information in this SPD, you can contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).

Flexible Spending Account Benefit Programs



Benefits-at-a-Glance ........................................................................................ 89 Participating in FSAs ........................................................................................ 91

How Your Accounts Work............................................................................ 91 Changing Contributions During the Year ..................................................... 92 How Much You Can Deposit........................................................................ 93 How Much Can Be Reimbursed .................................................................. 94 Pre-Tax Contributions — Issues to Consider .............................................. 94 When Coverage Ends.................................................................................. 95

Healthcare FSA ................................................................................................ 96 Whose Expenses Can Be Reimbursed ....................................................... 96 Eligible Healthcare Expenses ...................................................................... 96 Non-eligible Healthcare Expenses............................................................... 98 Making Contributions during a FMLA Leave of Absence............................. 99 COBRA Continuation Coverage for Healthcare FSAs............................... 100

Dependent Day Care FSA.............................................................................. 101 Whose Expenses Can Be Reimbursed ..................................................... 101 Eligible Dependent Day Care Expenses.................................................... 101 Non-eligible Dependent Day Care Expenses ............................................ 102 Making Contributions during a Leave of Absence ..................................... 103 Federal Dependent Tax Credit .................................................................. 103

Paying Yourself Back ..................................................................................... 104 Submitting Expenses ................................................................................. 104 Claim Decisions and Appeals .................................................................... 105 Right of the Plan to Obtain Information...................................................... 106



Benefits-at-a-Glance Flexible Spending Accounts (FSAs) help you pay for eligible expenses with money that is free from most income taxes. You put aside a portion of your pay on a Pre-Tax basis to cover eligible out-of-pocket healthcare or dependent day care expenses. That portion of your pay is not subject to federal, Social Security, and, in most cases, state or local income taxes. Then, when you or your dependents incur an eligible expense, the FSA reimburses you for the expenses that you’ve paid. The table below provides a comparison of the key features of the Healthcare FSAs and Dependent Day Care FSA.

FSA Comparison

HSA Traditional Healthcare FSA

Limited Purpose Healthcare FSA

Dependent Day Care FSA

Who’s Eligible Eligible Bosch associates enrolled in the Bosch CDHP 80 or CDHP 90 Benefit Options

Any Bosch associate who does not have an HSA

Any Bosch associate enrolled in the Bosch CDHP 80 or the CDHP 90 Benefit Options, and who also has an HSA

All eligible Bosch associates

Who Contributes

Bosch, with associate contributions optional

Associate only



HSA Traditional Healthcare FSA


Dependent Day Care FSA

Annual Contribution Limits

For the 2015 calendar year, up to $3,350 individual, $6,650 family on a Pre-Tax basis

Reduced dollar for dollar by Bosch’s contribution to the HSA each calendar year. If you are age 55 or older, you may contribute an additional $1,000 per calendar year

Associates may contribute between $120 and $2,550 to a Healthcare FSA each Plan Year on a tax-free basis.

Associates may contribute between $120 and $5,000 to a Dependent Day Care FSA each Plan Year on a tax-free basis.

Eligible Expenses

See “Eligible Expenses” in the Healthcare Benefit Programs section of this SPD.

See IRS Publications 502 and 969 for details

Medical expenses

Prescription drug expenses

Dental expenses

Vision expenses


Dental expenses

Vision expenses


Pre-kindergarten education

Care outside your home

Dependent day care or day camp

Transportation to get the dependent to and from a care facility (eligible only if transportation is provided by the caregiver)

Age restrictions apply

See IRS Publications 503 for details

Funding Rules Funds earn interest at a rate established by BenefitWallet; funds remaining at Plan Year end may be rolled over for use in future years

Funds do not earn interest; funds remaining at Plan Year end are forfeited



Participating in FSAs This section explains who is eligible to participate in FSAs, making changes during the year, how the accounts work, how much you can deposit and be reimbursed, Pre-Tax contribution issues to consider, when coverage ends and how to continue coverage through COBRA.

How Your Accounts Work The Flexible Spending Accounts help you save money by offering you the ability to set aside money on a Pre-Tax basis. There are three types of flexible spending accounts:

Traditional Healthcare FSA,

Limited Purpose Healthcare FSA, and

Dependent Day Care FSA.

You may elect to participate in either a Healthcare FSA (whether Traditional or Limited Purpose) or the Dependent Day Care FSA or both.

Your participation in a Health Savings Account (HSA) will determine which type of Healthcare FSA you can enroll in. Because of the many tax advantages an HSA provides, if you have an HSA, the government only allows you to participate in a Limited Purpose Healthcare FSA at the same time as the HSA. If you don’t have an HSA (or are ineligible for Pre-Tax contributions to an HSA) but are enrolled in a CDHP, you may still participate in a Traditional Healthcare FSA by calling the Bosch Benefits Center.

Payroll deductions will be taken out of your regular pay to reach your annual goal amount and deposited into an account set up specifically for you. If you elect to contribute to both a Healthcare and Dependent Day Care FSA, two separate accounts will be maintained. When you incur eligible expenses, you simply submit a claim for reimbursement as outlined under “Paying Yourself Back” on page 104.

Contributions to the FSAs are deposited on a Pre-Tax basis. This means that you will not pay federal (and in most cases state) income tax or Social Security taxes on the money contributed to the FSAs. However, there are some important tax regulations you need to consider when deciding how much to contribute. See “IRS Rules” under “Pre-Tax Contributions — Issues to Consider” on page 94 for more information.

The Bosch Choice Welfare Benefit Plan Year runs from April 1 to March 31 of the following year. Your Flexible Spending Account contribution elections do not carry over from year-to-year. Unspent balances are forfeited. To continue contributing, you must re-enroll every Plan Year during the Annual Enrollment period.



When Contributions Begin

Your FSA contributions will begin as soon as administratively possible following your election. The amount you elect to put in your accounts is contributed over the Plan Year in equal installments, through payroll deductions, on a Pre-Tax basis.

Note: If you are enrolling at any time other than Annual Enrollment, the amount you elect to contribute will be deducted in equal installments, based on the number of deduction periods remaining in the Plan Year (i.e., if you are enrolling in November, the amount you elect will be deducted in equal installments through March 31).

Be sure to review your paycheck after you enroll to make sure that the appropriate deductions are being processed. If you have any questions, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).

Changing Contributions During the Year You may experience certain events during the Plan Year that would allow you to change your contributions to the FSAs; these are referred to as change in status events. To receive the coverage you want, you must change your contributions within 60 days of the event.

If you do not change your contributions within 60 days of the event, your next opportunity to make a change will be during the Annual Enrollment period.

You can enroll or change the level of contributions to the FSAs during the year only if a change in status event occurs. The following are change in status events for the FSAs:

You or your eligible dependents become eligible or ineligible for FSA coverage because of a change in:

legal marital status (such as marriage, divorce, legal separation or annulment),

number of dependents (such as birth, death, adoption, placement for adoption* or court ordered guardianship),

an eligible dependent’s status (for example, your dependent is no longer eligible for coverage due to age or student status), or

employment status (for example, ending or starting employment, changing from part-time to full-time or vice versa, or a change in residence or worksite if it affects eligibility for benefits).

For the Healthcare FSA only, you or your eligible dependents become eligible for or lose COBRA coverage or extended coverage under USERRA, Medicare or Medicaid.

For the Dependent Day Care FSA only, you experience a significant increase or decrease in your eligible dependent day care expenses for a dependent day care provider who is not your relative, or your dependent day care provider changes.

* Placement for adoption means that, in anticipation of a child’s adoption, the person with whom the child is being placed has the legal obligation for at least 50% of the child’s support.

Please review your paycheck after you enroll to make sure that the appropriate deductions are being processed. If you have any questions, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).



If you experience a change in status event as listed above, you have 60 days from the date of the event to access the Bosch Benefits Center website or call the Bosch Benefits Center and change your benefit elections. For contact information, see the Contact Information section of this SPD.

The benefit change you request must be consistent with the qualifying life event. For example, if you have a baby, you can enroll or increase contributions to the Dependent Day Care FSA; however, you cannot drop or decrease contributions to that account.

For all change in status events, your new elections will become effective on the date of the event if you provide timely notice of the event.

If you do not provide timely notice of the change in status event and complete a new election within the 60-day timeframe, your contributions will remain as is and any money deposited into the accounts will not be refunded.

How Much You Can Deposit The following chart provides current contribution amounts for the Plan Year (April 1 – March 31).

FSA Minimum Plan Year Contribution

Maximum Plan Year Contribution

Traditional Healthcare $120 $2,550

Limited Purpose Healthcare

$120 $2,550

Dependent Day Care $120 $5,000

The following calendar year limits also apply to the Dependent Day Care FSA:

if you are married or in a domestic partnership and file a joint tax return, you and your spouse/domestic partner may contribute only a combined total of $5,000, if you are married or in a domestic partnership and file separately, you and your spouse/domestic partner may contribute only $2,550 each,

if you are married or in a domestic partnership and your spouse/domestic partner earns less than $5,000, you cannot be reimbursed for more than your spouse/domestic partner’s/domestic partner’s earned income (unless your spouse/domestic partner is disabled or a full-time student), and

if you are married or in a domestic partnership and your spouse/domestic partner is disabled or a full-time student, he or she will be treated as earning $250 each month ($500 if you are caring for two or more dependents, including your spouse/domestic partner).



How Much Can Be Reimbursed How much you can receive depends on the Flexible Spending Account from which you request reimbursement:

You can receive reimbursement from your Healthcare FSA (Traditional or Limited Purpose) — up to the total amount elected for the year — regardless of how much is in your account when you make your request.

You can receive reimbursement from your Dependent Day Care FSA – only up to the balance that is in your account at the time you submit your request. As more money is deposited into your account, you will receive the balance of the amount requested.

For more information about submitting expenses, see “Paying Yourself Back” on page 104.

Pre-Tax Contributions — Issues to Consider This section provides important information that may affect how much you elect to contribute to the Flexible Spending Accounts.

IRS Rules

By allowing you to contribute to the FSAs on a Pre-Tax basis (meaning that you pay no federal income or Social Security taxes, and in most cases no state taxes on your contributions), the Internal Revenue Service (IRS) has established the following rules:

Rule 1 – Use It or Lose It. If your eligible expenses are less than what you have put into the account at the end of the Plan Year, any unused money cannot be returned to you or carried over into the next Plan Year.

Rule 2 – No Transfers. The Healthcare and Dependent Day Care FSAs must be maintained separately — money cannot be transferred from one account to the other. You cannot use your Healthcare FSA for reimbursement of dependent day care expenses, or vice versa.

In addition, any amount remaining in either of your accounts when your participation in the Plan ends will also be forfeited.

If you have dependent day care expenses, you also need to consider whether it would save you more money to use the Dependent Day Care FSA, the child care tax credit (that can be claimed on your federal taxes) or both. It may be helpful to discuss these options with your financial or tax advisor, and to review IRS Publication 503 (available at www.irs.gov). Additional information is located under “Dependent Day Care FSA” beginning on page 101.

Please Note: Certain nondiscrimination rules apply the FSAs. If, at any time, the Company determines that the FSAs may not satisfy any of these nondiscrimination rules, the Company may take whatever action it deems appropriate to comply with these rules. The action may include, without limitation, changing your elections, with or without your consent, but the Company will notify you of any changes to your FSA elections.

Note

Refunds from the FSAs due to incorrect enrollments are not allowed per IRS rules.



Plan Carefully

Contribute only as much as you think you will need for the Plan Year — any money in your account(s) not used for eligible expenses at the end of the Plan Year will be forfeited.

Note: Claims can be submitted up until June 30 for eligible expenses incurred by March 31 (the last day of the Plan Year).

Effect on Other Benefits

Making Pre-Tax contributions to the FSAs may slightly reduce your future Social Security benefits. For most people, the reduction will be very small.

Unemployment or Workers’ Compensation benefits may also be slightly reduced if you become eligible for them.

When Coverage Ends Except for rights outlined under “COBRA Continuation Coverage for Healthcare FSAs,” your ability to contribute to the Healthcare and Dependent Day Care FSAs will end if:

your employment ends for any reason, including retirement,

you are no longer eligible for the FSAs,

you fail to pay required contributions, or

the Plan is terminated, canceled or amended.

Although you may file a claim up until June 30 for any qualified expenses incurred during the Plan Year while you were still covered by the FSA, expenses incurred after your coverage ends generally will not be reimbursed. Note: For the Dependent Care FSA, you can incur expenses after your termination of employment up until March 31 (the end of the Plan Year) and submit them for reimbursement; however, keep in mind that expenses for reimbursement must be submitted on or before the June 30 deadline.

When coverage ends, you may continue contributing on an After-Tax basis to the Traditional or Limited Purpose Healthcare FSA for the duration of the Plan Year in which a qualifying event occurs. See “COBRA Continuation Coverage for Healthcare FSAs” on page 100 and “COBRA Continuation Coverage” in Healthcare Benefit Programs for more information about continuing your coverage under COBRA.

Note

You may be able to continue contributing to the Healthcare FSA on an After-Tax basis; see “COBRA Continuation Coverage for Healthcare FSAs” on page 100 for more information.



Healthcare FSA Although the Benefit Programs may pay for many of your healthcare expenses, not all your bills will be covered. You can pay for those expenses that are not covered by the Healthcare Benefit Programs through your Healthcare FSA. There are two Healthcare FSAs available under this Plan:

Traditional Healthcare FSA. This FSA can be used to pay for expenses such as medical, dental and vision plan deductibles, prescription drug coinsurance, prescription eyeglasses and contacts, and prescribed over-the-counter drugs.

Limited Purpose Healthcare FSA. This FSA is available to associates who participate in a Health Savings Account (HSA) — and can be used only to pay eligible dental and vision care expenses. (See “Medical Benefit Program” in the Healthcare Benefit Programs section for more information about HSAs.)

Regardless of the option you elect, you can contribute from $120 to $2,550 to the Healthcare FSA each Plan Year.

Whose Expenses Can Be Reimbursed Your Healthcare FSA can be used to reimburse:

your own healthcare expenses, and

healthcare expenses incurred by your spouse/domestic partner and other eligible dependents, even if they are not covered by a Medical Benefit Program.

Refer to “Who Is Eligible” in Participating in the Plan for who is an eligible dependent.

Eligible Healthcare Expenses Eligible healthcare expenses are unreimbursed expenses for medical care for you and your eligible dependents that are not covered by a healthcare plan and that would qualify as deductions on your federal tax return. These expenses must not have been reimbursed through insurance or any other source. Generally, eligible healthcare expenses are incurred for the diagnosis, cure, treatment or prevention of disease.

Eligible Dependents

This definition of dependent is different from that used for the Dependent Day Care FSA.



Traditional Healthcare FSA

Eligible healthcare expenses for the Traditional Healthcare FSA include:

health insurance deductibles,

coinsurance and/or copays for services and supplies; for example:

doctor’s office visits,

eye exams,

prescription drugs;

charges above the Reasonable and Customary amount covered by a healthcare plan (i.e., charges you are required to pay to your healthcare provider), and

expenses not covered by a healthcare plan, such as:

medically necessary aids prescribed by a physician, including hearing aids, false teeth, orthopedic shoes, crutches, braces and elastic hosiery,

surgery to correct or improve vision,

prescription sunglasses,

routine foot care,

smoking cessation programs,

smoking cessation drugs that are prescribed by a physician and are not available over-the-counter,

weight loss programs, treatments and prescriptions that are prescribed by your physician to treat a medical illness (for example, heart disease),

life improvement tools for the visual or hearing impaired, including guide dogs, Braille books and magazines and telephone equipment,

special schools that teach Braille to a visually impaired person, lip-reading to a hearing impaired person and remedial language training to correct a condition caused by a birth defect,

childbirth classes for the mother-to-be only,

over-the-counter medications or drugs, but only if prescribed by a physician, or

infertility treatments.


Eligible healthcare expenses for the Limited Purpose Healthcare FSA include coinsurance and/or copays for dental and vision care services.

For a complete list of eligible healthcare expenses, you can review PayFlex’s website at healthhub.com. You also can review IRS Publication 502 or 969 at the IRS’ website at www.irs.gov or on the CDHP Resource Center.



Non-eligible Healthcare Expenses You cannot use your Healthcare FSA (Traditional or Limited Purpose) to reimburse expenses for:

over-the-counter medications or drugs unless prescribed by a physician,

insurance premiums (contributions to participate in the Bosch Choice Welfare Benefit Plan or any other insurance premiums),

amounts covered by any medical, dental or vision plan (including Medicare or any other state or federal program),

weight loss programs and treatments that are not prescribed by your physician to treat a medical illness (for example, heart disease),

supplies not related to an illness, disease or defect,

charges for a nurse to care for a healthy baby,

cosmetic surgery,

dental bleaching or any other teeth whitening,

illegal surgical procedures or drugs,

expenses incurred before your date of participation in the Healthcare FSA or after the date your participation ends,

medical care for which you take an itemized tax deduction on your federal tax return,

expenses incurred for a dependent who is not an eligible dependent,

dependent day care expenses (these should be considered for reimbursement through your Dependent Day Care FSA),

expenses for long-term care,

treatment or care that is merely beneficial to one’s general health, such as an expense for recreation, or health clubs and nutrition, even if prescribed by a physician,

expenses that are incurred after the end of the Plan Year (March 31).

If you are uncertain if a healthcare expense qualifies for reimbursement under the Traditional or Limited Purpose Healthcare FSAs, contact the claims administrator for assistance (see “Submitting Expenses” on page 104 for information) or review PayFlex’s website at healthhub.com.

Any reimbursement paid for an ineligible healthcare expense under the Healthcare FSA will be subject to applicable income and other taxes.



Making Contributions during a FMLA Leave of Absence Paid Leave

If you are taking a paid FMLA leave of absence, you will continue making contributions to the Healthcare FSA on a Pre-Tax basis pursuant to your enrollment form. Your participation in the Healthcare FSA will continue as if you had never left your employment and you may be reimbursed for eligible healthcare expenses incurred during the period of your leave.

Unpaid Leave

If you take an unpaid leave of absence, you have the following choices:

End your participation in the Healthcare FSA and stop making contributions to it during the period of your leave. Taking unpaid leave qualifies as a change in status event that would permit you to stop your contributions to the Healthcare FSA.

If you elect to end your coverage under the Healthcare FSA, healthcare expenses incurred during the period of your leave would not be eligible for reimbursement — even if you resume participation in the Healthcare FSA when you return from your leave. If you have not incurred claims that exceed your current contributions, then you may elect to remain out of the Healthcare FSA or you may elect to resume your participation in the Healthcare FSA for the remainder of the Plan Year.

If you return from the leave during the same calendar year and you have received reimbursements of claims in excess of your current contributions, you will resume your participation in the Healthcare FSA for the remainder of the Plan Year. When you resume participation in the Healthcare FSA, you may either:

resume participation at the level in effect before your leave started and increase your Pre-Tax payroll deductions for the remaining portion of the calendar year to make up the unpaid contributions (which allows you to be reimbursed up to the full amount you had elected for the calendar year); or

resume participation by keeping your payroll deductions at the same level as was in effect before your leave began (your annual coverage level will be prorated, and the total amount you will be entitled to be reimbursed from your Healthcare FSA will be reduced by the amount of the contributions you did not make during the period of your leave).

You may not, however, reduce your benefit elections for the Healthcare FSA below the amount already reimbursed to you from the Healthcare FSA.

Continue your participation in the Healthcare FSA but discontinue contributions during the period of your leave. If you elect to continue your participation in the Healthcare FSA during the period of your leave, upon your return from leave during the same calendar year, your Pre-Tax payroll deductions will be automatically increased to make up the unpaid contributions you did not make during your leave. Healthcare expenses incurred during your leave are eligible for reimbursement.



Returning From Leave during a Subsequent Calendar Year

Upon your return to employment with the Company during a subsequent calendar year, you will be able to make a new election under the Healthcare FSA for that calendar year. You will not, however, be able to make Pre-Tax contributions in one Plan Year for coverage that would be effective during a subsequent calendar year.

Before taking a leave of absence, you should discuss your choices with the Company to determine what choice is best for you.

COBRA Continuation Coverage for Healthcare FSAs The COBRA continuation coverage that you may elect for the Healthcare FSA is different from the COBRA continuation coverage that you may elect for the Healthcare Benefit Programs. You may elect COBRA continuation coverage for your Healthcare FSA only if you have an unused balance in your account at the time of termination or when your participation in the Healthcare FSA would otherwise end (i.e., you must have not already received reimbursements of claims in excess of your current contributions at the time of the qualifying event).

COBRA continuation coverage for the Healthcare FSA is only available until the end of the Plan Year in which the qualifying event occurs. If you are eligible for COBRA continuation coverage for the Healthcare FSA, you would have to pay for the coverage on an After-Tax basis (plus a two percent administrative fee, if applicable). Reimbursement cannot occur until the money is paid and processed into your account.

Important Note

To elect COBRA continuation coverage for your Healthcare FSA, you must have an unused balance in your account at the time of termination or when your participation in the Healthcare FSA would otherwise end.



Dependent Day Care FSA Many families require dependent day care services for their children or sometimes for a disabled parent. This type of care can be expensive — which is why the Company offers the Dependent Day Care FSA. You can set aside tax-free dollars to help pay for those expenses. In order to use this account, you must follow the guidelines listed below:

you must be at work during the time your eligible dependents (as listed under “Whose Expenses Can Be Reimbursed”) are receiving care,

if you are married or in a domestic partnership, your spouse/domestic partner must also be working, attending school full-time or be physically or mentally disabled, and

if you are married or in a domestic partnership, and your spouse/domestic partner earns less than $5,000, you cannot be reimbursed for more than your spouse’s/domestic partner’s earned income, unless your spouse/domestic partner is disabled or a full-time student. For more information about contribution limits, see “How Much You Can Deposit” on page 93.

Whose Expenses Can Be Reimbursed You can use the Dependent Day Care FSA to pay for care provided to your eligible dependents, including:

your children under age 13 whom you include as exemptions for tax purposes, and

dependents of any age who are unable to care for themselves because of a mental or physical disability and who have the same residence as you for more than one-half of the calendar year. Periodic verification through medical records will be required.

Eligible Dependent Day Care Expenses Eligible expenses are those that would qualify for a child care tax credit on your federal tax return. These services may be provided inside or outside your home by babysitters, companions or eligible day care centers. Services, however, may not be provided by someone you claim as a dependent on your tax return or by your child under the age of 19.

If care is provided for a disabled dependent (over the age of 13), the care must be provided at your home or the dependent must regularly spend at least eight hours each day in your home.

Eligible Dependents

This definition of dependent is different from that used for the Healthcare FSA, as well as for other Benefit Programs.



The following types of dependent day care expenses are eligible for reimbursement through this account:

summer day camp,

pre-school,

day care center,

before- or after-school care,

care provided inside or outside your home by anyone other than your spouse/domestic partner or your dependents,

a nurse or caregiver for an elderly relative, and

services of a housekeeper whose duties include, in part, providing for a qualified dependent.

For a complete list of eligible dependent day care expenses, you can review PayFlex’s website at healthhub.com, review Publication 503 on the IRS’ website at www.irs.gov or ask for Publication 503 from your local IRS office.

Day Care Inside Your Home

If services are performed in your home, you may be required to treat the caregiver as an employee and withhold income and Social Security taxes. See IRS Publication 926 for more information about household employees.

Day Care Outside Your Home

If the facility you select provides care for more than six non-resident individuals, it must comply with all state and local regulations in order to have the expenses reimbursed.

Record Keeping

In order to pay dependent care expenses with Pre-Tax dollars, you need to keep a record of the name, address and Social Security number (or federal employer identification number) of each person or organization that is paid to provide care. You will need to include this information on IRS Form 2441 that is filed with your tax return (or Schedule 2 if you file Form 1040A).

Non-eligible Dependent Day Care Expenses You cannot use your Dependent Day Care FSA to reimburse expenses for:

care provided by your spouse/domestic partner, your dependents for income tax purposes or your children under age 19,

expenses for which you claim a dependent care tax credit on your federal income tax return,

expenses incurred for a dependent during any period that you could not claim that individual as a dependent on your income tax return,

expenses incurred before your date of participation in the Dependent Day Care FSA or after the date your participation ends,

kindergarten tuition,



overnight camp (prorating for daytime hours is not allowed),

agency referral charges or finder’s fees for placement of a nanny,

caregiver’s transportation to or from the dependent care location,

healthcare expenses (these should be considered for reimbursement through your Healthcare FSA),

cost for clothing, entertainment or food, and

housekeeping expenses not related to dependent care.

If you are uncertain if an expense qualifies for reimbursement under the Dependent Day Care FSA, contact the claims administrator for assistance (see “Submitting Expenses” on page 104 for information) or review PayFlex’s website at healthhub.com.

Any reimbursement paid for ineligible dependent day care expenses under the Dependent Day Care FSA will be subject to applicable income and other taxes.

Making Contributions during a Leave of Absence If you take a paid or unpaid leave of absence (whether or not FMLA qualified) that lasts for no more than two calendar weeks, you will remain a participant in the Dependent Day Care FSA during this time. Any eligible dependent day care expenses incurred during your leave are eligible for reimbursement from your Dependent Day Care FSA. If your leave is unpaid, your Pre-Tax payroll deductions will be adjusted, when you return from leave during the same Plan Year, to make up any amounts missed during your leave. If you take a paid or unpaid leave of absence (whether or not FMLA qualified) that lasts two or more calendar weeks, your participation in the Dependent Day Care FSA will end, and you will need to re-elect participation upon your return from leave by contacting the Bosch Benefits Center.

Federal Dependent Tax Credit You are not eligible to receive both federal dependent care tax credits and reimbursement under the Dependent Day Care FSA for the same expense. Before enrolling in the Dependent Day Care FSA, you should determine whether reimbursement of eligible dependent day care expenses under the Dependent Day Care FSA is better for you than the federal dependent care tax credits that may be available for the same expense. You can find the tax credit amount in IRS Publication 503, available on the IRS’ website at www.irs.gov.

Keep in mind, unless your spouse/domestic partner is disabled or a full-time student, you cannot take a child care tax credit or use the Dependent Day Care FSA if your spouse/domestic partner does not work. You’ll have to decide which option is best for your situation. A tax advisor can help you determine the best approach.



Paying Yourself Back When you have eligible expenses, you will generally need to pay for them out of pocket and submit a claim for reimbursement. You may submit claims to your Traditional or Limited Purpose Healthcare FSA up to your total annual contribution at any time during the year. For the Dependent Day Care FSA, you may only be reimbursed up to the amount you have contributed at the time you submit your claim.

Submitting Expenses To be reimbursed for expenses, simply complete and submit a claim form, available online at the Bosch Benefits Center, along with the following information:

a copy of the bill,

the date of service,

details about the expenses, including:

For Healthcare FSA. An Explanation of Benefits (EOB) statement (to receive this statement, you must first file a claim with your healthcare plan),

For Dependent Day Care FSA. Dependent information (name and age) and the provider’s name, address, tax ID number or Social Security number, and a receipt of payment.

Send your claims to:

PayFlex Systems USA, Inc. P.O. Box 3039 Omaha, NE 68103-3039

Or use Express Claims at healthhub.com to file online.

For your records, be sure to make copies of all the information you submit. Claims will be processed timely, provided you have included all necessary information and documentation.

Deadline for Submitting Expenses

You have until June 30 each year to submit any expenses incurred during the previous Plan Year. The Plan Year is April 1 through March 31.

If you still have a balance in your account after June 30, that money will be forfeited.

Keep in Mind

If you have money remaining in your Healthcare FSA as the end of the Plan Year approaches, you may wish to buy an extra pair of glasses, prescription sunglasses or contact lenses to use the money.



Claim Decisions and Appeals

Healthcare FSAs If your claim for a benefit is denied in whole or in part, you will be notified by the Claims Administrator within 30 days of the date your claim was received. It will include:





In some cases, it may take up to 15 extra days to review your claim application; however, any extension will not go beyond 45 days from the date your claim was first received. If additional time is necessary, you will be notified by the end of the initial 30-day period of:



If additional information is needed to process your claim, you will be given at least 45 days to furnish that information. You also have the right to receive, on written request and without charge, copies of information relevant to your claim.

Appealing a Claim

You have 180 days from the date you receive the written denial of your claim to appeal. An appeal is a review by the Claims Administrator. Your appeal will not be reviewed by the same person (or their subordinate) who denied the claim in the first place. In addition, if a medical issue is involved, an independent medical opinion will be obtained.

The Claims Administrator has 60 days from the date it receives your appeal to respond. Although the decisions of the Claims Administrator are final and binding, if you are not satisfied with the results of the appeal, you may have the right to file a lawsuit under the Employee Retirement Income Security Act (ERISA). However, you must file such a suit no more than 180 days after you are notified of the result of the appeal and you may not file such a suit unless you have first complied with the claims and appeals procedures in a timely manner. See “Your Right to Benefits” in the Administrative Information section for more information about lawsuits under ERISA.

Address for Claim Appeals

An appeal, or any information regarding an appeal, must be sent in writing to:

PayFlex P.O. Box 3039 Omaha, NE 68103-3039



Dependent Day Care FSAs If a claim for a benefit is denied in whole or in part, you or your beneficiary will be notified by the Claims Administrator within 90 days of the date the claim was received. In some cases, it may take up to 90 extra days to review the claim application; however, any extension will not go beyond 180 days from the date the claim was first received.

If additional information is needed to process the claim, you or your beneficiary will be given at least 45 days to furnish that information.

Appealing a Claim

You or your beneficiaries have 60 days from the date you or your beneficiary receive the written statement to appeal. An appeal is a review by the Claims Administrator.

The Claims Administrator has 60 days from the date it receives the appeal to respond. The decisions of the Claims Administrator are final and binding.



PayFlex 700 Blackstone Centre Omaha, NE 68131

Right of the Plan to Obtain Information The Plan may provide or obtain any information needed for proper administration of the Flexible Spending Accounts. You may also need to provide additional information, if requested, in order to receive reimbursements.

Overpayment

The Plan may recover payments (from persons or plans) that exceed Plan provisions for expenses paid on behalf of you or your dependents. If an overpayment is made, the Plan will request that the money be returned. If the excess is not returned voluntarily, the Plan reserves the right to bring a legal action for the excess, or to offset other benefits, to the extent permitted by law.


Insurance Benefit Programs The Company provides you with the Insurance Benefit Programs. The benefits available through these Programs are designed to offer financial protection for you and your family in the event of an unexpected loss. The Company offers the following Insurance Benefit Programs: The Life Insurance Benefit Program allows you to choose from the following

options:

The Associate Life Insurance option pays a benefit to your designated beneficiary upon your death. The Company provides Basic Life Insurance coverage of two times your annual base pay at no cost to you. You can also purchase additional Optional Life Insurance coverage level of one to eight times your annual base pay — or decrease your coverage to one times your annual base pay (see “Associate Life Insurance” on page 117 for more information. Note: Any coverage over two times Basic Life Insurance is considered Optional Life Insurance. In addition, note that the cost of employer-paid Basic Life Insurance in excess of $50,000 will be treated as imputed income to you subject to both federal income and FICA taxes (see “Your Cost” on page 112 ).

The Spouse Life Insurance option pays a benefit to you if your spouse/domestic partner dies. You can select from five coverage options.

The Child(ren) Life Insurance option covers your dependent children. You can select from two coverage options.

The Accidental Death and Dismemberment (AD&D) Insurance Benefit Program protects you against certain accidental losses. The Company provides two times your annual base pay at no cost to you. You can also purchase additional AD&D coverage from one to eight times your annual base pay. Note: Any coverage over two times your annual base pay is considered Optional AD&D insurance. If you elect coverage for yourself, you can also purchase coverage for your spouse/domestic partner and your eligible children.

The Business Travel Accident Insurance Benefit Program provides coverage of four times your annual base pay if you die in an accident while traveling on Company business.

This portion of the SPD summarizes key features of the Insurance Benefit Programs. You may also request more detailed summaries or certificates prepared by the insurance carriers for the Insurance Benefit Programs. Please see the Contact Information section for insurance carriers’ (i.e., Claims Administrator’s) contact information. If there is a conflict between this SPD and the summary or certificate prepared by the insurance carrier, the summary or certificate prepared by the insurance carrier controls.



Insurance Benefit Programs


The benefits provided under the Insurance Benefit Programs are provided pursuant to insurance contracts issued to Bosch by the insurance carriers. The insurance contracts control over all other documents.


Benefits-at-a-Glance ...................................................................................... 109 Participating in the Insurance Benefit Programs ............................................ 111

When Coverage Begins............................................................................. 111 Your Cost................................................................................................... 112 Evidence of Insurability (EOI) .................................................................... 113 Your Beneficiary ........................................................................................ 114 When Coverage Ends................................................................................ 114 Continuing Coverage ................................................................................. 115

Life Insurance Benefit Program...................................................................... 117 Associate Life Insurance............................................................................ 117 Spouse Life Insurance ............................................................................... 120 Child(ren) Life Insurance ........................................................................... 120

AD&D Insurance Benefit Program.................................................................. 121 Coverage for You....................................................................................... 121 Coverage for Your Dependents ................................................................. 123 Covered Accidental Losses ....................................................................... 123 Benefit Payments....................................................................................... 124 Seatbelt and Airbag Benefits ..................................................................... 124 When AD&D Benefits Are Not Paid ........................................................... 125

Business Travel Accident Insurance Benefit Program ................................... 127 How to File Insurance Claims......................................................................... 128

If Your Claim Is Denied.............................................................................. 129



Benefits-at-a-Glance Life and accident insurance help protect you and your family against the financial hardships that can accompany an accident or a death. The Company helps you protect your loved ones by providing you with Company-paid life and accident insurance coverage. You may also purchase additional life and accident insurance coverage for yourself and your eligible dependents. The table below provides an overview of the life and accident insurance coverages available through the Company.

Life Insurance Accidental Death & Dismemberment (AD&D) Insurance and Optional AD&D (OAD&D) Insurance


Associate The Company automatically provides coverage equal to two times your base pay (base pay is rounded to the next higher $1,000) at no cost to you, up to a maximum of $2 million. See “Your Cost” on page 112 for the Basic Life credit option.

You may purchase additional Optional Life Insurance coverage, up to eight times your annual base pay. The maximum coverage amount for Optional Life is $2 million.

The Company automatically provides coverage equal to two times your base pay (base pay is rounded to the next higher $1,000) at no cost to you.

You may also purchase additional OAD&D Insurance coverage, up to eight times your annual base pay. The maximum coverage amount for AD&D Insurance is $2 million.

The Company automatically provides coverage equal to four times your annual base pay (up to a maximum of $1 million)



Life Insurance Accidental Death & Dismemberment (AD&D) Insurance and Optional AD&D (OAD&D) Insurance


Spouse/Domestic Partner

You may purchase Dependent Life Insurance coverage in the following amounts:

$10,000

$25,000

$50,000

$75,000

$100,000

Note: Dependent Life Insurance coverage may not exceed your total combined life insurance coverage.

You may purchase coverage equal to 60% of your associate OAD&D coverage

N/A

Child(ren) You may purchase Dependent Life Insurance coverage for your dependent children in the following amounts:

$1,000 for children under 6 months of age

$5,000

$10,000

Note: Age restrictions and student status apply to children aged 19 to 25.

You may purchase coverage equal to 15% of your associate OAD&D coverage for dependent child(ren) only

N/A

Family N/A You may purchase coverage equal to 50% of your associate OAD&D coverage for your spouse/domestic partner and 10% for your children

N/A



Participating in the Insurance Benefit Programs This section provides important information about the Insurance Benefit Programs, including when coverage begins, evidence of insurability, naming your beneficiary, when coverage ends and how to continue coverage.

When Coverage Begins Life and AD&D Insurance coverage for yourself and your eligible dependents, if applicable, begins on your first day of work if you enroll within 31 days of the date you become eligible.

If you do not enroll for benefits within 31 days of becoming eligible, you will automatically receive:

Associate Basic Life Insurance equal to two times your annual base pay,

Associate Basic AD&D Insurance equal to two times your annual base pay, and

Business Travel Accident Insurance.

In this case, you will not receive Life or AD&D Insurance coverage for your spouse/domestic partner or your eligible dependent children.

If you do not enroll within 31 days, your next opportunity to enroll will be during the Annual Enrollment period unless you experience a change in status event. For more information about change in status events, see “Change in Status Events” under “When You Can Enroll” in the Participating in the Plan section.

Based on your elections, or if you decide to enroll at a later date, coverage may be subject to approval (see “Evidence of Insurability (EOI)” on page 113 for more information).

Your Business Travel Accident Insurance coverage also begins on your first day of work. Coverage is automatically provided; you do not need to make an election.

Delayed Coverage

If you are absent from work on the day your coverage is scheduled to begin, or you do not begin work on the date scheduled, coverage will begin on the date you return to active employment. See the certificates for the Insurance Benefit Programs for more information about the active employment requirement.

If an eligible dependent is confined at home under a physician’s care, receiving or applying to receive disability benefits from any source, or hospitalized on the date coverage is scheduled to begin, coverage for this dependent will begin on the date the dependent is no longer confined, receiving or applying to receive disability benefits from any source, or hospitalized.



Your Cost The chart below illustrates who is responsible for paying the cost of coverage.

Benefit Who Pays for Coverage

Associate Life Insurance

The Company pays the full cost of one or two times your annual base pay. (You receive a credit if you choose coverage of one times annual base pay.) You pay for any additional coverage on an After-Tax* basis.

Spouse Life Insurance

You pay the entire cost of coverage on an After-Tax* basis.

Child(ren) Life Insurance

You pay the entire cost of coverage on an After-Tax* basis.

Accidental Death and Dismemberment (AD&D) Insurance

The Company pays the full cost of one or two times annual base pay. (You receive a credit if you choose coverage of one times annual base pay.) You pay for any additional coverage for yourself, or for you and your family, on an After-Tax* basis.


The Company pays the full cost of coverage.

* Paying for your benefits on a After-Tax basis means that premiums are deducted from your pay after federal income, Social Security taxes, and in most cases state taxes, have been calculated — which means you generally do not pay taxes on those benefits when you or your beneficiary receives them. In addition, note that the cost of Associate Life Insurance in excess of $50,000 will be treated as imputed income to you subject to both federal income and FICA taxes.

Premiums, where they apply, are paid automatically through payroll deductions and will begin as soon as administratively possible following your election. The cost of each option is shown on your personal enrollment worksheet and depends on:

the Benefit Programs you elect,

your age (for Associate Life Insurance) as of January 1, and

your spouse/partner’s age (for Spouse Life Insurance) as of January 1.

The cost for Child(ren) Life Insurance is based on the amount of insurance you elect, regardless of the number of children you enroll.

Credits

If you elect Associate Basic Life and AD&D Insurance of one times your annual base pay, you will be eligible for a credit. Any credit will be included in your paychecks throughout the year as taxable income.

Review Your Paycheck

Please review your paycheck after you enroll to make sure that the appropriate deductions are being processed. If you have any questions, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally)



Evidence of Insurability (EOI) Evidence of insurability, also known as statement of health, is a statement or proof of a person’s physical condition. If EOI is required, the person seeking insurance coverage will need to complete a medical questionnaire. The situations that require EOI are described in the chart below.

The Bosch Benefits Center will notify you if EOI is required when coverage is elected. Your or your family’s current amount of coverage will stay in effect until the increased amount has been approved by the insurance company.

The Cost of Obtaining EOI

You may be required to pay for any costs associated with obtaining EOI. This includes, but is not limited to, the cost of a physical, lab work or the cost of copying your medical records.

When EOI Is Required: Life Insurance

Situations Requiring EOI When EOI Will Be Requested

You Must Provide EOI When…

You elect Associate Optional Life Insurance greater than four times your annual base pay or the Optional Life Insurance amount exceeds $900,000, whichever amount is lesser

Initial enrollment

Change in status event

Annual Enrollment

You elect to increase your life insurance coverage by more than one level

You make a late request for Optional Life Insurance

You increase your coverage from Basic Life Insurance to any form of Optional Life Insurance

You increase your coverage from one level that was below the EOI amount and that one higher level increase amount is now above EOI amount


Annual Enrollment

Your Spouse/Domestic Partner Must Provide EOI When…

You elect Spouse Life Insurance of $75,000 or $100,000 Initial enrollment


Annual Enrollment

You make a late request for Dependent Spouse Life Insurance

An election is made to increase spouse/domestic partner life insurance coverage by more than one level

You increase your coverage from one level that was below the EOI amount and that one higher level increase amount is now above EOI amount


Annual Enrollment

Important Note!

Whether EOI is required and found acceptable is determined exclusively by the insurance carrier providing Life and AD&D benefits. If for any reason the insurance carrier determines that any associate or dependent is not insurable, the Company has no obligation to provide alternative coverage.



Your Beneficiary Beneficiaries are individuals who will receive the proceeds of your Associate Life, AD&D and Business Travel Accident Insurance coverage upon your death. As long as state law allows, you may name anyone as your beneficiary. You may also designate the same or different beneficiaries for each Benefit Program for which you are enrolled. Keep in mind, however, that payments cannot be made to beneficiaries under age 18 (minors). Benefits will be paid to court-appointed legal guardians of minors.

If you purchase Life or AD&D Insurance coverage for your spouse/domestic partner or your children, you are automatically the beneficiary.

You may change your beneficiary at any time electronically on the Bosch Benefits Center website or by calling the Bosch Benefits Center. The change will take effect when it is received. If there are no surviving beneficiaries at the time of your death, payment will be made according to the terms of the insurance contract.

After your benefits have been paid to your most recently designated beneficiary (as determined by the Plan Administrator), the Plan will have no obligation to pay benefits to any other person.

Your beneficiary can only be changed by updating the electronic form on the Bosch Benefits Center website or by calling the Bosch Benefits Center to request a beneficiary change. Any agreements between you and your beneficiary, for example, a settlement that is part of a divorce proceeding, will not change your beneficiary.

When Coverage Ends Life and AD&D Insurance coverage for you will end:

on the date your employment ends for any reason, including retirement or death,

on the date you are no longer eligible for the Plan, the Life Insurance Benefit Program or the AD&D Insurance Benefit Program (as applicable),

on the last day for which you have made the required premium contributions where they apply, or

on the date the Company terminates the Plan, the Life Insurance Benefit Program or the AD&D Insurance Benefit Program.

Life Insurance coverage for your spouse/domestic partner will end on the date:

your coverage ends,

he or she is no longer your spouse/domestic partner, or

he or she turns age 70.

Life Insurance coverage for your children will end on the date:

your coverage ends, or

Keep in Mind

If you have a change in status event, you may want to change your beneficiary designation.

Benefits Available at Retirement

For more information about what benefits are available to you at retirement, if any, see the Bosch Choice Retiree Welfare Benefit Plan SPD available from the Bosch Benefits Center.



the end of the month in which the eligible dependent turns age 26. You are responsible for removing over age children from coverage. This is not monitored by the Plan and benefits are not paid for children who do not meet qualifications at the time of a claim.

Business Travel Accident Insurance coverage for you will end on the date:

your employment ends for any reason, including retirement and death,

you are no longer eligible for the Plan or the Business Travel Accident Insurance Program, or

the Company terminates the Plan or the Business Travel Accident Insurance Program.

Continuing Coverage If your employment with the Company ends for any reason (including retirement) or you are no longer eligible for coverage under the Life and AD&D Insurance Benefit Programs due to a reduction in hours, you may be able to continue coverage for yourself and your covered dependents. You have two options:

Portable Coverage. Allows you to continue coverage; however, coverage is not portable for individuals who have an injury or sickness that has a material effect on life expectancy.

Conversion. Is available when coverage is not portable. There are no limits on continuing coverage for pre-existing injuries or illnesses; however, your cost for coverage will be higher.

To continue coverage under one of these options, you must enroll within 31 days of the qualifying event. For more information, see “Portable Coverage and Conversion” on page 115.

Important Note about Continuing Coverage

Portable coverage and conversion rights are provided by the insurance carrier that provides coverage under the Life and AD&D Insurance Benefit Programs, and are subject to change depending on the policies of the insurance carrier. If the insurance carrier does not permit portable or conversion coverage for any reason, the Company will have no obligation to provide alternative coverage.

Portable coverage or conversion is not available for the Business Travel Accident Insurance Benefit Program.

Portable Coverage and Conversion Portable coverage refers to the ability to transfer Life and AD&D Insurance coverage from a group (Company-offered) policy to an individual policy. If you elect portable coverage or conversion, you, your spouse and/or your dependents pay the full cost of coverage. Costs are calculated by MetLife.

You must elect portable coverage for yourself in order to elect portable coverage for your dependents. However, in the case of your death, your insured dependents may elect portable coverage for themselves. For more information, see “Limits on Portable Coverage.”

Note

If, at the time your coverage ends, you or your covered dependents have an injury or sickness that has a material effect on life expectancy, you may be able to convert coverage.

Coverage at Age 70…

At age 70, you can elect portable coverage for your child even if you do not have a covered spouse/domestic partner.



If you want to port AD&D coverage, you must also port Life Insurance coverage. In addition, the amount of AD&D insurance you or your dependents elect to port must be equal the amount of Life Insurance that is ported. The minimum amount of coverage that can be ported is $20,000 for you.

Limits on Portable Coverage

Portable coverage is not available to you or your covered dependents if there is an injury or sickness that has a material effect on life expectancy. In addition, you cannot apply for portable coverage for your dependents unless you have elected portable coverage for yourself.

In the case of your death, your covered spouse/domestic partner must elect portable coverage for your children. If you do not have a covered spouse/domestic partner at the time of your death, your children will be eligible to port coverage on their own.

Keep in Mind

You and your dependents must be enrolled under the Bosch Choice Life and/or AD&D Insurance Benefit Programs at the time you apply for portable coverage.

When Portable Coverage Ends

Portable coverage will end if:

you attain age 80,

your spouse/domestic partner attains age 70,

you, your spouse/domestic partner or your eligible children fail to make premium payments, or

the policy is cancelled.

Coverage for a child will also end when he or she no longer meets the Plan’s eligibility requirements, as listed under “Who Is Eligible” in the Participating in the Plan section.

Conversion

If you or your dependents are not eligible to apply for portable coverage due to an injury or illness that has a material effect on life expectancy or because portable coverage ends, a conversion policy may be an option. If you convert coverage, you, your spouse/domestic partner and/or your dependents pay the full cost of coverage. Costs are calculated by MetLife.

Contact MetLife for information about availability, premiums and benefits of conversion policies.

Portability and conversion forms are also available on the Bosch Benefits Center website.

If You Do Not Pay Required Premiums

If portable coverage ends due to failure to pay a required premium, portable coverage cannot be reinstated.

Note!

If, at the time your coverage ends, you or your covered dependents have an injury or sickness that has a material effect on life expectancy, you may be able to convert coverage.



Life Insurance Benefit Program Ensuring your family’s financial well being is an important aspect of the financial planning process. That is why the Company offers you, your spouse/domestic partner and your eligible children life insurance coverage.

Associate Life Insurance Associate Life Insurance pays a benefit to your designated beneficiary upon your death. You may choose from two levels of Company-paid Basic Life Insurance coverage (see “Credits” under “Your Cost” on page 112 for credit information):

1 × annual base pay (Company paid, you receive a credit if you elect this level of coverage), or

2 × annual base pay (Company paid).

You may also choose to purchase one of eight levels of Optional Life Insurance:

1 × annual base pay,






7 × annual base pay, or

8 × annual base pay, maximum $2 million.

The Company pays the full cost of coverage if you elect one or two times annual base pay. You pay for the entire cost of any additional coverage on an After-Tax basis. Any coverage more than two times pay is considered Associate Optional Life Insurance for enrollment purposes.

Depending on the option you elect, coverage may be subject to approval by the insurance company. See “Evidence of Insurability (EOI)” on page 113 for more information.



Annual Base Pay

Coverage is based on your pay in effect on the January 1 prior to the beginning of the Plan Year. Base pay includes your salary, any elective deferred compensation and pre-tax premiums, flexible spending account contributions and elective savings plan contributions. Base pay does not include any overtime pay, bonuses, shift differential pay, relocation pay, employer-paid retirement or fringe benefits not normally included in cash compensation. If a claim is filed, it would pay out at your current level of pay, not the Annual Base Pay as of January 1.

For sales associates earning commission, any commission sales wages paid in the last 24-month period will be averaged and annualized for this period. The calculated annualized commission amount will then be added to your benefit salary affecting benefit coverage and contributions. This “look back” will be calculated each January 1st with the benefit commission wage used for the entire Plan Year. For purposes of determining your coverage, your annual base pay will be rounded to the nearest thousand.

Imputed Income

Federal law requires you to pay income tax on the value of employer-paid life insurance that exceeds $50,000. If your employer-paid life insurance coverage is more than $50,000, imputed income will appear on your paycheck. This additional amount is added to your W-2 as taxable income and is subject to both federal income and FICA taxes.

If Your Pay Changes During the Year If your annual base pay changes after January 1:

Associate Life Insurance coverage will be based on the amount of your new pay as of the effective date of the pay change, and

any premium you pay will remain the same until the beginning of the next Plan Year (April 1).

If you are not actively at work on the day the change in pay takes effect, the change will become effective on the date you return to work.

Maximum Benefit The maximum benefit payable for Basic Associate Life Insurance is a maximum of $2 million. Optional Associate Life Insurance has a separate maximum benefit payable of $2 million.

Accelerated Benefit If you become terminally ill while you are covered by the Associate Life Insurance option, or your spouse/domestic partner becomes terminally ill while he or she is covered by Spouse Life Insurance option, you may elect to receive 50% of your benefit (up to $250,000) while you are living if your physician certifies in writing that for you or your spouse/domestic partner:

your life expectancy has been dramatically limited,

you have a medical prognosis of 24 months or less to live, or

you are not expected to recover from your illness.

Keep in Mind

Based on your elections at the time you receive a pay increase, evidence of insurability may be required. See “Evidence of Insurability (EOI)” on page 113 for more information.



To receive the benefit, you must submit a request to the insurance company in writing along with the prognosis from your or your spouse/partner’s doctor. If you or your spouse/domestic partner is approved for the accelerated benefit, you will receive a lump sum payment. This option is only available once during your or your spouse’s lifetime. Upon your or your spouse/partner’s death, the remaining portion of the Life Insurance benefit will be paid to the beneficiary you have named.

The maximum accelerated benefit that can be paid is:

$250,000 for Associate Basic Life Insurance,

$250,000 for Optional Life Insurance, and

$50,000 for Spouse Life Insurance.

Accelerated benefits will not be paid if:

you or your spouse/domestic partner have assigned your Life Insurance benefits,

your or your spouse/partner’s condition results from:

attempted suicide,

intentionally injuring yourself,

alcohol or drug abuse,

a war or war-like action in time of peace, or

any event occurring while you are in violation of criminal law, or

the total amount of your Associate Life Insurance coverage is less than $10,000.

In addition, an accelerated benefit can be paid only to you. If the insurance company is notified that all or a portion of your accelerated benefit will be paid to anyone other than you (for example, to a former spouse/domestic partner or as part of a divorce agreement), payment will not be made.

Coverage at Age 70 and Older Your Basic Life Insurance will reduce when you turn 70. The percentage your beneficiary will receive is based on your age at the time of your death, as outlined in the chart below:

Age at Death… Percentage of Basic Life Insurance Your Beneficiary Will Receive…

70 through age 74 65%


80 and older 30%

When Benefits Will Not Be Paid Associate Optional Life Insurance benefits will not be paid if you commit suicide, while sane or insane, within two years after the effective date of coverage or the effective date of an increase in coverage.



Spouse Life Insurance Spouse Life Insurance pays a benefit to you if your spouse/domestic partner dies. You are automatically the beneficiary of this benefit. The Company offers five coverage options:

$10,000,

$25,000,

$50,000,

$75,000, or

$100,000.

If you elect Spouse Life Insurance, you pay the full cost of this coverage on an After-Tax basis. You may not elect spouse/domestic partner life insurance coverage that exceeds the amount of your combined Basic and Optional Life Insurance coverage. Depending on the option you choose, coverage may be subject to approval by the insurance company. See “Evidence of Insurability (EOI)” on page 113 for more information. Spouse Life Insurance ends when your spouse/domestic partner reaches age 70.

Please Note: If you are married to another Bosch associate, you may not elect Spouse Life Insurance for your spouse/domestic partner.

When Benefits Will Not Be Paid

Spouse Life Insurance benefits will not be paid if your spouse/domestic partner commits suicide, while sane or insane, within two years after the effective date of coverage or the effective date of an increase in coverage.

Child(ren) Life Insurance You can purchase life insurance coverage for your children up to age 26. This coverage pays a benefit to you if your child dies. Benefits will not be paid for dependents over the age of 26.

The Company offers two coverage options:

$5,000 per child (age six months and older), or

$10,000 per child (age six months and older).

If you elect Child(ren) Life Insurance, you pay the full cost of this coverage on an After-Tax basis.

Please Note: If a child is eligible for coverage under more than one associate, only one associate may cover the child. Both associates may not elect Child(ren) Life Insurance on the same child.

Depending on the option you choose, coverage may be subject to approval by the insurance company. See “Evidence of Insurability (EOI)” on page 113 for more information.

Note

The maximum benefit payable for a child one day old to six months of age is $1,000.



AD&D Insurance Benefit Program The AD&D Insurance Benefit Program provides an extra measure of protection for you and your family members in the event of:

covered accidental losses, and

unavoidable exposure to the elements. You can choose coverage for yourself only, or you can choose coverage for yourself and your family (your spouse/domestic partner and/or your eligible dependent children). The benefit paid is based on the severity of the loss. To receive benefits, the accident must occur while you are covered by the AD&D Insurance Benefit Program and the covered loss must occur within one year of the date of the accident.

Coverage for You You may choose from two levels of Company-paid coverage:

1 × annual base pay (Company paid, you receive a credit if you elect this level of coverage), or

2 × annual base pay (Company paid).

You may choose from eight levels of Optional AD&D coverage:







7 × annual base pay, or

8 × annual base pay, maximum $2 million.

The Company pays the full cost of coverage if you elect one or two times annual base pay. You pay the full cost for any additional coverage you elect on an After-Tax basis. Any coverage more than two times pay is considered Optional AD&D for enrollment purposes.

Depending on the option you elect, coverage may be subject to approval by the insurance company. See “Evidence of Insurability (EOI)” on page 113 for more information.

Keep in Mind

AD&D coverage is not a substitute for life insurance protection. These benefits are paid only if death or injury is the result of an accident and are paid in addition to your life insurance benefits.



Annual Base Pay

Coverage is based on your pay in effect on the January 1 prior to the beginning of the Plan Year. Base pay includes your salary, any elective deferred compensation and pre-tax premiums, flexible spending account contributions and elective savings plan contributions. Base pay does not include any overtime pay, bonuses, shift differential pay, relocation pay, employer-paid retirement or fringe benefits not normally included in cash compensation.

For sales associates earning commission, any commission sales wages paid in the last 24-month period will be averaged and annualized for this period. The calculated annualized commission amount will then be added to your benefit salary affecting benefit coverage and contributions. This “look back” will be calculated each January 1st with the benefit commission wage used for the entire Plan Year. For purposes of determining your coverage, your annual base pay will be rounded to the nearest thousand.

If Your Pay Changes during the Year

If your annual base pay changes after January 1:

AD&D Insurance coverage will be based on the amount of your new pay as of the effective date of the pay change, and

any premium you pay will remain the same until the beginning of the next Plan Year (April 1).

If you are not actively at work on the day the change in pay takes effect, the change will become effective on the date you return to work.

Maximum Benefit The maximum benefit payable for Associate AD&D Insurance is a maximum of $2 million.

Coverage at Age 70 and Older Your Associate Basic AD&D Insurance coverage will reduce when you turn 70. The percentage your beneficiary will receive is based on your age at the time of your death, as outlined in the chart below:

Age at Death… Percentage of Associate AD&D Insurance Your Beneficiary Will Receive…



80 and older 30%

Keep in Mind

Based on your elections at the time you receive a pay increase, evidence of insurability may be required. See “Evidence of Insurability (EOI)” on page 113 for more information.



Coverage for Your Dependents If you elect to cover yourself and your family (your spouse/domestic partner and/or your eligible dependent children), your dependents will receive a percentage of the amount of coverage you have elected for yourself, as listed below.

Coverage Options Benefit

Spouse/domestic partner only

(no covered children)

60% of your OAD&D Insurance coverage

Spouse/domestic partner and children

Spouse/domestic partner: 50% of your OAD&D Insurance coverage

Each child: 10% of your OAD&D Insurance coverage

Children only

(no covered spouse/domestic partner)

Each child: 15% of your OAD&D Insurance coverage

If you elect OAD&D Insurance coverage for your family, you pay the full cost of this coverage on an After-Tax basis.

Covered Accidental Losses If you or a covered dependent dies or suffers a loss within 12 months after the date of a covered accident, the Plan will pay a percentage of the AD&D benefits you are enrolled for at the time of the accident.

Covered Accidental Loss1 Percentage of AD&D Benefit Paid

Life2 100%

Both hands, both feet, the complete, irrevocable loss of sight in both eyes or any combination

100%

One hand, one foot or the complete, irrevocable loss of sight in one eye

50%

Thumb and index finger of the same hand 25%

Speech and hearing in both ears 100%

Speech or hearing in both ears 50%

Quadriplegia (Total paralysis of arms and legs) 100%

Paraplegia (Total paralysis of both legs) 50%

Hemiplegia (Total paralysis of arm and leg on one side of the body)

50%

1. Loss means the complete severance of the hand, foot, thumb or finger. In reference to the eye, loss means complete, irrecoverable loss of sight. Loss of speech and hearing means the entire and irrecoverable loss that has lasted continuously for 12 consecutive months following the injury. Loss also means loss of life.

2. In the case of a death, the insurance company (at its cost and of its choice) has the right to require an autopsy, as long as the request is within the laws of the state.



Medical Exams

While an AD&D claim is pending, the insurance company has the right to request an exam by a physician of its choice and as often as reasonable.

Transportation

If you die at least 100 miles away from your principle residence, an additional $5,000 benefit is available to cover the preparation and transportation to a mortuary chosen by you or your authorized representative. Note: The transportation benefit applies only to Basic AD&D coverage.

Missing Persons

If, after one year from the date of an accident, a covered person has not been found because the vehicle transporting him or her made a forced landing, sank, disappeared or was wrecked, a loss of life benefit will be paid to the beneficiary.

Benefit Payments If you or your covered dependents suffer a loss, other than death, the benefit will be paid directly to you. If you die, benefits will be paid to the beneficiary you have designated. If your spouse/domestic partner or a child dies, a benefit payment will be made to you. If there are no surviving beneficiaries at the time of your or your dependent’s death, payment will be made according to the terms of the insurance contract.

How Payments Are Made

Benefit payments will be made as follows:

If the amount to be paid is less than $5,000:

for a covered loss other than death, a lump sum payment will be made to you, or

upon your death, a lump sum payment will be made to your beneficiary.

If the amount to be paid is $5,000 or more, a checking account, containing the full amount of the benefit, will be set up in your or your beneficiary’s name for immediate access. The beneficiary will receive a checkbook and monthly statements. There are free check writing privileges and no maintenance fees. You or your beneficiary may withdraw all of the money at once or over time. The account pays interest at rates comparable to current money market accounts and is fully guaranteed by the insurance company.

A benefit payment can also be made according to a settlement option, as long as the request is made in writing.

Seatbelt and Airbag Benefits If you or your covered dependents are involved in an accident, a seatbelt or airbag benefit may be available. This benefit would be paid in addition to your and your dependent’s AD&D coverage.



Seatbelt Benefit

If you or your covered dependents are wearing seatbelts at the time of an automobile accident, an additional 10% benefit, with a minimum benefit of $1,000 and a maximum benefit of $25,000, for each covered person involved in the accident may be payable. To be eligible for this benefit, the seatbelt must:

meet published federal safety standards,

have been installed by the car manufacturer,

not have been altered after being initially installed by the manufacturer,

have been in actual use and properly fastened at the time of the covered accident, and

be certified in the official report, or by the investigating officer, as being in the correct position at the time of the covered accident.

A copy of the police accident report must be submitted with the claim for benefits.

Airbag Benefit

An airbag benefit of an additional 5%, with a minimum benefit of $1,000 and a maximum benefit of $10,000, will be paid in addition to your and your dependent’s AD&D coverage if, at the time of a covered accident:

the private passenger car is equipped with an air bag in the location where you or your covered dependents are seated, and

the seatbelt(s) were in actual use and properly fastened.

A copy of the police accident report must be submitted with the claim for benefits.

When Seatbelt and Airbag Benefits Are Not Paid

A seatbelt or airbag benefit will not be paid to a driver who, at the time of the accident:

does not have a current, valid driver’s license, or

is under the influence of alcohol or drugs.

When AD&D Benefits Are Not Paid AD&D benefits will not be paid if an accidental death or injury occurs directly from:

physical or mental illness, diagnosis of or treatment for the illness,

an infection, unless caused by an external wound that can be seen and which was sustained in an accident or by the accidental ingestion of a poisonous food substance,

suicide or attempted suicide,

intentionally injuring oneself,

the use of any drug or medicine,



a war, or a war-like action in time of peace, including terrorist acts,

committing or attempting to commit a felony, other serious crime or an assault,

any poison or gas voluntarily taken, administered or absorbed,

service in the armed forces of any country or international authority (except the United States National Guard),

driving a vehicle while intoxicated as defined by the laws of the jurisdiction in which the vehicle was being operated,

operating, learning to operate or serving as a member of a crew of an aircraft,

being in any aircraft operated by or under any military authority (other than the Military Airlift Command),

being in any aircraft used for a test or experimental purposes,

being in any aircraft used or designed for flight beyond the Earth’s atmosphere, or

being in any aircraft for the purpose of descent from such aircraft while in flight (except for self-preservation).



Business Travel Accident Insurance Benefit Program The Company provides you with coverage under the Business Travel Accident Insurance Benefit Program of four times your annual base pay, up to $1 million, at no cost to you.

This benefit is paid if you die or are seriously injured in an accident while traveling on Company business. A life insurance benefit of $25,000 for your spouse/domestic partner and $10,000 for each of your eligible children may also be paid if they have been authorized by the Company to travel with you.

This insurance coverage is in addition to any Associate Life and AD&D Insurance coverage for which you are enrolled. Business Travel Accident Insurance coverage is automatically provided to you. You do not need to make an election.

Important Note about Coverage!

Business Travel Accident Insurance does not cover accidents that occur while traveling to or from your regular place of work on a daily basis.



How to File Insurance Claims While this section provides instructions on how to file a claim for benefits under the Life, AD&D and Business Travel Accident Insurance Benefit Programs, the Bosch HR Service Center is available to assist you, or your family, through this process. For the death of an insured, written notice and the proof of claim must be sent to the insurance company as soon as is reasonably possible after the insured individual’s death. The proof of claim must include the cause of the death. In this situation, a certified copy of the death certificate and enrollment documents will also be required. Contact the Bosch HR Service Center for notification and assistance with claim filing.

For a covered loss, written notice and the proof of claim must be sent to the insurance company no later than 90 days after the date of a covered loss (e.g., if a covered loss occurred on July 1, written notice and proof of claim must be sent by September 29 of the same year). The proof of claim must include:

the date of the covered loss,

the covered person(s) involved in the claim,

the cause and extent of the covered loss, and

the name and address of any hospital or institution where treatment was received, including all attending physicians.

The insurance company may also require you or your family to provide an authorization to obtain additional medical and non-medical information.

Right of the Plan to Obtain Information

The Plan may provide or obtain any information needed for proper administration of the Life, AD&D or Business Travel Accident Insurance Benefit Programs. You or your beneficiary may also need to provide additional information, if requested, in order to receive payments.

Overpayment

The Plan may recover payments that exceed Plan provisions for benefits paid. If an overpayment is made, the Plan will request that the money be returned. If the excess is not returned voluntarily, the Plan reserves the right to bring a legal action for the excess, or to offset other benefits, to the extent permitted by law.

For information about what to do if your claim is denied, refer to the Insurance carrier’s summaries and certificates for the Life Insurance, AD&D Insurance and Business Travel Accident Insurance Benefit Programs.

90-Day Notification Period

If it is not possible to provide proof within 90 days, you must notify the Plan Administrator of the claim within the 90-day period and provide the proof no later than one year after the time proof is otherwise required. Exceptions may be made in the absence of legal capacity, in the sole discretion of the Plan Administrator.



If Your Claim Is Denied If a claim for a benefit is denied in whole or in part, you or your beneficiary will be notified by the Plan Administrator within 90 days of the date the claim was received. It will include:





In some cases, it may take up to 90 extra days to review the claim application; however, any extension will not go beyond 180 days from the date the claim was first received. If additional time is necessary, you or your beneficiary will be notified by the end of the initial 90-day period of:


an estimate of when the claim will be resolved.

If additional information is needed to process the claim, you or your beneficiary will be given at least 45 days to furnish that information. You or your beneficiary also have the right to receive, on written request and without charge, copies of information relevant to the claim.

Appealing a Claim

You or your beneficiaries have 60 days from the date you or your beneficiary receive the written statement to appeal. An appeal is a review by the Plan Administrator or its representative. The appeal will not be reviewed by the same person (or their subordinate) who denied the claim in the first place. In addition, if a medical issue is involved, an independent medical opinion will be obtained.

The Plan Administrator has 60 days from the date it receives the appeal to respond. Although the decisions of the Plan Administrator are final and binding, if you or your beneficiary are not satisfied with the results of the appeal, you or your beneficiary may have the right to file a lawsuit under the Employee Retirement Income Security Act (ERISA). See “Your Right to Benefits” in the Administrative Information section for more information about lawsuits under ERISA.



Metropolitan Life Insurance Company – Group Life Claims P.O. Box 6100 Scranton, PA 18505-6100


Disability Benefit Program The Company provides you with short term disability (STD) coverage and the Long Term Disability (LTD) Insurance Benefit Program to help provide financial protection against the loss of your income. STD and LTD benefits replace a portion of your pay if you are unable to work because of an approved illness or injury.

This portion of the SPD summarizes key features of the LTD Insurance Benefit Program. Please see “Benefits-at-a-Glance” on page 133 for some basic information about STD coverage, including where you can get details about the STD benefits available to eligible associates. Although mentioned in this SPD, STD coverage is not offered as a Benefit Program under the Plan, nor is it covered by ERISA.

The LTD Insurance Benefit Program allows you to choose from the following options: Basic LTD Coverage. Basic LTD pays 50% of your monthly base pay. This

coverage is paid for by the Company at no cost to you.

Optional LTD Coverage. Optional LTD pays an additional 15% for a total of 65% of your monthly base pay. If you elect this option, the Company pays for the portion of your coverage that provides 50% of your monthly base pay and you pay for the additional 15% of coverage on an After-Tax basis.

This portion of the SPD summarizes key features of the LTD Insurance Benefit Program. Every effort has been made to accurately describe the LTD Insurance Benefit Program in this SPD. However, these benefits are offered and controlled by a group insurance contract with the insurance carrier for the LTD Benefit Program. You may request a more detailed summary or certificate prepared by the insurance carrier for the LTD Insurance Benefit Program. Please see the Contact Information section for the insurance carrier’s (i.e., Claims Administrator’s) contact information. If there is a conflict between this SPD and the group insurance contract, summary or certificate prepared by the insurance carrier, the group insurance contract, summary or certificate prepared by the insurance carrier controls. The benefits provided under the LTD Insurance Benefit Program are provided pursuant to insurance contracts issued to the Company by the insurance carrier. The insurance contract controls over all other documents.



Disability Benefit Program



Benefits-at-a-Glance ...................................................................................... 133 Participating in Disability Benefits................................................................... 134

Who Is Eligible ........................................................................................... 134 When Coverage Begins............................................................................. 134 Your Cost................................................................................................... 135 Changing Coverage during the Year ......................................................... 135 Waiver of Long Term Disability Premium .................................................. 136 When Coverage Ends................................................................................ 136 Continuation of Other Benefits................................................................... 136

Long Term Disability Insurance Benefit Program........................................... 138 How Your LTD Benefits Work.................................................................... 138 Coordination with Other Benefits ............................................................... 143 Social Security Benefits ............................................................................. 144 How to File Claims..................................................................................... 145 If Your Claim Is Denied.............................................................................. 146



Benefits-at-a-Glance Disability coverage is designed to safeguard your earning power due to sickness, injury or pregnancy and cannot work. The following summary provides an overview of the short term disability (STD) and Long Term Disability (LTD) coverage available through the Company.

Short Term Disability Coverage

The Company automatically provides coverage to replace a percentage of your monthly base pay at no cost to you.

Benefits Available

Exempt and Non Exempt Employees. Consult your division’s STD policy for information on when coverage begins and the amount of benefit provided.

Direct and Indirect Hourly Employees. Consult your division’s STD policy for information on when coverage begins and the amount of benefit provided.

For more information about the STD benefit available to you, please contact the HR Service Center or refer to the STD policy for your division.

Long Term Disability Coverage

Basic LTD Coverage

The Company automatically provides coverage to replace 50% of your monthly base pay at no cost to you. Note for Robert Bosch Tool Corporation employees: If you filed a claim prior to the changes made on April 1, 2014, you will not be affected by certain provisions (which only apply to claims after April 1, 2014).

Optional LTD Coverage

You may purchase an additional coverage of 15% for a total income replacement benefit of 65% of your monthly base pay. You pay for the additional 15% of coverage.

Maximum Monthly Benefit

The combined maximum monthly benefit for Basic and Optional LTD coverage is $18,000. There is a minimum monthly benefit of $100.

Important Note

Although mentioned in this SPD as part of the disability benefits available to eligible associates, short term disability (“STD”) coverage is not a part of the Bosch Choice Welfare Benefit Plan; nor is it covered by the Employee Retirement Income Security Act of 1974 (ERISA). Instead, it is provided as a payroll practice out of the general assets of the Company.



Participating in Disability Benefits This section provides important information about the Long Term Disability (LTD) Insurance Benefit Program, including who is eligible to participate, when coverage begins, waiver of premium, when coverage ends and how to continue coverage. For information about the STD benefit available to you, please contact the HR Service Center or refer to the STD policy for your division.

Who Is Eligible You are eligible to participate in the LTD Insurance Benefit Program if you satisfy the eligibility and enrollment requirements described under “Who Is Eligible” in the Participating in the Plan section.

You do not have to enroll in any other Benefit Program to participate in the LTD Insurance Benefit Program.

When Coverage Begins Basic (Company-paid) LTD coverage begins on your first day of eligible full-time employment. Optional LTD coverage also begins on your first day of eligible full-time employment if you enroll within 31 days of the date on which you become eligible (see “Who Is Eligible” in the Participating in the Plan section).

Note for Robert Bosch Tool Corporation employees: If you filed a claim prior to the changes made on April 1, 2014, you will not be affected by certain provisions (which only apply to claims after April 1, 2014).

If you do not enroll for Optional LTD within 31 days of becoming eligible, you will automatically receive Basic LTD coverage of 50% of your monthly base pay.

If you decide to enroll for Optional LTD at a later date (meaning you choose to increase your level of protection from 50% to 65%), coverage will begin on the date your Evidence of Insurability (EOI) application is approved.

If you become disabled within the first 12 months after your effective date of coverage, your benefits may be postponed. See “Pre-existing Conditions” on page 139 for more information.

Evidence of Insurability

Whether EOI is required and found acceptable is determined exclusively by the LTD insurance carrier providing disability benefits. If, for any reason, the LTD insurance carrier determines that any associate is not insurable, the Company has no obligation to provide alternative coverage. Please refer to the summary or certificate prepared by the insurance carrier for additional information about the active employment requirement.



Delayed Coverage

If you are absent from work on the day your coverage is scheduled to begin, or you do not begin work on the date scheduled, coverage will begin on the date you return to active employment. Please refer to the summary or certificate prepared by the insurance carrier for additional information about the active employment requirement.

Your Cost The chart below illustrates who is responsible for paying the cost of LTD coverage.

Coverage Options Benefit Who Pays for Coverage

Basic LTD 50% of your monthly base pay

Company

65% of your monthly base pay

50% Company

Optional LTD

15% You


If you elect Optional LTD coverage, you pay for the additional 15% of coverage, through payroll deductions, on an After-Tax basis. Your premiums will depend on the amount of your annual salary. Payroll deductions will begin as soon as administratively possible following your election.

Changing Coverage during the Year You may experience certain events during the Plan Year that would allow you to change your LTD coverage. These change in status events are explained under “Change in Status Events” in the Participating in the Plan section.

If you want to add Optional LTD benefits more than 31 days after becoming eligible, coverage will take effect on the date your Evidence of Insurability (EOI) application is approved, as long as you are actively at work.

Important to Keep in Mind…

Enrolling for Optional LTD coverage (65% of monthly base pay) during the year does not mean that you are covered right away. You must first be approved for coverage by submitting an Evidence of Insurability EOI) form.

Whether EOI is required and found acceptable is determined exclusively by the insurance carrier providing disability benefits. If, for any reason, the insurance carrier determines that any associate is not insurable, the Company has no obligation to provide alternative coverage.

Please review your paycheck after you enroll to make sure that the appropriate deductions are being processed. If you have any questions, contact the Bosch Benefits Center at 800-207-9012 (857-362-5996 internationally).



Waiver of Long Term Disability Premium If you are enrolled for Optional LTD coverage and the insurance company has approved your disability, premiums will be waived if you become totally or permanently disabled and are receiving LTD benefits.


When Coverage Ends Long Term Disability coverage will end according to the age reduction shown in “Maximum Benefit Period” on page 142 or:

on the date your employment ends for any reason, including retirement or death,

on the date you are no longer eligible for the Plan or the LTD Insurance Benefit Program,

on the last day for which you have made the required premium contributions where they apply, or

on the date the Company terminates the Plan or the LTD Insurance Benefit Program.

Continuation of Other Benefits The information below summarizes how your disability leave will affect the Benefit Programs you and your dependents are enrolled in at the time you become disabled.

Vacation

Vacation may stop accruing while on disability. You can opt to receive some or all of your remaining accrued vacation paid out upon commencement of LTD. Your monthly LTD benefit will be reduced by any payments you receive from vacation. After six months of LTD, all remaining accrued vacation will be paid out through payroll.

COBRA Continuation Coverage

If, at the time you become disabled, you and your dependents are enrolled in a Healthcare Benefit Program (under the Medical, Dental, Vision or Employee Assistance Program Benefit Programs), coverage under the Healthcare Benefit Programs in which you and your dependents are enrolled will continue, at no cost to you, for up to 24 months during your approved long term disability leave. This 24-month period paid for by the Company runs concurrently with the coverage normally provided under COBRA continuation coverage.



In addition to the 24 months of Healthcare Benefit Program coverage provided during your long term disability leave, Healthcare Benefit Program coverage may continue for up to five months on COBRA for a total 29 month period of COBRA continuation available to disabled individuals, if you provided a copy of the Social Security Disability Notice of Award to the Bosch Benefits Center before the end of your 24 months on disability (otherwise, your coverage will terminate at the end of the 24 month disability period). If you have been approved for Social Security Disability benefits and would like to continue on COBRA, please fax a copy of the Notice of Award to the Bosch Benefits Center at 800-250-8416 (ATTN: 31 BSW PRI) before the end of your 24 months of Company-paid coverage.

If your eligible dependents have the right to receive COBRA coverage for more than 29 months, they will have the right to elect the additional coverage at the end of the 29-month period. For additional information about COBRA continuation coverage, see “COBRA Continuation Coverage” in the Healthcare Benefit Programs section of this SPD.

Life Insurance Benefit Programs

If you are approved for LTD, you may be eligible for a Life Insurance Premium Waiver. Contact MetLife for more information on the Life Insurance Premium Waiver benefit.

All dependent coverage under the Life Insurance Benefit Program or AD&D Insurance Benefit Program will end when you have been approved for LTD benefits.




Long Term Disability Insurance Benefit Program Long Term Disability (LTD) Insurance provides financial protection by paying a portion of your income while you are disabled. This section outlines your benefits under the LTD Insurance Benefit Program, including how total disability is defined and how long LTD benefits last.

How Your LTD Benefits Work If you become disabled, notify the HR Service Center immediately. LTD benefits begin only after you have been totally disabled for 180 days. This is referred to as the elimination period. Sick pay and short term disability coverage may provide a benefit during all or a portion of the 180-day elimination period. Contact the HR Service Center for more information on sick pay and short term disability coverage.

If you are approved for benefits and have completed the elimination period, the LTD Insurance Benefit Program will pay a benefit equal to 50% or 65% of your monthly base pay, depending on the benefit level you elected. The amount you receive is based on your earnings before your disability began. Payments will be made directly to you.

You will receive a benefit payment every month while you are disabled, as long as you provide proof and conclusive medical evidence that supports your disability. Benefits are paid based on a rolling calendar month basis. The checks issued represent payments for the current calendar month. For example, if the benefit start date is 3/12/14, the first check issued will represent benefits beginning 3/12/14 through 4/11/14. The check will issue on or about 4/4/14 which is about a week prior to the paid through date.

For more information about maximum benefit periods, see “Maximum Benefit Period” on page 142.



Important Definitions

Annual Base Pay

Disability coverage is based on your pay in effect on the January 1 prior to the beginning of the Plan Year. Base pay includes your salary, any elective deferred compensation and Pre-Tax premiums, flexible spending account contributions and elective savings plan contributions. Base pay does not include any overtime pay, bonuses, shift differential pay, relocation pay, employer-paid retirement or fringe benefits not normally included in cash compensation.

For sales associates earning commission, any commission sales wages paid in the last 24-month period will be averaged and annualized for this period. The calculated annualized commission amount will then be added to your benefit salary affecting benefit coverage and contributions. This “look back” will be calculated each January 1st with the benefit commission wage used for the entire Plan Year. LTD payment is based on your base pay at the time you became disabled.

Total Disability

Total disability exists for the LTD Insurance Benefit Program when, as the result of an injury or illness, you:

are unable to earn during the elimination period and the next 24 months of sickness or accidental injury, more than 80% of your predisability earnings at your own occupation for any employer in your local economy, and

are unable to perform the material duties of your own occupation, and

after such period, are unable to earn more than 80% of your predisability earnings at any gainful occupation for any employer in your local economy, and

are unable to perform the duties of any gainful occupation for which you are reasonably qualified taking into account your training, education and experience.

To be totally disabled, you must be under the regular care of a physician with a defined treatment plan appropriate for your disability.

See “Limited Disability Benefits” for exceptions.

Monthly Benefit Limits

The minimum benefit payable is $100 each month. The maximum benefit payable is $18,000 each month.

Pre-existing Conditions

A pre-existing condition is any injury or illness, including pregnancy, for which you were diagnosed, treated, consulted, received care, received services or incurred expenses, took prescription medication, or had medications prescribed during the 90-day period before your coverage began. Benefits for any disability caused by or resulting from a pre-existing condition will be payable only if the disability begins after you have worked at least one full day after having been covered for 12 consecutive months.



Paying Taxes on Your Benefits

Any benefits you receive due to coverage under the Basic LTD Plan (which is entirely employer paid) will be subject to federal taxes.

If you have Optional LTD coverage, a portion of the benefits you receive will not be subject to federal taxes because you pay for the additional 15% of coverage on an After-Tax basis. Whether your benefits at either the 50% or 65% level are subject to state income tax will depend on the state in which you reside.

Recurring Disabilities and the Elimination Period Note for Robert Bosch Tool Corporation employees: If you filed a claim prior to the changes made on April 1, 2014, you will not be affected by certain provisions (which only apply to claims after April 1, 2014).

During the Elimination Period

If, during the 180-day elimination period, you return to work for a period of 180 days or less, and become disabled again due to the same or related sickness or accidental injury, the elimination period will resume as if the disability had been continuous.

If, during the 180-day elimination period, you return to work for a period of more than 180 days, and become disabled again due to the same or related sickness or accidental injury, it will be treated as a new disability and will be subject to a new 180-day elimination period before benefits are paid.

After the Elimination Period

If, after the 180-day elimination period, you return to work for a period of 180 days or less and become disabled again due to the same or related sickness or accidental injury, your disability will resume as if the disability had been continuous. The Plan Administrator will consider such disability to be part of the original disability and will use the same earnings and apply the same provisions and conditions that were used in the original disability.

If, after the 180-day elimination period, you return to work for a period of more than 180 days and become disabled again due to the same or related sickness or accidental injury, it will be treated as a new disability and will be subject to a new 180-day elimination period before benefits are paid.

Rehabilitation Incentives Our goal is to focus on the associate’s abilities, instead of disabilities. Therefore, if you participate in a Rehabilitation Incentive Program, your monthly benefit will be increased by 10%.

Work Incentive

If you return to work either full-time or part-time, while still receiving a disability benefit, your monthly benefit will be increased by your Rehabilitation Incentive Program benefit.



Your monthly benefit, as adjusted by the Rehabilitation Incentive Program, will not be reduced by the amount you earn from working, except to the extent that such adjusted monthly benefit plus the amount you earn from working and the income you receive from other income exceeds 100% of your pre-disability earnings.

After the first 24 months following your 180-day elimination period, your monthly benefit will be reduced by 50% of the amount you earn while disabled.

Return to Work Services

This program aims to identify the necessary training and therapy that can help you return to work. When working with Rehabilitation Vendor Specialists, they continue to collaborate with you and your doctor to develop an appropriate return-to-work plan. In many cases, this means helping you to become functional to return to your former occupation or may lead to a new occupation. The services include vocational analyses, retraining programs, job modifications/accommodations, job seeking skills and job placement assistance.

Family Care Incentive

If you work or participate in a Rehabilitation Incentive Program while you are disabled, you may be reimbursed for monthly expenses up to $400. This monthly allowance includes expenses you incur for each family member to provide care for you or your spouse’s/domestic partner’s child or family member. The following conditions apply:

Care for a child:

The child must be living with you as part of your household, dependent on you for support and under age 13.

Child care must be provided by a licensed child care provider or other care provider who may not be a member of your immediate family or living in your residence.

Care for a family member:

The family member must be living with you as part of your household, chiefly dependent on you for support and incapable of independent living regardless of age, due to mental or physical handicap as defined by applicable law.

Care for your family members may not be provided by a member of your immediate family.

Moving Expense Incentive

If you participate in a Rehabilitation Program while you are disabled, the Plan may reimburse you for expenses you incur in order to move to a new residence recommended as part of such Rehabilitation Program. Such expense must be approved by MetLife in advance.

The Plan will not reimburse you for moving expenses if they were provided by a member of your immediate family or someone living in your residence.



Date Benefit Payments End Benefit payments will stop:

when you have reached the maximum benefit period (see the “Maximum Benefit Period” table),

on the date you are no longer disabled or meet the definition of disability as defined by the LTD Insurance Benefit Program,

when benefit ends under Limited Disability Benefits (e.g., 24 month musculoskeletal, mental or nervous disorders, drug and alcohol limitations),

the date you fail to have a medical exam requested by the LTD Insurance Benefit Program,

the date you fail to provide required proof of continuing disability,

if you are able to work in your regular occupation or any occupation for which you are reasonably qualified, on a part- or full-time basis, but choose not to, or

on the date you die.

Maximum Benefit Period If you become disabled, benefits are payable until the earliest of your recovery, your death or the end of your maximum benefit period, as listed below.

Age When Disability Begins Maximum Benefit Period

Under 60 To age 65

60 – 69 Earlier of five years or attainment of age 70

69 or older 12 months The Maximum Benefit Period is also subject to the Limited Disability Benefits section.

Limited Disability Benefits

If your disability, as determined by the LTD insurance carrier, is one of the following, benefits will be paid for a maximum of 24 months.

mental or nervous disorders or disease unless due to schizophrenia, dementia, or organic brain disease,

neuromusculoskeletal and soft tissue disorder unless there is objective medical evidence of:

seropositive arthritis,

spinal tumors, malignancy, or vascular malformations,

radiculopathies,

myelopathies,

traumatic spinal cord necrosis, or

musculopathies,

chronic fatigue syndrome and related conditions, or

alcohol, drug or substance abuse or dependency.



When Benefits Are Not Paid You will not receive LTD benefits if your disability is caused by or results from:

a pre-existing condition in the 90 days before your insurance or any increase in the amount of insurance takes effect, unless you have been actively at work for one full day following the end of 12 consecutive months from your effective date of coverage,

war or any act of war (declared or undeclared), or insurrection, rebellion or terrorist act,

intentionally self-inflicted injuries while sane or insane,

active participation in a riot,

attempted suicide, or

an injury sustained while committing or attempting to commit a felony.

Survivor Benefits If you have been disabled for 180 days or more and die while receiving (or are entitled to receive) LTD benefits, a benefit equal to three times your net monthly benefit will be paid in a lump sum to your beneficiary. The beneficiary you have designated for your life insurance coverage will receive the LTD survivor benefit.

Coordination with Other Benefits Your monthly LTD benefit will be reduced by any payments you or your dependents receive (based on your work or earnings) from the following sources:

disability income from any group insurance plan,

any governmental retirement system, except benefits payable under a federal government employee pension benefit,

disability or retirement benefits under the United States Social Security Act (see “Social Security Benefits” on page 144), the Canadian pension plans or other similar laws,

compulsory benefit laws, including Worker’s Compensation and Occupational Disease,

wages or other compensation you receive from the Company; however, if you return to work on a part-time basis for purposes of rehabilitation, the compensation you receive may be excluded from the offset (for more information on this provision, contact Bosch HR Service at 855-922-5547 to review the Certificate of Insurance),

no-fault auto disability payments,

commissions or money the Company is entitled to receive from you, including vested renewal commissions but excluding commissions or money that you earned prior to becoming disabled that are paid after the disability has begun,

disability or retirement benefits that you are eligible to receive under a group retirement plan, including the Bosch Pension Plan, and

any payments or benefits received from the following sources:



Railroad Retirement Act,

laws providing for maritime maintenance and cure,

any sick pay, vacation pay or other salary continuation that the Company pays to you,

unemployment insurance law or program, and

recovery amounts that you receive for loss of income as a result of claims against a third party by judgment, settlement or otherwise, including future earnings.

Your monthly LTD benefit will not be reduced by the following sources:

distributions from a 401(k), profit sharing or thrift plan, including the Bosch Savings Incentive Plan,

individual disability policies or franchise policies,

payments that reduce the face value of any life insurance policies,

accidental death and dismemberment (AD&D) benefits,

veteran’s disability payment or government/military pension benefits,

early retirement benefits that have not been voluntarily taken by you,

reasonable attorney fees included in any award or settlement. If the attorney fess are incurred because of your successful pursuit of Social Security disability benefits, such fees are limited to hose approved by the Social Security Administration,

group credit insurance,

mortgage disability insurance benefits, and

retirement benefits for which you pay.

Social Security Benefits In addition to the income you receive from the LTD Insurance Benefit Program, you may also be entitled to receive Social Security disability benefits. Keep in mind that these benefits are not automatic — you must apply for them after five months of total disability, provided your injury or illness meets the definition of total disability under the Social Security Act.

If you are eligible for Social Security disability benefits, the Claims Administrator reserves the right to adjust your LTD benefit based on an estimated Social Security benefit (both primary and family), even if you do not apply for it. You must pursue Social Security disability benefits through each level of appeal including the Administrative Law Judge level. The Claims Administrator will not, however, estimate Social Security benefits while your application and appeals are pending if you sign a reimbursement agreement.

If, after the appeals process, it is determined that LTD Insurance Benefit Program benefits have been underpaid, you will receive a lump sum payment to make up the difference between your actual benefits and the amount that should have been paid. If benefits have been overpaid, you will be required to make a lump sum reimbursement to the Plan Administrator.

Applying for Social Security Benefits

Keep in mind that Social Security disability benefits are not automatic — you must apply for them after five months of total disability, provided your injury or illness meets the definition of total disability under the Social Security Act.



Your spouse/domestic partner and dependent children may also be eligible for Social Security disability benefits during the time you are unable to work.

Social Security Freeze

Once you begin receiving benefits from the LTD Insurance Benefit Program, any cost-of-living increases applied to your Social Security disability benefit will not affect the benefit you receive under this Plan. Instead, your total disability income will increase. For more information, contact the Social Security Administration at 800-772-1213.

How to File Claims Notify your Supervisor and the Claims Administrator immediately if you believe you will need to be off work for an extended period of time as a result of an injury, illness or pregnancy. The summary or certificate prepared by the insurance carrier for the LTD Insurance Benefit Program has additional claims procedures. Refer to the summary and certification provided by the insurance carrier for additional information.

The LTD insurance carrier will correspond directly with you and your physician(s) regarding your transition from STD to LTD benefits.

Note: Though there is a 180-day elimination period before LTD benefits can begin, in order for you to receive timely payments, your disability claim must be approved by the insurance company before the elimination period ends. In general, the approval process can take up to 45 days. Therefore, notification should be provided to the claims administrator no later than 90 – 120 days after becoming disabled.

Deadline for Submitting Claims

The claims administrator must receive your completed claim and proof of disability no later than 90 days after your 180-day elimination period ends (e.g., if your elimination period ends on July 1, your completed claim and proof of disability must be received by September 29 of the same year). If you are unable to provide your claim and proof of disability within this 90-day timeframe, you must notify the claims administrator of the claim within the 90-day period and provide the proof no later than one year after your 180-day elimination period ends.

Right of the Plan to Obtain Information

The LTD Insurance Benefit Program may provide or obtain any information needed for proper administration of the LTD Insurance Benefit Program. You may also need to provide additional information, if requested, in order to receive payments.

Overpayment

The Plan may recover payments that exceed Plan provisions for benefits paid. If an overpayment is made, the Plan will request that the money be returned. If the excess is not returned voluntarily, the Plan reserves the right to bring a legal action for the excess or to offset other benefits, to the extent permitted by law.

Keep in Mind

LTD benefits will not begin automatically at the end of the elimination period. Before any payments start, the claims administrator must approve your claim for disability. It can take up to 45 days to complete this process. In some cases, the claims administrator may request up to two additional extensions of 30 days each to complete the approval process.



If Your Claim Is Denied For information about what to do if your claim is denied, refer to the LTD Insurance Benefit Program summary or certificate prepared by the LTD insurance carrier. The requirements found in the summaries and certificates will control.

In general, if your claim for a benefit is denied in whole or in part, you will be notified by the insurance company within 45 days of the date your claim was received. It will include:





In some cases, the insurance company may need additional time to process your claim. The period of time needed to process the claim may be extended twice, each time by up to 30 days. You will be notified of the first extension before the end of the original 45-day period, and of the second extension, if necessary, before the end of the first 30-day extension. Each notice will explain:

the reasons for the delay,

any unresolved issues, and


If additional information is needed to process your claim, you will be given at least 45 days to furnish that information.

If the insurance company denies your claim, you have 45 days from the date you receive the written statement to appeal (e.g., if you received the written statement on July 1, you have until December 28 of the same year to appeal). An appeal is a review by the Claims Administrator or its representative. All appeals must be in writing and may include a statement of the reason you believe your claim should not have been denied. You also have the right to receive, on written request and without charge, information relevant to your claim as defined by the Department of Labor regulations.

The Claims Administrator will independently review the insurance company’s denial of your claim. If the reason that the claim was denied involved a medical determination, such as a determination that you are not disabled, the Claims Administrator will consult with an independent healthcare professional with appropriate training and experience, who will not be the same healthcare professional originally consulted by the insurance company.

Keep in Mind

If you become disabled while you are on a covered leave of absence, your benefit will be determined by using your monthly earnings in effect just prior to the date your leave began.



Appealing a Claim

The Claims Administrator has 45 days from the date it receives your appeal to respond. If your appeal requires special study, it may take an additional 45 days to reach a decision. In this situation, you will be notified of the reason for the delay by the end of the original 45-day period. Except as provided in the following paragraph, the decisions of the Claims Administrator are final and binding.

If your claim is denied upon appeal, you may have the right to file a lawsuit under the Employee Retirement Income Security Act (ERISA) for your benefit. However, you must file such a suit no more than 90 days after you are notified of the result of the appeal and you may not file such a suit unless you have first complied with the claims and appeals procedures in a timely manner. See “Your Right to Benefits” in the Administrative Information section for more information.



MetLife Disability P.O. Box 14590 Lexington, KY 40511-4590

Note

Please provide the Claim Number on all mail and fax documents sent to MetLife Disability.


Administrative Information The Administrative Information section provides an overview of information regarding the impact of a leave of absence, general Plan information, and your legal rights under the Employee Retirement Income Security Act of 1974 (ERISA).

Leaves of Absence This section provides information describing how the benefits you are receiving under the Plan’s Benefit Programs (other than the Healthcare FSA and Dependent Day Care FSA) may be impacted during a leave of absence. See the Flexible Spending Account Benefit Programs section in this SPD for a description of how Healthcare FSA and Dependent Day Care FSA benefits are handled during leaves of absence.

FMLA Leave of Absence

Under the Family and Medical Leave Act of 1993, as amended (FMLA), you may qualify for up to a 12-week leave of absence (or a 26-week leave of absence in the case of being a caregiver for a service member). With Company approval, you may take an FMLA leave of absence and remain a participant in the Plan during this time. You will remain eligible for the same Benefit Program benefits that you were receiving immediately before the start of your FMLA leave (other than the Business Travel Accident Insurance Benefit Program). The Company will continue to pay its share of the cost of your coverage.

If you are on a paid leave of absence, the Company will continue to make payroll deductions to collect your share of any benefit costs through those deductions.

If you are on an unpaid leave of absence, you will receive a direct bill invoice through the mail from Ceridian. You must make the payment within 60 days of the due date or coverage will end.

Robert Bosch Tool Corporation Associates

If you are on an unpaid leave of absence, your healthcare payroll deductions will be taken in arrears from your first paycheck once you return to work.

If you do not wish to receive some or all of the coverage during your FMLA leave that you were receiving just prior to your leave, you must inform the Bosch Benefits Center before the start of your leave of absence. Your participation will end on the date your FMLA leave begins. When you return from your FMLA leave on a timely basis, you will be immediately eligible under the Benefit Programs.

You should refer to the Company’s Leave of Absence Policy and consult with your local Human Resources Representative before taking any leave.

Administrative Information


Medical or Personal Leave of Absence

If you take a non-FMLA medical leave of absence due to personal illness, accident or pregnancy/maternity, or if you take a personal leave of absence, you may continue to participate in the Benefit Programs you were enrolled in immediately before the start of your non-FMLA leave (other than the Business Travel Accident Insurance Benefit Program). The Company will continue to pay its share of the cost of your coverage.

If you are on a paid leave of absence the Company will continue to make payroll deductions to collect your share of any benefit costs through those deductions.

If you are on an unpaid leave of absence, you will receive a direct bill invoice through the mail from Ceridian. You must make the payment within 60 days of the due date or coverage will end.

Robert Bosch Tool Corporation Associates

If you are on an unpaid leave of absence, your healthcare payroll deductions will be taken in arrears from your first paycheck once you return to work.

You should refer to the Company’s Leave of Absence Policy and consult with your local Human Resources Representative before taking any leave.

Military Leave of Absence

If you take a military leave in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended (USERRA), you may elect to continue participation for yourself and your covered dependents in the Healthcare Benefit Programs you were enrolled in immediately before the start of your military leave. The Company will continue to pay its share of the cost of your coverage for the first three months of your military leave. Your share of any benefit costs for coverage during this time will be deducted from your differential pay. After this initial three-month period, you may elect to continue coverage at no cost under the Healthcare Benefit Programs, through COBRA, for the remaining 21 months of your military leave.

If you do not wish to receive some or all of the Healthcare Benefit Program coverage during your military leave that you were receiving just prior to your leave, you must inform the Bosch Benefits Center before the start of your leave. Your participation will end on the date your leave begins.

If your participation in any of the Plan’s Benefit Programs ends during your military leave, you may resume participation in the Benefit Programs on the date of your timely return to employment at the end of your qualified military leave.



Plan Information Plan Administration

Robert Bosch LLC is the Plan Administrator and has sole responsibility for the administration of the Plan. The Plan Administrator has full discretionary authority to: interpret the Plan; determine eligibility for and the amount of benefits; determine the status and rights of participants, beneficiaries and other persons; make rulings; make regulations and prescribe procedures; gather needed information; prescribe forms (including the Enrollment Form); to exercise all of the power and authority contemplated by ERISA and the Code with respect to the Plan; employ or appoint persons to help or advise in any administrative functions; to appoint trustees; and generally do anything needed to operate, manage and administer the Plan. The Plan Administrator has the necessary discretionary authority and control over the Plan to require deferential judicial review.

The Plan has other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary responsibility among the Plan’s fiduciaries and may delegate responsibilities to others. Any allocation or delegation must be done in writing and kept with the records of the Plan. For the insured benefits, the Plan Administrator has delegated its fiduciary duties with respect to Claims processing and benefit determinations to the insurance companies. For the Self-funded Benefit Programs, the Plan Administrator has delegated its fiduciary duties with respect to initial and in some cases, final Claims determinations to the Claims Administrator. These delegates have the full extent of the Plan Administrator’s authority and duties with respect to those responsibilities delegated to them.

Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent requested by ERISA, no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of another Plan fiduciary, to the extent provided in ERISA Section 405(a).

Type of Plan Administration

Some of the benefits provided under the Plan are insured by various insurance companies and some are Self-funded and administered by the Claims Administrator. For some of the Self-funded Benefit Programs, the Company has designated third parties to provide administration services for these Benefit Programs under an administrative services contract. These third parties merely process Claims and make initial and in some cases, final Claims determinations. They do not insure that any of your benefits will be paid.

OTHER IMPORTANT INFORMATION ABOUT THIS PLAN

Plan Name

Bosch Choice Welfare Benefit Plan

Plan Number

501

Important Note

Although mentioned in this SPD as part of the disability benefits available to eligible associates, short term disability (“STD”) coverage is not a part of the Bosch Choice Welfare Benefit Plan; nor is it covered by the Employee Retirement Income Security Act of 1974 (ERISA). Instead, It is provided as a payroll practice out of the general assets of the Company.



Plan Sponsor and Agent for Service of Legal Process

Robert Bosch LLC 2800 South 25th Avenue Broadview, IL 60155 708-865-5200

Plan Administrator

Robert Bosch LLC 2800 South 25th Avenue Broadview, IL 60155 708-865-5200

Employer Identification Number

36-2903176

Plan Year

April 1 to March 31

Type of Plan

The Plan is a welfare benefits plan offering the following benefits: medical (including prescription drug), dental, vision, EAP, wellness, life, accidental death and dismemberment, business travel accident benefits and long term disability benefits; a cafeteria plan offering pre-tax contributions for medical, dental, and vision coverage; after-tax contributions for supplemental life, accidental death and dismemberment, and business travel accident insurance as well as for optional long term disability benefits; and a health care flexible spending account and a dependent care flexible spending account.

Only the welfare benefit programs that are qualified benefits (as defined by the Code) are part of the cafeteria plan. Spousal and dependent life insurance benefits are offered as welfare benefits under the Plan, however, they are not qualified benefits and therefore not part of the cafeteria plan.

Plan Funding

The Company pays part of the cost for some Benefit Programs and you are responsible (through your Benefit Contributions) for paying your share of the cost of these Benefit Programs for yourself and your family. The Company pays the entire cost for some Benefit Programs, while you pay the full cost of coverage for other Benefit Programs.

The Medical and Dental Benefit Programs are self-funded by the Company, which means the Company pays the Benefit Programs’ benefits from its general assets and the benefits are not provided through insurance.

The HMO, Vision, EAP, Life Insurance, AD&D Insurance, Business Travel Accident Insurance, and LTD Benefit Programs are insured. That means the Company’s contributions and your contributions (if any) are used to pay insurance premiums to insurance companies, and the insurance companies pay the benefits under insurance policies or contracts.



Only associates who elect to participate in the FSAs make contributions to the Flexible Spending Account Benefit Programs, with reimbursements administered by a third party designated by the Company.

You are also responsible for Coinsurance, Copayments and Deductibles that may be required under the terms of the Benefit Programs. The “Coinsurance” is your cost sharing amount of expenses after you have met the Deductible. The “Copayment” is the flat dollar amount of health care expenses you incur that you are responsible for paying. The “Deductible” is the amount you must pay each year for healthcare expenses before any benefits are payable under the Plan. See the Booklets prepared by the Claims Administrators for more information relating to the Coinsurance, Copayments and the Deductibles.

The benefits provided under the Plan will be paid, to the extent permitted under ERISA and the Code, from the general assets of the Company, employee contributions, and insurance contracts. Nothing in this Plan will be construed to require the Company to maintain any fund for its own contributions or segregate any amount which it is obligated to contribute for the benefit of any participant, and no participant or other person will have any Claim against, right to, or security or other interest in, any fund, account or asset of the Company from which any payment under the Plan may be made.

Amendment or Termination of the Plan

Robert Bosch LLC reserves the right to amend, modify, suspend or terminate this Plan or any of the Benefit Programs provided under the Plan at any time in any manner, in its sole discretion, by written action of the Retirement and Benefits Plans Committee. Any amendment or modification adopted will be in writing and executed by the Committee. Any amendment may be made effective retroactively to the extent not prohibited by ERISA and the Code. Coverage upon Plan termination will be governed by the terms of each Benefit Program.

Limitation on Rights

The Plan does not constitute a contract between you and the Company, nor is it to be consideration or inducement for your employment. Nothing contained in the Plan gives you the right to be retained in the service of the Company or to interfere with the right of the Company to discharge you at any time, with or without cause, regardless of the effect that the discharge will have upon you as a participant in the Plan.

Enrollment Information

For purposes of the HIPAA Privacy and Security Rules, determining the employee’s eligibility for the Plan or any Benefit Program offered under the Plan or enrolling employees in the Plan is an enrollment function performed by the Company. Employee and dependent eligibility and enrollment information is the Company’s information and not the Plan’s information while it is held and transmitted by the Company.



Overpayments

An “Overpayment” occurs if the Plan pays an amount not payable under the Plan, if the Plan pays an expense or benefit more than once, or if an expense or benefit is paid by both the Plan and a third party. An expense or benefit is considered paid if it is paid to you or to someone else (for example, to a health care provider) on your behalf.

If an Overpayment is made by the Plan, the Plan has the right to recover the Overpayment. If that Overpayment is made to a health care provider, the Plan may request a refund of the Overpayment from either you or the provider. If the refund is not received from either you or the provider, the Overpayment may be deducted from future Plan benefits available to you or your covered dependents or from your wages, but the amounts withheld may not reduce your pay below the applicable state minimum wage law to the extent permitted by law.

Acceptance and Cooperation

If you accept benefits under the Plan, you are considered to have accepted its terms, and you agree to perform any act and to execute any documents which may be necessary or desirable to carry out the terms of the Plan.

Non-assignability of Rights

No interest under the Plan is subject to assignment or alienation, whether voluntary or involuntary. Any attempt to assign or alienate any interest under the Plan will be void.

Construction

Words used in the masculine apply to the feminine where applicable. Wherever the context of this SPD dictates, the plural should be read as the singular, and the singular as the plural. Where any time period is given in days, the reference is to calendar days, unless otherwise specified.

Errors

An error cannot give a benefit to you if you are not actually entitled to the benefit.

Fraud and Abuse

Knowingly and willfully engaging in fraudulent behavior, including executing, or attempting to execute, a scheme to defraud the Plan, or to obtain by means of false or fraudulent pretenses, any of the money or property owned by or under the control of the Plan, by your or your covered dependent, may result in immediate termination from coverage under the Plan. Additionally, if you or your covered dependents knowingly and willfully falsify, conceal, or cover up any material fact, or make any materially false or fictitious, or fraudulent statements in connection with enrollment in the Plan, or the receipt of health care benefits under the Plan, coverage under the Plan may be terminated. The Plan Administrator has the right to seek full recovery of any losses from, and to pursue criminal and civil prosecution against any individuals committing fraudulent behavior.



Your Right to Benefits Statement of ERISA Rights

The Employee Retirement Income Security Act of 1974 (ERISA) spells out certain rights and duties for benefit plans. ERISA is a federal law that sets standards and defines procedures for employee benefit plans. As a participant in the Plan, you are entitled to certain rights and protections under ERISA. ERISA provides that all Plan participants shall be entitled to:

Receive Information about Your Plan and Benefits

Examine, without charge, at the Plan Administrator’s office and at other specified locations such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the Plan Administrator copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and an updated summary plan description. The Plan Administrator may make a reasonable charge for the copies.

Receive a summary of the Plan’s summary annual report. The Plan Administrator is required by law to furnish each participant with a copy of this summary financial report.

Continue Group Health Plan Coverage

Continue health care coverage for yourself or your Covered Dependents if there is a loss of coverage under the Plan as a result of a Qualifying Event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA Continuation Coverage rights.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the persons who are responsible for the operation of the Plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and the other Plan participants and beneficiaries. No one, including your Company, your union, or any other person, may fire you or otherwise discriminate against you to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial, all within certain time schedules.



Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive them in 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator.

If you have a Claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan’s decision or lack of a decision concerning a medical child support order, you may file suit in federal court.

If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your Claim is frivolous.

Assistance with Your Questions

If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact:

the nearest Area Office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory, or

the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.

You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration at 1-800-998-7542.

Non-assignment of Benefits Generally, benefits under the Plan may not be sold, transferred, pledged or assigned except as permitted by law. In certain situations, however, court orders may require benefits to be provided for a certain individual or individuals, typically an employee’s family member.

Affiliates and Subsidiaries Participating in the Plan United States affiliates and subsidiaries of Robert Bosch LLC may adopt the Plan, subject to Robert Bosch LLC’s consent. Any affiliate or subsidiary that participates in the Plan cannot amend or terminate the Plan itself, but it may, acting through its Board of Directors or delegate, and subject to the consent of Robert Bosch LLC, terminate its participation in the Plan or any of the Plan’s Benefit Programs.



The Plan benefits all U.S. non-union active eligible associates with the exception of employees of the following affiliates and subsidiaries:

Robert Bosch Battery Systems, LLC

BSH Home Appliances

sia, Abrasives Holding Inc., USA

Robert Bosch Steering

Climatec

Osgood

Associates on assignment through employment contracts and third party nationals

Associates on assignment in foreign countries (Expatriates)

Any other affiliate or subsidiary that has not adopted the Plan


Contact Information For case management, advance approval, forms, claims, questions or provider directories, refer to the contact information below.

Benefit Program Claims Administrator and Toll-free Phone Number

Website

Medical — CDHP 80 Option and CDHP 90 Option

(including MSA Program/Advance Approval)

CDHP 80 Group Number: 014862

CDHP 90 Group Number: 014900

BlueCross BlueShield of Illinois

866-540-2130

www.bcbsil.com

Health Savings Account BenefitWallet

877-472-4200

mybenefitwallet.com

Prescription Drug

Group Account Identification: JYCA

Express Scripts

866-962-9794

www.express-scripts.com

Dental

Group Number: 0151240

MetLife Dental

800-942-0854

(800-244-6224)

mybenefits.metlife.com

Vision

Group Number: 12089335

Vision Service Plan (VSP)

800-877-7195

www.vsp.com

Employee Assistance Program

CIGNA Behavioral Health

800-554-6931

www.cignabehavioral.com

Online Employer ID: robertbosch (no space, all lower case)

Flexible Spending Accounts

PayFlex

800-284-4885

www.healthhub.com

Note

There may be periods when these systems are not available due to technical or maintenance requirements. Under no circumstances will the Company or the Bosch Benefits Center be liable for any loss caused by failure to implement associate instructions.

Contact Information


Benefit Program Claims Administrator and Toll-free Phone Number

Website

Life Insurance and AD&D Insurance

Robert Bosch Tool Corporation Associates Group Number: 105270

All Others Group Number: 105267

MetLife

800-858-6506

www.metlife.com

Long Term Disability*

Robert Bosch Tool Corporation Associates Group Number: 104845

All Others Group Number: 104842

MetLife

800-858-6506

www.metlife.com

Bosch Benefit Center**

Automated Phone System

Inside the U.S. Call toll-free at 800-207-9012

Outside the U.S. Call toll-free at 857-362-5996

Phone Customer Service Representative

Either number listed above

www.ibenefitcenter.com

Qualified Medical Child Support Orders (QMCSOs)

Contact Bosch HR Service at 855-922-5547 or the Bosch Benefits Center at 800-207-9012

* Contact information also applies if you have questions about Short Term Disability and FMLA Leave.

** The Bosch Benefits Center can be accessed by phone or Internet.

Address information for various providers is located under “How to File Claims” in the applicable Benefit Program sections in this SPD.

robert bosch llc - myhealth.mercerhrs.com...robert bosch llc (the company) has established the bosch...

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