In the event of any discrepancy between this Benefits ... Annual Enrollment Guide with...In the event of any discrepancy between this Benefits Guide and the ... Domestic Partner Affidavit,

In the event of any discrepancy between this Benefits Guide and the Summary PlanDescription (also known as the Employee Benefits Handbook), the information in the SummaryPlan Description will prevail.

Table of Contents

Eligibility & Life Events ................................................................................. 1

Medical, Prescription Drug, Dental and Vision Overview .......................................... 7

Medical Plan Chart.................................................................................... 9 Prescription Drug Chart ............................................................................. 12 Dental Plan Chart .................................................................................... 14 Vision Plan Chart ..................................................................................... 16

Wellness Program....................................................................................... 17

Spending & Savings Accounts ......................................................................... 19

Life & Security .......................................................................................... 20

Employee Assistance Program ........................................................................ 21

Retirement Savings Plan ............................................................................... 22

Pension Plans............................................................................................ 22

Retiree Benefits......................................................................................... 23

Financial Planning Services............................................................................ 24

Travel Guide............................................................................................. 25

2015 Benefit Monthly Rates ........................................................................... 26

Ceridian Self-Service User Guide ..................................................................... 28

Benefits Website........................................................................................ 31

Required Disclosures ................................................................................... 32

General Notice of COBRA Continuation Coverage Rights....................................... 32 Notice of Privacy Practices ......................................................................... 35 HIPAA Special Enrollment Rights Notice .......................................................... 38 Women's Health and Cancer Rights Act ........................................................... 39 Newborns' and Mothers' Health Protection Act .................................................. 39 Medicare Part D Disclosure / Notice of Creditable Coverage.................................. 40 Medicaid and the Children's Health Insurance Program (CHIP) ................................ 42

1

Eligibility & Life Events

Benefits Eligibility ChartIn general, this chart reflects the benefits for which you are eligible.

Benefit Plans

Full-Time(Working 20+

hours perweek)

Part-Time,Temporary and

Seasonal(Working lessthan 20 hours

per week)

Part-Time,Temporary and

Seasonal(Working 20+

hours perweek)

Medical Plan Yes No Yes

Wellness Plan Yes No Yes

Dental Plan Yes No Yes

Vision Plan Yes No Yes

Flexible Spending Accounts Yes No Yes

Long-Term Disability Yes No Yes

Long-Term Disability Buy-up Yes No Yes

Basic Life Insurance Yes No Yes

Basic Personal Accident Insurance Yes No Yes

Voluntary Personal AccidentInsurance

Yes No Yes

Group Universal Life Insurance(GUL)

Yes No Yes

Voluntary Personal AccidentInsurance

Yes No Yes

Employee Assistance Plan Yes Yes Yes

Financial Assistance Plan Yes Yes Yes

Retirement Savings Plan Yes Yes Yes

Pension * * *

Retiree Medical * * *

Retiree Dental * * *

*See the Employee Benefits Handbook for details on these plans eligibility requirements. These plans were closed to new entrants effective 1/1/08.

2

Dependent Eligibility

Spouse / Domestic PartnerYour spouse is the person to whom you are legally married under the law of the state in which you were married, even if you reside in a state whose laws do not recognize the validity of your marriage.

Your domestic partner is the person of the same or opposite sex with whom you have entered into a civil union or substantially similar legal relationship (other than a common law marriage) that is legally recognized under state law, or withrespect to whom all of the following requirements have been met:

Both of you are at least 18 years old, oflegal age, and mentally competent to enter into contracts, and have been so for at least six months.

You are each other’s sole domesticpartner, have been so for at least six months, with the intent to remain so indefinitely.

You reside together in the sameprincipal residence, have done so for at least six months prior to the date of the signed Affidavit, and intend to do so indefinitely.

You are emotionally committed to oneanother and share joint responsibilities for your common welfare and financial obligations, and have done so for at least six months.

Neither of you are legally married northe domestic partner of anyone else, nor have you been married or the domestic partner of anyone else within the last six months.

You are not related by blood to anextent that would prohibit marriage in the state in which you reside.

In order for your domestic partner to enroll in the Plan, you must either submit the certification or other documentation of your civil union or other similar legal relationship, or a signed, notarizedDomestic Partner Affidavit. You can

download the Affidavit from the Benefitswebsite at: www.ineosbenefits.com.If you wish to drop your Domestic Partnerfrom coverage, you and your Domestic Partner will need to complete another Affidavit requesting the change.

Child(ren)Your child includes:

Your natural child, stepchild, legallyadopted child (including a child placed for adoption), foster child, or child for whom you have legal guardianship, until the end of the month in which the child attains age 26;

Your spouse's or domestic partner'snatural child, stepchild, or legally adopted child (including a child placed for adoption), if the child is a tax dependent of the spouse or domestic partner;

A child who is covered by the Plan andis permanently and totally disabled at the time he or she turns 26. Such child can continue coverage if proof of disability is provided to the applicable benefits administrator before age 26.

Supporting Documentation RequirementsDocumentation supporting yourdependent's eligibility is required within 30 days of enrollment. Supporting documentation may include a marriage certificate, certificate of civil union, Domestic Partner Affidavit, birth certificate, legal guardianship papers, foster child documentation, etc. Please review the Life Events Chart for information regarding what supporting documentation is required when making changes to your coverage or to the coverage of your dependents.

MisrepresentationIf you misrepresent a dependent’seligibility to enroll in the INEOS plans or do not timely notify the Company when a dependent is no longer eligible under the INEOS plans, this will be considered fraud

3

and may result in disciplinary action up to and including termination of employment.

Additional Domestic Partner InformationIn general, domestic partner coverage is a taxable benefit under IRS Regulations. If your domestic partner qualifies as a dependent for income tax purposes, the domestic partner coverage is not taxable to the employee. In order to qualify as a dependent for income tax purposes the Internal Revenue Code requires that all of the following must be true for the applicable tax year:

The domestic partner’s principal placeof residence is the home of the employee and has been the full calendar year;

The domestic partner is a member ofthe employee’s household and has been the full calendar year;

The employee financially supports thedomestic partner to the degree required by the Internal Revenue Code;

At no time during the taxable year doesthe relationship between the employee and the domestic partner violate local law;

The domestic partner must not be a“qualifying child” of the employee or any other taxpayer; and

The domestic partner must be a U.S.citizen, a U.S. national, or a resident of the U.S., Canada, or Mexico.

You should consult with a tax advisor for assistance in determining whether or not your domestic partner qualifies as your dependent for income tax purposes and any questions you may have regarding your state specific taxation.

Defense of Marriage Act (DOMA)The Supreme Court has ruled the definition of marriage under Section 3 of the Defense of Marriage Act is unconstitutional. If youwere married in a State where same sex marriage is legal, you should enroll your partner as a “Spouse” and submit thecertificate of marriage to the Benefits Department. You should not enroll your spouse as a Domestic Partner.

4

Life Events Guide

When you have a qualifying life event outside of the annual Open Enrollment period and wish to make changes to your benefit plans, you may do so, however supporting documentation is required as proof of the event. The following charts show what documentation is required for the different life events and where the information will be housed (in your HR file or the Benefits Department).

All supporting documentation must be returned to your local HR Department within 30 days of the event date in orderfor your changes to be effective. Whenadding coverage, if HR is not notified of the Life Event and provided the supporting documentation within 30 days, you will have to wait until the next Open Enrollment to make your changes.

In the event one of your dependents is no longer eligible, notice must be given as soon as possible on or before the event date. Supporting documentation must be provided to HR prior to your request being processed. All changes will be processed as soon as possible upon receipt of notification and supporting documentation.

Rules for Changing CoverageMedical, Dental and Vision - You may adddependents to your coverage as well as yourself if you are currently not enrolled. You will not be able to change the plan previously elected, only the tier or coverage level. For instance, if you are enrolled in the 80% PPO Plan, you cannot change your election to the 90% PPO Plan due to the life event, only change the tier and add/delete dependents. You can initiate a coverage change through Ceridian Self Service as well as update dependent information.

Flexible Spending Accounts (including both health care and dependent care accounts) – You may increase your election when you add dependents to your existing coverage or enroll for the first time. You

are able to decrease your election when you remove dependents from your existing coverage. The same rules apply for traditional and limited purpose FSA accounts.

Health Savings Accounts – You may change your election at any time during the year even if you do not experience a life event. In order to enroll in a Health Savings Account you must be enrolled in the Account Based High Deductible medical plan. See the Health Savings Account section for details on how to enroll and make changes to your election.

Group Universal Life - You can enroll in or change your coverage amount at any time without a qualifying life event. Evidence of Insurability (EOI) may be required if you are increasing the coverage for yourself, your spouse or domestic partner.

Voluntary Personal Accident - You can enroll in or change your coverage amount at any time without a qualifying life event. Evidence of Insurability (EOI) is not required for this benefit.

Long Term Disability Buy-up – You can enroll or cancel your coverage amount at any time without a qualifying life event. Evidence of Insurability (EOI) may be required to secure this benefit.

Retirement Savings Plan – You can make changes to your contribution election and/or beneficiary information at any time.

Pension Plans – You can change your beneficiary information at any time.

How to Change your Coverage and/or Beneficiary DesignationsMedical, Dental, Vision and FlexibleSpending Accounts - You can initiate a coverage change through Ceridian Self Service by selecting and saving the relevant life event – birth or adoption of child, change of marital status, spouse eligibility, etc. HR will receive notification of your request and will approve it upon

5

receipt of the supporting documentation. Once the request is approved, you will have the option in Self Service to update your benefits. Beneficiary information is not housed in Self Service.

Health Savings Accounts – You can change your election through Ceridian Self Service at any time. If enrolling for the first time, see the HSA section for furtherinstructions.

Voluntary Benefits – You can initiate a coverage change directly with the Customer Service Representatives at CIGNA or online via the CIGNA Trusted Advisor website. Beneficiary information is not housed in Ceridian Self Service. Beneficiary changes are handled

electronically through CIGNA’s website. While reviewing your beneficiary information for voluntary benefits, be sure to also check your company provided Basic Life Insurance and Basic Personal Accident insurance beneficiary designations.

Retirement Savings Plan - You can review and/or update not only your contribution elections, but also your beneficiary information online at the T. Rowe Price website.

Pension Plans – You can review and/or update your beneficiary information by completing a Beneficiary Designation Form. The form can be found online via Towers Watson’s website.

Life Events –Lose Coverage

Supporting Documentation RequiredDocuments Housed

By:

Marriage(Enrolling in your spouse’s coverage)

Marriage Certificate or other documentation supporting the legal relationship

Human Resources

Divorce Divorce Decree(The full legal document is required)

BenefitsDepartment

Legal Separation Court documents Human Resources

End of a domestic partnership

Domestic Partner Affidavit Termination Form

Benefits Department

Dependent Child’s StatusChange(No longer an eligible dependent)

Copy of Birth Certificate(if not already on file)

Human Resources

Death of a Dependent Copy of the Death Certificate Human Resources

Loss of other coverage(Spouse, Domestic Partner and/or child)

HIPAA Certificate of Creditable Coverage reflecting the end date of coverage or proof of loss from an employer or government agency

Human Resources

Enrollment in the BP Retiree Medical Plan

BP Enrollment Confirmation Human Resources

6

Life Event –Gain Coverage

Supporting Documentation RequiredDocuments Housed

By:

Marriage(Enrolling spouse on your coverage)

Marriage Certificate or other documentation supporting the legal relationship

Human Resources

New Domestic Partnership

Domestic Partner Affidavit FormBenefits Department

Birth of a childBirth Certificate or Certificate from Hospital

Human Resources

Adoption Final court approved adoption papersBenefitsDepartment

Legal guardianship or custody of a child

Final court order or Medical Support Order from the State of Residence

Benefits Department

Employment related changes of a Spouse or Domestic Partner

HIPAA Certificate of Credible Coverage from a prior insurance company

Human Resources

Spouse or Domestic Partner’s annual enrollment

Copy of Open Enrollment information from the employer

Human Resources

Gain of other coverage(Spouse, Domestic Partner and/or child)

Confirmation of coverage with effective date from an employer or government agency

Human Resources

Dependent Child’s Status Change - Disability

Medical Plan - BCBS Disabled Dependent Form (provide the original to BCBS and a copy to HR)

Dental and Vision Plans - Physician’s letter or other documentation certifying the disability (provide the original to the vendor and a copy to HR)

Human Resources

7

Medical, Prescription Drug, Dental and Vision Overview

Medical PlansThe INEOS medical plans, administered byBlue Cross Blue Shield (BCBS) of Illinois, offer the advantage of a comprehensive, nationwide network of providers. By using network providers, you and the Company share in the savings of negotiated fees with hospitals, highly qualified doctors and other healthcare providers. Our plans provide the financial security of annual out-of-pocket limits coupled with unlimited lifetime benefits per person to protect you and your family.

Choose the plan that best meets your needs! You have the choice of three different plans: an 80% PPO Plan, 90% PPO Plan, and 85% Account Based Health Plan (ABHP). The 80% and 90% PPO Plans are traditional coinsurance plans whereas the 85% ABHP is a high deductible plan. The benefits covered and networks available under the plans are the same. See the Employee Benefits Handbook for specific information regarding coverage.

Along with the medical plans you have two tools to help you be a good health care consumer: the Integrated Provider Finder (IPF) and the Benefits Value Advisor. The Integrated Provider Finder is a web-based tool offered by BCBS that prioritizes service providers by cost, quality and outcomes.Here you can search for providers, procedures and facilities within a certain geographic region and obtain cost information BEFORE you have any services performed. You can access information and locate networkproviders via the internet at www.bcbsil.com.

The Benefits Value Advisor (BVA) is a concierge service which provides you with advisors armed and ready to assist you with navigating the healthcare system and finding quality, cost-effective providers and facilities. They can assist you with making appointments, help you understand your benefits, provide general information about any health condition you may have, assist you

with the pre-certification process, and inform you about available online educational tools.

To reach a BVA, simply call the customer service number on your ID card. Blue Cross Blue Shield’s BVA’s are available from 8:30 am to 6:00 pm CST, Monday through Friday at (888) 979-4516. Pre-certifications should be processed through the Blue Care Connection customer service representatives at (800) 826-8551.

Prescription Drug PlanBlue Cross Blue Shield, a leading name inprescription drug plans nationwide, allows you to access prescription drugs, helpful information and other related services through their Pharmacy Benefits Manager, Prime Therapeutics. A separate enrollment election is not required – when you enroll in coverage under one of the medical plans, you are automatically enrolled in the prescription drug plan.

Customer Service Representatives are available at (800) 423-1973, 24 hours a day, 7 days a week to answer your questions regarding your prescription drugs and/or order processing. To place an order for Specialty Drugs, you should have your doctor contact a customer service representative at (877) 627-MEDS (6337) or, they can fax your prescription to (877) 828-3939. You can access additional information via the internetat www.bcbsil.com.

State Health Exchange NoticeUnder PPACA, employers are required to provide a notice to employees about the state's health insurance exchanges. Youwill find the Notice after the Required Disclosures section of this guide.

Summary of Benefits and CoverageAlso under PPACA, group health plans arerequired to provide a Summary of Benefits and Coverage (SBC) that provides you with a concise document detailing, in plain language, simple and consistent information

8

about health plan benefits and coverage. The SBC will help you better understand the coverage you have and allow you to compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. When making your medical plan election, you should use these SBCs along with the information provided in the Medical section of this Benefits Guide. You will find the SBCs for each of the INEOS medical plans after the Required Disclosures section of this Guide.

Dental PlanThe INEOS dental plan combines the freedom to choose your dentist with the cost-savings advantage of network providers through one of the nation’s premier dental plan providers, Humana Dental. Help in locating network providers in your area is just a phone call away (800) 233-4013 or via the internet atwww.humanadental.com. Customer servicerepresentatives are available from 8:00 am through 6 pm, Monday through Friday regardless of your time zone.

Vision PlanThe INEOS Vision Plan is offered through VSP.With VSP doctors, you will enjoy quality and personalized care. Besides helping you see better, routine eye exams can detect symptoms of serious conditions such as glaucoma, cataracts and diabetes. Eye exams for children may discover problems that can hinder learning and development.

VSP network doctors are in medical offices and shopping centers – close to home and work. Most offer evening and weekend hours and accept walk-ins. New patients are always welcome. Here’s how you get started:

1. Choose a VSP doctor at www.vsp.com orcall (800) 877-7195.

2. Make an appointment and tell the doctoryou are a VSP member.

3. That’s it! No ID cards or filling out claimforms.

Dollar for dollar you get the best value from your VSP benefit when you visit a VSP network doctor. If you decide not to see a VSP doctor, copays still apply. You will also receive a lesser benefit and typically pay more out-of-pocket. At the time of your appointment, you are required to pay the provider in full. To receive reimbursement under the Plan, you will have to submit a claim to VSP. If you decide to see a provider not in the network, we suggest that you call VSP first.

Waiving CoverageIf you choose not to participate in the Medicaland/or Dental benefits offered, you will need to waive your coverage. When doing so, you will receive $100 per month for opting out of Medical and $8.33 per month for opting out of Dental. If you are an employee and a dependent (spouse or child) covered by another INEOS employee, you are exempt from receiving the opt-out credits.

9

Medic

al Pla

n C

hart

80%

PPO

Pla

n90%

PPO

Pla

n85%

ABH

PIn

-Netw

ork

Out-

of-

Netw

ork

In-N

etw

ork

Out-

of-

Netw

ork

In-N

etw

ork

Out-

of-

Netw

ork

Genera

l In

form

ati

on

Deduct

ible

(excl

udes

copays

)

$450/pers

on

$1,3

50/fa

mily

$900/pers

on

$2,7

00/fa

mily

$700/pers

on

$2,1

00/fa

mily

$1,4

00/pers

on

$4,2

00/fa

mily

$1,7

50/pers

on

$5,2

50/fa

mily

Out-

of-

pock

et

maxim

um

$2,0

00/pers

on

$4,0

00/fa

mily

(incl

udes

copays

, co

insu

rance

and

deduct

ible

)

$4,0

00/pers

on

$8,0

00/fa

mily

(incl

udes

copays

, co

insu

rance

and

deduct

ible

)

$2,0

00/pers

on

$4,0

00/fa

mily

(incl

udes

copays

, co

insu

rance

and

deduct

ible

)

$4,0

00/pers

on

$8,0

00/fa

mily

(incl

udes

copays

, co

insu

rance

&

deduct

ible

)

$2,5

00/pers

on

$7,5

00/fa

mily

(incl

udes

deduct

ible

, co

insu

rance

and R

x)

Lif

eti

me

maxim

um

benefi

tN

one

None

None

None

None

For

the

foll

ow

ing

treatm

ents

and

serv

ices,

the

medic

alpla

nopti

ons

pay:

Physi

cian

Off

ice

Vis

its

Pri

mary

care

off

ice v

isit

100% a

fter

$20

copay

60% a

fter

deduct

ible

100%

aft

er

$20

copay

70% a

fter

deduct

ible

85%

aft

er

deduct

ible

65%

aft

er

deduct

ible

Speci

alist

off

ice v

isit

100% a

fter

$30

copay

60% a

fter

deduct

ible

100%

aft

er

$30

copay

70% a

fter

deduct

ible

85% a

fter

deduct

ible

65% a

fter

deduct

ible

Mate

rnit

y se

rvic

es

80% a

fter

deduct

ible

60% a

fter

deduct

ible

90% a

fter

deduct

ible

70% a

fter

deduct

ible

85%

aft

er

deduct

ible

65%

aft

er

deduct

ible

Lab a

nd X

-ray

80% a

fter

deduct

ible

60% a

fter

deduct

ible

90% a

fter

deduct

ible

70% a

fter

deduct

ible

85%

aft

er

deduct

ible

65%

aft

er

deduct

ible

Pre

venta

tive

Care

(Routi

ne

Serv

ices

Only

)

Annual

phys

icals

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100%

65%

Well

-Wom

en

Pre

venta

tive

Care

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100%

65%

Routi

ne G

yneco

logic

al Exam

(1 e

xam

eve

ry c

ale

ndar

year

in a

ddit

ion t

o r

outi

ne p

hysi

cal)

Routi

ne B

reast

Exam

and/or

Mam

mogra

m

FD

A-a

ppro

ved c

ontr

ace

pti

on m

eth

ods

and c

ounse

ling

In

terp

ers

onal and d

om

est

ic v

iole

nce

scr

eenin

g &

co

unse

ling

Sc

reenin

g f

or

gest

ati

onal

dia

bete

s

Bre

ast

feedin

g s

upport

, su

pplies

and c

ounse

ling

C

ounse

ling f

or

sexuall

y tr

ansm

itte

d i

nfe

ctio

ns

H

IV s

creenin

g a

nd c

ounse

ling

H

PV t

est

ing f

or

wom

en a

t le

ast

30 y

ears

old

(D

NA)

Routi

ne

Dig

ital

Rect

al

Exam

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100%

65%

Routi

ne

Pro

state

Speci

fic

Anti

gen (

PSA

) te

sts

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

Routi

ne B

one D

ensi

ty T

est

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

10

80%

PPO

Pla

n90%

PPO

Pla

n85%

ABH

PIn

-Netw

ork

Out-

of-

Netw

ork

In-N

etw

ork

Out-

of-

Netw

ork

In-N

etw

ork

Out-

of-

Netw

ork

Colo

rect

al

Cance

rSc

reenin

g100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

Routi

ne C

olo

nosc

opy

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

Well

-Child C

are

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

Imm

uniz

ati

ons,

HPV

vacc

ine,

Shin

gle

s va

ccin

e100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

Smokin

g C

ess

ati

on

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

Obesi

ty S

creenin

g &

Counse

ling

100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

Routi

ne L

ab P

roce

dure

s100%

60% a

fter

deduct

ible

100%

70% a

fter

deduct

ible

100% 6

5%

Em

erg

ency S

erv

ices

Hosp

ital em

erg

ency

room

(appli

es

to f

aci

lity

charg

es

only

) th

e c

opay

is w

aiv

ed i

fadm

itte

d

80% a

fter

$100

copay

80%

aft

er

$100

copay

90% a

fter

$100

copay

90% a

fter

$100

copay

85% a

fter

deduct

ible

65% a

fter

deduct

ible

Am

bula

nce

80% a

fter

deduct

ible

80% a

fter

deduct

ible

90% a

fter

deduct

ible

90% a

fter

deduct

ible

85%

aft

er

deduct

ible

65%

aft

er

deduct

ible

Outp

ati

ent

Serv

ices

(serv

ices

pro

vid

ed

oth

er

than

ina

physi

cia

n’s

off

ice)

Outp

ati

ent

surg

ery

faci

lity

80% a

fter

deduct

ible

60% a

fter

deduct

ible

90% a

fter

deduct

ible

70% a

fter

deduct

ible

85%

aft

er

deduct

ible

65%

aft

er

deduct

ible

Phys

icia

n/su

rgeon a

nd

rela

ted p

rofe

ssio

nal fe

es

80% a

fter

deduct

ible

60% a

fter

deduct

ible

90% a

fter

deduct

ible

70% a

fter

deduct

ible

85% a

fter

deduct

ible

65% a

fter

deduct

ible

Lab a

nd X

-ray

80% a

fter

deduct

ible

60% a

fter

deduct

ible

90% a

fter

deduct

ible

70% a

fter

deduct

ible

85%

aft

er

deduct

ible

65%

aft

er

deduct

ible

Radia

tion

thera

py/

chem

oth

era

py

80% a

fter

deduct

ible

60% a

fter

deduct

ible

90% a

fter

deduct

ible

70% a

fter

deduct

ible

85%

aft

er

deduct

ible

65%

aft

er

deduct

ible

Inpati

ent

Hosp

ital

Serv

ices

Room

and b

oard

, fa

cility

serv

ices

and s

upplies

(incl

udes

menta

l healt

h/su

bst

ance

abuse

)

80% a

fter

deduct

ible

$100 c

opay

per

adm

issi

on a

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60% a

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deduct

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$100 c

opay

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adm

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90% a

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$100 c

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70% a

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deduct

ible

$100 c

opay p

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adm

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85% a

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65% a

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11

80%

PPO

Pla

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PPO

Pla

n85%

ABH

PIn

-Netw

ork

Out-

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In-N

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Out-

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Out-

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Phys

icia

n h

osp

ital

visi

ts,

surg

ery

and r

ela

ted

pro

fess

ional fe

es

(incl

udes

mate

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y &

new

born

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)

80% a

fter

deduct

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60% a

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deduct

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90% a

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deduct

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70% a

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deduct

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85% a

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deduct

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65% a

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Lab,

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ay

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deduct

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60% a

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90% a

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deduct

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70% a

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deduct

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85% a

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65% a

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Skille

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(120 d

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80% a

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60% a

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deduct

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90% a

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70% a

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85%

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65%

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(120 v

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pla

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80% a

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60% a

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90% a

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70% a

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deduct

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85%

aft

er

deduct

ible

65%

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Hosp

ice c

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80% a

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deduct

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60% a

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deduct

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90% a

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deduct

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70% a

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deduct

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85% a

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deduct

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65% a

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deduct

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Pri

vate

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20 v

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pla

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80% a

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deduct

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60% a

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deduct

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90% a

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deduct

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70% a

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deduct

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85%

aft

er

deduct

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65%

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er

deduct

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Menta

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bst

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abuse

80% a

fter

deduct

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60% a

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deduct

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90% a

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deduct

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70% a

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deduct

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85%

aft

er

deduct

ible

65%

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er

deduct

ible

Oth

er

Covere

dServ

ices

Chir

opra

ctic

care

80% a

fter

deduct

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60% a

fter

deduct

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90% a

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deduct

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70% a

fter

deduct

ible

85%

aft

er

deduct

ible

65%

aft

er

deduct

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Heari

ng

Aid

Exam

,Fit

ting,

and D

evi

ce

$5,0

00 m

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um

per

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on

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ry36

month

s

80% a

fter

deduct

ible

60% a

fter

deduct

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90% a

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deduct

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70% a

fter

deduct

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85% a

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deduct

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65% a

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deduct

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Ort

hoti

cs,

dura

ble

medic

al

equip

ment;

consu

mable

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80% a

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deduct

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60% a

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deduct

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90% a

fter

deduct

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70% a

fter

deduct

ible

85% a

fter

deduct

ible

65% a

fter

deduct

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Pro

stheti

cappliances

&w

igs

80% a

fter

deduct

ible

60% a

fter

deduct

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90% a

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deduct

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70% a

fter

deduct

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85%

aft

er

deduct

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65%

aft

er

deduct

ible

Infe

rtilit

y tr

eatm

ent

80% a

fter

deduct

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60% a

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deduct

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90% a

fter

deduct

ible

70% a

fter

deduct

ible

85% a

fter

deduct

ible

65% a

fter

deduct

ible

Steri

liza

tion

(tubal

ligati

on

or

vase

ctom

y)80% a

fter

deduct

ible

60% a

fter

deduct

ible

90% a

fter

deduct

ible

70% a

fter

deduct

ible

85%

aft

er

deduct

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65%

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deduct

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Phys

ical,

occ

upati

onal

&sp

eech t

hera

py)

90 v

isit

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thera

py p

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year

80% a

fter

deduct

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60% a

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deduct

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90% a

fter

deduct

ible

70% a

fter

deduct

ible

85% a

fter

deduct

ible

65% a

fter

deduct

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Card

iac

Rehabilit

ati

on

80% a

fter

deduct

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60% a

fter

deduct

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90% a

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deduct

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70% a

fter

deduct

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85%

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er

deduct

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65%

aft

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deduct

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12

Prescription Drug Chart

80% & 90% PPO Plans 85% ABHP

Copay/Co-insurance

Retail(30 day supply)

Mail Service(90 day supply)

Retail or Mail Order

Generic $8 copay $20 copay 15% after deductible

Brand nameFormulary

20%maximum of $40 per Rx


15% after deductible

Brand nameNon-Formulary



15% after deductible

Out-Of-Pocket Maximum

$1,500/Person and $3,000/FamilyOPM separate from Medical

$2,500/Employee Only$7,500/All Other Tiers

OPM includes Medical

Out of Network benefits are paid at the same level as In Network Benefits.

Additional Prescription Drug Provisions

Prior AuthorizationUnder this part of the program, your physician will be required to obtain authorization through BlueCross and Blue Shield of Illinois in order for you to receive benefits for certain medications and drugcategories. A complete list of these drugs can be found on the BCBS website. Please allow up to 10business days for approval provided all information is complete and is received timely.

Prior AuthorizationCategory

Prescription Drugs within the Category

Acne Antibiotics Adoxa, Aldodox, Avidoxy, Avidoxy DK, Doryx (and generic equivalents),Doxycycline, Monodox, Nicazeldoxy, Oracea, Oraxyl, Vibramycin, Dynacin, Minocin, Minocin Kit, Solodyn (and generic equivalents), Morigidox Kit, Nutridox Kit, Ocudox Kit

Acne Topical Atralin, Avita, Retin-A, Retin-A Micro, Tretin-X, Tazorac, Ziana, Differin,Adapalene

Androgens/Anabolic Steroids Anadrol-50, Androderm, Androgel, Android, Androxy, danazol, First-Testosterone, Depo-Testosterone, Delatestryl, Methitest, Oxandrin, Striant, Testim, Testred, Fortesta, Axiron, Aveed, Vogelxo

Antifungal Agents Noxafil, VfendAttention DeficitHyperactivity Disorder (adults)

Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Dexedrine, Dextrostat,Focalin, Focalin XR, Intuniv, Liquadd, Methylin, Metadate CD, Metadate ER, Ritalin, Ritalin LA, Ritalin SR, Strattera, Vyvanse

Growth Hormones Egrifta, Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ,Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive

Hepatitis B & C Infergen, Pegasys, PegIntron, Incivek, Victrelis, Olysio, SovaldiNarcolepsy Nuvigil, ProvigilOral Fentanyl Actiq, Fentora, Onsolis, Abstral, Subsys, LazandaOncology Afinitor, Afinitor Disperz, Bosulif, Caprelsa, Cometriq, Erivedge, Gleevec,

Hexalen, Hycamtin, Gilotrif, Iclusig, Imbruvica, Inlyta, Jakafi, Lysodren, Mekinist, Matulane, Nexavar, Oforta, Pomalyst, Revlimid, Sprycel, Stivarga, Sutent, Sylatron, Tafinlar, Tarceva, Targretin, Tasigna, Temodar, Thalomid, Tretinoin, Tykerb, Votrient, Xalkori, Xeloda, Xtandi, Zelboraf, Zolinza, Zytiga

Pain Management Suboxone, Subutex, ZubsolvSpecial Kuvan, Arcalyst, Ampyra, Forteo, Aranesp, Epogen, Procrit, Juxtapid,

Kynamro, Gattex, Purpura, Adcirca, Revatio, Letairis, Tracleer, Kalydeco, H.P. Acthar Gel, Xenazine, Promacta, Signifor, Ravicti, Buphenyl, Opsumit, Xyrem

13

Step TherapyThe Step Therapy program is designed to encourage the initial use of alternative medications generally recognized as safe and effective which are also lower in cost. Under this program, in order to receive coverage the member may need to first try a proven, cost-effective medication before progressing to a more costly treatment, if necessary. After the member has a prescription history for a lower-cost medication, coverage will automatically be provided for a more costly medication included in the program. See the BCBS website for additional information.

Step Therapy Category Prescription Drugs within the CategoryAntidepressants Aplenzin, Celexa, Cymbalta, Effexor, Effexor XR, Forfivo XL, Fluoxetine 60 mg

tabs, Lexapro, Luvox CR, maprotiline, Oleptro, Paxil, Paxil CR, Pexeva,Pristiq, Prozac, Prozac Weekly, Remeron, Remeron SolTab, venlafaxine ER tabs, Viibryd, Viibryd Starter Kit, Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zoloft, Brintellix, Desvenlafaxine fumarate, Fetzima, Desvenlafaxine ER

Cholesterol (LipidManagement)

Advicor, Altoprev, Lescol, Lescol XL, Lipitor, Liptruzet, Livalo, Mevacor,Pravachol, Simcor, Vytorin, Zocor

Diabetes (GLP-1 ReceptorAgonsits)

Bydureon, Byetta, Victoza, Tanzeum

Gastroesophageal RefluxDisease (Proton Pump Inhibitors – PPI)

Aciphex, Dexilant, First-lansoprazole Suspension Kit, First-OmeprazoleSuspension Kit, Nexium, omeprazole/sodium bicarbonate, Prevacid, Prilosec, Protonix, Zegerid, Esomeprazole Strontium

Glucose Test Strips All non-formulary brand test strips and disks (formulary brands are Bayer andRoche brands)

Pain Management Celebrex, Duexis, VimovoInfertility Gonal F, Gonal F RFFIron Chelator FerriproxMultiple Sclerosis Aubagio, Avonex, Extavia, GilenyaRheumatoidArthritis/Psoriasis

Cimzia, Enbrel, Humira, Kineret, Orencia subcutaneous, Simponi, Xeljanz,Otezla, Actemra subcutaneous, Entyvio, Stelara

Specialty MedicationsSpecialty medications include those used in the treatment of complex medical conditions, such as hepatitis, hemophilia, multiple sclerosis, rheumatoid arthritis and other conditions requiring self-administered specialty medications. (See the BCBS website for a complete listing of specialty medications.) Through Prime Therapeutics, you can have your covered specialty medication delivered directly to you, if it is a self-administered drug, or to your doctor’s office. Since many specialty medications have unique shipping or handling requirements, all shipments are arranged with you through Prime Therapeutics. Medications are shipped in plain, secure, tamper-resistant packaging. To place an order, have your doctor call (877) 627-MEDS (6337) or fax your prescription to (877) 828-3939.

14

Dental Plan Chart

The chart below reflects the treatments and services covered under the Dental Plan.

General Information Humana Dental DPO Plan

Deductible In-Network Out-Of-Network

Individual $25 $25

Individual + One $50 $50

Family $75 $75

Plan Year Maximum $1,500 per person $1,500 per person

Lifetime Maximum Unlimited Unlimited

Orthodontia Maximum(Lifetime)

$1,750 per person $1,750 per person

The following services will be covered in and out of network for the category indicated:Diagnostic and Preventative 100%, no deductible

Covered Services Include: Oral Exams2 times in one calendar year

Sealants1 per tooth per lifetime

Full Mouth X-rays or Panorex X-ray1 time within 36 months

Space Maintainer

Bitewing X-ray2 times in one calendar year

Palliative (emergency) Treatment

Prophylaxis/Cleaning2 times in one calendar year

Oral Cancer ScreeningOver the age of 40

Fluoride1 time in one calendar year (no age limit)

Pulp vitality testing andbacteriological studies for determination of bacteriologic agents

Basic Restoration 85% after deductible

Covered Services Include: Fillings

(includes composite fillings onanterior and bicuspids)

Apexification/recalcification

Periodontal surgeryOnce per quadrant every 3 years; based on the date services areperformed

Tissue Conditioning

Periodontal Scaling/Root Planning1 time per quadrant within 3 years; based on the date services are performed

Occlusal Adjustments1 time per quadrant every 3 years; based on the date services are performed

Periodontal Maintenance2 times per year

Full mouth debridementOnly once per lifetime

Pulp CappingExcludes final restoration

Therapeutic pulpotomyExcludes final restoration

Fixed and removable appliancesfor correction of harmful habits

Re-cementation of inlays/onlays,veneers, crowns and bridges

Appliances for treating bruxism(grinding teeth), occlusal guards and night guardsReline and repair not covered

Application of desensitizingmedications where periodontal treatment has been performed

15

Basic Restoration (cont.) 85% after deductible

Oral surgery Local chemotherapeutic agents(Site Therapy)

Administration of generalanesthesia when medically necessary, in conjunction with covered oral surgical procedures

Drug injections done in conjunctionwith oral surgery

Stainless steel crowns Injections of therapeutic drugs,except oral surgery

Consultations Endodontics (root canals)

Extractions

Major Restoration 50% after deductible

Covered Services Include: Non-surgical treatment of TMJdisorders

Labial veneersno more than once per tooth in aperiod of 60 months

Core Buildup Repair of Implants

Cone beam imaging Diagnostic casts

Prosthodontic Posts and cores

Inlays and onlays1 time per 5 years

Crowns1 time per 5 years

Implant servicesincludes sinus augmentation and bone replacement and graft for ridgepreservation

Crown repair

Removable or fixed bridgework Bridge1 time per 5 years

Complete Denture1 time per 5 years

Partial denture1 time per 5 years

Relinings and rebasings of existingremovable dentures

Partial or complete denturerepairs/adjustments

Addition of teeth to a partialremovable denture

Orthodontia (no deductible)

16

Vision Plan ChartThe charts below reflect the treatments and services covered under the Vision Plan.

In-Network Providers Out-of-Network Providers

Service orMaterials

Copay Plan PaysService or Materials

CopayMaximumAmount Reimbursed

Eye Exam $10100% after

copayEye Exam $10

$45 aftercopay

Contact LensExam*

Up to$60

100% aftercopay

Contact LensExam*

Up to$60

$45 aftercopay

Elective ContactLenses

$0100% up to

$130Elective ContactLenses

$0 $105

Necessary ContactLenses

$25100% after

copayNecessary ContactLenses

$25$210 after

copayLenses – SingleVision

$25100% after

copayLenses - SingleVision

$25$30 after

copayLenses - LinedBifocal

$25100% after

copayLenses - LinedBifocal

$25$50 after

copayLenses - LinedTrifocal

$25100% after

copayLenses - LinedTrifocal

$25$65 after

copay

Lenses - Lenticular $25100% after

copayLenses - Lenticular $25

$100 aftercopay

Frames $25100% aftercopay, up to $130

Frames $25$70 after

copay

Low VisionSupplemental Testing

$0 100%Low VisionSupplemental Testing

$0 $125

Low VisionSupplemental Aids

$0 75%Low VisionSupplemental Aids

$0 75%

Diabetic Eye Exam $20100% after

copayDiabetic Eye Exam $20

$100 aftercopay

SpecialOphthalmological Services(Diabetic Eye Care)

$0 100%

SpecialOphthalmological Services(Diabetic Eye Care)

$0$120 per individual

service

*Copay based on network provider’s fee schedule.

17

Wellness Program

Healthy employees are an important elementof a strong organization. The Balanced LivingWellness Program is aimed at increasing employees’ awareness of their own personal health risks with the belief that annual testing and early detection will help greatly to mitigate future illness.

Who is EligibleIf you are enrolled in one of the INEOS Healthplans you are eligible. (Union employees areeligible to participate based on their Collective Bargaining Agreement.) You can be an active employee, on a Leave of Absence, or on Short-Term Disability. As long as you participate in an INEOS Health Plan, you are an eligible participant. Other dependents such as children and ex-spouses cannot participate.

How the Program WorksIf you choose to participate in the Program,you will receive a discount on your monthly medical premium if you accumulate 9,500 points during the Wellness Plan Year. If you cover a spouse or domestic partner under the medical program, they must also participate in order for you to receive the medical premium discount. This is an annual program that involves the completion of certain requirements every year. The Wellness Planyear runs from October 1st through September 30th of each year. The discount will be applied to the following calendar year. If you choose not to participate, you will pay a surcharge on your monthly premiums.

Participation is easy. All you need to do is complete the following:

Core Activities Have a routine annual physical or medical

visit (3,000 points) Have a blood screen to test cholesterol

and blood glucose levels (3,000 Points) Take the online health risk assessment

(3,000 points)

By completing the Core Activities you will accumulate a total of 9,000 points.

To achieve your 9,500 point goal, you can choose from Bonus Activities to accumulate additional points.

Bonus Activities Health Coaching – Talk with a Health

Coach and earn up to 100 points per call. The maximum number of points allowed for this activity is 500 or 5 calls.

Benefits Value Advisor – Talk with anAdvisor and earn up to 100 points per call. The maximum number of points allowed for this activity is 500 or 5 calls.

Keas Wellness Portal - Earn 500 points bycompleting activities of your choice on the Keas website at:https://play.keas.com/ineos.

Completing Program Requirements

Routine Annual Physical/Medical VisitThe wellness program will not define exactlywhat your doctor should check for your routine physical or during a medical visit. That is between you and your doctor. The aim is to have you visit a doctor once a year to have your health reviewed and items such as your blood pressure and heart rate checked. If you have completed the annual physical and appropriate lab work due to requirements from your job, you will not be required to do it again.

Blood ScreeningThe program requires that you have yourcholesterol (lipid panel) and blood sugars (blood glucose) checked annually. Your doctor may, however, request other lab tests based on your personal health.

Health Risk Assessment (HRA)An online HRA is used to provide a picture of your current health and quality of life, plus potential future health risks. The HRA asks questions to understand your individual lifestyle practices and behaviors related to health and wellness. It will also incorporate your blood screening values to produce a more accurate report of your current health status.

18

New Entrants to the Program

New and Rehired EmployeesAll newly hired and rehired employees will automatically receive the premium discount upon their initial enrollment with INEOS. Depending upon your hire date (or rehire date) the program requirements for future discounts will differ.

Employees Hired between January 1 and August 1

Assuming you enroll in an INEOS Health Plan upon hire, to receive the premium discount for the following year, you must complete the 3 core requirements (annual physical, blood work and HRA) bySeptember 30th. For subsequent years,the requirements are the same as all other employees.

Employees Hired On or After August 1 through December 31Since it may not be possible to complete the core and additional requirements before the wellness window closes on September 30th,you will not be required to do any wellness activities for the remainder of the year in which you were newly hired. For subsequent years, the requirements are the same as all other employees.

Life Events between January 1 and August 1 If you experience a Life Event before August1st and wish to enroll for the first time or add a spouse to coverage, you must complete the 3 core requirements (annual physical, bloodwork and HRA) by September 30th. Forsubsequent years, the requirements are the same as all other employees.

Life Events On or After August 1 through December 31If you experience a Life Event after August 1st

and wish to enroll for the first time or add a spouse to coverage, it may not be possible to complete the core and additional requirements before the wellness window closes on September 30. Thus, you will not be required to do any wellness activities for this year. For subsequent years, the

requirements are the same as all other employees.

Open EnrollmentIf you are an active employee that is not enrolled in an INEOS medical plan and wish to do so at open enrollment, you will automatically receive the premium discount upon enrollment. In future years, you will be required to complete the same criteria (core requirements and bonus activities) as all other employees.

How Your Medical Premiums Are Calculated

Active Employees (Currently Enrolled in Medical)When developing the annual medical rates, the Company will determine an 80%/20% cost sharing for the employer and employee medical plan premiums. If you complete the program’s requirements, the medical rate discount will then be applied to medical premiums, as follows:

The Employee Only and Employee +Children tiers will be reduced by $120 a year.

The Employee + Spouse and Employee +Family tiers will be reduced by $240 per year.

Conversely, if you choose not to participate a surcharge will apply. Medical rates will be increased above the 20% employee premium, as follows:

The Employee Only and Employee +Children tiers will be increased by $360 a year.

The Employee + Spouse and Employee +Family tiers will be increased by $720 per year.

The rate discount and surcharge will be evaluated each year and will be based on current participation levels of the program.

Please refer to the Employee Benefits Handbook for details regarding the Program.

19

Spending & Savings Accounts

The INEOS Flexible Benefits Plan is a smartand convenient way for you to stretch your paycheck and receive real tax savings. It affords you the opportunity to pay certain out-of-pocket medical, dental, vision and dependent care expenses with pre-tax money. The Plan allows you to reduce your salary via payroll deduction and use that amount to:

make contributions to a Health CareFlexible Spending Account (FSA);

make contributions to a Dependent CareFlexible Spending Account (FSA); and/or

make contributions to a Health SavingsAccount (HSA).

In other words, pay your eligible expenses with tax-free money!

If you are enrolled in the 80% and 90% PPOPlans, you are eligible to participate in the Health Care FSA. If you are enrolled in the85% ABHP, you are eligible to participate in the HSA and Limited Purpose FSA. A Health Savings Account works similarly to but is very different from a Health Care FSA. Detailed information can be found in the Employee Benefits Handbook under the Spending & Savings Account section. You can also contact CONEXIS, our FSA and HSA Administrator, if you have questions. CONEXIS Customer Service Representatives can be reached at (866) 279-8385. Additional information can also be found on the CONEXIS website athttps://Mybenefits.conexis.com.

Eligible ExpensesYou decide how to use your money and whento draw against your account. Examples ofqualifying expenses for the FSA and HSA accounts can be found in the Employee Benefits Handbook under the Spending & Savings Account section. You can also find a complete list of eligible expenses on the CONEXIS and/or IRS websites.

Contribution LimitsThe government sets limits on the amount ofmoney you can set aside to use for your FSA and/or HSA accounts. For 2015, the following limits apply:

Dependent Care FSA – maximum of $5,000 Health Care FSA – maximum of $2,500 Limited FSA – maximum of $2,500 Health Savings Account – maximum of

$3,350 for Employee Only coverage; maximum of $6,650 for all other coverage tiers. If you are age 55 or older you can contribute an additional $1,000.

Debit CardsWhen you have eligible expenses, you can payfor them with your benefit card. This cardoperates just like any credit transaction at merchants that accept Visa and can be used for Health Care expenses (the benefit card cannot be used for Dependent Care Spending Accounts). The money is taken directly out of your Flexible Spending Account (FSA) or Health Savings Account (HSA), thereby avoiding any cash flow issues. The CONEXIS Benefit Card is provided to participants free of charge. If you wish to have a card issued for your spouse, you may request an additional card by calling CONEXIS. Be sure to keep your receipts so you can substantiate the expense if needed.

If a provider or store does not accept payment by Visa or, if you don’t have your card with you at the time, you can pay for an eligible expense out of your own pocket and submit a paper claim for reimbursement.

Run out PeriodYou will have until March 31st to submit alleligible expenses for the plan year just completed. If you do not use the amounts in your Dependent Care FSA account by the end of the year, you will forfeit the balance. For Health Care FSA accounts, you can roll over up to $500 into the next year. HSAs allow all balances to rollover. There is no “use-it-or-lose-it” rule.

Analyze Your Costs CarefullyWhether it’s the Health Care Account,Dependent Care Account or Health SavingsAccount, you should carefully plan how much you will save each year. Expense worksheets can be found in the Employees BenefitsHandbook.

20

Life & Security

Basic Life Insurance PlanThe Company provides you with life insurancein the amount of 1 ½ times your base compensation up to a maximum of $1 million. Coverage is automatic and is fully paid by the Company. Upon attainment of age 65 your benefit may decrease.

If your Basic Life insurance amount is over $50,000, you will have to pay “imputed income”, which is income tax on the cost of the coverage for any amount over $50,000. The amount of tax is based on IRS tax tables and will be reported on your W-2 form each year.

To elect your beneficiaries for life insurance, you will need to access your account at CIGNA.

Group Universal Life Insurance Plan (GUL)In addition to your Company provided Basic Life Insurance, you have the opportunity to elect additional life insurance coverage foryourself, your spouse and your eligible children (up to age 25).

Coverage is available in amounts of 1 to 8 times your base annual salary, rounded to the next higher $10,000, if not already an even multiple. You may also apply for coverage to protect your spouse and children. For spousal coverage, you may apply for benefits in$10,000 increments up to a maximum of $250,000. You may also purchase coverage for your dependent child(ren) who are older than 14 days old up to age 25. For just one premium, you can insure all of your dependent children with a $25,000 policy.

Guarantee Issue Amounts for New HiresAs a new hire, you can receive 1 times yourbase annual salary in coverage up to the maximum of $300,000 (whichever is less) without completing any additional Evidence of Insurability (EOI) paperwork. Any amounts selected greater than $300,000 will require EOI and must be approved by CIGNA prior to coverage beginning.

For spousal coverage, EOI will not be required for amounts up to $30,000. Any applications for amounts from $30,000 up to $250,000 (plan maximum), will require EOI and must be approved by CIGNA prior to coverage commencing.

The GUL Program provides life insurance coverage at group rates and gives you the chance to build cash value through the program’s Cash Accumulation Fund. These options give you flexibility as you plan for your family’s future financial needs.

Personal Accident Insurance (PAI) PlanThe Company provides you with PersonalAccident Insurance equal to 1 ½ times your annual base pay, up to a maximum of $1 million in coverage. The plan pays a benefit if you die or are dismembered as the result of an accident. In the event of death, this benefit is payable in addition to any life insurance benefit. Enrollment in this coverage is automatic.

Voluntary Personal Accident Insurance (VPAI) PlanVPAI insurance coverage is available for youand your family at group rates. You canobtain coverage up to 6 times your annual base pay to a maximum of $1 million, if you suffer a loss due to an accident. You must be enrolled in the Plan in order to purchase coverage for your dependents. The maximum benefit for a spouse is $250,000; for children, the maximum benefit amount is $10,000.

You do not need to provide Evidence of Insurability to obtain this coverage. This coverage also applies while traveling for business or pleasure.

Long Term Disability Plan (LTD)The Company provides you with Long Term Disability insurance equal in the amount of60% of your monthly eligible compensation, if you are disabled beyond 26 weeks (6 months). The minimum LTD benefit is $100 per month. The maximum is $20,000 per month minus any offsetting benefits. Eligible earnings are defined as your annual base compensation, excluding over time, commissions and bonus.

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Buy-Up OptionThis plan offers you the opportunity to buy additional coverage up to 65% of your monthly eligible compensation. The cost of additional coverage is based on your age and eligible earnings per $100 of coverage. As you age and earnings change, your costs will be adjusted automatically.

For information on how to file a LTD claim, please reference the Employee Benefit Handbook.

How to Enroll, Make Changes to Voluntary Benefits and Elect BeneficiariesTo apply for, make changes to voluntary coverage (GUL, VPAI and LTD Buy-Up), and to elect beneficiaries for all of your life insurance policies, you may do so by calling CIGNA at (800) 828-3485 or via their websiteat: www.cignatrustedadvisor.com/ineos

To access your account through CIGNATrusted Advisor for the first time, click on the “My Account” link in the upper right hand corner, then click on “Register”, next read the terms and conditions and click “I Agree”.

To complete the registration process, enter your last 6 digits of your SSN and your date of birth. Once this information is confirmed, you will then be asked to create a username and password. If you have any technical difficulties or have any questions throughout the enrollment process, please contact CIGNA directly.

Employee Assistance Program

All employees have access to the Companyprovided Employee Assistance Plan (EAP) through CIGNA Behavioral Health. CIGNA’s EAP provides access to in-person behavioral health assistance, telephonic counseling and online tools.

The program offers covered employees and their families:

Access to telephonic counseling 24 hours aday, seven days a week and up to 3, free in-person sessions from CIGNA’s Masters and Ph.D.-level licensed behavioral health clinicians

Life event referrals and research Health Rewards discount program Personal Stress Navigator

To discover the full array of benefits that the Program has to offer, visit their website atwww.cignabehavioral.com or you can callCIGNA’s Customer Service Representatives(888) 371-1125. Our Employer ID is “ineos”.

There is no need to make an election for thiscoverage. The Company will automaticallyenroll you.

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Retirement Savings Plan

The INEOS Retirement Savings Plan is a 401(k)plan that lets you save up to 75% of your eligible pay towards retirement. You can elect to contribute on a before-tax, Roth or after-tax basis, or a combination, up to legal limits. Effective 1/1/2013, the Company matches pre-tax, catch-up and Roth contributions $1 for $1 up to 6%. All employees are eligible to receive a 3% company base contribution regardless of participation. Some employees may also be eligible for other company contributions called transition credits. Please see the Employee Benefits Handbook for details. The above mentioned provisions may not apply to all union employees.

All contributions and investment gains or losses are credited to your plan account. You choose how your savings are invested from a wide variety of investment options. You – not the Company – assume all the investment risk. That means your account will benefit from any investment gains and experience any investments losses as well. You have a variety of different investment options from which to choose, including a Self-Directed Brokerage account.

You have access to your account through the Plan’s loan provisions, and, under certain conditions, may withdraw a portion of your account while still working with the Company.

The Plan is intended to be a “qualified retirement plan” under Section 401(a) of the Internal Revenue Code and to meet the requirements of Code Section 401(k).

The Plan is administered by T. Rowe Price. Additional information can be obtained by calling T. Rowe Price at (800) 922-9945 or via their website at www.rps.troweprice.com.

Please refer to the Employee BenefitsHandbook at www.ineosbenefits.com foreligibility requirements and other plan details.

Pension Plans

As an active employee hired prior to1/1/2008, you may be eligible for benefits under a pension plan sponsored by INEOS. If you are eligible for a benefit, you will receive an annual pension statement along with other information each year. For further information regarding the pension plans, you should refer to the Employee Benefits Handbook.

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Retiree Benefits

As an active employee hired prior to1/1/2008, you may be eligible for retiree medical and/or dental benefits under the INEOS Retiree Welfare Plan.

Retiree Medical EligibilityThe plan’s eligibility requirements are age 55with 10 years of service at the time you leave the Company. Employees hired 1/1/2008 and thereafter will not be eligible for Retiree benefits.

If you were an INEOS USA employee at or beyond age 50 with 10 years of service upon the transition from BP on December 16, 2005, you will be eligible for retiree medical coverage from BP and not the INEOS Plan. Please contact the BP Benefits Center for more information.

To be eligible for Subsidized Medicare-Eligible coverage, that is coverage for the remainder of your life, you must be at least age 50 with 10 years of service on January 1, 2013. Once you enroll in Medicare, your INEOS retiree rate will be reduced to 1/3 of the pre-Medicare or pre-65 cost.

Retiree Dental EligibilityThe Plan’s eligibility requirements are age 55with 10 years of service at the time you retire. If you worked at one of the following INEOS Heritage Companies prior to 1/1/2008, you will be eligible for retiree dental:

ABS Melamines Phenol Oxide Styrolution – except Texas City

Employees hired 1/1/2008 and thereafter will not be eligible for Retiree Dental benefits. Also, employees from an INEOS USA heritage company are not eligible for this benefit.

Calculating Your Retiree MultiplierWhen you retire and enroll in the RetireeMedical Plan your monthly premium will be based upon your age at the time of

retirement. If you retire before age 62, youwill pay a higher premium or a multiple of the rate. INEOS subsidizes coverage for retirees and their spouses. Coverage for children and families are an option; however the retiree will pay the full cost of insurance for children.

The table below reflects the multipliers in effect for each age:

Age Multiplier62+ 1.061 1.260 1.459 1.658 1.857 2.056 2.255 2.4

For more information regarding the retiree rates, company cost share and company maximum contributions please reference the Retiree Benefits Guide found on the INEOS Benefits website.

How to Enroll for Retiree BenefitsAt the time of your retirement, you willreceive a retirement package from the Plan Administrator with your enrollment options and retiree medical and/or dental costs. This package will contain an enrollment form for you to complete and return to the Benefits Department. You will have 30 days within which to enroll. If you do not you’re your election in a timely manner, you will forfeit the ability to enroll in the future.

Paying For Your Retiree BenefitsOnce the Benefits Department has receivedyour enrollment form, you will begin receiving bills directly from CONEXIS, the Company’s Benefits Billing provider. You will receive monthly invoices and will be required to send your payment directly to CONEXIS for processing. You may view your accountonline via https://Mybenefits.conexis.com.You can also set up an ACH from your bank to CONEXIS to make your monthly payments. If you have questions regarding your bill or this process, contact CONEXIS at (877) 722-2667.

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Financial Planning Services

To help you with your retirement planning,INEOS provides access to two powerful financial planning resources – the EY Financial Planner Line® and the Ernst & Young Financial Planning Center. These resources are designed to help you make the best use of your benefit plans and plan for your financial future. Best of all, the services are free to you.

How The Program WorksYou get unlimited, toll-free telephone accessto experienced and credentialed financial planners who are educated in INEOS benefit plan offerings. When you call the EY Financial Planner Line®, you will be connected with a planner who offers confidential, objective and personalized financial planning guidance in a wide range of areas. Financial Planners are available at (866) 544-6299 from 8 am – 7 pm CST, Monday-Friday, except holidays.

You can also request personalized printed financial reports. Prepared by Ernst & Young financial planners, personalized reports are available to help you plan in specific areas of personal finance.

Useful resources can be accessed on the web. On the Ernst & Young Financial Planning Center website, you’ll find a wealth of informative articles, tips, financial calculators and videos.

For a personalized experience, employees can call E&Y at (866) 544-6299, or go tohttp://INEOS.eyfpc.com to register for thewebsite using Company Code: INEOS and set up an individual login id using your work email, date of birth and home zip code.

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Travel Guide

Questions regarding your benefit plans mayarise when traveling outside of the country, either for personal travel or business. Where do I go for treatment in the case of an emergency? How are my claims processed? Do I have to pay for services out of pocket? This section of the guide will help answer these questions.

Medical – Blue Cross Blue Shield (BCBS)While traveling out of the country, you haveaccess to the BCBS World Wide network of physicians and hospitals. Providers and hospitals that participate in this network can be found by accessing the BCBS website(www.bcbsil.com) and clicking on the “Find adoctor” link.

If you do not have access to a computer while traveling, you can call the Customer Service number on the back of your BCBS insurance card to help locate an in-network provider.

Dental – HumanaDentalHumana does not have an Internationalnetwork of providers. Typically payment willbe requested at the time services are rendered from the provider. For claims processing, submit a claim form to Humana with an itemized receipt for reimbursement. It is preferred to have the receipt in English and in US currency; however, if it is not, Humana will translate it for payment.

Vision - VSPWhile traveling outside of the United States,vision services will need to be paid out of pocket at the point of sale. VSP does not have an International network of providers. VSP will reimburse you based on the out of network benefit levels provided that a reimbursement form is completed with an itemized statement.

FSA & HSA – CONEXISThe CONEXIS Flexible Spending AccountBenefit Card cannot be used at the point of sale when traveling outside of the country. If you incur eligible expenses while traveling, a

claim form must be submitted to CONEXIS with a receipt for reimbursement.

CIGNA Secure TravelAn emergency can be much more difficult todeal with when you are traveling. In theevent that an unfortunate situation arises –injury, illness, death, theft, natural disaster, disease outbreak or terrorism – knowing that CIGNA Secure Travel is available to you can provide added peace of mind in unfamiliar surroundings. You can be on the other side of the world or only a couple of hours away from home and still get the help you need.

Available to employees, CIGNA Secure Travel provides emergency medical and travel services, as well as helpful pre-trip planning assistance, when travelling 100 miles or more away from home on company business or vacation. Toll-free customer service representatives are available 24 hours a day, 365 days a year. In an emergency, the Customer Service Center can even accept collect calls.

Health Care CoverageImagine that you require medical care while traveling on company business or you are onvacation in another country—a country where care may not be comparable to western medical standards. CIGNA Secure Travel can arrange and cover the cost of transportation to the nearest appropriate hospital or medical facility. This program will also provide up-front payment, often required when abroad, for medical services – saving you from having to pay expenses out-of-pocket at that time. And, in the event of a fatality, CIGNA will arrange and covert the cost of transporting remains back to the country of origin. CIGNA Secure Travel places no coverage limit on either of these services.

You may contact the Customer Service Representatives at CIGNA Secure Travel by calling (888) 226-4567 from the U.S. and Canada. From other locations call collect at (202) 331-7635. Or to reach them by fax, dial (202) 331-1528.

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2015 Benefit Monthly Rates

With Wellness DiscountEmployee

OnlyEmployee +

SpouseEmployee +

ChildrenEmployee +

Family80% PPO Plan $77.67 $139.34 $155.62 $226.5690% PPO Plan $126.67 $222.76 $241.86 $357.8785% ABHP $3.35 $8.73 $24.46 $88.32

With Wellness SurchargeEmployee

OnlyEmployee +

SpouseEmployee +

ChildrenEmployee +

Family80% PPO Plan $117.67 $219.34 $195.62 $306.5690% PPO Plan $166.67 $302.76 $281.86 $437.8785% ABHP $43.34 $88.73 $64.46 $168.33

EmployeeOnly

Employee +Spouse

Employee +Children

Employee +Family

Dental $10.18 $20.21 $20.30 $31.09Vision $8.67 $12.97 $13.88 $22.17

Group Universal Life(per $1,000 of Monthly Eligible Earnings)

Long-Term Disability Buy-Up Option

(per $100 of Monthly Eligible Earnings)

Age Bracket Smoker Non-Smoker Age Bracket 65% Buy-Up<25 $0.046 $0.039 18-39 $0.084

25 - 29 $0.053 $0.045 40-44 $0.12630 – 34 $0.058 $0.049 45-49 $0.18535 – 39 $0.063 $0.054 50-54 $0.21040 – 44 $0.100 $0.088 55-59 $0.16545 – 49 $0.150 $0.136 60-64 $0.12650 – 54 $0.230 $0.212 65-69 $0.08855 – 59 $0.430 $0.365 70+ $0.08860 – 64 $0.660 $0.59065 - 69 $1.152 $0.943

Voluntary Personal Accident Insurance(per $1,000 of coverage)

Coverage Level PremiumSingle $0.020Family $0.034

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2015 Domestic Partner Benefit Monthly Rates

With Wellness DiscountEmployee +

Domestic Partner

Employee +Dom.Part’sChildren

Employee +Dom.Part +

Family80% PPO Plan $61.66 $77.94 $148.8990% PPO Plan $96.09 $115.19 $231.2085% ABHP $5.38 $21.11 $84.98

With Wellness SurchargeEmployee +

Domestic Partner




Employee +Domestic Partner



FamilyDental DPO $10.03 $10.13 $20.91Vision $4.30 $5.21 $13.50

Imputed IncomeWith Wellness Discount





Imputed IncomeWith Wellness Surcharge





Dental DPO $27.12 $27.38 $56.55

How are paycheck deductions calculated?The employee’s portion of the premium isdeducted on a pre-tax basis and, the domestic partner coverage is deducted on an after-tax basis.

How is the Imputed Income calculated?The Company paid portion of the cost is taxedin the form of imputed income. To properlytax the benefit, the imputed income amount is added to the paycheck as gross pay under the “Hours & Earnings” section so that taxes can be calculated and withdrawn for that

specific amount. The earnings description onthe paycheck is “Dom Prt Incom”. This sameamount is deducted from the paycheck under the “Deductions” section with the description “Dom Prt Incom”. The earnings and deduction amounts net to zero. The Imputed Income amount is the taxable amount for the benefit--this is not the cost of insurance.

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Ceridian Self-Service User Guide

How to Enroll and Make Changes to Your ElectionsThe Ceridian Self-Service Portal is an internetbased application that can be accessed from anywhere you have an internet connection--not only on the INEOS network. This portal should be used for the following benefits and payroll items:

electing benefits when you are newlyhired

adding or changing dependentinformation

changing benefits when you have aqualifying life event (such as marriage, divorce, birth of a child, etc.)

electing benefits during OpenEnrollment

viewing benefit statements changing your home address viewing or updating emergency

contacts viewing earnings statements viewing past W2 statements

Go to an Internet browser and enter this URL: https://sourceselfservice2.ceridian.com/ineosfluor. The Self-Service Login page willappear.

Login InstructionsEnter your assigned user name and password.(Your user name is your clock number. It is the last 5 digits of the ID number found on your paystub.) If you have never logged in before, your password will initially be the last 4 digits of your SSN. Next, click “Log In” or press the Enter key on the keyboard. Once you log on successfully, you will be asked to create a unique password. Passwords must be between 8-20 characters, contain at least one digit (0-9), contain at least one uppercase and one lowercase alphabetic character, may contain special characters (i.e. !@#%&*) and cannot contain your first or last name or ID.

If you require further assistance or need your password reset, please email the Ceridian Self-Service Administrator at:[email protected]

How to Add or Verify a DependentTo add dependent information, click on the“dependents” link under the Personal Information section on the Home Page. You must first add your dependents on this screen or they will not be available to select during your benefit election process.

To add a new dependent, click “Add”, to delete a dependent, click “delete” and to change a dependent’s information, click on their name. If you delete a dependent, they will not disappear from this view immediately as they may hold historical information on your record.

Please make sure to double check the “Gender” drop down menu as it defaults to “Female”. Also, please include date of birth and SSN of your dependents as this is required information for covering a dependent on your health plans. If you do not have the SSN initially, please come back later and update their record when it is available.

How to Complete Your Medical, Dental, and Vision EnrollmentsOn the Home screen, you should see anenrollment notice which will provide you with a deadline for completing your enrollment. Click on the link, “Please enroll now” to begin the enrollment process.

The first page will ask you to verify your list of dependents and your marital status. Please note that even if you are not including someone in your benefits at this time, they may show here if you have covered them in the past. It is not necessary to delete them again. Once you verify this information is accurate, click “Next”.

If it seems to take a long time to process, do not be alarmed. Please be patient as this page may take a few minutes to load.

The next screen shows a list of your currently enrolled benefit options along with your covered dependents. Next to each section is a blue button titled, “Change” which should be used to show all available benefit plans for enrollment. If you are enrolling at Open Enrollment, you may see a message that

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states you are no longer eligible for this plan along with a red lined box around the plan. This means that a new plan must be selected. Please click on the “Change” button and proceed with choosing a new plan.

You will notice that in each Benefit Plan section, there will be plans listed in two separate background shades. One set ofbenefits is for employees and the other is for Domestic Partners. If you are not enrolling a Domestic Partner, make sure that you do not choose these options. Instructions forenrolling or changing Domestic Partner coverage can be found below.

Once your selection has been made, you will be returned to the main election screen. If you are covering dependents on this plan, you will now see a new button titled, “Cover Dependents”. Please click on the button to advance to the next screen. Next, put a check mark next to your designated dependent(s) and click “Save” to complete your changes. Likewise, if you want to remove a dependent from being covered on a specific plan, de-select the check mark box next to their name.

Each enrollment is unique. If you chooseyour dependents on the medical plan, the system will not automatically know if you want these same dependents on your dental or vision plans.

If you are electing a plan that includes dependents (i.e. employee + spouse) and you do not complete the “Covered Dependents”section, you will get an error message when you try to save your enrollment.

How to Enroll or Change Domestic Partner CoverageAll employees are eligible to enroll Domestic Partners (same or opposite sex). If you are not enrolling a Domestic Partner, you may disregard these instructions.

Electing domestic partner coverage will require you to enroll in TWO benefit plans for each benefit option. For instance, two plans will be needed for medical, two for dental and two for vision. The reason for this set up

is to allow for a pre-tax deduction for the employee’s portion of the plan. The second plan designates the after-tax deduction for the domestic partner coverage.

The first plan will be titled as any other plan available; however, the tier or “coverage”will be specific to the domestic partner option. The second plan will have “Domestic Partner” attached to the end of the description for the plan. Therefore, you will have two plans that look like the below:

Plan #1: 80% PPO PlanPlan #2: 80% PPO Plan – Domestic Partner(or 90% PPO Plan, or 85% ABHP if you are selecting that plan)

Plan #1: Humana DentalPlan #2: Humana Dental – Domestic Partner

Plan#1: Vision PlanPlan#2: Vision Plan – Domestic Partner

Next, when selecting the two plans, you will also need to make sure the tier or “coverage”is the same for each plan you are choosing. The available coverage/tier options are:

Employee + Domestic PartnerEmployee + Dom.Part’s Children Employee + Dom.Part + Family

If you wish to cover other dependents, you will need to add them to the employee plans. Those are the plans without “Domestic Partner” at the end of the name.

How to Complete your Flexible Spending Account EnrollmentsFlexible Spending Accounts require that you re-elect your contributions on an annual basis. A Health Care FSA account is for you and your covered dependents health care expenses. A Limited FSA account is for dental and vision expenses only. A Dependent Care FSA account is for dependent care expenses such as day care or elder care services. Please note that a Dependent Care account is NOT for health care expenses for your dependents.

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You will see three choices for FSA accounts, one for the Health Care FSA, one for the Limited FSA and one for Dependent Care FSA. If you had either of these benefits in the prior year, the system will automatically default to your prior election. If you wish to keep the same election, click “Save.” Otherwise, click “Change” to make a new election. If you do not want to enroll for the next calendar year, deselect the check mark in the “Elect”column.

How to Complete your Health Savings Account Plan ElectionIf you have enrolled in the 85% ABHP, you will be eligible to enroll in the HSA plan. Before enrolling through Ceridian Self-Service, you must go to the Conexis website and submit an application for an account. You will then be notified by the Benefits Department once your application has been approved so that you can log into Self-Service to complete your elections. Once approved, go to the“Benefits” section of Self-Service and click on the “Health Savings Account Enrollment” link. Here you will be able to designate the dollaramount you want to contribute per pay check. You can change this amount as often as you like throughout the year.

Finalizing Your Elections in Ceridian Self-Service during Open EnrollmentOnce you are finished designating your elections for the next calendar year, you have several options available to finalize the enrollment process. You can:

Click on “Complete Enrollment” and all ofyour changes will be saved

Click on “Save Selections and Enroll Later”which will allow you to keep going back into the system and making changes.

Click on “Start Over” and all of yourchanges will be lost and you will be returned to the beginning of the enrollment process.

Click on “Cancel” and all of your changeswill be lost and you will be returned to the Home page.

After you have “Completed your Enrollment”you are given the option to print a Benefit

Confirmation Statement reflecting your new/changed elections. It is highly recommended that you print your statement at the time you have completed theenrollment process in order to keep record of your new elections.

If you do not choose to print the benefit confirmation statement at this time, you can access it from the Home page under the Benefits Section. There are two links under the Benefit Section, one which will reflect your “Current Benefits” and one that will show your new elections. The Benefits Summary will show your new elections. At the bottom of the Benefits Summary screen, there is a link that allows you to view your new elections. This link will take you back to the original confirmation you received after you completed the enrollment.

The “Current Benefits Statement” will only show your current year benefit elections as of the date you are accessing the website.

If you “Complete Enrollment” but later decide that you want to make a change to your election, you may still do so. On the Home Page you will see a link that states “Reset your benefits enrollment”. Keep in mind that if you reset your enrollment, this does not extend the due date for completing your elections. You will need to go back into the enrollment process and complete your elections within the designated time frame.

How to Complete your Life, PAI and LTD Insurance ElectionsCompany provided Life, PAI and LTD benefits do not require an election. You are automatically enrolled and can view your coverage when enrolling in other benefits. As a convenience to you, Group Universal Life, Voluntary Personal Accident Insurance and Long Term Disability benefits will also display on your Benefits Summary. See the Life & Security section of the guide for enrollment instructions.

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Benefits Website

Check out the INEOS Benefits Website atwww.ineosbenefits.com for more informationregarding all benefit plans and the Employee Benefits Handbook.

Since the website contains company-confidential information, you will need to register under your INEOS email address to use the site.

Registration is an easy 2-step process:

1. After clicking on the "Register" linkunder the Login button on the website you will need to complete a registration form that will be submitted to the Benefits Department for authorization. You will receive 2 emails, one thanking you for registering and another once your registration has been approved.

2. The second email will contain a linkfor you to set your personal access code (password). You will then be able to use the website from anycomputer connected to the internet.

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Required Disclosures

General Notice of COBRA Continuation Coverage Rights

IntroductionYou’re getting this notice because yourecently gained coverage under the INEOS Welfare Benefit Plan. This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description (also known as the Employees Benefit Handbook) or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA Continuation Coverage?COBRA continuation coverage is acontinuation of Plan coverage when it would otherwise end because of a life event. This is also called a "qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you're an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

Your hours of employment are reduced, or Your employment ends for any reason

other than your gross misconduct.

If you're the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

Your spouse dies; Your spouse’s hours of employment are

reduced; Your spouse’s employment ends for any

reason other than his or her gross misconduct;

Your spouse becomes entitled to Medicarebenefits (under Part A, Part B, or both); or

You become divorced or legally separatedfrom your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

The parent-employee dies; The parent-employee’s hours of

employment are reduced;

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The parent-employee’s employment endsfor any reason other than his or her gross misconduct;

The parent-employee becomes entitled toMedicare benefits (Part A, Part B, or both);

The parents become divorced or legallyseparated; or

The child stops being eligible for coverageunder the Plan as a “dependent child.”

When is COBRA Continuation Coverage Available?The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

The end of employment or reduction ofhours of employment;

Death of the employee; Commencement of a proceeding in

bankruptcy with respect to the employer; or

The employee’s becoming entitled toMedicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to the employer's local HR representative.

The Plan Administrator may require you to fill out applicable forms at that time. If you do not provide this notice or follow the Plan Administrator's procedures, you or your dependents will not be entitled to COBRA continuation coverage.

How is COBRA Continuation Coverage Provided?Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified

beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lastsfor 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended. See below.

Disability Extension of 18-Month Period of COBRA Continuation CoverageIf you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

In order to obtain this extended coverage, notice of the disability determination must be provided to the employer's local HR representative by the qualified beneficiary within 18 months of the qualifying event andwithin 60 days after the later of the date: (i) of the Social Security Administration's disability determination, (ii) of the qualifying event, (iii) the qualified beneficiary loses or would lose coverage due to the qualifying event, or (iv) on which the qualified beneficiary is informed of his or her obligation to provide notice (and you are hereby so informed through this Notice). The Plan Administrator may require you to fill out applicable forms at that time. If you do notprovide this notice or follow the PlanAdministrator's procedures, you or your

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dependents will not be entitled to anadditional period of COBRA continuationcoverage due to disability.

The qualified beneficiary is responsible for notifying the employer's local HR representative within 30 days after the later of the date: (i) of the determination that the disabled qualified beneficiary is no longer disabled or (ii) on which the qualified beneficiary is informed of his or her obligation to provide notice (and you are hereby so informed through this Notice)

Second Qualifying Event Extension of 18-Month Period of Continuation CoverageIf your family experiences another qualifyingevent during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, orboth); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extensionis only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other Coverage Options Besides COBRA Continuation Coverage?Yes. Instead of enrolling in COBRAcontinuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.”Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options atwww.healthcare.gov.

If You Have QuestionsQuestions concerning your Plan or your COBRAcontinuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visitwww.dol.gov/ebsa. (Addresses and phonenumbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visitwww.HealthCare.gov.

Keep Your Plan Informed of Address ChangesTo protect your family’s rights, let the PlanAdministrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan Administrator Contact Information

INEOS USA LLC2600 South Shore Boulevard, Suite 500 League, TX 77573(281) 535-4229

How to EnrollIf you and/or your dependents experience aqualifying event of which the Company has been given notice, you will receive a COBRA enrollment package from the COBRA Administrator.

You have 60 days within which to elect COBRA coverage. The 60 day period begins to run from the later of (i) the date you would lose coverage under the Plan due to the qualifying event, or (ii) the date on which the Plan Administrator or the COBRA Administrator notifies you that you have the option to elect COBRA coverage. Each qualified beneficiary has an independent right to elect COBRA coverage. You may elect COBRA coverage on

35

behalf of your spouse, and parents may elect COBRA coverage on behalf of their children.

Your and/or your dependents' coverage under the Plan is terminated the end of the month in which the qualifying event occurs. Your coverage will be retroactively reinstated if you elect COBRA coverage by timely completing and returning your COBRA enrollment package and your first COBRA payment. You may also elect COBRA online athttps://Mybenefits.conexis.com.

Please keep in mind that when you leave theCompany, your coverage is terminated. If you elect COBRA, your coverage will be reinstated as of the date of your severance, termination or retirement once your COBRA enrollment has been completed and your first payment is received. After 60 days to elect, you have 45 days to pay your initial premium.

COBRA CostsThe qualified beneficiary is responsible forpaying the COBRA premium. Premiums are102% of the total cost of the coverage, or 150% of the total cost of the coverage in the event of a disability. COBRA premiums will change each year.

How to Pay for COBRAThe COBRA Administrator will send youmonthly invoices for the amount owed based on the coverage you elected. You may view your account online athttps://Mybenefits.conexis.com. You canalso set up an ACH from your bank to the COBRA Administrator to make your monthly payments.

The initial premium payment, which is for the time period between the date of thequalifying event and the date you elected COBRA coverage, must be made within 45days after the date of your COBRA coverage election. Failure to pay this initial premium by the due date will result in cancellation of coverage retroactive to the date coverage would have terminated without a COBRA coverage election.

Thereafter, if you fail to send your payment to the COBRA Administrator within 30 days

of the due date, your COBRA coverage will be cancelled effective as of the due date.

Notice of Privacy Practices

This notice describes how medical informationabout you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your RightsWhen it comes to your health information,you have certain rights. This section explainsyour rights and some of our responsibilities to help you.

Get a copy of your health and claims recordsYou can ask to see or get a copy of yourhealth and claims records and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims recordsYou can ask us to correct your health andclaims records if you think they are incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communicationsYou can ask us to contact you in a specificway (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or shareYou can ask us not to use or share certainhealth information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared informationYou can ask for a list (accounting) of thetimes we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include

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all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy noticeYou can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for youIf you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violatedYou can complain if you feel we have violated your rights by contacting us using the above information. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or atwww.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing acomplaint.

Your ChoicesFor certain health information, you can tell usyour choices about what we share. If youhave a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, closefriends, or others involved in payment for your care

Share information in a disaster reliefsituation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes Sale of your information

Other Uses and Disclosures

How do we typically use or share your health information?We typically use or share your healthinformation in the following ways.

Help manage the health care treatment you receiveWe can use your health information and shareit with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Run our organizationWe can use and disclose your information torun our organization and contact you when necessary.

We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Pay for your health servicesWe can use and disclose your healthinformation as we pay for your health services.

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Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your planWe may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

How else can we use or share your health information?We are allowed or required to share yourinformation in other ways – usually in ways that contribute to the public good, such aspublic health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issuesWe can share health information about youfor certain situations such as:

Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or

domestic violence Preventing or reducing a serious threat to

anyone’s health or safety

Do researchWe can use or share your information forhealth research.

Comply with the lawWe will share information about you if stateor federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying withfederal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral directorWe can share health information about youwith organ procurement organizations. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requestsWe can use or share health information aboutyou:

For workers’ compensation claims For law enforcement purposes or with a law

enforcement official With health oversight agencies for activities

authorized by law For special government functions such as

military, national security, and presidential protective services

Respond to lawsuits and legal actionsWe can share health information about you inresponse to a court or administrative order, or in response to a subpoena.

Our Responsibilities We are required by law to maintain the

privacy and security of your protected health information.

We will let you know promptly if a breachoccurs that may have compromised the privacy or security of your information.

We must follow the duties and privacypractices described in this notice and give you a copy of it.

We will not use or share your informationother than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

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Changes to the Terms of This NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

This Notice of Privacy Practices applies to the following organizations.This Notice of Privacy Practices applies to the INEOS Welfare Benefit Plan and the INEOS Retiree Welfare Benefit Plan, which include the benefits in the group health plans sponsored by INEOS USA LLC that pay for the cost of, or provide, medical, dental, vision, prescription drug, and medical flexible spending benefits. It does not apply to other benefits such as life insurance, disability benefits, or accidental death and dismemberment insurance. If you receive health benefits through an insurance company through the INEOS Welfare Benefit Plan or INEOS Retiree Welfare Benefit Plan, such as vision benefits, you may also receive a notice from the insurer. That notice will describe how the insurer will use your health information and provide your rights.

HIPAA Security Privacy Officer

Pete Train, Benefits Director INEOS USA LLC2600 South Shore Boulevard, Suite 500 League, TX 77573

Effective Date: January 1, 2015

For HIPAA security questions contact the HIPAA Security Privacy Officer.

HIPAA Privacy Officer

Carrie Stotts, Benefits Manager INEOS USA LLC3030 Warrenville Road, Suite 645 Lisle, IL 60532

Effective Date: January 1, 2015

For HIPAA Privacy questions contact the HIPAA Privacy Officer.

HIPAA Special Enrollment Rights NoticeIf you are declining enrollment for yourself or your dependent spouse or children in the INEOS Medical Plan because of other health insurance or group health plan coverage, you should know that you may be able to enroll yourself and your dependents in the Plan ifyou or your dependents lose eligibility for that other coverage (or if the other employer stops contributing toward the other coverage).However, you must request enrollment in the Plan within 30 days after your or your dependents' other coverage ends (or after the other employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents.However, you must request enrollment in the Plan within 30 days after the marriage, birth, adoption, or placement for adoption.

Lastly, if you and/or your dependents were eligible for coverage under the Plan but were not covered, and you and/or your dependents either: (1) lose coverage under a Medicaid plan or a state children's health plan because of a loss of eligibility, or (2) become eligible for premium assistance with respect to a Medicaid plan or a state children's health plan, you may elect coverage under the Plan if you request enrollment within 60 days after loss of such coverage or eligibility for premium assistance.

To request special enrollment or obtain more information, contact:

Pete Train, Benefits Director INEOS USA LLC2600 South Shore Boulevard, Suite 500 League, TX 77573

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Women's Health and Cancer Rights Act

The INEOS Medical Plan provides coverage for:

All stages of reconstruction of the breaston which the mastectomy has been

performed; Surgery and reconstruction of the other

breast to produce a symmetrical appearance; and Prostheses and physical complications of

mastectomy, including lymphedemas, in amanner determined in consultation with the attending physician and the patient.

Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.

For more information, contact your Plan Administrator:

Benefits Administration Committee INEOS USA LLC2600 South Shore Boulevard, Suite 500 League, TX 77573(281) 535-4229

Newborns' and Mothers' Health Protection Act

The INEOS Medical Plan generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

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Medicare Part D Disclosure / Notice of Creditable Coverage

Read and keep this Disclosure Notice if you or your dependents have or soon will be eligible for Medicare Coverage. If you or your dependents are not eligible for Medicare and will not become eligible for Medicare in the next twelve months, this Disclosure Notice does not apply to you.

Please read this notice carefully and keep it where you can find it. You will need it when you receive information from prescriptiondrug plan sponsors and Medicare concerning Medicare Part D prescription drug coverage.You will also need it if you decide not to buy Medicare Part D prescription drug coverage now, but buy it later. This notice has information about your current prescriptiondrug coverage under the INEOS Medical Plan and prescription drug coverage available for people with Medicare. It also explains theoptions you have for prescription drug coverage and can help you decide whether or not you want to enroll in the Medicare Part D prescription drug program. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Part D prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. If you or your dependents are not eligible for Medicare coverage, you are not eligible for the Part D prescription drug benefit and the information in this Notice does not apply to you.

Important Facts about Your Health Plan Coverage & Medicare Prescription Drug Coverage

1. Medicare prescription drug coveragebecame available in 2006 to everyone with Medicare. You can obtain this coverage if you join a Medicare Part D Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a

standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. INEOS has determined that theprescription drug coverage offered by the 80% PPO Plan and 90% PPO Plan are, on average for all plan participants, expected to pay out as much as the standard Part D coverage will pay. This coverage is considered "Creditable Coverage." This means that if you decide to keep your INEOS Medical Plan drug coverage and wait to enroll in a Medicare prescription drug plan, you will not have to pay a late enrollment penalty to Medicare if you later enroll in the Medicare prescription drug plan.

When Can You Join a Medicare Drug Plan?You can join a Medicare drug plan when you first become eligible for Medicare, and each year from October 15th through December 7th. This may mean that you may have to wait to join a Medicare prescription drug plan and that you may pay a higher premium if you join later. However, if you or your spouse leave employer coverage that is creditable (such as the INEOS Medical Plan) or if you otherwise lose other creditable coverage through no fault of your own, you and yourspouse may be eligible for a two (2) month "Special Enrollment Period" to sign up for a Medicare prescription drug plan after theemployer coverage ends, and without having to pay extra for your Medicare prescription drug coverage.

What Are My Choices?Your existing prescription drug coverage with the INEOS Medical Plan provides coverage that is, on average, at least as good as the standard Medicare prescription drug coverage. This means that you can keep your INEOS Medical Plan prescription drug coverage and not pay extra if you wait to enroll in Medicare drug coverage later (unless you have a gap in prescription drug coverage).

You may enroll in a Medicare prescription drug plan without losing your prescription

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drug coverage under the INEOS Medical Plan (unless you do not meet other eligibility requirements under the INEOS Medical Plan). This also applies to your covered dependents. Therefore, you may:

Keep the INEOS Medical Plan coverage anddelay your enrollment in a Medicare prescription drug plan without penalty;

Drop the INEOS Medical Plan coverage andenroll in a Medicare prescription drug plan (remember, if you drop the INEOS Medical Plan coverage, you will lose your medicalbenefits as well as your prescription drug coverage under the INEOS Medical Plan); or

Keep the INEOS Medical Plan coverage andenroll in a Medicare prescription drug plan.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Prescription Drug Plan?If you drop or lose your current coverageunder the INEOS Medical Plan and don’t join a Medicare prescription drug plan within 63 consecutive days after your current coverage ends, you may pay more (a penalty) to join a Medicare prescription drug plan later.

If you go 63 consecutive days or longer without creditable prescription drug coverage that is at least as good as Medicare's prescription drug coverage, your monthly premium for Part D coverage may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have "creditable coverage." For example, if you drop your INEOS Medical Plan coverage and go nineteen months without creditable coverage, your Part D premium will always be at least 19% higher than what most other people pay(i.e., the Medicare base beneficiary premium). You will have to pay this higher premium (a penalty) as long as you have Medicare coverage. You also may have to wait until the following October to enroll in Medicare Part D coverage that will be effective the next January 1. In other words, you most likely do not want to drop

your INEOS Medical Plan coverage until you are enrolled in the Medicare coverage.

You Need to Make A DecisionWhen you make your decision, you shouldalso compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Your decision will be a personal decision based on factors such as the medications you currently take, whether those medications are covered by the INEOS Medical Plan's prescription drug coverage or the Medicare prescription drug plan, whether your pharmacy is a part of the Medicare prescription drug plan, the premiums, deductibles, copays, and coinsurance you pay, and your income level.Most people will not need coverage under both the INEOS Medical Plan and a Medicare prescription drug plan.

You should also know that if you drop or lose your prescription drug coverage under the INEOS Medical Plan and you don't enroll in Medicare prescription drug coverage when your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later.

For More Information about This Notice or Your Current Prescription Drug Coverage

Contact the person listed below for furtherinformation or, you may call your local HR Representative.

NOTE: You’ll receive this notice each year. You will also receive this notice at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if the INEOS Medical Plan coverage changes. You may also request a copy of this notice at any time.

For More Information about Your Options Under Medicare Prescription Drug CoverageMore detailed information about Medicareplans that offer prescription drug coverage is in the “Medicare & You” handbook. You will get a copy of the handbook in the mail every

42

year from Medicare. You may also be contacted directly by Medicare prescription drug plans.

For more information about Medicare prescription drug coverage:

Visit www.medicare.gov Call your State Health Insurance

Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.

Call (800) MEDICARE (800-633-4227). TTYusers should call (877) 486-2048.

For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available. For more information about this extra help, visit Social Security on the web atwww.socialsecurity.gov, or call them at(800) 772-1213 (TTY 1-800-325-0778).

Remember: Keep this CreditableCoverage notice. If you decide to joinone of the Medicare drug plans, you maybe required to provide a copy of thisnotice when you join to show whether ornot you have maintained creditablecoverage and, therefore, whether or notyou are required to pay a higher premium(a penalty).

Date: January 1, 2015

Contact:

Peter Train, Director of Benefits INEOS USA LLC2600 South Shore Blvd, Suite 500 League City, TX 77573(281) 535-4229

Medicaid and the Children's Health Insurance Program (CHIP)

If you or your children are eligible forMedicaid or CHIP and you're eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren't eligible for Medicaid or CHIP, you won't be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For moreinformation, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial(877) KIDS NOW or www.insurekidsnow.gov tofind out how to apply. If you qualify, ask yourstate if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren't already enrolled. This is called a "special enrollment" opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor atwww.askebsa.dol.gov or call (866) 444-EBSA(3272).

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To see if any other states have added a premium assistance program since January 31, 2014, or for more information on special enrollment rights, contact either:

U.S. Department of LaborEmployee Benefits Security Administrationwww.dol.gov/ebsa(866) 444-EBSA (3272)OMB Control Number 1210-0137 (expires 10/31/2016)

U.S. Department of Health & Human Services Centers for Medicare & Medicaid Serviceswww.cms.hhs.gov(877) 267-2323, Menu Option 4, Ext. 61565

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If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2014. Contact your State for more information on eligibility.

ALABAMA – Medicaid COLORADO – MedicaidWebsite: http://www.medicaid.alabama.govPhone: 1-855-692-5447

Medicaid Website: http://www.colorado.gov/Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943ALASKA – Medicaid

Website:http://health.hss.state.ak.us/dpa/programs/medicaid/Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529

ARIZONA – CHIP FLORIDA – Medicaid

Website: http://www.azahcccs.gov/applicantsPhone (Outside of Maricopa County): 1-877-764-5437Phone (Maricopa County): 602-417-5437

Website:https://www.flmedicaidtplrecovery.com/Phone: 1-877-357-3268GEORGIA – MedicaidWebsite: http://dch.georgia.gov/ - Click onPrograms, then Medicaid, then Health Insurance Premium Payment (HIPP)

Phone: 1-800-869-1150IDAHO – Medicaid MONTANA – MedicaidMedicaid Website:http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssistance/tabid/1510/Default.aspxMedicaid Phone: 1-800-926-2588

Website:http://medicaidprovider.hhs.mt.gov/clientpages/clientindex.shtml Phone: 1-800-694-3084

INDIANA – Medicaid NEBRASKA – MedicaidWebsite: http://www.in.gov/fssaPhone: 1-800-889-9949

Website: www.ACCESSNebraska.ne.govPhone: 1-800-383-4278

IOWA – Medicaid NEVADA – MedicaidWebsite: www.dhs.state.ia.us/hipp/Phone: 1-888-346-9562

Medicaid Website: http://dwss.nv.gov/Medicaid Phone: 1-800-992-0900

KANSAS – MedicaidWebsite: http://www.kdheks.gov/hcf/Phone: 1-800-792-4884

KENTUCKY – Medicaid NEW HAMPSHIRE – MedicaidWebsite: http://chfs.ky.gov/dms/default.htmPhone: 1-800-635-2570

Website:http://www.dhhs.nh.gov/oii/documents/hippapp.pdfPhone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIPWebsite: http://www.lahipp.dhh.louisiana.govPhone: 1-888-695-2447

Medicaid Website:http://www.state.nj.us/humanservices/dmahs/clients/medicaid/Medicaid Phone: 609-631-2392 CHIP Website:http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710

MAINE – MedicaidWebsite:http://www.maine.gov/dhhs/ofi/public-assistance/index.html

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Phone: 1-800-977-6740TTY 1-800-977-6741

MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid

Website: http://www.mass.gov/MassHealthPhone: 1-800-462-1120

Website:http://www.nyhealth.gov/health_care/medicaid/Phone: 1-800-541-2831

MINNESOTA – Medicaid NORTH CAROLINA – MedicaidWebsite: http://www.dhs.state.mn.us/

Click on Health Care, then Medical AssistancePhone: 1-800-657-3629

Website: http://www.ncdhhs.gov/dmaPhone: 919-855-4100

MISSOURI – Medicaid NORTH DAKOTA – MedicaidWebsite:http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005

Website:http://www.nd.gov/dhs/services/medicalserv/medicaid/Phone: 1-800-755-2604

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1-888-365-3742

Website: http://health.utah.gov/uppPhone: 1-866-435-7414

OREGON – Medicaid VERMONT– MedicaidWebsite: http://www.oregonhealthykids.govhttp://www.hijossaludablesoregon.govPhone: 1-800-699-9075

Website: http://www.greenmountaincare.org/Phone: 1-800-250-8427

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIPWebsite: http://www.dpw.state.pa.us/hippPhone: 1-800-692-7462

Medicaid Website:http://www.dmas.virginia.gov/rcp-HIPP.htmMedicaid Phone: 1-800-432-5924CHIP Website: http://www.famis.org/CHIP Phone: 1-866-873-2647

RHODE ISLAND – Medicaid WASHINGTON – MedicaidWebsite: www.ohhs.ri.govPhone: 401-462-5300

Website:http://www.hca.wa.gov/medicaid/premiumpymt/ pages/index.aspxPhone: 1-800-562-3022 ext. 15473

SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid

Website: http://www.scdhhs.govPhone: 1-888-549-0820

Website: www.dhhr.wv.gov/bms/Phone: 1-877-598-5820, HMS Third Party Liability

SOUTH DAKOTA - Medicaid WISCONSIN – MedicaidWebsite: http://dss.sd.govPhone: 1-888-828-0059

Website:http://www.badgercareplus.org/pubs/p-10095.htmPhone: 1-800-362-3002

TEXAS – Medicaid WYOMING – MedicaidWebsite: https://www.gethipptexas.com/Phone: 1-800-440-0493

Website:http://health.wyo.gov/healthcarefin/equalitycarePhone: 307-777-7531

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered

to correspond to the Marketplace application.

3. Employer name

4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees. Eligible employees are:

Some employees. Eligible employees are:

• With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended

to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium

discount through the Marketplace. The Marketplace will use your household income, along with other factors,

to determine whether you may be eligible for a premium discount. If, for example, your wages vary from

week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly

employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the

employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your

monthly premiums.

INEOS USA LLC 20-1981933

2600 South Shore Boulevard, Suite 500 281-535-4229

League City TX 77573

Peter M. Train, Director of Benefits and Payroll

[email protected]

✔

✔

✔

All employees scheduled to work 20 hours or more per week will be eligible to participate in the INEOSHealth Plans.

The employee's spouse or domestic partner; the employee's child (natural child, stepchild, legally adoptedchild placed for adoption, or foster child) until age 26; a spouse's or domestic partner's child if a taxdependent of the spouse or domestic partner; a child age 26 or older who is permanently and totally disabledand covered by the Plan prior to attaining age 26.

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered

to correspond to the Marketplace application.

3. Employer name

4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees. Eligible employees are:

Some employees. Eligible employees are:

• With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended

to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium

discount through the Marketplace. The Marketplace will use your household income, along with other factors,

to determine whether you may be eligible for a premium discount. If, for example, your wages vary from

week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly

employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the

employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your

monthly premiums.

INEOS USA LLC 20-1981933

2600 South Shore Boulevard, Suite 500 281-535-4229

League City TX 77573

Peter M. Train, Director of Benefits and Payroll

[email protected]

✔

✔

✔

All employees scheduled to work 20 hours or more per week will be eligible to participate in the INEOSHealth Plans.

The employee's spouse or domestic partner; the employee's child (natural child, stepchild, legally adoptedchild placed for adoption, or foster child) until age 26; a spouse's or domestic partner's child if a taxdependent of the spouse or domestic partner; a child age 26 or older who is permanently and totally disabledand covered by the Plan prior to attaining age 26.

1

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 80%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

This

is o

nly

a su

mm

ary.

If y

ou w

ant m

ore

deta

il ab

out y

our c

over

age

and

cost

s, yo

u ca

n ge

t the

com

plet

e te

rms i

n th

e po

licy

or p

lan

docu

men

t at w

ww

.bcb

sil.c

om o

r by

calli

ng 1

-888

-979

-451

6.

Impo

rtan

t Que

stio

ns

Ans

wer

s W

hy th

is M

atte

rs:

Wha

t is

the

over

all

dedu

ctib

le?

PPO

$4

50 P

erso

n/$1

,350

Fam

ily

Non

-PPO

$9

00 P

erso

n/$2

,700

Fam

ily

Doe

sn’t

appl

y to

cer

tain

pre

vent

ive

serv

ices

, pre

scrip

tions

, em

erge

ncy

room

se

rvic

es, o

r offi

ce c

opay

s.

You

mus

t pay

all

the

cost

s up

to th

e de

duct

ible

am

ount

bef

ore

this

plan

beg

ins t

o pa

y fo

r cov

ered

serv

ices y

ou u

se.

Chec

k yo

ur p

olicy

or p

lan d

ocum

ent t

o se

e w

hen

the

dedu

ctib

le st

arts

ove

r (us

ually

, but

not

alw

ays,

Janu

ary

1st).

See

the

char

t sta

rting

on

page

2 fo

r how

muc

h yo

u pa

y fo

r cov

ered

serv

ices

afte

r you

mee

t th

e de

duct

ible

.

Are

ther

e ot

her

dedu

ctib

les

for s

peci

fic

serv

ices

?

Yes

. $10

0 de

duct

ible

for h

ospi

tal

adm

issio

n.

Ther

e ar

e no

oth

er sp

ecifi

c de

duct

ible

s.

You

mus

t pay

all

of th

e co

sts f

or th

ese

serv

ices u

p to

the

spec

ific

dedu

ctib

le

amou

nt b

efor

e th

is pl

an b

egin

s to

pay

for t

hese

serv

ices

.

Is th

ere

an o

ut–o

f–po

cket

lim

it on

my

expe

nses

?

Yes

. PPO

$2

,000

Per

son/

$4,0

00 F

amily

N

on-P

PO

$4,0

00 P

erso

n/$8

,000

Fam

ily

RX O

ut-o

f-Poc

ket E

xpen

se L

imit:

$1

,500

Indi

vidu

al/ $

3,00

0 Fa

mily

The

out-o

f-poc

ket l

imit

is th

e m

ost y

ou c

ould

pay

dur

ing

a co

vera

ge p

erio

d (u

suall

y on

e ye

ar) f

or y

our s

hare

of t

he c

ost o

f cov

ered

serv

ices.

Thi

s lim

it he

lps

you

plan

for h

ealth

car

e ex

pens

es.

Wha

t is

not i

nclu

ded

in

the

out–

of–p

ocke

t lim

it?

Pres

crip

tion

drug

s, pr

emiu

ms,

balan

ced-

bille

d ch

arge

s, an

d he

alth

care

this

plan

do

esn’

t cov

er.

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

don’

t cou

nt to

war

d th

e ou

t–of

–poc

ket

limit.

Doe

s th

is p

lan

use

a ne

twor

k of

pro

vide

rs?

Yes

. Visi

t ww

w.b

cbsi

l.com

or c

all

1-88

8-97

9-45

16 fo

r a li

st o

f Par

ticip

atin

g pr

ovid

ers.

If y

ou u

se a

n in

-net

wor

k do

ctor

or o

ther

hea

lth c

are

prov

ider

, thi

s plan

will

pay

som

e or

all

of th

e co

sts o

f cov

ered

serv

ices.

Be

awar

e, yo

ur in

-net

wor

k do

ctor

or h

ospi

tal

may

use

an

out-o

f-net

wor

k pr

ovid

er fo

r som

e se

rvice

s. P

lans u

se th

e te

rm in

-ne

twor

k, p

refe

rred

, or p

artic

ipat

ing

for p

rovi

ders

in th

eir n

etw

ork.

See

the

char

t st

artin

g on

pag

e 2

for h

ow th

is pl

an p

ays d

iffer

ent k

inds

of p

rovi

ders

.

Do

I nee

d a

refe

rral

to

see

a sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out p

erm

issio

n fr

om th

is pl

an.

Are

ther

e se

rvic

es th

is

plan

doe

sn’t

cove

r?

Yes

. So

me

of th

e se

rvic

es th

is pl

an d

oesn

’t co

ver a

re li

sted

on

page

5. S

ee y

our p

olic

y or

plan

doc

umen

t for

add

ition

al in

form

atio

n ab

out e

xclu

ded

serv

ices

.

2

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 80%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

C

opay

men

ts a

re fi

xed

dolla

r am

ount

s (fo

r exa

mpl

e, $1

5) y

ou p

ay fo

r cov

ered

hea

lth c

are,

usua

lly w

hen

you

rece

ive

the

serv

ice.

C

oins

uran

ce is

your

shar

e of

the

cost

s of a

cov

ered

serv

ice,

calc

ulat

ed a

s a p

erce

nt o

f the

allo

wed

am

ount

for t

he se

rvic

e. Fo

r exa

mpl

e, if

the

plan

’s al

low

ed a

mou

nt fo

r an

over

nigh

t hos

pita

l sta

y is

$1,0

00, y

our c

oins

uran

ce p

aym

ent o

f 20%

wou

ld b

e $2

00.

This

may

cha

nge

if yo

u ha

ven’

t met

you

r ded

uctib

le.

Th

e am

ount

the

plan

pay

s for

cov

ered

serv

ices

is b

ased

on

the

allo

wed

am

ount

. If a

n ou

t-of-n

etw

ork

prov

ider

cha

rges

mor

e th

an th

e al

low

ed a

mou

nt, y

ou m

ay h

ave

to p

ay th

e di

ffere

nce.

For e

xam

ple,

if an

out

-of-n

etw

ork

hosp

ital c

harg

es $

1,50

0 fo

r an

over

nigh

t sta

y an

d th

e al

low

ed a

mou

nt is

$1,

000,

you

may

hav

e to

pay

the

$500

diff

eren

ce. (

This

is ca

lled

bala

nce

billi

ng.)

Th

is pl

an m

ay e

ncou

rage

you

to u

se P

PO p

rovi

ders

by

char

ging

you

low

er d

educ

tible

s, co

paym

ents

and

coi

nsur

ance

am

ount

s. C

omm

on

Med

ical

Eve

nt

Serv

ices

You

May

Nee

d Yo

ur C

ost I

f Yo

u U

se a

n

PPO

P

rovi

der

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce

or c

linic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

$20

copa

y/vi

sit

40%

coi

nsur

ance

Co

pay

appl

ies t

o of

fice

visit

onl

y.

Spec

ialist

visi

t $3

0 co

pay/

visit

40

% c

oins

uran

ce

Copa

y ap

plie

s to

offic

e vi

sit o

nly.

Oth

er p

ract

ition

er o

ffice

visi

t 20

% c

oins

uran

ce

40%

coi

nsur

ance

Li

mite

d to

chi

ropr

actic

and

os

teop

athi

c m

anip

ulat

ions

.

Prev

entiv

e ca

re/s

cree

ning

/im

mun

izat

ion

No

Char

ge

40%

coi

nsur

ance

---

none

---

If y

ou h

ave

a te

st

Diag

nost

ic te

st (x

-ray,

bloo

d w

ork)

20

% c

oins

uran

ce

40%

coi

nsur

ance

---

none

---

Imag

ing

(CT/

PET

scan

s, M

RIs)

20

% c

oins

uran

ce

40%

coi

nsur

ance

---

none

---

3

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 80%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

Your

Cos

t If

You

Use

an

PP

O

Pro

vide

r

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

drug

s to

tre

at y

our i

llnes

s or

co

nditi

on

Mor

e in

form

atio

n ab

out p

resc

riptio

n dr

ug c

over

age

is av

ailab

le a

t w

ww

.bcb

sil.co

m.

Gen

eric

drug

s

$8 c

opay

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

$20

copa

y/

pres

crip

tion

for u

p to

a 9

0 da

y su

pply.

$8 c

opay

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

$20

copa

y/

pres

crip

tion

for u

p to

a 9

0 da

y su

pply.

Certa

in w

omen

’s pr

even

tativ

e se

rvice

s w

ill b

e co

vere

d w

ith n

o co

st to

the

mem

ber.

For a

full

list o

f the

se

pres

crip

tions

and

/or s

ervi

ces,

plea

se

cont

act C

usto

mer

Ser

vice

.

Form

ular

y br

and

drug

s

20%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

15%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

90

day

supp

ly.

20%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

15%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

90

day

supp

ly.

30 d

ay su

pply:

Max

$40

per

pr

escr

iptio

n; 9

0 da

y su

pply:

Max

$10

0 pe

r pre

scrip

tion.

Se

e ab

ove

(refe

r to

gene

ric).

Non

-For

mul

ary

bran

d dr

ugs

30%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

25%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

90

day

supp

ly.

30%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

25%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

90

day

supp

ly.

30 d

ay su

pply:

Max

$60

per

pr

escr

iptio

n; 9

0 da

y su

pply:

Max

$15

0 pe

r pre

scrip

tion.

Se

e ab

ove

(refe

r to

gene

ric).

Spec

ialty

dru

gs

$8 c

opay

/gen

eric

pres

crip

tion.

20

% c

oins

uran

ce/

Form

ular

y br

and

pres

crip

tion.

30

% c

oins

uran

ce/

Non

-For

mul

ary

bran

d pr

escr

iptio

n.

30 d

ay su

pply.

Not

Cov

ered

Form

ular

y br

and

$40

max

imum

N

on-F

orm

ular

y br

and

$60

max

imum

. Sp

ecial

ty re

tail

limite

d to

a 3

0 da

y su

pply

.

If y

ou h

ave

outp

atie

nt s

urge

ry

Faci

lity

fee

(e.g

., am

bulat

ory

surg

ery

cent

er)

20%

coi

nsur

ance

40

% c

oins

uran

ce

---no

ne---

Ph

ysic

ian/s

urge

on fe

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

4

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 80%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

Your

Cos

t If

You

Use

an

PP

O

Pro

vide

r

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

imm

edia

te m

edic

al

atte

ntio

n

Em

erge

ncy

room

serv

ices

$1

00 c

opay

plu

s 20

% c

oins

uran

ce.

$100

cop

ay p

lus

20%

coi

nsur

ance

. Co

pay

waiv

ed if

adm

itted

.

Em

erge

ncy

med

ical

trans

porta

tion

20%

coi

nsur

ance

20

% c

oins

uran

ce

---no

ne---

U

rgen

t car

e 20

% c

oins

uran

ce

40%

coi

nsur

ance

---

none

---

If y

ou h

ave

a ho

spita

l sta

y

Faci

lity

fee

(e.g

., ho

spita

l roo

m)

$100

cop

ay p

lus

20%

coi

nsur

ance

$1

00 c

opay

plu

s 40

% c

oins

uran

ce

---no

ne---

Phys

ician

/sur

geon

fee

20%

coi

nsur

ance

40

% c

oins

uran

ce

---no

ne---

If y

ou h

ave

men

tal

heal

th, b

ehav

iora

l he

alth

, or s

ubst

ance

ab

use

need

s

Men

tal/

Beha

vior

al he

alth

outp

atien

t ser

vice

s 20

% c

oins

uran

ce

40%

coi

nsur

ance

---

none

---

Men

tal/

Beha

vior

al he

alth

inpa

tient

serv

ices

$1

00 c

opay

plu

s 20

% c

oins

uran

ce

$100

cop

ay p

lus

40%

coi

nsur

ance

---

none

---

Subs

tanc

e us

e di

sord

er o

utpa

tient

serv

ices

20

% c

oins

uran

ce

40%

coi

nsur

ance

---

none

---

Subs

tanc

e us

e di

sord

er in

patie

nt se

rvic

es

$100

cop

ay p

lus

20%

coi

nsur

ance

$1

00 c

opay

plu

s 40

% c

oins

uran

ce

---no

ne---

If y

ou a

re p

regn

ant

Pren

atal

and

post

nata

l car

e $2

0 co

pay

40%

coi

nsur

ance

Co

pay

appl

ies t

o fir

st p

rena

tal v

isit

(per

pre

gnan

cy).

Del

iver

y an

d all

inpa

tient

serv

ices

$1

00 c

opay

plu

s 20

% c

oins

uran

ce

$100

cop

ay p

lus

40%

coi

nsur

ance

---

none

---

5

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 80%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

Your

Cos

t If

You

Use

an

PP

O

Pro

vide

r

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

help

re

cove

ring

or h

ave

othe

r spe

cial

hea

lth

need

s

Hom

e he

alth

care

20

% c

oins

uran

ce

40%

coi

nsur

ance

Li

mite

d to

120

visi

ts p

er b

enef

it pe

riod.

Re

habi

litat

ion

serv

ices

20

% c

oins

uran

ce

40%

coi

nsur

ance

Li

mite

d to

90

visit

s per

ben

efit

perio

d.

Hab

ilita

tion

serv

ices

20

% c

oins

uran

ce

40%

coi

nsur

ance

Li

mite

d to

90

visit

s per

ben

efit

perio

d.

Skill

ed n

ursin

g ca

re

$100

cop

ay p

lus

20%

coi

nsur

ance

$1

00 c

opay

plu

s 40

% c

oins

uran

ce

Lim

ited

to 1

20 d

ays p

er b

enef

it pe

riod.

Dur

able

med

ical

equi

pmen

t 20

% c

oins

uran

ce

40%

coi

nsur

ance

Bene

fits a

re li

mite

d to

item

s use

d to

se

rve

a m

edic

al pu

rpos

e. D

ME

be

nefit

s are

pro

vide

d fo

r bot

h pu

rcha

se a

nd re

ntal

equi

pmen

t (up

to

the

purc

hase

pric

e).

Hos

pice

serv

ice

20%

coi

nsur

ance

40

% c

oins

uran

ce

---no

ne---

If y

our c

hild

nee

ds

dent

al o

r eye

car

e

Eye

exa

m

Not

Cov

ered

N

ot C

over

ed

---no

ne---

G

lasse

s N

ot C

over

ed

Not

Cov

ered

D

enta

l che

ck-u

p N

ot C

over

ed

Not

Cov

ered

Excl

uded

Ser

vice

s &

Oth

er C

over

ed S

ervi

ces:

Se

rvic

es Y

our P

lan

Doe

s N

OT

Cov

er (T

his

isn’

t a c

ompl

ete

list.

Che

ck y

our p

olic

y or

pla

n do

cum

ent f

or o

ther

exc

lude

d se

rvic

es.)

A

cupu

nctu

re

Co

smet

ic S

urge

ry

D

enta

l Car

e (A

dult)

Lo

ng T

erm

Car

e

Rout

ing

Eye

Car

e (A

dult)

Ro

utin

g Fo

ot C

are

(with

the

exce

ptio

n of

pe

rson

with

diag

nosis

of d

iabet

es)

W

eigh

t Los

s Pro

gram

O

ther

Cov

ered

Ser

vice

s (T

his

isn’

t a c

ompl

ete

list.

Che

ck y

our p

olic

y or

pla

n do

cum

ent f

or o

ther

cov

ered

ser

vice

s an

d yo

ur c

osts

for t

hese

se

rvic

es.)

Ba

riatri

c Su

rger

y

Chiro

prac

tic C

are

H

earin

g A

id

In

ferti

lity

Trea

tmen

t

Mos

t cov

erag

e pr

ovid

ed o

utsid

e th

e U

nite

d St

ates

. See

ww

w.b

cbsil

.com

N

on-E

mer

genc

y Ca

re W

hen

Trav

elin

g O

utsid

e th

e U

.S

Pr

ivat

e D

uty

Nur

sing

(with

the

exce

ptio

n of

inpa

tient

priv

ate

duty

nur

sing)

6

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 80%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Your

Rig

hts

to C

ontin

ue C

over

age:

If

you

lose

cov

erag

e un

der t

he p

lan, t

hen,

dep

endi

ng u

pon

the

circ

umst

ance

s, Fe

dera

l and

Sta

te la

ws m

ay p

rovi

de p

rote

ctio

ns th

at a

llow

you

to k

eep

healt

h co

vera

ge. A

ny su

ch ri

ghts

may

be

limite

d in

dur

atio

n an

d w

ill re

quire

you

to p

ay a

pre

miu

m, w

hich

may

be

signi

fican

tly h

ighe

r tha

n th

e pr

emiu

m y

ou p

ay

whi

le c

over

ed u

nder

the

plan

. Oth

er li

mita

tions

on

your

righ

ts to

con

tinue

cov

erag

e m

ay a

lso a

pply

. Fo

r mor

e in

form

atio

n on

you

r rig

hts t

o co

ntin

ue c

over

age,

cont

act t

he p

lan a

t 1-8

88-9

79-4

516.

You

may

also

con

tact

you

r sta

te in

sura

nce

depa

rtmen

t, th

e U

.S. D

epar

tmen

t of L

abor

, Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istra

tion

at 1

-866

-444

-327

2 or

ww

w.d

ol.g

ov/e

bsa,

or th

e U

.S. D

epar

tmen

t of H

ealth

and

H

uman

Ser

vice

s at 1

-877

-267

-232

3 x6

1565

or w

ww

.cciio

.cms.g

ov.

Your

Grie

vanc

e an

d A

ppea

ls R

ight

s:

If y

ou h

ave

a co

mpl

aint o

r are

diss

atisf

ied

with

a d

enial

of c

over

age

for c

laim

s und

er y

our p

lan, y

ou m

ay b

e ab

le to

app

eal o

r file

a g

rieva

nce.

For

qu

estio

ns a

bout

you

r rig

hts,

this

notic

e, or

ass

istan

ce, y

ou c

an c

onta

ct B

lue

Cros

s and

Blu

e Sh

ield

of I

llino

is at

1-8

88-9

79-4

516

or v

isit w

ww

.bcb

sil.co

m, o

r co

ntac

t the

U.S

Dep

artm

ent o

f Lab

or's

Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istra

tion

at 1

-866

-444

-EBS

A (3

272)

or v

isit w

ww

.dol

.gov

/ebs

a/he

althr

efor

m.

Add

ition

ally,

a co

nsum

er a

ssist

ance

pro

gram

can

help

you

file

you

r app

eal.

Cont

act t

he Il

linoi

s Dep

artm

ent o

f Ins

uran

ce a

t (87

7) 5

27-9

431

or v

isit

http

://i

nsur

ance

.illin

ois.g

ov.

Doe

s th

is C

over

age

Prov

ide

Min

imum

Ess

entia

l Cov

erag

e?

The

Affo

rdab

le C

are

Act

requ

ires m

ost p

eopl

e to

hav

e he

alth

care

cov

erag

e th

at q

ualif

ies a

s “m

inim

um e

ssen

tial c

over

age.”

Thi

s pl

an o

r pol

icy

does

pr

ovid

e m

inim

um e

ssen

tial c

over

age.

D

oes

this

Cov

erag

e M

eet t

he M

inim

um V

alue

Sta

ndar

d?

The

Affo

rdab

le C

are

Act

est

ablis

hes a

min

imum

valu

e st

anda

rd o

f ben

efits

of a

hea

lth p

lan. T

he m

inim

um v

alue

stan

dard

is 6

0% (a

ctua

rial v

alue)

. Thi

s he

alth

cov

erag

e do

es m

eet t

he m

inim

um v

alue

sta

ndar

d fo

r the

ben

efits

it p

rovi

des.

Lang

uage

Acc

ess

Serv

ices

: Sp

anish

(Esp

añol

): Pa

ra o

bten

er a

siste

ncia

en E

spañ

ol, l

lame

al 1-

888-

979-

4516

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galo

g (T

agalo

g): K

ung

kaila

ngan

nin

yo a

ng tu

long

sa T

agalo

g tu

maw

ag sa

1-88

8-97

9-45

16.

Chin

ese

(中文

): 如果需要中文的帮助，请拨打这个号码

1-88

8-97

9-45

16.

Nav

ajo (D

ine)

: Din

ek'eh

go sh

ika

at'o

hwol

nin

ising

o, k

wiij

igo

holn

e' 1-

888-

979-

4516

. ––

––––

––––

––––

––––

––––

To se

e exa

mples

of h

ow th

is pla

n mi

ght c

over

costs

for a

samp

le me

dical

situa

tion,

see th

e nex

t pag

e.–––

––––

––––

––––

––––

–––

7

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 80%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 C

over

age

Exa

mpl

es

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Hav

ing

a ba

by

(nor

mal

deliv

ery)

Man

agin

g ty

pe 2

dia

bete

s (ro

utin

e m

ainte

nanc

e of

a

wel

l-con

trolle

d co

nditi

on)

Abo

ut th

ese

Cov

erag

e Ex

ampl

es:

Thes

e ex

ampl

es sh

ow h

ow th

is pl

an m

ight

cov

er

med

ical

care

in g

iven

situ

atio

ns. U

se th

ese

exam

ples

to se

e, in

gen

eral,

how

muc

h fin

ancia

l pr

otec

tion

a sa

mpl

e pa

tient

mig

ht g

et if

they

are

co

vere

d un

der d

iffer

ent p

lans.

A

mou

nt o

wed

to p

rovi

ders

: $7,

540

P

lan

pays

$5,

810

P

atie

nt p

ays

$1,7

30

Sa

mpl

e ca

re c

osts

: H

ospi

tal c

harg

es (m

othe

r) $2

,700

Ro

utin

e ob

stet

ric c

are

$2,1

00

Hos

pita

l cha

rges

(bab

y)

$900

A

nest

hesia

$9

00

Labo

rato

ry te

sts

$500

Pr

escr

iptio

ns

$200

Ra

diol

ogy

$200

V

acci

nes,

othe

r pre

vent

ive

$40

Tot

al

$7,5

40

Patie

nt p

ays:

D

educ

tibles

$4

50

Copa

ys

$30

Coin

sura

nce

$1,0

10

Lim

its o

r exc

lusio

ns

$150

T

otal

$1

,640

A

mou

nt o

wed

to p

rovi

ders

: $5,

400

P

lan

pays

$4,

120

P

atie

nt p

ays

$1,3

60

Sa

mpl

e ca

re c

osts

: Pr

escr

iptio

ns

$2,9

00

Med

ical

Equ

ipm

ent a

nd S

uppl

ies

$1,3

00

Offi

ce V

isits

and

Pro

cedu

res

$700

E

duca

tion

$300

La

bora

tory

test

s $1

00

Vac

cine

s, ot

her p

reve

ntiv

e $1

00

Tot

al

$5,4

00

Patie

nt p

ays:

D

educ

tibles

$4

50

Copa

ys

$510

Co

insu

ranc

e $2

40

Lim

its o

r exc

lusio

ns

$80

Tot

al

$1,2

80

Not

e: Th

ese

exam

ples

are

bas

ed o

n in

divi

dual

cove

rage

onl

y.

This

is

not a

cos

t es

timat

or.

Don

’t us

e th

ese

exam

ples

to

estim

ate

your

act

ual c

osts

un

der t

his p

lan. T

he a

ctua

l ca

re y

ou re

ceiv

e w

ill b

e di

ffere

nt fr

om th

ese

exam

ples

, and

the

cost

of

that

car

e w

ill a

lso b

e di

ffere

nt.

See

the

next

pag

e fo

r im

porta

nt in

form

atio

n ab

out

thes

e ex

ampl

es.

8

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 80%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 C

over

age

Exa

mpl

es

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Que

stio

ns a

nd a

nsw

ers

abou

t the

Cov

erag

e Ex

ampl

es:

Wha

t are

som

e of

the

assu

mpt

ions

beh

ind

the

Cov

erag

e Ex

ampl

es?

Co

sts d

on’t

incl

ude

prem

ium

s.

Sam

ple

care

cos

ts a

re b

ased

on

natio

nal

aver

ages

supp

lied

by th

e U

.S.

Dep

artm

ent o

f Hea

lth a

nd H

uman

Se

rvice

s, an

d ar

en’t

spec

ific

to a

pa

rticu

lar g

eogr

aphi

c ar

ea o

r hea

lth p

lan.

Th

e pa

tient

’s co

nditi

on w

as n

ot a

n ex

clud

ed o

r pre

exist

ing

cond

ition

.

All

serv

ices

and

trea

tmen

ts st

arte

d an

d en

ded

in th

e sa

me

cove

rage

per

iod.

Ther

e ar

e no

oth

er m

edica

l exp

ense

s for

an

y m

embe

r cov

ered

und

er th

is pl

an.

O

ut-o

f-poc

ket e

xpen

ses a

re b

ased

onl

y on

trea

ting

the

cond

ition

in th

e ex

ampl

e.

The

patie

nt re

ceiv

ed a

ll ca

re fr

om in

-ne

twor

k pr

ovid

ers.

If th

e pa

tient

had

re

ceiv

ed c

are

from

out

-of-n

etw

ork

prov

ider

s, co

sts w

ould

hav

e be

en h

ighe

r.

Wha

t doe

s a

Cov

erag

e Ex

ampl

e sh

ow?

Fo

r eac

h tre

atm

ent s

ituat

ion,

the

Cove

rage

E

xam

ple

help

s you

see

how

ded

uctib

les,

copa

ymen

ts, a

nd c

oins

uran

ce c

an a

dd u

p. It

als

o he

lps y

ou se

e w

hat e

xpen

ses m

ight

be

left

up to

you

to p

ay b

ecau

se th

e se

rvic

e or

tre

atm

ent i

sn’t

cove

red

or p

aym

ent i

s lim

ited.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y ow

n ca

re n

eeds

?

N

o. T

reat

men

ts sh

own

are

just

exa

mpl

es.

The

care

you

wou

ld re

ceiv

e fo

r thi

s co

nditi

on c

ould

be

diffe

rent

bas

ed o

n yo

ur

doct

or’s

advi

ce, y

our a

ge, h

ow se

rious

you

r co

nditi

on is

, and

man

y ot

her f

acto

rs.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y fu

ture

exp

ense

s?

N

o. C

over

age

Exa

mpl

es a

re n

ot c

ost

estim

ator

s. Y

ou c

an’t

use

the

exam

ples

to

estim

ate

cost

s for

an

actu

al co

nditi

on. T

hey

are

for c

ompa

rativ

e pu

rpos

es o

nly.

You

r ow

n co

sts w

ill b

e di

ffere

nt d

epen

ding

on

the

care

you

rece

ive,

the

price

s you

r pr

ovid

ers

char

ge, a

nd th

e re

imbu

rsem

ent

your

hea

lth p

lan a

llow

s.

Can

I us

e C

over

age

Exam

ples

to

com

pare

pla

ns?

Y

es. W

hen

you

look

at t

he S

umm

ary

of

Bene

fits a

nd C

over

age

for o

ther

plan

s, yo

u’ll

find

the

sam

e Co

vera

ge E

xam

ples

. W

hen

you

com

pare

plan

s, ch

eck

the

“Pat

ient P

ays”

box

in e

ach

exam

ple.

The

small

er th

at n

umbe

r, th

e m

ore

cove

rage

th

e pl

an p

rovi

des.

Are

ther

e ot

her c

osts

I sh

ould

co

nsid

er w

hen

com

parin

g pl

ans?

Y

es. A

n im

porta

nt c

ost i

s the

pre

miu

m

you

pay.

Gen

erall

y, th

e lo

wer

you

r pr

emiu

m, t

he m

ore

you’

ll pa

y in

out

-of-

pock

et c

osts

, suc

h as

cop

aym

ents

, de

duct

ible

s, an

d co

insu

ranc

e. Y

ou

shou

ld a

lso c

onsid

er c

ontri

butio

ns to

ac

coun

ts su

ch a

s hea

lth sa

ving

s acc

ount

s (H

SAs)

, flex

ible

spen

ding

arr

ange

men

ts

(FSA

s) o

r hea

lth re

imbu

rsem

ent a

ccou

nts

(HRA

s) th

at h

elp y

ou p

ay o

ut-o

f-poc

ket

expe

nses

.

1

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

This

is o

nly

a su

mm

ary.

If y

ou w

ant m

ore

deta

il ab

out y

our c

over

age

and

cost

s, yo

u ca

n ge

t the

com

plet

e te

rms i

n th

e po

licy

or p

lan

docu

men

t at w

ww

.bcb

sil.c

om o

r by

calli

ng 1

-888

-979

-451

6.

Impo

rtan

t Que

stio

ns

Ans

wer

s W

hy th

is M

atte

rs:

Wha

t is

the

over

all

dedu

ctib

le?

PPO

$70

0 Pe

rson

/$2,

100F

amily

N

on-P

PO $

1,40

0 Pe

rson

/$4,

200

Fam

ily.

Doe

sn’t

appl

y to

cer

tain

pre

vent

ive

serv

ices

, pre

scrip

tions

, em

erge

ncy

room

se

rvic

es, o

r offi

ce c

opay

s.

You

mus

t pay

all

the

cost

s up

to th

e de

duct

ible

am

ount

bef

ore

this

plan

beg

ins t

o pa

y fo

r cov

ered

serv

ices y

ou u

se.

Chec

k yo

ur p

olicy

or p

lan d

ocum

ent t

o se

e w

hen

the

dedu

ctib

le st

arts

ove

r (us

ually

, but

not

alw

ays,

Janu

ary

1st).

See

the

char

t sta

rting

on

page

2 fo

r how

muc

h yo

u pa

y fo

r cov

ered

serv

ices

afte

r you

mee

t th

e de

duct

ible

.

Are

ther

e ot

her

dedu

ctib

les

for s

peci

fic

serv

ices

?

Yes

. $10

0 de

duct

ible

for

hosp

ital a

dmiss

ion.

Th

ere

are

no o

ther

spec

ific

dedu

ctib

les.

You

mus

t pay

all

of th

e co

sts f

or th

ese

serv

ices u

p to

the

spec

ific

dedu

ctib

le

amou

nt b

efor

e th

is pl

an b

egin

s to

pay

for t

hese

serv

ices.

Is th

ere

an o

ut–o

f–po

cket

lim

it on

my

expe

nses

?

Yes

. PPO

$2,

000

Pers

on/$

4,00

0 Fa

mily

N

on-P

PO

$4,0

00 P

erso

n/$8

,000

Fam

ily

RX O

ut-o

f-Poc

ket E

xpen

se L

imit:

$1

,500

Indi

vidu

al/ $

3,00

0 Fa

mily

The

out-o

f-poc

ket l

imit

is th

e m

ost y

ou c

ould

pay

dur

ing

a co

vera

ge p

erio

d (u

suall

y on

e ye

ar) f

or y

our s

hare

of t

he c

ost o

f cov

ered

serv

ices

. Th

is lim

it he

lps

you

plan

for h

ealth

car

e ex

pens

es.

Wha

t is

not i

nclu

ded

in

the

out–

of–p

ocke

t lim

it?

Pres

crip

tion

drug

s, pr

emiu

ms,

balan

ced-

bille

d ch

arge

s, an

d he

alth

care

this

plan

do

esn’

t cov

er.

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

don’

t cou

nt to

war

d th

e ou

t–of

–poc

ket

limit.

Doe

s th

is p

lan

use

a ne

twor

k of

pro

vide

rs?

Yes

. Visi

t ww

w.b

cbsi

l.com

or c

all

1-88

8-97

9-45

16 fo

r a li

st o

f Par

ticip

atin

g pr

ovid

ers.

If y

ou u

se a

n in

-net

wor

k do

ctor

or o

ther

hea

lth c

are

prov

ider

, thi

s plan

will

pay

so

me

or a

ll of

the

cost

s of c

over

ed se

rvic

es.

Be a

war

e, yo

ur in

-net

wor

k do

ctor

or

hosp

ital m

ay u

se a

n ou

t-of-n

etw

ork

prov

ider

for s

ome

serv

ices

. Pl

ans u

se th

e te

rm in

-net

wor

k, p

refe

rred

, or p

artic

ipat

ing

for p

rovi

ders

in th

eir n

etw

ork.

See

th

e ch

art s

tarti

ng o

n pa

ge 2

for h

ow th

is pl

an p

ays d

iffer

ent k

inds

of p

rovi

ders

.

Do

I nee

d a

refe

rral

to

see

a sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out p

erm

issio

n fr

om th

is pl

an.

Are

ther

e se

rvic

es th

is

plan

doe

sn’t

cove

r?

Yes

. So

me

of th

e se

rvic

es th

is pl

an d

oesn

’t co

ver a

re li

sted

on p

age

5. S

ee y

our p

olic

y or

plan

doc

umen

t for

add

ition

al in

form

atio

n ab

out e

xclu

ded

serv

ices

.

2

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

C

opay

men

ts a

re fi

xed

dolla

r am

ount

s (fo

r exa

mpl

e, $1

5) y

ou p

ay fo

r cov

ered

hea

lth c

are,

usua

lly w

hen

you

rece

ive

the

serv

ice.

Coi

nsur

ance

is yo

ur sh

are

of th

e co

sts o

f a c

over

ed se

rvic

e, ca

lculat

ed a

s a p

erce

nt o

f the

allo

wed

am

ount

for t

he se

rvic

e. Fo

r exa

mpl

e, if

the

plan

’s al

low

ed a

mou

nt fo

r an

over

nigh

t hos

pita

l sta

y is

$1,0

00, y

our c

oins

uran

ce p

aym

ent o

f 20%

wou

ld b

e $2

00.

This

may

cha

nge

if yo

u ha

ven’

t met

you

r ded

uctib

le.

Th

e am

ount

the

plan

pay

s for

cov

ered

serv

ices

is b

ased

on

the

allo

wed

am

ount

. If a

n ou

t-of-n

etw

ork

prov

ider

cha

rges

mor

e th

an th

e al

low

ed a

mou

nt, y

ou m

ay h

ave

to p

ay th

e di

ffere

nce.

For e

xam

ple,

if an

out

-of-n

etw

ork

hosp

ital c

harg

es $

1,50

0 fo

r an

over

nigh

t sta

y an

d th

e al

low

ed a

mou

nt is

$1,

000,

you

may

hav

e to

pay

the

$500

diff

eren

ce. (

This

is ca

lled

bala

nce

billi

ng.)

Th

is pl

an m

ay e

ncou

rage

you

to u

se P

PO p

rovi

ders

by

char

ging

you

low

er d

educ

tible

s, co

paym

ents

and

coi

nsur

ance

am

ount

s. C

omm

on

Med

ical

Eve

nt

Serv

ices

You

May

Nee

d Yo

ur C

ost I

f Yo

u U

se a

n

PPO

P

rovi

der

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce

or c

linic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

$20

copa

y/vi

sit

30%

coi

nsur

ance

Co

pay

appl

ies t

o of

fice

visit

onl

y.

Spec

ialist

visi

t $3

0 co

pay/

visit

30

% c

oins

uran

ce

Copa

y ap

plie

s to

offic

e vi

sit o

nly.

Oth

er p

ract

ition

er o

ffice

visi

t 10

% c

oins

uran

ce

30%

coi

nsur

ance

Li

mite

d to

Chi

ropr

actic

and

O

steo

path

ic m

anip

ulat

ions

.

Prev

entiv

e ca

re/s

cree

ning

/im

mun

izat

ion

No

Char

ge

30%

coi

nsur

ance

---

none

---

If y

ou h

ave

a te

st

Diag

nost

ic te

st (x

-ray,

bloo

d w

ork)

10

% c

oins

uran

ce

30%

coi

nsur

ance

---

none

---

Imag

ing

(CT/

PET

scan

s, M

RIs)

10

% c

oins

uran

ce

30%

coi

nsur

ance

2

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

C

opay

men

ts a

re fi

xed

dolla

r am

ount

s (fo

r exa

mpl

e, $1

5) y

ou p

ay fo

r cov

ered

hea

lth c

are,

usua

lly w

hen

you

rece

ive

the

serv

ice.

Coi

nsur

ance

is yo

ur sh

are

of th

e co

sts o

f a c

over

ed se

rvic

e, ca

lculat

ed a

s a p

erce

nt o

f the

allo

wed

am

ount

for t

he se

rvic

e. Fo

r exa

mpl

e, if

the

plan

’s al

low

ed a

mou

nt fo

r an

over

nigh

t hos

pita

l sta

y is

$1,0

00, y

our c

oins

uran

ce p

aym

ent o

f 20%

wou

ld b

e $2

00.

This

may

cha

nge

if yo

u ha

ven’

t met

you

r ded

uctib

le.

Th

e am

ount

the

plan

pay

s for

cov

ered

serv

ices

is b

ased

on

the

allo

wed

am

ount

. If a

n ou

t-of-n

etw

ork

prov

ider

cha

rges

mor

e th

an th

e al

low

ed a

mou

nt, y

ou m

ay h

ave

to p

ay th

e di

ffere

nce.

For e

xam

ple,

if an

out

-of-n

etw

ork

hosp

ital c

harg

es $

1,50

0 fo

r an

over

nigh

t sta

y an

d th

e al

low

ed a

mou

nt is

$1,

000,

you

may

hav

e to

pay

the

$500

diff

eren

ce. (

This

is ca

lled

bala

nce

billi

ng.)

Th

is pl

an m

ay e

ncou

rage

you

to u

se P

PO p

rovi

ders

by

char

ging

you

low

er d

educ

tible

s, co

paym

ents

and

coi

nsur

ance

am

ount

s. C

omm

on

Med

ical

Eve

nt

Serv

ices

You

May

Nee

d Yo

ur C

ost I

f Yo

u U

se a

n

PPO

P

rovi

der

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce

or c

linic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

$20

copa

y/vi

sit

30%

coi

nsur

ance

Co

pay

appl

ies t

o of

fice

visit

onl

y.

Spec

ialist

visi

t $3

0 co

pay/

visit

30

% c

oins

uran

ce

Copa

y ap

plie

s to

offic

e vi

sit o

nly.

Oth

er p

ract

ition

er o

ffice

visi

t 10

% c

oins

uran

ce

30%

coi

nsur

ance

Li

mite

d to

Chi

ropr

actic

and

O

steo

path

ic m

anip

ulat

ions

.

Prev

entiv

e ca

re/s

cree

ning

/im

mun

izat

ion

No

Char

ge

30%

coi

nsur

ance

---

none

---

If y

ou h

ave

a te

st

Diag

nost

ic te

st (x

-ray,

bloo

d w

ork)

10

% c

oins

uran

ce

30%

coi

nsur

ance

---

none

---

Imag

ing

(CT/

PET

scan

s, M

RIs)

10

% c

oins

uran

ce

30%

coi

nsur

ance

3

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

Your

Cos

t If

You

Use

an

PP

O

Pro

vide

r

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

drug

s to

tre

at y

our i

llnes

s or

co

nditi

on

Mor

e in

form

atio

n ab

out p

resc

riptio

n dr

ug c

over

age

is av

ailab

le a

t w

ww

.bcb

sil.co

m.

Gen

eric

drug

s

$8 c

opay

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

$20

copa

y/

pres

crip

tion

for u

p to

a 9

0 da

y su

pply.

$8 c

opay

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

$20

copa

y/

pres

crip

tion

for u

p to

a 9

0 da

y su

pply.

Certa

in w

omen

’s pr

even

tativ

e se

rvice

s w

ill b

e co

vere

d w

ith n

o co

st to

the

mem

ber.

For a

full

list o

f the

se

pres

crip

tions

and

/or s

ervi

ces,

plea

se

cont

act C

usto

mer

Ser

vice

.

Form

ular

y br

and

drug

s

20%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

15%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

90

day

supp

ly.

20%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

15%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

90

day

supp

ly.

30 d

ay su

pply:

Max

$40

per

pr

escr

iptio

n; 9

0 da

y su

pply:

Max

$10

0 pe

r pre

scrip

tion.

See

abov

e (re

fer t

o ge

neric

).

Non

-For

mul

ary

bran

d dr

ugs

30%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

25%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

90

day

supp

ly.

30%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

30

day

supp

ly.

25%

coi

nsur

ance

/ pr

escr

iptio

n fo

r up

to a

90

day

supp

ly..

30 d

ay su

pply:

Max

$60

per

pr

escr

iptio

n; 9

0 da

y su

pply:

Max

$15

0 pe

r pre

scrip

tion.

Se

e ab

ove

(refe

r to

gene

ric).

Spec

ialty

dru

gs

$8 c

opay

/gen

eric

pres

crip

tion.

20

% c

oins

uran

ce/

Form

ular

y br

and

pres

crip

tion.

30

% c

oins

uran

ce/

Non

-For

mul

ary

bran

d pr

escr

iptio

n.

30 d

ay su

pply.

Not

Cov

ered

Form

ular

y br

and

$40

max

imum

N

on-F

orm

ular

y br

and

$60

max

imum

. Sp

ecial

ty re

tail

limite

d to

a 3

0 da

y su

pply

.

4

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

Your

Cos

t If

You

Use

an

PP

O

Pro

vide

r

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou h

ave

outp

atie

nt s

urge

ry

Faci

lity

fee

(e.g

., am

bulat

ory

surg

ery

cent

er)

10%

coi

nsur

ance

30

% c

oins

uran

ce

---no

ne---

Phys

ician

/sur

geon

fees

10

% c

oins

uran

ce

30%

coi

nsur

ance

---

none

---

If y

ou n

eed

imm

edia

te m

edic

al

atte

ntio

n

Em

erge

ncy

room

serv

ices

$1

00 c

opay

plu

s 10

% c

oins

uran

ce.

$100

cop

ay p

lus

10%

coi

nsur

ance

Co

pay

waiv

ed if

adm

itted

.

Em

erge

ncy

med

ical t

rans

porta

tion

10%

coi

nsur

ance

10

% c

oins

uran

ce

---no

ne---

U

rgen

t car

e 10

% c

oins

uran

ce

30%

coi

nsur

ance

---

none

---

If y

ou h

ave

a ho

spita

l sta

y Fa

cilit

y fe

e (e

.g.,

hosp

ital r

oom

) $1

00 c

opay

plu

s 10

% c

oins

uran

ce

$100

cop

ay p

lus

30%

coi

nsur

ance

---

none

---

Phys

ician

/sur

geon

fee

10%

coi

nsur

ance

30

% c

oins

uran

ce

---no

ne---

If y

ou h

ave

men

tal

heal

th, b

ehav

iora

l he

alth

, or s

ubst

ance

ab

use

need

s

Men

tal/

Beha

vior

al he

alth

outp

atien

t ser

vice

s 10

% c

oins

uran

ce

30%

coi

nsur

ance

---

none

---

Men

tal/

Beha

vior

al he

alth

inpa

tient

serv

ices

$1

00 c

opay

plu

s 10

% c

oins

uran

ce

$100

cop

ay p

lus

30%

coi

nsur

ance

---

none

---

Subs

tanc

e us

e di

sord

er o

utpa

tient

serv

ices

10

% c

oins

uran

ce

30%

coi

nsur

ance

---

none

---

Subs

tanc

e us

e di

sord

er in

patie

nt se

rvic

es

$100

cop

ay p

lus

10%

coi

nsur

ance

$1

00 c

opay

plu

s 30

% c

oins

uran

ce

---no

ne---

If y

ou a

re p

regn

ant

Pren

atal

and

post

nata

l car

e $2

0 co

pay

30%

coi

nsur

ance

Co

pay

appl

ies t

o fir

st p

rena

tal v

isit

(per

pre

gnan

cy).

Del

iver

y an

d all

inpa

tient

serv

ices

$1

00 c

opay

plu

s 10

% c

oins

uran

ce

$100

cop

ay p

lus

30%

coi

nsur

ance

---

none

---

5

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

Your

Cos

t If

You

Use

an

PP

O

Pro

vide

r

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

help

re

cove

ring

or h

ave

othe

r spe

cial

hea

lth

need

s

Hom

e he

alth

care

10

% c

oins

uran

ce

30%

coi

nsur

ance

Li

mite

d to

120

visi

ts p

er b

enef

it pe

riod.

Re

habi

litat

ion

serv

ices

10

% c

oins

uran

ce

30%

coi

nsur

ance

Li

mite

d to

90

visit

s per

ben

efit

perio

d.

Hab

ilita

tion

serv

ices

10

% c

oins

uran

ce

30%

coi

nsur

ance

Li

mite

d to

90

visit

s per

ben

efit

perio

d.

Skill

ed n

ursin

g ca

re

$100

cop

ay p

lus

10%

coi

nsur

ance

$1

00 c

opay

plu

s 30

% c

oins

uran

ce

Lim

ited

to a

120

day

s per

ben

efit

perio

d.

Dur

able

med

ical

equi

pmen

t 10

% c

oins

uran

ce

30%

coi

nsur

ance

Bene

fits a

re li

mite

d to

item

s use

d to

se

rve

a m

edic

al pu

rpos

e. D

ME

be

nefit

s are

pro

vide

d fo

r bot

h pu

rcha

se a

nd re

ntal

equi

pmen

t (up

to

the

purc

hase

pric

e).

Hos

pice

serv

ice

10%

coi

nsur

ance

30

% c

oins

uran

ce

---no

ne---

If y

our c

hild

nee

ds

dent

al o

r eye

car

e

Eye

exa

m

Not

Cov

ered

N

ot C

over

ed

---no

ne---

G

lasse

s N

ot C

over

ed

Not

Cov

ered

D

enta

l che

ck-u

p N

ot C

over

ed

Not

Cov

ered

Excl

uded

Ser

vice

s &

Oth

er C

over

ed S

ervi

ces:

Se

rvic

es Y

our P

lan

Doe

s N

OT

Cov

er (T

his

isn’

t a c

ompl

ete

list.

Che

ck y

our p

olic

y or

pla

n do

cum

ent f

or o

ther

exc

lude

d se

rvic

es.)

A

cupu

nctu

re

Co

smet

ic S

urge

ry

D

enta

l Car

e (A

dult)

Lo

ng T

erm

Car

e

Rout

ine

Eye

Car

e (A

dult)

Ro

utin

g Fo

ot C

are

(with

the

exce

ptio

n of

pe

rson

with

the

diag

nosis

of d

iabet

es)

W

eigh

t Los

s Pro

gram

O

ther

Cov

ered

Ser

vice

s (T

his

isn’

t a c

ompl

ete

list.

Che

ck y

our p

olic

y or

pla

n do

cum

ent f

or o

ther

cov

ered

ser

vice

s an

d yo

ur c

osts

for t

hese

se

rvic

es.)

Ba

riatri

c Su

rger

y

Chiro

prac

tic C

are

H

earin

g A

ids

In

ferti

lity

Trea

tmen

t

Mos

t cov

erag

e pr

ovid

ed o

utsid

e th

e U

nite

d St

ates

. See

ww

w.b

cbsil

.com

N

on-E

mer

genc

y Ca

re W

hen

Trav

elin

g O

utsid

e th

e U

.S

Pr

ivat

e D

uty

Nur

sing

(with

the

exce

ptio

n of

inpa

tient

priv

ate

duty

nur

sing)

6

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s Plan

Cov

ers &

Wha

t it C

osts

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Your

Rig

hts

to C

ontin

ue C

over

age:

If

you

lose

cov

erag

e un

der t

he p

lan, t

hen,

dep

endi

ng u

pon

the

circ

umst

ance

s, Fe

dera

l and

Sta

te la

ws m

ay p

rovi

de p

rote

ctio

ns th

at a

llow

you

to k

eep

healt

h co

vera

ge. A

ny su

ch ri

ghts

may

be

limite

d in

dur

atio

n an

d w

ill re

quire

you

to p

ay a

pre

miu

m, w

hich

may

be

signi

fican

tly h

ighe

r tha

n th

e pr

emiu

m y

ou p

ay

whi

le c

over

ed u

nder

the

plan

. Oth

er li

mita

tions

on

your

righ

ts to

con

tinue

cov

erag

e m

ay a

lso a

pply

. Fo

r mor

e in

form

atio

n on

you

r rig

hts t

o co

ntin

ue c

over

age,

cont

act t

he p

lan a

t 1-8

88-9

79-4

516.

You

may

also

con

tact

you

r sta

te in

sura

nce

depa

rtmen

t, th

e U

.S. D

epar

tmen

t of L

abor

, Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istra

tion

at 1

-866

-444

-327

2 or

ww

w.d

ol.g

ov/e

bsa,

or th

e U

.S. D

epar

tmen

t of H

ealth

and

H

uman

Ser

vice

s at 1

-877

-267

-232

3 x6

1565

or w

ww

.cciio

.cms.g

ov.

Your

Grie

vanc

e an

d A

ppea

ls R

ight

s:

If y

ou h

ave

a co

mpl

aint o

r are

diss

atisf

ied

with

a d

enial

of c

over

age

for c

laim

s und

er y

our p

lan, y

ou m

ay b

e ab

le to

app

eal o

r file

a g

rieva

nce.

For

qu

estio

ns a

bout

you

r rig

hts,

this

notic

e, or

ass

istan

ce, y

ou c

an c

onta

ct B

lue

Cros

s and

Blu

e Sh

ield

of I

llino

is at

1-8

88-9

79-4

516

or v

isit w

ww

.bcb

sil.co

m, o

r co

ntac

t the

U.S

Dep

artm

ent o

f Lab

or's

Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istra

tion

at 1

-866

-444

-EBS

A (3

272)

or v

isit w

ww

.dol

.gov

/ebs

a/he

althr

efor

m.

Add

ition

ally,

a co

nsum

er a

ssist

ance

pro

gram

can

help

you

file

you

r app

eal.

Cont

act t

he Il

linoi

s Dep

artm

ent o

f Ins

uran

ce a

t (87

7) 5

27-9

431

or v

isit

http

://i

nsur

ance

.illin

ois.g

ov.

Doe

s th

is C

over

age

Prov

ide

Min

imum

Ess

entia

l Cov

erag

e?

The

Affo

rdab

le C

are

Act

requ

ires m

ost p

eopl

e to

hav

e he

alth

care

cov

erag

e th

at q

ualif

ies a

s “m

inim

um e

ssen

tial c

over

age.”

Thi

s pl

an o

r pol

icy

does

pr

ovid

e m

inim

um e

ssen

tial c

over

age.

D

oes

this

Cov

erag

e M

eet t

he M

inim

um V

alue

Sta

ndar

d?

The

Affo

rdab

le C

are

Act

est

ablis

hes a

min

imum

valu

e st

anda

rd o

f ben

efits

of a

hea

lth p

lan. T

he m

inim

um v

alue

stan

dard

is 6

0% (a

ctua

rial v

alue)

. Thi

s he

alth

cov

erag

e do

es m

eet t

he m

inim

um v

alue

sta

ndar

d fo

r the

ben

efits

it p

rovi

des.

Lang

uage

Acc

ess

Serv

ices

: Sp

anish

(Esp

añol

): Pa

ra o

bten

er a

siste

ncia

en E

spañ

ol, l

lame

al 1-

888-

979-

4516

. Ta

galo

g (T

agalo

g): K

ung

kaila

ngan

nin

yo a

ng tu

long

sa T

agalo

g tu

maw

ag sa

1-88

8-97

9-45

16.

Chin

ese

(中文


1-88

8-97

9-45

16.

Nav

ajo (D

ine)

: Din

ek'eh

go sh

ika

at'o

hwol

nin

ising

o, k

wiij

igo

holn

e' 1-

888-

979-

4516

. ––

––––

––––

––––

––––

––––

To se

e exa

mples

of h

ow th

is pla

n mi

ght c

over

costs

for a

samp

le me

dical

situa

tion,

see th

e nex

t pag

e.–––

––––

––––

––––

––––

–––

7

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 C

over

age

Exa

mpl

es

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Hav

ing

a ba

by

(nor

mal

deliv

ery)

Man

agin

g ty

pe 2

dia

bete

s (ro

utin

e m

ainte

nanc

e of

a

wel

l-con

trolle

d co

nditi

on)

Abo

ut th

ese

Cov

erag

e Ex

ampl

es:

Thes

e ex

ampl

es sh

ow h

ow th

is pl

an m

ight

cov

er

med

ical

care

in g

iven

situ

atio

ns. U

se th

ese

exam

ples

to se

e, in

gen

eral,

how

muc

h fin

ancia

l pr

otec

tion

a sa

mpl

e pa

tient

mig

ht g

et if

they

are

co

vere

d un

der d

iffer

ent p

lans.

A

mou

nt o

wed

to p

rovi

ders

: $7,

540

P

lan

pays

$6,

150

P

atie

nt p

ays

$1,3

90

Sa

mpl

e ca

re c

osts

: H

ospi

tal c

harg

es (m

othe

r) $2

,700

Ro

utin

e ob

stet

ric c

are

$2,1

00

Hos

pita

l cha

rges

(bab

y)

$900

A

nest

hesia

$9

00

Labo

rato

ry te

sts

$500

Pr

escr

iptio

ns

$200

Ra

diol

ogy

$200

V

acci

nes,

othe

r pre

vent

ive

$40

Tot

al

$7,5

40

Patie

nt p

ays:

D

educ

tibles

$7

00

Copa

ys

$30

Coin

sura

nce

$510

Li

mits

or e

xclu

sions

$1

50

Tot

al

$1,3

90

A

mou

nt o

wed

to p

rovi

ders

: $5,

400

P

lan

pays

$4,

020

P

atie

nt p

ays

$1,3

80

Sa

mpl

e ca

re c

osts

: Pr

escr

iptio

ns

$2,9

00

Med

ical

Equ

ipm

ent a

nd S

uppl

ies

$1,3

00

Offi

ce V

isits

and

Pro

cedu

res

$700

E

duca

tion

$300

La

bora

tory

test

s $1

00

Vac

cine

s, ot

her p

reve

ntiv

e $1

00

Tot

al

$5,4

00

Patie

nt p

ays:

D

educ

tibles

$7

00

Copa

ys

$490

Co

insu

ranc

e $1

10

Lim

its o

r exc

lusio

ns

$80

Tot

al

$1,3

80

Not

e: Th

ese

exam

ples

are

bas

ed o

n in

divi

dual

cove

rage

onl

y.

This

is

not a

cos

t es

timat

or.

Don

’t us

e th

ese

exam

ples

to

estim

ate

your

act

ual c

osts

un

der t

his p

lan. T

he a

ctua

l ca

re y

ou re

ceiv

e w

ill b

e di

ffere

nt fr

om th

ese

exam

ples

, and

the

cost

of

that

car

e w

ill a

lso b

e di

ffere

nt.

See

the

next

pag

e fo

r im

porta

nt in

form

atio

n ab

out

thes

e ex

ampl

es.

8

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 90%

PPO

Med

ical

Pla

n C

over

age

Perio

d: 0

1/01

/201

5 - 1

2/31

/201

5 C

over

age

Exa

mpl

es

C

over

age

for:

Indi

vidu

al+Fa

mily

| P

lan

Typ

e: P

PO

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Que

stio

ns a

nd a

nsw

ers

abou

t the

Cov

erag

e Ex

ampl

es:

Wha

t are

som

e of

the

assu

mpt

ions

beh

ind

the

Cov

erag

e Ex

ampl

es?

Co

sts d

on’t

incl

ude

prem

ium

s.

Sam

ple

care

cos

ts a

re b

ased

on

natio

nal

aver

ages

supp

lied

by th

e U

.S.

Dep

artm

ent o

f Hea

lth a

nd H

uman

Se

rvice

s, an

d ar

en’t

spec

ific

to a

pa

rticu

lar g

eogr

aphi

c ar

ea o

r hea

lth p

lan.

Th

e pa

tient

’s co

nditi

on w

as n

ot a

n ex

clud

ed o

r pre

exist

ing

cond

ition

.

All

serv

ices

and

trea

tmen

ts st

arte

d an

d en

ded

in th

e sa

me

cove

rage

per

iod.

Ther

e ar

e no

oth

er m

edica

l exp

ense

s for

an

y m

embe

r cov

ered

und

er th

is pl

an.

O

ut-o

f-poc

ket e

xpen

ses a

re b

ased

onl

y on

trea

ting

the

cond

ition

in th

e ex

ampl

e.

The

patie

nt re

ceiv

ed a

ll ca

re fr

om in

-ne

twor

k pr

ovid

ers.

If th

e pa

tient

had

re

ceiv

ed c

are

from

out

-of-n

etw

ork

prov

ider

s, co

sts w

ould

hav

e be

en h

ighe

r.

Wha

t doe

s a

Cov

erag

e Ex

ampl

e sh

ow?

Fo

r eac

h tre

atm

ent s

ituat

ion,

the

Cove

rage

E

xam

ple

help

s you

see

how

ded

uctib

les,

copa

ymen

ts, a

nd c

oins

uran

ce c

an a

dd u

p. It

als

o he

lps y

ou se

e w

hat e

xpen

ses m

ight

be

left

up to

you

to p

ay b

ecau

se th

e se

rvic

e or

tre

atm

ent i

sn’t

cove

red

or p

aym

ent i

s lim

ited.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y ow

n ca

re n

eeds

?

N

o. T

reat

men

ts sh

own

are

just

exa

mpl

es.

The

care

you

wou

ld re

ceiv

e fo

r thi

s co

nditi

on c

ould

be

diffe

rent

bas

ed o

n yo

ur

doct

or’s

advi

ce, y

our a

ge, h

ow se

rious

you

r co

nditi

on is

, and

man

y ot

her f

acto

rs.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y fu

ture

exp

ense

s?

N

o. C

over

age

Exa

mpl

es a

re n

ot c

ost

estim

ator

s. Y

ou c

an’t

use

the

exam

ples

to

estim

ate

cost

s for

an

actu

al co

nditi

on. T

hey

are

for c

ompa

rativ

e pu

rpos

es o

nly.

You

r ow

n co

sts w

ill b

e di

ffere

nt d

epen

ding

on

the

care

you

rece

ive,

the

pric

es y

our

prov

ider

s ch

arge

, and

the

reim

burs

emen

t yo

ur h

ealth

plan

allo

ws.

Can

I us

e C

over

age

Exam

ples

to

com

pare

pla

ns?

Y

es. W

hen

you

look

at t

he S

umm

ary

of

Bene

fits a

nd C

over

age

for o

ther

plan

s, yo

u’ll

find

the

sam

e Co

vera

ge E

xam

ples

. W

hen

you

com

pare

plan

s, ch

eck

the

“Pat

ient P

ays”

box

in e

ach

exam

ple.

The

small

er th

at n

umbe

r, th

e m

ore

cove

rage

th

e pl

an p

rovi

des.

Are

ther

e ot

her c

osts

I sh

ould

co

nsid

er w

hen

com

parin

g pl

ans?

Y

es. A

n im

porta

nt c

ost i

s the

pre

miu

m

you

pay.

Gen

erall

y, th

e lo

wer

you

r pr

emiu

m, t

he m

ore

you’

ll pa

y in

out

-of-

pock

et c

osts

, suc

h as

cop

aym

ents

, de

duct

ible

s, an

d co

insu

ranc

e. Y

ou

shou

ld a

lso c

onsid

er c

ontri

butio

ns to

ac

coun

ts su

ch a

s hea

lth sa

ving

s acc

ount

s (H

SAs)

, flex

ible

spen

ding

arr

ange

men

ts

(FSA

s) o

r hea

lth re

imbu

rsem

ent a

ccou

nts

(HRA

s) th

at h

elp y

ou p

ay o

ut-o

f-poc

ket

expe

nses

.

1

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Sum

mar

y of

Ben

efits

and

Cov

erag

e: W

hat t

his P

lan C

over

s & W

hat i

t Cos

ts

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

This

is o

nly

a su

mm

ary.

If y

ou w

ant m

ore

deta

il ab

out y

our c

over

age

and

cost

s, yo

u ca

n ge

t the

com

plet

e te

rms i

n th

e po

licy

or p

lan

docu

men

t at w

ww

.bcb

sil.c

om o

r by

calli

ng 1

-888

-979

-451

6.

Impo

rtan

t Que

stio

ns

Ans

wer

s W

hy th

is M

atte

rs:

Wha

t is

the

over

all

dedu

ctib

le?

$1,7

50 P

erso

n/$5

,250

Fam

ily

PPO

& N

on-P

PO

Doe

sn’t

appl

y to

cer

tain

pre

vent

ive

serv

ices

, pre

scrip

tions

, em

erge

ncy

room

se

rvic

es, o

r offi

ce c

opay

s.

You

mus

t pay

all

the

cost

s up

to th

e de

duct

ible

am

ount

bef

ore

this

plan

beg

ins t

o pa

y fo

r cov

ered

serv

ices y

ou u

se.

Chec

k yo

ur p

olicy

or p

lan d

ocum

ent t

o se

e w

hen

the

dedu

ctib

le st

arts

ove

r (us

ually

, but

not

alw

ays,

Janu

ary

1st).

See

the

char

t sta

rting

on

page

2 fo

r how

muc

h yo

u pa

y fo

r cov

ered

serv

ices

afte

r you

mee

t th

e de

duct

ible

.

Are

ther

e ot

her

dedu

ctib

les

for s

peci

fic

serv

ices

? N

o.

You

mus

t pay

all

of th

e co

sts f

or th

ese

serv

ices u

p to

the

spec

ific

dedu

ctib

le

amou

nt b

efor

e th

is pl

an b

egin

s to

pay

for t

hese

serv

ices.

Is th

ere

an o

ut–o

f–po

cket

lim

it on

my

expe

nses

? Y

es. $

2,50

0 Pe

rson

/$7,

500

Fam

ily

The

out-o

f-poc

ket l

imit

is th

e m

ost y

ou c

ould

pay

dur

ing

a co

vera

ge p

erio

d (u

suall

y on

e ye

ar) f

or y

our s

hare

of t

he c

ost o

f cov

ered

serv

ices

. Th

is lim

it he

lps

you

plan

for h

ealth

car

e ex

pens

es.

Wha

t is

not i

nclu

ded

in

the

out–

of–p

ocke

t lim

it?

Pres

crip

tion

drug

s, pr

emiu

ms,

balan

ced-

bille

d ch

arge

s, an

d he

alth

care

this

plan

do

esn’

t cov

er.

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

don’

t cou

nt to

war

d th

e ou

t–of

–poc

ket

limit.

Doe

s th

is p

lan

use

a ne

twor

k of

pro

vide

rs?

Yes

. Visi

t ww

w.b

cbsi

l.com

or c

all 1

-88

8-97

9-45

16 fo

r a li

st o

f Par

ticip

atin

g pr

ovid

ers.

If y

ou u

se a

n in

-net

wor

k do

ctor

or o

ther

hea

lth c

are

prov

ider

, thi

s plan

will

pay

som

e or

all

of th

e co

sts o

f cov

ered

serv

ices

. Be

aw

are,

your

in-n

etw

ork

doct

or o

r hos

pita

l m

ay u

se a

n ou

t-of-n

etw

ork

prov

ider

for s

ome

serv

ices.

Plan

s use

the

term

in-

netw

ork,

pre

ferr

ed, o

r par

ticip

atin

g fo

r pro

vide

rs in

their

net

wor

k. S

ee th

e ch

art

star

ting

on p

age

2 fo

r how

this

plan

pay

s diff

eren

t kin

ds o

f pro

vide

rs.

Do

I nee

d a

refe

rral

to

see

a sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out p

erm

issio

n fr

om th

is pl

an.

Are

ther

e se

rvic

es th

is

plan

doe

sn’t

cove

r?

Yes

. So

me

of th

e se

rvic

es th

is pl

an d

oesn

’t co

ver a

re li

sted

on p

age

5. S

ee y

our p

olic

y or

plan

doc

umen

t for

add

ition

al in

form

atio

n ab

out e

xclu

ded

serv

ices

.

1

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Sum

mar

y of

Ben

efits

and

Cov

erag

e: W

hat t

his P

lan C

over

s & W

hat i

t Cos

ts

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

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stio

ns: C

all 1-

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or v

isit u

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abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

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8 to

requ

est a

cop

y.

This

is o

nly

a su

mm

ary.

If y

ou w

ant m

ore

deta

il ab

out y

our c

over

age

and

cost

s, yo

u ca

n ge

t the

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plet

e te

rms i

n th

e po

licy

or p

lan

docu

men

t at w

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om o

r by

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ng 1

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-979

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Impo

rtan

t Que

stio

ns

Ans

wer

s W

hy th

is M

atte

rs:

Wha

t is

the

over

all

dedu

ctib

le?

$1,7

50 P

erso

n/$5

,250

Fam

ily

PPO

& N

on-P

PO

Doe

sn’t

appl

y to

cer

tain

pre

vent

ive

serv

ices

, pre

scrip

tions

, em

erge

ncy

room

se

rvic

es, o

r offi

ce c

opay

s.

You

mus

t pay

all

the

cost

s up

to th

e de

duct

ible

am

ount

bef

ore

this

plan

beg

ins t

o pa

y fo

r cov

ered

serv

ices y

ou u

se.

Chec

k yo

ur p

olicy

or p

lan d

ocum

ent t

o se

e w

hen

the

dedu

ctib

le st

arts

ove

r (us

ually

, but

not

alw

ays,

Janu

ary

1st).

See

the

char

t sta

rting

on

page

2 fo

r how

muc

h yo

u pa

y fo

r cov

ered

serv

ices

afte

r you

mee

t th

e de

duct

ible

.

Are

ther

e ot

her

dedu

ctib

les

for s

peci

fic

serv

ices

? N

o.

You

mus

t pay

all

of th

e co

sts f

or th

ese

serv

ices u

p to

the

spec

ific

dedu

ctib

le

amou

nt b

efor

e th

is pl

an b

egin

s to

pay

for t

hese

serv

ices.

Is th

ere

an o

ut–o

f–po

cket

lim

it on

my

expe

nses

? Y

es. $

2,50

0 Pe

rson

/$7,

500

Fam

ily

The

out-o

f-poc

ket l

imit

is th

e m

ost y

ou c

ould

pay

dur

ing

a co

vera

ge p

erio

d (u

suall

y on

e ye

ar) f

or y

our s

hare

of t

he c

ost o

f cov

ered

serv

ices

. Th

is lim

it he

lps

you

plan

for h

ealth

car

e ex

pens

es.

Wha

t is

not i

nclu

ded

in

the

out–

of–p

ocke

t lim

it?

Pres

crip

tion

drug

s, pr

emiu

ms,

balan

ced-

bille

d ch

arge

s, an

d he

alth

care

this

plan

do

esn’

t cov

er.

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

don’

t cou

nt to

war

d th

e ou

t–of

–poc

ket

limit.

Doe

s th

is p

lan

use

a ne

twor

k of

pro

vide

rs?

Yes

. Visi

t ww

w.b

cbsi

l.com

or c

all 1

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8-97

9-45

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r a li

st o

f Par

ticip

atin

g pr

ovid

ers.

If y

ou u

se a

n in

-net

wor

k do

ctor

or o

ther

hea

lth c

are

prov

ider

, thi

s plan

will

pay

som

e or

all

of th

e co

sts o

f cov

ered

serv

ices

. Be

aw

are,

your

in-n

etw

ork

doct

or o

r hos

pita

l m

ay u

se a

n ou

t-of-n

etw

ork

prov

ider

for s

ome

serv

ices.

Plan

s use

the

term

in-

netw

ork,

pre

ferr

ed, o

r par

ticip

atin

g fo

r pro

vide

rs in

their

net

wor

k. S

ee th

e ch

art

star

ting

on p

age

2 fo

r how

this

plan

pay

s diff

eren

t kin

ds o

f pro

vide

rs.

Do

I nee

d a

refe

rral

to

see

a sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out p

erm

issio

n fr

om th

is pl

an.

Are

ther

e se

rvic

es th

is

plan

doe

sn’t

cove

r?

Yes

. So

me

of th

e se

rvic

es th

is pl

an d

oesn

’t co

ver a

re li

sted

on p

age

5. S

ee y

our p

olic

y or

plan

doc

umen

t for

add

ition

al in

form

atio

n ab

out e

xclu

ded

serv

ices

.

2

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Sum

mar

y of

Ben

efits

and

Cov

erag

e: W

hat t

his P

lan C

over

s & W

hat i

t Cos

ts

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

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n T

ype:

HSA

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stio

ns: C

all 1-

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4516

or v

isit u

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om.

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you

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n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

C

opay

men

ts a

re fi

xed

dolla

r am

ount

s (fo

r exa

mpl

e, $1

5) y

ou p

ay fo

r cov

ered

hea

lth c

are,

usua

lly w

hen

you

rece

ive

the

serv

ice.

Coi

nsur

ance

is yo

ur sh

are

of th

e co

sts o

f a c

over

ed se

rvic

e, ca

lculat

ed a

s a p

erce

nt o

f the

allo

wed

am

ount

for t

he se

rvic

e. Fo

r exa

mpl

e, if

the

plan

’s al

low

ed a

mou

nt fo

r an

over

nigh

t hos

pita

l sta

y is

$1,0

00, y

our c

oins

uran

ce p

aym

ent o

f 20%

wou

ld b

e $2

00.

This

may

cha

nge

if yo

u ha

ven’

t met

you

r ded

uctib

le.

Th

e am

ount

the

plan

pay

s for

cov

ered

serv

ices

is b

ased

on

the

allo

wed

am

ount

. If a

n ou

t-of-n

etw

ork

prov

ider

cha

rges

mor

e th

an th

e al

low

ed a

mou

nt, y

ou m

ay h

ave

to p

ay th

e di

ffere

nce.

For e

xam

ple,

if an

out

-of-n

etw

ork

hosp

ital c

harg

es $

1,50

0 fo

r an

over

nigh

t sta

y an

d th

e al

low

ed a

mou

nt is

$1,

000,

you

may

hav

e to

pay

the

$500

diff

eren

ce. (

This

is ca

lled

bala

nce

billi

ng.)

Th

is pl

an m

ay e

ncou

rage

you

to u

se P

PO p

rovi

ders

by

char

ging

you

low

er d

educ

tible

s, co

paym

ents

and

coi

nsur

ance

am

ount

s. C

omm

on

Med

ical

Eve

nt

Serv

ices

You

May

Nee

d Yo

ur C

ost I

f Yo

u U

se a

n

PPO

P

rovi

der

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce

or c

linic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

15%

coi

nsur

ance

35

% c

oins

uran

ce

---no

ne---

Spec

ialist

visi

t 15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Oth

er p

ract

ition

er o

ffice

visi

t 15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Prev

entiv

e ca

re/s

cree

ning

/im

mun

izat

ion

No

Char

ge

35%

coi

nsur

ance

---

none

---

If y

ou h

ave

a te

st

Diag

nost

ic te

st (x

-ray,

bloo

d w

ork)

15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Imag

ing

(CT/

PET

scan

s, M

RIs)

15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

2

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Sum

mar

y of

Ben

efits

and

Cov

erag

e: W

hat t

his P

lan C

over

s & W

hat i

t Cos

ts

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

C

opay

men

ts a

re fi

xed

dolla

r am

ount

s (fo

r exa

mpl

e, $1

5) y

ou p

ay fo

r cov

ered

hea

lth c

are,

usua

lly w

hen

you

rece

ive

the

serv

ice.

Coi

nsur

ance

is yo

ur sh

are

of th

e co

sts o

f a c

over

ed se

rvic

e, ca

lculat

ed a

s a p

erce

nt o

f the

allo

wed

am

ount

for t

he se

rvic

e. Fo

r exa

mpl

e, if

the

plan

’s al

low

ed a

mou

nt fo

r an

over

nigh

t hos

pita

l sta

y is

$1,0

00, y

our c

oins

uran

ce p

aym

ent o

f 20%

wou

ld b

e $2

00.

This

may

cha

nge

if yo

u ha

ven’

t met

you

r ded

uctib

le.

Th

e am

ount

the

plan

pay

s for

cov

ered

serv

ices

is b

ased

on

the

allo

wed

am

ount

. If a

n ou

t-of-n

etw

ork

prov

ider

cha

rges

mor

e th

an th

e al

low

ed a

mou

nt, y

ou m

ay h

ave

to p

ay th

e di

ffere

nce.

For e

xam

ple,

if an

out

-of-n

etw

ork

hosp

ital c

harg

es $

1,50

0 fo

r an

over

nigh

t sta

y an

d th

e al

low

ed a

mou

nt is

$1,

000,

you

may

hav

e to

pay

the

$500

diff

eren

ce. (

This

is ca

lled

bala

nce

billi

ng.)

Th

is pl

an m

ay e

ncou

rage

you

to u

se P

PO p

rovi

ders

by

char

ging

you

low

er d

educ

tible

s, co

paym

ents

and

coi

nsur

ance

am

ount

s. C

omm

on

Med

ical

Eve

nt

Serv

ices

You

May

Nee

d Yo

ur C

ost I

f Yo

u U

se a

n

PPO

P

rovi

der

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce

or c

linic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

15%

coi

nsur

ance

35

% c

oins

uran

ce

---no

ne---

Spec

ialist

visi

t 15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Oth

er p

ract

ition

er o

ffice

visi

t 15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Prev

entiv

e ca

re/s

cree

ning

/im

mun

izat

ion

No

Char

ge

35%

coi

nsur

ance

---

none

---

If y

ou h

ave

a te

st

Diag

nost

ic te

st (x

-ray,

bloo

d w

ork)

15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Imag

ing

(CT/

PET

scan

s, M

RIs)

15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

3

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Sum

mar

y of

Ben

efits

and

Cov

erag

e: W

hat t

his P

lan C

over

s & W

hat i

t Cos

ts

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

Your

Cos

t If

You

Use

an

PP

O

Pro

vide

r

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

drug

s to

tre

at y

our i

llnes

s or

co

nditi

on

Mor

e in

form

atio

n ab

out p

resc

riptio

n dr

ug c

over

age

is av

ailab

le a

t w

ww

.bcb

sil.co

m.

Gen

eric

drug

s 15

% c

oins

uran

ce

15%

coi

nsur

ance

Ce

rtain

wom

en’s

prev

enta

tive

serv

ices

will

be

cove

red

with

no

cost

to th

e m

embe

r. Fo

r a fu

ll lis

t of t

hese

pr

escr

iptio

ns a

nd/o

r ser

vice

s, pl

ease

co

ntac

t Cus

tom

er S

ervi

ce.

30 d

ay re

tail/

90 d

ay m

ail

Form

ular

y br

and

drug

s 15

% c

oins

uran

ce

15%

coi

nsur

ance

N

on-F

orm

ular

y br

and

drug

s 15

% c

oins

uran

ce

15%

coi

nsur

ance

Spec

ialty

dru

gs

Cove

red

Not

Cov

ered

If y

ou h

ave

outp

atie

nt s

urge

ry

Faci

lity

fee

(e.g

., am

bulat

ory

surg

ery

cent

er)

15%

coi

nsur

ance

35

% c

oins

uran

ce

---no

ne---

Ph

ysic

ian/s

urge

on fe

es

15%

coi

nsur

ance

35

% c

oins

uran

ce

If y

ou n

eed

imm

edia

te m

edic

al

atte

ntio

n

Em

erge

ncy

room

serv

ices

15

% c

oins

uran

ce

15%

coi

nsur

ance

---

none

---

Em

erge

ncy

med

ical t

rans

porta

tion

15%

coi

nsur

ance

15

% c

oins

uran

ce

---no

ne---

U

rgen

t car

e 15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

If y

ou h

ave

a ho

spita

l sta

y

Faci

lity

fee

(e.g

., ho

spita

l roo

m)

15%

coi

nsur

ance

35

% c

oins

uran

ce

---no

ne---

Phys

ician

/sur

geon

fee

15%

coi

nsur

ance

35

% c

oins

uran

ce

---no

ne---

4

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Sum

mar

y of

Ben

efits

and

Cov

erag

e: W

hat t

his P

lan C

over

s & W

hat i

t Cos

ts

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

Your

Cos

t If

You

Use

an

PP

O

Pro

vide

r

Your

Cos

t If

You

Use

an

N

on-P

PO

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou h

ave

men

tal

heal

th, b

ehav

iora

l he

alth

, or s

ubst

ance

ab

use

need

s

Men

tal/

Beha

vior

al he

alth

outp

atien

t ser

vice

s 15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Men

tal/

Beha

vior

al he

alth

inpa

tient

serv

ices

15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Subs

tanc

e us

e di

sord

er o

utpa

tient

serv

ices

15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Subs

tanc

e us

e di

sord

er in

patie

nt se

rvic

es

15%

coi

nsur

ance

35

% c

oins

uran

ce

---no

ne---

If y

ou a

re p

regn

ant

Pren

atal

and

post

nata

l car

e 15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

Del

iver

y an

d all

inpa

tient

serv

ices

15

% c

oins

uran

ce

35%

coi

nsur

ance

---

none

---

If y

ou n

eed

help

re

cove

ring

or h

ave

othe

r spe

cial

hea

lth

need

s

Hom

e he

alth

care

15

% c

oins

uran

ce

35%

coi

nsur

ance

Li

mite

d to

120

visi

ts p

er b

enef

it pe

riod.

Re

habi

litat

ion

serv

ices

15

% c

oins

uran

ce

35%

coi

nsur

ance

Li

mite

d to

90

visit

s per

ben

efit

perio

d.

Hab

ilita

tion

serv

ices

15

% c

oins

uran

ce

35%

coi

nsur

ance

Li

mite

d to

90

visit

s per

ben

efit

perio

d.

Skill

ed n

ursin

g ca

re

15%

coi

nsur

ance

35

% c

oins

uran

ce

Lim

ited

to 1

20 d

ays p

er b

enef

it pe

riod.

Dur

able

med

ical

equi

pmen

t 15

% c

oins

uran

ce

35%

coi

nsur

ance

Bene

fits a

re li

mite

d to

item

s use

d to

se

rve

a m

edic

al pu

rpos

e. D

ME

be

nefit

s are

pro

vide

d fo

r bot

h pu

rcha

se a

nd re

ntal

equi

pmen

t (up

to

the

purc

hase

pric

e).

Hos

pice

serv

ice

15%

coi

nsur

ance

35

% c

oins

uran

ce

---no

ne---

If y

our c

hild

nee

ds

dent

al o

r eye

car

e

Eye

exa

m

Not

Cov

ered

N

ot C

over

ed

---no

ne---

G

lasse

s N

ot C

over

ed

Not

Cov

ered

D

enta

l che

ck-u

p N

ot C

over

ed

Not

Cov

ered

5

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Sum

mar

y of

Ben

efits

and

Cov

erag

e: W

hat t

his P

lan C

over

s & W

hat i

t Cos

ts

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Excl

uded

Ser

vice

s &

Oth

er C

over

ed S

ervi

ces:

Se

rvic

es Y

our P

lan

Doe

s N

OT

Cov

er (T

his

isn’

t a c

ompl

ete

list.

Che

ck y

our p

olic

y or

pla

n do

cum

ent f

or o

ther

exc

lude

d se

rvic

es.)

A

cupu

nctu

re

Co

smet

ic S

urge

ry

D

enta

l Car

e (A

dult)

Lo

ng T

erm

Car

e

Rout

ing

Eye

Car

e (A

dult)

Ro

utin

g Fo

ot C

are

(with

the

exce

ptio

n of

pe

rson

with

diag

nosis

of d

iabet

es)

W

eigh

t Los

s Pro

gram

O

ther

Cov

ered

Ser

vice

s (T

his

isn’

t a c

ompl

ete

list.

Che

ck y

our p

olic

y or

pla

n do

cum

ent f

or o

ther

cov

ered

ser

vice

s an

d yo

ur c

osts

for t

hese

se

rvic

es.)

Ba

riatri

c Su

rger

y

Chiro

prac

tic C

are

H

earin

g A

ids

In

ferti

lity

Trea

tmen

t

Mos

t cov

erag

e pr

ovid

ed o

utsid

e th

e U

nite

d St

ates

. See

ww

w.b

cbsil

.com

N

on-E

mer

genc

y Ca

re W

hen

Trav

elin

g O

utsid

e th

e U

.S

Pr

ivat

e D

uty

Nur

sing

(with

the

exce

ptio

n of

inpa

tient

priv

ate

duty

nur

sing)

Yo

ur R

ight

s to

Con

tinue

Cov

erag

e:

If y

ou lo

se c

over

age

unde

r the

plan

, the

n, d

epen

ding

upo

n th

e ci

rcum

stan

ces,

Fede

ral a

nd S

tate

law

s may

pro

vide

pro

tect

ions

that

allo

w y

ou to

kee

p he

alth

cove

rage

. Any

such

righ

ts m

ay b

e lim

ited

in d

urat

ion

and

will

requ

ire y

ou to

pay

a p

rem

ium

, whi

ch m

ay b

e sig

nific

antly

hig

her t

han

the

prem

ium

you

pay

w

hile

cov

ered

und

er th

e pl

an. O

ther

lim

itatio

ns o

n yo

ur ri

ghts

to c

ontin

ue c

over

age

may

also

app

ly.

For m

ore

info

rmat

ion

on y

our r

ight

s to

cont

inue

cov

erag

e, co

ntac

t the

plan

at 1

-888

-979

-451

6. Y

ou m

ay a

lso c

onta

ct y

our s

tate

insu

ranc

e de

partm

ent,

the

U.S

. Dep

artm

ent o

f Lab

or, E

mpl

oyee

Ben

efits

Sec

urity

Adm

inist

ratio

n at

1-8

66-4

44-3

272

or w

ww

.dol

.gov

/ebs

a, or

the

U.S

. Dep

artm

ent o

f Hea

lth a

nd

Hum

an S

ervi

ces a

t 1-8

77-2

67-2

323

x615

65 o

r ww

w.cc

iio.cm

s.gov

. Yo

ur G

rieva

nce

and

App

eals

Rig

hts:

If

you

hav

e a

com

plain

t or a

re d

issat

isfie

d w

ith a

den

ial o

f cov

erag

e fo

r clai

ms u

nder

you

r plan

, you

may

be

able

to a

ppea

l or f

ile a

grie

vanc

e. F

or

ques

tions

abo

ut y

our r

ight

s, th

is no

tice,

or a

ssist

ance

, you

can

con

tact

Blu

e Cr

oss a

nd B

lue

Shie

ld o

f Illi

nois

at 1

-888

-979

-451

6 or

visi

t ww

w.b

cbsil

.com

, or

cont

act t

he U

.S D

epar

tmen

t of L

abor

's E

mpl

oyee

Ben

efits

Sec

urity

Adm

inist

ratio

n at

1-8

66-4

44-E

BSA

(327

2) o

r visi

t ww

w.d

ol.g

ov/e

bsa/

healt

href

orm

. A

dditi

onall

y, a

cons

umer

ass

istan

ce p

rogr

am c

an h

elp y

ou fi

le y

our a

ppea

l. Co

ntac

t the

Illin

ois D

epar

tmen

t of I

nsur

ance

at (

877)

527

-943

1 or

visi

t ht

tp:/

/ins

uran

ce.il

linoi

s.gov

.

Doe

s th

is C

over

age

Prov

ide

Min

imum

Ess

entia

l Cov

erag

e?

The

Affo

rdab

le C

are

Act

requ

ires m

ost p

eopl

e to

hav

e he

alth

care

cov

erag

e th

at q

ualif

ies a

s “m

inim

um e

ssen

tial c

over

age.”

Thi

s pl

an o

r pol

icy

does

pr

ovid

e m

inim

um e

ssen

tial c

over

age.

6

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Sum

mar

y of

Ben

efits

and

Cov

erag

e: W

hat t

his P

lan C

over

s & W

hat i

t Cos

ts

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Doe

s th

is C

over

age

Mee

t the

Min

imum

Val

ue S

tand

ard?

Th

e A

fford

able

Car

e A

ct e

stab

lishe

s a m

inim

um v

alue

stan

dard

of b

enef

its o

f a h

ealth

plan

. The

min

imum

valu

e st

anda

rd is

60%

(act

uaria

l valu

e). T

his

heal

th c

over

age

does

mee

t the

min

imum

val

ue s

tand

ard

for t

he b

enef

its it

pro

vide

s.

Lang

uage

Acc

ess

Serv

ices

: Sp

anish

(Esp

añol

): Pa

ra o

bten

er a

siste

ncia

en E

spañ

ol, l

lame

al 1-

888-

979-

4516

. Ta

galo

g (T

agalo

g): K

ung

kaila

ngan

nin

yo a

ng tu

long

sa T

agalo

g tu

maw

ag sa

1-88

8-97

9-45

16.

Chin

ese

(中文


1-88

8-97

9-45

16.

Nav

ajo (D

ine)

: Din

ek'eh

go sh

ika

at'o

hwol

nin

ising

o, k

wiij

igo

holn

e' 1-

888-

979-

4516

. ––

––––

––––

––––

––––

––––

To se

e exa

mples

of h

ow th

is pla

n mi

ght c

over

costs

for a

samp

le me

dical

situa

tion,

see t

he n

ext p

age.–

––––

––––

––––

––––

––––

–

7

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Cov

erag

e E

xam

ples

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Hav

ing

a ba

by

(nor

mal

deliv

ery)

Man

agin

g ty

pe 2

dia

bete

s (ro

utin

e m

ainte

nanc

e of

a

wel

l-con

trolle

d co

nditi

on)

Abo

ut th

ese

Cov

erag

e Ex

ampl

es:

Thes

e ex

ampl

es sh

ow h

ow th

is pl

an m

ight

cov

er

med

ical

care

in g

iven

situ

atio

ns. U

se th

ese

exam

ples

to se

e, in

gen

eral,

how

muc

h fin

ancia

l pr

otec

tion

a sa

mpl

e pa

tient

mig

ht g

et if

they

are

co

vere

d un

der d

iffer

ent p

lans.

A

mou

nt o

wed

to p

rovi

ders

: $7,

540

P

lan

pays

$4,

890

P

atie

nt p

ays

$2,6

50

Sa

mpl

e ca

re c

osts

: H

ospi

tal c

harg

es (m

othe

r) $2

,700

Ro

utin

e ob

stet

ric c

are

$2,1

00

Hos

pita

l cha

rges

(bab

y)

$900

A

nest

hesia

$9

00

Labo

rato

ry te

sts

$500

Pr

escr

iptio

ns

$200

Ra

diol

ogy

$200

V

acci

nes,

othe

r pre

vent

ive

$40

Tot

al

$7,5

40

Patie

nt p

ays:

D

educ

tibles

$1

,750

Co

pays

$0

Co

insu

ranc

e $7

50

Lim

its o

r exc

lusio

ns

$150

T

otal

$2

,650

A

mou

nt o

wed

to p

rovi

ders

: $5,

400

P

lan

pays

$2,

890

P

atie

nt p

ays

$2,5

10

Sa

mpl

e ca

re c

osts

: Pr

escr

iptio

ns

$2,9

00

Med

ical

Equ

ipm

ent a

nd S

uppl

ies

$1,3

00

Offi

ce V

isits

and

Pro

cedu

res

$700

E

duca

tion

$300

La

bora

tory

test

s $1

00

Vac

cine

s, ot

her p

reve

ntiv

e $1

00

Tot

al

$5,4

00

Patie

nt p

ays:

D

educ

tibles

$1

,750

Co

pays

$4

70

Coin

sura

nce

$210

Li

mits

or e

xclu

sions

$8

0 T

otal

$2

,510

N

ote:

Thes

e ex

ampl

es a

re b

ased

on

indi

vidu

al co

vera

ge o

nly.

This

is

not a

cos

t es

timat

or.

Don

’t us

e th

ese

exam

ples

to

estim

ate

your

act

ual c

osts

un

der t

his p

lan. T

he a

ctua

l ca

re y

ou re

ceiv

e w

ill b

e di

ffere

nt fr

om th

ese

exam

ples

, and

the

cost

of

that

car

e w

ill a

lso b

e di

ffere

nt.

See

the

next

pag

e fo

r im

porta

nt in

form

atio

n ab

out

thes

e ex

ampl

es.

8

of 8

Ineo

s U

SA L

LC/S

tyro

lutio

n A

mer

ica

LLC

: 85%

AB

HP

Cov

erag

e Pe

riod:

01/

01/2

015

- 12/

31/2

015

Cov

erag

e E

xam

ples

Cov

erag

e fo

r: In

divi

dual+

Fam

ily |

Pla

n T

ype:

HSA

Que

stio

ns: C

all 1-

888-

979-

4516

or v

isit u

s at w

ww

.bcb

sil.c

om.

If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

view

the

Glo

ssar

y at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CUni

form

Glo

ssar

y.pdf

or c

all 1

-855

-756

-444

8 to

requ

est a

cop

y.

Que

stio

ns a

nd a

nsw

ers

abou

t the

Cov

erag

e Ex

ampl

es:

Wha

t are

som

e of

the

assu

mpt

ions

beh

ind

the

Cov

erag

e Ex

ampl

e s?

Co

sts d

on’t

incl

ude

prem

ium

s.

Sam

ple

care

cos

ts a

re b

ased

on

natio

nal

aver

ages

supp

lied

by th

e U

.S.

Dep

artm

ent o

f Hea

lth a

nd H

uman

Se

rvice

s, an

d ar

en’t

spec

ific

to a

pa

rticu

lar g

eogr

aphi

c ar

ea o

r hea

lth p

lan.

Th

e pa

tient

’s co

nditi

on w

as n

ot a

n ex

clud

ed o

r pre

exist

ing

cond

ition

.

All

serv

ices

and

trea

tmen

ts st

arte

d an

d en

ded

in th

e sa

me

cove

rage

per

iod.

Ther

e ar

e no

oth

er m

edica

l exp

ense

s for

an

y m

embe

r cov

ered

und

er th

is pl

an.

O

ut-o

f-poc

ket e

xpen

ses a

re b

ased

onl

y on

trea

ting

the

cond

ition

in th

e ex

ampl

e.

The

patie

nt re

ceiv

ed a

ll ca

re fr

om in

-ne

twor

k pr

ovid

ers.

If th

e pa

tient

had

re

ceiv

ed c

are

from

out

-of-n

etw

ork

prov

ider

s, co

sts w

ould

hav

e be

en h

ighe

r.

Wha

t doe

s a

Cov

erag

e Ex

ampl

e sh

ow?

Fo

r eac

h tre

atm

ent s

ituat

ion,

the

Cove

rage

E

xam

ple

help

s you

see

how

ded

uctib

les,

copa

ymen

ts, a

nd c

oins

uran

ce c

an a

dd u

p. It

als

o he

lps y

ou se

e w

hat e

xpen

ses m

ight

be

left

up to

you

to p

ay b

ecau

se th

e se

rvic

e or

tre

atm

ent i

sn’t

cove

red

or p

aym

ent i

s lim

ited.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y ow

n ca

re n

eeds

?

N

o. T

reat

men

ts sh

own

are

just

exa

mpl

es.

The

care

you

wou

ld re

ceiv

e fo

r thi

s co

nditi

on c

ould

be

diffe

rent

bas

ed o

n yo

ur

doct

or’s

advi

ce, y

our a

ge, h

ow se

rious

you

r co

nditi

on is

, and

man

y ot

her f

acto

rs.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y fu

ture

exp

ense

s?

N

o. C

over

age

Exa

mpl

es a

re n

ot c

ost

estim

ator

s. Y

ou c

an’t

use

the

exam

ples

to

estim

ate

cost

s for

an

actu

al co

nditi

on. T

hey

are

for c

ompa

rativ

e pu

rpos

es o

nly.

You

r ow

n co

sts w

ill b

e di

ffere

nt d

epen

ding

on

the

care

you

rece

ive,

the

price

s you

r pr

ovid

ers

char

ge, a

nd th

e re

imbu

rsem

ent

your

hea

lth p

lan a

llow

s.

Can

I us

e C

over

age

Exam

ples

to

com

pare

pla

ns?

Y

es. W

hen

you

look

at t

he S

umm

ary

of

Bene

fits a

nd C

over

age

for o

ther

plan

s, yo

u’ll

find

the

sam

e Co

vera

ge E

xam

ples

. W

hen

you

com

pare

plan

s, ch

eck

the

“Pat

ient P

ays”

box

in e

ach

exam

ple.

The

small

er th

at n

umbe

r, th

e m

ore

cove

rage

th

e pl

an p

rovi

des.

Are

ther

e ot

her c

osts

I sh

ould

co

nsid

er w

hen

com

parin

g pl

ans?

Y

es. A

n im

porta

nt c

ost i

s the

pre

miu

m

you

pay.

Gen

erall

y, th

e lo

wer

you

r pr

emiu

m, t

he m

ore

you’

ll pa

y in

out

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pock

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cop

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insu

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