2020

2020 Benefits

Enrollment Guide

This guide highlights the main features of many of the benefit plans sponsored by Harcros Chemicals Inc. Full details of

these plans are contained in the legal documents governing the plans. If there is any discrepancy between the plan

documents and the information described here, the plan documents will govern. In all cases, the plan documents are the

exclusive source for determining rights and benefits under the plans. Participation in the plans does not constitute an

employment contract. Harcros Chemicals Inc. reserves the right to modify, amend or terminate any benefit plan or

practice described in this guide. Nothing in this guide guarantees that any new plan provisions will continue in effect for

any period of time.

Table of Contents

Benefits Overview 4

Wellness Matters 6

Medical & Prescription Drug Plan 7

Savings & Expense Account Options 11

Dental Plan 14 Vision Plan 15

Life And AD&D Insurance 16

Disability Coverage 17

Employee Assistance Program 18

Paid Time Off 19

Retirement 20

Employee Stock Ownership Plan 21

Annual Compliance Notices 22

Summary of Benefits & Coverage: PPO Plan

37

Summary of Benefits & Coverage: High Deductible Health Plan

44

Important Contacts 51

Turn to page 22 for important government-mandated notices pertaining to premium subsidies that may be available to certain individuals. Those notices are: • Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) • Health Insurance Marketplace Coverage Options and Your Health Coverage, and • Medicare Part D Notice

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Benefits Overview

Our Benefits Program Has You Covered Most days, we all count on our simple routines to get us through. Getting the kids to school, beating the traffic to work

and finishing dinner in time to enjoy a favorite hobby. But sometimes things don’t always go as planned. Like when your

head cold turns into the flu and you have to be out of work. Or your son’s football game ends with a broken leg. Or even

when your spouse learns he needs an extensive root canal. That’s when Harcros Chemicals Inc.’s benefits are there to

help you.

Below is an overview of our benefits program, which gives you the coverage you need for all types of things life brings

your way. Harcros allows you to choose the plans that work best for your own needs—and your pocketbook. The key to

getting the most from our benefits program is to take an active role in understanding and using the plans so that you are

getting the best value for the money you spend.

Medical Plan - UMR / UnitedHealthcare (UHC) • $800 PPO Plan

• $3,000 High Deductible Health Plan

Prescription Drug – Navitus

Delta – Delta Dental of Kansas

Vision Plan – VSP

Flexible Spending Accounts (FSA) & Health Savings Accounts (HSA) – Discovery Benefits

Basic & Optional Life/AD&D – The Standard

Long Term Disability – The Standard

Salary Continuation Program – Harcros

Business Travel Accident – Mutual of Omaha

Employee Assistance Program – LifeWorks

401k Retirement Plan – MassMutual

Employee Stock Option Program (ESOP) – Harcros

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When Coverage Begins

Initial Enrollment When you first join Harcros Chemicals Inc., you have 30 days to enroll yourself and your dependents for benefits. If you enroll on time, coverage begins the first of the month following 30 days of employment. If you do not enroll within 30 days of becoming eligible, you will automatically be enrolled in company-sponsored benefits, such as Basic Life and the Employee Assistance Program (EAP), but you will have to wait until the next annual Open Enrollment to enroll for other benefits and make changes to coverage.

Annual Enrollment During annual Open Enrollment, coverage takes effect on January 1 of the following year.

Who Is Eligible? If you are a full-time employee scheduled to work at least 30 hours or more per week, you and your eligible dependents may enroll in the benefits described in this guide. Your eligible dependents include:

• Your legal spouse • Your dependent children to the end of the month they turn age 26 • Disabled dependents may be covered beyond the dependent limiting age. Please contact HR for information.

Medical Spousal Carve-Out Rule If your spouse works full-time and is eligible for medical coverage through his or her employer, your spouse will not be eligible for medical and prescription drug coverage under the Harcros Chemicals Employee Welfare Benefit Plan (Medical and Prescription plans). If your spouse qualifies for coverage under the Harcros Medical Plan, you will need to complete a Spousal Affidavit Form.

Making Changes to Coverage Once you make your benefit elections, these choices remain in effect until the next annual Open Enrollment unless you have a qualified status change or you or your eligible dependents become eligible for coverage through special enrollment rules. If you have a qualified status change or you have another allowable event, you can make certain changes during the plan year. However, you must make your enrollment change within 30 days of the event by completing a Benefit Changes/Enrollment form and returning it to Human Resources. If you do not return your form within 30 days, you will have to wait until the next Open Enrollment to make new elections. Qualified status changes include, but are not limited to:

• Change in number of eligible dependents due to birth, adoption, placement for adoption or death • Change in legal marital status, including marriage, divorce, or death of a spouse • Change in residence or workplace that changes you or your dependent’s eligibility for coverage • Change in employment status, such as starting or ending employment, for you, your spouse or your children

For a more complete list of qualified status changes, please contact Human Resources.

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Wellness Matters At Harcros, wellness is a part of our culture. We have a holistic approach to wellness that makes getting healthier easier and more fun. It isn’t about points. It’s about you. How you eat, how you move, and how you feel. It’s a great way for all of us, employees and families, to become healthier together.

Fitness Center Reimbursement

Regular exercise is an essential part of a healthy lifestyle. That’s why Harcros will pick up the cost of a qualified health

club membership or fitness classes taken at an approved fitness club—up to $240 per year!

Activity Tracker Reimbursement

The simplest way to get moving is to get walking! To help you get moving, Harcros will reimburse up to $56 for a smart

watch of your choice. **This benefit applies to New Hires only.

How it Works

– Employees will be eligible for reimbursement once every 12 months.

– To qualify, you will need to:

o Fill out and return the Gym Reimbursement Form, available at benefits.harcros.com.

o Provide an annual gym membership payment receipt.

o Provide validated proof of at least 8 gym visits per month.

All the details can be found on the Gym Reimbursement Form. Please return your completed form to Sabrina Harrison.

Preventive Services If you are enrolled in one of the Harcros Medical plans, Preventive Services are covered at 100% every calendar year on

both plans if there isn’t a diagnosis and you see an in-network provider. These services can include:

• Physician Examinations

• Urinalysis

• Glucose Screening

• Electrocardiogram (EKG)

• Pelvic Exam and Pap Smears

• Mammograms

• Colorectal Cancer Exams

• Immunizations

• Birth Control (generic only)

• Flu Shot

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Medical Plan Harcros Chemicals Inc.’s medical plan options provide coverage for the same types of expenses, such as doctor’s office

visits, preventive care, prescription drugs and hospitalization. You choose the option that makes the most sense for you

and your family based on your needs. The Harcros medical coverage through UMR with the United Health Care Choice

Plus network provides access to a nationwide network of high-quality physicians, hospitals, and facilities.

Plan Options When it comes to medical coverage, Harcros Chemicals Inc. offers:

• UHC Choice Plus PPO $800 Plan – Paired with Flexible Spending Account • UHC Choice Plus High Deductible Health Plan (HDHP) $3,000 – Paired with Health Savings Account

Please note that both plan options utilize the same national network for both medical and prescription drug services.

In-Network Care Both plans offer in-network and out-of-network benefits. When you need care, you decide whether to go to a

UnitedHealthcare (UHC) in-network doctor or to an out-of-network provider. If you receive care from in-network

doctors and facilities, your out-of-pocket costs will be lower than if you use out-of-network providers and facilities

because UHC network providers discount their fees. If you choose to receive care from an out-of-network provider, the

medical plan pays a lower benefit and you must file a claim to receive reimbursement for covered expenses.

Finding a Network Provider For the quickest, most up-to-date information, visit www.UMR.com and select Find a Provider. Enter

“UnitedHealthcare Choice Plus” and click search. Then, select the View Providers button.

Search by Category

– People: Doctors and other health care providers

– Places: Hospitals, clinics, imaging centers

– Tests and Imaging: Lab tests, screenings, scans

– Services and Treatments: Office visits, surgeries

– Care by Condition: Area of the body, type of illness

Search Results Include

– Preferred Provider Status

– Patient Reviews

– Average Cost for Procedure or Visit

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Choose the Right Health Care Setting Where you go for Medical services can make a big difference in how much you pay and how long you wait to see a health care provider. The chart below can assist in selecting the right setting based on your needs.

TYPE OF CARE WAIT TIME COST**

TeladocSM - 800-835-2362 or Teladoc.com You may request a consultation from a board-certified doctor any time of day, seven days a week, by phone or online. Teladoc physicians can diagnose routine ailments, recommend treatments and prescribe medications.

5 minutes Approximate

wait time for doctor to respond

$45 per consultation

When to go*

• Cold or flu

• Bronchitis

• Respiratory infection

• Sinus problems

• Allergies

• Urinary tract infection

• Pediatric care

• Poison ivy or pink eye

New for 2020: Teledoc will now offer behavioral health services! As a member, you can choose the

licensure, specialties, gender and languages of your provider and use the same provider throughout

the course of care. You may access a provider seven days a week, 7am to 9pm local time.

48 hours All behavioral health

appointment requests are accepted

$85-$95

per session. $200 initial diagnostic

evaluation.

Retail clinic/convenient care clinic Retail clinics, sometimes called convenient care clinics, are in retail stores, supermarkets and pharmacies.

15 minutes on average

$50-$100

Approximate cost per service

When to go*

• Colds or flu

• Sinus infections

• Allergies

• Vaccinations or screenings

• Minor sprains, burns, or rashes

• Headaches or sore throats

Urgent care/walk-in clinic Urgent care centers, sometimes called walk-in clinics, are often open in the evenings and on weekends.

20-30 minutes Approximate

wait time

$150 -$200 Average cost

When to go*

• Sprains and strains

• Mild asthma attacks

• Sore throats

• Minor broken bones or cuts

• Minor infections or rashes

• Earaches

Clinical care (your doctor’s office) Seeing your doctor is important. Your doctor knows your medical history and any ongoing health conditions.

When to go*

• Preventive services and vaccinations • Medical problems or symptoms that are not an immediate,

serious threat to your health or life

1 week or more

Approximate wait time for an appointment

$100-$150 Average cost

PPO Plan – Plan A

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PPO $800 Plan

Plan Benefits In-Network Out-of-Network

Deductible (Calendar Year) Employee Employee + One Family

$800

$1,600 $2,400

$7,500

$15,000 $15,000

Coinsurance (Plan pays)

80% 60%

Out-of-Pocket Max (includes Deductible) Employee Employee + One

Family

$2,200 $4,400 $4,400

$15,000 $30,000 $30,000

Office Visits 80% coinsurance after ded. 60% coinsurance after ded.

Preventive Care Covered 100%

Teladoc Visit 80% coinsurance after ded.

($45 charge) N/A

Urgent Care 80% coinsurance after ded. 60% coinsurance after ded.

Emergency Room 80% coinsurance after ded.

Inpatient Hospital Services 80% coinsurance after ded. 60% coinsurance after ded.

Outpatient Services 80% coinsurance after ded. 60% coinsurance after ded.

Labs and Radiology / x-ray 80% coinsurance after ded. 60% coinsurance after ded.

Prescription Drug Plan

Out-of-Pocket Max Employee Employee + One Family

$2,000 $4,000 $6,000

Retail Prescription Drug Coverage

(up to 31-day supply)

Tier 1: $10 copay Tier 2: $50 copay Tier 3: $75 copay

Specialty 20% up to $200

You pay for the prescription and the plan will reimburse you the

cost not to exceed the predominant Reimbursement

Rate minus the copay A 90-day prescription drug supply may be attained at your local pharmacy.

The plan covers all prescription tobacco cessation products and diabetic supplies at 100%.

Monthly Employee Contribution

Employee Only $215

Employee + One $430

Family $645

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High Deductible Health Plan – Plan B HDHP $3,000 Plan

Plan Benefits In-Network Out-of-Network

Deductible (Calendar Year) Employee Employee + One Family

$3,000 $6,000 $6,000

$7,500

$15,000 $15,000

Coinsurance (Plan pays)

100% 60%

Out-of-Pocket Max (includes Deductible & Prescription Drugs)

Employee Employee + One

Family

$3,000 $6,000 $6,000

$15,000 $30,000 $30,000

Office Visits 100% coinsurance after ded. 60% coinsurance after ded.

Preventive Care Covered 100%

Teladoc Visit 100% coinsurance after ded.

($45 charge) N/A

Urgent Care 100% coinsurance after ded. 60% coinsurance after ded.

Emergency Room 100% coinsurance after ded.

Inpatient Hospital Services 100% coinsurance after ded. 60% coinsurance after ded.

Outpatient Services 100% coinsurance after ded. 60% coinsurance after ded.

Labs and Radiology / x-ray 100% coinsurance after ded. 60% coinsurance after ded.

Prescription Drug Plan

Retail Prescription Drug Coverage

(up to 31-day supply) 100% coinsurance after ded. 60% coinsurance after ded.

A 90-day prescription drug supply may be attained at your local pharmacy.

The plan covers all prescription tobacco cessation products and diabetic supplies at 100%.

Harcros contributes monthly to your HSA based on your HDHP enrollment tier. Annual Contribution:

• Employee $500

• Employee + One $1,000

• Family $1,500

Monthly Employee Contribution

Employee Only $85

Employee + One $170

Family $255

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Savings & Expense Account Options Your eligibility to participate in the various types of savings account options depends on your medical plan election.

Health Savings Accounts A Health Savings Account (HSA) allows you to pay for current or save for future qualified medical, dental, and vision

expenses on a tax-free basis. You are eligible to open an HSA if you are:

• Covered by an HSA-qualified High Deductible Health Plan (HDHP)

• Not covered by another non-HDHP (including a spouse's plan and/or a General-Purpose healthcare FSA set up by

you or your spouse)

• Not enrolled in Medicaid, Medicare or Tricare

• Not eligible to be claimed as a dependent on another person's tax return

• You nor your spouse may have a Medical FSA

HSA funds can be used to pay for any "qualified medical expense" not covered through other plans. You can use your

funds to pay for qualified expenses for yourself as well as your spouse, and/or your tax-code dependents. Funds used

for purposes other than to pay for "qualified medical expenses" are taxable as income and subject to a 20% tax penalty.

HSA Funding

Harcros will make contributions to your HSA monthly. Individuals age 55 and older covered by a HDHP can make a

catch-up contribution of an additional $1,000 during the 2020 calendar year. However, account holders age 65+ who are

enrolled in Medicare are no longer eligible to make contributions into an HSA or receive employer contributions to an

HSA.

HDHP Enrollment Harcros Annual

Contribution Maximum Employee

Contribution 2020 IRS Mandated

Combined Maximum

Employee Only $500 $3,050 $3,550

Employee + One $1,000 $6,100 $7,100

Family $1,500 $5,600 $7,100

Tax Benefits

Heath Savings Accounts are triple tax-advantaged where balances can accumulate over time. HSAs can also be used to

accumulate savings; unused funds carry over each year and continue to earn interest, tax-free. HSAs are completely

employee-owned. All documentation and receipts must be saved for HSA transactions. The Internal Revenue Service

(IRS) administers Health Savings Accounts. For more information, please refer to IRS Publication 969 or visit

www.irs.gov.

Note: If you are not eligible to make contributions to an HSA due to your enrollment in Medicare, Tricare or if you have

a non-tax code dependent, an HRA / FSA may be available to you.

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Savings & Expense Account Options Your eligibility to participate in the various types of savings account options depends on your medical plan election.

Flexible Spending Accounts A Flexible Spending Account (FSA) allows you to reduce your taxable income by setting aside pre-tax dollars to pay for

qualified dental, vision and dependent care expenses. Harcros offers three types of FSAs:

• The Health Care FSA allows you to contribute an annual maximum amount of $2,700 to pay for qualified medical, dental, and vision related expenses.

• The Limited-Purpose FSA allows you to contribute an annual maximum amount of $2,700 to pay for dental and

vision related expenses only. Employees may not enroll in both a Medical FSA and a Limited-Purpose FSA; however,

members enrolled in a HDHP are eligible to enroll in a Limited-Purpose FSA in addition to a Health Savings Account

(HSA).

• The Dependent Care FSA allows you to contribute up to an annual maximum of $5,000 if single or married filing

jointly; $2,500 if you are married filing separately. You can use this account to pay for expenses associated with the

care of children under the age of 13 or for a disabled spouse or parent while you work. The account can be used or

daycare, preschool, after school care, summer day camp and elder care.

FSA Reimbursements

Careful planning of your expenses is recommended. Changes to your contribution elections are not permitted unless you

have a qualified life status change. The election you make when you enroll is binding for the entire plan year (January 1

to December 31), unless you have a qualifying status change.

• The Harcros plan allows for an additional 2 ½ month “grace period” to incur expenses for the Health Care and Limited Purpose FSA into the next calendar year. This “grace period” is January 1st through March 15th.

• Unused amounts are subject to the use-it-or-lose-it rule and are forfeited.

• Expenses incurred during the “grace period” may be first reimbursed from the funds remaining from the prior year, then from the current year.

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HSA & FSA Access and Claims Submission You may view your account balances, file claims online, or obtain additional information via the Discovery Benefits website

at www.discoverybenefits.com. You may also manage your account by downloading the Discovery Benefits mobile app.

Qualified Expenses This is a quick reference list of qualified FSA and HSA expenses. Expenses are eligible provided they are not reimbursed

through insurance or other sources. This list is a guide only and is subject to change by the IRS. Please refer to IRS

Publication 502 or consult a tax advisor for details.

Examples of Eligible Expenses

• Acupuncture

• Alcohol/drug dependency treatment

• Bandages

• Braille books, magazines

• Chiropractic services

• Contact lens expenses

• Crutches

• Dental expenses (non-cosmetic)

• Diagnostic/X-Ray/lab fees

• Doctor fees

• Eyeglasses/eye surgery

• Hearing aids

• Hospital services

• Insulin

• Lactation expenses

• Nursing home medical services

• Orthotic inserts

• Osteopathic services

• Prescription medications

• Prosthesis

• Special education for the handicapped

• Surgical/therapy fees

• Telephone equipment for hearing-impaired or

visually-impaired

• Wheelchairs, walkers

Examples of Eligible Over-the-Counter

Medications Requiring a Prescription

• Acid controllers

• Allergy/sinus medications

• Cold, cough, and flu medications

• Pain relief medications

• Sleep aids and sedatives

• Stomach remedies

Ineligible Expenses

• Expenses reimbursable by insurance or Medicare

• Federal itemized deduction expenses

• Cosmetic treatment and supplies

• Hair transplants

• Health/fitness club fees

• Non-prescription medication and drugs

• Nutritional/vitamin supplements

• Personal use items

• Premium payments for health, dental or vision care

coverage

• Weight loss programs (for general health)

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Dental Plan Harcros’s Dental Plan is administered by Delta Dental of Kansas. Harcros’s dental plan provides you and your family with

coverage for typical dental expenses, such as cleanings, x-rays, fillings and orthodontia for children.

Dental PPO Plan The Dental PPO allows you the freedom to visit any dentist, without referrals, for all

your dental care. If you receive care from one of Delta Dental’s preferred dentists,

you’ll pay less for your care. If you choose a non-preferred dentist, your share of costs

will generally be higher, and you may need to file your own claims.

Dental Plan Highlights Plan Feature Delta Dental PPO Network

Annual Deductible Individual Family

$50

$100

Annual Benefit Maximum $10,000

Preventive Services Exams, routine cleanings, x-rays, space maintainers, sealants, fluoride treatment

100% (no deductible)

Basic Services Fillings, periodontics, endodontics, crowns, extractions, general anesthesia.

80% after deductible

Major Services Restorative, bridges, dentures, implants

50% after deductible

Orthodontia Adult and Child Lifetime Maximum of $1,500

50% after deductible

Employee Monthly

Contribution

Employee $25

Employee + One $50

Family $75

For a list of Delta Dental preferred dentists, go to www.deltadentalks.com.

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Vision Plan The Harcros Vision Plan promotes preventive care through regular eye exams and provides coverage for corrective materials, such as glasses and contact lenses. The Vision Plan is administered through VSP.

Vision Coverage If you enroll for vision coverage, you can go to any eye care provider you choose for care. However, if you choose providers

who are part of the VSP network, you will receive a discount on services. To find a network provider, go to www.vsp.com.

The Vision Plan is designed to cover eye care needs that are visually necessary. You must pay extra if you choose certain cosmetic or elective eyewear, so be sure to ask your eye doctor what items are covered by the plan before you purchase materials.

Vision Plan Highlights Plan Feature In-Network Benefit Frequency

Eye Exam $10 copay Every calendar year

Lenses $25 copay for all lenses

• Single Vision, lined bifocal, and lined trifocal lenses

• Polycarbonate lenses for dependent children

Every calendar year

Lens Enhancements • Standard progressive lenses $50

• Premium progressive lenses $95-$105

• Custom progressive lenses $150- $175 Every calendar year

Frames • $130 allowance for a wide selection of frames

• $150 allowance for featured frame brands

• An additional 20% savings on amounts over the allowance Every other calendar

year

Contact Lenses (Instead of Glasses)

• $130 allowance for contacts, copay does not apply

• Up to $60 for contact lens exam (fitting and evaluation) Every calendar year

Employee Monthly

Contribution

Employee $6.88

Employee +Spouse $11.01

Employee + Child(ren) $11.24

Family $18.12

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Life Insurance Harcros Chemicals Inc. offers life insurance coverage to provide financial protection in the event of a loss. This coverage is administered through The Standard.

Basic Life & AD&D Insurance Harcros Chemicals Inc. provides Life and AD&D insurance for all eligible employees at no cost.

• Hourly Employees Benefit Employee $50,000, Spouse $10,000, Child $2,000

• Salaried & Chemical Technicians Employee 2x Annual Earnings ($750,000 Max)

Voluntary Life & AD&D Insurance In addition to your Basic Life and AD&D benefit, you may purchase Voluntary Life and AD&D Insurance not only for

yourself, but also for your spouse and your dependent children. However, you may only elect coverage for your spouse

and/or dependents if you enroll in Voluntary Life and AD&D coverage for yourself. You pay for the cost of Voluntary Life

and AD&D insurance on an after-tax basis through payroll deductions.

Voluntary Life

• Employee:

o You may apply for Voluntary Life insurance in increments of $10,000 to a maximum of $750,000.

o New Hire Guarantee Issue Amount: $200,000

• Spouse:

o You may apply for Voluntary Life insurance in increments of $5,000 to a maximum of $250,000.

o New Hire Guarantee Issue Amount: $20,000

• Child(ren):

o You may apply for Voluntary Life insurance for $10,000.

o New Hire Guarantee Issue Amount: $10,000

Voluntary AD&D

• Employee:

o You may apply for Voluntary AD&D insurance in increments of $10,000 to a maximum of $500,000.

or

• Family:

o You may apply for Voluntary AD&D insurance in increments of $10,000 to a maximum of $500,000.

o Spouse receives 40% of your Voluntary AD&D benefit; Child receives 20% of your Voluntary AD&D benefit.

If you wish to apply for more than the guarantee issue amounts listed above, you will be required to complete an evidence of insurability form. See Human Resources for the appropriate form.

You must designate a beneficiary for Basic and Voluntary Life Insurance benefits when you enroll.

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Disability Coverage Harcros provides disability coverage which will replace a percentage of your income if you cannot work because of

illness, injury or pregnancy.

Salary Continuation

Harcros Chemicals Inc. provides full-time employees with salary continuation benefits based on the length of time you have worked for Harcros.

ELIGIBILITY COMPANY PAID BENEFIT

Less than 2 months No Benefit

2 Months – Less than 1 Year 100% – 1 Month; 20% – 5 Months

1 Year – Less than 5 Years 100% – 2 Months; 60% – 4 Months

5 Years – Less than 10 Years 100% – 4 Months; 60% – 2 Months

10 Years or Greater 100% – 6 Months

Long Term Disability If you remain totally disabled and unable to work for more than 180 days, you may be eligible for Long Term Disability

(LTD) benefits. Harcros automatically provides you LTD benefits that replaces up to 60% of your base pay, up to a

maximum of $10,000 per month. You are eligible for LTD benefits following 30 days of service. Your monthly LTD

benefit will be reduced by Social Security and any other disability income you are eligible to receive (such as Workers’

Compensation).

Travel Assist

The Standard includes Travel Assistance through an arrangement with UnitedHealthcare Global. This provides an

additional sense of security for you and your eligible family members any time you travel more than 100 miles from

home or internationally for trips of up to 180 days. A single phone call helps you and your family with emergencies that

may arise while traveling, including a wide range of medical, legal and travel-related issues. There’s no enrollment

process – all employees are automatically covered. Contact Human Resources for more information.

Life Tool Kit

Life Services Toolkit resources are automatically available to you through The Standard. You have access to

comprehensive online resources including: estate planning assistance, identity theft prevention, financial planning,

health and wellness and funeral arrangements. Beneficiaries can also access services on grief support, financial

counseling, legal services and more for up to 12 months after the date of death. Contact Human Resources for more

information.

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Employee Assistance Program Your well-being, productiveness and happiness depend on balancing your life at home and your life at work. It’s difficult to be on task on the job if you’re worried about problems at home, and you can’t devote enough time to yourself and your family if you’re feeling overwhelmed by work issues. LifeWorks is available 24 hours a day, seven days a week, to help you and your family find answers and resolve personal problems. Confidential support, guidance and resources are available to help you be happier and more productive. The EAP provides resources and help regarding many issues, including the following: • Adoption issues

• Alcohol and drug abuse

• Anxiety

• Budgeting, financial worries, and reducing debt

• Child care and parenting issues

• Concern about another person’s alcohol or drug abuse

• Conflict at work

• Crisis and trauma

• Depression

• Elder care/caregiving issues

• Gambling and other addictions

The EAP consultant will discuss your needs and concerns with you, listen, and assess the situation. Depending on your situation, the EAP consultant may:

• Work with you and help you plan to resolve your issues or concerns

• Refer you to a support group

• Guide you to helpful resources in your community

• Refer you to a specialist or local counselor for ongoing counseling

• Help you navigate the EAP website for helpful resources, including articles, booklets, recordings, and more. Remember, no problem is too big or too small. The EAP encourages employees and those close to them to seek help early, before a minor problem becomes more serious. When in doubt, contact the EAP for help or support. Assistance is available for you or immediate household family members by calling 1-877-234-5151. You can also log onto www.lifeworks.com.

• Grief and loss

• Job burnout

• Legal matters

• Relationship issues

• Separation and divorce

• Stress

• Workplace change

• Domestic abuse

• Work-related problems and job stress

• Education issues

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Paid Time Off

Paid Holidays Harcros Chemicals Inc. recognizes ten (10) paid holidays each year. Shortly before the beginning of each year, the

Human Resources Department will post and circulate a list of the holidays to be observed for each year.

Paid Vacation Only full and part time regular employees are eligible for vacation. Part time employees receive vacation on a pro-rated

basis. Eligibility is based upon continuous length of service:

• 1 to 4 Years – 10 Vacation Days/Year

• 5 to 9 Years – 15 Vacation Days/Year

• 10 to 19 Years – 20 Vacation Days/Year

• 20 Years and above – 25 Vacation Days/Year

Employees hired before July 1st, will be eligible for 1 week of vacation after completing 4 months of continuous service. Employees hired on or after July 1st do not qualify for vacation in that calendar year. Part-time employee vacation will be a pro-rated portion of the full-time amount.

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Retirement Savings Plan We all look forward to the time when we can retire with financial security. To help you prepare for the goal, Harcros

Chemicals Inc. is pleased to work with Mass Mutual to provide you with the Retirement Savings Plan as part of your

compensation package. For eligibility requirements please contact the Human Resources Department, or the Harcros

intranet site.

Your Contributions

Before-Tax Contributions: Through payroll deduction, you may choose to make Before-Tax contributions from 1% to

100% of your eligible pay as defined in the plan. Please note, the IRS does limit the amount you can contribute to the

plan on a before-tax basis.

Roth Contributions: Through payroll deduction, you may choose Roth salary deferral contributions up to the maximum

under the law. These Roth contributions are elective deferrals that you elect to contribute to your Roth account on an

after-tax basis.

After-Tax Contributions: You may make after-tax contributions from 1% to 5% of your eligible pay. After-tax

contributions of certain highly paid employees may be future limited. You’ll be informed about any additional limits that

apply to you.

Harcros Chemicals Inc. Contributions Company Matching Contributions To help your savings grow even faster, Harcros Chemicals Inc. contributes $.6667 to your account for every dollar you

contribute up to 6% of your eligible pay. Harcros Chemicals Inc. only matches on the Before-Tax and Roth contributions.

Safe Harbor Contributions To help your savings grow faster, Harcros Chemicals Inc. will contribute 3% of eligible compensation that will be allocated

among all eligible employees.

Directing Contributions You decide how to invest all your contributions to the plan except for any contributions to the plan made by Harcros

Chemicals Inc. in company stock. You may direct these contributions to any or all the plan’s investment options in any

manner you wish, in multiples of 1%. A Roth IRA contribution model is also available for those interested. In addition,

you have the option to change how new money, or future contributions, should be invested. These changes may be made

online at www.retiresmart.com

Vesting You are always 100% vested in the value of your own contributions, the 3% Safe Harbor contribution and the investment

earnings on those contributions. There is a 3-year vesting period on employer contributions. A year of vesting for the

Harcros Chemicals Inc. contributions is based on 1,000 hours of services worked in a plan year.

• Less than three years of service - 0% Vested

• Upon completion of 3 years of service - 100% Vested

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Employee Stock Ownership Plan

Congratulations! You’re an owner!! Even though Employee Stock Ownership Plans (ESOP) have been around for many years, most of us don’t know much

about them. Here are some facts you’ll want to know about your new Harcros ESOP.

✓ An ESOP is a type of retirement plan that makes it possible for you to share in the value of our company.

✓ The ESOP is different from our 401k plan, as you cannot contribute to your ESOP account and all contributions

to the account are made by the company.

✓ There is no paperwork to complete and shares of stock will be automatically contributed to your account each

year if you are an eligible employee. You will be required to complete a beneficiary designation form.

✓ All Harcros employees are eligible to participate. Each year you will receive a statement showing how much

stock was added to your ESOP account as well as the total number of shares of stock you have in your account

and their value.

✓ Each year the company will be valued by an independent, third-party appraisal firm that is qualified to perform

business valuations.

✓ Your shares will be 100% vested after three years of service or age 65.

✓ For vesting purposes, 1,000 hours of service is considered a vesting year.

✓ Employees hired before June 30th will join the plan in that year. Employees hired after July 1st will join the plan

the following year.

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Annual Compliance Notices • Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP)

• Health Insurance Marketplace Coverage Options and Your Health Coverage

• Notice of Privacy Practices

• Newborn & Mothers Health Protection Notice

• Medicare Part D Notice

• COBRA Rights Notice

• Women’s Health and Cancer Rights Act

• Expanded Coverage for Women’s Preventive Care

• Notice of Special Enrollment Rights

Summaries of Benefits and Coverage

22

The government-required Summaries of Benefits and Coverage (SBCs), which summarize important information about

your medical plan options, are available starting on page 37 and online at Paycor, www.paycor.com

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid 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 more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed on the following page, 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, dial 1-877-KIDS NOW, or visit www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state 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 at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the States listed on the following page, you may be eligible for assistance paying your employer health plan premiums. The list of States is current as of July 31, 2019. Contact your State for further information on eligibility. To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either:

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, ext. 61565

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State Website/E-mail Phone

Alabama (Medicaid) http://www.myalhipp.com 1-855-692-5447

Alaska (Medicaid) Premium Payment Program: http://myakhipp.com

Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

E-mail: CustomerService@MyAKHIPP.com

1-866-251-4861

Arkansas (Medicaid) http://myarhipp.com/ 1-855-692-7447

Colorado (Medicaid and CHIP) Medicaid: http://www.healthfirstcolorado.com/

CHIP: http://www.colorado.gov/pacific/hcpf/child-health-plan-plus

1-800-221-3943

1-800-359-1991

State relay 711

Florida (Medicaid) http://www.flmedicaidtplrecovery.com/hipp/ 1-877-357-3268

Georgia (Medicaid) https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp 678-564-1162 ext 2131

Indiana (Medicaid) Healthy Indiana Plan for low-income adults 19-64: http://www.in.gov/fssa/hip/

All other Medicaid: http://www.indianamedicaid.com

1-877-438-4479

1-800-403-0864

Iowa (Medicaid) http://dhs.iowa.gov/Hawki 1-800-257-8563

Kansas (Medicaid) http://www.kdheks.gov/hcf/ 1-785-296-3512

Kentucky (Medicaid) https://chfs.ky.gov 1-800-635-2570

Louisiana (Medicaid) http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 1-888-695-2447

Maine (Medicaid) http://www.maine.gov/dhhs/ofi/public-assistance/index.html 1-800-442-6003

TTY: Maine relay 711

Massachusetts (Medicaid and

CHIP)

http://www.mass.gov/eohhs/gov/departments/masshealth/ 1-800-862-4840

Minnesota (Medicaid) https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-

programs/programs-and-services/other-insurance.jsp

1-800-657-3739

Missouri (Medicaid) https://www.dss.mo.gov/mhd/participants/pages/hipp.htm 573-751-2005

Montana (Medicaid) http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP 1-800-694-3084

Nebraska (Medicaid) http://www.ACCESSNebraska.ne.gov 1-855-632-7633

Lincoln: 402-473-7000

Omaha: 402-595-1178

Nevada (Medicaid) http://dhcfp.nv.gov/ 1-800-992-0900

New Hampshire (Medicaid) https://www.dhhs.nh.gov/oii/hipp.htm 603-271-5218 or

1-800-852-3345, ext. 5218

New Jersey (Medicaid and CHIP) Medicaid: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

CHIP: http://www.njfamilycare.org/index.html

Medicaid: 609-631-2392

CHIP: 1-800-701-0710

New York (Medicaid) https://www.health.ny.gov/health_care/medicaid/ 1-800-541-2831

North Carolina (Medicaid) https://dma.ncdhhs.gov/ 919-855-4100

North Dakota (Medicaid) http://www.nd.gov/dhs/services/medicalserv/medicaid/ 1-844-854-4825

Oklahoma (Medicaid and CHIP) http://www.insureoklahoma.org 1-888-365-3742

Oregon (Medicaid) http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

1-800-699-9075

Pennsylvania (Medicaid) http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremium

paymenthippprogram/index.htm

1-800-692-7462

Rhode Island (Medicaid and CHIP) http://www.eohhs.ri.gov/ 1-855-697-4347 or

401-462-0311

South Carolina (Medicaid) https://www.scdhhs.gov 1-888-549-0820

South Dakota (Medicaid) http://dss.sd.gov 1-888-828-0059

Texas (Medicaid) http://gethipptexas.com/ 1-800-440-0493

Utah (Medicaid and CHIP) Medicaid: https://medicaid.utah.gov/

CHIP: http://health.utah.gov/chip

1-877-543-7669

Vermont (Medicaid) http://www.greenmountaincare.org/ 1-800-250-8427

Virginia (Medicaid and CHIP) Medicaid: http://www.coverva.org/programs_premium_assistance.cfm

CHIP: http://www.coverva.org/programs_premium_assistance.cfm

Medicaid: 1-800-432-5924

CHIP: 1-855-242-8282

Washington (Medicaid) http://www.hca.wa.gov/ 1-800-562-3022, Ext. 15473

West Virginia (Medicaid) http://mywvhipp.com/ 1-855-699-8447

Wisconsin (Medicaid and CHIP) https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf 1-800-362-3002

Wyoming (Medicaid) http://wyequalitycare.acs-inc.com/ 307-777-7531

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Health Insurance Marketplace Coverage Options and Your Health Coverage

Part A: General Information

Since key parts of the health care law took effect in 2014, there is another way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the Marketplace and employment-based health coverage offered by your employer.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be

eligible for a tax credit that lowers your monthly premium right away. Typically, you can enroll in a Marketplace

health plan during the Marketplace’s annual Open Enrollment period or if you experience a qualifying life event.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage,

or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends

on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be

eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from

your employer that would cover you (and not any other members of your family) is more than 9.5% of your

household income for the year, or if the coverage your employer provides does not meet the "minimum value"

standard set by the Affordable Care Act, you may be eligible for a tax credit.

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this

employer contribution — as well as your employee contribution to employer-offered coverage — is often excluded

from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are

made on an after-tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or

contact Human Resources.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

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

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

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

• As your employer, we offer a health plan to some employees.

Eligible employees are:

• All fulltime employees working 30 or more hours per week

• With respect to dependents, we do offer coverage.

Eligible dependents are:

• Legally married spouse

• Dependent children to age 26, this includes (adopted, legal guardianship, court ordered, and child dependents who cannot support themselves due to physical or mental handicap).

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.

3. Employer name Harcros Chemicals Inc.

4. Employer Identification Number (EIN) 43-1935062

5. Employer address 5200 Speaker Road

6. Employer phone number 913-321-3131

7. City Kansas City

8. State KS

9. ZIP code 66106

10. Who can we contact about employee health coverage at this job? Dana Palermo

11. Phone number (if different from above)

12. E-mail address DPalermo@harcros.com

X

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Harcros Chemicals Inc. Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Our Company’s Pledge to You This notice is intended to inform you of the privacy practices followed by Harcros Chemicals Inc. and the Plan’s legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The notice also explains the privacy rights you and your family members have as participants of the Plan. It is effective on January 1, 2020.

The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions. We want to assure the participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy. Harcros Chemicals Inc. requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined below.

Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule. Generally, protected health information is information that identifies an individual created or received by a health care provider, health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions, provision of health care, or payment for health care, whether past, present or future.

How We May Use Your Protected Health Information Under the HIPAA Privacy Rule, we may use or disclose your protected health information for certain purposes without your permission. This section describes the ways we can use and disclose your protected health information.

Payment. We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits, seek reimbursement from a third party, or coordinate benefits with another health plan under which you are covered. For example, a health care provider that provided treatment to you will provide us with your health information. We use that information in order to determine whether those services are eligible for payment under our group health plan.

Health Care Operations. We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities, resolution of internal grievances, and evaluating plan performance. For example, we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs.

However, we are prohibited from using or disclosing protected health information that is genetic information for our underwriting purposes.

Treatment. Although the law allows use and disclosure of your protected health information for purposes of treatment, as a health plan we generally do not need to disclose your information for treatment purposes. Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment, payment, and health care operations.

As permitted or Required by Law. We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law. We are permitted by law to share information, subject to certain requirements, in order to communicate information on health-related benefits or services that may be of interest to you, respond to a court order, or provide information to further public health activities (e.g., preventing the spread of disease) without your written authorization. We are also permitted to share protected health information during a corporate restructuring such as a merger, sale, or acquisition. We will also disclose health information about you when required by law, for example, in order to prevent serious harm to you or others.

27

Pursuant to Your Authorization. When required by law, we will ask for your written authorization before using or disclosing your protected health information. Uses and disclosures not described in this notice will only be made with your written authorization. Subject to some limited exceptions, your written authorization is required for the sale of protected health information and for the use or disclosure of protected health information for marketing purposes. If you choose to sign an authorization to disclose information, you can later revoke that authorization to prevent any future uses or disclosures.

To Business Associates. We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan. We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information. For example, we may disclose your protected health information to a Business Associate to administer claims. Business Associates are also required by law to protect protected health information.

To the Plan Sponsor. We may disclose protected health information to certain employees of Harcros Chemicals Inc. for the purpose of administering the Plan. These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized additional disclosures. Your protected health information cannot be used for employment purposes without your specific authorization.

Your Rights

Right to Inspect and Copy. In most cases, you have the right to inspect and copy the protected health information we maintain about you. If you request copies, we will charge you a reasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format.

Right to Amend. If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to amend your health information. If we deny your request, you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information.

Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2) to you; (3) pursuant to your authorization; (4) to your friends or family in your presence or because of an emergency; (5) for national security purposes; or (6) incidental to otherwise permissible disclosures.

Your request for an accounting must be submitted in writing to the person listed below. You may request an accounting of disclosures made within the last six years. You may request one accounting free of charge within a 12-month period.

Right to Request Restrictions. You have the right to request that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. You also have the right to request that we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or friend. Your request for restrictions must be submitted in writing to the person listed below. We will consider your request, but in most cases are not legally obligated to agree to those restrictions.

Right to Request Confidential Communications. You have the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address.

28

Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements.

Right to Receive a Paper Copy of this Notice. If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the person listed below.

Our Legal Responsibilities We are required by law to maintain the privacy of your protected health information, provide you with this notice about our legal duties and privacy practices with respect to protected health information and notify affected individuals following a breach of unsecured protected health information.

We may change our policies at any time and reserve the right to make the change effective for all protective health information that we maintain. In the event that we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.

If you have any questions or complaints, please contact:

Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131

Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed above. You also may send a written complaint to the U.S. Department of Health and Human Services — Office of Civil Rights. The person listed above can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.

NEWBORN & MOTHERS HEALTH PROTECTION NOTICE For maternity hospital stays, in accordance with federal law, the Plan does not 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 delivery. However, federal law generally does not prevent the mother’s or newborn’s attending care provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). The plan cannot require a provider to prescribe a length of stay any shorter than 48 hours (or 96 hours following a Cesarean delivery).

29

Important Notice from Harcros Chemicals Inc. About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Harcros Chemicals Inc. and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. 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 Medicare 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.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this

coverage if you join a Medicare 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.

Navitus has determined that the prescription drug coverage offered by the Harcros Chemicals Inc. plans are, on

average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage

pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you

can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare 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 to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current plan will not be affected. If you do decide to join a Medicare drug plan and drop your current plan coverage, be aware that you and your dependents may not be able to get this coverage back until next open enrollment.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

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Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Harcros Chemicals Inc. changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare 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 “Medicare & You”

handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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

Remember: Keep this creditable coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

January 1, 2020

Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131

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COBRA Rights Notice

You’re getting this notice because you recently gained coverage under a group health plan (the 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 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 a continuation 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 Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from 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; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”

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Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Harcros Chemicals Inc., and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

When Is COBRA 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 of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer • The employee’s becoming entitled to Medicare 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.

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 lasts for 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:

Disability Extension of 18-Month Period of Continuation Coverage If 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.

Second Qualifying Event Extension of 18-Month Period of Continuation Coverage If your family experiences another qualifying event 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, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is 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 COBRA continuation 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

33

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 at www.healthcare.gov.

If You Have Questions Questions concerning your Plan or your COBRA continuation 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 visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Keep Your Plan Informed of Address Changes To protect your family’s rights, let the Plan Administrator 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 Contact Information January 1, 2020

Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131

34

Women’s Health and Cancer Rights Act of 1998

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultations with the attending physician and the patient, for:

• All states of reconstruction of the breast on which the mastectomy was performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses • Treatment of physical complications of the mastectomy, including lymphedema

These benefits will be provided subject to the same deductibles, copays and coinsurance applicable to other medical and surgical benefits provided under your medical plan. For more information on WHCRA benefits, contact your medical plan administrator.

January 1, 2020

Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131

Expanded Coverage for Women’s Preventive Care Under the Affordable Care Act, Harcros Chemicals Inc. provides female plan participants with expanded access to

recommended in-network preventive services, including contraceptives, without cost sharing.

Additional women’s preventive services that will be covered without cost sharing requirements include:

• Well-woman visits

• Gestational diabetes screening

• HPV DNA testing

• STI counseling, and HIV screening and counseling

• Contraception and contraceptive counseling

• Breastfeeding support, supplies, and counseling

• Domestic violence screening

For a description of what these items include, visit https://www.healthcare.gov/preventive-care-women/.

.

35

HIPAA Notice of Special Enrollment Rights

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires group health plans to provide a special enrollment opportunity to an employee (or COBRA enrollee) upon the occurrence of specific events. This Chart summarizes the qualifying events and the corresponding special enrollment rights. This notice is being provided to insure that you understand your right to apply for the Harcros Chemicals Inc. Group Health Care Plan. You should read this notice even if you plan to waive coverage at this time.

EVENT SPECIAL ENROLLMENT RIGHT

Acquisition of New Dependent(s) due to Marriage • Employee may enroll the employee (if not previously

enrolled).

• Employee may also enroll newly-eligible spouse and/or newly-eligible stepchild(ren).

Acquisition of New Child due to birth or adoption (including placement for adoption)

• Employee may enroll the employee (if not previously enrolled).

• Employee may also enroll spouse and/or newly-eligible child(ren).

Gain Eligibility for Premium Assistance Subsidy under Medicaid or CHIP

• Employee may enroll the employee and the spouse or child(ren) who have become eligible for the premium assistance.

Loss of Other Health Coverage if due to:

• Loss of eligibility. o Death of spouse; divorce, legal separation o Child loses status (e.g. reaches age limit) o Employment change (e.g. termination, reduction in

hours, unpaid FMLA)

• Expiration of COBRA maximum period

• Moving out of HMO plan’s service area

• Other employer terminates its plan (or discontinues employer contributions)

• Employee may enroll the employee (if not previously enrolled).

• Employee may also enroll spouse and/or children who have lost other health coverage.

Note: Person losing the Other Health Coverage must have had the other coverage since the date of this employer plan’s most recent enrollment opportunity.

Loss of Medicaid or CHIP coverage • Employee may enroll the employee and the spouse or

child(ren) who have lost Medicaid/CHIP entitlement.

Notes:

1. HIPAA Special Enrollees must be given 31 days (from the date of the event) to enroll.

2. For events related to Medicaid/CHIP, the special enrollment period is 60 days.

3. Special enrollment, if elected, must take effect no later than the first day of the month following the enrollment request. If the event is the birth or adoption of a child, the special enrollment must take effect retroactively on the date of birth or adoption (or placement for adoption).

To request special enrollment or obtain more information, please contact:

Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131

36

Su

mm

ary

of

Ben

efit

s an

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ove

rag

e: W

hat t

his

Pla

n C

over

s &

Wha

t Y

ou P

ay F

or C

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ervi

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C

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31/2

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R:

HA

RC

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S IN

C.:

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ove

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divi

dual

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amily

| P

lan

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e: P

PO

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e 1

of

7

Th

e S

um

mar

y o

f B

enef

its

and

Co

vera

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(SB

C)

do

cum

ent

will

hel

p y

ou

ch

oo

se a

hea

lth

pla

n. T

he

SB

C s

ho

ws

you

ho

w y

ou

an

d t

he

pla

n w

ou

ld

shar

e th

e co

st f

or

cove

red

hea

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car

e se

rvic

es. N

OT

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Info

rmat

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ab

ou

t th

e co

st o

f th

is p

lan

(ca

lled

th

e p

rem

ium

) w

ill b

e p

rovi

ded

sep

arat

ely.

T

his

is o

nly

a s

um

mar

y. F

or m

ore

info

rmat

ion

abou

t you

r co

vera

ge, o

r to

get

a c

opy

of th

e co

mpl

ete

term

s of

cov

erag

e, v

isit

ww

w.u

mr.

com

or

by c

allin

g 1-

800-

826-

9781

. For

gen

eral

def

initi

ons

of c

omm

on te

rms,

suc

h as

allo

wed

am

ount

, bal

ance

bill

ing,

coi

nsur

ance

, cop

aym

ent,

dedu

ctib

le, p

rovi

der,

or

othe

r un

derli

ned

term

s se

e th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.um

r.co

m o

r ca

ll 1-

800-

826-

9781

to r

eque

st a

cop

y.

Imp

ort

ant

Qu

esti

on

s A

nsw

ers

Wh

y th

is M

atte

rs:

Wh

at is

th

e o

vera

ll d

edu

ctib

le?

$8

00 p

erso

n / $

2,40

0 fa

mily

In-n

etw

ork

$7,5

00 p

erso

n / $

15,0

00 fa

mily

Out

-of-

netw

ork

Gen

eral

ly, y

ou m

ust p

ay a

ll th

e co

sts

from

pro

vide

rs u

p to

the

dedu

ctib

le a

mou

nt

befo

re th

is p

lan

begi

ns to

pay

. If y

ou h

ave

othe

r fa

mily

mem

bers

on

the

plan

, eac

h fa

mily

mem

ber

mus

t mee

t the

ir ow

n in

divi

dual

ded

uctib

le u

ntil

the

tota

l am

ount

of

dedu

ctib

le e

xpen

ses

paid

by

all f

amily

mem

bers

mee

ts th

e ov

eral

l fam

ily

dedu

ctib

le.

Are

th

ere

serv

ices

co

vere

d b

efo

re y

ou

mee

t yo

ur

ded

uct

ible

?

Yes

. Pre

vent

ive

care

ser

vice

s ar

e co

vere

d be

fore

you

mee

t you

r de

duct

ible

.

Thi

s pl

an c

over

s so

me

item

s an

d se

rvic

es e

ven

if yo

u ha

ven’

t yet

met

the

dedu

ctib

le a

mou

nt. B

ut a

cop

aym

ent o

r co

insu

ranc

e m

ay a

pply

. For

exa

mpl

e, th

is

plan

cov

ers

cert

ain

prev

entiv

e se

rvic

es w

ithou

t cos

t-sh

arin

g an

d be

fore

you

mee

t yo

ur d

educ

tible

. See

a li

st o

f cov

ered

pre

vent

ive

serv

ices

at

http

s://w

ww

.hea

lthca

re.g

ov/c

over

age/

prev

entiv

e-c

are-

bene

fits/

Are

th

ere

oth

er

ded

uct

ible

s fo

r sp

ecif

ic

serv

ices

?

No.

Y

ou d

on’t

have

to m

eet d

educ

tible

s fo

r sp

ecifi

c se

rvic

es.

Wh

at is

th

e o

ut–

of–

po

cket

lim

it f

or

this

pla

n?

$2

,200

per

son

/ $4,

400

fam

ily In

-net

wor

k $1

5,00

0 pe

rson

/ $3

0,00

0 fa

mily

Out

-of-

netw

ork

The

out

-of-

pock

et li

mit

is th

e m

ost y

ou c

ould

pay

in a

yea

r fo

r co

vere

d se

rvic

es.

If

you

have

oth

er fa

mily

mem

bers

in th

is p

lan,

they

hav

e to

mee

t the

ir ow

n ou

t-of

-po

cket

lim

its u

ntil

the

over

all f

amily

out

-of-

pock

et li

mit

has

been

met

.

Wh

at is

no

t in

clu

ded

in

the

ou

t–o

f–p

ock

et li

mit

?

Cop

aym

ents

for

cert

ain

serv

ices

, pen

altie

s,

prem

ium

s, b

alan

ce b

illin

g ch

arge

s, a

nd h

ealth

ca

re th

is p

lan

does

n’t c

over

.

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.

Will

yo

u p

ay le

ss if

yo

u

use

a n

etw

ork

pro

vid

er?

Y

es. S

ee w

ww

.um

r.co

m o

r ca

ll 1-

800-

826-

9781

fo

r a

list o

f net

wor

k pr

ovid

ers.

Thi

s pl

an u

ses

a pr

ovid

er n

etw

ork.

You

will

pay

less

if y

ou u

se a

pro

vide

r in

the

plan

’s n

etw

ork.

You

will

pay

the

mos

t if y

ou u

se a

n ou

t-of

-net

wor

k pr

ovid

er, a

nd

you

mig

ht r

ecei

ve a

bill

from

a p

rovi

der

for

the

diffe

renc

e be

twee

n th

e pr

ovid

er’s

ch

arge

and

wha

t you

r pl

an p

ays

(a b

alan

ce b

illin

g). B

e aw

are,

you

r ne

twor

k pr

ovid

er m

ight

use

an

out-

of-n

etw

ork

prov

ider

for

som

e se

rvic

es (

such

as

lab

wor

k). C

heck

with

you

r pr

ovid

er b

efor

e yo

u ge

t ser

vice

s.

Do

yo

u n

eed

a r

efer

ral t

o

see

a sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out a

ref

erra

l.

37

P

age

2 o

f 7

A

ll co

paym

ent a

nd c

oins

uran

ce c

osts

sho

wn

in th

is c

hart

are

afte

r yo

ur d

educ

tible

has

bee

n m

et, i

f a d

educ

tible

app

lies.

Co

mm

on

M

edic

al E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er

Imp

ort

ant

Info

rmat

ion

In

-net

wo

rk

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-n

etw

ork

(Y

ou

will

pay

th

e m

ost

)

If y

ou

vis

it a

h

ealt

h c

are

pro

vid

er’s

o

ffic

e o

r cl

inic

Prim

ary

care

vis

it to

trea

t an

inju

ry

or il

lnes

s 20

% C

oins

uran

ce

40%

Coi

nsur

ance

N

one

Spe

cial

ist v

isit

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Non

e

Pre

vent

ive

care

/scr

eeni

ng/

imm

uniz

atio

n N

o ch

arge

; D

educ

tible

Wai

ved

No

char

ge;

Ded

uctib

le W

aive

d

You

may

hav

e to

pay

for

serv

ices

that

ar

en't

prev

entiv

e. A

sk y

our

prov

ider

if

the

serv

ices

you

nee

d ar

e pr

even

tive.

T

hen

chec

k w

hat y

our

plan

will

pay

fo

r.

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y, b

lood

wor

k)

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Non

e

Imag

ing

(CT

/PE

T s

cans

, MR

Is)

20

% C

oins

uran

ce

40%

Coi

nsur

ance

N

one

38

P

age

3 o

f 7

Co

mm

on

M

edic

al E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er

Imp

ort

ant

Info

rmat

ion

In

-net

wo

rk

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-n

etw

ork

(Y

ou

will

pay

th

e m

ost

)

If y

ou

nee

d

dru

gs

to t

reat

yo

ur

illn

ess

or

con

dit

ion

. M

ore

info

rmat

ion

abou

t pr

escr

iptio

n dr

ug c

over

age

is a

vaila

ble

at

ww

w.n

avitu

s.co

m

Gen

eric

dru

gs (

Tie

r 1)

30

Day

Sup

ply:

$10

90

Day

Sup

ply:

$30

N

ot C

over

ed

Effe

ctiv

e Ja

nuar

y 1,

202

0, W

algr

eens

ph

arm

acie

s ar

e no

long

er a

n in

-ne

twor

k ph

arm

acy.

If y

ou h

ave

ques

tions

, abo

ut a

ltern

ativ

e ph

arm

acie

s, p

leas

e co

ntac

t Nav

itus

at

866-

333-

2757

.

Pre

ferr

ed b

rand

dru

gs (

Tie

r 2)

30

Day

Sup

ply:

$50

90

Day

Sup

ply:

$15

0 N

ot C

over

ed

Non

-pre

ferr

ed b

rand

dru

gs (

Tie

r 3)

30

Day

Sup

ply:

$75

90

Day

Sup

ply:

$22

5 N

ot C

over

ed

Spe

cial

ty d

rugs

(T

ier

4)

30 D

ay S

uppl

y: 2

0%, $

100

min

imum

, $20

0 m

axim

um

90 D

ay S

uppl

y: N

/A

Not

Cov

ered

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(e

.g.,

ambu

lato

ry s

urge

ry c

ente

r)

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

Out

-of-

netw

ork.

Phy

sici

an/s

urge

on fe

es

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Non

e

If y

ou

nee

d

imm

edia

te

med

ical

at

ten

tio

n

Em

erge

ncy

room

car

e 20

% C

oins

uran

ce

20%

Coi

nsur

ance

In

-net

wor

k de

duct

ible

app

lies

to

Out

-of-

netw

ork

bene

fits

Em

erge

ncy

med

ical

tran

spor

tatio

n 20

% C

oins

uran

ce

20%

Coi

nsur

ance

In

-net

wor

k de

duct

ible

app

lies

to

Out

-of-

netw

ork

bene

fits

Urg

ent c

are

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Non

e

39

P

age

4 o

f 7

Co

mm

on

M

edic

al E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er

Imp

ort

ant

Info

rmat

ion

In

-net

wo

rk

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-n

etw

ork

(Y

ou

will

pay

th

e m

ost

)

If y

ou

hav

e a

ho

spit

al s

tay

Fac

ility

fee

(e.g

., ho

spita

l roo

m)

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

Out

-of-

netw

ork.

Phy

sici

an/s

urge

on fe

e 20

% C

oins

uran

ce

40%

Coi

nsur

ance

N

one

If y

ou

hav

e m

enta

l hea

lth

, b

ehav

iora

l h

ealt

h, o

r su

bst

ance

ab

use

nee

ds

Out

patie

nt s

ervi

ces

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

for

Par

tial

hosp

italiz

atio

n O

ut-o

f-ne

twor

k.

Inpa

tient

ser

vice

s 20

% C

oins

uran

ce

40%

Coi

nsur

ance

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

Out

-of-

netw

ork.

If y

ou

are

p

reg

nan

t

Offi

ce v

isits

N

o ch

arge

; D

educ

tible

Wai

ved

No

char

ge;

Ded

uctib

le W

aive

d C

ost s

harin

g do

es n

ot a

pply

to c

erta

in

prev

entiv

e se

rvic

es. D

epen

ding

on

the

type

of s

ervi

ces,

ded

uctib

le,

copa

ymen

t or

coin

sura

nce

may

app

ly.

Mat

erni

ty c

are

may

incl

ude

test

s an

d se

rvic

es d

escr

ibed

els

ewhe

re in

the

SB

C (

i.e. u

ltras

ound

).

Chi

ldbi

rth/

deliv

ery

prof

essi

onal

se

rvic

es

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Chi

ldbi

rth/

deliv

ery

faci

lity

serv

ices

20

% C

oins

uran

ce

40%

Coi

nsur

ance

40

P

age

5 o

f 7

Co

mm

on

M

edic

al E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er

Imp

ort

ant

Info

rmat

ion

In

-net

wo

rk

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-n

etw

ork

(Y

ou

will

pay

th

e m

ost

)

If y

ou

nee

d

hel

p

reco

veri

ng

or

hav

e o

ther

sp

ecia

l hea

lth

n

eed

s

Hom

e he

alth

car

e 20

% C

oins

uran

ce

40%

Coi

nsur

ance

100

Max

imum

vis

its p

er c

alen

dar

yea

r;

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

Out

-of-

netw

ork.

Reh

abili

tatio

n se

rvic

es

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Non

e

Hab

ilita

tion

serv

ices

N

ot c

over

ed

Not

cov

ered

N

one

Ski

lled

nurs

ing

care

20

% C

oins

uran

ce

40%

Coi

nsur

ance

100

Max

imum

day

s pe

r ca

lend

ar y

ear;

P

reau

thor

izat

ion

is r

equi

red.

If y

ou

don’

t get

pre

auth

oriz

atio

n, b

enef

its

coul

d be

red

uced

by

$500

of t

he to

tal

cost

of t

he s

ervi

ce O

ut-o

f-ne

twor

k.

Dur

able

med

ical

equ

ipm

ent

20%

Coi

nsur

ance

40

% C

oins

uran

ce

Pre

auth

oriz

atio

n is

req

uire

d fo

r D

ME

in

exc

ess

of $

500

for

rent

als

or $

1,50

0 fo

r pu

rcha

ses.

If y

ou d

on’t

get

prea

utho

rizat

ion,

ben

efits

cou

ld b

e re

duce

d by

$50

0 pe

r oc

curr

ence

O

ut-o

f-ne

twor

k.

Hos

pice

ser

vice

20

% C

oins

uran

ce

40%

Coi

nsur

ance

N

one

If y

ou

r ch

ild

nee

ds

den

tal

or

eye

care

Chi

ldre

n’s

eye

exam

N

ot c

over

ed

Not

cov

ered

N

one

Chi

ldre

n’s

glas

ses

Not

cov

ered

N

ot c

over

ed

Non

e

Chi

ldre

n’s

dent

al c

heck

-up

Not

cov

ered

N

ot c

over

ed

Non

e

41

P

age

6 o

f 7

Exc

lud

ed S

ervi

ces

& O

ther

Co

vere

d S

ervi

ces:

Ser

vice

s Y

ou

r P

lan

Do

es N

OT

Co

ver

(Ch

eck

you

r p

olic

y o

r p

lan

do

cum

ent

for

mo

re in

form

atio

n a

nd

a li

st o

f an

y o

ther

exc

lud

ed s

ervi

ces.

)

•

Acu

punc

ture

•

Infe

rtili

ty tr

eatm

ent

•

Rou

tine

eye

care

(A

dult)

•

Cos

met

ic s

urge

ry

•

Long

-ter

m c

are

•

Rou

tine

foot

car

e

•

Den

tal c

are

(Adu

lt)

•

Non

-em

erge

ncy

care

whe

n tr

avel

ing

outs

ide

the

U.S

. •

Wei

ght l

oss

prog

ram

s O

ther

Co

vere

d S

ervi

ces

(Lim

itat

ion

s m

ay a

pp

ly t

o t

hes

e se

rvic

es. T

his

isn

’t a

co

mp

lete

list

. Ple

ase

see

you

r p

lan

do

cum

ent.

)

•

Bar

iatr

ic s

urge

ry

•

Hea

ring

aids

•

Priv

ate-

duty

nur

sing

(O

utpa

tient

car

e)

•

Chi

ropr

actic

car

e

Yo

ur

Rig

hts

to

Co

nti

nu

e C

ove

rag

e: T

here

are

age

ncie

s th

at c

an h

elp

if yo

u w

ant t

o co

ntin

ue y

our

cove

rage

afte

r it

ends

. The

con

tact

info

rmat

ion

for

thos

e ag

enci

es is

: U.S

. Dep

artm

ent o

f Lab

or's

Em

ploy

ee B

enef

its S

ecu

rity

Adm

inis

trat

ion

at 1

-866

-444

-EB

SA

(32

72)

or w

ww

.Hea

lthC

are.

gov.

Oth

er c

over

age

optio

ns m

ay

be a

vaila

ble

to y

ou to

o, in

clud

ing

buyi

ng in

divi

dual

insu

ranc

e co

vera

ge th

roug

h th

e H

ealth

Insu

ranc

e M

arke

tpla

ce. F

or m

ore

info

rmat

ion

abou

t the

Mar

ketp

lace

, vis

it w

ww

.Hea

lthC

are.

gov

or c

all 1

-800

-318

-259

6.

Yo

ur

Gri

evan

ce a

nd

Ap

pea

ls R

igh

ts:

The

re a

re a

genc

ies

that

can

hel

p if

you

have

a c

ompl

aint

aga

inst

you

r pl

an fo

r a

deni

al o

f a c

laim

. Thi

s co

mpl

aint

is c

alle

d a

grie

vanc

e or

app

eal.

For

mor

e in

form

atio

n ab

out y

our

right

s, lo

ok a

t the

exp

lana

tion

of b

enef

its y

ou w

ill r

ecei

ve fo

r th

at m

edic

al c

laim

. You

r pl

an d

ocum

ents

als

o pr

ovid

e co

mpl

ete

info

rmat

ion

to s

ubm

it a

clai

m, a

ppea

l or

a gr

ieva

nce

for

any

reas

on to

you

r pl

an. F

or m

ore

info

rmat

ion

abou

t you

r rig

hts,

this

not

ice,

or

assi

stan

ce,

cont

act:

U.S

. Dep

artm

ent o

f Lab

or's

Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istr

atio

n at

1-8

66-4

44-E

BS

A (

3272

) or

ww

w.H

ealth

Car

e.go

v. A

dditi

onal

ly, a

con

sum

er

assi

stan

ce p

rogr

am m

ay h

elp

you

file

your

app

eal.

A li

st o

f sta

tes

with

Con

sum

er A

ssis

tanc

e P

rogr

ams

is a

vaila

ble

at w

ww

.Hea

lthC

are.

gov

and

http

://cc

iio.c

ms.

gov/

prog

ram

s/co

nsum

er/c

apgr

ants

/inde

x.ht

ml.

Do

es t

his

pla

n P

rovi

de

Min

imu

m E

ssen

tial

Co

vera

ge?

Yes

If

you

don’

t hav

e M

inim

um E

ssen

tial C

over

age

for

a m

onth

, you

’ll h

ave

to m

ake

a pa

ymen

t whe

n yo

u fil

e yo

ur ta

x re

turn

unl

ess

you

qual

ify fo

r an

exe

mpt

ion

from

the

requ

irem

ent t

hat y

ou h

ave

heal

th c

over

age

for

that

mon

th.

Do

es t

his

pla

n M

eet

the

Min

imu

m V

alu

e S

tan

dar

d?

Yes

If

your

pla

n do

esn’

t mee

t the

Min

imum

Val

ue S

tand

ards

, you

may

be

elig

ible

for

a pr

emiu

m ta

x cr

edit

to h

elp

you

pay

for

a pl

an th

roug

h th

e M

arke

tpla

ce.

––––––––––––––––––––––

To

see

exam

ples

of ho

w thi

s pl

an m

ight

cov

er c

osts

for

a s

ampl

e m

edical

situa

tion

, se

e th

e ne

xt pa

ge.––––––––––––––––––––––

42

T

he p

lan

wou

ld b

e re

spon

sibl

e fo

r th

e ot

her

cost

s of

thes

e E

XA

MP

LE c

over

ed s

ervi

ces.

P

age

7 o

f 7

Man

agin

g J

oe’

s ty

pe

2 D

iab

etes

(a y

ear

of r

outin

e in

-net

wor

k ca

re o

f a w

ell-

cont

rolle

d co

nditi

on)

Peg

is H

avin

g a

Bab

y (9

mon

ths

of in

-net

wor

k pr

e-na

tal c

are

and

a ho

spita

l del

iver

y)

Mia

’s S

imp

le F

ract

ure

(in-n

etw

ork

emer

genc

y ro

om v

isit

and

follo

w u

p ca

re)

Ab

ou

t th

ese

Co

vera

ge

Exa

mp

les:

◼

Th

e p

lan

's o

vera

ll d

edu

ctib

le

$800

◼

Sp

ecia

list

coin

sura

nce

20

%

◼ H

osp

ital

(fa

cilit

y) c

oin

sura

nce

20

%

◼ O

ther

co

insu

ran

ce

20%

T

his

EX

AM

PL

E e

ven

t in

clu

des

ser

vice

s lik

e:

Spe

cial

ist o

ffice

vis

its (

pren

atal

car

e)

Chi

ldbi

rth/

Del

iver

y P

rofe

ssio

nal S

ervi

ces

Chi

ldbi

rth/

Del

iver

y F

acili

ty S

ervi

ces

Dia

gnos

tic te

sts

(ultr

asou

nds

and

bloo

d w

ork)

S

peci

alis

t vis

it (a

nest

hesi

a)

To

tal E

xam

ple

Co

st

$12,

800

In t

his

exa

mp

le, P

eg w

ou

ld p

ay:

Cos

t Sha

ring

Ded

uctib

les

$800

Cop

aym

ents

$0

Coi

nsur

ance

$1

,400

Wha

t isn

’t co

vere

d

Lim

its o

r ex

clus

ions

$1

00

Th

e to

tal P

eg w

ou

ld p

ay is

$2

,300

◼ T

he

pla

n's

ove

rall

ded

uct

ible

$8

00

◼ S

pec

ialis

t co

insu

ran

ce

20%

◼

Ho

spit

al (

faci

lity)

co

insu

ran

ce

20%

◼

Oth

er c

oin

sura

nce

20

%

Th

is E

XA

MP

LE

eve

nt

incl

ud

es s

ervi

ces

like:

P

rimar

y ca

re p

hysi

cian

offi

ce v

isits

(in

clud

ing

dise

ase

educ

atio

n)

Dia

gnos

tic te

sts

(blo

od w

ork)

P

resc

riptio

n dr

ugs

Dur

able

med

ical

equ

ipm

ent (

gluc

ose

met

er)

To

tal E

xam

ple

Co

st

$7,4

00

In t

his

exa

mp

le, J

oe

wo

uld

pay

:

Cos

t Sha

ring

Ded

uctib

les*

$8

00

Cop

aym

ents

$0

Coi

nsur

ance

$8

0

Wha

t isn

’t co

vere

d

Lim

its o

r ex

clus

ions

$6

,000

Th

e to

tal J

oe

wo

uld

pay

is

$6,8

80

◼ T

he

pla

n's

ove

rall

ded

uct

ible

$8

00

◼ S

pec

ialis

t co

insu

ran

ce

20%

◼

Ho

spit

al (

faci

lity)

co

insu

ran

ce

20%

◼

Oth

er c

oin

sura

nce

20

%

Th

is E

XA

MP

LE

eve

nt

incl

ud

es s

ervi

ces

like:

E

mer

genc

y ro

om c

are

(incl

udin

g m

edic

al s

uppl

ies)

D

iagn

ostic

test

s (x

-ray

) D

urab

le m

edic

al e

quip

men

t (cr

utch

es)

Reh

abili

tatio

n se

rvic

es (

phys

ical

ther

apy)

To

tal E

xam

ple

Co

st

$1,9

00

In t

his

exa

mp

le, M

ia w

ou

ld p

ay:

Cos

t Sha

ring

Ded

uctib

les*

$8

00

Cop

aym

ents

$0

Coi

nsur

ance

$2

00

Wha

t isn

’t co

vere

d

Lim

its o

r ex

clus

ions

$0

Th

e to

tal M

ia w

ou

ld p

ay is

$1

,000

Th

is is

no

t a

cost

est

imat

or.

Tre

atm

ents

sho

wn

are

just

exa

mpl

es o

f how

this

pla

n m

ight

cov

er m

edic

al c

are.

You

r ac

tual

cos

ts w

ill b

e di

ffere

nt d

epen

ding

on

the

actu

al c

are

you

rece

ive,

the

pric

es y

our

prov

ider

s ch

arge

, and

man

y ot

her

fact

ors.

Foc

us o

n th

e co

st s

harin

g am

ount

s (d

educ

tible

s, c

opay

men

ts a

nd c

oins

uran

ce)

and

excl

uded

ser

vice

s un

der

the

plan

. Use

this

info

rmat

ion

to c

ompa

re th

e p

ortio

n of

co

sts

you

mig

ht p

ay u

nder

diff

eren

t hea

lth p

lans

. Ple

ase

note

thes

e co

vera

ge e

xam

ples

are

bas

ed o

n se

lf-on

ly c

over

age.

Not

e: T

hese

num

bers

ass

ume

the

patie

nt d

oes

not p

artic

ipat

e in

the

plan

’s w

elln

ess

prog

ram

. If y

ou p

artic

ipat

e in

the

plan

’s w

elln

ess

prog

ram

, you

may

be

able

to

redu

ce y

our

cost

s. F

or m

ore

info

rmat

ion

abou

t the

wel

lnes

s pr

ogra

m, p

leas

e co

ntac

t: w

ww

.um

r.co

m o

r ca

ll 1-

800-

826-

9781

. *N

ote:

Thi

s pl

an h

as o

ther

ded

uctib

les

for

spec

ific

serv

ices

incl

uded

in th

is c

over

age

exam

ple.

See

"A

re th

ere

othe

r de

duct

ible

s fo

r sp

ecifi

c se

rvic

es?”

" ro

w a

bove

.

43

Su

mm

ary

of

Ben

efit

s an

d C

ove

rag

e: W

hat t

his

Pla

n C

over

s &

Wha

t You

Pay

For

Cov

ered

Ser

vice

s

Co

vera

ge

Per

iod

: 01

/01/

2020

– 1

2/31

/202

0

UM

R:

HA

RC

RO

S C

HE

MIC

AL

S IN

C.:

767

0-0

0-41

3652

002

C

ove

rag

e fo

r: In

divi

dual

+ F

amily

| P

lan

Typ

e: H

DH

P

Pag

e 1

of

7

Th

e S

um

mar

y o

f B

enef

its

and

Co

vera

ge

(SB

C)

do

cum

ent

will

hel

p y

ou

ch

oo

se a

hea

lth

pla

n. T

he

SB

C s

ho

ws

you

ho

w y

ou

an

d t

he

pla

n w

ou

ld

shar

e th

e co

st f

or

cove

red

hea

lth

car

e se

rvic

es. N

OT

E:

Info

rmat

ion

ab

ou

t th

e co

st o

f th

is p

lan

(ca

lled

th

e p

rem

ium

) w

ill b

e p

rovi

ded

sep

arat

ely.

T

his

is o

nly

a s

um

mar

y. F

or m

ore

info

rmat

ion

abou

t you

r co

vera

ge, o

r to

get

a c

opy

of th

e co

mpl

ete

term

s of

cov

erag

e, v

isit

ww

w.u

mr.

com

or

by c

allin

g 1-

800-

826-

9781

. For

gen

eral

def

initi

ons

of c

omm

on te

rms,

suc

h as

allo

wed

am

ount

, bal

ance

bill

ing,

coi

nsur

ance

, cop

aym

ent,

dedu

ctib

le, p

rovi

der,

or

othe

r un

derli

ned

term

s se

e th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.um

r.co

m o

r ca

ll 1-

800-

826-

9781

to r

eque

st a

cop

y.

Imp

ort

ant

Qu

esti

on

s A

nsw

ers

Wh

y th

is M

atte

rs:

Wh

at is

th

e o

vera

ll d

edu

ctib

le?

$3,0

00 p

erso

n / $

6,00

0 fa

mily

In-n

etw

ork

$7,5

00 p

erso

n / $

15,0

00 fa

mily

Out

-of-

netw

ork

$3,0

00 In

-net

wor

k / $

7,50

0 O

ut-o

f-ne

twor

k M

axim

um a

mou

nt th

at a

ny o

ne p

erso

n w

ill

satis

fy to

war

ds th

e an

nual

fam

ily d

educ

tible

Gen

eral

ly, y

ou m

ust p

ay a

ll th

e co

sts

from

pro

vide

rs u

p to

the

dedu

ctib

le a

mou

nt

befo

re th

is p

lan

begi

ns to

pay

. If y

ou h

ave

othe

r fa

mily

mem

bers

on

the

plan

, eac

h fa

mily

mem

ber

mus

t mee

t the

ir ow

n in

divi

dual

ded

uctib

le u

ntil

the

tota

l am

ount

of

dedu

ctib

le e

xpen

ses

paid

by

all f

amily

mem

bers

mee

ts th

e ov

eral

l fam

ily

dedu

ctib

le.

Are

th

ere

serv

ices

co

vere

d b

efo

re y

ou

mee

t yo

ur

ded

uct

ible

?

Yes

. Pre

vent

ive

care

ser

vice

s ar

e co

vere

d be

fore

you

mee

t you

r de

duct

ible

.

Thi

s pl

an c

over

s so

me

item

s an

d se

rvic

es e

ven

if yo

u ha

ven’

t yet

met

the

de

duct

ible

am

ount

. But

a c

opay

men

t or

coin

sura

nce

may

app

ly. F

or e

xam

ple,

this

pl

an c

over

s ce

rtai

n pr

even

tive

serv

ices

with

out c

ost-

shar

ing

and

befo

re y

ou m

eet

your

ded

uctib

le. S

ee a

list

of c

over

ed p

reve

ntiv

e se

rvic

es a

t ht

tps:

//ww

w.h

ealth

care

.gov

/cov

erag

e/pr

even

tive

-car

e-be

nefit

s/

Are

th

ere

oth

er

ded

uct

ible

s fo

r sp

ecif

ic

serv

ices

?

No.

Y

ou d

on’t

have

to m

eet d

educ

tible

s fo

r sp

ecifi

c se

rvic

es.

Wh

at is

th

e o

ut–

of–

po

cket

lim

it f

or

this

pla

n?

$3,0

00 p

erso

n / $

6,00

0 fa

mily

In-n

etw

ork

$15,

000

pers

on /

$30,

000

fam

ily O

ut-o

f-ne

twor

k $3

,000

In-n

etw

ork

/ $15

,000

Out

-of-

netw

ork

Max

imum

am

ount

that

any

one

per

son

will

sa

tisfy

tow

ards

the

annu

al fa

mily

out

-of-

pock

et

The

out

-of-

pock

et li

mit

is th

e m

ost y

ou c

ould

pay

in a

yea

r fo

r co

vere

d se

rvic

es.

If yo

u ha

ve o

ther

fam

ily m

embe

rs in

this

pla

n, th

ey h

ave

to m

eet t

heir

own

out-

of-

pock

et li

mits

unt

il th

e ov

eral

l fam

ily o

ut-o

f-po

cket

lim

it ha

s be

en m

et.

Wh

at is

no

t in

clu

ded

in

the

ou

t–o

f–p

ock

et li

mit

?

Cop

aym

ents

for

cert

ain

serv

ices

, pen

altie

s,

prem

ium

s, b

alan

ce b

illin

g ch

arge

s, a

nd h

ealth

ca

re th

is p

lan

does

n’t c

over

.

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.

Will

yo

u p

ay le

ss if

yo

u

use

a n

etw

ork

pro

vid

er?

Y

es. S

ee w

ww

.um

r.co

m o

r ca

ll 1-

800-

826-

9781

fo

r a

list o

f net

wor

k pr

ovid

ers.

Thi

s pl

an u

ses

a pr

ovid

er n

etw

ork.

You

will

pay

less

if y

ou u

se a

pro

vide

r in

the

plan

’s n

etw

ork.

You

will

pay

the

mos

t if y

ou u

se a

n ou

t-of

-net

wor

k pr

ovid

er, a

nd

you

mig

ht r

ecei

ve a

bill

from

a p

rovi

der

for

the

diffe

renc

e be

twee

n th

e pr

ovid

er’s

ch

arge

and

wha

t you

r pl

an p

ays

(a b

alan

ce b

illin

g). B

e aw

are,

you

r ne

twor

k pr

ovid

er m

ight

use

an

out-

of-n

etw

ork

prov

ider

for

som

e se

rvic

es (

such

as

lab

wor

k). C

heck

with

you

r pr

ovid

er b

efor

e yo

u ge

t ser

vice

s.

Do

yo

u n

eed

a r

efer

ral t

o

see

a sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out

a re

ferr

al.

44

P

age

2 o

f 7

A

ll co

paym

ent a

nd c

oins

uran

ce c

osts

sho

wn

in th

is c

hart

are

afte

r yo

ur d

educ

tible

has

bee

n m

et, i

f a d

educ

tible

app

lies.

Co

mm

on

M

edic

al E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er

Imp

ort

ant

Info

rmat

ion

In

-net

wo

rk

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-n

etw

ork

(Y

ou

will

pay

th

e m

ost

)

If y

ou

vis

it a

h

ealt

h c

are

pro

vid

er’s

o

ffic

e o

r cl

inic

Prim

ary

care

vis

it to

trea

t an

inju

ry

or il

lnes

s N

o ch

arge

40

% C

oins

uran

ce

Non

e

Spe

cial

ist v

isit

No

char

ge

40%

Coi

nsur

ance

N

one

Pre

vent

ive

care

/scr

eeni

ng/

imm

uniz

atio

n N

o ch

arge

; D

educ

tible

Wai

ved

No

char

ge;

Ded

uctib

le W

aive

d

You

may

hav

e to

pay

for

serv

ices

that

ar

en't

prev

entiv

e. A

sk y

our

prov

ider

if

the

serv

ices

you

nee

d ar

e pr

even

tive.

T

hen

chec

k w

hat y

our

plan

will

pay

fo

r.

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y, b

lood

wor

k)

No

char

ge

40%

Coi

nsur

ance

N

one

Imag

ing

(CT

/PE

T s

cans

, MR

Is)

N

o ch

arge

40

% C

oins

uran

ce

Non

e

45

P

age

3 o

f 7

Co

mm

on

M

edic

al E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er

Imp

ort

ant

Info

rmat

ion

In

-net

wo

rk

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-n

etw

ork

(Y

ou

will

pay

th

e m

ost

)

If y

ou

nee

d

dru

gs

to t

reat

yo

ur

illn

ess

or

con

dit

ion

. M

ore

info

rmat

ion

abou

t pr

escr

iptio

n dr

ug c

over

age

is a

vaila

ble

at

ww

w.n

avitu

s.co

m

Gen

eric

dru

gs (

Tie

r 1)

$0

afte

r de

duct

ible

N

ot C

over

ed

Effe

ctiv

e Ja

nuar

y 1,

202

0, W

algr

eens

ph

arm

acie

s ar

e no

long

er a

n in

-ne

twor

k ph

arm

acy.

If y

ou h

ave

ques

tions

, abo

ut a

ltern

ativ

e ph

arm

acie

s, p

leas

e co

ntac

t Nav

itus

at

866-

333-

2757

.

Pre

ferr

ed b

rand

dru

gs (

Tie

r 2)

$0

afte

r de

duct

ible

N

ot C

over

ed

Non

-pre

ferr

ed b

rand

dru

gs (

Tie

r 3)

$0

afte

r de

duct

ible

N

ot C

over

ed

Spe

cial

ty d

rugs

(T

ier

4)

$0 a

fter

dedu

ctib

le

Not

Cov

ered

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(e

.g.,

ambu

lato

ry s

urge

ry c

ente

r)

No

char

ge

40%

Coi

nsur

ance

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

Out

-of-

netw

ork.

Phy

sici

an/s

urge

on fe

es

No

char

ge

40%

Coi

nsur

ance

N

one

If y

ou

nee

d

imm

edia

te

med

ical

at

ten

tio

n

Em

erge

ncy

room

car

e N

o ch

arge

N

o ch

arge

In

-net

wor

k de

duct

ible

app

lies

to

Out

-of-

netw

ork

bene

fits

Em

erge

ncy

med

ical

tran

spor

tatio

n N

o ch

arge

N

o ch

arge

In

-net

wor

k de

duct

ible

app

lies

to

Out

-of-

netw

ork

bene

fits

Urg

ent c

are

No

char

ge

40%

Coi

nsur

ance

N

one

46

P

age

4 o

f 7

Co

mm

on

M

edic

al E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er

Imp

ort

ant

Info

rmat

ion

In

-net

wo

rk

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-n

etw

ork

(Y

ou

will

pay

th

e m

ost

)

If y

ou

hav

e a

ho

spit

al s

tay

Fac

ility

fee

(e.g

., ho

spita

l roo

m)

No

char

ge

40%

Coi

nsur

ance

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

Out

-of-

netw

ork.

Phy

sici

an/s

urge

on fe

e N

o ch

arge

40

% C

oins

uran

ce

Non

e

If y

ou

hav

e m

enta

l hea

lth

, b

ehav

iora

l h

ealt

h, o

r su

bst

ance

ab

use

nee

ds

Out

patie

nt s

ervi

ces

No

char

ge

40%

Coi

nsur

ance

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

for

Par

tial

hosp

italiz

atio

n O

ut-o

f-ne

twor

k.

Inpa

tient

ser

vice

s N

o ch

arge

40

% C

oins

uran

ce

Pre

auth

oriz

atio

n is

req

uire

d. If

you

do

n’t g

et p

reau

thor

izat

ion,

ben

efits

co

uld

be r

educ

ed b

y $5

00 o

f the

tota

l co

st o

f the

ser

vice

Out

-of-

netw

ork.

If y

ou

are

p

reg

nan

t

Offi

ce v

isits

N

o ch

arge

; D

educ

tible

Wai

ved

No

char

ge;

Ded

uctib

le W

aive

d C

ost s

harin

g do

es n

ot a

pply

to c

erta

in

prev

entiv

e se

rvic

es. D

epen

ding

on

the

type

of s

ervi

ces,

ded

uctib

le,

copa

ymen

t or

coin

sura

nce

may

app

ly.

Mat

erni

ty c

are

may

incl

ude

test

s an

d se

rvic

es d

escr

ibed

els

ewhe

re in

the

SB

C (

i.e. u

ltras

ound

).

Chi

ldbi

rth/

deliv

ery

prof

essi

onal

se

rvic

es

No

char

ge

40%

Coi

nsur

ance

Chi

ldbi

rth/

deliv

ery

faci

lity

serv

ices

N

o ch

arge

40

% C

oins

uran

ce

47

P

age

5 o

f 7

Co

mm

on

M

edic

al E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er

Imp

ort

ant

Info

rmat

ion

In

-net

wo

rk

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-n

etw

ork

(Y

ou

will

pay

th

e m

ost

)

If y

ou

nee

d

hel

p

reco

veri

ng

or

hav

e o

ther

sp

ecia

l hea

lth

n

eed

s

Hom

e he

alth

car

e N

o ch

arge

40

% C

oins

uran

ce

100

Max

imum

vis

its p

er c

alen

dar

year

; P

reau

thor

izat

ion

is r

equi

red.

If y

ou

don’

t get

pre

auth

oriz

atio

n, b

enef

its

coul

d be

red

uced

by

$500

of t

he to

tal

cost

of t

he s

ervi

ce O

ut-o

f-ne

twor

k.

Reh

abili

tatio

n se

rvic

es

No

char

ge

40%

Coi

nsur

ance

N

one

Hab

ilita

tion

serv

ices

N

ot c

over

ed

Not

cov

ered

N

one

Ski

lled

nurs

ing

care

N

o ch

arge

40

% C

oins

uran

ce

100

Max

imum

day

s pe

r ca

lend

ar y

ear;

P

reau

thor

izat

ion

is r

equi

red.

If y

ou

don’

t get

pre

auth

oriz

atio

n, b

enef

its

coul

d be

red

uced

by

$500

of t

he to

tal

cost

of t

he s

ervi

ce O

ut-o

f-ne

twor

k.

Dur

able

med

ical

equ

ipm

ent

No

char

ge

40%

Coi

nsur

ance

Pre

auth

oriz

atio

n is

req

uire

d fo

r D

ME

in

exc

ess

of $

500

for

rent

als

or $

1,50

0 fo

r pu

rcha

ses.

If y

ou d

on’t

get

prea

utho

rizat

ion,

ben

efits

cou

ld b

e re

duce

d by

$50

0 pe

r oc

curr

ence

O

ut-o

f-ne

twor

k.

Hos

pice

ser

vice

N

o ch

arge

40

% C

oins

uran

ce

Non

e

If y

ou

r ch

ild

nee

ds

den

tal

or

eye

care

Chi

ldre

n’s

eye

exam

N

ot c

over

ed

Not

cov

ered

N

one

Chi

ldre

n’s

glas

ses

Not

cov

ered

N

ot c

over

ed

Non

e

Chi

ldre

n’s

dent

al c

heck

-up

Not

cov

ered

N

ot c

over

ed

Non

e

48

P

age

6 o

f 7

Exc

lud

ed S

ervi

ces

& O

ther

Co

vere

d S

ervi

ces:

Ser

vice

s Y

ou

r P

lan

Do

es N

OT

Co

ver

(Ch

eck

you

r p

olic

y o

r p

lan

do

cum

ent

for

mo

re in

form

atio

n a

nd

a li

st o

f an

y o

ther

exc

lud

ed s

ervi

ces.

)

•

Acu

punc

ture

•

Infe

rtili

ty tr

eatm

ent

•

Rou

tine

eye

care

(A

dult)

•

Cos

met

ic s

urge

ry

•

Long

-ter

m c

are

•

Rou

tine

foot

car

e

•

Den

tal c

are

(Adu

lt)

•

Non

-em

erge

ncy

care

whe

n tr

avel

ing

outs

ide

the

U.S

. •

Wei

ght l

oss

prog

ram

s O

ther

Co

vere

d S

ervi

ces

(Lim

itat

ion

s m

ay a

pp

ly t

o t

hes

e se

rvic

es. T

his

isn

’t a

co

mp

lete

list

. Ple

ase

see

you

r p

lan

do

cum

ent.

)

•

Bar

iatr

ic s

urge

ry

•

Hea

ring

aids

•

Priv

ate-

duty

nur

sing

(O

utpa

tient

car

e)

•

Chi

ropr

actic

car

e

Yo

ur

Rig

hts

to

Co

nti

nu

e C

ove

rag

e: T

here

are

age

ncie

s th

at c

an h

elp

if yo

u w

ant t

o co

ntin

ue y

our

cove

rage

afte

r it

ends

. The

con

tact

info

rmat

ion

for

thos

e ag

enci

es is

: U.S

. Dep

artm

ent o

f Lab

or's

Em

ploy

ee B

enef

its S

ecu

rity

Adm

inis

trat

ion

at 1

-866

-444

-EB

SA

(32

72)

or w

ww

.Hea

lthC

are.

gov.

Oth

er c

over

age

optio

ns m

ay

be a

vaila

ble

to y

ou to

o, in

clud

ing

buyi

ng in

divi

dual

insu

ranc

e co

vera

ge th

roug

h th

e H

ealth

Insu

ranc

e M

arke

tpla

ce. F

or m

ore

info

rmat

ion

abou

t the

Mar

ketp

lace

, vis

it w

ww

.Hea

lthC

are.

gov

or c

all 1

-800

-318

-259

6.

Yo

ur

Gri

evan

ce a

nd

Ap

pea

ls R

igh

ts:

The

re a

re a

genc

ies

that

can

hel

p if

you

have

a c

ompl

aint

aga

inst

you

r pl

an fo

r a

deni

al o

f a c

laim

. Thi

s co

mpl

aint

is c

alle

d a

grie

vanc

e or

app

eal.

For

mor

e in

form

atio

n ab

out y

our

right

s, lo

ok a

t the

exp

lana

tion

of b

enef

its y

ou w

ill r

ecei

ve fo

r th

at m

edic

al c

laim

. You

r pl

an d

ocum

ents

als

o pr

ovid

e co

mpl

ete

info

rmat

ion

to s

ubm

it a

clai

m, a

ppea

l or

a gr

ieva

nce

for

any

reas

on to

you

r pl

an. F

or m

ore

info

rmat

ion

abou

t you

r rig

hts,

this

not

ice,

or

assi

stan

ce,

cont

act:

U.S

. Dep

artm

ent o

f Lab

or's

Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istr

atio

n at

1-8

66-4

44-E

BS

A (

3272

) or

ww

w.H

ealth

Car

e.go

v. A

dditi

onal

ly, a

con

sum

er

assi

stan

ce p

rogr

am m

ay h

elp

you

file

your

app

eal.

A li

st o

f sta

tes

with

Con

sum

er A

ssis

tanc

e P

rogr

ams

is a

vaila

ble

at w

ww

.Hea

lthC

are.

gov

and

http

://cc

iio.c

ms.

gov/

prog

ram

s/co

nsum

er/c

apgr

ants

/inde

x.ht

ml.

Do

es t

his

pla

n P

rovi

de

Min

imu

m E

ssen

tial

Co

vera

ge?

Yes

If

you

don’

t hav

e M

inim

um E

ssen

tial C

over

age

for

a m

onth

, you

’ll h

ave

to m

ake

a pa

ymen

t whe

n yo

u fil

e yo

ur ta

x re

turn

unl

ess

you

qual

ify fo

r an

exe

mpt

ion

from

the

requ

irem

ent t

hat y

ou h

ave

heal

th c

over

age

for

that

mon

th.

Do

es t

his

pla

n M

eet

the

Min

imu

m V

alu

e S

tan

dar

d?

Yes

If

your

pla

n do

esn’

t mee

t the

Min

imum

Val

ue S

tand

ards

, you

may

be

elig

ible

for

a pr

emiu

m ta

x cr

edit

to h

elp

you

pay

for

a pl

an th

roug

h th

e M

arke

tpla

ce.

800-

826-

9781

.

––––––––––––––––––––––

To

see

exam

ples

of ho

w thi

s pl

an m

ight

cov

er c

osts

for

a s

ampl

e m

edical

situa

tion

, se

e th

e ne

xt pa

ge.––––––––––––––––––––––

49

T

he p

lan

wou

ld b

e re

spon

sibl

e fo

r th

e ot

her

cost

s of

thes

e E

XA

MP

LE c

over

ed s

ervi

ces.

P

age

7 o

f 7

Man

agin

g J

oe’

s ty

pe

2 D

iab

etes

(a y

ear

of r

outin

e in

-net

wor

k ca

re o

f a w

ell-

cont

rolle

d co

nditi

on)

Peg

is H

avin

g a

Bab

y (9

mon

ths

of in

-net

wor

k pr

e-na

tal c

are

and

a ho

spita

l del

iver

y)

Mia

’s S

imp

le F

ract

ure

(in-n

etw

ork

emer

genc

y ro

om v

isit

and

follo

w u

p ca

re)

Ab

ou

t th

ese

Co

vera

ge

Exa

mp

les:

◼

Th

e p

lan

's o

vera

ll d

edu

ctib

le

$3,0

00

◼ S

pec

ialis

t co

insu

ran

ce

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osp

ital

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cilit

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his

EX

AM

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ven

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clu

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vice

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cial

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ffice

vis

its (

pren

atal

car

e)

Chi

ldbi

rth/

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iver

y P

rofe

ssio

nal S

ervi

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ldbi

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iver

y F

acili

ty S

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gnos

tic te

sts

(ultr

asou

nds

and

bloo

d w

ork)

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peci

alis

t vis

it (a

nest

hesi

a)

To

tal E

xam

ple

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st

$12,

800

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his

exa

mp

le, P

eg w

ou

ld p

ay:

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t Sha

ring

Ded

uctib

les

$3,0

00

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aym

ents

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nsur

ance

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t isn

’t co

vere

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its o

r ex

clus

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$1

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e to

tal P

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$3

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he

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is E

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incl

ud

es s

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rimar

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hysi

cian

offi

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isits

(in

clud

ing

dise

ase

educ

atio

n)

Dia

gnos

tic te

sts

(blo

od w

ork)

P

resc

riptio

n dr

ugs

Dur

able

med

ical

equ

ipm

ent (

gluc

ose

met

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To

tal E

xam

ple

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st

$7,4

00

In t

his

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oe

wo

uld

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t Sha

ring

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uctib

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$1

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aym

ents

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nsur

ance

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t isn

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vere

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its o

r ex

clus

ions

$6

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e to

tal J

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uld

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$7,2

00

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he

pla

n's

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is E

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like:

E

mer

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(incl

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g m

edic

al s

uppl

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D

iagn

ostic

test

s (x

-ray

) D

urab

le m

edic

al e

quip

men

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utch

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Reh

abili

tatio

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phys

ical

ther

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tal E

xam

ple

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st

$1,9

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ia w

ou

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ay:

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t Sha

ring

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uctib

les*

$1

,900

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aym

ents

$0

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nsur

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t isn

’t co

vere

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its o

r ex

clus

ions

$0

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e to

tal M

ia w

ou

ld p

ay is

$1

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Th

is is

no

t a

cost

est

imat

or.

Tre

atm

ents

sho

wn

are

just

exa

mpl

es o

f how

this

pla

n m

ight

cov

er m

edic

al c

are.

You

r ac

tual

cos

ts w

ill b

e di

ffere

nt d

epen

ding

on

the

actu

al c

are

you

rece

ive,

the

pric

es y

our

prov

ider

s ch

arge

, and

man

y ot

her

fact

ors.

Foc

us o

n th

e co

st s

harin

g am

ount

s (d

educ

tible

s, c

opay

men

ts a

nd c

oins

uran

ce)

and

excl

uded

ser

vice

s un

der

the

plan

. Use

this

info

rmat

ion

to c

omp

are

the

port

ion

of

cost

s yo

u m

ight

pay

und

er d

iffer

ent h

ealth

pla

ns. P

leas

e no

te th

ese

cove

rage

exa

mpl

es a

re b

ased

on

self-

only

cov

erag

e.

Not

e: T

hese

num

bers

ass

ume

the

patie

nt d

oes

not p

artic

ipat

e in

the

plan

’s w

elln

ess

prog

ram

. If y

ou p

artic

ipat

e in

the

plan

’s w

elln

ess

prog

ram

, you

may

be

able

to

redu

ce y

our

cost

s. F

or m

ore

info

rmat

ion

abou

t the

wel

lnes

s pr

ogra

m, p

leas

e co

ntac

t: w

ww

.um

r.co

m o

r ca

ll 1-

800-

826-

9781

. *N

ote:

Thi

s pl

an h

as o

ther

ded

uctib

les

for

spec

ific

serv

ices

incl

uded

in th

is c

over

age

exam

ple.

See

"A

re th

ere

othe

r de

duct

ible

s fo

r sp

ecifi

c se

rvic

es?”

" ro

w a

bove

.

50

Important Contacts

Benefit Company Phone Number Website

Medical UMR

UnitedHealthcare Network

800-826-9781 www.umr.com

Prescription Drug Navitus 866-333-2757 www.navitus.com

Dental Delta Dental of Kansas 800-234-3375 www.deltadentalks.com

Vision VSP 800-877-7195 www.vsp.com

Health Savings Account (HSA) Discovery Benefits 866-451-3399 www.discoverybenefits.com

Flexible Spending Accounts (FSA)

Discovery Benefits 866-451-3399 www.discoverybenefits.com

Life Insurance The Standard 800-877-5176 www.thestandard.com

Long Term Disability The Standard 800-877-5176 www.thestandard.com

Retirement 401k Plan MassMutual 800-743-5274 www.retiresmart.com

Employee Assistance Plan (EAP)

LifeWorks 877-234-5152 www.lifeworks.com

Travel Assistance The Standard

UnitedHealthcare Global

240-330-1380 Global 866-455-9188 US &

Canada Email: ops@gga-usa.com

51

The information in this Enrollment Guide is presented for illustrative purposes and is based on information

provided by the employer. The text contained in this Guide was taken from various summary plan descriptions

and benefit information. While every effort was taken to accurately report your benefits, discrepancies, or errors

are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan

documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and

Accountability Act of 1996. If you have any questions about your Guide, please refer to your Employee Manual

for additional information or contact your benefits manager.

52