Robert Bosch LLC - myhealth.mercerhrs.com Retirees April 2015 i Retiree Welfare Benefit Plan Robert Bosch LLC (the Company) ... This section provides an overview for participating

Robert Bosch LLC

Retiree Welfare Benefit Plan

Summary Plan Description

This Summary Plan Description (SPD) describes the Retiree Welfare Benefit Plan with benefits based on an April 1 – March 31 Plan Year. The SPD effective date is April 1, 2015.


Bosch Retirees April 2015 i

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

Receipt of this SPD does not guarantee eligibility to the Plan, Benefit Programs or Benefit Program options described in the SPD. See “Who Is Eligible” on page 2 for eligibility requirements.

If you cannot find the information you are looking for in this SPD, see “Contact Information” on page 92 for important web addresses and phone numbers, or contact the Bosch Benefits Center with any questions you may have.

In This Section See Page

About This SPD.................................................................................................. 1 Participating in the Plan...................................................................................... 2

Who Is Eligible ............................................................................................... 2 Coverage Options.......................................................................................... 7 When You Can Enroll .................................................................................... 8 When Coverage Begins................................................................................. 9 Your Cost....................................................................................................... 9 COBRA Continuation Coverage .................................................................. 12 When You Have Coverage Elsewhere ........................................................ 15 When Coverage Ends.................................................................................. 20 Eligibility Claims........................................................................................... 20

Retiree Medical Benefit Program...................................................................... 22 Overview of the Retiree Medical Benefit Program....................................... 23 Medical Review Program............................................................................. 28 Comparison of Medical Benefit Program Options........................................ 29 Additional Information about Covered Care and Services........................... 41 Important Terms for Understanding Your Benefits ...................................... 45 Medical Expenses Not Covered .................................................................. 50 Prescription Benefits.................................................................................... 52

Retiree Vision Benefit Program ........................................................................ 56 Summary of Vision Benefits......................................................................... 56 Important Terms .......................................................................................... 58 Vision Expenses Not Covered ..................................................................... 58

Retiree Dental Benefit Program........................................................................ 60 Summary of Dental Benefits ........................................................................ 61


ii April 2015 Bosch Retirees

Important Terms .......................................................................................... 62 Dental Expenses Not Covered .................................................................... 65

Retiree Life Insurance Benefit Program ........................................................... 67 How to File Claims ........................................................................................... 68

Decisions on Claims and Appeal Procedures.............................................. 70 Administrative Information................................................................................ 86

Plan Information........................................................................................... 86 Your Right to Benefits.................................................................................. 89 Non-assignment of Benefits......................................................................... 90 Amendment or Termination of the Plan ....................................................... 90 Affiliates and Subsidiaries Participating in the Plan..................................... 91

Contact Information .......................................................................................... 92


Bosch Retirees April 2015 1

About This SPD The Employee Retirement Income Security Act of 1974 (ERISA) requires the Plan to maintain an SPD and provide a copy of the SPD to Plan participants.

This SPD provides you with most of the information you need to know about the Benefit Programs offered under the Plan, and is divided into the following sections:

“Participating in the Plan” beginning on page 2 provides general information about who is eligible to participate in the Benefit Programs available under the Plan and enrolling for benefits.

“Retiree Medical Benefit Program” beginning on page 22 includes more specific information about the Retiree Medical Benefit Program, including the options available, Health Savings Accounts (HSAs) and prescription drug coverage.

“Retiree Dental Benefit Program” beginning on page 60 includes more specific information about the Retiree Dental Benefit Program for Robert Bosch Tool Corporation retirees.

“Retiree Vision Benefit Program” beginning on page 56 includes more specific information about the Retiree Vision Benefit Program for Robert Bosch Tool Corporation retirees.

“Retiree Life Insurance Benefit Program” beginning on page 67 describes the life insurance benefits offered to all other retirees.

“Administrative Information” beginning on page 86 provides general administrative information about the Plan.

“Contact Information” on page 92 provides web addresses and phone numbers so you know who to contact to get information about your benefits.

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


2 April 2015 Bosch Retirees

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

Coverage may be available for certain post-65 eligible retirees as described in this SPD.

Who Is Eligible The eligibility requirements vary for certain divisions, locations or subsidiaries as described in the different sections below.

General Retirees

For eligible employees of the Company or a participating company (see “Affiliates and Subsidiaries Participating in the Plan” on page 91.

You are eligible to participate in the Plan if you:

are a non-union full-time U.S. employee of the Company, or an affiliate or a subsidiary,

retired from the Company or a participating company after reaching age 55,

had a minimum of 10 years of service, and

are under age 65.

Rexroth (Wooster Site) Retirees


are a non-union full-time U.S. employee of Rexroth at the Wooster, Ohio site,

retired from Rexroth prior to January 1, 1990, and

were age 40 with five years of service as of January 1, 1990.

Rexroth (Michigan Site) Retirees


are a non-union full-time U.S. employee of Rexroth at the Buchanan, Michigan site,

were age 40 with five years of service as of September 1, 2003,

retired from Rexroth after age 55, and

are under age 65 or ineligible for Medicare.

Important

You do not need to be receiving a pension payment from the Company to be eligible for the Plan coverage. See “Your Cost” on page 9 for additional payment information.



Bosch Braking (Former Allied Signal Associates)

You are eligible to participate in the Plan if:

you are a full-time U.S. employee of Bosch Braking and a former employee of Allied Signal who became an employee of Bosch Braking as part of the May 1, 1997 Allied Signal acquisition, and

your age and service equals 60 points, with a minimum of five years of service as of the Allied Signal acquisition on May 1, 1997.

Your coverage may extend beyond age 65.

Akebono (former Bosch Braking Systems)

You may be eligible to participate in the Plan upon termination of employment from Akebono. If this applies to you, contact the Bosch Benefits Center within 30 days of your termination.

Bosch Fuel Systems

You are eligible to participate in the Plan if:

you are a full-time U.S. employee of Bosch Fuel Systems, and

your age and service equaled 60 points as of April 1, 2000.

Your coverage may extend beyond age 65.

Automotive Service Solutions


are a non-union, full-time U.S. employee of the Company (or a participating company),

retired from the Company or a participating company after reaching age 55,


are under age 65.

Note: Automotive Service Solutions retirees are not eligible for the Bosch contribution described under Where Your HSA Money Comes From in the “Health Savings Account” section and are responsible for 100% of the retiree medical coverage cost.

Robert Bosch Tool Corporation (Including Grandfathered Bosch CIT Group)


retired from Robert Bosch Tool Corporation after reaching age 55,

had a minimum of 5 years of service,

have not been rehired by Bosch as a benefits-eligible associate, and

are under age 65 or ineligible for Medicare.



Robert Bosch Tool Corporation – Grandfathered Pioneer Retirees


retired from Robert Bosch Tool Corporation after reaching age 55,


were hired before July 1, 1994.

Over Age 65

Unless otherwise indicated in this SPD, when you or your Spouse/Domestic Partner attain age 65 or become eligible for Medicare, your coverage or your Spouse’s/Domestic Partner’s coverage under the Plan will end.

Note: If you retire and are rehired by the Company as a benefits-eligible associate, you lose your eligibility for retiree medical coverage.

An Exception. You are eligible for post-65 coverage under the Indemnity Benefit Option if you are a grandfathered Bosch Choice Braking or Bosch Fuel Systems retiree age 65 or older.

Eligible Dependents

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

legal Spouse to whom you are married at the time you retire, or Domestic Partner if you retired after April 1, 2013, who is under age 65 (see “Spouse Eligibility” box and “Domestic Partner Coverage Details” below),

dependent children (natural or adopted) under age 19, or before age 25 if a full-time student,

dependent children of any age who are handicapped or totally disabled and who were enrolled in this program before age 19, or before age 25 if a full-time student (proof of disability must be furnished upon request), and

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

In addition, in the event of your death, your Spouse/Domestic Partner and/or dependents who are covered at the time of your death may continue coverage at full cost (subject to eligibility).

Dependent Coverage Details

Spouse Coverage Details

If you elect coverage for yourself at the time you retire, you can also elect coverage for your Spouse/Domestic Partner. He or she must be under age 65 and covered under the medical Benefit Program under the Plan as of the date you retire. If you do not elect coverage for your eligible dependents when you enroll in the Plan, then they will not be eligible for coverage under the Plan at a later date.

Coverage is available to your Spouse/Domestic Partner if you are over age 65, as long as other eligibility requirements are met.

Dependent Coverage

You may cover a child who qualifies as your dependent for the Retiree Medical Benefit Plan even if the child’s parent has the right to claim the child as a dependent for tax purposes under the terms of your divorce. See “Qualified Medical Child Support Order” (QMCSO) on page 7 for details.



If you are covering your Spouse/Domestic Partner when you reach age 65 or die prior to age 65, he or she can continue coverage, at full cost (100%), until age 65. Note: this does not apply to grandfathered Bosch Choice and Robert Bosch Tool Corporation retirees. Your dependent children may also continue coverage at full cost as long as they meet the eligibility requirements. See “Dependent Child(ren) Coverage” below.

If your marriage ends and you remarry, your new Spouse/Domestic Partner is not eligible for coverage under the Plan. However, your former Spouse/Domestic Partner can continue medical coverage under the consolidated Omnibus Budget Reconciliation Act (COBRA) for up to 36 months. See “COBRA Continuation Coverage” on page 12 for more information.

Domestic Partner Coverage Details

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

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

Intend to remain in a committed relationship;

Share the same permanent address;

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

Be at least age 18;

Must not have been in a different domestic partner relationship or marriage within the last six months; and

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

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

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



Dependent Child(ren) Coverage

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

natural children,

legally adopted children,

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

stepchildren,

children of your Domestic Partner,

foster children, and

children under your legal guardianship residing with you.

Not Covered Under the Plan

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

are in the military,

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

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

Tax Implications

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

Reside with you;

Receive over 50% of their support from you;

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

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

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

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

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

Placement for Adoption

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



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

retiree only,

retiree and Spouse/Domestic Partner,

retiree and child(ren), and

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

You will be able to choose the level of coverage you want for Medical Benefit Program. However, to cover your Spouse/Domestic Partner or eligible dependent under the Medical Benefit Program, you must be enrolled in the Plan yourself.

There may be additional coverage options for your Spouse/Domestic Partner and covered Dependent Children if you retire on or after age 65. Contact the Bosch Benefits Center for more information.

If you are an eligible retiree, you will be offered the choice between enrolling in this Plan or electing COBRA continuation coverage (for 18 months) under the Plan. By electing to participate in this Plan, you will waive your right to COBRA continuation coverage under the Plan. You will not be able to elect COBRA continuation coverage under the Plan at a later time. However, your eligible dependents covered under this Plan may have qualifying events that would entitle them to COBRA continuation coverage under this Plan. See “COBRA Continuation Coverage” on page 12 for more information.

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

If you are an eligible retiree and are married to an active associate of the Company, please keep in mind the following limitations on coverage:

you may elect coverage under the retiree or active plan, but not both, and

if a child is eligible for coverage, only you or your Spouse/Domestic Partner may cover the child.

Qualified Medical Child Support Order

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

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

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

QMCSO Coverage…

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



When You Can Enroll When you terminate Bosch employment and have met the requirements for retiree medical benefits, you will have 31 days to enroll and make elections through the Bosch Benefit Center. You must also enroll eligible dependents at this time.

If you do not enroll when you are first eligible, you and your dependents will not be able to enroll in the future.

Annual Enrollment

As a participant in the Plan, you can make new decisions about your Benefit Program options once a year during the designated Annual Enrollment period (usually in February). Your new elections will become effective on April 1 and will remain in effect until you make a change at the next Annual Enrollment.

Changes During the Plan Year

During the Plan Year you cannot change your Benefit Program elections except under limited conditions. You may remove a dependent or stop your participation in the Plan at any time. However, once you stop your participation or your dependent’s participation in the Plan, you may not enroll in the Plan at a later date.

You can enroll an eligible dependent child or change your Medical Benefit Program coverage during the year if:

you gain a dependent child through birth, adoption or placement for adoption,

you become the guardian of a dependent through a court order, or

a previously covered child regains full-time student status.

You may also change your dependent child benefit elections for the Retiree Medical Benefit Program if a judgment, decree, or order, resulting from a divorce, legal separation, annulment, or change in legal custody (including a qualified medical child support order) is entered by a court of competent jurisdiction and it requires accident or health coverage for your child under this Plan or it requires another individual to provide the coverage for the child.

If one of these events takes place, you have 60 days from the date of the event to access the Bosch Benefits Center website or call the Bosch Benefits Center and change your benefit elections. For contact information, see “Contact Information” on page 92.

If you do not provide timely notice of these events to the Bosch Benefits Center and complete a new election within the 60-day timeframe, you will not be able to change coverage until the next Annual Enrollment period.

Important

You must be enrolled in the Plan to add dependents as a result of the events listed above. If you do not add coverage for a dependent within 60 days of the event, you will not be able to add him or her to the Plan in the future.

Keep in Mind

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

Placement for Adoption

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



If your dependent is no longer an eligible dependent, you will need to access the Bosch Benefits Center website or call the Bosch Benefits Center and change your benefit elections within 60 days of the event. For contact information, see “Contact Information” on page 92.

In general, your benefit elections may automatically change when:

your dependent is no longer eligible for coverage due to age or student status,

you are unable to provide proof of dependent eligibility documentation, or

you or your Spouse/Domestic Partner become eligible for Medicare.

Participation may end for that ineligible dependent retroactive to the date determined that he or she became an ineligible dependent.

When Coverage Begins Coverage for you and your eligible dependents begins on the first day of the month following the month in which you became eligible. You must enroll within 31 days of your eligibility date.

Your Cost The cost of each Medical Benefit Program will depend on the:

Medical Benefit Program option you elect, and

number of dependents you want to enroll.

If you are covering your Spouse/Domestic Partner and your coverage ends because you reach age 65 or die prior to age 65, he or she can continue coverage, at full cost (100%), until age 65. Note: this does not apply to grandfathered Bosch Choice and Robert Bosch Tool Corporation retirees.

Your dependent children may also continue coverage at full cost as long as they meet the eligibility requirements. See “Dependent Child(ren) Coverage” under “Who Is Eligible” on page 2.

Robert Bosch Tool Corporation Retirees

You will pay the full cost unless you have 30 continuous years of service as a Robert Bosch Tool Corporation associate and were hired prior to July 1, 1994. You will be billed monthly or can request that the premium be deducted from your monthly pension check. The remainder of this section does not apply to you.


You will be billed monthly unless you have a pension when you enroll and the costs of your benefits is no more than 80% of your pension. The remainder of this section does not apply to you.

Important

If you are receiving a pension, you may have contributions for your share of Medical Benefit Program costs deducted from your pension check as long as long as the monthly pension amount is greater than your contribution amount. The Internal Revenue Service requires that this deduction be made on an After-Tax basis. If you are not receiving a pension, you will need to pay your contributions for Medical Benefit Program coverage by submitting a check on a monthly basis to the direct payment administrator.



For All Others

The amount Bosch contributes to the cost of your medical benefits is based on a calculation that has two parts:

Part A. Your retiree medical years, plus

Part B. Your age at retirement.

Once this total is calculated, use the Contribution Schedule shown below to determine the percentage of cost Bosch will contribute toward your medical coverage.

The cost calculation and an example are both outlined below.

Part A: Retiree Medical Years

Retiree medical years are counted in whole years (as explained below) and are equal to the lesser of:

your last day worked minus the date on which you turn age 40, - OR -

your last day worked minus your hire date plus 10 years.

Part B: Age at Retirement

Age at retirement is your age on your last day of work; only whole years are counted.

Contribution Schedule

Your retiree medical years (Part A) and age at retirement (Part B) are added together. The total number, as shown below, determines how much Bosch pays toward the cost of your medical coverage. For those who retire between the ages of 55-59, your contribution is 100% and your accumulated points will be applied to this contribution schedule after you reach age 60.

Total Points

(Part A + Part B)

Bosch Pays Retiree Pays

55 – 59 0% 100%

60 – 64 50% 50%

65 – 69 60% 40%

70 – 74 70% 30%

75 – 79 75% 25%

80 or more 80% 20%

Example

In this example, the retiree was:

born on September 18, 1940,

hired on July 1, 1975, and

retired on April 1, 2002.



Part A = Retiree Medical Years

Take the lesser of:

Last Day Worked: April 1, 2002

MINUS

Date in which the retiree turned age 40: September 18, 1980

EQUALS

21 whole years

- OR -


MINUS

Retiree’s hire date plus 10 years: July 1, 1975 + 10 years

EQUALS

16 whole years

Part A result: 16

Part B = Age at Retirement


MINUS

Birth date: September 18, 1940

EQUALS

61 whole years

Part A result: 61

Total Points = Part A + Part B

Part A: 16

PLUS

Part B: 61

EQUALS

77 points

In this example, the retiree has a total of 77 points. Based on the Contribution Schedule outlined in this section, Bosch would pay 75% of the cost of medical coverage and the retiree would pay 25%.

Note: Automotive Service Solution retirees are not eligible for Bosch contributions and are responsible for 100% of the retiree medical coverage cost.

Please review your pension check or billing statement after you enroll to make sure that the appropriate contributions are being processed. If you have any questions, contact the Bosch Benefits Center at 800-207-9012.



COBRA Continuation Coverage Under certain circumstances your eligible dependents covered by the Plan have the right, under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), to continue healthcare coverage under the Medical Benefit Program.

COBRA coverage is available to your covered dependents when you or they would otherwise lose group health coverage under the Plan. This section generally explains COBRA coverage, when it may become available to your family, and what you need to do to protect the right to receive it. COBRA coverage for the Plan is administered by the COBRA administrator listed in “Contact Information” on page 92.

You may have other options available to you when you lose coverage under the Healthcare Benefit Programs. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about may of these options at www.healthcare.gov.

Qualifying Events

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

Your covered dependent spouse will become a qualified beneficiary if he/she loses coverage under the Medical Benefit Program because any of the following qualifying events occur:

your death,

you become entitled to Medicare benefits (under Part A, Part B, or both), or

you become divorced or legally separated from your Spouse/Domestic Partner.

Your covered dependent child will become a qualified beneficiary if he or she loses coverage under the Medical Benefit Program because any of the following qualifying events occur:

your death,

you become entitled to Medicare benefits (under Part A, Part B, or both), or

your child stops being eligible for coverage under the Medical Benefit Program as an eligible dependent.

Your HSA under COBRA

If you participate in one of the Bosch CDHP Benefit Options and have a Health Savings Account (HSA) through the Plan’s benefit provider, you can take your HSA with you when your Medical Benefit Program coverage ends. However, if you continue your medical coverage under COBRA once your active or retiree benefits end, the Company will not provide contributions to your HSA. See “Health Savings Account” on page 25 for more information.



Additionally, you and your covered dependents may become a qualified beneficiary in the event of a loss of coverage due to a proceeding in bankruptcy under Title II of the U.S. Code with respect to the Company.

Notification Process and Timeframes

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

When the qualifying event is your death or your entitlement to Medicare benefits (under Part A, Part B, or both), the Bosch Benefits Center will notify the COBRA administrator of the qualifying event.

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

the date of the qualifying event, or

the date on which you or a covered dependent loses (or would lose) healthcare coverage under the Medical Benefit Program.

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

Electing COBRA Continuation Coverage

If it is determined that your covered dependents qualify for COBRA coverage, they may individually decide whether or not to continue coverage. Each of your covered dependents will have the right to elect the same coverage under the Medical Benefit Program in which he or she was enrolled immediately before the qualifying event. Parents may elect to continue coverage on behalf of their covered dependent children.

If your covered dependent wants to elect COBRA coverage, he or she must do so within 60 days of the date the COBRA election was sent by the COBRA administrator.

Premium Payments

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



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

Duration of Coverage

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

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

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

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

the date the qualified beneficiary first becomes entitled to Medicare benefits (under Part A or Part B, or both); provided the qualified beneficiary becomes enrolled in Medicare benefits after his/her election of COBRA continuation coverage (this rule does not apply in the event of a Bankruptcy under Title II of the U.S. Code),

for a proceeding in Bankruptcy under Title II of the U.S. Code, the date of your death, and with respect to your surviving spouse, the date of your surviving spouse’s death, or

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

If a covered dependent’s COBRA coverage is terminated for any reason before the maximum period of coverage to which you were entitled, your covered dependent will be notified of that fact and provided with an explanation of why continuation coverage was terminated.



Questions about COBRA Continuation Coverage

If you have questions about COBRA coverage, you may contact the COBRA administrator. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration in your area or visit its website at www.dol.gov/ebsa. Addresses and phone numbers of Regional and District Employee Benefits Security Administration offices are available through its website. For more information about the Health Insurance Marketplace, visit www.HealthCare.gov.

Keep the Plan Informed of Address Changes

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

When You Have Coverage Elsewhere If you or your dependents are covered under the Plan and also participate in or receive benefits from other coverage (Medicare or your spouse’s plan, for example) or from a third party, certain rules apply, as described in this section.

Coordination of Benefits (COB) The Plan coordinates its benefits with other group plans to reimburse you or your dependent up to the allowable payment from these Plans. An allowable expense is any expense covered at least in part by the Plan. Coordination of benefit information is collected during Annual Enrollment periods.

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

As a Retiree. If you are not actively working for another company and not covered under another group health plan, the Plan is primary — it pays its benefit first without regard to any other plan.

For a Spouse Who Has Other Healthcare Insurance. The Plan is secondary — benefits from the Plan will be adjusted so that the total benefit payable will not be greater than the maximum reimbursement under the Plan.

If You Have Children and You and Your Spouse Have Separate Medical Coverage. The plan of the parent whose birthday comes first in the year is considered to be the primary plan; the other plan is secondary.

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

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

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



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

Coordinating Benefits with Medicare

When you or your dependents are eligible for Medicare, the Plan is primary for each of you as follows:

while you are actively employed by the Company, or

during a covered person’s first 30 months of end-stage renal disease treatment.

In these cases, Medicare must be secondary. However, a covered person may elect to end coverage under the Plan and have Medicare coverage alone. For information, call the Bosch Benefits Center. For contact information, see “Contact Information” on page 92.

When your active employment ends, Medicare coverage becomes primary for you and any Medicare-eligible dependents. (For purposes of coordinating benefits with Medicare, your active employment ends when you retire or terminate employment, or after a six-month leave of absence.) Medicare is also primary after 30 months of end-stage renal disease treatment.

When Medicare is primary and Plan coverage is secondary, benefits are coordinated with Medicare Part A and Part B benefits that the covered person is eligible to receive. This applies whether or not the benefits are actually paid by Medicare.

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

Terms to Know

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

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

Note!

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



Subrogation

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

Reimbursement

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

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

Constructive Trust

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

Lien Rights

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

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

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

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



First-Priority Claim

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

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

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

Applicability to All Settlements and Judgments

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

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

Cooperation

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

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

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



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

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

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

Interpretation

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

Jurisdiction

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

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

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

The Claims Administrator may delegate these functions.



When Coverage Ends Retirees

Your coverage under the Plan will end:

on the last day of the month prior to your 65th birthday (unless you are eligible for coverage after reaching age 65, as described under “Who Is Eligible” on page 2),

if you fail to pay your contributions, on the last day for which you have made contributions,

if the Plan, Benefit Program or Benefit Program option is terminated, canceled or amended, on the effective date of such termination, cancellation or amendment, and

on the date you are rehired by Bosch as a benefits eligible associate.

Coverage and contributions will also end upon your death; however, your spouse or dependent children may continue coverage by paying the entire premium until they no longer meet the requirements as listed under “Who Is Eligible” on page 2.

Grandfathered Bosch Choice and Robert Bosch Tool Corporation Retirees

Your spouse or dependent children may continue coverage without paying the entire premium.

Dependents

Except for the rights outlined under “COBRA Continuation Coverage” on page 12, coverage for your dependents will end:

on the day a dependent is no longer eligible,

if you fail to provide the dependent verification documentation requested,

if you fail to pay required contributions, on the last day for which you have made contributions, or

if the Plan, a Benefit Program or Benefit Program option is terminated, canceled or amended, on the effective date of such termination, cancellation or amendment.

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



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

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

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

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

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

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

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



Retiree Medical Benefit Program The Plan provides broad, comprehensive protection to cover a wide range of medical providers, services and supplies. You may be able to elect one of the following options under the Retiree Medical Benefit Program:

Bosch CDHP 80 Benefit Option, or


Preferred Provider Organization (PPO) – Basic Benefit Option, or

Preferred Provider Organization (PPO) – Plus Benefit Option. If you are a grandfathered Bosch Choice Braking or Bosch Fuel Systems retiree who is age 65 or older, you may be eligible to elect the Indemnity Benefit Option. Otherwise, Retiree Medical coverage is available only to pre-65 retirees and their eligible dependents.

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

Note: The Retiree Medical Benefit Program options have a Medical Services Advisory (MSA) Program, including Advance Approval, to ensure that you are receiving the appropriate medical care in the most effective setting possible and that the services are covered. See “Medical Review Program” on page 28 for more information.

Important

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

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

An Important Note!

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



In addition, nothing in this SPD shall be construed to provide vested, nonforfeitable, nonchangeable or nonterminable benefits, or any rights thereto. Receipt of this communication should not be considered to mean that you are a participant or eligible to participate in the Plan, Benefit Programs or Benefit Programs options described in the SPD.

If You Have Questions

If you have any questions about this SPD or any provision of the Benefit Programs, contact the appropriate Benefit Program provider listed in “Contact Information” on page 92 or call the Bosch Benefits Center at 800-207-9012.

If You Need Help Understanding This Summary

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

Overview of the Retiree Medical Benefit Program This section describes the benefit options that may be available to you under the Retiree Medical Benefit Program.

Consumer Driven Health Care Plans

A Consumer Driven Health Care Plan (CDHP) is a health plan designed to help participants take more responsibility for their personal health. CDHPs combine higher deductibles with preventive care covered at 100% and the option to enroll in a tax-free Health Savings Account (HSA). For more details, see “Health Savings Account” on page 25.

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


Bosch CDHP 90 Benefit Option.

Note: Automotive Service Solutions retirees are not eligible for these two Benefit Options, and therefore cannot participate in a Health Savings Account.

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

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

Important

Because physicians and hospitals frequently change their affiliations with networks and organizations, printed directories become quickly outdated. To ensure that the provider you are going to receive treatment from is currently in-network, contact the Claims Administrator for your medical Benefit Option before each visit or hospital stay. For contact information, see “Contact Information” on page 92.



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

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

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

Specific details about these Benefit Options are outlined in the “Comparison of Medical Benefit Program Options” beginning on page 29. See “Prescription Benefits” beginning on page 52 for more information on how prescription drugs are covered under the CDHPs.

Preferred Provider Organization (PPO)

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

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

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

There are two PPO options offered by the Company:

PPO Basic Benefit Option, and

PPO Plus Benefit Option.

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

Specific details about these benefits options are outlined in the “Comparison of Medical Benefit Program Options” beginning on page 29. See “Prescription Benefits” beginning on page 52 for more information on how prescription drugs are covered under the PPO Benefit Options.



Indemnity Benefit Option

If you are a grandfathered Bosch Choice Braking or Bosch Fuel Systems post-65 retiree, you are eligible to elect the Indemnity Benefit Option. This option allows you to receive medical care and services from any physician or facility you choose. In addition, you do not need to select a primary care physician, nor do you need referrals for a specialist.

Specific details of this option are outlined in the “Comparison of Medical Benefit Program Options” beginning on page 29. See “Prescription Benefits” beginning on page 52 for more information on how prescription drugs are covered under this Plan.

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

your contributions up to certain limits are deductible on your federal income tax return and in some states on your state income tax return,

any contributions by the Company (or Robert Bosch Tool Corporation), investment earnings and qualified distributions are all exempt from federal income tax, FICA (Social Security and Medicare) tax and state income taxes (for most states),

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

the dollars that remain in your account at the end of the year will roll over to the next year, making your account a convenient, easy way to save and invest to pay for future medical expenses.

If you enroll in one of the Bosch CDHP Benefit Options and open an HSA through the Plan’s benefit provider, BenefitWallet, you will automatically receive an annual Company contribution to your account, even if you don’t contribute yourself. The Company reserves the right to discontinue contributions at any time at its discretion.

You may contribute to your HSA by sending a check to BenefitWallet. The contributions you make to your HSA before attaining age 65 may be deducted on your federal income tax return as long as you are participating in one of the CDHP Benefit Options. HSAs are individually owned accounts (like IRAs) and are not part of a Company benefit plan. The HSA is not an ERISA plan nor a Benefit Option under the Plan. For more information on health savings accounts, you may refer to IRS Publication 969 at www.irs.gov.

Note: If you were a CDHP Benefit Option participant before you retired, any amount remaining in your account can still be used for eligible retiree medical expenses. There is no change to the account.

Save Your Receipts!

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

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



As a retiree, you can withdraw money from your HSA after you turn age 65 for non-medical expenses and avoid the tax penalty. However, you must still pay regular taxes. Consult your tax advisor for more information on health savings accounts.

HSA Contributions

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

$3,350 individual, and

$6,650 family.

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

Where Your HSA Money Comes From

Company Contributions

If you enroll in one of the Bosch CDHP Benefit Options and open an HSA through the Plan’s benefit provider, BenefitWallet, you will automatically receive a Company contribution to your account in one lump sum at the start of the plan year, even if you don’t contribute yourself. If you retire mid-year of the Plan year, you will receive the remainder as a lump sum (contributions while active are applied). (See “Health Savings Account” on page 25.)

You will continue to receive this contribution as a retiree if you were enrolled in a CDHP before retirement and you continue to participate after retirement. The Company reserves the right to discontinue contributions at its discretion. Note: If you continue your medical coverage under COBRA once your active or retiree benefits end (see “COBRA Continuation Coverage” beginning on page 12), the Company will not provide contributions to your HSA.

Your Contributions

In addition to the contributions that Bosch will make on your behalf, you may make additional After-Tax contributions directly to BenefitWallet during the year, up to the calendar year maximum limit set by the IRS (less any Company contributions). See “Health Savings Account” on page 25.

Earnings

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

HSA Catch Up Contributions

If you are age 55 or older and not enrolled in Medicare, you may make catch up contributions, in addition to regular contributions, to your HSA. In 2015, the maximum catch up contribution amount is $1,000.



Eligible Expenses

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

Qualified medical expenses include (but are not limited to):

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

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

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

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

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

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

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

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

annual physicals,

routine colonoscopies,

routine mammograms, and

immunizations.

For more information about this coverage, call the Claims Administrator. See “Contact Information” on page 92 for detailed contact information.



Medical Review Program Medical Services Advisory (MSA) Program

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

The Bosch Choice Retiree Medical Benefit Options, including Bosch CDHP 80 Benefit Option, Bosch CDHP 90 Benefit Option, PPO Basic Benefit Option, PPO Plus Benefit Option and Indemnity Benefit Option, require advance approval of certain services through the Medical Services Advisory (MSA) Program.

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

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

meet the requirements of your medical coverage.

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

The MSA Program is available from 7:00 a.m. to 6:00 p.m. Central Time, Monday through Friday. You may leave a message with the answering service after hours or on weekends; an MSA advisor will call you back the next business day. For applicable phone numbers or website addresses, see “Contact Information” on page 92.

Advance Approval

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

Care or Services Timeframe

Inpatient Hospital Stays

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

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

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

Skilled Nursing Facility At least 1 business day before admission



Care or Services Timeframe

Home Health Care At least 1 business day before receiving care

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

Transplants At least 1 business day before the procedure

Failure to Receive Advance Approval

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

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

Maximum Penalty

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

Comparison of Medical Benefit Program Options While all of the Benefit Options under the Medical Benefit Program provide broad protection, there are some differences between the Plans. The following two charts compare the Bosch CDHP Benefit Options and the PPO Benefit Options side by side. The Indemnity Plan is summarized following the “PPO Benefit Option Comparison” chart.

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

For more information, see “Additional Information about Covered Care and Services” beginning on page 41 and “Important Terms for Understanding Your Benefits” beginning on page 45.

Note: Automotive Service Solutions retirees are not eligible for the CDHP Benefit Options. Please see the “PPO Benefit Option Comparison” chart below.



CDHP Benefit Option Comparison

CDHP 80 Benefit Option CDHP 90 Benefit Option

Plan Pays You Pay Plan Pays You Pay

Medical And Prescription Drug Coverage

Nothing until the deductible is met

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

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

100% until the deductible is met

Coinsurance until out-of-pocket maximum is met

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







Preventive Care 100% $0 100% $0

Health Savings Account (HSA)

For Robert Bosch Tool Corporation Retirees

The Company contributes:

$595 individual

$1,190 family

For All Others


$500 individual

$1,000 family

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

$3,350 individual

$6,650 family

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

For Robert Bosch Tool Corporation Retirees


$595 individual

$1,190 family

For All Others


$500 individual

$1,000 family

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

$3,350 individual

$6,650 family

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

Annual Deductible Bosch’s HSA contribution can reduce your annual deductible

$1,900 individual

$3,800 family

Bosch’s HSA contribution can reduce your annual deductible

$1,300 individual

$2,600 family





Coinsurance1 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Annual Out-of-Pocket Maximum

(amounts include annual deductible and copays)

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

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

In-Network

$2,500 individual

$5,000 family

Out-of-Network

$5,000 individual

$10,000 family

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

In-Network

$2,500 individual

$5,000 family

Out-of-Network

$5,000 individual

$10,000 family

Outpatient Doctor’s Office Visits

Treatment for illness/injury

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Allergy Treatments

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Diagnostic and Laboratory Testing

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network





Second Surgical Opinions

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Outpatient Preadmission Testing

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Hospital Services

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Emergency Room Visit

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Ambulance Services

Limited to R&C allowance

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Urgent Care Facility

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Physical, Speech, Occupational Therapy

$4,000 annual maximum per therapy, in-network and out-of-network services combined

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Chiropractic Therapy

20 visit annual maximum per Plan Year

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network





Maternity

Prenatal and Postnatal Care

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Delivery 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Family Planning 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Durable Medical Equipment

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

External Prosthetic Appliances

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Organ Transplants2

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

80% in-network

Not covered out-of-network

20% in-network

100% out-of-network

90% in-network


10% in-network

100% out-of-network

All Other Transplants

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

60% out-of-network

10% in-network

40% out-of-network

Dental Care3

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

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network





TMJ

Excludes orthodontic care; $2,500 lifetime maximum

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Outpatient Private Duty Nursing

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Skilled Nursing Facility and Rehabilitation

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Hospice Care

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Mental Health and Chemical Dependency

Inpatient care (no day limit)

Outpatient care (no visit limit)

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

1. If your out-of-network provider is a noncontracted provider, your claims will be paid at the Medicare reimbursement rate.

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

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



PPO Benefit Option Comparison

PPO Basic PPO Plus


Medical Coverage Nothing until the deductible is met












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

60% (out-of-network)

$25 office visit copay, no deductible (in-network)

40%, no deductible, $500 maximum each Plan Year (out-of-network)

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

70% (out-of-network)

$20 office visit copay, no deductible (in-network)

30%, no deductible, $500 maximum each Plan Year (out-of-network)

Health Savings Account (HSA)

HSA not available for PPO Options




Annual Deductible N/A In-Network $600 individual

$1,200 family

Out-of-Network $1,200

individual

$2,400 family

N/A In-Network $300

individual

$600 family

Out-of-Network $600

individual

$1,200 family



PPO Basic PPO Plus


Coinsurance 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network


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

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

In-Network $3,000

individual

$6,000 family


individual

$12,000 family


In-Network $1,500

individual

$3,000 Family


individual

$6,000 family



$25 copay in-network

60% out-of-network


40% out-of-network


70% out-of-network


30% out-of-network

Allergy Treatments

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network


Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Second Surgical Opinions

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network


80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Hospital Services

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network



PPO Basic PPO Plus


Emergency Room Visit

Emergency 100% after

$100 copay (waived if admitted)

Emergency $100 copay

(waived if admitted)

Emergency 100% after

$100 copay (waived if admitted)

Emergency $100 copay


Non-emergency 80% after


60% after $100 copay out-of-network










Ambulance Services

(limited to R&C allowance)

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Urgent Care Facility

80% after $50 copay in-network









$4,000 annual maximum per type of therapy per Plan Year

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Chiropractic Therapy

20 combined visits per Plan Year

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Maternity

Prenatal and Postnatal Care

100% after $25 initial visit copay in-network

60% out-of-network

$25 initial visit copay in-network

40% out-of-network

100% after $20 initial visit copay in-network

70% out-of-network

$20 initial visit copay in-network

30% out-of-network



PPO Basic PPO Plus


Delivery 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Family Planning 80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network


80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network


80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

Organ Transplants2

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

80% in-network


20% in-network


90% in-network


10% in-network


All Other Transplants

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

60% out-of-network

10% in-network

40% out-of-network

Dental Care3

Accidental injury to natural, sound teeth

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network

TMJ

Excludes appliances and orthodontic care; $2,500 lifetime maximum

80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network


80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

90% out-of-network

10% in-network

10% out-of-network



PPO Basic PPO Plus



80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network

Hospice Care

Inpatient

Outpatient

80% in-network

60% out-of-network

20% in-network

40% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network




80% in-network

80% out-of-network

20% in-network

20% out-of-network

90% in-network

70% out-of-network

10% in-network

30% out-of-network





(for eligible post-65 retirees only)


Plan Pays You Pay

Preventive Care 100% after $20 office visit copay

$20 office visit copay, no deductible

Health Savings Account (HSA) HSA not available for this option

HSA not available for this option

Annual Deductible N/A $300 individual

$600 family

Coinsurance1 80% 20%


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


$1,500 individual

$3,000 family



100% after $20 copay $20 copay




Plan Pays You Pay

Allergy Treatments 80% 20%


Inpatient

Outpatient

80% 20%

Second Surgical Opinions 80% 20%


80% 20%

Hospital Services

Inpatient

Outpatient

80% 20%

Emergency Room Visit Emergency 100% after $100 copay


Emergency $100 copay (waived if

admitted)

Non-emergency 80% after $100 copay

Non-emergency 20% after $100 copay

Ambulance Services

(limited to R&C allowance)

80% 20%

Urgent Care Facility 80% after $50 copay 20% after $50 copay


80% 20%

Chiropractic Therapy 80% 20%

Maternity

Prenatal and Postnatal Care 80% 20%

Delivery 80% 20%

Family Planning 80% 20%

Durable Medical Equipment 80% 20%

External Prosthetic Appliances 80% 20%

Organ Transplants2

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

80% 20%

All Other Transplants 80% 20%

Dental Care3

Accidental injury to natural, sound teeth

80% 20%




Plan Pays You Pay

TMJ

Excludes appliances and orthodontic care; $2,500 lifetime maximum

80% 20%


80% 20%


80% 20%

Hospice Care

Inpatient

Outpatient

80% 20%




80% 20%




Additional Information about Covered Care and Services This section provides additional information about the covered care and services offered by the Plan. Services are subject to deductibles and coinsurance as noted in the “Comparison of Medical Benefit Program Options” tables beginning on page 29.

Ambulance Service

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

Breast Reconstruction Following Mastectomy

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

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

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

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

Women’s Health and Cancer Rights Act

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




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


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

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


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

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

Family Planning

Family planning includes:

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

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

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

Home Health Care

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

Coverage for Wigs

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

Fertility Drugs

For information about fertility drugs, see “Prescription Benefits” beginning on page 52.



Hospice Care

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

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

Maternity Care

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

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

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

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

Midwife Services

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

Organ Transplants

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

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

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

Who Is a Companion?

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



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

Transplant services include:

compatibility testing,

medical, surgical and hospital services for the recipient,

procurement of an organ from a donor, and

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

For additional information, contact the Claims Administrator listed under “Contact Information” on page 92.

Outpatient Hospital, Surgical and Facility Services

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

Residential Treatment Centers

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

Routine Preventive Care

This benefit covers routine exams (including gynecological exams/Pap tests) and immunizations. Routine preventive care also covers non-diagnosed diagnostic and laboratory testing such as mammograms, various types of cancer screenings and bone density tests. For specific information on your benefits, as well as any limitations that may be applicable, contact the Claims Administrator listed under “Contact Information” on page 92.

Skilled Nursing Facility

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

TMJ (Temporomandibular Joint) Syndrome

TMJ Disorder is a condition of the joints linking the jawbone and skull, as well as muscles and other tissues related to that joint. Covered services for TMJ, Craniomandibular Joint Disorders and other conditions of the joints include surgical procedures and non-surgical care, up to a $2,500 lifetime maximum.



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

Coinsurance

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

Covered Expenses

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

Deductible

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

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

If you have retiree only coverage under the PPO or Indemnity Benefit Options, once you meet the individual deductible, the Plan will pay its share of your eligible charges for the rest of the Plan Year (or until you reach the annual out-of-pocket maximum). If you have coverage for your spouse and/or child(ren), the Plan pays it share of covered charges once you or any combination of family members satisfy the family deductible.

For the CDHP Benefit Options, the family deductible must be satisfied before the Plan pays its share of the cost for any covered person’s eligible expenses (required under HSA rules). However, any combination of deductible-eligible expenses incurred by you or your covered family members apply to the family deductible. Once the family deductible is met, the Plan will pay its share of covered charges for you or any of your covered family members for the rest of that Plan Year (or until you reach the annual out-of-pocket maximum).

Experimental or Investigational

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

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

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



a part of an ongoing clinical trial, or

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

Family Coverage

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

retiree and spouse,

retiree and child(ren), and

family (retiree, spouse and child[ren]).

Hospital

An institution licensed as a hospital that:

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

is supervised by a staff of physicians,

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

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

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

Lifetime Maximum

There is no limit to the amount of benefits you, or any of your covered dependents, can receive during a lifetime with the exception of TMJ. The TMJ benefit is subject to a lifetime maximum, as described in the “Comparison of Medical Benefit Program Options” beginning on page 29 and under “Additional Information about Covered Care and Services” beginning on page 41.

Medically Necessary

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

Out-of-Network

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



Out-of-Pocket Maximum

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

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

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

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

prescription drug expenses,

expenses not covered by the Benefit Program, or

expenses considered not medically necessary.

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

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

Primary Care Physician (PCP)

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

Physician

A physician is a medical practitioner who is:

licensed to prescribe and administer drugs or to perform surgery,

operating within the scope of his or her license, and

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



Limited Benefits Paid When Non-Participating Providers Are Used

You should be aware that when you elect to utilize the services of a Non-Participating Provider for a Covered Service in non-emergency situations, benefit payments to such Non-Participating Provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy’s fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical area where the services are performed), or other method as defined by the plan. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED UNDER THIS COVERAGE AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Non-Participating Providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill. Participating Providers have agreed to accept discounted payments for services with no additional billing to the member other than Coinsurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling the toll free telephone number on your identification card.

Eligible Charge…..means (a) in the case of a Provider, other than a Professional Provider, which has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to you at the time Covered Services are rendered, such Provider’s Claim Charge for Covered Services and (b) in the case of a Provider, other than a Professional Provider, which does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to you at the time Covered Services are rendered, will be the lesser of:

the Provider’s billed charges, or;

the Claim Administrator non-contracting Eligible Charge. Except as otherwise provided in this section, the non-contracting Eligible Charge is developed from base Medicare reimbursements and represents approximately 100% of the base Medicare reimbursement rate and will exclude any Medicare adjustment(s) which is/are based on information on the Claim.

Notwithstanding the preceding sentence, the non-contracting Eligible Charge for Coordinated Home Care Program Covered Services will be 50% of the Non-Participating or Non-Administrator Provider’s standard billed charge for such Covered Services.

The base Medicare reimbursement rate described above will exclude any Medicare adjustment(s) which is/are based on information on the Claim.

When a Medicare reimbursement rate is not available for a Covered Service or is unable to be determined on the information submitted on the Claim, the Eligible Charge for Non-Participating or Non-Administrator Providers will be 50% of the Non-Participating or Non-Administrator Provider’s standard billed charge for such Covered Service.



The Claim Administrator will utilize the same Claim processing rules and/or edits that it utilizes in processing Participating Provider Claims for processing Claims submitted by Non-Participating or Non-Administrator Providers which may also alter the Eligible Charge for a particular service. In the event the Claim Administrator does not have any Claim edits or rules, the Claim Administrator may utilize the Medicare claim rules or edits that are used by Medicare in processing the Claims. The Eligible Charge will not include any additional payments that may be permitted under the Medicare laws or regulations which are not directly attributable to a specific Claim, including, but not limited to, disproportionate share payments and graduate medical education payments.

Any change to the Medicare reimbursement amount will be implemented by the Claim Administrator within 145 days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor.

Maximum Allowance…..means (a) the amount which Participating Professional Providers have agreed to accept as payment in full for a particular Covered Service. All benefit payments for Covered Services rendered by Participating Professional Providers will be based on the Schedule of Maximum Allowances which these Providers have agreed to accept as payment in full. (b) For Non-Participating Professional Providers, the Maximum Allowance will be the lesser of:

the Provider’s billed charges, or;

the Claim Administrator non-contracting Maximum Allowance. Except as otherwise provided in this section, the non-contracting Maximum Allowance is developed from base Medicare reimbursements and represents approximately 100% of the base Medicare reimbursement rate and will exclude any Medicare adjustment(s) which is/are based on information on the Claim.

Notwithstanding the preceding sentence, the non-contracting Maximum Allowance for Coordinated Home Care Program Covered Services will be 50% of the Non-Participating Professional Provider’s standard billed charge for such Covered Services.

The base Medicare reimbursement rate described above will exclude any Medicare adjustment(s) which is/are based on information on the Claim.

When a Medicare reimbursement rate is not available for a Covered Service or is unable to be determined on the information submitted on the Claim, the Maximum Allowance for Non-Participating Professional Providers will be 50% of the Non-Participating Professional Provider’s standard billed charge for such Covered Service.



The Claim Administrator will utilize the same Claim processing rules and/or edits that it utilizes in processing Participating Professional Provider Claims for processing Claims submitted by Non-Participating Professional Providers which may also alter the Maximum Allowance for a particular service. In the event the Claim Administrator does not have any Claim edits or rules, the Claim Administrator may utilize the Medicare claim rules or edits that are used by Medicare in processing the Claims. The Maximum Allowance will not include any additional payments that may be permitted under the Medicare laws or regulations which are not directly attributable to a specific Claim, including, but not limited to, disproportionate share payments and graduate medical education payments.

Any change to the Medicare reimbursement amount will be implemented by the Claim Administrator within 145 days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor.

Single Coverage

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

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

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

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

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

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

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

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

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

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

reversals of voluntary sterilizations and certain infertility services,

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



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

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

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

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

transsexual surgery and related services,

acupuncture,

over-the-counter disposable or consumable medical supplies,

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

hearing exams or hearing aids,

eye exams and expenses associated with eye exercises,

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

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

expenses paid through a public program other than Medicaid,

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

speech therapy which is not restorative in nature,

experimental and/or investigational procedures,

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

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

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

non-medical ancillary services, including vocational rehabilitation, behavioral training, employment counseling, driving safety and services, training or educational therapy for learning disabilities, developmental delays, autism or mental retardation,

medical treatment for a person age 65 or older, or their dependent, who is covered under this Benefit Program as a retiree when payment is denied by Medicare because treatment was received from an out-of-network provider (where applicable),



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

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

exercise and hygienic equipment,

over-the-counter drugs, diet pills, minoxidil or Retin-A, unless medically necessary and prescribed by a physician,

educational testing or therapy,

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

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

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

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

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

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

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

dental implants,

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

claims submitted after the time for submission has expired (see “`How to File Claims” on page 68).

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



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

Under a CDHP Benefit Option. Prescription drugs are covered like any other covered expense, with deductibles and coinsurance amounts that apply to other eligible expenses. (You also can use your HSA to help pay for covered expenses.) See the “Summary of Prescription Drug Benefits” charts on page 53 for information about coverage under the CDHPs.

Under the Other Options. Copays apply for generic drugs and minimum or maximum coinsurance amounts apply to brand name drugs. See the “Summary of Prescription Drug Benefits” charts below for information about coverage under the other Plans.

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

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

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

To receive the greatest savings through a retail pharmacy, you must visit a participating pharmacy. If you choose a non-participating pharmacy, you must pay 100% of the prescription price and then submit a claim form, along with your original receipt, to Express Scripts for reimbursement. (See “How to File Claims” on page 68 for more information.)

Summary of Prescription Drug Benefits

Prescription Drug Benefits — CDHP 80 and CDHP 90 Benefit Options



Retail Pharmacy

(30-day supply)

Generic Nothing until deductible is met

80% after deductible, in-network

60% after deductible, out-of-network

100% until deductible is met



Nothing until deductible is met










Brand Name













Mail Order Service

(90-day supply)

Generic Nothing until deductible is met












Brand Name













Prescription Drug Benefits — PPO Basic, PPO Plus or Indemnity Benefit Options

Drug Type Retail Pharmacy (30-day supply) Mail Order Service (90-day supply)

Generic $10 copay $20 copay

Brand Name 20% coinsurance

Minimum payment $25*

Maximum payment $50

20% coinsurance

Minimum payment $50*

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

amount.



Important Terms

Brand Name

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

Retail

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

Generic

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



Retiree Vision Benefit Program Robert Bosch Tool Corporation retirees only

Under the Vision Benefit Program, you can visit a VSP provider or obtain care from a non-network provider. However, you receive greater benefits if you use a VSP network provider. The Retiree Vision Benefit Program provides benefits for:

eye exams, and

glasses (lenses and frames), or

contact lenses.

For coverage information and plan features, review the following “Summary of Vision Benefits.”


You are automatically enrolled in the Vision Benefit Program when you elect to participate in one of the Medical Benefit Program options.

Summary of Vision Benefits The chart below highlights key features of the Retiree Vision Benefit Program. For detailed information about your benefits, see “Important Terms” on page 58.

Every effort has been made to accurately describe the Retiree Vision Benefit Program in this SPD. However, these benefits are offered and controlled by a group insurance contract with the insurance carrier. You may request more detailed summaries or certificates prepared by the insurance carrier. Please see the “Contact Information” section on page 92 for insurance carrier’s (i.e., Claims Administrator’s) contact information. If there is a conflict between this SPD and the group insurance contract, summary, or certificate prepared by the insurance carrier, the group insurance contract, summary or certificate prepared by the insurance carrier will control.

Frequency In-Network Out-of-Network

Plan Procedures

Provider Restriction

N/A VSP providers Any provider

Responsibility for Filing Claims

N/A VSP providers You pay for expenses up front and then submit an itemized bill (claims must be filed within 12 months of the service)



Frequency In-Network Out-of-Network

Care and Services

Eye Exams Once every 12 months $10 copay Plan reimburses up to $42

Eyeglass Lenses*

Single Vision Plan reimburses up to $32

Lined Bifocal Plan reimburses up to $50

Lined Trifocal Plan reimburses up to $60

Frames* Once every 24 months

$20 copay for lenses and/or frames

Plan reimburses up to $45

Contact Lenses Lenses and fitting

Plan pays up to $150

Elective 15% discount off in-network professional services when you purchase contact lenses

Plan reimburses up to $130

Medically Necessary

Plan pays up to $150

Plan reimburses up to $210 (in-network prescription required)

Additional Pairs of Prescription Glasses See “Important Terms” on page 58 for additional information

Adults: Eyeglass lenses or contacts once every 12 months and frames once every 24 months

Children (under age 19): Eyeglass lenses and frames or contact lenses once every 12 months

Plan pays 100% Not covered

Laser Correction Surgery See “Important Terms” on page 58 for additional information

No frequency restrictions

20% discount on full sets of glasses (frames and lenses)

Not covered

One procedure for each participant in a lifetime

In-network centers offer a 10% – 25% discount off their Usual and Customary fees

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



Important Terms This section describes covered services and terms that have significant meaning under the vision plan administered by VSP.

Additional Pairs of Glasses

You and your covered dependents can receive a 20% discount on a full set of glasses (frames and lenses) that are purchased during the 12-month period following the eye exam through the VSP provider who last performed the covered exam.

Laser Correction Surgery

Laser correction surgery includes procedures such as LASIK. Though discounts will vary by location, an in-network center on average offers a 15% to 20% discount off their usual and customary fees. Additionally, if the laser center is offering a price reduction, VSP members will receive 5% off their best-advertised price, whichever is lower.

Medically Necessary

Contacts are considered medically necessary if prescribed by a participating VSP doctor for certain conditions. A VSP doctor must receive prior approval from VSP.

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

blended lenses,

oversize lenses,

cosmetic lenses,

optional cosmetic processes,

UV (ultraviolet) protected lenses,

coating of the lens or lenses,

laminating of the lens or lenses,

certain limitations on low vision care,

a frame that costs more than the Plan allowance, or

contact lenses (except as outlined in the “Summary of Vision Benefits” on page 56).



The following professional services or materials are not covered:

orthoptics or vision training and any associated supplemental testing,

plano lenses (non-prescription),

two pairs of glasses instead of bifocals,

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

medical or surgical treatment of the eyes,

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

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



Retiree Dental Benefit Program Robert Bosch Tool Corporation retirees only

The dental benefits offered by the Retiree Dental Benefit Program are designed to encourage regular, preventive care that can help you avoid more extensive and costly care later. You can enroll for dental benefits even if you do not elect medical benefits. Dental care is offered through MetLife Dental. Under this Benefit Program you can visit a preferred network provider or obtain care from a non-network provider. All benefits are paid based on the allowable amount — a set fee established by MetLife Dental for each covered procedure. Here is how it works:

If you obtain care from an in-network provider, you will only be responsible for any copays or coinsurance amounts because the dentists that are a part of the MetLife Dental network have agreed to accept the allowable amount as payment in full.

If you obtain care from an out-of-network provider, your cost for care and services may be higher because MetLife Dental will only pay benefits based on the allowable amount. If your expenses exceed these limits, you will be responsible for that amount and it will not be applied to your deductible.

For more information on allowable amounts, see the “Summary of Dental Benefits” on page 45 and “Important Terms” on page 62.

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

Every effort has been made to accurately describe the Retiree Dental Benefit Program in this SPD. However, these benefits are offered and controlled by a group insurance contract with the insurance carrier. You may request more detailed summaries or certificates prepared by the insurance carrier. Please see the “Contact Information” section on page 92 for insurance carrier’s (i.e., Claims Administrator’s) contact information. If there is a conflict between this SPD and the group insurance contract, summary, or certificate prepared by the insurance carrier, the group insurance contract, summary or certificate prepared by the insurance carrier will control.

Be a Smart Consumer!

Get a pre-treatment estimate so you are not surprised by an expensive bill for services you thought were covered. See “Pre-treatment Estimate” under “Important Terms” on page 62 for details.



Benefits Provided for Necessary and Appropriate Services

The Dental Benefit Program covers necessary and appropriate dental procedures when they are performed by a licensed dentist. To be necessary and appropriate, a service must be:

consistent with symptoms, diagnoses or treatment of the condition, disease or injury,

in accordance with standards of good dental practice, and

the most appropriate supply or level of service that can safely be provided.

Procedures provided solely for the convenience of you or your dentist will not be covered.

MetLife Dental determines what is necessary and appropriate based on a review of dental records describing the condition and treatment. MetLife Dental may decide a service is not necessary and appropriate under the terms of the plan even if your dentist has furnished, prescribed, ordered, recommended or approved the service.

Summary of Dental Benefits The following chart highlights key features of your dental benefits. Once your deductible is met, the Plan will pay a portion of the cost for covered care and services. These coinsurance amounts are listed as percentages in the chart below. Keep in mind that if you use out-of-network providers, you will be responsible for any costs that exceed the allowable amount and that amount may not be applied to your deductible.

For additional information about your benefits, see “Important Terms” on page 62.

Covered Care and Services In-Network or Out-of-Network

Responsibility to file claims In-Network: Your dentist

Out-of-Network: You

See “How to File Claims” on page 68 for more information

Responsibility to obtain a pre-treatment estimate/plan

You

Deductible

Retiree only $50

Retiree + spouse $150

Retiree + children or retiree + spouse and child(ren)

$150/family

Important

Because dentists frequently change their affiliations with networks and organizations, printed directories become quickly outdated. To ensure that the dentist you are going to receive treatment from is currently in network, contact the Claims Administrator before each visit. For contact information, see “Contact Information” on page 92.



Covered Care and Services In-Network or Out-of-Network

Plan Year Maximum Benefit

Costs for preventive care are counted towards the maximum benefit

The Plan Year maximum benefit does not include orthodontia (see “Orthodontia Care” row below for separate lifetime maximum)

$1,500/person

Preventive Care 100%, no deductible

Basic Care 80%*

Major Care 50%*

Orthodontia Care 50% of the pre-treatment estimate, no deductible, lifetime maximum of $1,500*

* Benefits will be paid based on the allowable amount. See “Important Terms” on page 62 for more information.

Important Terms This section describes covered services and explains terms that have significant meaning under the dental plan.

Allowable Amount

Services or care provided by a dentist who is not an in-network preferred provider are limited to the allowable amount — the set fee established by MetLife Dental for each covered procedure. If you receive care from an out-of-network provider, you will be responsible for any costs that exceed the allowable amount. That amount may not be applied toward your deductible.

Basic Care

Basic care is divided into three classes:

Class I:

fillings (silver amalgam, silicate and plastic restorations),

simple extractions,

stainless steel crowns,

oral surgery consisting of surgical extractions, fractures, dislocation treatment and treatment of cysts and tumors,

apicoectomy,

root canal therapy, and

general anesthesia (limited to certain covered procedures) administered by a licensed dentist.



Class II:

periodontal maintenance prophylaxis,

gingival curettage,

periodontal scaling and root planning,

gingivectomy or gingivoplasty,

gingival flap procedures,

mucogingival surgery,

osseous surgery to include flap entry and closure,

bone replacement grafts (excluding the use of synthetic bone), and

occlusal guards.

Class III: Simple repairs to complete or partial dentures, limited to:

adjustments,

repair of broken denture base,

replacement of missing or broken teeth,

repair or replacement of broken clasp, and

replacement of broken teeth.

Coinsurance

Once you meet the deductible, where applicable, the Plan will pay a percentage of covered expenses for you and your family. For example, if the Plan pays 80% of an expense, you pay the remaining 20%. You are responsible for your portion of the coinsurance amount until you meet the Plan Year maximum benefit, at which time you become responsible for 100% of the cost, as outlined in the chart under “Summary of Dental Benefits” on page 61.

Covered Expenses

Covered dental expenses include any dental treatment, care, service or supply provided or ordered by a dentist or dental hygienist that are necessary for the care of your or your dependents’ teeth. All care must be started and completed while you are covered under the Plan.

Deductible

The deductible is the portion of covered expenses you pay each year before the Plan pays benefits.

Covered expenses applied to your in-network deductible also count toward your out-of-network deductible and vice-versa.



For retiree only coverage, once an individual has met his or her deductible, the Plan pays its share of covered charges for the rest of the Plan Year, up to the Plan Year maximum benefit. For family coverage, once any combination of family members pays covered expenses totaling the amount of the family deductible, the Plan pays its share of covered charges for the rest of the Plan Year.

Preventive Care

The Plan will pay charges for the following services:

oral exam/cleaning — two every 12 months,

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

space maintainers — for children under age 12,

bitewing x-rays — one set every 12 months,

full-mouth or panoramic x-rays – one complete set every 36 months,

sealants – for children under age 16, one treatment per permanent molar every 36 months, and

emergency exam for pain.

Major Care

The Plan will pay charges for these major, restorative services (also referred to by MetLife Dental as Class IV services) listed below:

inlays and onlays,

crowns,

dentures, full and partial,

denture reline or rebase,

bridgework — including repair and replacement,

repairs involving adding teeth or clasps, and

tissue conditioning.

The Plan will not pay for the replacement of any prosthetic appliance, crown or bridge within five years of the last placement or a replacement that has been previously covered under this Plan.

Orthodontic Care

Orthodontic care is provided to correct problems such as overbites and cross bites by straightening or repositioning teeth. Orthodontic services are limited to:

one diagnosis and treatment plan, including the initial exam, x-rays, models and photographs within a five-year period,

minor treatment for tooth guidance,

Important!

Your dentist must submit a pre-treatment estimate of any major care services and the treatment plan must be approved before your dentist performs the services in order to obtain benefits.

Pre-Treatment Note

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



minor treatment to control harmful habits,

interceptive orthodontic treatment,

comprehensive orthodontic treatment,

treatment of atypical or extended skeletal case, and

post-treatment stabilization.

Pre-treatment Estimate

It is in your best interest to receive a pre-treatment estimate before you receive extensive dental work (i.e., services estimated to cost $200 or more). In addition, some services, such as major and orthodontic care, require your dentist to provide a pre-treatment estimate before services are performed in order for you to obtain benefits.

Your dentist should submit a claim form to the Claims Administrator, before any treatment begins, containing the full description of the treatment plan he or she feels you need and the estimated costs, including diagnostic x-rays and other supporting records. The Claims Administrator will then provide you with a pre-treatment estimate — what services are covered and what alternative treatments are available.

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

Temporomandibular Joint (TMJ) Syndrome

TMJ Syndrome is a condition of the joints linking the jawbone and skull, as well as muscles and other tissues related to that joint. Services or supplies for the diagnosis or treatment of TMJ are not covered by this Plan.

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

out-of-network charges in excess of the allowable amount,

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

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

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

replacement of a lost, missing or stolen prosthetic device, including space maintainers,

services performed through a medical department, clinic or similar facility provided or maintained by the Company,

Important

Your dentist must submit a pre-treatment estimate of any orthodontic care and the treatment plan must be approved before your dentist performs the services in order to obtain benefits. Treatment, including necessary appliances, may not exceed a maximum of 36 months.



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

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

duplicate prosthetic devices or any other duplicate appliance,

oral hygiene, dietary instruction or plaque-control programs,

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

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

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

any dental services if benefits or services for all or any part of the expenses are provided under any other group coverage for which you are enrolled,

replacement or repair of orthodontic appliances,

services or supplies for the diagnosis and treatment of Temporomandibular Joint syndrome/dysfunction/surgery,

crown over implant,

prescription drugs, pre-medications or injections,

charges for hospitalization (including hospital visits),

mounted case analysis,

laboratory tests or examinations,

bleaching,

implants,

consultations,

complete occlusal adjustment,

services provided by an anesthesiologist, or

claims submitted more than 12 months after the end of the Plan Year.

Important

The standards for coverage of dental expenses change from time to time. You will receive periodic notices of important changes or modifications to the Plan (to the extent that they are inconsistent with the benefits described in this SPD). However, all changes to covered benefits are binding, even without notice.

If you have any questions as to whether a particular dental procedure is covered under current standards, you should always check before incurring the expense, even if a pre-treatment estimate is not required.

The Claims Administrator has the final authority, in its sole discretion, to determine whether any benefit is covered under the Plan, and its determinations are conclusive and binding on all participants and dependents. See “How to File Claims” on page 68 for more information about filing claims and “Administrative Information” beginning on page 86 for details on administration of the Plan.



Retiree Life Insurance Benefit Program Not applicable for Robert Bosch Tool Corporation retirees

If you are enrolled in the Retiree Medical Benefit Program, Bosch automatically provides you with $10,000 of life insurance coverage; you do not need to enroll separately. This benefit is provided at no cost to you and does not require proof of good health. Life insurance coverage will end when your retiree medical coverage ends, or at age 65, whichever occurs first. Every effort has been made to accurately describe the Retiree Life Insurance Benefit Program in this SPD. However, these benefits are offered and controlled by a group insurance contract with the insurance carrier. You may request more detailed summaries or certificates prepared by the insurance carrier. Please see the “Contact Information” section on page 92 for insurance carrier’s (i.e., Claims Administrator’s) contact information. If there is a conflict between this SPD and the group insurance contract, summary, or certificate prepared by the insurance carrier, the group insurance contract, summary or certificate prepared by the insurance carrier will control.

Naming a Beneficiary

Beneficiaries are individuals who will receive the proceeds of your Retiree Life Insurance coverage upon your death. As long as state law allows, you may name anyone as your beneficiary.

The beneficiary designation(s) you made as an active associate will continue to be in effect when you retire. You may change your beneficiary at any time by accessing the Bosch Benefits Center website (see “Contact Information” on page 92 for the web address). The change will take effect when it is received. If there are no surviving beneficiaries at the time of your death, payment will be made according to the terms of the insurance contract or state law.

Changing Your Beneficiary

Your beneficiary can only be changed electronically by entering the information on the Bosch Benefits Center website (see “Contact Information” on page 92 for the web address) or by calling the Bosch Benefit center at 800-207-9012. Any agreements between you and your beneficiary, for example, a settlement that is part of a divorce proceeding, will not change your beneficiary. After your benefits have been paid to your most recently designated beneficiary (as determined by the Claims Administrator), the Plan will have no obligation to pay benefits to any other person.

Keep in Mind

If you have a change in status, you may want to change your beneficiary designation.



How to File Claims This section provides instructions on how to file a claim for retiree medical, dental, vision and prescription drug expenses, as well as how to file a claim for life insurance benefits. Each of the Benefit Options and Benefit Programs has a Claims Administrator, appointed by the Plan Administrator, to process claims under that Benefit Program. The summaries or certificates produced by the insurance carriers may have additional claims procedures. Please refer to those documents for more information. You can obtain claim forms for medical, vision, dental and prescription drug benefits from the Claims Administrator, or on the Bosch Benefits Center website in the “Health” tab under the “Forms” section. In addition, many of the Claims Administrators have websites from which the appropriate claim forms can be printed. If you have any questions about how to obtain or file a claim, contact the Bosch Benefits Center.

You always have the right to file a formal claim if you are advised by any provider that any service you feel should be covered is not eligible, or if you have any other dispute over the coverage provided under the Plan. If you are advised that any service is not covered, you must file a formal claim within the appropriate time period for that Benefit Program.

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

your Social Security number,

the name of the patient,

the date and description of each service, including diagnosis,

the reason (illness or injury) for each charge,

an itemized copy of all charges, and

the name and address of the provider.

To be eligible for reimbursement:

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

all dental claims must be received within 12 months from the end of the Plan Year (e.g., for the Plan Year beginning April 1, 2015, all claims must be received by March 31, 2016),



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

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

You will be responsible for expenses not filed within these timeframes. If you have questions, contact the Bosch Benefits Center or the Claims Administrator. For contact information, see “Contact Information” on page 92.

Medical Claims

If you receive supplies or services from in-network providers under the Bosch CDHP 80 Benefit Option, Bosch CDHP 90 Benefit Option, PPO Basic Benefit Option or PPO Plus Benefit Option, you do not have to file claims.

If you receive services from an out-of-network provider, or are enrolled in the Indemnity Benefit Option, you may need to complete and submit a claim form. You can get claim forms for medical benefits from the Bosch Benefits Center. Claims and bills must be submitted to BlueCross BlueShield. For address information, contact the Claims Administrator (see “Contact Information” on page 92).

Prescription Drug Claims

Retail

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

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

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

Mail Order

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

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

Life Insurance Claims

Your beneficiary must file a claim for the life insurance proceeds not more than 12 months after your death. Contact the Bosch HR Service Center at 1-800-922-5547 to initiate the claim.



Right of the Plan to Obtain Information

The Plan may provide or obtain any information needed for proper administration of the Retiree Life Insurance Benefit Program. Your beneficiary may also need to provide additional information, if requested, in order to receive payments.

For information about what to your beneficiary should do if the claim is denied, refer to the Insurance carrier’s summaries and certificates for the Retiree Life Insurance Benefit Program.

Dental Claims

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

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

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

Vision Claims

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

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

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

Decisions on Claims and Appeal Procedures For the Retiree Vision, Dental and Life Insurance Benefit Programs, refer to the certificates issued by the insurance carrier for appeal procedures.

Claim Filing and Appeals In order to obtain your benefits under this benefit program, it is necessary for a Claim to be filed with the Claim Administrator. To file a Claim, usually all you will have to do is show your ID card to your Hospital or Physician (or other Provider). They will file your Claim for you. Remember however, it is your responsibility to ensure that the necessary Claim information has been provided to the Claim Administrator.

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



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

To file your own Claim, follow these instructions:

1. Complete a Claim Form. These are available from your Employee Benefits Department or from the Claim Administrator’s office.

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

3. Mail the completed Claim Form with attachments to:

Blue Cross and Blue Shield of Illinois P. O. Box 805107 Chicago, Illinois 60680-4112

In any case, Claims must be filed no later than twelve months after the date a service is received. Claims not filed within twelve months from the date a service is received, will not be eligible for payment.

Should you have any questions about filing Claims, ask your Employee Benefits Department or call the Claim Administrator’s office.

Internal Claims Determinations and Appeals Process

Initial Claims Determinations

The Claim Administrator will usually pay all Claims within 30 days of receipt of all information required to process a Claim. The Claim Administrator will usually notify you, your valid assignee or your authorized representative, when all information required to pay a Claim within 30 days of the Claim’s receipt has not been received. (For information regarding assigning benefits, see “Non-assignment of Benefits” on page 90 in the “Administrative Information” section of this benefit booklet.) If you fail to follow the procedures for filing a pre-service claim (as defined below), you will be notified within 5 days (or within 24 hours in the case of a failure regarding an urgent care/expedited clinical claim (as defined below). Notification may be oral unless the claimant requests written notification.

If a Claim Is Denied or Not Paid in Full

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

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

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



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

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

The reasons for denial;

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

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

Subject to privacy laws and other restrictions, if any, the identification of the Claim, date of service, health care provider, Claim amount(if applicable), diagnosis, treatment and denial codes with their meanings and the standards used;

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

In certain situations, a statement in non-English language(s) that future notices of Claim denials and certain other benefit information may be available in such non-English language(s);

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

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

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

In the case of a denial of an urgent care/expedited clinical claim, a description of the expedited review procedure applicable to such claims. An urgent care/expedited claim decision may be provided orally, so long as written notice is furnished to the claimant within 3 days of oral notification;

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



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

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

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

Inquiries and Complaints

An “Inquiry” is a general request for information regarding claims, benefits, or membership.

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

The Claim Administrator has a team available to assist you with Inquiries and Complaints. Issues may include, but are not limited to, the following:

Claims

Quality of care

When your Complaint relates to dissatisfaction with a claim denial (or partial denial), then you have the right to a claim review/appeal as described in the “Claim Appeal Procedures” on page 75.

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

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

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

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



Claim Appeal Procedures—Definitions

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

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

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

A “Final Internal Adverse Benefit Determination” means an Adverse Benefit Determination that has been upheld by the Claim Administrator or your Employer at the completion of the Claim Administrator’s or Employer’s internal review/appeal process.



Claim Appeal Procedures

If you have received an Adverse Benefit Determination, you may have your Claim reviewed on appeal. The Claim Administrator will review its decision in accordance with the following procedures. The following review procedures will also be used for Claim Administrator’s (i) coverage determinations that are related to non-urgent care that you have not yet received if approval by your plan is a condition of your opportunity to maximize your benefits and (ii) coverage determinations that are related to care that you are receiving at the same time as the determination. Claim reviews are commonly referred to as “appeals.” Within 180 days after you receive notice of an Adverse Benefit Determination, you may call or write to the Claim Administrator to request a claim review. The Claim Administrator will need to know the reasons why you do not agree with the Adverse Benefit Determination. You may call 1-877-284-9302 or send your request to:

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

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

The Claim Administrator will provide you or your authorized representative with any new or additional evidence or rationale and any other information and documents used in the denial or the review of your Claim without regard to whether such information was considered in the initial determination. No deference will be given to the initial Adverse Benefit Determination. Such new or additional evidence or rationale and information will be provided to you or your authorized representative sufficiently in advance of the date a final decision on appeal is made in order to give you a chance to respond. The appeal will be conducted by individuals associated with the Claim Administrator and/or by external advisors, but who were not involved in making the initial denial of your Claim. Before you or your authorized representative may bring any action to recover benefits the claimant much exhaust the appeal process and must raise all issues with respect to a claim and must file an appeal or appeals and the appeals must be finally decided by the Claim Administrator or your Employer.



Urgent Care/Expedited Clinical Appeals

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

Other Appeals

Upon receipt of a non-urgent pre-service or post-service appeal the Claim Administrator shall render a determination of the appeal within 30 days after the appeal has been received by the Claim Administrator or such other time as required or permitted by law.

If You Need Assistance

If you have any questions about the Claims procedures or the review procedure, write or call the Claim Administrator Headquarters at 1-800-538-8833. The Claim Administrator offices are open from 8:45 A.M. to 4:45 P.M., Monday through Friday.

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

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

Notice of Appeal Determination

The Claim Administrator will notify the party filing the appeal, you, and, if a clinical appeal, any health care provider who recommended the services involved in the appeal, orally of its determination followed-up by a written notice of the determination.

The written notice will include:

1. The reasons for the determination;

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



3. Subject to privacy laws and other restrictions, if any, the identification of the Claim, date of service, health care provider, Claim amount (if applicable), and information about how to obtain diagnosis, treatment and denial codes with their meanings;

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

5. In certain situations, a statement in non-English language(s) that future notices of Claim denials and certain other benefit information may be available in such non-English language(s);

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

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

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

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

If the Claim Administrator’s or your Employer’s decision is to continue to deny or partially deny your Claim or you do not receive timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Your external review rights are described in the “Expedited External Review” on page 82.

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

Some of the operations of the Claim Administrator are regulated by the Illinois Department of Insurance. Filing an appeal does not prevent you from filing a Complaint with the Illinois Department of Insurance or keep the Illinois Department of Insurance from investigating a Complaint.

You must exercise the right to internal appeal as a precondition to taking any action against the Claim Administrator, either at law or in equity. If you have an adverse appeal determination, you may file civil action in a state or federal court.

Standard External Review

You or your authorized representative (as described above) may make a request for a standard external review or expedited external review of an Adverse Benefit Determination or Final Internal Adverse Benefit Determination by an independent review organization (IRO).



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

A “Final Internal Adverse Benefit Determination” means an Adverse Benefit Determination that has been upheld by the Claim Administrator at the completion of the Claim Administrator’s internal review/appeal process.

Request for external review. Within 4 months after the date of receipt of a notice of an Adverse Benefit Determination or Final Internal Adverse Benefit Determination from the Claim Administrator, you or your authorized representative must file your request for standard external review. If there is no corresponding date 4 months after the date of receipt of such a notice, then the request must be filed by the first day of the fifth month following the receipt of the notice. For example, if the date of receipt of the notice is October 30, because there is no February 30, the request must be filed by March 1. If the last filing date would fall on a Saturday, Sunday, or Federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday, or Federal holiday.

Preliminary review. Within 5 business days following the date of receipt of the external review request, the Claim Administrator must complete a preliminary review of the request to determine whether:

You are, or were, covered under the plan at the time the health care item or service was requested or, in the case of a retrospective review, was covered under the plan at the time the health care item or service was provided;

The Adverse Benefit Determination or the Final Adverse Benefit Determination does not relate to your failure to meet the requirements for eligibility under the terms of the plan (e.g., worker classification or similar determination);

You have exhausted the Claim Administrator’s internal appeal process unless you are not required to exhaust the internal appeals process under the interim final regulations. Please read the “Exhaustion” on page 83 for additional information and exhaustion of the internal appeal process; and

You or your authorized representative have provided all the information and forms required to process an external review.



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

Referral to Independent Review Organization. When an eligible request for external review is completed within the time period allowed, Claim Administrator will assign the matter to an independent review organization (IRO). The IRO assigned will be accredited by URAC or by similar nationally−recognized accrediting organization. Moreover, the Claim Administrator will take action against bias and to ensure independence. Accordingly, the Claim Administrator must contract within at least (3) IROs for assignments under the plan and rotate claims assignments among them (or incorporate other independent, unbiased methods for selection of IROs, such as random selection). In addition, the IRO may not be eligible for any financial incentives based on the likelihood that the IRO will support the denial of benefits.

The IRO must provide the following:

Utilization of legal experts where appropriate to make coverage determinations under the plan.

Timely notification to you or your authorized representative, in writing, of the request’s eligibility and acceptance for external review. This notice will include a statement that you may submit in writing to the assigned IRO within ten business days following the date of receipt of the notice additional information that the IRO must consider when conducting the external review. The IRO is not required to, but may, accept and consider additional information submitted after 10 business days.

Within 5 business days after the date of assignment of the IRO, the Claim Administrator must provide to the assigned IRO the documents and any information considered in making the Adverse Benefit Determination or Final Internal Adverse Benefit Determination. Failure by the Claim Administrator to timely provide the documents and information must not delay the conduct of the external review. If the Claim Administrator fails to timely provide the documents and information, the assigned IRO may terminate the external review and make a decision to reverse the Adverse Benefit Determination or Final Internal Adverse Benefit Determination. Within 1 business day after making the decision, the IRO must notify the Claim Administrator and you or your authorized representative.



Upon receipt of any information submitted by you or your authorized representative, the assigned IRO must within 1 business day forward the information to the Claim Administrator. Upon receipt of any such information, the Claim Administrator may reconsider its Adverse Benefit Determination or Final Internal Adverse Benefit Determination that is the subject of the external review. Reconsideration by the Claim Administrator must not delay the external review. The external review may be terminated as a result of the reconsideration only if the Claim Administrator decides, upon completion of its reconsideration, to reverse its Adverse Benefit Determination or Final Internal Adverse Benefit Determination and provide coverage or payment. Within 1 business day after making such a decision, the Claim Administrator must provide written notice of its decision to you and the assigned IRO. The assigned IRO must terminate the external review upon receipt of the notice from the Claim Administrator.

Review all of the information and documents timely received. In reaching a decision, the assigned IRO will review the claim de novo and not be bound by any decisions or conclusions reached during the Claim Administrator’s internal claims and appeals process applicable under paragraph (b) of the interim final regulations under section 2719 of the Public Health Service (PHS) Act. In addition to the documents and information provided, the assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, will consider the following in reaching a decision:

Your medical records;

The attending health care professional’s recommendation;

Reports from appropriate health care professionals and other documents submitted by the Claim Administrator, you, or your treating provider;

The terms of your plan to ensure that the IRO’s decision is not contrary to the terms of the plan, unless the terms are inconsistent with applicable law;

Appropriate practice guidelines, which must include applicable evidence−based standards and may include any other practice guidelines developed by the Federal government, national or professional medical societies, boards, and associations;

Any applicable clinical review criteria developed and used by the Claim Administrator, unless the criteria are inconsistent with the terms of the plan or with applicable law; and

The opinion of the IRO’s clinical reviewer or reviewers after considering information described in this notice to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.

Written notice of the final external review decision must be provided within 45 days after the IRO receives the request for the external review. The IRO must deliver the notice of final external review decision to the Claim Administrator and you or your authorized representative.



The notice of final external review decision will contain:

A general description of the reason for the request for external review, including information sufficient to identify the claim (including the date or dates of service, the health care provider, the claim amount (if applicable), the diagnosis code and its corresponding meaning, the treatment code and its corresponding meaning, and the reason for the previous denial);

The date the IRO received the assignment to conduct the external review and the date of the IRO decision;

References to the evidence or documentation, including the specific coverage provisions and evidence−based standards, considered in reaching its decision;

A discussion of the principal reason or reasons for its decision, including the rationale for its decision and any evidence−based standards that were relied on in making its decision;

A statement that the determination is binding except to the extent that other remedies may be available under State or Federal law to either the Claim Administrator and you or your authorized representative;

A statement that judicial review may be available to you or your authorized representative; and

Current contact information, including phone number, for any applicable office of health insurance consumer assistance or ombudsman established under PHS Act section 2793.

After a final external review decision, the IRO must maintain records of all claims and notices associated with the external review process for six years. An IRO must make such records available for examination by the Claim Administrator, State or Federal oversight agency upon request, except where such disclosure would violate State or Federal privacy laws, and you or your authorized representative.

Reversal of plan’s decision. Upon receipt of a notice of a final external review decision reversing the Adverse Benefit Determination or Final Internal Adverse Benefit Determination, the Claim Administrator immediately must provide coverage or payment (including immediately authorizing or immediately paying benefits) for the claim.



Expedited External Review

Request for expedited external review. Claim Administrator must allow you or your authorized representative to make a request for an expedited external review with the Claim Administrator at the time you receive:

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

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

Preliminary review. Immediately upon receipt of the request for expedited external review, the Claim Administrator must determine whether the request meets the reviewability requirements set forth in the “Standard External Review” on page 77. The Claim Administrator must immediately send you a notice of its eligibility determination that meets the requirements set forth in the “Standard External Review” on page 77..

Referral to independent review organization. Upon a determination that a request is eligible for external review following the preliminary review, the Claim Administrator will assign an IRO pursuant to the requirements set forth in the “Standard External Review” on page 77. The Claim Administrator must provide or transmit all necessary documents and information considered in making the Adverse Benefit Determination or Final Internal Adverse Benefit Determination to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method.

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

Notice of final external review decision. The Claim Administrator’s contract with the assigned IRO must require the IRO to provide notice of the final external review decision, in accordance with the requirements set forth in the “Standard External Review” on page 77, as expeditiously as your medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within 48 hours after the date of providing that notice, the assigned IRO must provide written confirmation of the decision to the Claim Administrator and you or your authorized representative.



Exhaustion

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

Inquiries and Complaints

For purposes of the Medical Benefit Program:

An “inquiry” is a general request for information regarding claims, benefits, or membership.

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

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

claims, and

quality of care.

When your complaint relates to dissatisfaction with a claim denial (or partial denial), then you have the right to a claim review/appeal as described in the “Claim Appeal Procedures” on page 75.

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

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

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



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

Addresses for Claim Appeals

Medical Benefit Program

An appeal, or any information regarding an appeal, for the PPO Basic, PPO Plus, CDHP 80 and CDHP 90 Benefit Options must be sent in writing to:

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

Dental Benefit Program

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

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

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

Prescription Benefits

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

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

Fax: 877-852-4070

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



Advance Approval

Advance approval, as described under the “Medical Review Program” on page 28, is required for all inpatient hospital stays, stays at a skilled nursing facility, home healthcare, in-home private duty nursing and transplants. As long as there is no urgent care required, the following rules will apply to advance approval:

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

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

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

Urgent Care

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

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

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

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



Administrative Information The “Administrative Information” section provides an overview of information regarding general Plan information and your legal rights under the Employee Retirement Income Security Act of 1974 (ERISA).

Plan Information Plan Name

The official name of the Plan is the Bosch Choice Retiree Welfare Benefit Plan.

The Retiree Medical Benefit Program, Retiree Life Insurance Benefit Program, Retiree Vision Benefit Program and Retiree Dental Benefit Program are welfare benefits provided under the Plan.

Plan Number

520

Plan Sponsor

Robert Bosch LLC 2800 South 25th Avenue Broadview, IL 60155 708-865-5200

Plan Administrator and Agent for Service of Legal Process

Retirement and Benefits Plans Committee Robert Bosch LLC 2800 South 25th Avenue Broadview, IL 60155 708-865-5200

Employer Identification Number

36-2903176

Plan Year

April 1 to March 31

Type of Plan

The Plan is a welfare benefits plan offering the following benefits: medical benefits, prescription drug benefits, life insurance, vision insurance and dental insurance.

Plan Funding

The Benefit Options under the Retiree Medical Benefit Program are self-funded by the Company, which means the Company pays the Benefit Programs’ benefits from its general assets and the benefits are not provided through insurance.



The Retiree Life Insurance Benefit Program, Retiree Vision Benefit Program and Retiree Dental Benefit Program are insured. That means the Company’s contributions and your contributions (if any) are used to pay insurance premiums to insurance companies, and the insurance companies pay the benefits under insurance policies or contracts.

Nothing in the Plan will be construed to require the Company to maintain any fund for its own contributions or segregate any amount which it is obligated to contribute for the benefit of any participant, and no participant or other person will have any claim against, right to, or security or other interest in, any fund, account or asset of the Company from which any payment under the Plan may be made.

Plan Administration

The Retirement and Benefits Plans Committee (Committee) is the Plan Administrator and has sole responsibility for the administration of the Plan. The Plan Administrator has full discretionary authority to:

interpret the Plan,

determine eligibility for and the amount of benefits,

determine the status and rights of participants, beneficiaries and other persons,

make rulings,

make regulations and prescribe procedures,

gather needed information,

prescribe forms,

exercise all of the power and authority contemplated by the Employee Retirement Income Security Act of 1974 (ERISA) and the Internal Revenue Code (Code) with respect to the Plan,

employ or appoint persons to help or advise in any administrative functions,

appoint trustees, and

generally do anything needed to operate, manage and administer the Plan.

The Plan has other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary responsibility among the Plan’s fiduciaries and may delegate responsibilities to others. Any allocation or delegation must be done in writing and kept with the records of the Plan.

For the insured benefits, the Plan Administrator has delegated its fiduciary duties with respect to claims processing and benefit determinations to the insurance companies. These delegates have the full extent of the Plan Administrator’s authority and duties with respect to those responsibilities delegated to them.



For the self-funded Benefit Programs, the Plan Administrator has designated third parties to provide administration services for these Programs under an administrative services contract. These third parties process claims and make initial and in some cases, final claims determinations. They do not insure any of your benefits will be paid. The Plan Administrator delegated its fiduciary duties with respect to initial and final claims determinations for the self-funded Benefits Programs to the Programs’ third party administrator(s). These delegates have the full extent of the Plan Administrator’s authority and duties with respect to those responsibilities delegated to them.

Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent requested by ERISA, no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of another Plan fiduciary, to the extent provided in ERISA Section 405(a).

Enrollment Information

For purposes of the HIPAA Privacy and Security Rules, determining the employee’s eligibility for the Plan or any Benefit Program offered under the Plan or enrolling employees in the Plan is an enrollment function performed by the Company. Employee and dependent eligibility and enrollment information is the Company’s information and not the Plan’s information while it is held and transmitted by the Company.

Construction

Words used in the masculine apply to the feminine where applicable. Wherever the context of this SPD dictates, the plural should be read as the singular, and the singular as the plural. Where any time period is given in days, the reference is to calendar days, unless otherwise specified.

Errors

An error cannot give a benefit to you if you are not actually entitled to the benefit.

Fraud and Abuse

Knowingly and willfully engaging in fraudulent behavior, including executing, or attempting to execute, a scheme to defraud the Plan, or to obtain by means of false or fraudulent pretenses, any of the money or property owned by or under the control of the Plan, by your or your covered dependent, may result in immediate termination from coverage under the Plan. Additionally, if you or your covered dependents knowingly and willfully falsify, conceal, or cover up any material fact, or make any materially false or fictitious, or fraudulent statements in connection with enrollment in the Plan, or the receipt of health care benefits under the Plan, coverage under the Plan may be terminated. The Plan Administrator has the right to seek full recovery of any losses from, and to pursue criminal and civil prosecution against any individuals committing fraudulent behavior.



Your Right to Benefits Statement of ERISA Rights

The Employee Retirement Income Security Act of 1974 (ERISA) spells out certain rights and duties for benefit plans. ERISA is a federal law that sets standards and defines procedures for employee benefit plans. As a participant in the Plan, ERISA entitles you to certain rights and protection. ERISA provides that all Plan participants are entitled to:

Receive Information about Your Plan and Benefits

Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, copies of the latest annual report (Form 5500 Series) and updated summary plan descriptions. The administrator may make a reasonable charge for the copies.

Receive a copy of the Plan’s summary annual report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

Continue Group Health Plan Coverage

You may be able to continue healthcare coverage for you, your spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. Your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan for the rules relating to your COBRA continuation coverage rights.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the associate benefit plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a pension or welfare benefit or for exercising your rights under ERISA.

Enforce Your Rights

If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial, all within certain time schedules.



Under ERISA, there are steps you can take to enforce your rights. For instance, if you request materials from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator.

If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or federal court, provided that you have first complied with the Plan’s claim and appeal procedures. In addition, if you disagree with the Plan’s decision or lack of a decision concerning the qualified status of a medical child support order, you may file suit in federal court.

If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Help With Your Questions

If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact:

the nearest Area Office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory, or

the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.

You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Non-assignment of Benefits Generally, benefits under the Plan may not be sold, transferred, pledged or assigned except as permitted by law. In certain situations, however, court orders may require benefits to be provided for a certain individual or individuals, typically an employee’s family member.

Amendment or Termination of the Plan The Plan Administrator reserves the right to amend, modify, suspend or terminate the Plan or any of the Benefit Programs provided under the Plan at any time and for any reason, by written action of the Committee.

Any amendment or modification requiring Committee action for adoption will be in writing and executed by the Committee. Any amendment may be made retroactively to the extent not prohibited by ERISA and the Code. Coverage upon Plan termination will be governed by the terms of each Benefit Program.



Affiliates and Subsidiaries Participating in the Plan United States affiliates and subsidiaries of Robert Bosch LLC may adopt the Plan, subject to Robert Bosch LLC’s consent (participating companies). References to the “Company” in this SPD shall include such participating companies, unless the context clearly indicates otherwise.

Any affiliate or subsidiary of Robert Bosch LLC that participates in the Plan cannot amend or terminate the Plan itself, but it may, acting through its Board of Directors or delegate, and subject to the consent of the Company, terminate its participation in the Plan or any of the Plan’s Benefit Programs.

Groups of Eligible Retirees Covered Under the Plan

Groups of eligible retirees include all U.S. non-union eligible retirees of the Company and affiliates and subsidiaries of the Company, excluding retirees from the following companies and divisions:

BSH Home Appliances

sia Abrasives Holding Inc., USA

Hagglunds Drives, Inc.

Rineer Hydraulics

Telex Communications

Bosch Rexroth Corporation (except grandfathered associates from the Wooster, Ohio and Buchanan, MI locations)

ViTel Net

Health Hero Network

Bosch Automotive Motor Systems Group Salaried Associates

Bosch Braking (except for Allied Signal Associates)

Vetronix

Buderus Hydronix

RTI Technologies

Any other affiliate or subsidiary that has not adopted the Plan



Contact Information For case management, advance approval, forms, claims, questions or provider directories, refer to the contact information below.

Benefit Program Claims Administrator and Toll-free Phone Number

Website

Medical

(including MSA Program/Advance Approval)

CDHP 80 Group Number: 014862

CDHP 90 Group Number: 014900

PPO Basic Group Number: 014669

PPO Plus Group Number: 014668

Indemnity Benefit Group Number: 014670 (for certain retirees only)

BlueCross BlueShield of Illinois

866-540-2130

www.bcbsil.com

Health Savings Account BenefitWallet

877-472-4200

www.HSAmember.com

Prescription Drug

Group Account Identification: JYCA

Express Scripts

866-962-9794

www.express-scripts.com

Life Insurance

Group Number: 105267

MetLife

800-858-6506

www.metlife.com

Dental


MetLife Dental

800-942-0854

www.metlife.com/dental

Vision


Vision Service Plan (VSP)

800-877-7195

www.vsp.com

Note

There may be periods when these systems are not available due to technical or maintenance requirements. Under no circumstances will the Company or the Bosch Benefits Center be liable for any loss caused by failure to implement associate instructions.



Benefit Program Claims Administrator and Toll-free Phone Number

Website

Bosch Benefits Center*

Automated Phone System

Inside the U.S. Call toll-free at 800-207-9012

Outside the U.S. Call toll-free at 857-362-5996

www.ibenefitcenter.com

Qualified Medical Child Support Orders (QMCSOs)

Contact Bosch HR Service at 855-922-5547 or the Bosch Benefits Center at 800-207-9012

* The Bosch Benefits Center can be accessed by phone or Internet.

Address information for various providers is located under “How to File Claims” on page 68 of this SPD.

Documents

Robert Bosch LLC - myhealth.mercerhrs.com Retirees April 2015 i Retiree Welfare Benefit Plan Robert Bosch LLC (the Company) ... This section provides an overview for participating