2017 Health & Welfare Plan Information and Employee ... · 2017 Annual Enrollment Guide Active...

2017 Annual Enrollment Guide Active Employee Version rev

2017 Health & Welfare Plan Information and Employee Contribution Amounts

Enroll online: www.benefits.sabic-ip.com

Or by phone: 1-877-SABIC-US (1-877-722-4287)

Annual Enrollment November 14 – November 29, 2016

Note: SABIC employees who will be transitioning with the Polymershapes business do not need to enroll in SABIC’s 2017 benefits. These employees will sign up for benefits later this year through the new owners.

http://www.benefits.sabic-ip.com/

2017 Annual Enrollment Guide Active Employee Version 2

Contents of This Guide

Welcome to 2017 Annual Enrollment .................................................................................................................. 3

What's Changing for 2017 ............................................................................................................................. 3

Making Changes During the Year ................................................................................................................. 6

Dependent Information .................................................................................................................................. 6

Medical Plan Options for 2017 ...................................................................................................................... 6

SABIC Plan for Health ................................................................................................................................... 7

SABIC Health Care Preferred ....................................................................................................................... 7

Factors to Consider……………………………………………………………………………………………….....7

Medical Plan Comparison Chart ................................................................................................................... 8

Wellness Incentives ………………………………………………………………………………………………. 12

Flexible Spending Accounts (FSAs) ........................................................................................................... 13

Enroll ........................................................................................................................................................... 14

Enroll Online or by Phone ........................................................................................................................... 14

Appendix ..................................................................................................................................................... 14

Medical Plan Options .................................................................................................................................. 14

2017 Health Care Contributions for Full-Time Employees ......................................................................... 17

SABIC Plan for Health Full- and Part-Time Employee Incentives .............................................................. 19

2017 SABIC Dental Plan Contributions ...................................................................................................... 19

2017 SABIC Vision Plan Contributions ....................................................................................................... 19

2017 Contributions for Part-Time Employees ............................................................................................. 20

2017 Medical Plan Rates for Part-Time Employees ................................................................................... 20

2017 Dental Rates for Part-Time Employees ............................................................................................. 20

2017 Vision Plan Rates for Part-Time Employees ...................................................................................... 20

Other Important Benefit Notes for Part-Time Employees ........................................................................... 21

Health Plan Administrator ........................................................................................................................... 21

HIPAA Privacy Notice ................................................................................................................................. 22

Summary of Material Modifications ............................................................................................................. 26

Required Notices ......................................................................................................................................... 38

The information provided herein is for discussion purposes only and does not in any way amend or modify the terms of any of the benefit plans or arrangements herein described. In the event of any conflict between the terms of a benefit plan or arrangement and the information provided in this document, the terms of the plan/arrangement shall control. SABIC reserves the right to amend, change or terminate benefits described in this document.

Your Annual Enrollment period is November 14 – November 29, 2016. There are some changes to our medical plans this year that you will want to review.

1. If you don’t make an active election for 2017 you will remain enrolled in your current medical plan (including any Health Savings Account (HSA) contributions you elected last year). Health Care and Dependent Care Flexible Spending Account elections will not default.

2. You should review all of your options to determine what plans best fit your life.


Welcome to 2017 Annual Enrollment

SABIC is committed to offering a comprehensive and affordable Health & Welfare Benefits Program to its employees. Annual Enrollment offers an opportunity to take advantage of this valuable coverage. The Annual Enrollment period is November 14 – November 29, 2016. Now is the time to review your current benefits coverage and determine what benefits will provide the best coverage for you and your family in the coming year. If you do not actively enroll, you will default to your current coverages. However, Flexible Spending Account (FSA) contributions will not default. If you want to make contributions to the Health Care and/or Dependent Care Flexible Spending Accounts for 2017, you must make an active election.

During Annual Enrollment, you may elect coverage under the following plans:

Medical/Prescription Drug

Health Savings Account (for SABIC Plan for Health)

Dental

Vision

Life Insurance*

Dependent Life Insurance*

Accidental Death and Dismemberment

Flexible Spending Accounts

Long-Term Disability**

Long-Term Care*

* These benefits require Medical Evidence of Insurability (MEOI), satisfactory to the applicable Insurance

Company. ** If elections require MEOI, you will be prompted during enrollment.

Contribution amounts are listed in the Appendix of this document. Keep in mind if your annual pay changes, your contributions may also change during the plan year.

What’s changing for 2017?

For more details on the changes or additional plan clarifications please review the Summary Material Modification section of this guide starting on page 26.

Medical Plans

Applies to Health Care Preferred, SABIC Plan for Health Option A and Option B

Telemedicine

A benefit is available for telemedicine through the health plan administrators. For Anthem participants the service is www.livehealthonline.com, for UHC, the service is available on the Health4Me App that is on the www.myuhc.com website. CDPHP participants should consider either the Anthem or UHC programs until CDPHP has developed their own telemedicine provider. For CDPHP, the participant will need to submit the claim to CDPHP.

If you are a participant in the Health Care Preferred Plan, there will be an $8 copay after the deductible. For participants in SABIC Plan for Health Option A or B the cost of the service is applied to the deductible.

The cost of a Telemedicine visit is approximately ½ the cost of a low level visit to your primary care physician.

If a participant uses a non-participating provider, the participant will need to bill their health plan.

Center of Excellence (COE)

Currently there is a COE benefit for Transplants that includes a $10,000 Travel and Lodging Benefit for eligible participants. Effective Plan Year 2017 additional programs for COE such as Bariatric Surgery, Cancer, Congenital Health Disease and Spine and Joint conditions has been added to the COE benefit. Participants will need prior authorization and may be required to be engaged in a Case Management program in order to receive the enhanced benefit.

Health Care Preferred participants will have $0 copay for inpatient services after the deductible is applied. SABIC Plan for Health Option A & B participants will have 100% coverage after the deductible is met.

Each health plan administrator will process the Travel & Lodging Benefit. Full details of the Travel and

http://www.livehealthonline.com/

http://www.myuhc.com/


Lodging Benefit will be available from the health plan. The Travel and Lodging Benefit will be for the employee and one other person. There are limits and restrictions in order to have the reimbursements paid.

Participants of the SABIC Medical Plans should consult with the health plan to verify if the COE program fits the medical condition, they have.

In and Out of Network Deductibles and Out of Pocket Amounts

Effective Plan Year 2017, deductibles and out of pocket amounts will no longer cross apply. This means deductible or out of pocket amounts applied to in network services will not cross apply to out of network deductible or out of pocket amounts. Any out of network deductible or out of pocket amounts will not apply to in network deductible or out of pocket amounts.

Spinal Manipulations

SABIC Medical Plan Options has a limit on spinal manipulations. The limit is 15 visits for the code of spinal manipulations for combined in and out of network services.

Transsexual Surgery

The exclusion for Transsexual Surgery will be removed effective January 1, 2017. Participants should verify with the health plan administrator prior to any services being rendered to review covered services and obtain any prior authorizations.

Applied Behavioral Analysis (ABA)

Services for Applied Behavioral Analysis will be provided for covered participants if criteria is met. Participants should verify with the administrator prior to any services being rendered to review covered services and obtain any prior authorizations. Participants enrolled in Health Care Preferred should check with Beacon Health Options and participants enrolled in SABIC Plan for Health Option A or Option B should check with their health plan administrator for additional information.

Wellness Program

Wellness Incentive

The annual wellness incentive each active employee who is enrolled in a SABIC Medical Plan Options can earn up to $150 for Plan Year 2017. The $150 would also be available to one enrolled dependent/spouse over the age of 18. For an employee enrolled in a family plan (2 or more enrollees) there is a maximum of $300.

The process to earn the incentive will be contingent on the completion of the Health Assessment at the ActiveHealth website (www.myactivehealth.com/sabic) during the calendar year of January 1 to December 31, 2017. If the Health Assessment is not completed, incentives will not be paid.

The process to earn a $75 incentive will be to complete and report the claim number and date of service for your Annual Physical on the ActiveHealth website (www.myactivehealth.com/sabic).

To earn the additional $75 a participant must complete one of the following options:

Digital coaching on MyActiveHealth.com/sabic – complete 100 heartbeats ($75)

Telephonic coaching – complete 3 calls with ActiveHealth for either Active Lifestyle Coaching or Condition Management ($75)

Note: Members are limited to earning a maximum of 25 heartbeats per week on the Digital Coaching Program.

For participants of the Health Care Preferred plan, up to a total of $150 will be received as a reduction to the employee’s health care payroll contribution.

For participants of the SABIC Plan for Health Option A or B, up to a total of $150 will be deposited in the employee’s Health Savings Account. The account must be open to allow the deposit of the incentive.

http://www.myactivehealth.com/sabic



All incentive actions for plan year 2017 must be completed by December 31, 2017. Incentives for Plan Year 2017 will be paid out no later than April 15, 2018.

ActiveHealth will report on a monthly basis to SABIC Benefits Team to record all completed actions.

Incentive / Reward Management Program

A program within the ActiveHealth website to allow employees and dependents over the age of 18 to track progress on challenges and incentive actions.

Life Style Coaching

A new program with ActiveHealth that allows employees to enroll in a Life Style Coaching Program. The participant can self-enroll or ActiveHealth will reach out to the participant. The employee does not have to be enrolled in a SABIC Medical Plan Option but does have to be eligible.

SABIC Plan for Health Option A and Option B

Health Savings Account (HSA)

The IRS determines the amount allowed each year that an individual could contribute to a Health Savings Account. For plan year 2017, the maximum annual amount that can be contributed to a Health Savings Account (HSA) is increased to $3,400 for an individual and unchanged at $6,750 for family. For employees over the age of 55 an additional $1000 per year can be contributed to your HSA.

Capital District Physician’s Health Plan (CDPHP)

CDPHP will be offered in the Capital District of NY (Albany NY area) as a health administrator for SABIC Plan for Health Option A or B. Employees can elect CDPHP as the administrator for Option A or B and use the same network of physicians and hospitals as the Health Care Preferred plan administered by CDPHP. CDPHP will use the BenefitWallet bank for the Health Savings Account (HSA). Employees will have the option of selecting Anthem or CDPHP to administer the SABIC Plan for Health Option A and B for the Albany, NY area during Annual Enrollment.

Pharmacy

For all refills and new prescriptions, for routine maintenance drugs effective January 1, 2017, the scripts will be available exclusively by mail order. Participants will be notified by mail in late fall 2016 if the current prescriptions they are taking will be affected by the new requirement.

Express-Scripts will work with the participant to obtain a new 90-day prescription from the prescribing doctor to receive the script from mail order.

After January 1, 2017 if the participants fills the script at retail, Express-Scripts will send notification to the participant that they are required to use mail order. Express-Scripts will allow the script to be filled 2 times at retail, for the 3rd refill that is not filled at mail order, Express-Scripts will deny the claim and the member will be charged the full cost of the drug. The amount the participant has to pay will not be charged to their deductible or out of pocket amounts. The full cost of the drug will continue to be applied as long as the script is filled at a retail location.

There is also a new link to review medication pricing prior to switching plans - www.express-scripts.com/SABIC

Eligibility Changes

Medical Coverage for Interns / Coops

Medical coverage for interns will be offered effective January 1, 2017. SABIC Plan for Health Option B will be the only medical plan offered to interns/coops. The coverage will be effective date of hire and the intern/coop will have 31 days to make an election. If the intern/coop does not make an election within 31 days of becoming eligible, they will have to wait for the next annual enrollment or until they experience a

http://www.express-scripts.com/SABIC

http://www.express-scripts.com/SABIC


qualified life status event (birth of child, other loss of coverage, etc.). No incentives will be available and Dental and Vision are not available to the intern/co-op.

Dental and Vision for Dependent Children

Eligibility for SABIC Dental and Vision Plans will be changed to allow coverage for valid dependents up to the end of the month they turn Age 26 regardless of student status. This will match the eligibility rules for SABIC Medical Plan Options.

Valid Dependents that meet the new criteria for coverage can be added to Dental and Vision for a January 1, 2017 effective date during Annual Enrollment.

Vision Plan

Basic Vision

A routine annual eye examination and a benefit for glasses/contacts has been added to the SABIC Basic Vision plan. There will be a $10 copay for the eye exam and an additional $10 copay for the glasses/contact annual benefit.

Making Changes During the Year You may add, delete or change coverage once each year during the Annual Enrollment period for an effective date of January 1. To make changes at any other time during the year you must have a qualified status change (marriage, birth of child, etc.) in order to change your coverage level. You have 63 days from the event date to make any changes. You will be required to provide necessary supporting documentation when making changes to your coverage (divorce papers, birth and marriage certificates, etc.) You can make these changes online at www.benefits.sabic-ip.com or by calling 1-877 SABIC US (1-877-722-4287).

Dependent Information

SABIC Married Employees If two SABIC employees want to be covered under one medical policy, the higher-paid employee must cover the lower-paid employee and any dependents. If you are married to another SABIC employee and you want to be covered under separate Medical Plan policies, then either employee may cover the dependent children.

Eligible Dependents Your eligible dependents include:

Your spouse:

For Medical, Dependent Life, Dental and Vision coverage

Up to age 26 (ending at the end of the month in which the dependent turned Age 26).

Appropriate documentation and social security number(s) of dependents will be required prior to enrollment.

Medical Plan Options for 2017 For 2017, SABIC employees may choose from three medical plans:

SABIC Plan for Health Option A

SABIC Plan for Health Option B

SABIC Health Care Preferred


SABIC Plan for Health

SABIC Plan for Health (SPFH) Options A and B combine a health plan with a health savings account (HSA) funded by you and SABIC with pre- and/or post-tax contributions. There is an opportunity to invest the funds through a bank associated with your health plan according to the investment options you choose. This means your money can grow year over year—allowing you to accumulate funds for future medical expenses. Medical plans with HSAs work differently than traditional medical plans. See the Appendix for important information about HSAs. You must actively enroll if you want to open a HSA—you can receive up to $650 (individual) and $1300 (family) incentive contributions to your HSA when you open an HSA with the bank affiliated with the SABIC Plan for Health administrator.

SABIC Health Care Preferred SABIC Health Care Preferred (SHCP) plan provides medical coverage through a network of providers. When you see your primary care physician and are referred to other providers within the SHCP network, care is covered at 100% after you satisfy a co-pay. Also, there is no deductible or co-pay for in-network preventive care services.

Factors to Consider To review your total health and pharmacy costs for the year to help you decide which SABIC Medical Plan Option best suits your needs – please visit the SABIC Benefits Website for the health plan you are enrolled in. Or, use of the following URLs to go directly to the correct medical plan administrator website.

www.anthem.com

www.cdphp.com

www.myuhc.com

www.express-scripts.com


Medical Plan Comparison Chart

Following is a comparison of SABIC medical plan options. You may also view a plan comparison on the SABIC Benefits Website at www.benefits.sabic-ip.com.

SABIC Health Care Preferred SABIC Plan for Health with HSA

PPO Consumer Directed

In-Network Out-of-Network In-Network Out-of-Network

Care must be

performed or

authorized by your

primary care

physician or

benefits

administrator, as

required

Benefits are paid

up to reasonable,

necessary and

customary

amounts

Benefits are paid

up to reasonable,

necessary and

customary

amounts

General Information

Medical Plan Annual Deductible

No carryover

deductible

Individual Annual Deductible on all services except preventive and

pharmacy is $300 Family (2 or more) Annual Deductible

on all services except preventive and pharmacy is

$600

Individual Out of Network Annual Deductible on all services $1,000.

Family (2 or more) Annual Deductible

on all services $2,000.

Option A

Deductible Individual: $1,300 2 or more: $2,600

Medical and Pharmacy combined

Out of Pocket

Individual: $4,350 Individual in a family plan - $6,850, total

family $7,900 2 or more considered

family and OOP Includes deductible

Option A

Deductible Individual: $2,700 2 or more: $4,800


Out of Pocket

Individual: $8,700 2 or more: $15,800 Includes deductible

Maximum Out-of-Pocket

Medical Annual Out- of- Pocket Individual

$3,700 Family $7,400 (Includes

Deductible and co-pays) Pharmacy

$2,250 per member up to $4,500 per

family

Includes Deductible

Annual Out-of-Pocket Individual $7,500 / Family

$15,000

Other Plan Option Offered

NO Yes, Option B

Option B Components

Does Not Apply Option B all components the same except Deductible and coinsurance






Differences for Option B

Does Not Apply Option B Deductible

Individual: $4,000 - $4,500

2 or more: $6,850 Medical and

Pharmacy combined. Coinsurance would

be at 100% after deductible met for an

individual.

Out of Pocket

Individual: $4,000 -$4,500

Individual in a family plan (2 or more):

$6,850. Total family OOP is $8,000 - $9,000. Once 1

individual in family has met deductible,

other family members pay 40% coinsurance until Total OOP is met.

Option B Deductible

Individual: $4,000 - $4,500

2 or more: $8,000 - $9,000


Out of Pocket

Individual: $11,000 2 or more $18,000 Includes deductible

Fee Schedule Contracted rates for network providers/facilities; Out-of-Network

providers/facilities reasonable and customary amounts apply

Contracted rates for network providers/facilities; Out-of-network

providers/facilities reasonable and customary amounts apply

Claims Filing Limit You must submit claims by June 30th for expenses incurred during previous calendar

year

You must submit claims by June 30th for expenses incurred during previous calendar

year

Secondary Coverage Payments

Maintenance of Benefits rules apply HSA rules drive maintenance of benefits

Contributions Higher per pay period contributions based on Wage Band and Family Size

Option A less than HCP – Option B is $0

Option A is according to Wage Band and Family Size Tier

Health Savings Account

Does Not Apply 2017 maximum Amounts permitted by IRS 1 person - $3400

2 or more persons - $6,750 55+ catch up - $1,000

Incentives for well and sick for initial enrollments to total no more than $650

individual and $1300 family

HSA-eligible expenses will only be applied against available HSA account balance if

employee elects to use account

Incentive amounts apply to over age 18





Health Savings Account Company Contribution Amount

Does Not Apply Automatic $500 Individual to open account, up to $650 with incentives—Individual

Automatic $1000 to open account, up to $1300 with incentives—Family

Existing HSA participants will also receive initial $500/$1000 contribution

Wellness Incentives and Initiatives

Payroll Contribution Reductions - $150 Employee / $150 dependent over the age of

18. See Wellness Incentive sheet for requirements.

Health Savings Account - Automatic $500 Individual to open account, up to $650 with

incentives—Individual Automatic $1000 to open account, up to

$1,300 with incentives—Family

Existing HSA participants will also receive initial $500/$1000 contribution

Flexible Spending Account (SPFH Limited Purpose Only)

Up to $2,550 annually to be used for Medical, Pharmacy, Vision, Dental and other OTC as allowed by IRS regulations; Medical Claims automatically fed to vendor for FSA

Limited FSA account up to $2,550 annually to be used for Vision, Dental and other OTC

as allowed by IRS regulations; Not to be used for medical or pharmacy co-pays,

coinsurance or deductibles

Lifetime Maximum N/A N/A

Cancer screenings 100% coverage,

no deductible

80% coverage,

after deductible

100% coverage,

no deductible

60% coverage,

no deductible

Centers of Excellence – For

organ transplants, you may be offered an opportunity to use a Center of Excellence – a nationally recognized medical institution known for quality care and experience in performing certain types of transplants. If you accept treatment at a recommended Center of Excellence, the plan covers eligible hospital expenses. It also covers reasonable expenses for lodging, transportation for the patient and one member of the patient’s immediate family, provided the travel is approved in advance by the benefits administrator

Approval by Benefits Administrator

required

100% Coverage, after deductible

T & L guidelines - $10,000 lifetime per covered individual or 12 months from the

surgery date

Not applicable Approval by Benefits Administrator

required

100% coverage, after deductible. T& L guidelines -

$10,000 lifetime per covered individual or 12 months from the

surgery date

Not covered; See hospital, physician

and surgery benefits

Chemotherapy and radiation therapy

100% coverage

after deductible

80% coverage,

after deductible

80% coverage

after deductible*

80% coverage,

after deductible





Spinal Manipulations – up to 15 visits in a

calendar year (network and out-of-network combined), when necessary to treat a medical condition

100% coverage,

after deductible with a $25 co-pay for

each office visit/treatment

session

80% coverage,

after deductible

80% coverage

after deductible*

60% coverage,

after deductible

Dental Plan Services

Not Covered; Carve Out Vendor METLIFE Not Covered; Carve Out Vendor METLIFE

Diagnostic imaging procedures – such

as X-rays and EKGs used to diagnose an illness or injury

100% coverage

after deductible

80% coverage,

after deductible

80% coverage

after deductible*

60% coverage

after deductible

Diagnostic laboratory procedures – such

as blood and urine tests used to diagnose an illness or injury

100% coverage

after deductible

80% coverage,

after deductible

80% coverage

after deductible*

60% coverage,

after deductible

Dialysis – services

provided for end-stage renal dialysis in your home or at a facility

100% coverage

after deductible

80% coverage,

after deductible Advance approval

is required by benefits

administrator or benefits will not be

paid

80% coverage

after deductible*

60% coverage,




paid

Extended care facilities –

semiprivate room and board, special services, prescription drugs and medical supplies in a facility that provides 24-hour skilled nursing care, for up to 120 continuous days, when the stay is for convalescent care that requires medical supervision and skilled nursing services and when ordered by a physician

100% coverage,

after deductible

80% coverage,



administrator; otherwise, benefits will be reduced by

half, up to a maximum of $1,000

80% coverage

after deductible*

60% coverage,

after your deductible Advance approval



paid





Home health care –

when services are performed by a home health care agency and the treatment program is approved in advance by the benefits administrator

100% coverage

after deductible

80% coverage,

after deductible

Advance approval is required by

benefits administrator or

benefits will not be paid

80% coverage

after deductible*

60% coverage,

after deductible

Advance approval is required by

benefits administrator or

benefits will not be paid.

*Option B once deductible is met for an individual plan pays 100% for network-level services. Plan B if total OOP is not met for entire family, after $6,850 paid for 1 individual, plan pays at 60%, member pays 40%.

Wellness Incentives Available

The annual wellness incentive each active employee who is enrolled in a SABIC Medical Plan Options can earn up to $150 for Plan Year 2017. The $150 would also be available to one enrolled dependent/spouse over the age of 18. For an employee enrolled in a family plan (2 or more enrollees) there is a maximum of $300 available.











Questions regarding this incentive should be directed to the SABIC Benefits Service Center at 1-877-722-4287. Employees can receive assistance on the process to earn the incentives and where to go to look to see if the payment has been made to the employee or to the Health Savings Account by calling the SABIC Benefits Service Center.




Flexible Spending Accounts (FSAs) Flexible Spending Accounts (FSAs) can help you reduce the amount of income tax you owe. If you participate in the Health Care and/or Dependent Care Flexible Spending Account(s), you can contribute a portion of your pay from each paycheck into the flexible spending account before taxes are taken out, which reduces your taxable income. You can then use the money in this account to pay for your out-of-pocket health care and/or dependent day care expenses as you incur them. (If you enroll in SABIC Plan for Health Option A or Option B, there will be an impact on how the FSA is used. Please see below for a description of the “Limited Purpose Health Care FSA” provided in combination with the SABIC Plan for Health.)

2017 Maximum Amount allowed per IRS for Health Care Flexible Spending Account is $2,550.

To see How Health Care FSAs help you save, log onto the SABIC Benefits Website at www.benefits.sabic-ip.com and access the estimating tool available while you enroll.

Limited Health Care Flexible Spending Account If you elect the SABIC Plan for Health Option A or B, there will be an impact on your Limited Purpose Health Care Flexible Spending Account (FSA). First and foremost, you can only use your FSA funds for dental and vision expenses. Here are some tips for using the HSA and FSA together:

Don’t put too much in your Limited Purpose Health Care FSA. Only contribute what you’re sure you will use. You may not need to contribute as much to your Limited Purpose Health Care FSA to cover all of your expected health care expenses, because you’ll have the SABIC Plan for Health HSA.

Use the FSA Calculator on www.benefits.sabic-ip.com to determine how much to contribute.

The Limited Purpose Health Care FSA can be used to pay health care expenses like dental, vision hardware and LASIK procedures.

How Dependent Day Care Flexible Spending Accounts Help You Save You can use your Dependent Day Care FSA to reimburse yourself for a number of different expenses, including:

Child care fees

Day care fees for a handicapped dependent

Day care fees for an elderly dependent

Note: Highly Compensated Employees (HCE) may have election reduced due to IRS Regulations. 2015 HCE are reduced to yearly maximum of $2,500.

Timing of Flexible Spending Account Eligible Expenses Claims for plan year 2017 are for services rendered from January 1, 2017 to December 31, 2017. For both accounts, you will have until June 30, 2017 to submit claims incurred by the FSA deadline for 2017. IMPORTANT FSA Information: If you want to participate in either the Health Care or Dependent Day Care FSA in 2017, you MUST enroll during Annual Enrollment—your 2016 elections will not carry over for 2017. You may contribute from $100 to $2,550 a year in the Health Care FSA. You can contribute from $100 to $5,000 in the Dependent Day Care FSA if you file a joint tax return or $2,500 if you and your spouse file separate returns. Special rules apply if your spouse is disabled or a full-time student or if the IRS considers you to be highly compensated. Please consult with your tax advisor to determine how these rules apply to your situation. For a review of the regulations as well as a list of allowable expenses, go to: http://www.irs.gov and look for information posted on 2016 / 2017 Flexible Spending Accounts.



http://www.irs.gov/


Enroll Enroll for your 2017 benefits at the Your SABIC Total Rewards Website (www.benefits.sabic-ip.com). If you don’t make an active election you will default to your current coverage (with some exceptions, see page 3 for details). When you log into the SABIC Benefits Website, you will be able to view all of your available benefits plans and can make changes.

Enroll Online or by Phone You may enroll via the Your SABIC Total Rewards Website at www.benefits.sabic-ip.com – your one-stop for all of your benefits needs. In addition to having all benefits information in one location, only one user ID and password is required. Once you are logged in you will have a personalized directory of all your benefits information, including Health and Insurance, Retirement, Your SABIC Total Rewards and more!

If you prefer, you may also enroll via the SABIC Benefits Service Center by calling 1-877-SABIC-US (1-877-722-4287).

If you are already registered or a current user of the www.benefits.sabic-ip.com Website - all you do is use your current User ID and password. If you have any issues with your user ID or password, please call the SABIC Benefits Service Center, 1-877-SABIC-US (1-877-722-4287).

Questions If you have any questions, you may contact the SABIC Benefits Service Center at 1-877-SABIC US (1-877-722-4287). Customer Service Representatives are available Monday through Friday, between 8 a.m. and 8 p.m. Eastern Time, except Federal holidays.

Appendix This section provides additional plan details, as well as a listing of the rates that determine your cost for coverage for each plan that requires contributions. When you log on to the Your SABIC Total Rewards Website (www.benefits.sabic-ip.com), you will find personalized contribution amounts that reflect factors specific to you such as your location (for some medical options), your income (for medical contributions), your age (for life insurance), your employment status (full-time vs. part-time), and your pay frequency. If you have any questions about your costs for coverage, please call the SABIC Benefits Service Center at 1-877-SABIC US (1-877-722-4287).

Medical Plan Options

SABIC Plan For Health When you enroll in the SABIC Plan for Health Option A or Option B:

SABIC contributes $500 (individual) or $1000 (2 or more coverage level) to an HSA. You can earn additional incentives when you take the Health Risk Questionnaire AND complete the required wellness actions ($150 employee/$150 spouse or dependent over age 18). You can receive from the company a maximum total contribution to your HSA of $650 (individual) or $1300 (2 or more coverage level). Account must be open and active to receive incentives.

The plan pays 100% of the cost of many in-network preventive care services, even before you’ve satisfied your deductible. You don’t pay for these services, so you save money.

You keep your unused HSA balance and it will roll over in your account. If you are using the investment options in your HSA, your balance can grow over time. If you don’t use all of your HSA dollars in 2016, the unused balance carries over to 2017 and you can use these funds in the future if you remain enrolled in this plan.

../../../../../../../AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/Windows/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/temp/Local%20Settings/Temporary%20Internet%20Files/Documents%20and%20Settings/amdoncas.HEWITT-NA/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Carol/Local%20Settings/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/OLK59/www.benefits.sabic-ip.com



HSA Basics As part of your enrollment in the SABIC Plan for Health (Option A or B), once you have opened your account, you will receive an HSA Welcome Kit that will include your HSA debit card and other important HSA documents. In order to receive your HSA incentive contributions from SABIC, you will need to open/activate your HSA. The incentive will be posted to your HSA if it is open by January 1, 2017 within 30 days of the 1st pay period in 2017. If you delay opening your account, it usually takes approximately 30-60 days for the initial incentive to be deposited.

Tax-Advantaged Savings Opportunity You earn interest on your HSA funds (those from the company as well as your own pre-tax contributions). You also have the opportunity to invest your funds as long as you maintain a minimum balance ($2,000 if your plan administrator is United Healthcare and $1,500 if your plan administrator is Anthem or CDPHP). Any investment and interest earnings in your account are federally tax-deferred. Depending on the state where you live, you may save on your state income tax as well.

You will receive an HSA debit card to pay your health providers or pharmacy directly for eligible expenses. Money you use from your HSA to pay for qualified medical expenses is federally tax-free. If you use money from your HSA for products or services related to anything other than qualified medical expenses before age 65, that money is taxable and subject to a tax penalty. For a complete list of the rules and requirements for HSAs go to www.irs.gov or check the links on the Your SABIC Total Rewards Website during annual enrollment (www.benefits.sabic-ip.com). You have access electronically to your account activity or if you elect paper, account information will be mailed to your home.

Who Pays for What in the SABIC Plan for Health (Option A and B)? Here’s how the SABIC Plan for Health (Option A and B) and the HSA work together:

1. Use Your Health Savings Account (HSA) to Pay for Eligible Expenses HSA dollars you spend on eligible medical, prescription drug and behavioral health services help satisfy SABIC Plan for Health’s annual deductible. Both in-network and out-of-network expenses are covered, but in-network services are provided at a discounted rate—so you save. You may also elect to contribute your own pre-tax dollars to the HSA. 2017 maximum amounts permitted by the IRS are $3,400 (individual) and $6,750 (2 or more coverage level). If you are age 55 or over, you may contribute an additional $1,000. Maximum amounts include your own and the company’s contributions. Your account balance can roll over to the next plan year.

2. Meet Your Annual Deductible The annual deductible amount varies depending upon whether you elect SABIC Plan for Health Option A or B, the coverage level you choose and whether you use in-network or out-of-network providers. You can pay expenses that count towards satisfying your deductible with your HSA.

3. Coinsurance Phase After meeting the individual (and/or family) deductible, the plan (company) pays 80%, you pay 20% for in-network services for Option A. For Option B if one individual in the family has met the deductible of $6,850, that one individual will have claims paid at 100% and remaining family members will have claims paid at 60% for in network service. The plan (company) pays 60% and you pay 40% for out-of-network services in both Option A and B. The balance is billed to you and you can use your HSA funds to pay this amount.

4. Out-of-Pocket Maximum Once the out-of-pocket maximum is met, SABIC pays 100%. This is the “safety net” that guards you against high or unexpected medical costs by limiting the amount you pay for medical services each year. For example, if you chose Individual coverage under SABIC Plan for Health Option A, and you paid a total of $4,350 on eligible in-network expenses, the company would begin paying 100% of your eligible expenses for the rest of the year. If you are enrolled in SABIC Plan for Health Option B, the individual Out of Pocket Maximum is $6,850 (includes deductible). If a family member has met the $6,850 all of their claims would be paid at 100% and remaining family members would pay 40% until total Out of Pocket amount of $8000 or $9000 was met. You can pay expenses that count towards satisfying your out-of-pocket with your HSA.

http://www.irs.gov/

http://www.benefits.sabic.us.com/


Saving for Retirement Health Care Expenses and Health Savings Accounts (HSAs)

If you are under age 65, you may enroll in SABIC Plan for Health Option A or B and open a Health Savings Account (HSA). The HSA provides an opportunity for pre-65 participants to not only save on taxes, but also build savings to pay for future Retiree Health Insurance expenses.

This note is to remind you that SABIC has capped its subsidy for pre- and post-65 Retiree Health Insurance at 2011 levels. This means that if Retiree Health Insurance costs increase in subsequent years, the company’s contribution level will remain at 2011 levels and any increases will be passed on to Retiree Health Insurance participants.

SABIC Plan for Health Drug Classifications Where Co-pay Applies—No Deductible

If you are not sure what drug classification you are taking, check with your pharmacy. These examples are

the drug classifications that are considered preventive. In most cases, generic drugs only are covered at low or no cost copay. Brand name drugs will be more expensive.

Prenatal, Geriatric and Pediatric vitamins

Weight-loss agents

Fluoride preparation

Disulfiram (alcoholism treatment)

Oral contraceptives

Intravaginal/Implantable Contraceptives

Diaphragms/Cervical Caps

Lipid-/cholesterol-lowering agents

Proton pump inhibitors – change to “Anti-Ulcer Medications”

Antihypertensives (high blood pressure)

Agents for osteoporosis

Erythroid and Myeloid stimulants (used to treat certain leukemia cases)

Antiplatelet drugs - Aggrenox, Plavix

Aromatase inhibitors (used to treat some breast and ovarian cancers)

Diabetic Agents

Vaccines

Anti-Malarial Drugs

SABIC Health Care Preferred

Advantages to the SABIC Health Care Preferred (SCHP) include:

Coordinated care through your primary care physician;

Low out-of-pocket costs for covered services;

Full coverage for preventive care; and

No claim forms to file in network.

You always have the option to go out-of-network for care, although you’ll have to pay a greater share of the cost and, in general, file claim forms if you do. Not all SHCP administrators require that you choose a primary care physician. The following chart shows how prescription drugs are paid for if you are enrolled in SABIC Health Care Preferred.


Retail Mail Order

Supply 30-Day 90-Day

Co-pay

Generic: $15

Preferred Brand: $30

Non-Preferred Brand: $50

Generic: $ 22

Preferred Brand: $ 65

Non-Preferred Brand: $125

Maximum Annual Out of Pocket

Individual: $2,250

Family: $4,500

Individual: $2,250

Family: $4,500

The chart above also applies to the copay for the list of preventive drugs for SABIC Plan for Health. According to the Affordable Care Act, effective January 1, 2013, Women’s Preventive Prescriptions are covered at $0 copay if they are generic or no generic is available and the drug is a single source brand name. Routine maintenance drugs are offered exclusively at Mail Order.

2017 Health Care Contributions Full-Time Employees Your contributions for medical coverage, as well as for dental and vision coverage if you “buy up” from the Basic plans depend on the plan you choose and the coverage category you select. The coverage categories available to you are shown below:

Coverage Categories Examples

One-Person Employee

Two-Person Employee plus spouse Employee + 1 child

Three or More Employee plus spouse + 1 or more children Employee plus 2 or more children

In addition, your contributions depend on your pay and your access to other coverage through a working spouse. On the following pages, the weekly contribution rates for each of the medical plan options are shown. If you log onto the SABIC Benefits Website (www.benefits.sabic-ip.com), you will find only the specific rates for the options you are eligible to choose. Keep in mind if your annual pay changes, your contributions may also change during the plan year.

The medical plan contribution rates shown in the following charts are the starting point for calculating your contributions. Amount of deduction may not match paycheck deduction due to rounding.

2017 SABIC Health Care Preferred Contribution Rates

Your weekly payroll deductions are:

Annual Pay One-Person Coverage Two-Person Coverage Three or More Coverage

Up to $24,999 $26.43 $58.53 $75.72

$25,000–$37,499 $26.43 $58.53 $75.72

$37,500–$49,999 $32.93 $71.44 $94.07

$50,000–$74,999 $37.62 $80.07 $108.26

$75,000–$99,999 $42.65 $89.69 $124.64

$100,000–$149,999 $51.87 $107.96 $154.79

$150,000 or more $67.47 $138.92 $209.03

../../../../../../../AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/Windows/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/temp/Local%20Settings/Temporary%20Internet%20Files/Documents%20and%20Settings/amdoncas.HEWITT-NA/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Carol/Local%20Settings/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/OLK59/www.benefits.sabic-ip.com


2017 SABIC Plan for Health Contribution Rates

Option A



Up to $24,999 $15.69 $31.36 $47.02

$25,000–$37,499 $15.69 $31.36 $47.05

$37,500–$49,999 $15.69 $31.36 $47.05

$50,000–$74,999 $15.69 $31.36 $47.05

$75,000–$99,999 $20.63 $41.27 $61.90

$100,000–$149,999 $20.63 $41.27 $61.90

$150,000 or more $20.63 $41.27 $61.90

Option B



Up to $24,999 $0 $0 $0

$25,000–$37,499 $0 $0 $0

$37,500–$49,999 $0 $0 $0

$50,000–$74,999 $0 $0 $0

$75,000–$99,999 $0 $0 $0

$100,000–$149,999 $0 $0 $0

$150,000 or more $0 $0 $0

Spousal Surcharge If you enroll for dependent coverage through the company and your working spouse or same-sex domestic partner does not enroll in medical coverage offered by his or her employer (i.e., an employer other than the company), you’ll need to pay an additional contribution each week.

If Your Annual Pay Is… Your Additional Weekly Payroll Deduction Is…

Up to $24,999 $ 5.00

$25,000–$37,499 $15.00

$37,500–$49,999 $25.00

$50,000–$74,999 $35.00

$75,000–$99,999 $45.00

$100,000+ $55.00

You’ll be asked to certify periodically that your working spouse or same-sex domestic partner has coverage, they are a valid dependent and to provide information about that coverage, or to certify that his or her employer does not offer medical coverage, to avoid the additional payroll deduction. If you don’t respond, the additional payroll deduction is applied automatically. This surcharge will apply to SABIC Health Care Preferred and SABIC Plan for Health both Option A and Option B. If your spouse’s work status changes you must call the SABIC Benefits Service Center within 63 days to change the surcharge status.


SABIC Plan for Health for Full and Part-Time Employee Incentives When you elect the SABIC Plan for Health you will receive an incentive in your Health Savings Account for Plan Year 2017. This money will be deposited into your Health Savings Account within 30 days of the account being opened for 2017. This money is your money to use or save. The account must be active for the money to be deposited.

Coverage Category Employee Action Incentive Amount to be Deposited into Your HSA

Single (1) Enroll in SABIC Plan for Health $500

Family *(2 or more) Enroll in SABIC Plan for Health $1000

Single (1) Complete HRA & Other Wellness Actions $150

Family *(2 or more) Complete HRA & Other Wellness Actions $300

Total Single (1) Complete All Incentives Available $650

Total Family *(2 or more)

Complete All Incentives Available $1300

*2 or more applies to Adults only over the age of 18. In order to receive the maximum amount for Family Incentives – 2 Adult members must complete the requirement.

2017 SABIC Dental Options Following are the employee contributions for the Dental Plan option.

Dental Plan Options—Weekly Employee Contribution

Plan One-Person Two-Person Three Person

Basic Dental $1.90 $3.80 $5.70

Premium Dental $4.62 $9.24 $13.86

2017 SABIC Vision Plan Options Following are the employee contributions for the Vision Plan options.

Vision Plan Options—Weekly Employee Contribution

Plan One-person Two-person Three or More

Basic Vision $0.24 $0.47 $0.69

Premium Vision $2.35 $4.71 $7.07


2017 Contributions for Part-Time Employees The chart below shows the impact on your health care benefit costs:

Work Schedule (Weekly) Benefit Treatment

> 30 Hours Regular full time contributions

> 20 but < 30 Hours Employees moving from full-time to part-time: Increased contributions required for medical, dental and vision coverage. Spousal surcharge applies. New contribution rate effective the 1st pay period after your new schedule begins. New employees starting as part-time: Part-time employee contributions effective first day of employment

< 20 Hours Not eligible for medical/dental coverage (statutory benefits only)

The chart below shows contribution rates for employees working between 20 and 30 hours per week (and who are therefore eligible for benefits):

2017 Medical Plan Rates for Part-Time Employees

Your Plan Option

Weekly Contribution Based on Your Coverage Tier

One-Person Coverage

Two-Person Coverage

Three or More Coverage

SABIC Health Care Preferred $68.14 $136.24 $204.41

SABIC Plan for Health Option A $18.66 $37.32 $55.97

SABIC Plan for Health Option B $0 $0 $0

Working Spouse Surcharge also applies if applicable. See chart on page 18.

Incentives for Electing SABIC Plan for Health—Part-Time Employees (see chart on page 19).

2017 Dental Rates for Eligible Part-Time Employees

Part Time

Weekly Contributions, Based on Your Coverage Tier

One-Person Coverage Two-Person Coverage Three or More Coverage

Dental Basic $2.86 $5.70 $8.56

Dental Premium $6.93 $13.86 $20.79

2017 Vision Rates for Eligible Part-Time Employees

Your Plan Option

Weekly Contributions Based on Your Coverage Tier

One-Person Coverage Two-Person Coverage Three or More

Coverage

Vision Basic Option $0.24 $0.47 $0.69

Vision Premium Option $2.35 $4.71 $7.07


Other Important Benefit Notes for Part-Time Employees

A part-time employee can be covered as a dependent spouse of a full-time SABIC employee, as long as the higher-paid employee carries the dependent coverage.

Benefits such as Pension, Basic Life Insurance and Accidental Death and Dismemberment, and time off are automatically adjusted by your part-time schedule.

Under Life Insurance and Accidental Death and Dismemberment Insurance, the minimum coverage is not applicable if you work less than 32 hours per week.

Health Plan Administrator The following chart shows the medical plan administrator by the state in which you reside.

State Health Care Preferred SABIC Plan for Health

(Option A and B)

AL and WV United Healthcare (UHC) Anthem

AK, AZ, AR, CA, CO, CT, DE, DC, FL, GA, HI, ID, IA, KS,KY, LA,ME, MD, MN, MS, MO, MT, NE, NV, NH,

NJ, NM, ND, OK, OR, RI, SC, SD, TN, TX, UT, VT, VA, WA, WI, WY

UHC UHC

IL, IN, MA, MI, NC Anthem Anthem

NY Albany NY area - CDPHP NYC area - UHC All other NY - Anthem

Albany NY area – Anthem and CDPHP NYC area - UHC All other NY - Anthem

OH UHC WV Border - Washington, Athens, Meigs County OH - Anthem All other OHIO - UHC

PA UHC Anthem and UHC

Please visit the respective plan administrator websites for more information: www.myuhc.com (Choice Plus Network); www.anthem.com (National PPO Network) www.cdphp.com (Self Insured Network).


http://www.anthem.com/

http://www.cdphp.com/


HIPAA Privacy Notice—What Are My Rights Under the HIPAA Privacy Regulations?

Your right to privacy The Department of Health and Human Services issued comprehensive federal regulations effective April 14, 2003 that give individuals broad protections over the privacy of their personal health information. These regulations, issued under the Health Insurance Portability and Accountability Act (HIPAA), protect the confidentiality of your personal health information and allow you access to your medical records. These regulations apply to the SABIC health benefit plans described in this handbook, and those plans will be referred to collectively in this section as the “Plan.”

This section summarizes your rights under the HIPAA privacy regulations and acts as the Plan’s Notice of Privacy Practices.

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

This Notice of Privacy Practices describes the ways that the Plan may use and disclose plan participants’ protected health information to carry out treatment, payment and health care operations, and for other purposes that are permitted or required by law. It also sets out the Plan’s legal obligations concerning protected health information. Additionally, this Notice describes plan participants’ rights to access and control their protected health information. Please review the following information carefully.

Plan responsibilities The Plan is required by law to maintain the privacy of plan participants’ protected health information, and is also required to provide plan participants with a copy of this Notice. The Plan must abide by the terms of this Notice. The provisions of this Notice may be changed from time to time, and such changes may affect all protected health information maintained by the benefit plans. If the terms of this Notice are materially changed, a revised Notice will be provided to plan participants.

What is “Protected Health Information”? Protected health information is individually identifiable health information, including demographic information, collected from a plan participant or created or received by a health care provider, a health plan (including the Plan), or health care clearinghouse and that relates to the following information regarding the plan participant: 1) past, present or future physical or mental health or condition; 2) the provision of health care; or 3) the past, present or future payment for the provision of health care.

Primary uses and disclosures of protected health information The Plan has the right to use and disclose your protected health information for several different purposes. The examples below illustrate the types of uses and disclosures that may be made without written authorization by the plan participant.

Payment Protected health information may be used or disclosed to evaluate plan experience, to determine cost share, or otherwise fulfill responsibilities for coverage and providing benefits as established under your benefit plan. For example, protected health information may be disclosed when a provider requests information regarding eligibility for coverage or to determine if a treatment received was medically necessary.

Health care operations The Plan may use or disclose your protected health information to support our business functions. These functions include, but are not limited to: quality assessment and improvement, reviewing provider performance, licensing, and business planning and business development. For example, we may use such information: 1) to provide plan participants with information about disease management programs; 2) to respond to a customer service inquiry; 3) to review the quality of services being provided under the plans; or 4) to conduct audits or medical review of claims activity.


Treatment Although the Plan does not provide treatment, the Plan may disclose protected health information to health care providers for their treatment purposes. For example, the Plan may provide protected health information to health care providers in an emergency situation should the provider seek information about previous treatments received by a plan participant and be unable to contact previous health care providers.

Business associates The Plan contracts with individuals and entities (known as “business associates”) to perform various functions or to provide certain types of services. Some of the functions they provide are administering claims, utilization management or member service support. To perform these functions or to provide the services, business associates will receive, create, maintain, use or disclose protected health information, but only if the business associates agree in writing to contract terms designed to appropriately safeguard protected health information.

Plan sponsor The plans may disclose your protected health information to the Company, acting as plan sponsor, for purposes related to the operation of the health benefit plan, such as eligibility, enrollment, payment, audit and accounting functions. The Company is not permitted to use protected health information for any purpose other than administration of the Plan.

Enrolled dependents and family members In some cases, plan participants may receive mail or e-mail enrollment forms or other materials containing protected health information about themselves or their dependents.

Other Possible Uses and Disclosures of Protected Health Information The following is a description of other possible ways in which the Plan may (and is permitted to) use or disclose your protected health information.

Health oversight activities The Plan may disclose protected health information to a health oversight agency for activities authorized by law, such as: audits; investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities.

Required by law The Plan may use or disclose protected health information to the extent that federal, state or local law requires the use or disclosure. For example, the Plan is required to disclose protected health information to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining plan compliance with the HIPAA Privacy Regulations.

Public health activities The Plan may use or disclose protected health information for public health activities that are permitted or required by law. For example, information may be used or disclosed for the purpose of preventing or controlling disease, injury or disability.

Abuse or neglect The Plan may disclose protected health information to a government authority authorized by law to receive reports of abuse, neglect or domestic violence. Also, as required by law, the Plan may disclose protected health information to a governmental entity authorized to receive such information if the plans have reason to believe that a plan participant has been a victim of abuse, neglect or domestic violence.

Legal proceedings The Plan may disclose protected health information: 1) in the course of any judicial or administrative proceeding; 2) in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized); and 3) in response to a subpoena, a discovery request or other lawful process.

Law enforcement Under certain conditions, the Plan may disclose protected health information to law enforcement officials. Some of the reasons for such a disclosure may include: 1) it is required by law or some other legal process; 2) it is necessary to locate or identify a suspect, fugitive, material witness or missing person; and 3) it is necessary to provide evidence of a crime that occurred on our premises.


Coroners, medical examiners, funeral directors The Plan may disclose protected health information to a coroner or medical examiner for purposes of identifying a deceased person, determining a cause of death, or to perform other duties authorized by law. The Plan also may disclose, as authorized by law, information to funeral directors.

Organ Donation The Plan may disclose protected health information to an entity engaged in the process of organ, eye, or tissue donation or transplantation for the purpose of facilitating such donation and transplantation.

Research The Plan may disclose protected health information for research purposes, subject to legal restrictions.

To prevent a serious threat to health or safety Consistent with applicable federal and state laws, the Plan may disclose protected health information, in the event that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. The Plan may disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military activity and national security; protective services Under certain conditions, the Plan may disclose your protected health information if you are, or were, Armed Forces personnel for activities deemed necessary by appropriate military command authorities. The Plan also may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities.

Inmates With respect to inmates of a correctional institution, the Plan may disclose your protected health information to the correctional institution so it may provide health care to such inmates or to assure the health and safety of such inmates and the health and safety of others, including for the safety of the correctional institution.

Workers’ Compensation The Plan may disclose protected health information to comply with Workers’ Compensation laws and other similar programs that provide benefits for work-related injuries or illnesses.

Others involved in the participant’s health care Unless the plan participant objects, the Plan may disclose protected health information to a friend or family member that the plan participant has identified as being involved in his or her health care. The Plan also may disclose information to an entity assisting in a disaster relief effort so that family members can be notified about a plan participant’s condition, status and location. If the plan participant is not present or able to agree to these disclosures of his or her protected health information, then the Plan may, using its professional judgment, determine whether the disclosure is in the plan participant’s best interest.

Other uses and disclosures of your protected health information Other uses and disclosures of protected health information that are not described above will be made only with written authorization of the affected plan participant. Once an authorization has been provided, the plan participant may revoke the authorization in writing, and this revocation will be effective for future uses and disclosures of protected health information. However, the revocation will not be effective for information already used or disclosed in reliance on the authorization.

Plan participants’ rights The following is a description of plan participants’ rights with respect to your protected health information.

Right to inspect and copy Plan participants have the right to inspect and obtain a copy of their protected health information, with some limited exceptions. Such records will usually include enrollment, billing, claims payment, case or medical management records or records that are used to make decisions about health care benefits. To inspect and obtain a copy of protected health information that is contained in a designated record set, the plan participant must submit a request in writing. The Plan may charge a fee for the costs of copying, mailing or other supplies associated with such a request. The Plan may deny a request to inspect and copy protected health information in certain limited circumstances. If a plan participant is denied access to his or her information, the plan participant may request that the denial be reviewed.


Right to amend If a plan participant believes that his or her protected health information is incorrect or incomplete, he or she may request that we amend the information. The request must be in writing. Additionally, the request should include the reason the amendment is necessary. In certain cases, the Plan may deny a request for an amendment, including if it is not in writing or does not include a reason that supports the request. In addition, requests may be denied if the protected health information in question:

Is accurate and complete;

Was not created by the Plan;

Is not part of the protected health information kept by or for the Plan; or

Is not part of the protected health information which a plan participant would be permitted to inspect and copy.

If a request is denied, the plan participant has the right to file a statement of disagreement, though the Plan has the right to rebut that statement of disagreement.

Right to request a restriction Plan participants have the right to request a restriction on the protected health information used or disclosed for payment or health care operations. The plans are not required to agree to any restriction. Even if the Plan does agree to the restriction, the information may be used or disclosed if it is needed to provide emergency treatment. Requests for restriction must be in writing, and should contain: 1) the information to be limited; and 2) the desired method to limit use and/or disclosure of the information.

Right to request confidential communications If a plan participant believes that a disclosure of all or part of his or her protected health information may endanger him or her, the plan participant may reasonably request that the Plan communicates regarding the information in an alternative manner or at an alternative location. For example, a plan participant may request to be contacted only via his or her work address or work e-mail. Requests for restriction must be in writing and contain: 1) which protected health information to be communicated in an alternative manner or at an alternative location; and 2) a statement that the disclosure of all or part of this information in a manner inconsistent with the requested instructions would put the individual in danger.

Right to an accounting Plan participants have a right to an accounting of most disclosures of their protected health information that are for reasons other than payment or health care operations. An accounting will include the date(s) of the disclosure, to whom the disclosure was made, a brief description of the information disclosed and the purpose for the disclosure. Requests for an accounting must be in writing, and may be for disclosures made up to six years before the date of the request, but in no event for disclosures made before April 14, 2003. A first request within a 12-month period will be free. For additional requests, the plans may charge you for the costs of providing the request. The requestor will be notified of the cost involved, and the requestor may choose to withdraw or modify the request before any costs are incurred.

Right to a paper copy of this notice Plan participants have the right to a paper copy of this Notice, even if the individual has previously agreed to accept this Notice electronically. Send any requests to the address shown below.

What if I want more information or have a complaint about the handling of my protected health information? If you have any questions, or want additional information about these privacy policies and procedures, please contact the Privacy Leader at SABIC, 1 Plastics Avenue, Pittsfield, MA 01201. In addition, if you believe that the Company has violated your privacy rights, you may file a complaint by writing to the same address. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services. Complaints filed directly with the Secretary must:

1. Be in writing; 2. Contain the name of the entity against which the complaint is lodged; 3. Describe the relevant issue; and 4. Be filed within 180 days of the time you became or should have become aware of the problem.

The Company will not penalize or in any other way retaliate against you for filing a complaint with the Secretary or with SABIC.


Summary of Material Modifications (Updates performed to SABIC Benefits Handbook (Summary Plan Descriptions))

The following summary of material modifications (SMMs) updates the current SABIC Handbook (which serves as the Summary Plan Description for certain SABIC benefits plans) and should be kept with your previously issued benefits materials. Changes will be effective January 1, 2017, except where noted.

Medical Plans

Applies to Health Care Preferred, SABIC Plan for Health Option A and Option B

Telemedicine

A benefit is available for telemedicine through the health plan administrators. For Anthem participants the service is www.livehealthonline.com, for UHC, the service is available on the Health4Me App that is on the www.myuhc.com website. CDPHP participants should consider either the Anthem or UHC programs until CDPHP has developed their own telemedicine provider. For CDPHP, the participant will need to submit the claim to CDPHP.

If you are a participant in the Health Care Preferred Plan, there will be an $8 copay after the deductible. For participants in SABIC Plan for Health Option A or B the cost of the service is applied to the deductible.

The cost of a Telemedicine visit is approximately ½ the cost of a low level visit to your primary care physician.

If a participant uses a non-participating provider, the participant will need to bill their health plan.

Impacted Section: 3.6.4, 3.7.4

Center of Excellence (COE)

Currently there is a COE benefit for Transplants that includes a $10,000 Travel and Lodging Benefit for eligible participants. Effective Plan Year 2017 additional programs for COE such as Bariatric Surgery, Cancer, Congenital Health Disease and Spine and Joint conditions has been added to the COE benefit. Participants will need prior authorization and may be required to be engaged in a Case Management program in order to receive the enhanced benefit.

Health Care Preferred participants will have $0 copay for inpatient services after the deductible is applied. SABIC Plan for Health Option A & B participants will have 100% coverage after the deductible is met.

Each health plan administrator will process the Travel & Lodging Benefit. Full details of the Travel and Lodging Benefit will be available from the health plan. The Travel and Lodging Benefit will be for the employee and one other person. There are limits and restrictions in order to have the reimbursements paid.

Participants of the SABIC Medical Plans should consult with the health plan to verify if the COE program fits the medical condition, they have.


In and Out of Network Deductibles and Out of Pocket Amounts

Effective Plan Year 2017, deductibles and out of pocket amounts will no longer cross apply. This means deductible or out of pocket amounts applied to in network services will not cross apply to out of network deductible or out of pocket amounts. Any out of network deductible or out of pocket amounts will not apply to in network deductible or out of pocket amounts. Impacted Section: 3.6.3, 3.7.2

http://www.livehealthonline.com/



Spinal Manipulations

SABIC Medical Plan Options has a limit on spinal manipulations. The limit is 15 visits for the code of spinal manipulations for combined in and out of network services.

Impacted Section: 3.6.4, 3.7.4, 3.8

Transsexual Surgery

The exclusion for Transsexual Surgery will be removed effective January 1, 2017. Participants should verify with the health plan administrator prior to any services being rendered to review covered services and obtain any prior authorizations.

Impacted Section: 3.8

Applied Behavioral Analysis (ABA)

Services for Applied Behavioral Analysis will be provided for covered participants if criteria is met. Participants should verify with the administrator prior to any services being rendered to review covered services and obtain any prior authorizations. Participants enrolled in Health Care Preferred should check with Beacon Health Options and participants enrolled in SABIC Plan for Health Option A or Option B should check with their health plan administrator for additional information.

Impacted Section: 3.6.4

Wellness Program

Wellness Incentive

The annual wellness incentive each active employee who is enrolled in a SABIC Medical Plan Options can earn up to $150 for Plan Year 2017. The $150 would also be available to one enrolled dependent/spouse over the age of 18. For an employee enrolled in a family plan (2 or more enrollees) there is a maximum of $300.















Incentive / Reward Management Program

A program within the ActiveHealth website to allow employees and dependents over the age of 18 to track progress on challenges and incentive actions.


Life Style Coaching

A new program with ActiveHealth that allows employees to enroll in a Life Style Coaching Program. The participant can self-enroll or ActiveHealth will reach out to the participant. The employee does not have to be enrolled in a SABIC Medical Plan Option but does have to be eligible.


SABIC Plan for Health Option A and Option B

Health Savings Account (HSA)

The IRS determines the amount allowed each year that an individual could contribute to a Health Savings Account. For plan year 2017, the maximum annual amount that can be contributed to a Health Savings Account (HSA) is increased to $3,400 for an individual and unchanged at $6,750 for family. For employees over the age of 55 an additional $1000 per year can be contributed to your HSA.


Capital District Physician’s Health Plan (CDPHP)

CDPHP will be offered in the Capital District of NY (Albany NY area) as a health administrator for SABIC Plan for Health Option A or B. Employees can elect CDPHP as the administrator for Option A or B and use the same network of physicians and hospitals as the Health Care Preferred plan administered by CDPHP. CDPHP will use the BenefitWallet bank for the Health Savings Account (HSA). Employees will have the option of selecting Anthem or CDPHP to administer the SABIC Plan for Health Option A and B for the Albany, NY area during Annual Enrollment.

Impacted Section: Contacts

Pharmacy

For all refills and new prescriptions, for routine maintenance drugs effective January 1, 2017, the scripts will be available exclusively by mail order. Participants will be notified by mail in late fall 2016 if the current prescriptions they are taking will be affected by the new requirement.

Express-Scripts will work with the participant to obtain a new 90-day prescription from the prescribing doctor to receive the script from mail order.

After January 1, 2017 if the participants fills the script at retail, Express-Scripts will send notification to the participant that they are required to use mail order. Express-Scripts will allow the script to be filled 2 times at retail, for the 3rd refill that is not filled at mail order, Express-Scripts will deny the claim and the member will be charged the full cost of the drug. The amount the participant has to pay will not be charged to their deductible or out of pocket amounts. The full cost of the drug will continue to be applied as long as the script is filled at a retail location.

Impacted Section: 4.4.4, 4.4.8, 4.4.9


List of Prior Authorization and Covered Drugs for 2017

Prior Authorization Drug

(If the drug you take is on this list, Express Scripts will check to make sure it meets your plan’s conditions for coverage)

Brand Name Generic Name

Adcirca tadalafil

Adempas riociguat

Ampyra dalfampridine

Aralast™ NP, Glassia™, Prolastin, Prolastin-C,

Zemaira, alpha-1 proteinase inhibitor products

Aranesp darbepoetin alfa

Avonex interferon beta-1a

Betaseron, Extavia interferon beta-1b

Copaxone glatiramer acetate

Daliresp roflumilast

Egrifta tesamorelin

Epogen, Procrit epoetin alfa

Esbriet pirfenidone

Flolan epoprostenol

Genotropin, Humatrope, Norditropin, Nutropin,

Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-

Tropin, Zorbtive™ growth hormone products

Hetlioz tasimelteon

Hyalgan, Synvisc, Synvisc-One, Supartz, Orthovisc,

Monovisc®, Gel-One, Euflexxa hyaluronic acid derivatives

Increlex mecasermin

Lemtrada™ alemtuzumab

Letairis ambrisentan

Mircera methoxy polyethylene glycol-epoetin beta

Myalept™ metreleptin

Northera™ droxidopa

Ofev nintedanib

Opsumit® macitentan

Orenitram® treprostinil

Plegridy peginterferon beta-1a

Rebif interferon beta-1a

Remodulin treprostinil

Revatio sildenafil

Tracleer bosentan

Tysabri natalizumab

Tyvaso treprostinil

Uptravi Selexipag





Veletri epoprostenol

Ventavis iloprost

Xeomin incobotulinumtoxinA

Actemra tocilizumab

Cimzia certolizumab

Cinqair reslizumab

Cosentyx secukinumab

Enbrel etanercept

Entyvio™ vedolizumab

Forteo teriparatide

Granix® tbo-Filgrastim

Grastek, Oralair timothy/mixed grass pollen allergen extract

Humira adalimumab

Kineret anakinra

Lidoderm lidocaine

Lovaza, Vascepa™ omega- 3 fatty acids

Neulasta pegfilgrastim

Neupogen filgrastim

Nucala mepolizumab

Nuvigil armodafinil

Orencia abatacept

Otezla® apremilast

Provigil modafinil

Ragwitek short ragweed pollen allergen extract

Remicade infliximab

Rituxan rituximab





Simponi golimumab

Solaraze diclofenac 3% topical gel

Stelara ustekinumab

Taltz ixekizumab

Xolair omalizumab

Zarxio filgrastim, G-CSF

Actiq, Abstral, Fentora, Lazanda, Onsolis, Subsys™ fentanyl transmucosal drugs

Addyi™ flibanserin

Botox onabotulinumtoxinA

Caverject Impulse, Edex Injection, Muse Urethral Suppositories alprostadil products

Cialis tadalafil

Contrave® bupropion; naltrexone

Dysport abobotulinumtoxinA

Stendra™ avanafil

Byetta, Bydureon™, Trulicity, Victoza, Incretin

Mimetics GLP-1 agonists

Levitra, Staxyn™ vardenafil

Myobloc rimabotulinumtoxinB

Lumigan, Xalatan, Travatan/Z, Zioptan™, generics ophthalmic prostaglandin

Restasis cyclosporine

Symlin pramlintide

Tazorac® 0.05% and 0.1% cream, gel; Fabior 0.1% foam topical tazarotene products

Topamax topiramate

Trulicity™ dulaglutide

Zonegran zonisamide

Androderm, AndroGel, Axiron, Fortesta,Natesto,

Striant, Testim, First-Testosterone MC, First-Testosterone topical testosterone products

Retin-A, Retin-A Micro, Avita, Tretin•X, Atralin, generic

tretinoin products, Veltin™, Ziana topical tretinoin products

Viagra sildenafil

Adipex (phentermine], Bontril [phendimetrazine], Didrex [benzphetamine), Sanorex [mazindol], Suprenza [phentermine], Tenuate [diethylpropion], Xenical [orlistat], Belviq, Qsymia*

weight loss drugs





Aveed, Depo® - Testosterone [testosterone cypionate injection, generics], Delatestryl® [testosterone enanthate injection, generics], Testopel® [testosterone pellet] injectable testosterone products

Afinitor everolimus

Alecensa alectinib

Bosulif bosutinib

Caprelsa vandetanib

Cometriq™ cabozantinib

Cotellic cobimetinib

Erivedge™ vismodegib

Farydak panobinostat

Gilotrif afatinib

Gleevec imatinib

Ibrance palbociclib

Iclusig™ ponatinib

Imbruvica ibrutinib

Inlyta axitinib

Iressa gefitinib

Jakafi ruxolitinib

Lenvima™ lenvatinib

Lonsurf trifluridine; tipiracil

Lynparza olaparib

Mekinist™ trametinib

Nexavar sSorafenib

Ninlaro ixazomib

Odomzo sonidegib





Revlimid lenalidomide

Sprycel dasatinib

Stivarga regorafenib

Sutent sunitinib

Tafinlar dabrafenib

Tagrisso osimertinib

Tarceva erlotinib

Tasigna nilotinib

Temodar temozolomide

Thalomid thalidomide

Tykerb lapatinib

Votrient pazopanib

Xalkori crizotinib

Xtandi enzalutamide

Zelboraf vemurafenib

Zytiga abiraterone

Zykadia ceritinib




Afinitor (o) everolimus

Alecensa®(o) alectinib

Bosulif (o) bosutinib

Erbitux cetuximab

Gilotrif(o) afatinib


Gleevec(o) imatinib

Harvoni ledipasvir/sofosbuvir

Herceptin trastuzumab

Ibrance(o) palbociclib

Iclusig(o) ponatinib

Iressa®(o) gefitinib

Kadcyla ado-trastuzumab emtansine

Kalydeco™ ivacaftor

Lynparza(o) olaparib

Mekinist™(o) trametinib

Olysio™ simeprevir

PEG-Intron peginterferon alfa-2b

Pegasys peginterferon alfa-2a

Perjeta™ pertuzumab

Selzentry maraviroc

Sovaldi sofosbuvir

Sprycel(o) dasatinib

Stivarga(o) regorafenib

Tafinlar(o) dabrafenib

Tagrisso®(o) osimertinib

Tarceva(o) erlotinib

Tasigna(o) nilotinib

Tykerb(o) lapatinib

Vectibix panitumumab

Viekira dasabuvir; ombitasvir; paritaprevir; ritonavir

Xalkori crizotinib

Zelboraf(o) vemurafenib





Zepatier® elbasvir; grazoprevir

Zykadia®(o) ceritnib

Arcalyst rilonacept

Berinert C1 esterase inhibitor

Chenodal chenodiol

Cinryze C1 esterase inhibitor

Eylea aflibercept

Firazyr Icatibant

Ilaris canakinumab

Kalbitor ecallantide

Keveyis® dichlorphenamide

Korlym mifepristone

Krystexxa pegloticase

Kuvan sapropterin dihydrochloride

Lucentis ranibizumab

Macugen pegaptanib

Makena hydroxyprogesterone caproate

Nplate romiplostim

Promacta eltrombopag olamine

Ruconest® C1 esterase inhibitor, recombinant

Samsca tolvaptan

Xenazine tetrabenazine

Acthar Gel corticotropin

Boniva IV

Ibandronate

Reclast

bisphosphonates IV




Bivigam™

Carimune NF Nanofiltered

Flebogamma®

Hyqvia

Gammagard Liquid

Gammagard S/D

Octagam

Gamunex

Gamunex-C

Gammaked immune globulin intravenous

Gamunex-C

Hizentra

immune globulin subcutaneous

Vivaglobin

Gammaked immune globulin subcutaneous

Prolia denosumab

Somavert pegvisomant

Synagis palivizumab

Eligard

Lupron

Lupaneta leuprolide acetate,norethindrone acetate

Copegus, Rebetol, Ribasphere ribavirin

Impacted Section: 4

Eligibility Changes

Medical Coverage for Interns / Coops

Medical coverage for interns will be offered effective January 1, 2017. SABIC Plan for Health Option B will be the only medical plan offered to interns/coops. The coverage will be effective date of hire and the intern/coop will have 31 days to make an election. If the intern/coop does not make an election within 31 days of becoming eligible, they will have to wait for the next annual enrollment or until they experience a qualified life status event (birth of child, other loss of coverage, etc.). No incentives will be available and Dental and Vision are not available to the intern/coop.

Impacted Section: 2.1.3, 3.2, 3.5.2, 3.5.3, 3.5.4

Dental and Vision for Dependent Children

Eligibility for SABIC Dental and Vision Plans will be changed to allow coverage for valid dependents up to the end of the month they turn Age 26 regardless of student status. This will match the eligibility rules for SABIC Medical Plan Options.

Valid Dependents that meet the new criteria for coverage can be added to Dental and Vision for a January 1, 2017 effective date during Annual Enrollment.



Vision Plan

Basic Vision

A routine annual eye examination and a benefit for glasses/contacts has been added to the SABIC Basic Vision plan. There will be a $10 copay for the eye exam and an additional $10 copay for the glasses/contact annual benefit.



Required Notices

Adult Child Special Enrollment Notice Effective January 1, 2011, and as a result of the Patient Protection and Affordable Care Act, you may now cover your adult children in the SABIC Medical Plan up to end of the month in which they turn age 26.

An adult child includes your child who is married or unmarried, up to age 26, who is:

Your biological child;

Your legally adopted child; and

Your stepchild.

An adult child does not include children of an adult child or the adult child’s spouse.

Notice Lifetime Limit No Longer Applies and Enrollment Opportunity

The lifetime limit on the dollar value of benefits paid under the SABIC Medical Plan no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan if they are eligible employees or dependents.

Patient Protection Model Disclosure

SABIC Medical Plan generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from SABIC or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.

Women’s Health and Cancer Rights Act (WHCRA) As required by the Women’s Health and Cancer Rights Act (WHCRA) of 1998, SABIC Medical Options provides coverage for:

All stages of 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 physical complications of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient.

Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter. Contact your plan administrator as shown on the back of your medical ID card, for more information.


Health Care Reporting Requirements to the IRS for Plan Year 2016

The Affordable Care Act (ACA) requires employers to report to the IRS and to employees if health care coverage was offered to the employee during Plan Year 2016.

SABIC offers all employees that are scheduled to work at least 20 hours per week and are classified as full time or part-time employees, SABIC Plan for Health Option B. This plan meets the Minimum Essential Coverage and Affordability requirements according to the Affordable Care Act.

SABIC will comply with these regulations and employees who received pay and were eligible for health insurance coverage, at any time during calendar year 2016, will receive a form in the mail (see sample below) to be filed with their 2016 tax returns. Retirees and COBRA participants will also receive a form.

These forms will be mailed on or before January 31, 2017 to the employee’s address on file.

It is important that the employee has a correct address on file and that all eligible dependents social security numbers are on file. To verify or add a dependent’s social security number, please call the SABIC Benefits Service Center at 1-877-722-4287.

Sample

Individual Shared Responsibility Provision under the Affordable Care Act (ACA)

Starting in 2014, the individual shared responsibility provision calls for each individual to either have minimum essential coverage for each month, qualify for an exemption or make a payment when filing his or her federal income tax return.

The form above will satisfy the requirement to file with your 2016 taxes.

For additional information on the individual shared responsibility provision, see the IRS website for questions and answers. (http://www.irs.gov/Affordable-Care-Act).

http://www.irs.gov/Affordable-Care-Act


Non Discrimination Policy

As stated in the SABIC Code of Ethics Fair Employment Practices Policy, SABIC is committed to complying with all non-discrimination laws in the regions of the world where it conducts business. SABIC will treat all employees, regardless of their personal backgrounds or characteristics, with dignity and respect and provide fair treatment in the workplace. This Addendum is intended to supplement the SABIC Fair Employment Practices Policy with respect to the application of that Policy to SABIC’s operations in the Americas. Specifically, SABIC’s operations in the Americas will not discriminate in any aspect of employment, including hiring, compensation, promotion, discipline or dismissal, based on an individual’s race, color, religion, national origin, sex (including pregnancy), sexual orientation, gender identity, age, disability, veteran status, marital status, genetic information, or other category protected by law. This commitment includes a strict prohibition against workplace harassment based on any of the personal characteristics described above. If an employee believes that he/she has been subject to discriminatory treatment in violation of the principles established in this Addendum, the concern must be immediately reported to the Company through one of the available means described in the “Reporting Compliance Concerns” section of the Code of Ethics.

The information provided herein is for discussion purposes only and does not in any way amend or modify the terms of any of the benefit plans or arrangements herein described. In the event of any conflict between the terms of a benefit plan or arrangement and the information provided in this document, the terms of the plan/arrangement shall control. SABIC reserves the right to amend, change or terminate benefits described in this document.

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