2017 Retiree Plan Information and Contribution Amounts€¦ · This Guide pertains to Retirees,...

2017 Annual Enrollment Guide Retiree Version

2017 Retiree Plan Information and 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

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

2017 Annual Enrollment Guide Retiree Version 2

Contents of This Guide

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

Changes for 2017 .......................................................................................................................................... 3

Eligibility and Making Changes During the Year ........................................................................................... 5

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

Pre 65 Retiree Medical Plan Options for 2017.............................................................................................. 6

Medical Plan Comparison Chart for Pre 65 Retirees …………………………………………………………. 8

SABIC Health Care Preferred ..................................................................................................................... 12

SABIC Plan for Health ................................................................................................................................ 13

SABIC Pre-65 Retiree Dental and Vision Plans ……………………………………………………………..... 13

Post 65 Retiree Medical Benefits Plan ........................................................................................................ 14

Enroll ........................................................................................................................................................... 15

Enroll Online or by Phone ........................................................................................................................... 15

Appendix ..................................................................................................................................................... 15

Medical Plan Options .................................................................................................................................. 16

Health Plan Administrators……………………………………………………………………………………….. 19

2017 Health Care Contributions .................................................................................................................. 20

2017 SABIC Dental Plan Contributions ...................................................................................................... 23

2017 SABIC Vision Plan Contributions ....................................................................................................... 24

HIPAA Privacy Notice ................................................................................................................................. 26

Summary of Material Modifications ............................................................................................................. 30

Required Notices ......................................................................................................................................... 41

This Guide pertains to Retirees, Special Benefits Protected former employees and Eligible Survivors of an Active Employee.

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.

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


Welcome to 2017 Annual Enrollment

SABIC offers a comprehensive Health & Welfare Benefits Program to its retirees. 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.

During Annual Enrollment, you may elect coverage under the following Pre 65 plans:

Medical/Prescription Drug*

Dental**

Vision** * There is only one medical Plan for Post 65 Retirees. ** Applies to Pre 65 Retirees only.

Special Notice regarding Retiree Health Insurance Contribution Rates

This note is to remind you 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. This change applies to pre-65 and post-65 retirees, participants who qualify for Special Benefits and surviving dependents of active employees who were eligible for Retiree Health Insurance. The rates for 2017 reflect this cap. Contribution amounts are in the Appendix of this document.

Changes for 2017

For more details on the changes please review the Summary Material Modification section of this guide starting on page 30.

Pre – 65 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.

http://www.livehealthonline.com/

http://www.myuhc.com/


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.

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.

Pre – 65 Wellness Program

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 participant has to be enrolled in a SABIC Medical Plan Option.

Pre – 65 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.


Pre and Post 65 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.

Pre-65 Eligibility Changes

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.

Pre-65 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.

Eligibility and Making Changes During the Year

For Pre 65 Retirees - 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).

Post 65 Retiree – There is a one time opportunity to elect the SABIC Retiree Medical Benefits Plan (SRMBP) for the 1st of the month in which you turn age 65 or if you are covered by a group health plan at the age of 65, you may elect the Post 65 health plan once you lose the group health coverage. Proof of coverage will need to be provided to join the plan if you are over the age of 65. This does not apply if you were covered under SABIC Medical Plan Options for active employees prior to electing the Post 65 plan. To enroll in the Post 65 Retiree Medical Benefits Plan you contact the SABIC Benefits Service Center at 1-877-722-4287 (1-877-SABIC-US) within 60 days of the event or you lose your eligibility.

Special Notice regarding Medicare Coverage for Post 65

Medicare A & B is primary for Post 65 Retirees. Retirees must have Medicare A & B to participate in the SABIC Post 65 Retiree Medical Benefits Plan. Spouses of Pre 65 Retiree must have Medicare A & B if


they are eligible for the Medicare coverage. SABIC will be secondary for retirees and spouses of retirees who are enrolled in Medicare.

Special Notice regarding Survivor’s Coverage

If you are a Survivor of a SABIC active employee, and you remarry prior to age 65, you will lose your health care coverage eligibility effective the date you remarry. Survivors are responsible to notify the SABIC Benefits Service Center of the marriage date.

Special Notice regarding Retiree Health Insurance Contribution Rates

This note is to remind you 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. This change applies to pre-65 and post-65 retirees, participants who qualify for Special Benefits and surviving dependents of active employees who were eligible for Retiree Health Insurance. The rates for 2017 reflect this cap.

There is a very developed market for Post-65 Medical Coverage. We encourage you to closely examine all of your options for supplemental coverage for Medicare Part A & B. Be aware some supplemental plans do not cover pharmacy.

Dependent Information

SABIC Married Retirees Two SABIC retirees must be covered as individuals under the SABIC Medical Plan Options. If there are dependent children eligible for coverage, either retiree can cover the dependent children.

Eligible Dependents

In order to cover a dependent, the retiree has to also be covered by a SABIC Medical Option.

Your eligible dependents include:

Your spouse:

Children

For Medical, Dental and Vision Plan coverage

Up to age 26, the end of the month in which the dependent turns Age 26.

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

Pre 65 Retiree Medical Plan Options for 2017 For 2017, SABIC Pre 65 Retirees 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 with post-tax contributions. The funds in your HSA may be invested through a bank of your choosing. You can also choose to participate with the bank affiliated with the SABIC Plan for Health administrator. Anthem and CDPHP is affiliated with Benefit Wallet (www.mybenefitwallet.com ).

http://www.mybenefitwallet.com/


United HealthCare is affiliated with OptumHealth Bank (www.optumbank.com). Both banks allow you to connect from the health plan website to your HSA.

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 deductible and 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 (www.benefits.sabic-ip.com ) 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

http://www.optumbank.com/



Medical Plan Comparison Chart for Pre 65 Retirees

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

Individual in a family plan (2 or more):

$6,850.Medical and Pharmacy combined.

Individual OOP amount is the same as the deductible.

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 out of

pocket, 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 less than Option A.

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 - $3,400

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

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.

Approval by Benefits Administrator

required

100% Coverage, after deductible

Not applicable Approval by Benefits Administrator

required

100% coverage, after deductible.

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%.


2017 Pre 65 Health Care Preferred Plan Design

2017 Plan Design Deductible / Co-pay Amount for In Network Care

Deductible / Coinsurance Amount for Out of Network Care

Deductibles $300 Individual / $600 Family $1,000 Individual / $2,000 Family

PCP Visit $15 co-pay, after ded 80% Reasonable and Customary Amount after ded

Telemedicine Visit $8 co-pay, after ded 80% Reasonable and Customary Amount after ded

Mental Health / Substance Abuse Visit

$15 co-pay, after ded 80% Reasonable and Customary Amount after ded

OB/GYN Visit $25 co-pay, after ded 80% Reasonable and Customary Amount after ded

Chiropractic Visit $25 co –pay, after ded 80% Reasonable and Customary Amount after ded

Urgent Care Visit $30 co-pay, after ded 80% Reasonable and Customary Amount after ded

Specialist Visit $30 co-pay, after ded 80% Reasonable and Customary Amount after ded

ER Visit $100 co-pay, after ded 80% Reasonable and Customary Amount after ded

MRI, CT & PET Scan $100 co-pay, after ded 80% Reasonable and Customary Amount after ded

Outpatient Surgery $100 co-pay, after ded 80% Reasonable and Customary Amount after ded

Inpatient Hospital Visit $300 co-pay, after ded 80% Reasonable and Customary Amount after ded

Preventive Care $0 co-pay 80% Reasonable and Customary Amount after ded


2017 Pre 65 SABIC Plan for Health Option A & B

Option A Option B

In-Network

Deductible $1,300 indiv / $2,600 family $4,000 to $4,500 indiv

$6,850 for the family plan.

EE Coinsurance 20% 0% for individual, 40% for

family

OOP Max (includes deductible)

$4,350 indiv / $6,850 for an individual in a family plan. Total

out of pocket for the family is $7,900.

$4,000 to $4,500 indiv $6,850 for an individual in a

family plan. Total out of pocket for the family is $8,000 to

$9,000.

Preventive Care 100% covered, no ded 100% covered, no ded

Out-of-Network

Deductible $2,700 indiv / $4,800 family $4,000 to $4,500 indiv $8,000 to $9,000 family

EE Coinsurance 40% 40%

OOP Max (includes deductible) $8,700 indiv / $15,800 family $11,000 indiv / $18,000 family

Preventive Care 60% covered, no ded 60% covered, no ded

HSA Maximum Contribution

$3,400 indiv / $6,750 fam 55+ additional $1,000

$3,400 indiv / $6,750 fam 55+ additional $1,000

2017 SABIC Pre-65 Dental and Vision Dental and Vision Pre-65 Retiree plans are the same plans as the active employee plans.

Once a retiree or spouse turns age 65 (the first of the month in which they turn age 65), Dental and Vision ends. If the retiree turns age 65 first, the spouse will be offered COBRA at the COBRA rates for up to 36 months or when they turn age 65, whichever comes first. If the spouse turns age 65, the retiree continues in the plan until they turn age 65.

There is no continuation of dental or vision after age 65 for retirees.


2017 Post 65 Retiree Medical Benefits Plan at a Glance

Primary Care Physician charges — office visits 80%, after your deductible.

Specialist charges — office visits

Physical, occupational, speech, cardiac rehabilitation therapy; chiropractic care, obstetrical and gynecological care specialists

Other specialists

80%, after your deductible.

Physician charges — surgery 80% after your deductible.

Outpatient services — lab tests 80%, after your deductible.

Hospital stays 100%, after $300 co-pay for preferred facilities (maximum of 2 co-pays per family per year**); $400 co-pay for non-preferred facilities.

Hospital emergency care

100% coverage, after $100 co-pay.

Preventive care and health screenings Selected preventive care services and screenings are covered at 100% no deductible at participating provider.

SABIC Post 65 Retiree Medical Benefits Plan

Annual Deductible $450 individual

$ 900 family

Annual out-of-pocket limit $3,700 individual

$7,400 family

Annual prescription drug co-pay maximum $2,250 individual

$4,500 family

Lifetime maximum Unlimited

Medicare A & B is primary. Retirees must have Medicare A & B to participate in the SABIC Post 65 Retiree Medical Benefits Plan.

Contributions based on per participant covered and years of service for retiree. Out of network providers are covered at reasonable and customary rates. Preventive coverage is 80% out of network.


Retail Prescription drugs – up to 30 Day Supply

Affordable Care Act provisions apply

$15 —generic. $30 — brand.

$50 non preferred.

Mail Order Prescription drugs - up to 90 day Supply – Routine Maintenance Drugs exclusively offered at Mail Order - Affordable Care Act provisions apply

$22 — generic. $65 — brand. $125 - non preferred brand

Mental health treatment — outpatient 80% coverage, after your deductible.

Mental health treatment — inpatient 100% coverage, after $300 co-pay (maximum of 2 co-pays per family per year**).

** Combined for medical-surgical and mental health inpatient hospital stays.

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. 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 SABIC Benefits 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 last annual wage (for medical contributions) and your retiree status. 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).

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Medical Plan Options

SABIC Plan for Health – Pre 65 only

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. All bank fees are participant’s responsibility.

Tax-Advantaged Savings Opportunity You earn interest on your HSA funds. You also have the opportunity to invest your funds as long as you maintain a minimum balance ($2,000 if your plan administrator is UnitedHealthcare 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). Each month, you’ll receive a statement that shows all of your account activity.

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 post-tax dollars to the HSA. (Adjustments to your federal tax returns allow retirees to take advantage of the tax savings.) 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/ family) deductible, the plan (company) pays 80%, you pay 20% for in-network services for Option A. For Option B once the individual deductible has been met, the plan (company) pays 100% for in-network services for the person who has met their deductible. For the family members who have not paid a total of $6,850 out of pocket, the plan pays 60% and you pay 40% for in network out of pocket expenses. The balance is billed to you by the provider 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 in Option B and have individual coverage, once you have met $4,000 or $4,500 deductible, you have satisfied the total out of pocket amount and would have remaining claims for the year paid at 100%. If you are an individual in a family plan in Option B, have met the individual family deductible of $6,850, your claims would be paid at 100%. The remaining family members would need to satisfy the $8,000 or $9,000 total out of pocket amount. You can pay expenses that count towards satisfying your

http://www.irs.gov/

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


out-of-pocket with your HSA.

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.

Pharmacy Information for SABIC Plan for Health

For drugs that are not considered preventive, the full cost of the drug will be charged to your deductible. Once your deductible is met, in Option A, the company pays 80% of the cost until your out of pocket amount is met. In Option B, once the deductible is met for an individual or an individual in a family plan, and for a family when the out of pocket amount is met the company pays 100% of the charges. Routine maintenance drugs are offered exclusively at mail order.

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 for in network care.

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 Prescriptions for Access to Care 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.


Health Plan Administrator for Pre 65 Retirees

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) and www.cdphp.com (Self Insured network).

Post 65 Medical Plan Administrator Anthem is the carrier for all Post 65 Retirees regardless of what state you live in.

Pharmacy Express Scripts, Inc. (www.express-scripts.com) is the pharmacy administrator for all SABIC Retirees enrolled in a medical plan. You can verify what the co-pay or cost of the drug will be if you go to www.express-scripts.com and lookup the prescriptions you are currently taking.


http://www.anthem.com/

http://www.cdphp.com/

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

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


2017 Health Care Contributions Special Notice regarding Retiree Health Insurance Contribution Rates

This note is to remind you 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. This change applies to pre-65 and post-65 retirees, participants who qualify for Special Benefits and surviving dependents of active employees who were eligible for Retiree Health Insurance. The rates for 2017 reflect this cap.

Pre 65 Retirees This section lists 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 last active wage (for medical contributions), and your retiree status (years of service or special benefits protection). 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).

Coverage Categories Examples

One-Person Retiree or Surviving Spouse

Two-Person Retiree plus spouse or Retiree + 1 child

Three or More Retiree plus spouse + 1 or more children

Retiree plus 2 or more children

On the following pages, the monthly 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.

The medical plan contribution rates shown in the following charts are the starting point for calculating your contributions. Refer to your Employee Handbook to determine if you are Core, Delta, Special Benefits Protected or a Survivor. Numbers may not be exact due to rounding.

2017 SABIC Health Care Preferred Contribution Rates

For Retirees with 15+ years of Continuous Service at time of retirement (includes Disability Pensioner)

Your monthly contributions are:

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

Up to $24,999 $488.45 $993.95 $1461.32

$25,000–$37,499 $504.54 $1025.60 $1503.49

$37,500–$49,999 $523.36 $1062.98 $1556.57

$50,000–$74,999 $546.97 $1109.46 $1626.64

$75,000–$99,999 $574.27 $1163.75 $1711.63

$100,000–$149,999 $609.39 $1233.61 $1825.44

$150,000 or more $668.60 $1351.55 $2029.59

Core Retirees with 15+ years of Continuous Service at time of Retirement (includes Disability Pensioner)

../../../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

For Core Retirees 15+ years Continuous Service at time of Retirement (includes Disability Pensioner)



Up to $24,999 $416.25 $830.49 $1207.79

$25,000–$37,499 $424.77 $847.49 $1232.74

$37,500–$49,999 $433.72 $865.36 $1258.96

$50,000–$74,999 $445.94 $889.83 $1294.91

$75,000–$99,999 $460.24 $918.35 $1336.68

$100,000–$149,999 $479.59 $956.95 $1393.37

$150,000 or more $514.71 $1027.12 $1496.27

Option B

For Core Retirees 15+ years of Continuous Service at time of Retirement (includes Disability Pensioner)



All Wage Bands $276.57 $551.23 $795.46

Core Retirees 10-14 years of Continuous Service at time of Retirement


For Core Retirees with 10-14 years of Continuous Service at time of retirement


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

Monthly $618.18 $1236.48 $1832.96


Option A

For Core Retirees with 10-14 years of Continuous Service at time of Retirement



Monthly $523.19 $1044.16 $1525.01

Option B

For Core Retirees with 10-14 years of Continuous Service at time of Retirement



Monthly $400.68 $799.06 $1161.45


Core Special Benefits Protected former Employees with 25 years of Continuous Service at time of Layoff


Core Special Benefits Protected former Employees with 25 years of Continuous Service at time of Layoff



Monthly $721.16 $1442.45 $2163.70


Option A

Core Special Benefits Protected former Employees with 25 years Continuous Service at time of Layoff



Monthly $639.04 $1275.56 $1866.57

Option B

Core Special Benefits Protected former Employees with 25 years Continuous Service at time of Layoff



Monthly $500.28 $998.04 $1454.36

Core Survivors of Active Employee that has criteria for coverage


Core Survivor Rate



Monthly $618.18 $1236.48 $1832.96


Option A

Core Survivor Rate



Monthly $523.19 $1044.16 $1525.01

Option B

Core Survivor Rate



Monthly $400.68 $799.06 $1161.45


2017 Delta Pre-65 Retirees


Pre-65 Delta



Monthly $1089.55 $2179.22 $3268.81


Option A

Pre-65 Delta Rate



Monthly $962.13 $1920.86 $2818.00

Option B

Pre-65 Delta Rate



Monthly $774.72 $1546.05 $2260.12

2017 SABIC Core Retiree - Post 65 Medical Monthly Contribution Rates

2017 SABIC Dental Options for Pre 65 Retirees* Following are the Retiree contributions for the Dental Plan option.

Dental Plan Options—Monthly Contribution

Plan One-Person Two-Person Three Person

Core Basic Dental Retiree with 15+ years of continuous service at time of retirement $8.26 $16.52 $24.78

2013 SABIC -Core Post 65 Monthly Contribution Rates

One-Person Coverage Retiree Plus One

15+ years at time of retirement

$299.48 $570.27

10-14 years at time of retirement

$320.78 $609.71

25 + years at time of lay-off

$320.78 $609.71

Survivor Rate $320.78 $609.71


Core Basic Dental Retiree with 10-14 years of continuous service at time of retirement

$8.26 $16.52 $24.78

Core Basic Dental Special Benefits Protected Former EE with 25 years of service at time of Layoff

$11.74 $25.56 $35.43

Core Basic Dental Survivor Rate

$31.60 $63.25 $94.90

Delta Basic Dental 10+ Years of Service at age 60+ and Survivors

$31.60 $63.25 $94.90

Core Premium Dental Retiree with 15+ years of continuous service at time of retirement

$20.08 $40.17 $60.25

Core Premium Dental Retiree with 10-14 years of continuous service at time of retirement

$20.08 $40.17 $60.25

Core Premium Dental Special Benefits

Protected Former EE with 25 years of service at time

of Layoff $28.69 $57.43 $86.08

Core Premium Dental Survivor Rate

$48.12 $96.25 $146.94

Delta Premium Dental 10+ years of service at age 60+ and Survivors

$48.12 $96.25 $146.94

2017 SABIC Vision Plan Options for Pre 65 Retirees* Following are the retiree contributions for the Vision Plan options.

Vision Plan Options—Monthly Contribution

Plan One-person Two-person Three or More

Core Basic Vision

Retiree with 15+ years of continuous service at

time of retirement $1.04 $2.04 $3.00

Core Basic Vision

Retiree with 10-14 years of continuous service at


Core Basic Vision Special Benefits Protected Former EE with 25 years of service at time of Layoff

$2.09 $4.09 $6.17


Core Basic Vision Survivor Rate

$4.43 $8.78 $13.22

Delta Basic Vision $4.43 $8.78 $13.22

Core Premium Vision

Retiree with 15+ years of continuous service at


Core Premium Vision

Retiree with 10-14 years of continuous service at


Core Premium Vision Special Benefits

Protected Former EE with 25 years of service

at time of Layoff $10.74 $21.52 $32.34

Core Premium Vision Survivor Rate

$15.56 $31.13 $46.65

Delta Premium Vision Rate

$15.56 $31.13 $46.65

*Only the options you are eligible for will show on the SABIC Benefits Website www.sabic-ip.com 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 documents the terms of the plan/arrangement shall control. SABIC reserves the right to amend, change or terminate benefits described in this document.

http://www.sabic-ip.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.

Pre – 65 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.


Spinal Manipulations

http://www.livehealthonline.com/



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

Pre-65 Wellness Program

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.

Impacted Section: 3.2

Pre-65 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


Pre and Post 65 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


Pre 65 Eligibility Changes

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.

Impacted Section: 2.2.1,6.3.2

Pre 65 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. If your adult child’s coverage previously ended, or they were denied coverage or were not eligible for coverage because they aged out of the plan before age 26, you may enroll or reenroll them in the plan during this Annual Enrollment period as described in these materials.

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

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.

2017 Retiree Plan Information and Contribution Amounts€¦ · This Guide pertains to Retirees,...

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