Benefit Enrollment-2020USW REPRESENTED EMPLOYEES

TIME SENSITIVE MATERIAL ENCLOSED October 2019

What’s Inside... What’s New for 2020 1

How to Enroll /Dependent

Eligibility 3

Flexible Spending Account 4

Medical Coverage 5

Prescription Coverage 6

Dental Coverage 7

Vision Coverage 8

Health Reimbursement

Arrangement (HRA) 9

Flu Shots 10

CVS Extra Care Savings 11

Vendor Contact Information 12

Important Regulations/

Government Notices 13-24

Health Care Eligibility Change Form

25-26

Flexible Spending AccountForm

27

Married Couples Verification

Form 31-32

HAI Notice/Summary of

Benefits and Coverage 33-55

USW-Represented

October 2019

2019 Employee Benefits Guide

I/N Tek & I/N Kote is pleased to present your 2020 Employee Benefits Guide. During

Enrollment, you can enroll in or make changes to your benefit elections without

having a qualified life event (as described below). This guide explains the benefits

available to you. The benefit plan year will run from January 1, 2020 through

December 31, 2020.

If you want to enroll in any of the Flexible Spending Accounts (FSA’s) for 2020, you will need to complete the form on page 27.

I/N Tek & I/N Kote offers a comprehensive benefit package and employee

resources, demonstrating our commitment to you and your family’s overall health

and wellness. For the upcoming plan year, please make sure to carefully evaluate

your needs and learn about your benefit options prior to making your enrollment

decisions. At I/N Tek & I/N Kote, we continue to strive to provide the necessary

benefits to protect you and your family’s health, finances and future.

What's New for 2020? Health Care—you will now have the choice of two Healthcare plan offerings. See

page 5 for details.

Qualified Life Events The choices you make during Enrollment will be in effect for the 12-month plan year

from January 1, 2020 through December 31, 2020. However, you may make

changes during the year if you experience a qualified life event. A qualifying life event

is defined as:

• Termination or loss of coverage for yourself or eligible dependents

• Marriage

• Divorce or legal separation

• Death of an eligible dependent

• Birth or adoption of a dependent child

If you need to report a life event during the year, written notice of any change should

be sent to UMR (866) 268-3489 no later than 90 days after a qualified life event.

Reminder:This is also a great time to update your

life insurance beneficiary (ies)

To download a copy of the Beneficiary

Designation form visit the I/N Intranet =>Support =>Human Resources =>HR

forms

2020 USW Represented 1

IMPORTANT NOTICES:

FSA: If you wish to participate in a flexible spending account for

2020 you will need to fill out the FSA Election Form.

2019 FSA elections do NOT roll over.

Do I Need To Take Action?

Medical Complete form to make election for 2020.(See Health Care Eligibility Change Form on page 25)

Dental Complete form to make election for 2020.(See Health Care Eligibility Change Form on page 25)

Vision Complete form to make election for 2020.(See Health Care Eligibility Change Form on page 25)

FSA YES. If you wish to enroll in FSA for 2020 you MUST take actions. (See 2020 FSA Benefits Enrollment

Form on page 27)

Married Couples Only if you wish to be newly listed as a dependent spouse on your Active USW spouse’s plan. (See Married Couples Verification Form on page 31)

Life Insurance Complete form to make election for 2020 and complete the Beneficiary Designation form.*Life Insurance changes outside of a qualifying life event are subject to completing an Evidence of Insurability document.

Unlike the FSA, many of your elections at I/N Tek & I/N Kote will

roll over from year to year and do not require action. For a

breakdown of the elections that require action, please see the

chart below.

2020 USW Represented 2

How to Enroll If you would like to enroll in a 2020 Flexible Spending Account, you must do the following:

• Health Care Changes: Complete the Health Care Eligibility Change Form.

• Attach any required documentation and forward the completed and signed form to the email address or fax number

indicated on the respective form.

• Married Couples Verification: If both individuals are currently enrolled in this active plan, and one employee would like to be

listed as a dependent on their spouse’s plan, this form must be completed by both employees. Both employees must also

complete and submit the Health Care Eligibility Form to make this change.

• Flexible Spending Account : Complete the FSA Enrollment Form to elect enrollment in a Flexible Spending Account for 2020. I

If you would like to change your benefit coverage, add/remove eligible dependents during the year you must have a qualifyin life event.

Eligibility It is important to confirm the dependent information listed on your plan(s) is accurate and up-to-date. Any questions regarding

benefit options, plan rules, dependents or elections, contact the Human Resources at 574-654-1044.

Dependent Eligibility You may also enroll your eligible dependents in the I/N Tek & I/N Kote benefit plans when you enroll yourself. Your eligible

dependents include:

• Your spouse (the person to whom you are legally married).

• Your children under 26 years of age, including natural children (a blood descendant of the first degree), stepchildren, legally

adopted children (including children living with the adopting parents during the period of probation), or a child permanently

residing in your household of which you are the head and actually being supported solely by you and you have been

appointed the child’s legal guardian.

• Your children who are otherwise eligible dependents, who are mentally or physically disabled remain covered if they meet

the eligibility. To be eligible for coverage as an incapacitated dependent, the dependent must have been incapacitated prior

to age 19, meet federal guidelines for a covered dependent, and be covered under this plan prior to reaching age 26. You

must provide evidence of your child’s incapacity. Contact Highmark at 1--866-267-3280 regarding the disability evidence

process.

Spousal Premium Reimbursement Program The Spousal Premium Reimbursement Program states that if your non-Medicare eligible spouse works full-time (32 hours per

week or more) and is offered healthcare coverage by their employer, or is retired and is offered retiree healthcare coverage by

their former employer (other than I/N Tek & I/N Kote or its affiliates), they MUST enroll for coverage, even if there is a cost.

Healthcare coverage for spouses of active employees is defined as Employer-sponsored medical, dental, vision, and/or

prescription drug coverage. Premiums paid will be eligible for reimbursement by completing and submitting the

Reimbursement of Spouse Premium form. Every Employee with a spouse participating in the plan MUST complete the Spousal

Premium Reimbursement Program Status Inquiry Form. If you fail to complete and submit this form, your Spouse’s I/N Tek & I/N Kote coverage could be interrupted. Employees who waive I/N Tek & I/N Kote coverage will not be eligible for the Spousal

Premium Reimbursement Program.

Medical Opt-Out Reimbursement Employees who are eligible for benefits and choose to waive medical coverage will receive a waiver payment. If you elect to

waive coverage, you will receive an annual payment of $3,600, which will be prorated and paid to you on a pay period basis.

The reimbursement will be taxed as ordinary income and will be shown on your Form W-2. You will be required to show proof

of other coverage to UMR to be eligible for this payment. Please Note: If you and your spouse are both entitled to benefits

under this active plan, either of you may elect coverage as a dependent Spouse under the other’s plan. In the case of an

eligible Spouse who is entitled to coverage under a plan sponsored by I/N Tek & I/N Kote other than this plan, such Spouse

will not be eligible to enroll in this plan. Dependent spouses covered under this plan will not be eligible for a waiver payment.

If an employee eligible for this active plan is also a dependent Child of a participant under this active plan, such employee

may choose to enroll as a dependent Child under their parents plan, and not receive a waiver payment.

2020 USW Represented 3

Flexible Spending Account (FSA) Carrier: UMR Website: www.umr.com Phone: 1-800-826-9781

A Flexible Spending Account (FSA) is an easy, convenient way to get more out of your paycheck. It allows you to contribute a

predetermined amount of your pretax dollars to use toward eligible expenses. At I/N Tek & I/N Kote, we offer two types of

Flexible Spending Accounts: a Health Care Flexible Spending Account and a Dependent/Elder Day Care Flexible Spending

Account, both administered by UMR. To enroll, please complete the 2020 FSA Benefits Enrollment Form on page 27.

IRS rules allow you to contribute to your Flexible Spending Accounts through pretax payroll deductions. This means the money is

deposited in your account before any deductions for income tax, Social Security or state withholding taxes are taken from your

paycheck. If you don’t use the money you put into your FSA by the end of the year you lose it (except for up to $500 of health care

FSA money, which you can rollover to the next Plan year). This benefit is optional, and contributions are funded entirely by the

employee, not I/N Tek & I/N Kote.

Health Care FSA Health Care Flexible Spending Accounts reimburse you for eligible health care expenses that are not covered by your health

benefits plan, such as copayments, coinsurance, deductibles or certain vision, hearing or orthodontic care costs. You can submit

claims for yourself, your spouse and other covered dependents.

At the start of the plan year, you choose how much you want to set aside —subject to a $2,750 annual maximum. If you enroll in

Health Care FSA, when you incur a qualified expense, you can either submit a claim online or via fax or mail, along with

documentation of the claim, or use your debit card at the point of purchase. If you use your debit card it is important to keep your

receipts in case you are ever asked to show the transaction was for an eligible expense. Please note: When participating in the HRA

and the FSA together, it is important to note that the funds from the HRA must be exhausted before claims can be made to your

FSA account.

For more information, please refer to IRS Publication 502, entitled “Medical and Dental Expenses.”

Dependent/Elder Day Care FSA Dependent/Elder Day Care Reimbursement Accounts reimburse you for the costs of child care or other dependent care services so

that you and your spouse can go to work or school. This fund can be used for expenses associated with caring for your dependent

children, your spouse or another dependent who is incapable of self-care.

At the start of the plan year, you choose how much you want to set aside —$2,500 maximum if you are married and filing a

separate income tax return or $5,000 maximum if you are single or married filing a joint income tax return. If you enroll in a

Dependent Care FSA, when you incur a qualified expense, you can either submit a claim online or via fax or mail, along with the

documentation of the claim, or use your debit card at the point of purchase. If you use your debit card it is important that you keep

all receipts in case you are ever asked to show the transaction was for an eligible expense or if ever audited.

For more information, please refer to IRS Publication 503, entitled “Child and Dependent Care Credit.”

Institute for Career Development (ICD) Dependent Child Care Match Eligible Employees* may voluntarily designate any unused funds otherwise available through the ICD Tuition Reimbursement

Program to be matched to their personal contributions to a Dependent Care Flexible Spending Account up to $1,800.

Check with your local ICD Coordinator to confirm your

eligibility and complete the FSA Election Form indicating the

ICD Match. Matching contributions will be a dollar for dollar

match of your employee contributions, up to $1,800, and

not to exceed a total annual election of $5,000. Matching

contributions are only eligible for qualified dependent Child

Daycare.

*Columbus, Fleet, Obetz, Brickmason and Monessen excluded.

For more detailed FSA information, please refer to the

Summary Plan Description on the Benefits website at:

http://benefits.arcelormittalusa.com/?menu_key=800

$500 Rollover With the Health Care FSA, there is a $500 rollover feature. You can

rollover up to $500 of unused Health Care FSA balances remaining at

the end of the year to be carried over into the following year. The

$500 or less rollover amount will be in addition to whatever new

money you plan to put into your account through pre-tax payroll

deductions. You will still be able to elect up to the maximum amount

of $2,700 per calendar year. Any amounts remaining at the end of the

year over the $500 rollover will be forfeited.

Please note the Rollover does not apply to Dependent Care FSA.

You will not be allowed to reduce or stop your deposits to a Flexible

Spending Account during the year unless you have a qualified life

event. Once you enroll in the Flexible Spending Account during your Enrollment Period, you may continue to revise your election amounts

up until December 15, 2019. If you are planning on enrolling in an

FSA but are not sure of your election amount, enroll for a minimum

amount ($130 annual). You will have until December 15, 2019 to

refine your annual election amount.

ALWAYS SAVE YOUR RECEIPTS!

You may be required to provide

documentation.

2020 USW Represented 4

Medical CoverageCarrier: Highmark Website: www.highmarkbcbs.com Phone: 1-866-267-3280

I/N Tek & I/N Kote is committed to offering you benefit resources to meet the needs of you and your families healthcare.

For the 2020 plan year, I/N Tek & I/N Kote will provide you with the option of choosing between two different

healthcare plans, a Preferred Provider Organization plan (PPO) or a Consumer Driven Healthcare

Plan (CDHP), so that you may evaluate and select the plan that best meets your needs. Both medi-

cal plans are provided through Highmark Blue Cross and Blue Shield, and are not subject to em-

ployee paid premiums, however each plan is designed differently.

Both the PPO and the CDHP Plans give you the choice to receive care from both in-network and

out-of-network providers. However, you will maximize your coverage using providers within the

network and save on out-of-pocket costs. Both networks includes physicians, specialists, hospitals

and other healthcare providers. To find a network provider near you, or to see if your current pro-

vider participates in the network, you may visit www.highmarkbcbs.com or 1-866-267-3280.

Please see the information below to gain a better understanding of your options.

Please note: The PPO Plan is the same plan design as you were offered in 2019.

Features/

Services

Highmark BCBS

Based on Calendar Year

Member pays:

PPO Plan CDHP

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

Annual Deductible*:

- Individual

-Family$200

$400

$500

$1,000

$1,600

$3,200

$3,200

$6,400

Medical Out-of-Pocket

Maximum:

- Individual

- Family

$1,500

$3,000

$2,000

$4,000

$3,000*

$6,000* *Annual deductible is included

in MOOP total

$6,000*

$12,000* *Annual deductible is

included in MOOP total

Primary Care Doctor $20 after deductible 30% after deductible 20% after deductible 40% after deductible

Diagnostic Procedures

- Outpatient Lab Pathology

- MRI/MRA, CT/CTA Scan10% after deductible 30% after deductible 20% after deductible 40% after deductible

Overall Lifetime Maximum

(per person) Unlimited Unlimited Unlimited

Preventive Care

- Routine GYN Exam $0 30% after deductible $0 40% after deductible

Hospital Care Copay

-Inpatient Stay 10% after deductible 30% after deductible 20% after deductible 40% after deductible

Emergency Room Copay $50 (waived if admitted) 20% after deductible 20% after deductible

Urgent Care Facility $30 copay 20% after deductible 20% after deductible

Durable Medical Equipment 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Health Reimbursement

Arrangement (HRA)

Receive an employer contribution to an HRA by fulfilling the HAI

eligibility. Employer contribution in the amount of:

EE Only = $400,

EE + Children = $600

EE + Spouse OR EE + Family = $800

Auto-enrolled in HRA with CDHP enrollment.

EE Only Tier = $1,500

Other Tier = $2,500

Health Awareness

Initiative (HAI) If employees enrolled in the PPO plan fulfill HAI eligibility, the

incentive will be an employer contribution in a HRA (see above). Not HAI Eligible

2020 USW Represented 5

Prescription Drug Coverage Carrier: CVS/Caremark Website: www.caremark.com Phone: 1-800-925-5795

When you enroll in either Highmark medical plan, you

automatically receive prescription drug coverage through CVS

Caremark for the 2020 plan year. Please note that some

medications require prior authorization. You are also eligible

to receive free flu shots under your CVS Caremark benefit

plan.

A summary of the prescription benefits is provided in the chart below.

Prescription

Drug

Coverage

CVS Caremark

PPO CDHP

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

Retail

Up to 30 day supply

Generic: $10

Formulary Brand: $20

Non-Formulary Brand $60

Generic: 50%*

Formulary Brand: 50%*

Non-Formulary Brand: 50%* *of cost of drug

Generic: 20%

Formulary Brand: 20%

Non-Formulary Brand 20%

Generic: 50%*

Formulary Brand: 50%*

Non-Formulary Brand: 50%* *of cost of drug

Mail Order

31 to 90 day supply

Generic: $15

Formulary Brand: $30

Non-Formulary Brand $60

N/A

Generic: 20%

Formulary Brand: 20%

Non-Formulary Brand 20%

N/A

Specialty

-30 day supply or less

-31 to 90 day supplyFollow Retail copay structure

Follow Mail Order copay

structure

N/A Follow Retail copay structure

Follow Mail Order copay

structure

N/A

Mail Order Program The prescription plan includes a Mail Order program through

Caremark, which allows you to purchase a 90-day supply of

medications you take on an ongoing basis (known as maintenance

drugs). This program is mandatory for maintenance drugs; after

your first two fills of a maintenance medication at your local

pharmacy, you must use mail order. You can obtain a mail order

supply at a CVS pharmacy and pay the mail order copay. This

program provides you with savings and convenience while

minimizing trips to the pharmacy and reducing out-of-pocket costs

for prescriptions.

Keep You and Your Wallet Healthy with Generic Medications

Keep in mind that generic drugs are as safe and

effective as their brand-name counterparts, and

are significantly less expensive. If you are taking

several medications, the difference in cost for

generics and brand name drugs can be signifi-

cant.

Be sure that you are using the generic equiva-

lent rather then the brand name drug . If authori-

zation for a brand name drug with a generic

equivalent available is not obtained, the brand-

name drug will not be covered by the plan.

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Dental CoverageCarrier: United Concordia Website:

www.unitedconcordia.com

Phone: (1-866-267-3280 )

The calendar year maximum benefit for dental services is $2,250 per Member for Network providers and $1,750 per

Member for Out-of-Network providers. The dental plan gives you the option of going to any licensed provider you choose, but

if you go to a dentist who is In-Network, the plan benefits will be based on negotiated rates, thus you will save on dental

services. If you visit a dentist that is Out-of-Network, and the dentist charges more than the maximum allowed rate for a

particular dental service, you will have to pay the difference. To locate an In-Network Dentist near you, visit the website for

your provider listed above.

The Dental Plan Offers:

The freedom to see any provider— You can see any provid-

er, but receiving care from an in-network provider lowers

your out of pocket expenses.

Preventive care coverage— Preventive care is covered at

no cost to you.

An extensive network of providers— You have access to a

large national network of providers. In addition, your pro-

vider will submit the claims for you.

Feature/Service

Dental Network

Dental PPO

In-Network Out-of-Network

Annual Maximum Benefit/Person (not to exceed $2,250)

$2,250 $1,750

Member Pays:

Individual Calendar Year Deductible Excludes diagnostic and preventive services and orthodontia None $25

Family Calendar Year Annual Deductible Excludes diagnostic and preventive services and orthodontia None $50

Preventive and Diagnostic

Routine Oral Exam (2 per 12 month period)

Topical Fluoride, Bitewing X-Rays, Space Maintainers

$0

Basic Services 15%

Periodontal, Crown, Inlay and Onlay and Oral Surgery 15%

Orthodontia

Limited to children under age 19

Lifetime maximum of $2,500

40%

Prosthetics 50%

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Vision Coverage

Carrier: Davis Vision Website: www.davisvision.com Phone: 1-800-999-5431

Vision coverage is provided by Davis Vision for the 2020 plan year. Please refer to

the chart below for a summary of your vision benefits. The vision plan gives you the

option of going to any licensed provider you choose, but if you go to a provider who

is In-Network, the plan benefits will be based on negotiated rates, thus you will save

on vision services. To find an in-network provider visit the Davis Vision website at

www.davisvision.com.

Davis Vision

Feature/Service Under Age 19 Age 19 and Over

Frequency

Eye Exam Once every 12 months Once every 12 months

Spectacle Lenses Once every 12 months

Once every 24 months

(12 months if prescription changes)

Frames Once every 24 months Once every 24 months

Contact Lenses (in lieu of glasses) Once every 12 months

Once every 24 months

(12 months if prescription changes)

In-Network

Eye Exam $0

Spectacle Lenses $0

Frame—retail allowance $75

Contact Lenses (in lieu of glasses)

1 Pair Standard Daily Wear Lenses

Medically Necessary

Elective Allowance

$0

$0

$75*

Out-of-Network

Eye Exam Covered up to $50

Contact Lens Evaluation & Fitting

Daily Wear

Extended Wear

Covered up to $20

Covered up to $30

Spectacle Lenses

Single

Bifocal

Trifocal

Lenticular

Covered up to $50

Covered up to $55

Covered up to $60

Covered up to $65

Frames Covered up to $75

Contact Lenses

Non-Disposable

Disposables

Medically Necessary

Covered up to $60**

Covered up to $75

Covered up to $225

*Can be applied toward disposables or specialty contact lenses (including but not limited to extended wear, hard/soft bifocal, toric and gas permeable

lenses). ** Can be applied toward standard (hard/soft daily wear) or specialty contact lenses (including but not limited to extended wear, hard/soft bifocal,

toric and gas permeable lenses). Benefits include a low vision benefit, a discount contact lens mail order replacement program, and discounts on laser vision

correction surgery from select providers. 2020 USW Represented 8

Health Reimbursement Arrangement (HRA) Carrier: Highmark Website: www.highmarkbcbs.com Phone: 1-866-267-3280

What is a Health Reimbursement Arrangement (HRA)? A Health Reimbursement Arrangement (HRA) is an account completely

funded by I/N Tek & I/N Kote that reimburses employees for out-of-pocket

IRS eligible medical expenses. HRA funds are provided by I/N Tek & I/N Kote on a pre-tax basis therefore they are not taxable when used. Unlike a

cash payment, an HRA contribution is not subject to taxation and provides

additional savings to members.

How do I receive my HRA contribution? Under the PPO Plan: A participant is eligible for an HRA contribution, by

fulfilling HAI eligibility under the PPO plan. The employer contribution will be

provided in a lump sum annual contribution. For HAI eligibility, if you are

enrolled in a Employee + Spouse or Employee + Family tier, BOTH the

Employee and the Spouse must complete HAI eligibility to receive the HRA

contribution.

Under the CDHP Plan: Employees enrolled in the CDHP plan will

automatically receive an HRA contribution.

How do I contribute funds to my HRA? The HRA account is completely funded by I/N Tek & I/N Kote. No

employee contributions in the HRA are allowed under IRS

regulations.

What happens to my HRA balance at the end of the year? Under the PPO Plan: Active employees who have an HRA account with a balance at the end of the year can rollover $200 for

Employee Only or Employee + Children tiers and $400 for Employee + Spouse or Employee + Family tiers from year to year.

Under the CDHP Plan: Active employees can rollover funds from year to year if they remain in the CDHP plan.

Can I participate in an HRA if I am 65 and enrolled in Medicare? Yes, your participation in Medicare does not effect your eligibility to participate in the Health Reimbursement Arrangement

benefit.

What can I use my HRA funds for? HRA funds can be used to pay for IRS eligible expenses that are not covered by your insurance. Please refer to IRS

Publication 502 for a list of IRS approved medical expenses.

Can I participate in an HRA and FSA? You are eligible to participate in both the Health Reimbursement Arrangement (HRA) and the Medical Flexible Spending

Account (FSA) for the 2020 plan year. The HRA funds are contributions from I/N Tek & I/N Kote and the FSA funds are

employee contributions, both allow for IRS eligible medical expenses and require documentation (receipts) to substantiate

all claims. When participating in the HRA and the FSA together, it is important to note that the funds from the HRA must be

exhausted before claims can be made to your FSA account.

See the chart below for a Snapshot of how the HRA benefit will coordinate with other benefits:

Benefit: PPO Plan with Deductible CDHP Plan with Deductible and

Health Reimbursement Arrangement

Flexible Spending

Account (FSA)

Eligible to participate in both Health and

Dependent/Elder Day Care FSA.

If participate in both FSA and HRA, HRA funds must be ex-

hausted before FSA funds.

Eligible to participate in both Health and Dependent/Elder

Day Care FSA.

If participate in both FSA and HRA, HRA funds must be ex-

hausted before FSA funds.

FSA Rollover Health FSA allows for $500 rollover from year to year Health FSA allows for $500 rollover from year to year

Health

Reimbursement

Arrangement (HRA)

Receive an Employer Contribution in a HRA only

if HAI eligibility is met.

$400 EE Only

$600 EE + Children

$800 EE + Spouse or EE + Family

Auto enrolled in HRA if enrolled in the CDHP. Employer con-

tribution to the HRA: *Not eligible for HAI

$1,500 for EE Only Tier

$2,500 for Other Tier

HAI Rollover Active employees can rollover $200 for Employee Only and

Employee + Children tier or $400 for Employee + Spouse or

Employee + Family tier from year to year.

Active employees can rollover funds from year to year if they

remain in the CDHP plan.

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Contact Information

Benefit Provider Web Site or Email Address Phone Number

Medical Coverage www.highmarkbcbs.com 1-866-267-3280

Prescription Drug

Coverage www.caremark.com 1-800-925-5795

Dental www.unitedconcordia.com/dental

-insurance/1-866-267-3280

Dental (Minorca) www.deltadental.com 1-800-524-0149

Vision Coverage www.davisvision.com 1-800-999-5431

Health

Reimbursement

Arrangement www.highmarkbcbs.com 1-866-267-3280

Flexible Spending

Accounts

Email:

UMR-FlexEligibility@umr.com 1-877-310-3539

Long Term Disability www.reedgroup.com 1-844-507-5388

Open Enrollment/

Eligibility Questions

ArcelorMittal Open Enrollment

Hotline at UMR

Email:

ammail@umr.com 1-866-268-3489

Do you have a question about your coverage? Contact the appropriate vendor directly for questions regarding benefits,

claims process, choosing a doctor, ID cards and

copayments and deductibles.

2020 USW Represented 12

Ref: REALL-2020

Important Notice from I/N Tek & I/N Kote AboutYour Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. The Medicare Modernization

Act requires I/N Tek & I/N Kote to provide this notice to you and your dependents who areMedicare eligible or will become Medicare eligible within the next twelve months. (You may disregard this notice if you and/or your dependents will not be eligible for Medicare within the next year.)

This notice contains information about your current prescription drug coverage with I/N Tek & I/N Kote and prescription drug coverage available for people with Medicare. This information canhelp you

decide whether or not you want to enroll in a Medicare drug plan. If you are considering enrolling, you should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage may be found at the end of this notice. There are two important things you need to know about your current coverage and Medicare prescription drug coverage:

�Medicare prescription drug coverage became available in 2006 to everyone with Medicarethrough Medicare prescription drug plans and Medicare Advantage Plans (like an HMO orPPO) that offer prescription drug coverage. All Medicare prescription drug plans provide atleast a standard level of coverage set by Medicare. Some plans may also offer more coveragefor a higher monthly premium.

�It has been determined that the prescription drug coverage offered by I/N Tek & I/N Koteis, on average for all plan participants, expected to pay out at least as much as the standardMedicare prescription drug coverage will pay. The prescription drug coverage provided by I/N Tek & I/N Kote is considered Creditable Coverage. Because your existing coverage is on average at least as good as standard Medicare prescription drug coverage, you can keepthis coverage and not pay extra if you later decide to enroll in Medicare prescriptiondrug coverage.

When Can You Join A Medicare Drug Plan?

You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. If you lose creditable prescription drug coverage through no fault of your own, or if you decide to terminate your I/N Tek & I/N Kotecoverage, you will be eligible for a two (2) month special enrollment period during which you may enroll in a Medicare drug plan.

What Happens to Your Current Coverage If You Decide to Join a Medicare Drug Plan?

You will still have your prescription drug coverage through I/N Tek & I/N Kote in 2020, as long asyou stay employed at I/N Tek & I/N Kote and remain enrolled in the I/N Tek & I/N Kote health careplan. Note that if you are eligible for Medicare, although it is your choice whether to enroll in a Medicare prescription drug plan, it is probably not to your advantage to enroll while employed (unless you are eligible for extra financial help from Medicare).

Based on ArcelorMittal’s research, the Medicare prescription plans will provide little or no additional benefit if you enroll in addition to your I/N Tek & I/N Kote prescription drug coverage. (You will bepaying additional premiums for the Medicare prescription plan, and under the coordination of benefits provision, even if you enrolled in Medicare prescription drug coverage, you are covered as primary under your I/N Tek & I/N Kote plan for health care, including prescription drugs.)

2020 USW Represented 13

Ref: REALL-2020

If you do decide to enroll in a Medicare prescription drug plan and drop your I/N Tek & I/N Koteprescription drug coverage, you can only do so by dropping health coverage. You will be able to get this coverage back only by enrolling during the next annual open enrollment period (effective January 1st of the following year), unless you have a change in status event that permits reenrollment during the year.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with I/N Tek & I/N Kote andare eligible for but do not enroll in Medicare drug coverage after your current coverage ends, you may pay more to enroll in Medicare drug coverage later. If you go 63 days or longer without creditable prescription drug coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll.

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

Contact UMR at 1-800-654-6208 for further information about this notice. Contact CVS Caremark for further information about your current prescription drug coverage at 1-800-925-5795. NOTE: You will receive this notice each year and at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, or if this coverage through I/N Tek & I/N Kote changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans.

For more information about Medicare prescription drug plans:

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see your copy of the Medicare &You handbook for their telephone number) for personalized help,

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to enroll in a Medicare drug plan, you may be required to provide a copy of this notice when you join to show that you have maintained creditable coverage and are not required to pay a higher premium.

Date: Name of Entity/Sender:

Contact--Position/Office: Address:

Phone Number:

08/22/2019I/N Tek & I/N KotePlan Administrator, ArcelorMittal USA LLC 3210 Watling St., East Chicago, IN 46312

(219) 399-1200

2020 USW Represented 14

ARCELORMITTAL USA LLC WELFARE BENEFIT PLAN PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DIS-CLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFUL-LY.

THIS NOTICE GIVES YOU INFORMATION REQUIRED BY LAW about the duties and privacy practices of the ArcelorMittal USA LLC Welfare Benefit Plan (the “Plan”) to protect the privacy of your health information. The Plan provides medical, dental and flexible health care spending benefits to you as described in the applicable summary plan description. The terms of this notice apply only to these benefits. The Plan receives and maintains your health infor-mation in the course of providing these health benefits to you. The Plan hires individuals or entities to help it provide these benefits to you (“business associates”). These business associates also receive and maintain your health infor-mation in the course of assisting the Plan. The Plan is sponsored by ArcelorMittal USA LLC (the “Plan Sponsor”).

THE EFFECTIVE DATE OF THIS NOTICE IS September 23, 2013. The Plan is required to follow the terms of this notice until it is replaced. The Plan reserves the right to change the terms of this notice at any time. When the Plan makes changes to the privacy practices described in this notice, the Plan will send a revised notice to all individuals re-ceiving benefits from the Plan at that time. The Plan reserves the right to make the new changes apply to all your health information maintained by the Plan before and after the effective date of the new notice.

Uses and Disclosures of Your Health Information

The Plan will use and/or disclose your health information for the following purposes:

Health Care Providers’ Treatment Purposes. The Plan itself does not provide medical treatment, but it will dis-close your health information to a health care provider, upon request, if the provider is involved in mak-ing a decision about your care. For example, the Plan may disclose information about previous treat-ments you have received to a physician treating you in an emergency.

Payment. The Plan will use and/or disclose your health information to pay claims for covered health care ser-vices or to provide eligibility information to your physician when you receive treatment. For example, the Plan may share information with your physician to assist in filing claims for treatment you have re-ceived.

Health Care Operations. The Plan will use and/or disclose your health information for activities that are neces-sary to operate the Plan. Examples include using or disclosing your health information: (i) to conduct quality assessment and improvement activities, (ii) to submit claims for stop-loss coverage, (iii) to en-gage in care coordination or case management, (iv) to business associates of the Plan that perform ser-vices on behalf of it, or (v) to manage, plan or develop the Plan’s business.

Other Permitted or Required Uses and Disclosures

The Plan may disclose your health information for the following purposes related to the administration of the Plan with-out first obtaining your consent or authorization:

To Business Associates. The Plan may disclose your health information to business associates the Plan retains to provide a service on behalf of the Plan. Each business associate of the Plan must agree in writing to en-sure the continuing confidentiality and security of your health information.

To Plan Sponsor. The Plan may disclose your health information to the Plan Sponsor for certain administrative functions that the Plan Sponsor performs. The Plan Sponsor has agreed in writing to ensure the continu-ing confidentiality and security of your health information. The Plan Sponsor has also agreed not to use or disclose your health information for employment-related activities or for the administration of any of its other benefit plans without first obtaining your authorization.

2020 USW Represented 15

The Plan may use and/or disclose your health information for the following purposes without providing you an oppor-tunity to agree or object:

To comply with a legal requirement, such as allowing the U.S. Department of Health and Human Services to audit its records to determine compliance with federal laws protecting your privacy.

To contact you to give you information about treatment alternatives or other health-related benefits and ser-vices that may be of interest to you.

To comply with legal proceedings, such as a court or administrative order or a subpoena.

To law enforcement officials for limited law enforcement purposes.

To a family member, friend or other person for the purpose of helping you with your health care or with pay-ment for your health care, if the Plan is unsuccessful in receiving your permission to do this and deter-mines, in its best judgment, that such communication is appropriate.

To personal representatives appointed by you or designated by applicable law.

To avert a serious threat to your health or safety or the health or safety of others.

To a governmental agency authorized to oversee the health care system or government programs.

To federal officials for lawful intelligence, counterintelligence and other national security purposes.

To public health authorities for public health purposes.

To appropriate military authorities, if you are a member of the armed forces.

As authorized by law, to the extent necessary to comply with workers’ compensation laws.

Uses and Disclosures with Your Authorization

Certain uses and disclosures of your health information require your authorization, specifically, uses and disclosures involving: (i) psychotherapy notes, (ii) health information for marketing purposes and (iii) health information in in-stances constituting the sale of protected health information. The Plan will not use or disclose your health information for any purpose not specified in this notice without your written authorization. If you give the Plan written authoriza-tion to use or disclose your health information for a purpose that is not described in this notice, then, in most cases, you may revoke such authorization in writing at any time. Your revocation will be effective for all of your health infor-mation the Plan maintains, unless the Plan already has taken action in reliance on your authorization. If the authoriza-tion permits the Plan to disclose your health information to an insurance company, as a condition of coverage, other laws may allow the insurance company to continue to use your information to contest claims or coverage after you have revoked your authorization.

Your Rights

You have certain rights under law pertaining to the health information maintained by the Plan. You may make a writ-ten request to the Plan to do one or more of the following:

To send you a paper copy of this notice.

To review and obtain copies of your health information. This right is limited to information that is used by the Plan to make decisions such as claims, payment and enrollment records. In limited cases, the Plan does not have to agree to your request.

To correct your health information. This right is limited to information that is used by the Plan to make deci-sions such as claims, payment and enrollment records. In some cases, the Plan does not have to agree to your request.

To put additional restrictions on the Plan’s use and disclosure of your health information. The Plan does not have to agree to your request.

2020 USW Represented 16

To agree to communicate with you in confidence about your health information by a different means or at a different location than the Plan is currently doing. The Plan does not have to agree to your request unless such confidential communications are necessary to avoid endangering you and your request continues to allow the Plan to collect premiums and pay claims. Your request must specify the alter-native means or location to communicate with you in confidence.

To receive a list of disclosures of your health information that the Plan and its business associates made for certain purposes for a period of up to 6 years before the date you make a request. This right does not include disclosures made to carry out treatment, payment and health care operations; disclosures made to you; disclosures you authorized in writing; communications with family and friends; disclosures made for national security or intelligence purposes; disclosures to correctional institutions or law en-forcement officials; or disclosures made before April 14, 2003.

If you want to exercise any of your rights described in this notice, please contact the Contact Office (below). The Plan will give you the necessary information and forms for you to complete and return to the Contact Office. In some cas-es, the Plan may charge you a nominal, cost-based fee to carry out your request.

2020 USW Represented 17

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

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

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

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2019. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

ARKANSAS – Medicaid INDIANA – MedicaidWebsite: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child

Health Plan Plus (CHP+)IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plusCHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: http://dhs.iowa.gov/Hawki Phone: 1-800-257-8563

2020 USW Represented 18

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: https://chfs.ky.gov Phone: 1-800-635-2570

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

LOUISIANA – Medicaid NEW YORK – MedicaidWebsite: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid and CHIP Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347, or 401-462-0311 (Direct RIte Share Line)

NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

2020 USW Represented 19

To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

2020 USW Represented 20

SUMMARY ANNUAL REPORT

For ArcelorMittal USA LLC Welfare Benefits Plan

This is a summary of the annual report of the ArcelorMittal USA LLC Welfare Benefits Plan, EIN 71-0871875,

Plan No. 506, for period January 01, 2018 through December 31, 2018. The annual report has been filed with

the Employee Benefits Security Administration, as required under the Employee Retirement Income Security

Act of 1974 (ERISA).

ArcelorMittal USA LLC has committed itself to pay all health, supplemental unemployment, dental, vision,

temporary disability, severance pay, employee assistance program and certain long term disability claims

incurred under the terms of the plan.

Insurance Information

The plan has contracts with Prudential Insurance Company of America and Provident Life and Accident

Insurance Company to pay life insurance, accidental death & dismemberment and certain long-term disability,

claims incurred under the terms of the plan. The total premiums paid for the plan year ending December 31,

2018 were $17,101,414.

Your Rights To Additional Information

You have the right to receive a copy of the full annual report, or any part thereof, on request. The items listed

below are included in that report:

• insurance information, including sales commissions paid by insurance carriers;

To obtain a copy of the full annual report, or any part thereof, write or call the office of the Plan Administrator

at ArcelorMittal USA LLC: Attn. Plan Administrator: Employee Benefits Department, 3210 Watling Street,

East Chicago, IN 46312, or by telephone at (219) 399-1200.

You also have the legally protected right to examine the annual report at the main office of the plan, 3210

Watling Street, East Chicago, IN 46312 and at the U.S. Department of Labor in Washington, D.C., or to obtain

a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should

be addressed to: Public Disclosure Room, Room N-1513, Employee Benefits Security Administration, U.S.

Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13)(PRA), no persons are required to respond

to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)

control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of

information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also,

notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a

collection of information if the collection of information does not display a currently valid OMB control

number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average less than one minute per

notice (approximately 3 hours and 11 minutes per plan). Interested parties are encouraged to send comments

regarding the burden estimate or any other aspect of this collection of information, including suggestions for

reducing this burden, to the U.S. Department of Labor, Office of the Chief Information Officer, Attention:

Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 or

email DOL_PRA_PUBLIC@dol.gov and reference the OMB Control Number 1210-0040.

OMB Control Number 1210-0040 (expires 06/30/2022)

2020 USW Represented 21

Very Important Notice Regarding Continuation Coverage Rights for Health Plan Participants

On April 7, 1986, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) was signed into law

(Public Law 99-272, Title X). Under COBRA, most employers sponsoring group health plans must offer cov-

ered employees and their families the opportunity for a temporary extension of health coverage (called

"continuation coverage") at group rates in certain instances where coverage under the plan would otherwise

end. This notice is intended to inform you, in a summary fashion, of your rights and obligations under the

continuation coverage provisions of the COBRA law. Both you and your spouse should take the time to read

this notice carefully.

If you are an employee of I/N Tek & I/N Kote covered by ArcelorMittal’s group health plan, you have a right

to choose continuation coverage if you lose your group health coverage because of a reduction in your hours

of employment or the termination of your employment (for reasons other than gross misconduct on your

part).

You may be able to get coverage through the Health Insurance Marketplace that could costs less than CO-

BRA continuation coverage. For more information you can access the marketplace for your state at

www.HealthCare.gov.

If you are the spouse of an employee covered by ArcelorMittal’s group health plan you have a right to

choose this continuation coverage for yourself if you lose group health coverage under the plan for any of

the following four reasons:

1. The death of your spouse;

2. Termination of your spouse's employment or reduction in your spouse's hours of employment;

3. Divorce or legal separation from your spouse; or

Your spouse becomes entitled to (i.e. covered by) Medicare.

In the case of a dependent child of an employee covered by ArcelorMittal’s group health plan, the child has

the right to continuation coverage if group health coverage under the plan is lost for any of the following five

reasons:

1. The death of a parent;

2. Termination of a parent's employment or reduction in parent's hours of employment with Arce-

lorMittal;

3. Parents' divorce or legal separation;

4. A parent becomes entitled to (i.e. covered by) Medicare; or

5. The dependent ceases to be a "dependent child" under the plan.

Each individual who is covered under ArcelorMittal’s group health plan at the time of the qualifying event

has an independent right to elect continuation coverage. These individuals are called COBRA Qualified Bene-

ficiaries. The definition of a COBRA Qualified Beneficiary also includes a child who is born to or placed for

adoption with an individual who is already receiving COBRA coverage. Under COBRA, the covered employee

or a family member has the responsibility to inform the Plan Administrator of a divorce, legal separation, or a

child losing dependent status under the plan. Such notice must be made within 60 days of the event or the

date on which coverage would be lost because of the event. I/N Tek & I/N Kote has the responsibility to

notify the Plan Administrator of the employee's death, termination of employment or reduction in hours, or

entitlement to Medicare.

When the Plan Administrator is notified that one of the above named events has happened, the Plan Admin-

istrator will in turn notify you that you have the right to choose continuation coverage. Under the COBRA law,

you have at least 60 days from the date you would lose coverage, because of one of the events described

above, to inform the Plan Administrator that you want continuation coverage.

2020 USW Represented 22

If you do not choose continuation coverage, your group health insurance coverage will end. If you

choose continuation coverage, I/N Tek & I/N Kote is required to give you coverage that, as of the time

cover-age is being provided, is identical to the coverage provided under the plan to similarly situated

employ-ees or family members. The COBRA law requires that you be afforded the opportunity to

maintain con-tinuation coverage for 36 months (i.e. 3 years) unless you lost group health coverage

because of a ter-mination of employment or reduction in hours. In that case, the required continuation

coverage period is 18 months. The 18-month period may be extended to 36 months for a covered

dependent if a sec-ond event (e.g., divorce, legal separation, death, or Medicare entitlement) occurs

during the original 18-month period. In no event will continuation coverage last beyond 36 months from

the date of the event that originally made the individual eligible to elect coverage.

If a qualifying event that is termination of employment or reduction of hours occurs less than 18

months after the date an employee becomes entitled to (i.e. covered by) Medicare benefits, the cover-

age period for qualified beneficiaries other than the employee is extended to 36 months from the date

of the employee's original qualifying event date.

The 18-month period may be extended for an additional 11 months (for a total of 29 months) if a cov-

ered individual is determined to be disabled (under the rules for Social Security disability benefits) at

the time of termination of employment or reduction in hours and the plan administrator is notified of

that determination within 60 days of receipt of a disability determination letter from the Social Security

Administration and before the end of the original 18-month period. The affected individual also must

notify the Plan Administrator when it is determined (for purposes of Social Security disability benefits)

that the individual is no longer disabled.

The disability extension will also apply if the individual becomes disabled at any time during the first 60

days of continuation coverage and notifies the Plan Administrator within 60 days of receipt of a disabil-

ity determination letter from the Social Security Administration and before the end of the original 18-

month period. In addition, family members of the disabled individual, who became qualified for the

eleven month extension, are entitled to the 29-month extended coverage period, whether or not they

are disabled.

The COBRA law provides that your continuation coverage may be cut short of the full coverage period of

18, 29, or 36 months -- for any of the following reasons:

1. I/N Tek & I/N Kote no longer provides group health coverage to any of its employees;

2. The premium for your continuation coverage is not timely paid;

3. You become covered under another group health plan that does not contain any provision re-

stricting or limiting coverage of a "preexisting medical condition";

4. You become entitled to (i.e. covered by) Medicare; however, Medicare entitlement does not

end the continuation coverage period for family members that are not entitled to Medicare,

and their continuation coverage period may be extended to 36 months from the date of the

first qualifying event; or

5. There has been a final determination that you are no longer disabled, for beneficiaries who

qualified for an extra 11 months continuation coverage based on their disability at the time

of the qualifying event or within the first 60 days thereafter.

The circumstances under which group health plans can apply coverage limitations or exclusions for

preexisting conditions is restricted under the Health Insurance Portability and Accountability Act

(HIPAA). Therefore, for COBRA beneficiaries who enroll in another group health plan, the new re-

strictions may eliminate coverage limits based on preexisting conditions, thus allowing prior employers

to terminate continuation coverage. You do not have to show that you are insurable to choose continua-

tion coverage. However, continuation coverage under COBRA is provided subject to your eligibility for

coverage.

2020 USW Represented 23

Under the COBRA law, you are required to pay the full cost of the premium for your continuation cover-

age. A minimum 30-day "grace period" will be allowed for you to pay your regularly scheduled premiums.

Under the law, the plan may charge 2% of the total premium as an administration fee. This administra-

tion fee may be increased to 50% of the total premium during the 11-month disability extension period.

If you have any questions about COBRA, please contact the Human Resources Department of I/N Tek & I/N Kote Also, if you have changed marital status, or you or your spouse have changed your address;

please notify the Human Resources Department.

Patient Protection – Patient Access to Obstetrical and Gynecological Care

You do not need prior authorization from the plan or from any other person (including a primary care pro-

vider) 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 re-

quired to comply with certain procedures, including obtaining prior authorization for certain services, fol-

lowing a pre-approved treatment plan, or procedures for making referrals. For a list of participating health

care professionals who specialize in obstetrics or gynecology, contact Highmark at 1-866-267-3280.

Health Insurance Portability and Accountability Act (HIPAA) – State Children's Health Insurance Program (SCHIP) Loss of other coverage: If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other

health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan

if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your de-

pendents' other coverage). However, you must request enrollment within 31 days after your or your dependents' other cover-

age ends (or after the employer stops contributing toward the other coverage).

Loss of Medicaid or SCHIP coverage: If you decline enrollment for yourself or for an eligible dependent (including your spouse)

while Medicaid coverage or coverage under a state children's health insurance program is in effect, you may be able to enroll

yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must re-

quest enrollment within 60 days after you or your dependents' coverage ends under Medicaid or a state children's health insur-

ance program.

New dependent: If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to

enroll yourself and your new dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or

placement for adoption.

Eligibility for Medicaid or SCHIP premium assistance: If you or your dependents (including your spouse) become eligible for a

state premium assistance subsidy from Medicaid or through a state children's health insurance program with respect to cover-

age under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enroll-

ment within 60 days after your or your dependents' determination of eligibility for such assistance

2020 USW Represented 24

QUALIFIED LIFE EVENT OPEN ENROLLMENT NEW HIRE ENROLLMENT

Side 1 of 2 Rev. 11/2019 HR1-HCELIG-2019-V1 Page 25

ARCELORMITTAL USA HEALTH CARE ELIGIBILITY CHANGE FORM REPRESENTED HOURLY or O&T EMPLOYEES

Last Name First Name M.I. Payroll No. Social Security Number - -

Please check the changes that you need to make to your member records: (Check all that apply.)

Add spouse due to marriageTerminate spouse due to divorceTerminate spouse due to deathAdd child-birth / adoption / stepchildTerminate child due to deathTerminate child-no longer eligibleChange/Update Dependent status-

Handicap

Terminate dependent due to gaining other coverage

Enroll due to losing other coverageAdd dependent due to losing other

coverageWaive / Terminate coverage*Other________________________

*If you elect to waive coverage under thisplan and receive the annual payment of $3,600.00, payment will be prorated and paid to you on a pay period basis.

ONLY COMPLETE THE SECTIONS THAT APPLY TO CHANGES IN YOUR MEMBERSHIP RECORDS:Street Address City State Zip Code Phone

EmployeeAdd Waive Change

Spouse Add Drop Change

DependentAdd Drop Change

DependentAdd Drop Change

Social SecurityNumber. - - - - - - - -

Previous Last Name

New Last NameFirst Name

Middle InitialSex (M/F) M F M F M F M F

MembershipStatus

SingleMarried Spouse

Child StepchildOther ______________Handicapped > 26

Child StepchildOther ______________Handicapped > 26

Documentation Required

See other side. See other side. See other side. See other side.

Birth Date Month Day Year / /

Month Day Year / /

Month Day Year / /

Month Day Year / /

List additional dependent information on plain paper and attach. Check here if you are attaching a list of additional dependents.Attach required documentation per instructions on page 2 of this form.

(1) Email (2) Faxed Confirmation Delivery (3) Certified Mail

If the above change will affect your enrollment status, please check the appropriate box below. If it does not, leave blank :1. I elect to enroll in Medical/Rx, Vision & Dental Coverage as: Employee Only Employee & Spouse

Employee & Family Employee & Child(ren) OR

1. I elect to waive all health care coverage (Medical/RX, Vision and Dental) for myself and my eligible dependents.Note: To elect this option you must attach the required proof of other coverage .

2. I elect to waive Medical/RX only coverage for myself and my eligible dependents.Note: To elect this option you must attach the required proof of other coverage.

Signature Date Work Phone ArcelorMittal Business Unit/Location

- Return completed and signed form & copies of documents to HR. Questions Call: 1-574-654-1044 - Mail to HR -Benefits, 30755 Edsion Rd. New Carlisle, IN 46552 - OrEmail to HUMAN_RESOURCES@mittalco.com or Fax to 574-654-1043

QUALIFIED LIFE EVENT OPEN ENROLLMENT NEW HIRE ENROLLMENT

Side 2 of 2 Rev. 10/2019 HR1-HCELIG-2019-V1 Page 26

Internal Use Only: Status Approved Incomplete Late Termination/Change Date________ Initials ___________

Notes:______________________________________________________________________________________________________

____________________________________________________________________________________________________________

TO MAKE CHANGES TO YOUR COVERAGE OR TO CHANGE THE INFORMATION IN YOUR HEALTH CARE BENEFIT FILE, YOU MUST PROVIDE THE FOLLOWING DOCUMENTATION (CHECK OFF FORMS TO BE ATTACHED AND SEND COPIES ONLY, NO ORIGINALS):

1. Add spouse due to marriageMarriage Certificate

o If spouse was previously married, death certificate or divorce decree for prior marriage

2. Terminate spouse due to divorceDivorce decree

3. Terminate spouse or child due to deathDeath Certificate

4. Add child - BirthBirth CertificateSocial Security Card

5. Add child - AdoptionBirth CertificateAdoption OrderSocial Security Card

6. Add stepchildBirth CertificateSocial Security CardProof of other insurance, if any

7. Change/Update Dependent Status-HandicapHandicapped Dependent Certification FormTax return showing dependent status

8. Terminate/add dependent due to losing/gaining other coverage.Source of other coverage (is dependent covered as an employee or as a dependent of another person)Proof of date other coverage begins/terminatesIf adding spouse/dependent, Marriage Certificate, Birth Certificate and Social Security Card

9. Waive CoverageProof of other coverage, including coverage start date

10. Reinstatement from a WaiverProof of other insurance termination letter, Marriage Certificate, Birth Certificate and Social Security Card

Benefit enrollment requires a birth certificate and social security card as well as marriage certificate for spouse. This represents the acceptable documentation for benefit enrollment, without exception.

Page 27Rev-10/2019

OPEN ENROLLMENT NEW HIRE ENROLLMENT

ACTIVE REPRESENTED EMPLOYEE 2020FSA BENEFITS ENROLLMENT FORM

(Please print)

Employee Information

Last Name: First Name: Middle Initial:

Social Security Number: Payroll No. Date of Birth:

Address: Hire Date:

The Health Care Spending Account allows you to be reimbursed for qualified health care expenses incurred by you and

your dependents. Eligible expenses include medical and prescription drug copays, coinsurance and deductibles up to an

annual maximum of $2,750.

Health Care Spending Account Election

I Elect Coverage Amount to Deduct Per Pay on a Pre-Tax Basis:

$ (Maximum Limit: $105.77)

Annual Deduction: $

I Decline Coverage

The Dependent/Elder Day Care Spending Account allows you to be reimbursed for qualified day care expenses in

order to allow you and your spouse to work or go to school up to an annual maximum of $5,000. If you wish to enroll,

you must only choose either Option A OR Option B

Dependent / Elder Day Care Spending Account

OPTION A – Dependent / Elder Care with ICD Match* OPTION B – Dependent / Elder Care without ICD Match

Amount to Deduct Per Pay on a Pre-Tax Basis: $

(Maximum Limit: $192.30)

Annual Deduction: $

I Decline Coverage

*The following groups are NOT eligible to participate in the ICD Dependent / Elder Care match:

• Brickmason

• Fleet

• Columbus Coating

• Obetz

• Monessen

Authorization

To the best of my knowledge the information above is correct and I elect to participate in ArcelorMittal FSA benefit plans as indicated. I understand my employee contribution will be deducted from my earnings or any applicable disability benefits payments on a pre-tax basis in an amount based on my coverage election(s) above.

Authorization Signature Date Work Phone Home Phone

After signing, make a copy for your records and

return form by:

Mail: HR Benefits-

30755 Edison Rd

New Carlisle, IN 46552

Email: HUMAN_RESOURCES@mittal.com Phone: 574-654-1044

Fax: 574-654-1043

IMPORTANT: Retain proof of submission

(1) Email – retain e-mail and delivery notification for confirmation purposes

(2) Fax – retain fax confirmation delivery for confirmation purposes

(3) Certified Mail – retain proof of certified mailing for confirmation purposes -

Forms sent to I/N Tek &I/N Kote will be returned to the sender, not forwarded to

UMR. Your FSA elections will be confirmed in writing within 21 business days of

receipt.

� � � � � � � � � � � � � � � � � � � 28

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CHICAGO/#3352579.2

NOTICE REGARDING WELLNESS PROGRAM

The Health Awareness Initiative (“HAI”) is a voluntary wellness program available to all

employees that enroll in the Preferred Provider Organization plan (“PPO”). The program is

administered according to federal rules permitting employer-sponsored wellness programs that

seek to improve employee health or prevent disease, including the Americans with Disabilities

Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance

Portability and Accountability Act, as applicable, among others. If you choose to participate in

the wellness program you will be asked to complete a voluntary health screening that asks a

series of questions about your health-related activities and behaviors and whether you have or

had certain medical conditions (e.g., cancer, diabetes, or heart disease). You are not required to

complete the health screening or other medical examinations.

However, eligible employees who choose to participate in the wellness program will

receive an employer contribution to their health reimbursement account (“HRA”). Although you

are not required to complete the health screening, only employees who do so will receive the

employer contribution to their HRA.

The information from your health screening will be used to provide you with information

to help you understand your current health and potential risks, and may also be used to offer you

services through the wellness program. You also are encouraged to share your results or

concerns with your own doctor.

PROTECTIONS FROM DISCLOSURE OF MEDICAL INFORMATION

We are required by law to maintain the privacy and security of your personally

identifiable health information. Although the wellness program and I/N Tek & I/N Kote may use

aggregate information it collects to design a program based on identified health risks in the

workplace, the HAI provider will never disclose any of your personal information either publicly

or to the employer, except as necessary to respond to a request from you for a reasonable

accommodation needed to participate in the wellness program, or as expressly permitted by law.

Medical information that personally identifies you that is provided in connection with the

wellness program will not be provided to your supervisors or managers and may never be used to

make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed

except to the extent permitted by law to carry out specific activities related to the wellness

program, and you will not be asked or required to waive the confidentiality of your health

information as a condition of participating in the wellness program or receiving an incentive.

Anyone who receives your information for purposes of providing you services as part of the

wellness program will abide by the same confidentiality requirements. The only individual(s)

who will receive your personally identifiable health information are those professionals, such as

a registered nurse or doctor, who will only have access in order to provide you with services

under the wellness program.

In addition, all medical information obtained through the wellness program will be

maintained separate from your personnel records, information stored electronically will be

2020 USW Represented 33

CHICAGO/#3352579.2

encrypted, and no information you provide as part of the wellness program will be used in

making any employment decision. Appropriate precautions will be taken to avoid any data

breach, and in the event a data breach occurs involving information you provide in connection

with the wellness program, you will be notified immediately.

You may not be discriminated against in employment because of the medical information

you provide as part of participating in the wellness program, nor may you be subjected to

retaliation if you choose not to participate.

If you have questions or concerns regarding the Health Awareness Initiative, please

contact the Steelworkers Health and Welfare Fund at 888-831-3863.

2020 USW Represented 34

1 of 9

An exam

ple of a benefit book can

be found at https://shop.high

mark.com/sales/#!/sbc-agree

ments.

10699-00, 01, 05, 06, 10, 11, 15, 16, 20, 21, 25, 26, 30, 31, 35, 36, 40, 41, 50, 51, 55, 56, 60, 61, 65, 66, 70, 71, 75, 76, 80, 81, 85, 86, 90, 91, 95, 96

12359-00, 01, 05, 06, 10, 11, 15, 16, 20, 21

17901-00, 01, 05, 06, 10, 11, 15, 16, 20, 21, 25, 26, 30, 31, 35, 36

GE_010

69900_2020

0101_S

BC

Coverage Period: 01/01/2020 - 12/31/2020

Summary of Benefits and Coverage: W

hat this Plan Covers & W

hat Y

ou Pay For Covered

Services

I/N

Tek

& I/

N K

ote: PPO

Coverage for: Individual/Fam

ily

Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would

share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more inform

ation ab

out you

r coverage

, or to get a copy of the complete term

s of coverage, please visit w

ww.highm

arkbcbs.com or call

1-86

6-267-3280. F

or general definition

s of com

mon te

rms, such as allowed amount, b

alan

ce billing, coinsurance, copayment, deductible, provide

r, or other

underline

d term

s see the Glossary. You

can view the Glossary at www.HealthCare.go

v/sbc-glossary/ o

r call 1-866-267-3280

to reque

st a cop

y.

Important Questions

Answers

Why this Matters:

What is the overall

deductible?

$200 individual/$400 family

in-network.

$500 individual/$1,000 family

out-of-network.

Gen

erally, you

must pay all of the costs from

provide

rs up to the deductible amount

before th

is plan begins to pay. If you

have othe

r family mem

bers on the plan, each

family mem

ber must m

eet the

ir ow

n individual deductible until the total amount of

deductible expenses pa

id by all fam

ily mem

bers mee

ts the overall fam

ily ded

uctible.

Are there services

covered before you meet

your deductible?

Network dedu

ctible doe

s not a

pply to

office visits, preventive care services,

emerge

ncy room

care, emerge

ncy

med

ical tran

sportation, urgent care,

outpatient mental hea

lth, outpa

tient

substance ab

use, rehab

ilitation services,

eye exam

, hospice service, and

hearing

aids.

Cop

ayments and

coinsurance amounts

don't count toward the network

deductible.

This plan

covers some items an

d services even if you haven’t yet met the dedu

ctible

amou

nt. B

ut a copaymen

t or coinsurance may app

ly. F

or example, th

is plan covers

certain preven

tive services withou

t cost-sharing and before you mee

t you

r deductible.

See

a list of covered preventive services at

https://w

ww.healthcare.gov/coverage/preven

tive-care-ben

efits/.

Are there other deductibles

for specific services?

No.

You

don

’t ha

ve to mee

t deductibles for specific services.

What is the out-of-pocket limit

for this plan?

$1,500

individual/$3,000 family

in-network

$2,000

individual/$4,000 family

out-of-network.

The

out-of-pocket limit is the most you could pay in a yea

r for covered services. If you

ha

ve other fa

mily mem

bers in th

is plan, they have to meet their ow

n ou

t-of-pocket

limits until the overall fam

ily out-of-pocket limit has been met.

What is not included in the

out–of–pocket limit?

Premiums, balance-billed

cha

rges,

prescription drug

expen

ses an

d health

care th

is plan doesn’t cover.

Even though you pay these expenses, the

y don't cou

nt toward the out-of-pocket limit.

2020 USW Represented 35

2 of 9

Will you pay less if you

use a network provider?

Yes. F

or a list of network providers, see

www.highm

arkbcbs.com or call

1-86

6-267-3280.

This plan

uses a provider network. You

will pay less if you

use a provider in the plan’s

network. You will pay the most if you use an out-of-network provider, and you might

receive a bill from

a provider for the difference between the provider’s charge an

d wha

t your plan pays (balance billing).

Be aw

are your network provider might use an out-of-network provider for some

services (such as lab work). C

heck with you

r provider before you ge

t services.

Do I need a referral to see a

specialist?

No.

You

can

see

the specialist you

choose without a referral.

All copayment and coinsurance costs sho

wn in th

is chart are after your overall deductible has bee

n met, if a

deductible app

lies.

Common Medical

Event

Services You May Need

What You Will Pay

Limitations, Exceptions, and Other

Important Information

Network Provider

(You will pay the

least)

Out-of-Network

Provider (You will

pay the most)

If you visit a health

care provider’s

office or clinic

Prim

ary care visit to treat an injury or illne

ss

$20 copay/visit

30% coinsuran

ce

You

may have to pay fo

r services th

at

aren

’t preven

tive. Ask you

r provide

r if

the services needed are preven

tive.

The

n check what you

r plan will pay fo

r.

Please refer to your preventive sche

dule

for additional information.

Spe

cialist visit

$20 copay/visit

30% coinsuran

ce

Preventive care/Screening

/Immun

ization

No charge

for preventive care

services

30% coinsuran

ce

for preventive care

services

If you have a test

Diagn

ostic test (x-ray, blood work)

10% coinsuran

ce

30% coinsuran

ce

Precertification may be required.

Imag

ing (CT/PET scans, M

RIs)

10% coinsuran

ce

30% coinsuran

ce

Precertification may be required.

If you need drugs

to treat your illness

or condition

More inform

ation

about prescription

drug coverage is

available at

1-86

6-267-3280.

Gen

eric drugs

Not covered

Not covered

−−−−

−−−−

−−−n

one−

−−−−

−−−−

−−

Brand

drugs

Not covered

Not covered

If you have

outpatient surgery

Facility fe

e (e.g., am

bulatory surge

ry center)

10% coinsuran

ce

30% coinsuran

ce

Precertification may be required.

Physician

/surge

on fees

10% coinsuran

ce

30% coinsuran

ce

Precertification may be required.

2020 USW Represented 36

3 of 9

Common Medical

Event

Services You May Need

What You Will Pay

Limitations, Exceptions, and Other

Important Information

Network Provider

(You will pay the

least)

Out-of-Network

Provider (You will

pay the most)

If you need

immediate medical

attention

Emerge

ncy room

care

$50 copay/visit

$50 copay/visit

Cop

ay waived if ad

mitted as an

inpa

tient.

Out-of-network: Not sub

ject to

deductible.

Emerge

ncy medical transportation

No charge

No charge

Out-of-network: Not sub

ject to

deductible.

Urgen

t care

$30 copay/visit

$30 copay/visit

Out-of-network: Not sub

ject to

deductible.

If you have a

hospital stay

Facility fe

e (e.g., ho

spital room)

10% coinsuran

ce

30% coinsuran

ce

Precertification may be required.

Physician

/surge

on fee

10% coinsuran

ce

30% coinsuran

ce

Precertification may be required.

If you have mental

health, behavioral

health, or

substance abuse

needs

Outpatient services

$20 copay/visit

30% coinsuran

ce

Precertification may be required.

Inpatient services

10% coinsuran

ce

30% coinsuran

ce

Precertification may be required.

If you are pregnant

Office visits

10% coinsuran

ce

30% coinsuran

ce

Cost sha

ring does not apply fo

r preven

tive services.

Dep

ending on the type of services, a

copa

yment, coinsurance, or de

ductible

may app

ly.

Maternity care may include tests and

services described elsew

here in the

SBC (i.e. u

ltrasound

.)

Network: The first visit to determine

preg

nancy is covered at no charge

. Please refer to the Wom

en’s Hea

lth

Preventive Schedule for additiona

l inform

ation.

Precertification may be required.

Childbirth/delivery professional services

10% coinsuran

ce

30% coinsuran

ce

Childbirth/delivery facility services

10% coinsuran

ce

30% coinsuran

ce

2020 USW Represented 37

4 of 9

Common Medical

Event

Services You May Need

What You Will Pay

Limitations, Exceptions, and Other

Important Information

Network Provider

(You will pay the

least)

Out-of-Network

Provider (You will

pay the most)

If you need help

recovering or have

other special health

needs

Hom

e health care

10% coinsuran

ce

30% coinsuran

ce

Out-of-network: 30 visits per ben

efit

period.

Precertification may be required.

Reh

abilitation services

$20 copay/visit

30% coinsuran

ce

Com

bine

d ne

twork and out-o

f-ne

twork:

60 physical m

edicine visits and

occupational therapy visits per benefit

period.

Precertification may be required.

Hab

ilitation services

Not covered

Not covered

−−−−

−−−−

−−−n

one−

−−−−

−−−−

−−

Skilled nu

rsing care

10% coinsuran

ce

30% coinsuran

ce

Precertification may be required.

Durab

le medical equipment

20% coinsuran

ce

40% coinsuran

ce

Precertification may be required.

Hospice service

No charge

No charge

Out-of-network: Not sub

ject to

deductible.

Precertification may be required.

If your child needs

dental or eye care

Children’s Eye exam

$20 copay/visit

30% coinsuran

ce

Com

bine

d ne

twork and out-o

f-ne

twork:

One

diabetic eye exam per benefit

period.

Children’s Glasses

Not covered

Not covered

−−−−

−−−−

−−−n

one−

−−−−

−−−−

−−

Children’s Den

tal check-up

Not covered

Not covered

−−−−

−−−−

−−−n

one−

−−−−

−−−−

−−

2020 USW Represented 38

5 of 9

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

•Acupuncture

•Hab

ilitation services

•Rou

tine foot care

•Cosmetic surge

ry•

Long-term care

•Weigh

t loss prog

rams

•Den

tal care (Adult)

•Prescription drug

s

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

•Bariatric surge

ry•

Hea

ring aids

•Private-du

ty nursing

•Chiropractic care

•Infertility treatmen

t•

Rou

tine eye care (Adu

lt)

•Coverag

e provided

outside the United

States. See

http://www.bcbsa.com

•Non

-emergency care whe

n traveling ou

tside

the U.S.

Your Rights to Continue Coverage: There are age

ncies that can help if you want to continue you

r coverage after it ends. T

he con

tact inform

ation for those

agencies is: D

epartment o

f Labor’s Employee Benefits Security Adm

inistration at 1-866

-444-EBSA (3272

) or www.dol.gov/ebsa/healthreform

, or the Departmen

t of

Hea

lth and Hum

an Services, Cen

ter for Consumer Inform

ation and Insurance Oversight, at 1

-877

-267

-232

3 x615

65 or www.cciio.cms.go

v. The

Pennsylvania

Dep

artment o

f Con

sumer Services at 1-877

-881

-6388. Other options to continue coverage are available to you too, including bu

ying individu

al insurance coverage

through the Health Insurance Marketplace. F

or more inform

ation ab

out the

Marketplace, visit http://www.Hea

lthCare.go

v or call 1-800

-318

-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a com

plaint against your p

lan for a de

nial of a claim. T

his complaint is called a

grievance or app

eal. For more inform

ation ab

out you

r rights, look at the explanation of benefits you

will receive fo

r that med

ical claim. Y

our plan

docum

ents also

provide complete inform

ation to sub

mit a claim appea

l or a grievance for an

y reason to

your plan. F

or more inform

ation about your rights, this notice, or assistan

ce,

contact:

•You

r plan

adm

inistrator/employer.

•The

Departmen

t of Labor’s Employee Benefits Security Adm

inistration at 1-866-444-EBSA (32

72) or www.dol.gov/ebsa/he

althreform

.

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum

Essen

tial C

overage for a mon

th, you’ll have to make a pa

ymen

t when you file your tax return unless you qualify fo

r an exemption from

the

requ

iremen

t that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t m

eet the Minimum

Value Standards, you

may be eligible for a prem

ium ta

x cred

it to help you pay for a plan

through the Marketplace.

––––––––––

–––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––

––––––

2020 USW Represented 39

6 of 9

Abo

ut these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how

this plan might cover medical care. Your actual costs will be

diffe

rent dep

ending on the actual care you receive, the prices you

r providers charge, and

many othe

r factors. Focus on the cost sha

ring

amou

nts (deductibles, copaymen

ts and

coinsurance) and exclud

ed services un

der the

plan. Use th

is inform

ation to com

pare the po

rtion of

costs you might pay under different hea

lth plans. P

lease note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 mon

ths of in-network pre-na

tal care and a

hospital delivery)

Managing Joe’s type 2 Diabetes

(a yea

r of rou

tine in-network care of a well-

controlled condition

)

Mia’s Simple Fracture

(in-network em

ergency room

visit an

d follow up

care)

�The

plan’s overall deductible

�Spe

cialist copaymen

t �Hospital (facility) coinsurance

�Other coinsurance

$200

$20

10%

10%

�The

plan’s overall deductible

�Spe

cialist copaymen

t �Hospital (facility) coinsurance

�Other coinsurance

$200

$20

10%

10%

�The

plan’s overall deductible

�Spe

cialist copaymen

t �Hospital (facility) coinsurance

�Other coinsurance

$200

$20

10%

10%

This EXAMPLE event includes services like:

Spe

cialist office visits (prenatal care)

Childbirth/Delivery Professiona

l Services

Childbirth/Delivery Facility Services

Diagn

ostic tests (ultrasounds and blood work)

Spe

cialist visit (anesthesia)

This EXAMPLE event includes services like:

Prim

ary care physician office visits (including

disease education)

Diagn

ostic tests (blood work)

Prescription drug

s

Durab

le medical equipment (glucose meter)

This EXAMPLE event includes services like:

Emerge

ncy room

care (including medical supplies)

Diagn

ostic test (x-ray)

Durab

le medical equipment (crutches)

Reh

abilitation services (physical therapy)

Total Example Cost

$12,800

Total Example Cost

$7,400

Total Example Cost

$1,900

In this example, Peg would pay:

In this example, Joe would pay:

In this example, Mia would pay:

Cost Sharing

Cost Sharing

Cost Sharing

Ded

uctibles

$200

Ded

uctibles

$200

Ded

uctibles

$200

Cop

ayments

$0

Cop

ayments

$100

Cop

ayments

$200

Coinsuran

ce

$1,200

Coinsuran

ce

$400

Coinsuran

ce

$0

What isn’t covered

What isn’t covered

What isn’t covered

Limits or exclusions

$200

Limits or exclusions

$2,900

Limits or exclusions

$0

The total Peg would pay is

$1,600

The total Joe would pay is

$3,600

The total Mia would pay is

$400

Note: These num

bers assum

e the pa

tient does not participate in the plan’s wellness prog

ram. If you participate in the plan’s wellness prog

ram, you

may be ab

le to

redu

ce you

r costs. For more inform

ation about the

wellness program, p

lease contact: 1-866-267-3280

.

The

plan would be respon

sible for the other costs of these EXAMPLE

covered services.

2020 USW Represented 40

Insurance or benefit ad

ministration may be provided by Highm

ark Blue Cross Blue Shield an

d Highm

ark Choice Com

pany which are inde

penden

t licen

sees of the

Blue Cross and

Blue Shield Association. H

ealth care plan

s are subject to term

s of the bene

fit agree

ment.

To find more inform

ation abou

t Highm

ark’s be

nefits an

d op

erating procedures, such as accessing

the drug

form

ulary or using network providers,

plea

se go to DiscoverHighm

ark.com/Qua

lityA

ssuran

ce; o

r for a pa

per copy, call 1-855

-873-4106.

2020 USW Represented 41

7 of 9

2020 USW Represented 42

8 of 9

2020 USW Represented 43

9 of 9

Co

vera

ge

Per

iod

: 01

/01/

2020

– 1

2/31

/202

0 S

um

mar

y o

f B

enef

its

and

Co

vera

ge:

Wha

t thi

s P

lan

Cov

ers

& W

hat Y

ou P

ay F

or C

over

ed S

ervi

ces

US

W R

epre

sen

ted

PP

O E

mp

loye

es P

resc

rip

tio

n D

rug

Pla

n:

I/N T

ek &

I/N K

ote

Co

vera

ge

for:

All

Co

vera

ge

Tie

rs |

Pla

n T

ype:

PP

O R

x

1 o

f 5

Th

e S

um

mar

y o

f B

enef

its

and

Co

vera

ge

(SB

C)

do

cum

ent

will

hel

p y

ou

ch

oo

se a

hea

lth

pla

n. T

he

SB

C s

ho

ws

you

ho

w y

ou

an

d t

he

pla

n w

ou

ld

shar

e th

e co

st f

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cove

red

hea

lth

car

e se

rvic

es. N

OT

E:

Info

rmat

ion

ab

ou

t th

e co

st o

f th

is p

lan

(ca

lled

th

e p

rem

ium

) w

ill b

e p

rovi

ded

sep

arat

ely.

T

his

is o

nly

a s

um

mar

y. F

or m

ore

info

rmat

ion

abou

t you

r co

vera

ge, o

r to

get

a c

opy

of th

e co

mpl

ete

term

s of

cov

erag

e, g

o to

ht

tp://

bene

fits.

arce

lorm

ittal

usa.

com

. F

or g

ener

al d

efin

ition

s of

com

mon

term

s, s

uch

as a

llow

ed a

mou

nt, b

alan

ce b

illin

g, c

oins

uran

ce, c

opay

men

t, de

duct

ible

, pr

ovid

er, o

r ot

her

unde

rline

d te

rms

see

the

Glo

ssar

y. Y

ou c

an v

iew

the

Glo

ssar

y at

ww

w.d

ol.g

ov/e

bsa/

heal

thre

form

. Im

po

rtan

t Q

ues

tio

ns

An

swer

s W

hy

Th

is M

atte

rs:

Wh

at is

th

e o

vera

ll d

edu

ctib

le?

$

0 S

ee th

e C

omm

on M

edic

al E

vent

s ch

art b

elow

for

your

cos

ts fo

r se

rvic

es th

is p

lan

cove

rs.

Are

th

ere

serv

ices

co

vere

d b

efo

re y

ou

mee

t yo

ur

ded

uct

ible

?

No

See

the

Com

mon

Med

ical

Eve

nts

char

t bel

ow fo

r yo

ur c

osts

for

serv

ices

this

pla

n co

vers

.

Are

th

ere

oth

er

ded

uct

ible

s fo

r sp

ecif

ic

serv

ices

?

No

You

don

’t ha

ve to

mee

t ded

uctib

les

for

spec

ific

serv

ices

.

Wh

at is

th

e o

ut-

of-

po

cket

lim

it f

or

this

pla

n?

$1

,500

indi

vidu

al/$

3,00

0 fa

mily

T

he o

ut-o

f-po

cket

lim

it is

the

mos

t you

cou

ld p

ay in

a y

ear

for

cove

red

serv

ices

. If

you

have

oth

er

fam

ily m

embe

rs in

this

pla

n, th

e ov

eral

l fam

ily o

ut-o

f-po

cket

lim

it m

ust b

e m

et.

Wh

at is

no

t in

clu

ded

in

the

ou

t-o

f-p

ock

et li

mit

?

Pre

miu

ms,

bal

ance

-bill

ed c

harg

es

(unl

ess

bala

nced

bill

ing

is

proh

ibite

d), a

nd h

ealth

car

e se

rvic

es th

is p

lan

does

n’t c

over

.

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

don’

t cou

nt to

war

d th

e ou

t-of

-poc

ket l

imit.

Will

yo

u p

ay le

ss if

yo

u

use

a n

etw

ork

pro

vid

er?

Yes

. S

ee w

ww

.car

emar

k.co

m o

r ca

ll 1-

888-

202-

1654

for

a lis

t of

netw

ork

prov

ider

s.

Thi

s pl

an u

ses

a pr

ovid

er n

etw

ork.

You

will

pay

less

if y

ou u

se a

pro

vide

r in

the

plan

’s n

etw

ork.

Y

ou w

ill p

ay th

e m

ost i

f you

use

an

out-

of-n

etw

ork

prov

ider

, and

you

mig

ht r

ecei

ve a

bill

from

a

prov

ider

for

the

diffe

renc

e be

twee

n th

e pr

ovid

er’s

cha

rge

and

wha

t you

r pl

an p

ays

(a b

alan

ce b

ill).

Do

yo

u n

eed

a r

efer

ral t

o

see

a sp

ecia

list?

N

A

OM

B C

on

tro

l Nu

mb

ers

15

45

-22

29

, 12

10

-01

47

, an

d 0

93

8-1

14

6

2020 USW Represented 44

2

of

5

*F

or m

ore

info

rmat

ion

abou

t lim

itatio

ns a

nd e

xcep

tions

, see

the

plan

or

polic

y do

cum

ent a

t ht

tp://

bene

fits.

arce

lorm

ittal

usa.

com

.

All

cop

aym

ent

and

coin

sura

nce

cos

ts s

how

n in

this

cha

rt a

re a

fter

your

ded

uct

ible

has

bee

n m

et, i

f a d

edu

ctib

le a

pplie

s.

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er Im

po

rtan

t

Info

rmat

ion

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

vis

it a

hea

lth

ca

re p

rovi

der

’s o

ffic

e o

r cl

inic

Prim

ary

care

vis

it to

trea

t an

inju

ry o

r ill

ness

N

A

NA

Spe

cial

ist v

isit

NA

N

A

Pre

vent

ive

care

/scr

eeni

ng/

imm

uniz

atio

n

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y, b

lood

w

ork)

N

A

NA

Imag

ing

(CT

/PE

T s

cans

, MR

Is)

If y

ou

nee

d d

rug

s to

tr

eat

you

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out

pre

scri

pti

on

dru

g

cove

rag

e is

ava

ilabl

e at

ht

tp://

bene

fits.

arce

lorm

itta

lusa

.com

Gen

eric

dru

gs

$10/

reta

il pr

escr

iptio

n,

$15/

mai

l pre

scrip

tion

50%

/ret

ail p

resc

riptio

n R

etai

l cov

ers

up to

a 3

0-da

y su

pply

; Mai

l Ord

er

cove

rs u

p to

a 9

0-da

y su

pply

.

Pre

ferr

ed b

rand

dru

gs

$20/

reta

il pr

escr

iptio

n,

$30/

mai

l pre

scrip

tion

50%

/ret

ail p

resc

riptio

n A

fter

2 re

tail

phar

mac

y fil

ls, m

aint

enan

ce d

rugs

ar

e co

vere

d on

ly if

pur

chas

ed th

roug

h th

e m

ail

orde

r pr

ogra

m.

Non

-pre

ferr

ed b

rand

dru

gs

$30/

reta

il pr

escr

iptio

n,

$60/

mai

l pre

scrip

tion

50%

/ret

ail p

resc

riptio

n

Bra

nd n

ame

drug

s w

ith g

ener

ic e

quiv

alen

ts

are

not c

over

ed u

nles

s au

thor

ized

by

CV

S

Car

emar

k, li

sted

pay

men

t am

ount

s ap

ply

if au

thor

ized

. C

over

age

for

cert

ain

drug

s is

sub

ject

to p

rior

auth

oriz

atio

n an

d/or

qua

ntity

, dos

e or

dur

atio

n lim

its.

To

conf

irm w

heth

er th

is a

pplie

s to

a

cert

ain

drug

, con

tact

CV

S C

arem

ark

by c

allin

g 1-

888-

202-

1654

.

Spe

cial

ty d

rugs

S

ame

as a

bove

50

%/r

etai

l pre

scrip

tion

Mos

t spe

cial

ty d

rugs

req

uire

prio

r au

thor

izat

ion

and

mus

t be

fille

d at

CV

S C

arem

ark

Spe

cial

ty

Pha

rmac

ies.

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(e.g

., am

bula

tory

su

rger

y ce

nter

) N

A

NA

Phy

sici

an/s

urge

on fe

es

NA

N

A

If y

ou

nee

d im

med

iate

m

edic

al a

tten

tio

n

Em

erge

ncy

room

car

e N

A

NA

Em

erge

ncy

med

ical

tr

ansp

orta

tion

NA

N

A

2020 USW Represented 45

3

of

5

*F

or m

ore

info

rmat

ion

abou

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itatio

ns a

nd e

xcep

tions

, see

the

plan

or

polic

y do

cum

ent a

t ht

tp://

bene

fits.

arce

lorm

ittal

usa.

com

.

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

L

imit

atio

ns,

Exc

epti

on

s, &

Oth

er Im

po

rtan

t

Info

rmat

ion

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Ou

t-o

f-N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

Urg

ent c

are

NA

N

A

If y

ou

hav

e a

ho

spit

al

stay

Fac

ility

fee

(e.g

., ho

spita

l roo

m)

NA

N

A

Phy

sici

an/s

urge

on fe

es

NA

N

A

If y

ou

nee

d m

enta

l h

ealt

h, b

ehav

iora

l h

ealt

h, o

r su

bst

ance

ab

use

ser

vice

s

Out

patie

nt s

ervi

ces

NA

N

A

Inpa

tient

ser

vice

s N

A

NA

If y

ou

are

pre

gn

ant

Offi

ce v

isits

N

A

NA

Chi

ldbi

rth/

deliv

ery

prof

essi

onal

se

rvic

es

Chi

ldbi

rth/

deliv

ery

faci

lity

serv

ices

N

A

NA

If y

ou

nee

d h

elp

re

cove

rin

g o

r h

ave

oth

er s

pec

ial h

ealt

h

nee

ds

Hom

e he

alth

car

e N

A

NA

Reh

abili

tatio

n se

rvic

es

NA

N

A

Hab

ilita

tion

serv

ices

N

A

NA

Ski

lled

nurs

ing

care

N

A

NA

Dur

able

med

ical

equ

ipm

ent

NA

N

A

Hos

pice

ser

vice

s N

A

NA

If y

ou

r ch

ild n

eed

s d

enta

l or

eye

care

Chi

ldre

n’s

eye

exam

N

A

NA

Chi

ldre

n’s

glas

ses

NA

N

A

Chi

ldre

n’s

dent

al c

heck

-up

NA

N

A

Exc

lud

ed S

ervi

ces

& O

ther

Co

vere

d S

ervi

ces:

Ser

vice

s Y

ou

r P

lan

Gen

eral

ly D

oes

NO

T C

ove

r (C

hec

k yo

ur

po

licy

or

pla

n d

ocu

men

t fo

r m

ore

info

rmat

ion

an

d a

list

of

any

oth

er e

xclu

ded

ser

vice

s.)

•A

cupu

nctu

re

•R

outin

e fo

ot c

are

•C

osm

etic

sur

gery

•W

eigh

t los

s pr

ogra

ms

•D

enta

l car

e

•Lo

ng-t

erm

car

e

Oth

er C

ove

red

Ser

vice

s (L

imit

atio

ns

may

ap

ply

to

th

ese

serv

ices

. Th

is is

n’t

a c

om

ple

te li

st. P

leas

e se

e yo

ur

pla

n d

ocu

men

t.)

•B

aria

tric

sur

gery

•In

fert

ility

trea

tmen

t

•C

hiro

prac

tic c

are

•R

outin

e ey

e ca

re•

Hea

ring

aids

Yo

ur

Rig

hts

to

Co

nti

nu

e C

ove

rag

e: T

here

are

age

ncie

s th

at c

an h

elp

if yo

u w

ant t

o co

ntin

ue y

our

cove

rage

afte

r it

ends

. The

con

tact

info

rmat

ion

for

thos

e ag

enci

es is

: Dep

artm

ent o

f Lab

or’s

Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istr

atio

n at

1-8

66-4

44-E

BS

A (

3272

) or

ww

w.d

ol.g

ov/e

bsa/

heal

thre

form

. Oth

er c

over

age

optio

ns

2020 USW Represented 46

4

of

5

*F

or m

ore

info

rmat

ion

abou

t lim

itatio

ns a

nd e

xcep

tions

, see

the

plan

or

polic

y do

cum

ent a

t ht

tp://

bene

fits.

arce

lorm

ittal

usa.

com

.

may

be

avai

labl

e to

you

too,

incl

udin

g bu

ying

indi

vidu

al in

sura

nce

cove

rage

thro

ugh

the

Hea

lth In

sura

nce

Mar

ketp

lace

. For

mor

e in

form

atio

n ab

out t

he M

arke

tpla

ce,

visi

t ww

w.H

ealth

Car

e.go

v or

cal

l 1-8

00-3

18-2

596.

Yo

ur

Gri

evan

ce a

nd

Ap

pea

ls R

igh

ts:

The

re a

re a

genc

ies

that

can

hel

p if

you

have

a c

ompl

aint

aga

inst

you

r pl

an fo

r a

deni

al o

f a c

laim

. Thi

s co

mpl

aint

is c

alle

d a

grie

vanc

e or

app

eal.

For

mor

e in

form

atio

n ab

out y

our

right

s, lo

ok a

t the

exp

lana

tion

of b

enef

its y

ou w

ill r

ecei

ve fo

r th

at m

edic

al c

laim

. You

r pl

an d

ocum

ents

als

o pr

ovid

e co

mpl

ete

info

rmat

ion

to s

ubm

it a

clai

m, a

ppea

l, or

a g

rieva

nce

for

any

reas

on to

you

r pl

an. F

or m

ore

info

rmat

ion

abou

t you

r rig

hts,

this

not

ice,

or

assi

stan

ce,

cont

act:

Dep

artm

ent o

f Lab

or’s

Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istr

atio

n at

1-8

66-4

44-E

BS

A (

3272

) or

ww

w.d

ol.g

ov/e

bsa/

heal

thre

form

.

Do

es t

his

pla

n p

rovi

de

Min

imu

m E

ssen

tial

Co

vera

ge?

[Y

es]

If yo

u do

n’t h

ave

Min

imum

Ess

entia

l Cov

erag

e fo

r a

mon

th, y

ou’ll

hav

e to

mak

e a

paym

ent w

hen

you

file

your

tax

retu

rn u

nles

s yo

u qu

alify

for

an e

xem

ptio

n fr

om th

e re

quire

men

t tha

t you

hav

e he

alth

cov

erag

e fo

r th

at m

onth

.

Do

es t

his

pla

n m

eet

the

Min

imu

m V

alu

e S

tan

dar

ds?

[Y

es]

If

your

pla

n do

esn’

t mee

t the

Min

imum

Val

ue S

tand

ards

, you

may

be

elig

ible

for

a pr

emiu

m ta

x cr

edit

to h

elp

you

pay

for

a pl

an th

roug

h th

e M

arke

tpla

ce.

Lan

gu

age

Acc

ess

Ser

vice

s:

[Spa

nish

(E

spañ

ol):

Par

a ob

tene

r as

iste

ncia

en

Esp

añol

, lla

me

al [i

nser

t tel

epho

ne n

umbe

r].]

[Tag

alog

(T

agal

og):

Kun

g ka

ilang

an n

inyo

ang

tulo

ng s

a T

agal

og tu

maw

ag s

a [in

sert

tele

phon

e nu

mbe

r].]

[Chi

nese

(中文

): 如果需要中文的帮助，请拨打这个号码

[ins

ert t

elep

hone

num

ber]

.]

[Nav

ajo

(Din

e): D

inek

'ehg

o sh

ika

at'o

hwol

nin

isin

go, k

wiij

igo

holn

e' [i

nser

t tel

epho

ne n

umbe

r].]

––––

––––

––––

––––

––––

––T

o se

e ex

ampl

es o

f how

this

pla

n m

ight

cov

er c

osts

for

a sa

mpl

e m

edic

al s

ituat

ion,

see

the

next

sec

tion.

––––

––––

––––

––––

––––

––

2020 USW Represented 47

5

of

5

The

pla

n w

ould

be

resp

onsi

ble

for

the

othe

r co

sts

of th

ese

EX

AM

PLE

cov

ered

ser

vice

s.

Peg

is H

avin

g a

Bab

y (9

mon

ths

of in

-net

wor

k pr

e-na

tal c

are

and

a ho

spita

l del

iver

y)

Mia

’s S

imp

le F

ract

ure

(in-n

etw

ork

emer

genc

y ro

om v

isit

and

follo

w

up c

are)

Man

agin

g J

oe’

s ty

pe

2 D

iab

etes

(a y

ear

of r

outin

e in

-net

wor

k ca

re o

f a w

ell-

cont

rolle

d co

nditi

on)

◼T

he

pla

n’s

ove

rall

ded

uct

ible

$200

◼

Sp

ecia

list

[co

insu

ran

ce]

10%

◼

Ho

spit

al (

faci

lity)

[co

insu

ran

ce]

10%

◼

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er [

cost

sh

arin

g]

10%

T

his

EX

AM

PL

E e

ven

t in

clu

des

ser

vice

s lik

e:

Spe

cial

ist o

ffice

vis

its (

pren

atal

car

e)

Chi

ldbi

rth/

Del

iver

y P

rofe

ssio

nal S

ervi

ces

Chi

ldbi

rth/

Del

iver

y F

acili

ty S

ervi

ces

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gnos

tic te

sts

(ultr

asou

nds

and

bloo

d w

ork)

S

peci

alis

t vis

it (a

nest

hesi

a)

To

tal E

xam

ple

Co

st

$12,

731

In t

his

exa

mp

le, P

eg w

ou

ld p

ay:

Cos

t Sha

ring

Ded

uctib

les

$200

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aym

ents

$1

0

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nsur

ance

$1

,240

Wha

t isn

’t co

vere

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its o

r ex

clus

ions

$6

0

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e to

tal P

eg w

ou

ld p

ay is

$1

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he

pla

n’s

ove

rall

ded

uct

ible

$0

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pec

ialis

t [c

ost

sh

arin

g]

$ ◼

Ho

spit

al (

faci

lity)

[co

st s

har

ing

]%

◼

Oth

er [

cost

sh

arin

g]

%

Th

is E

XA

MP

LE

eve

nt

incl

ud

es s

ervi

ces

like:

P

rimar

y ca

re p

hysi

cian

offi

ce v

isits

(in

clud

ing

dise

ase

educ

atio

n)

Dia

gnos

tic te

sts

(blo

od w

ork)

P

resc

riptio

n dr

ugs

D

urab

le m

edic

al e

quip

men

t (gl

ucos

e m

eter

)

To

tal E

xam

ple

Co

st

$7,3

89

In t

his

exa

mp

le, J

oe

wo

uld

pay

:

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t Sha

ring

Ded

uctib

les

$200

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aym

ents

$1

80

Coi

nsur

ance

$2

73

Wha

t isn

’t co

vere

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Lim

its o

r ex

clus

ions

$5

5

Th

e to

tal J

oe

wo

uld

pay

is

$708

◼T

he

pla

n’s

ove

rall

ded

uct

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$ ◼

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ecia

list

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st s

har

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osp

ital

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cilit

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cost

sh

arin

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ther

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st s

har

ing

]%

Th

is E

XA

MP

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nt

incl

ud

es s

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like:

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mer

genc

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om c

are

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udin

g m

edic

al

supp

lies)

D

iagn

ostic

test

(x-

ray)

D

urab

le m

edic

al e

quip

men

t (cr

utch

es)

Reh

abili

tatio

n se

rvic

es (

phys

ical

ther

apy)

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tal E

xam

ple

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st

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In t

his

exa

mp

le, M

ia w

ou

ld p

ay:

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t Sha

ring

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uctib

les

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aym

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nsur

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its o

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clus

ions

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e to

tal M

ia w

ou

ld p

ay is

$3

13

Ab

ou

t th

ese

Co

vera

ge

Exa

mp

les:

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is is

no

t a

cost

est

imat

or.

Tre

atm

ents

sho

wn

are

just

exa

mpl

es o

f how

this

pla

n m

ight

cov

er m

edic

al c

are.

You

r ac

tual

cos

ts w

ill b

e di

ffere

nt d

epen

ding

on

the

actu

al c

are

you

rece

ive,

the

pric

es y

our

prov

ider

s ch

arge

, and

man

y ot

her

fact

ors.

Foc

us o

n th

e co

st s

harin

g am

ount

s (d

educ

tible

s, c

opay

men

ts a

nd c

oins

uran

ce)

and

excl

uded

ser

vice

s un

der

the

plan

. Use

this

info

rmat

ion

to c

ompa

re th

e po

rtio

n of

co

sts

you

mig

ht p

ay u

nder

diff

eren

t hea

lth p

lans

. Ple

ase

note

thes

e co

vera

ge e

xam

ples

are

bas

ed o

n se

lf-on

ly c

over

age.

2020 USW Represented 48

An

exam

ple

of a

ben

efit

book

can

be

foun

d at

http

s://s

hop.

high

mar

k.co

m/s

ales

/#!/s

bc-a

gree

men

ts.

1 o

f 7

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2019

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C

Co

vera

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Per

iod

: 01

/01/

2020

- 1

2/31

/202

0 S

um

mar

y o

f B

enef

its

and

Co

vera

ge:

Wha

t thi

s P

lan

Cov

ers

& W

hat Y

ou P

ay F

or C

over

ed

Ser

vice

s I/N

Tek

& I/N

Kot

e:

US

W C

DH

P M

edic

al &

Rx

Co

vera

ge

for:

Indi

vidu

al/F

amily

P

lan

Typ

e: C

DH

P

T

he

Su

mm

ary

of

Ben

efit

s an

d C

ove

rag

e (S

BC

) d

ocu

men

t w

ill h

elp

yo

u c

ho

ose

a h

ealt

h p

lan

. Th

e S

BC

sh

ow

s yo

u h

ow

yo

u a

nd

th

e p

lan

wo

uld

sh

are

the

cost

fo

r co

vere

d h

ealt

h c

are

serv

ices

. NO

TE

: In

form

atio

n a

bo

ut

the

cost

of

this

pla

n (

calle

d t

he

pre

miu

m)

will

be

pro

vid

ed s

epar

atel

y.

Th

is is

on

ly a

su

mm

ary.

For

mor

e in

form

atio

n ab

out y

our

cove

rage

, or

to g

et a

cop

y of

the

com

plet

e te

rms

of c

over

age,

ple

ase

visi

t ww

w.h

ighm

arkb

cbs.

com

or

call

1-86

6-26

7-32

80. F

or g

ener

al d

efin

ition

s of

com

mon

term

s, s

uch

as a

llow

ed a

mou

nt, b

alan

ce b

illin

g, c

oins

uran

ce, c

opay

men

t, de

duct

ible

, pro

vide

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r ot

her

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see

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Glo

ssar

y. Y

ou c

an v

iew

the

Glo

ssar

y at

ww

w.H

ealth

Car

e.go

v/sb

c-gl

ossa

ry/ o

r ca

ll 1-

866-

267-

3280

to r

eque

st a

cop

y.

Imp

ort

ant

Qu

esti

on

s A

nsw

ers

Wh

y th

is M

atte

rs:

Wh

at is

th

e o

vera

ll d

edu

ctib

le?

$1

,600

indi

vidu

al/$

3,20

0 fa

mily

net

wor

k.

$3,2

00 in

divi

dual

/$6,

400

fam

ily o

ut-o

f-ne

twor

k.

Gen

eral

ly, y

ou m

ust p

ay a

ll of

the

cost

s fr

om p

rovi

ders

up

to th

e de

duct

ible

am

ount

be

fore

this

pla

n be

gins

to p

ay. I

f you

hav

e ot

her

fam

ily m

embe

rs o

n th

e pl

an, e

ach

fam

ily m

embe

r m

ust m

eet t

heir

own

indi

vidu

al d

educ

tible

unt

il th

e to

tal a

mou

nt o

f de

duct

ible

exp

ense

s pa

id b

y al

l fam

ily m

embe

rs m

eets

the

over

all f

amily

ded

uctib

le.

Are

th

ere

serv

ices

co

vere

d

bef

ore

yo

u m

eet

you

r d

edu

ctib

le?

Net

wor

k de

duct

ible

doe

s no

t app

ly to

pr

even

tive

care

ser

vice

s an

d ho

spic

e se

rvic

e.

Coa

ymen

ts a

nd c

oins

uran

ce a

mou

nts

don'

t cou

nt to

war

d th

e ne

twor

k de

duct

ible

.

Thi

s pl

an c

over

s so

me

item

s an

d se

rvic

es e

ven

if yo

u ha

ven’

t yet

met

the

dedu

ctib

le

amou

nt. B

ut a

cop

aym

ent o

r co

insu

ranc

e m

ay a

pply

. For

exa

mpl

e, th

is p

lan

cove

rs

cert

ain

prev

entiv

e se

rvic

es w

ithou

t cos

t-sh

arin

g an

d be

fore

you

mee

t you

r de

duct

ible

. S

ee a

list

of c

over

ed p

reve

ntiv

e se

rvic

es a

t ht

tps:

//ww

w.h

ealth

care

.gov

/cov

erag

e/pr

even

tive-

care

-ben

efits

/.

Are

th

ere

oth

er d

edu

ctib

les

for

spec

ific

ser

vice

s?

No.

Y

ou d

on’t

have

to m

eet d

educ

tible

s fo

r sp

ecifi

c se

rvic

es.

Wh

at is

th

e o

ut-

of-

po

cket

lim

it

for

this

pla

n?

$3

,000

indi

vidu

al/$

6,00

0 fa

mily

net

wor

k.

$6,0

00 in

divi

dual

/$12

,000

fam

ily o

ut-o

f-ne

twor

k.

The

out

-of-

pock

et li

mit

is th

e m

ost y

ou c

ould

pay

in a

yea

r fo

r co

vere

d se

rvic

es. I

f you

ha

ve o

ther

fam

ily m

embe

rs in

this

pla

n, th

ey h

ave

to m

eet t

heir

own

out-

of-p

ocke

t lim

its u

ntil

the

over

all f

amily

out

-of-

pock

et li

mit

has

been

met

.

Wh

at is

no

t in

clu

ded

in t

he

ou

t–o

f–p

ock

et li

mit

?

Pre

miu

ms,

bal

ance

-bill

ed c

harg

es, a

nd

heal

th c

are

this

pla

n do

esn'

t cov

er d

o no

t app

ly to

you

r to

tal m

axim

um o

ut-o

f-po

cket

.

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

don'

t cou

nt to

war

d th

e ou

t-of

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ket l

imit.

Will

yo

u p

ay le

ss if

yo

u

use

a n

etw

ork

pro

vid

er?

Y

es. F

or a

list

of n

etw

ork

prov

ider

s, s

ee

ww

w.h

ighm

arkb

cbs.

com

or

call

1-

866-

267-

3280

.

Thi

s pl

an u

ses

a pr

ovid

er n

etw

ork.

You

will

pay

less

if y

ou u

se a

pro

vide

r in

the

plan

’s

netw

ork.

You

will

pay

the

mos

t if y

ou u

se a

n ou

t-of

-net

wor

k pr

ovid

er, a

nd y

ou m

ight

re

ceiv

e a

bill

from

a p

rovi

der

for

the

diffe

renc

e be

twee

n th

e pr

ovid

er’s

cha

rge

and

wha

t you

r pl

an p

ays

(bal

ance

bill

ing)

. B

e aw

are

your

net

wor

k pr

ovid

er m

ight

use

an

out-

of-n

etw

ork

prov

ider

for

som

e se

rvic

es (

such

as

lab

wor

k). C

heck

with

you

r pr

ovid

er b

efor

e yo

u ge

t ser

vice

s.

2020 USW Represented 49

2 o

f 7

Do

I n

eed

a r

efer

ral t

o s

ee a

sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out a

ref

erra

l.

All

cop

aym

ent

and

coin

sura

nce

cos

ts s

how

n in

this

cha

rt a

re a

fter

your

ove

rall

ded

uct

ible

has

bee

n m

et, i

f a d

educ

tible

app

lies.

Co

mm

on

Med

ical

E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s, E

xcep

tio

ns,

an

d O

ther

Im

po

rtan

t In

form

atio

n

Net

wo

rk P

rovi

der

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ou

will

pay

th

e le

ast)

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t-o

f-N

etw

ork

P

rovi

der

(Y

ou

will

p

ay t

he

mo

st)

If y

ou

vis

it a

hea

lth

ca

re p

rovi

der

’s

off

ice

or

clin

ic

Prim

ary

care

vis

it to

trea

t an

inju

ry o

r ill

ness

20

% c

oins

uran

ce

40%

coi

nsur

ance

Y

ou m

ay h

ave

to p

ay fo

r se

rvic

es th

at

aren

’t pr

even

tive.

Ask

you

r pr

ovid

er if

th

e se

rvic

es n

eede

d ar

e pr

even

tive.

T

hen

chec

k w

hat y

our

plan

will

pay

for.

Ple

ase

refe

r to

you

r pr

even

tive

sche

dule

fo

r ad

ditio

nal i

nfor

mat

ion.

Spe

cial

ist v

isit

20%

coi

nsur

ance

40

% c

oins

uran

ce

Pre

vent

ive

care

/Scr

eeni

ng/Im

mun

izat

ion

No

char

ge fo

r pr

even

tive

care

se

rvic

es

40%

coi

nsur

ance

for

prev

entiv

e ca

re

serv

ices

If y

ou

hav

e a

test

D

iagn

ostic

test

(x-

ray,

blo

od w

ork)

20

% c

oins

uran

ce

40%

coi

nsur

ance

P

rece

rtifi

catio

n m

ay b

e re

quire

d.

Imag

ing

(CT

/PE

T s

cans

, MR

Is)

20%

coi

nsur

ance

40

% c

oins

uran

ce

Pre

cert

ifica

tion

may

be

requ

ired.

If y

ou

nee

d d

rug

s to

tre

at y

ou

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out p

resc

rip

tio

n

dru

g c

ove

rag

e is

av

aila

ble

at

1-86

6-26

7-32

80.

Ret

ail 3

0-da

y su

pply

: Gen

eric

dru

gs, F

orm

ular

y B

rand

& N

on-F

orm

ular

y B

rand

20

% c

oins

uran

ce

50%

of t

he c

ost o

f dr

ug c

oins

uran

ce

RX

ben

efits

pro

vide

d by

CV

S C

arem

ark

Pre

vent

ive

med

icat

ions

(de

fined

in C

VS

pr

even

tive

ther

apy

drug

list

) ar

e co

vere

d at

100

%.

Cov

erag

e fo

r ce

rtai

n dr

ugs

is s

ubje

ct to

pr

ior

auth

oriz

atio

n an

d/or

qua

ntity

, dos

e or

dur

atio

n lim

its.

To

conf

irm w

heth

er

this

app

lies

to a

cer

tain

dru

g, c

onta

ct

CV

S C

arem

ark

by c

allin

g 1-

888-

202-

1654

.

Spe

cial

ity d

rugs

req

uire

prio

r au

thor

izat

ion

and

mus

t be

fille

d at

CV

S

Car

emar

k S

peci

alty

Pha

rmac

ies.

Mai

l Ser

vice

up

to 9

0-da

y su

pply

: Gen

eric

dr

ugs,

For

mul

ary

Bra

nd &

Non

-For

mul

ary

Bra

nd

Spe

cial

ty D

rugs

20%

coi

nsur

ance

20%

coi

nsur

ance

50%

of t

he c

ost o

f dr

ug c

oins

uran

ce

Not

Cov

ered

2020 USW Represented 50

3 o

f 7

Co

mm

on

Med

ical

E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s, E

xcep

tio

ns,

an

d O

ther

Im

po

rtan

t In

form

atio

n

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Ou

t-o

f-N

etw

ork

P

rovi

der

(Y

ou

will

p

ay t

he

mo

st)

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(e.g

., am

bula

tory

sur

gery

cen

ter)

20

% c

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ce

40%

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nsur

ance

P

rece

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catio

n m

ay b

e re

quire

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Phy

sici

an/s

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on fe

es

20%

coi

nsur

ance

40

% c

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uran

ce

Pre

cert

ifica

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may

be

requ

ired.

If y

ou

nee

d

imm

edia

te m

edic

al

atte

nti

on

Em

erge

ncy

room

car

e 20

% c

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ce

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nsur

ance

O

ut-o

f-ne

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k: S

ubje

ct to

net

wor

k de

duct

ible

.

Em

erge

ncy

med

ical

tran

spor

tatio

n 20

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ce

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nsur

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O

ut-o

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k: S

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net

wor

k de

duct

ible

.

Urg

ent c

are

20%

coi

nsur

ance

40

% c

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uran

ce

−−

−−

−−

−−

−−

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ne−

−−

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If y

ou

hav

e a

ho

spit

al s

tay

Fac

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fee

(e.g

., ho

spita

l roo

m)

20%

coi

nsur

ance

40

% c

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uran

ce

Pre

cert

ifica

tion

may

be

requ

ired.

Phy

sici

an/s

urge

on fe

e 20

% c

oins

uran

ce

40%

coi

nsur

ance

P

rece

rtifi

catio

n m

ay b

e re

quire

d.

If y

ou

hav

e m

enta

l h

ealt

h, b

ehav

iora

l h

ealt

h, o

r su

bst

ance

ab

use

n

eed

s

Out

patie

nt s

ervi

ces

20%

coi

nsur

ance

40

% c

oins

uran

ce

Pre

cert

ifica

tion

may

be

requ

ired.

Inpa

tient

ser

vice

s 20

% c

oins

uran

ce

40%

coi

nsur

ance

P

rece

rtifi

catio

n m

ay b

e re

quire

d.

If y

ou

are

pre

gn

ant

Offi

ce v

isits

20

% c

oins

uran

ce

40%

coi

nsur

ance

C

ost s

harin

g do

es n

ot a

pply

for

prev

entiv

e se

rvic

es.

Dep

endi

ng o

n th

e ty

pe o

f ser

vice

s, a

co

paym

ent,

coin

sura

nce,

or

dedu

ctib

le

may

app

ly.

Mat

erni

ty c

are

may

incl

ude

test

s an

d se

rvic

es d

escr

ibed

els

ewhe

re in

the

SB

C (

i.e. u

ltras

ound

.)

Net

wor

k: T

he fi

rst v

isit

to d

eter

min

e pr

egna

ncy

is c

over

ed a

t no

char

ge.

Ple

ase

refe

r to

the

Wom

en’s

Hea

lth

Pre

vent

ive

Sch

edul

e fo

r ad

ditio

nal

info

rmat

ion.

P

rece

rtifi

catio

n m

ay b

e re

quire

d.

Chi

ldbi

rth/

deliv

ery

prof

essi

onal

ser

vice

s 20

% c

oins

uran

ce

40%

coi

nsur

ance

Chi

ldbi

rth/

deliv

ery

faci

lity

serv

ices

20

% c

oins

uran

ce

40%

coi

nsur

ance

2020 USW Represented 51

4 o

f 7

Co

mm

on

Med

ical

E

ven

t S

ervi

ces

Yo

u M

ay N

eed

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s, E

xcep

tio

ns,

an

d O

ther

Im

po

rtan

t In

form

atio

n

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

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t-o

f-N

etw

ork

P

rovi

der

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ou

will

p

ay t

he

mo

st)

If y

ou

nee

d h

elp

re

cove

rin

g o

r h

ave

oth

er s

pec

ial h

ealt

h

nee

ds

Hom

e he

alth

car

e 20

% c

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nsur

ance

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ut-o

f-ne

twor

k: 3

0 vi

sits

per

ben

efit

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d, c

ombi

ned

with

vis

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nur

se.

Pre

cert

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may

be

requ

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Reh

abili

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rvic

es

20%

coi

nsur

ance

40

% c

oins

uran

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Com

bine

d ne

twor

k an

d ou

t-of

-net

wor

k:

60 p

hysi

cal m

edic

ine

visi

ts a

nd 6

0 oc

cupa

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rapy

vis

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er b

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it pe

riod.

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rece

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n m

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e re

quire

d.

Hab

ilita

tion

serv

ices

N

ot c

over

ed

Not

cov

ered

−

−−

−−

−−

−−

−−

none

−−

−−

−−

−−

−−

−

Ski

lled

nurs

ing

care

20

% c

oins

uran

ce

40%

coi

nsur

ance

P

rece

rtifi

catio

n m

ay b

e re

quire

d.

Dur

able

med

ical

equ

ipm

ent

20%

coi

nsur

ance

40

% c

oins

uran

ce

Pre

cert

ifica

tion

may

be

requ

ired.

Hos

pice

ser

vice

N

o ch

arge

N

o ch

arge

P

rece

rtifi

catio

n m

ay b

e re

quire

d.

If y

ou

r ch

ild n

eed

s d

enta

l or

eye

care

C

hild

ren’

s E

ye e

xam

20

% c

oins

uran

ce

40%

coi

nsur

ance

O

ne r

outin

e ey

e ex

am e

very

12

mon

ths.

Chi

ldre

n’s

Gla

sses

N

ot c

over

ed

Not

cov

ered

−

−−

−−

−−

−−

−−

none

−−

−−

−−

−−

−−

−

Chi

ldre

n’s

Den

tal c

heck

-up

Not

cov

ered

N

ot c

over

ed

−−

−−

−−

−−

−−

−no

ne−

−−

−−

−−

−−

−−

Exc

lud

ed S

ervi

ces

& O

ther

Co

vere

d S

ervi

ces:

Ser

vice

s Y

ou

r P

lan

Gen

eral

ly D

oes

NO

T C

ove

r (C

hec

k yo

ur

po

licy

or

pla

n d

ocu

men

t fo

r m

ore

info

rmat

ion

an

d a

list

of

any

oth

er e

xclu

ded

ser

vice

s.)

•A

cupu

nctu

re•

Hab

ilita

tion

serv

ices

•R

outin

e fo

ot c

are

•C

osm

etic

sur

gery

•Lo

ng-t

erm

car

e•

Wei

ght l

oss

prog

ram

s

•D

enta

l car

e (A

dult)

Oth

er C

ove

red

Ser

vice

s (L

imit

atio

ns

may

ap

ply

to

th

ese

serv

ices

. Th

is is

n’t

a c

om

ple

te li

st. P

leas

e se

e yo

ur

pla

n d

ocu

men

t.)

•B

aria

tric

sur

gery

•H

earin

g ai

ds•

Priv

ate-

duty

nur

sing

•C

hiro

prac

tic c

are

•In

fert

ility

trea

tmen

t•

Rou

tine

eye

care

(A

dult)

•C

over

age

prov

ided

out

side

the

Uni

ted

Sta

tes.

See

http

://w

ww

.bcb

s.co

m•

Non

-em

erge

ncy

care

whe

n tr

avel

ing

outs

ide

the

U.S

.

2020 USW Represented 52

5 o

f 7

Yo

ur

Rig

hts

to

Co

nti

nu

e C

ove

rag

e: T

here

are

age

ncie

s th

at c

an h

elp

if yo

u w

ant t

o co

ntin

ue y

our

cove

rage

afte

r it

ends

. The

con

tact

info

rmat

ion

for

thos

e ag

enci

es is

: Dep

artm

ent o

f Lab

or’s

Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istr

atio

n at

1-8

66-4

44-E

BS

A (

3272

) or

ww

w.d

ol.g

ov/e

bsa/

heal

thre

form

, or

the

Dep

artm

ent o

f H

ealth

and

Hum

an S

ervi

ces,

Cen

ter

for

Con

sum

er In

form

atio

n an

d In

sura

nce

Ove

rsig

ht, a

t 1-8

77-2

67-2

323

x615

65 o

r w

ww

.cci

io.c

ms.

gov.

The

Pen

nsyl

vani

a D

epar

tmen

t of C

onsu

mer

Ser

vice

s at

1-8

77-8

81-6

388.

Oth

er o

ptio

ns to

con

tinue

cov

erag

e ar

e av

aila

ble

to y

ou to

o, in

clud

ing

buyi

ng in

divi

dual

insu

ranc

e co

vera

ge

thro

ugh

the

Hea

lth In

sura

nce

Mar

ketp

lace

. For

mor

e in

form

atio

n ab

out t

he M

arke

tpla

ce, v

isit

http

://w

ww

.Hea

lthC

are.

gov

or c

all 1

-800

-318

-259

6.

Yo

ur

Gri

evan

ce a

nd

Ap

pea

ls R

igh

ts:

The

re a

re a

genc

ies

that

can

hel

p if

you

have

a c

ompl

aint

aga

inst

you

r pl

an fo

r a

deni

al o

f a c

laim

. Thi

s co

mpl

aint

is c

alle

d a

grie

vanc

e or

app

eal.

For

mor

e in

form

atio

n ab

out y

our

right

s, lo

ok a

t the

exp

lana

tion

of b

enef

its y

ou w

ill r

ecei

ve fo

r th

at m

edic

al c

laim

. You

r pl

an d

ocum

ents

als

o pr

ovid

e co

mpl

ete

info

rmat

ion

to s

ubm

it a

clai

m a

ppea

l or

a gr

ieva

nce

for

any

reas

on to

you

r pl

an. F

or m

ore

info

rmat

ion

abou

t you

r rig

hts,

this

not

ice,

or

assi

stan

ce,

cont

act:

•Y

our

plan

adm

inis

trat

or/e

mpl

oyer

.

•T

he D

epar

tmen

t of L

abor

’s E

mpl

oyee

Ben

efits

Sec

urity

Adm

inis

trat

ion

at 1

-866

-444

-EB

SA

(32

72)

or w

ww

.dol

.gov

/ebs

a/he

alth

refo

rm.

Do

es t

his

pla

n p

rovi

de

Min

imu

m E

ssen

tial

Co

vera

ge?

Yes

If

you

don’

t hav

e M

inim

um E

ssen

tial C

over

age

for

a m

onth

, you

’ll h

ave

to m

ake

a pa

ymen

t whe

n yo

u fil

e yo

ur ta

x re

turn

unl

ess

you

qual

ify fo

r an

exe

mpt

ion

from

the

requ

irem

ent t

hat y

ou h

ave

heal

th c

over

age

for

that

mon

th.

Do

es t

his

pla

n m

eet

the

Min

imu

m V

alu

e S

tan

dar

ds?

Yes

If

your

pla

n do

esn’

t mee

t the

Min

imum

Val

ue S

tand

ards

, you

may

be

elig

ible

for

a pr

emiu

m ta

x cr

edit

to h

elp

you

pay

for

a pl

an th

roug

h th

e M

arke

tpla

ce.

––––

––––

––––

––––

–To

see

exam

ples

of h

ow th

is p

lan

mig

ht c

over

cos

ts fo

r a

sam

ple

med

ical

situ

atio

n, s

ee th

e ne

xt p

age.––

––––

––––

––––

––––

––––

2020 USW Represented 53

6 o

f 7

Abo

ut th

ese

Cov

erag

e E

xam

ples

:

Th

is is

no

t a

cost

est

imat

or.

Tre

atm

ents

sho

wn

are

just

exa

mpl

es o

f how

this

pla

n m

ight

cov

er m

edic

al c

are.

You

r ac

tual

cos

ts w

ill b

e di

ffere

nt d

epen

ding

on

the

actu

al c

are

you

rece

ive,

the

pric

es y

our

prov

ider

s ch

arge

, and

man

y ot

her

fact

ors.

Foc

us o

n th

e co

st s

harin

g am

ount

s (d

educ

tible

s, c

opay

men

ts a

nd c

oins

uran

ce)

and

excl

uded

ser

vice

s un

der

the

plan

. Use

this

info

rmat

ion

to c

ompa

re th

e po

rtio

n of

co

sts

you

mig

ht p

ay u

nder

diff

eren

t hea

lth p

lans

. Ple

ase

note

thes

e co

vera

ge e

xam

ples

are

bas

ed o

n se

lf-on

ly c

over

age.

Peg

is H

avin

g a

Bab

y (9

mon

ths

of in

-net

wor

k pr

e-na

tal c

are

and

a ho

spita

l del

iver

y)

Man

agin

g J

oe’

s ty

pe

2 D

iab

etes

(a

yea

r of

rou

tine

in-n

etw

ork

care

of a

wel

l-co

ntro

lled

cond

ition

)

Mia

’s S

imp

le F

ract

ure

(in

-net

wor

k em

erge

ncy

room

vis

it an

d fo

llow

up

care

)

◼T

he p

lan’

s ov

eral

l ded

uctib

le◼

Spe

cial

ist c

oins

uran

ce◼

Hos

pita

l (fa

cilit

y) c

oins

uran

ce◼

Oth

er c

oins

uran

ce

$1,6

00

20%

20

%

20%

◼T

he p

lan’

s ov

eral

l ded

uctib

le◼

Spe

cial

ist c

oins

uran

ce◼

Hos

pita

l (fa

cilit

y) c

oins

uran

ce◼

Oth

er c

oins

uran

ce

$1,6

00

20%

20

%

20%

◼T

he p

lan’

s ov

eral

l ded

uctib

le◼

Spe

cial

ist c

oins

uran

ce◼

Hos

pita

l (fa

cilit

y) c

oins

uran

ce◼

Oth

er c

oins

uran

ce

$1,6

00

20%

20

%

20%

Th

is E

XA

MP

LE

eve

nt

incl

ud

es s

ervi

ces

like:

S

peci

alis

t offi

ce v

isits

(pr

enat

al c

are)

C

hild

birt

h/D

eliv

ery

Pro

fess

iona

l Ser

vice

s C

hild

birt

h/D

eliv

ery

Fac

ility

Ser

vice

s D

iagn

ostic

te

sts

(ultr

asou

nds

and

bloo

d w

ork)

Spe

cial

ist v

isit

(ane

sthe

sia)

Th

is E

XA

MP

LE

eve

nt

incl

ud

es s

ervi

ces

like:

P

rimar

y ca

re p

hysi

cian

offi

ce v

isits

(in

clud

ing

dise

ase

educ

atio

n) D

iagn

ostic

test

s (b

lood

wor

k)

Pre

scrip

tion

drug

s D

urab

le m

edic

al e

quip

men

t (g

luco

se m

eter

)

Th

is E

XA

MP

LE

eve

nt

incl

ud

es s

ervi

ces

like:

E

mer

genc

y ro

om c

are

(incl

udin

g m

edic

al s

uppl

ies)

D

iagn

ostic

test

(x-

ray)

Dur

able

med

ical

equ

ipm

ent

(cru

tche

s) R

ehab

ilita

tion

serv

ices

(ph

ysic

al

ther

apy)

To

tal E

xam

ple

Co

st

$12,

800

To

tal E

xam

ple

Co

st

$7,4

00

To

tal E

xam

ple

Co

st

$1,9

00

In t

his

exa

mp

le, P

eg w

ou

ld p

ay:

In t

his

exa

mp

le, J

oe

wo

uld

pay

: In

th

is e

xam

ple

, Mia

wo

uld

pay

:

Cos

t Sha

ring

Cos

t Sha

ring

Cos

t Sha

ring

Ded

uctib

les

$1,6

00

Ded

uctib

les

$1,6

00

Ded

uctib

les

$1,6

00

Cop

aym

ents

$0

C

opay

men

ts

$0

Cop

aym

ents

$0

Coi

nsur

ance

$2

,200

C

oins

uran

ce

$400

C

oins

uran

ce

$70

Wh

at is

n’t

co

vere

d

Wh

at is

n’t

co

vere

d

Wh

at is

n’t

co

vere

d

Lim

its o

r ex

clus

ions

$1

00

Lim

its o

r ex

clus

ions

$4

,300

Li

mits

or

excl

usio

ns

$0

Th

e to

tal P

eg w

ou

ld p

ay is

$3

,900

T

he

tota

l Jo

e w

ou

ld p

ay is

$6

,300

T

he

tota

l Mia

wo

uld

pay

is

$1,6

70

Not

e: T

hese

num

bers

ass

ume

the

patie

nt d

oes

not p

artic

ipat

e in

the

plan

’s w

elln

ess

prog

ram

. If y

ou p

artic

ipat

e in

the

plan

’s w

elln

ess

prog

ram

, you

may

be

able

to

redu

ce y

our

cost

s. F

or m

ore

info

rmat

ion

abou

t the

wel

lnes

s pr

ogra

m, p

leas

e co

ntac

t: 1-

866-

267-

3280

.

The

pla

n w

ould

be

resp

onsi

ble

for

the

othe

r co

sts

of th

ese

EX

AM

PLE

cov

ered

ser

vice

s.

2020 USW Represented 54

Insu

ranc

e or

ben

efit

adm

inis

trat

ion

may

be

prov

ided

by

Hig

hmar

k B

lue

Cro

ss B

lue

Shi

eld

and

Hig

hmar

k C

hoic

e C

ompa

ny w

hich

are

inde

pend

ent

licen

sees

of t

he B

lue

Cro

ss a

nd B

lue

Shi

eld

Ass

ocia

tion.

Hea

lth c

are

plan

s ar

e su

bjec

t to

term

s of

the

bene

fit a

gre

emen

t.

To

find

mor

e in

form

atio

n ab

out H

ighm

ark’

s be

nefit

s an

d op

erat

ing

proc

edur

es, s

uch

as a

cces

sing

the

drug

form

ular

y or

usi

ng n

etw

ork

prov

ider

s,

plea

se g

o to

Dis

cove

rHig

hmar

k.co

m; o

r fo

r a

pape

r co

py, c

all 1

-855

-873

-410

6.

2020 USW Represented 55

7 of 7

2020 USW Represented 56

This Employee Benefits Guide is intended as a summary and reference guide for I/N Tek & I/N Kote USA

employees. While this guide does not address every plan detail, an official plan document is available for

full benefit information. If there is a discrepancy between the summaries described in this document

and the plan document, the plan document will prevail.

2020 USW Represented 57