SUMMARY PLAN DESCRIPTION for the JOHNS MANVILLE RETIREE HEALTH CARE PLAN. and the JOHNS MANVILLE MEDICARE SUBSIDY HRA

Transcription

1 SUMMARY PLAN DESCRIPTION for the JOHNS MANVILLE RETIREE HEALTH CARE PLAN and the JOHNS MANVILLE MEDICARE SUBSIDY HRA January 2013

2 TABLE OF CONTENTS INTRODUCTION... 1 BENEFITS DESCRIBED IN THIS SPD... 1 ABOUT THIS SPD... 1 THIS SPD INCLUDES A SUMMARY OF THE MEDICARE HRA'S TERMS... 2 THIS SPD ALSO INCLUDES A SUMMARY OF THE PLAN S MEDICAL AND PRESCRIPTION DRUG BENEFITS... 3 Comparison of CIGNA and Aetna Medical Benefits... 3 QUESTIONS?... 4 IMPORTANT CONTACT INFORMATION... 5 REMINDERS... 5 FOLLOW PLAN PROCEDURES... 5 TAX IMPLICATIONS... 5 A WORD ABOUT YOUR PRIVACY... 6 HEALTH PROTECTION OVERVIEW... 7 SUMMARY OF THE PLAN S MEDICAL BENEFITS... 7 SUMMARY OF THE MEDICARE HRA BENEFITS... 8 PLAN AND MEDICARE HRA DETERMINATIONS ARE NOT HEALTH CARE ADVICE... 9 ELIGIBILITY AND ENROLLMENT ELIGIBILITY TO PARTICIPATE IN THE PLAN OR MEDICARE HRA Eligible Retirees Determination of Tax Dependent Status Other Rules of Eligibility for the Plan CONFIRMING ELIGIBLE DEPENDENT STATUS ENROLLING FOR COVERAGE UNDER THE PLAN IDENTIFICATION CARD EFFECTIVE DATE OF PLAN COVERAGE FOR ELIGIBLE RETIREES EFFECTIVE DATE OF PLAN COVERAGE FOR ELIGIBLE DEPENDENTS EFFECTIVE DATE OF HRA COVERAGE ANNUAL ENROLLMENT IN THE PLAN EFFECT OF DROPPING COVERAGE CHANGING YOUR COVERAGE UNDER THE MEDICARE HRA i -

3 TABLE OF CONTENTS (continued) CHANGING YOUR COVERAGE UNDER THE PLAN Dropping Coverage Loss Of Other Coverage Adding A New Dependent Change in Status Election Change to Correspond to Eligible Dependent s Coverage Requesting A Change Due To A Change in Status Or To Correspond To Eligible Dependent s Coverage ENROLLING A CHILD COVERED BY A QMCSO COST OF COVERAGE UNDER THE PLAN COST OF COVERAGE UNDER THE MEDICARE HRA Hardship Waiver Program PAYMENT METHODS: COVERAGE UNDER THE PLAN Company Retirement Check Deduction Direct Payment Late Payments PAYMENT METHODS: MEDICARE HRA MEDICAL BENEFITS UNDER THE PLAN OPEN ACCESS PLUS ( OAP ) PROGRAM AND POINT OF SERVICE ( POS ) PROGRAM CONSUMER CHOICE HEALTH PLAN ( CCHP ) PROGRAM AND CHOICE POS II HIGH DEDUCTIBLE HEALTH PLAN PROGRAM ( HDHP ) Prescription Drug Coverage Participation in a Health Savings Account ( HSA ) CIGNA OUT-OF-AREA NETWORK PROGRAM COINSURANCE AND COPAYMENTS Coinsurance Copayments MAXIMUM REIMBURSABLE CHARGE OR NEGOTIATED RATE SATISFYING THE ANNUAL DEDUCTIBLE Annual Deductible under the CIGNA OAP / Aetna POS Program and Out-of-Area Network Program Annual Deductible under the CIGNA CCHP / Aetna HDHP Program ii -

4 TABLE OF CONTENTS (continued) MEETING THE ANNUAL OUT-OF-POCKET MAXIMUM CIGNA OAP / Aetna POS Program and Out-of-Area Network Program CIGNA CCHP / Aetna HDHP Program MAXIMUM BENEFITS OTHER REQUIREMENTS MEDICAL NECESSITY COVERED EXPENSES PRECERTIFICATION Precertification Procedures In General Concurrent Review Retrospective Review Services and Supplies Subject to Precertification Precertification List CHECKING HOSPITAL BILLS CASE MANAGEMENT COVERED MEDICAL SERVICES AND SUPPLIES UNDER THE PLAN BENEFITS SUMMARIES ANESTHESIA BENEFITS CHIROPRACTIC CARE AND SPINAL MANIPULATION ACUPUNCTURE DURABLE MEDICAL EQUIPMENT EMERGENCY CARE HOME HEALTH CARE HOSPICE CARE HOSPITAL CARE MATERNITY CARE MENTAL HEALTH AND SUBSTANCE ABUSE ORGAN TRANSPLANTS Organ Transplant Benefit Maximum PHYSICIAN S OFFICE CARE iii -

5 TABLE OF CONTENTS (continued) PREADMISSION TESTING Limitations PREVENTIVE HEALTH CARE PROSTHETIC APPLIANCES SKILLED NURSING FACILITY SURGERY THERAPY (PHYSICAL, SPEECH, OCCUPATIONAL, CARDIAC, PULMONARY, COGNITIVE) MISCELLANEOUS SERVICES Diagnostic X-Ray and Lab Charges Therapeutic Services Other EXCLUDED MEDICAL SUPPLIES AND SERVICES UNDER THE PLAN WHAT IS NOT COVERED UNDER THE SELF-FUNDED MEDICAL PROGRAMS PRESCRIPTION DRUG BENEFITS UNDER THE PLAN PRESCRIPTION DRUG ADMINISTRATOR PHARMACY-PURCHASED PRESCRIPTION DRUGS CIGNA OAP / Aetna POS or Out-of-Area Network Program Pharmacy-Purchased Prescription Drug Benefits for the CIGNA CCHP / Aetna HDHP Program MAIL ORDER PRESCRIPTION DRUGS GENERIC DRUGS COVERED PRESCRIPTION DRUGS LIMITATIONS EXCLUSIONS NEW PRESCRIPTION DRUGS SPECIAL NOTICES REGARDING BENEFITS UNDER THE PLAN MINIMUM HOSPITAL STAYS FOR NEWBORNS AND MOTHERS RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMY NO DISCRIMINATION BASED ON GENETIC INFORMATION OR SPECIFIED HEALTH STATUS FACTORS iv -

6 TABLE OF CONTENTS (continued) WHEN HEALTH PROTECTION COVERAGE ENDS WHEN COVERAGE ENDS FOR ELIGIBLE RETIREES Eligible Retirees who are Former Union-Represented Employees WHEN COVERAGE ENDS FOR ELIGIBLE DEPENDENT CONTINUATION COVERAGE UNDER COBRA Qualifying Events Under the Plan Qualifying Events Under the Medicare HRA Termination Of COBRA Continuation Coverage Cost Of COBRA Continuation Coverage How To Apply For COBRA Continuation Coverage Paying For COBRA Continuation Coverage CONTINUATION COVERAGE FOLLOWING DEATH EXTENDED COVERAGE AFTER CONTINUATION COVERAGE ENDS CONTINUATION COVERAGE RIGHTS UNDER STATE LAW CLAIMING BENEFITS UNDER THE PLAN OR THE MEDICARE HRA SUBMITTING A MEDICAL CLAIM UNDER THE PLAN SUBMITTING A PRESCRIPTION DRUG CLAIM UNDER THE PLAN SUBMITTING A MEDICARE HRA SUBSIDY CLAIM OTHER SOURCES FOR EXPENSE REIMBURSEMENT HSA Participation WHEN YOUR CLAIM WILL BE DECIDED Post-Service Claims Pre-Service Claims Urgent Care Claims Concurrent Care Claims If You Fail to Follow the Claims Procedure NOTICE OF A CLAIM DENIAL v -

7 TABLE OF CONTENTS (continued) APPEALING A DENIED CLAIM Appeals: Plan Claims Level One Appeal Level Two Appeal Your Rights During the Appeals Administrator s Review of Your Appeal Appeals: Medicare HRA Subsidy VOLUNTARY REVIEWS OF CLAIMS APPEALS APPEAL TO THE PLAN ADMINISTRATOR NOTICE OF BENEFIT DETERMINATION ON APPEAL LEGAL ACTION COORDINATION OF BENEFITS, RESTITUTION AND SUBROGATION COORDINATION OF BENEFITS Coordination with Other Plan Coverage Coordination With No-Fault Insurance Coordination with Medicare Parts A and B RESTITUTION; PLAN S RIGHT OF FULL RECOVERY; THIRD PARTY LIABILITY Plan s Subrogation and Reimbursement Rights OTHER IMPORTANT INFORMATION PLAN NAME AND PLAN NUMBER TYPE OF PLAN PLAN YEAR PLAN SPONSOR PLAN ADMINISTRATOR AND CLAIMS ADMINISTRATORS Discretionary Authority Benefits Committee Self-Funded Medical Program Administrator / Claims Administrator Utilization Review Organization Fully-Insured Medical Program Administrator / Claims Administrator Prescription Drug Administrator COBRA Administrator Medicare HRA Administrator vi -

8 TABLE OF CONTENTS (continued) LEGAL CONTACT PLAN AND MEDICARE HRA FUNDING COLLECTIVE BARGAINING AGREEMENT FUTURE OF THE PLAN AND MEDICARE HRA NO GUARANTEE OF EMPLOYMENT LEGALLY ENFORCEABLE INVALID PROVISIONS INSPECTION OF PLAN DOCUMENTS FRAUDULENT CLAIMS AND MISREPRESENTATIONS ASSIGNMENT OF BENEFITS PAYMENT TO REPRESENTATIVE MISSING PERSON YOUR ERISA RIGHTS CIRCUMSTANCES THAT MAY AFFECT YOUR PLAN BENEFITS APPENDIX A DEFINITIONS... A-1 Adverse Benefit Determination... A-1 Aetna... A-1 Affiliate... A-1 Ambulatory Care Center... A-1 Appeals Administrator... A-2 Benefits Committee... A-2 Birthing Center... A-2 Board of Directors... A-3 Case Management... A-3 Case Manager... A-3 CCHP... A-3 Chemical Dependency Treatment Center... A-3 Child... A-3 CIGNA... A-4 CIGNA CCHP Program... A-4 CIGNA OAP Program... A-4 - vii -

9 TABLE OF CONTENTS (continued) Claims Administrator... A-4 COBRA... A-4 Code... A-4 Coinsurance... A-4 Company... A-4 Concurrent Review... A-5 Copayment or Copay... A-5 Coverage Option... A-5 Covered Service or Supply... A-5 Covered Expense... A-5 Deductible... A-5 Deemed Age 65 Date... A-5 Eligible Dependent... A-6 Eligible Retiree... A-6 ERISA... A-6 Experimental, Investigational or Unproven... A-6 FDA... A-6 Fully-Insured Medical Program... A-6 Geographic Area... A-6 HDHP Program... A-7 Hire Date... A-7 Home Health Care Agency... A-7 Hospice... A-7 Hospice Care Program... A-7 Hospital... A-8 Household... A-8 HSA... A-8 Illness... A-8 Immediate Relative... A-8 Incurred... A-9 Independent Review Organization... A-9 - viii -

10 TABLE OF CONTENTS (continued) Injury... A-9 In-Network Care or In-Network... A-9 In-Network Pharmacy... A-9 In-Network Provider... A-9 Inpatient... A-10 IRO... A-10 Insurer... A-10 Insurer s Booklet... A-10 Intensive Care/Coronary Care Unit... A-10 IRS... A-10 Maximum Reimbursable Charge... A-11 Medical Emergency... A-11 Medical Program... A-12 Medically Necessary... A-12 Medicare... A-12 Medicare HRA Administrator or Medicare Subsidy HRA Administrator... A-13 Medicare HRA or Medicare Subsidy HRA Program... A-13 Mentally Disabled... A-13 Morbid Obesity... A-13 Negotiated Rate... A-13 Network Administrator... A-14 Non-Service Related... A-14 Nurse... A-14 Nurse Midwife... A-14 OAP... A-14 Option or Coverage Option... A-14 Out-of-Area Network Program... A-14 Out-of-Network Care or Out-of-Network... A-14 Out-of-Network Pharmacy... A-14 Out-of-Network Provider... A-15 Out-of-Pocket Expenses... A-15 - ix -

11 TABLE OF CONTENTS (continued) Out-of-Pocket Maximum... A-15 Outpatient... A-16 Participant... A-16 Participating Company... A-16 Physician... A-16 Physically Disabled... A-17 Plan Administrator... A-17 POS Program... A-17 Precertification... A-17 Program... A-17 Provider... A-17 QMCSO... A-17 Relevant Information... A-18 Retiree... A-18 Retires or Retired... A-18 Retirement Date... A-18 Retrospective Review... A-18 Self-Funded Medical Program... A-18 Skilled Nursing Facility... A-18 Spouse... A-19 Structured Outpatient Program... A-19 Surgery... A-19 Surgery Center... A-20 Tax Dependent... A-21 Terminally Ill... A-22 Utilization Review Organization... A-22 Years of Service... A-22 - x -

12 TABLE OF CONTENTS (continued) APPENDIX B RETIREE ELIGIBILITY FORMER SALARIED EMPLOYEES AND RETIREES... B-1 APPENDIX B RETIREE ELIGIBILITY NON-UNION HOURLY EMPLOYEES AND RETIREES... B-5 APPENDIX B RETIREE ELIGIBILITY UNION HOURLY EMPLOYEES AND RETIREES... B-8 APPENDIX C CIGNA / AETNA HEALTHCARE BENEFIT SUMMARY CIGNA OAP / AETNA POS PROGRAM OPTION 1 ($400 DEDUCTIBLE)... C-1 APPENDIX D CIGNA/AETNA HEALTHCARE BENEFIT SUMMARY CIGNA OAP / AETNA POS PROGRAM OPTION 2 ($1,250 DEDUCTIBLE)... D-1 APPENDIX E CIGNA/AETNA HEALTHCARE BENEFIT SUMMARY CIGNA OAP / AETNA POS PROGRAM OPTION 3 ($2,500 DEDUCTIBLE)... E-1 APPENDIX F CIGNA/AETNA HEALTHCARE BENEFIT SUMMARY CIGNA CCHP / AETNA HDHP PROGRAM... F-1 APPENDIX G CIGNA HEALTHCARE BENEFIT SUMMARY OUT-OF-AREA NETWORK PROGRAM... G-1 - xi -

13 INTRODUCTION Johns Manville sponsors the Johns Manville Retiree Health Care Plan (the Plan ) and the Johns Manville Medicare Subsidy HRA (the "Medicare HRA") in order to provide medical benefits, including, under the Plan, prescription drug benefits, to certain Eligible Retirees of Johns Manville and each Participating Company (individually or jointly, the Company ) and their Eligible Dependents. This document serves as the summary plan description (this SPD ), as required by the Employee Retirement Income Security Act of 1974, as amended ( ERISA ), for the Plan and the Medicare HRA. BENEFITS DESCRIBED IN THIS SPD This SPD describes the Plan and Medicare HRA benefits available to certain Retirees of the Company. This SPD does not apply to any other employee or retiree group. A different summary plan description has been prepared to explain the Plan benefits available to other retiree groups. Please contact the Plan Administrator (see page100) if you would like to know what other groups of retirees are covered under the Plan. IMPORTANT NOTE: This SPD provides information about the Johns Manville Retiree Health Care Plan, which is referred to as the Plan. It also provides information about the Johns Manville Medicare Subsidy HRA, which is referred to as the Medicare HRA. There are important differences between the Plan and the Medicare HRA, including differences in eligibility and benefits. In general, only Eligible Retirees and Eligible Dependents who are under age 65 are eligible under the Plan. In general, Eligible Retirees and their legal Spouses who are age 65 or older are eligible only for the Medicare HRA. As you use this SPD, be sure to notice whether the provision you are reading relates to the Plan or the Medicare HRA. 1

14 ABOUT THIS SPD The information provided in this SPD is based on the provisions of the Plan, as amended and restated effective January 1, 2010, and as further amended effective January 1, 2010, January 1, 2011, January 1, 2012, and January 1, 2013, and the Medicare HRA as of January 1, This SPD supersedes and replaces, in its entirety, any summary of the Plan or the Medicare HRA that may have been previously given to you. This SPD is part of the official governing Plan and Medicare HRA documents, which are comprised of the formal legal Plan and Medicare HRA documents ( Plan Document and "Medicare HRA Document") and any documents that are specifically incorporated in the Plan Document or Medicare HRA Document by reference, such as this SPD. Please keep in mind that this SPD is only one of the documents governing the Plan and the Medicare HRA and does not describe all of the details of the Plan and the Medicare HRA. Other important details can be found in the Plan Document and the Medicare HRA Document and other documents that are incorporated in the Plan Document or the Medicare HRA Document by reference. The provisions of the Plan Document, the Medicare HRA Document, this SPD and other documents incorporated in the Plan Document or the Medicare HRA Document supplement each other and are interpreted by the Plan Administrator together to give effect to all such provisions. If, however, any of the terms of this SPD, the Plan Document, the Medicare HRA Document, and other governing documents are in conflict with each other and cannot all be given effect by the Plan Administrator, the order in which the documents will govern is as follows (i) the terms of any amendment to the document incorporated by reference in the Plan Document or the Medicare HRA Document (for example, a summary of material modifications to the SPD), (ii) the document incorporated by reference in the Plan Document or the Medicare HRA Document (for example, this SPD), (iii) the terms of any amendment to the Plan Document or the Medicare HRA Document, and (iv) the Plan Document or the Medicare HRA Document. The legal rights and obligations of any person having any interest in the Plan or the Medicare HRA are determined solely by the provisions of the Plan or the Medicare HRA as set forth in its governing documents. No other informal communications (written, electronic or oral) can modify the terms of the official Plan or Medicare HRA documents or confer any interest in the Plan or Medicare HRA on any person. You should read this SPD carefully in order to familiarize yourself with the provisions of the Plan and the Medicare HRA. You should keep this SPD in a safe place so that you can refer to it as needed from time to time. Although Johns Manville intends to continue the Plan and the Medicare HRA indefinitely, the Plan or the Medicare HRA may be changed, amended or terminated, in whole or in part, at any time and from time to time at the sole discretion of Johns Manville by written action of the Board of Directors of Johns Manville (the Board of Directors ) or its delegate. This means that, among other things, Johns Manville reserves the absolute right to change, amend, or require Participant contributions and change the amount of such contributions at any time and from time to time with respect to all or any group of Retirees. The Plan Administrator has the right and discretion to determine all matters of fact or interpretation 2

15 relative to the administration of the Plan or the Medicare HRA -- including questions of eligibility, interpretation of Plan and Medicare HRA provisions and any other matter. The decisions of the Plan Administrator and any other person or group of persons to whom such discretion has been delegated shall be conclusive and binding on all persons. THIS SPD INCLUDES A SUMMARY OF THE MEDICARE HRA'S TERMS This SPD is designed to describe the terms of the Medicare HRA, which provides to those who are eligible a subsidy that may be used to pay part or all of the cost of certain types of coverage. THIS SPD ALSO INCLUDES A SUMMARY OF THE PLAN S MEDICAL AND PRESCRIPTION DRUG BENEFITS Except as noted below, this SPD is designed to describe the medical and prescription drug benefits provided under the Plan to Eligible Retirees who have elected to be covered by one of the following health coverage components constituting the Self-Funded Medical Program of the Plan: CIGNA Open Access Plus Program (the CIGNA OAP Program ), the Aetna Choice POS II Program (the Aetna POS Program ), the CIGNA Consumer Choice Health Plan Program (the CCHP Program ), and the Aetna Choice POS II High Deductible Health Plan Program (the HDHP Program ). Comparison of CIGNA and Aetna Medical Benefits. The medical benefits provided through CIGNA and Aetna are identical for the healthcare programs of the same type. Here s how the CIGNA programs and Aetna programs line up: CIGNA Programs CIGNA OAP Program CIGNA CCHP Program CIGNA Out-of-Area Network Program Aetna Programs Aetna POS Program Aetna HDHP Program None Plan medical benefits are provided by CIGNA if you live in one of the following states: Alabama, Alaska, Arkansas, Colorado, Connecticut, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin and Wyoming. Plan medical benefits are provided by Aetna if you live in one of the following states: Arizona, California Delaware, Florida, Kansas, Michigan, Missouri, New Jersey, Ohio, Oklahoma, Pennsylvania and Texas. 3

16 If you are covered by one of the Plan s Fully-Insured Medical Programs. If you are an Eligible Retiree and you elect medical coverage through one of the Plan s currently available fullyinsured medical program Coverage Options (an insured HMO) (the Fully-Insured Medical Program ), certain sections of this SPD, including the description of the covered medical and prescription drug benefits, do not apply to you. Instead, a separate summary of benefits has been prepared by the Insurer (the Insurer s Booklet ) to describe the benefits provided under that Fully-Insured Medical Program. The Insurer s Booklet was (or will be) distributed to you separately. However, the Insurer s Booklet does not describe all of the material terms of the Plan that the Company wishes to bring to your attention. Accordingly, this SPD provides additional information about the Plan that applies to the Plan s Fully-Insured Medical Programs in order to add details or to clarify or correct any information in the Insurer s Booklet. Except where noted, if there are any discrepancies between the Insurer s Booklet and this document, this document will always govern. Together, this document and the Insurer s Booklet constitute the entire SPD, as required by ERISA, for Participants who are covered by one of the Plan s Fully-Insured Medical Programs. The Fully-Insured Medical Programs include the following: Fully-Insured Medical Program Kaiser Permanente of Colorado Kaiser Permanente of Georgia Covered Locations Denver, CO (metro-area) Winder, GA (or in the vicinity of) QUESTIONS? If you have any questions after reading this SPD, please contact the Plan Administrator at any time through myjmbenefits at or 4

17 IMPORTANT CONTACT INFORMATION Plan Benefit Contact Telephone Website General Questions myjmbenefits Medical Benefits under the CIGNA OAP Program, CIGNA CCHP Program, and CIGNA Out-of-Area Network Program Medical Benefits under the Aetna POS Program and Aetna HDHP Program Prescription Drug Coverage for CIGNA OAP Program, Aetna POS Program, and CIGNA Outof-Area Network Program Prescription Drug Coverage for CIGNA CCHP Program Prescription Drug Coverage for Aetna HDHP Program Medicare Subsidy HRA FOLLOW PLAN PROCEDURES CIGNA Aetna Life Insurance Company CVS Caremark Member Services CIGNA Home Delivery Pharmacy Aetna Pharmacy Management Aon Hewitt Navigators REMINDERS com/johnsmanville Please keep in mind that it is very important for you to follow the Plan s and the Medicare HRA's procedures, as summarized in this SPD, in order to obtain Plan or Medicare HRA benefits. For example, contacting someone other than the appropriate Claims Administrator in order to try to resolve a benefit claim issue is not following the Plan s procedures. If you do not follow the Plan s or the Medicare HRA's procedures for claiming a benefit or resolving an issue involving benefits, there is no guarantee that the benefits for which you may be eligible will be paid to you on a timely basis, or paid at all. TAX IMPLICATIONS No Company employee or third party hired by the Company can be responsible for advising you on the tax effects of your participation in any of the Programs under the Plan or the Medicare HRA. Because tax laws are constantly changing, you should consult a tax advisor if you have questions about how participation in any Company benefit plans will affect your personal tax situation. Neither the Company nor the Plan Administrator or Claims Administrator guarantee any specific tax consequences of participation in and receipt of benefits under this Plan or the Medicare HRA. 5

18 A WORD ABOUT YOUR PRIVACY The Plan and the Medicare HRA will use protected health information ( PHI ) to the extent of and in accordance with the uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996, as it may be amended ( HIPAA ). Specifically, the Plan and the Medicare HRA will use and disclose PHI for purposes related to health care treatment, payment for health care and health care operations. Please see the separately distributed Notice of Privacy Practices for more information. Throughout this document, certain words and phrases are capitalized. Generally, the definitions of these capitalized words and phrases can be found in Appendix A of this document. 6

19 HEALTH PROTECTION OVERVIEW When you are healthy, you do not think much about your health insurance needs. But if you become sick or injured, having good health care coverage becomes very important. As an Eligible Retiree of the Company, you may be eligible to participate in the Plan or, under certain circumstances, the Medicare HRA. In general, Eligible Retirees and their Eligible Dependents who are under age 65 are eligible to participate in the Plan, while Eligible Retirees and their legal Spouses who are 65 or older are eligible only for the Medicare HRA. There are some exceptions to these general rules so you must review the section on Eligibility and Enrollment in this document to determine eligibility. The Plan offers several Medical Programs and Coverage Options so that you can choose the level of health care coverage that best meets your family s needs. The Medicare HRA provides a subsidy that may be used to pay part or all of the cost of certain types of coverage. SUMMARY OF THE PLAN S MEDICAL BENEFITS The following is a brief summary of the medical benefits, including prescription drug benefits, available to Eligible Retirees and their Eligible Dependents under the Plan: If you are an Eligible Retiree and under 65, you and your Eligible Dependents who are under 65 may be covered under one of the Medical Program components of the Plan. The Plan offers several Medical Programs from which you may select coverage, including the Self-Funded Medical Programs (the self-funded CIGNA OAP / Aetna POS and the self-funded CIGNA CCHP / Aetna HDHP Programs and, if you live in an area where the CIGNA OAP / Aetna POS is not available, the CIGNA Out-of-Area Network Program) and the Fully-Insured Medical Programs (the fully-insured HMOs). The Medical Programs that are available to you depend on where you live and other eligibility criteria. If you have medical coverage elsewhere, you can choose no medical coverage. All of the Plan s Self-Funded Medical Programs cover the same medical services and supplies. However, different Medical Programs and Options cover benefits at different levels and have different Deductibles, Copayments and Out-of-Pocket Maximums. In order for any medical service or supply to be covered under a Self-Funded Medical Program (a Covered Service or Supply ), the service or supply must (1) be specifically listed in the Plan as covered by the Plan and (2) be Medically Necessary. In addition, the cost of such Covered Service or Supply will be covered by the Plan only to the extent that it is no more than the Maximum Reimbursable Charge or the Negotiated Rate for that service or supply. The Fully-Insured Medical Programs cover different benefits and have different rules. Separate Insurer s Booklets describe these Programs. Contact the Plan Administrator if you would like one of the Insurer s Booklets. 7

20 All of the Plan s Self-Funded Medical Programs provide prescription drug coverage. The self-funded CIGNA OAP / Aetna POS Programs and, if you live in an area where the CIGNA OAP / Aetna POS is not available, the CIGNA Out-of-Area Network Program, provide prescription drug coverage through Caremark. The prescription drug coverage under the self-funded CIGNA CCHP is provided through CIGNA s Home Delivery Pharmacy (formerly CIGNA Tel-Drug) and the prescription drug coverage under the selffunded Aetna HDHP is provided through Aetna Pharmacy Management. The cost for medical coverage under the Plan s Medical Programs is shared by you and the Company. The cost for medical coverage may change. The Plan s Medical Programs and the coverage options under the Medical Programs ( Coverage Options ) that are available are listed on your enrollment worksheet. Generally, the CIGNA Out-of-Area Network Program is available to you only if a CIGNA OAP / Aetna POS is not offered in the area where you live. Remember: Plan coverage is available to you only if you are an Eligible Retiree who is under age 65; Plan coverage is available to your legal Spouse only if your legal Spouse is under age 65; Plan coverage is available to your Eligible Dependents other than your legal Spouse only if either you or your legal Spouse is under age 65. SUMMARY OF THE MEDICARE HRA BENEFITS If you are an Eligible Retiree who is age 65 or older, you are eligible only for coverage under the Medicare HRA. If you are an Eligible Retiree who is under age 65, but your legal Spouse is age 65 or older and your legal Spouse was enrolled in the Plan continuously when he or she was eligible, your legal Spouse is eligible only for coverage under the Medicare HRA. Please note: if you are an Eligible Retiree who was covered under a collective bargaining agreement at the time of your retirement and you retired on or after February 1, 2004, you and your dependents are not eligible for any retiree medical benefits from Johns Manville upon attaining age 65. Your Children are never eligible for coverage under the Medicare HRA. The Medicare HRA provides a subsidy that may be used to pay part or all of the cost of certain types of coverage for certain Eligible Retirees and their legal Spouses. The Medicare HRA subsidy may be used toward payment of premiums for individual Medigap plans, Medicare Advantage plans, Medicare Prescription Drug plans, and Medicare Part B coverage, but not for group coverage. Medicare HRA subsidy amounts that are not used during the year will roll over and continue to be available in future years. 8

21 PLAN AND MEDICARE HRA DETERMINATIONS ARE NOT HEALTH CARE ADVICE Please keep in mind that the sole purpose of the Plan is to provide for the payment of certain health care expenses and not to guide or direct the course of treatment of any Participant. In addition, the sole purpose of the Medicare HRA is to provide a subsidy that may be used toward payment for certain coverage. A determination by the Plan Administrator or Claims Administrator that a particular course of treatment is not eligible for payment or is not covered under the Plan does not mean that the recommended course of treatment, services or procedures should not be provided to the individual or that they should not be provided in the setting or facility proposed. Only you and your health care Provider can decide what the right health care decision for you is. A determination by the Plan Administrator or Claims Administrator that particular coverage is not eligible for payment under the Medicare HRA does not mean that the coverage is not appropriate for, or needed by, the individual. Only you can decide what the right health coverage decision for you is. Decisions by the Plan Administrator, the Claims Administrator or the Appeals Administrator are decisions with respect to the Plan or Medicare HRA coverage only and do not constitute health care recommendations or advice. 9

22 ELIGIBILITY AND ENROLLMENT ELIGIBILITY TO PARTICIPATE IN THE PLAN OR MEDICARE HRA Eligible Retirees Eligible Retirees are those individuals who are former employees of the Company who meet the eligibility requirements to participate in the Plan or the Medicare HRA as set forth in Appendix B. Eligible Retirees who have elected to be covered under the Plan, or who are eligible for coverage under the Medicare HRA, are referred to as Participants. Eligible Dependents If you are an Eligible Retiree, certain of your Tax Dependents and/or your Spouse also may be eligible to participate in the Plan or the Medicare HRA. Your Tax Dependents and your Spouse who are eligible to participate in the Plan and for whom you have elected Plan coverage, and your Spouse who is eligible to participate in the Medicare HRA, are referred to as Eligible Dependents. The following individuals can be your Eligible Dependents: Your legal Spouse, determined as of the date you Retired. A person from whom you are legally separated or divorced is not your legal Spouse. A legal Spouse includes your common law spouse, if and only if (1) the state where you reside recognizes common law marriage, (2) you and your spouse jointly submit an affidavit regarding your marriage and (3) you receive approval from the Plan Administrator recognizing your common law spouse under the Plan. Important Note: If you claim you are married at common law, you and your common law spouse generally are regarded by law as legally married until you obtain a legal divorce or die. If your legal Spouse has not reached his or her Deemed Age 65 Date, he or she is eligible for coverage under the Plan. If your legal Spouse has reached his or her Deemed Age 65 Date, he or she is not eligible for coverage under the Plan but may be eligible for coverage under the HRA. Your unmarried Children who are under the age of 19 (or any Child under age 23, if enrolled as a full-time student in an accredited secondary school (or home schooling alternative) or college or university), but only if you and/or your legal Spouse is enrolled in the Plan. For purposes of determining a Child s full-time student status, a Child who takes a medically-necessary leave of absence from the school because of a serious Illness or Injury will continue to be an Eligible Dependent until the earlier of (a) the first anniversary of his medically-necessary leave or (b) the date he would otherwise lose coverage under the terms of the Plan (e.g., when the Child reaches age 23) if on the day immediately before his medical leave the Child was: (i) a dependent of a Retiree, (ii) enrolled in the Plan as an Eligible Dependent, and (iii) a full-time student at a post-secondary educational institution. 10

23 Your Mentally Disabled or Physically Disabled Children incapable of self-sufficiency who became disabled before the age of 19 or while eligible to be covered by the Plan, but only if you and/or your legal Spouse is enrolled in the Plan. You must submit proof of the Child s incapacity to the Plan Administrator within the earlier of (A) 31 calendar days after the dependent reaches age 19 or (2) 31 calendar days after the Child becomes Mentally Disabled or Physically Disabled, if such condition begins after the Child reaches age 19 but before reaching age 23. After the incapacity has continued for two years following the Child s reaching age 19, proof of continuing incapacity will be required no more than once each year. The Plan Administrator may require that the Child be examined by a Physician of the Plan Administrator s choice. For purposes of the Plan, a Child means any of the following individuals, provided that the individual has the same principal place of residence as you for more than one-half of the calendar year: Natural or legally adopted children (upon placement in your home); Stepchildren, determined as of the date you Retired, unless you legally adopt the child or are appointed by a court as the child s guardian; or Children for whom you have legal custody by court decree. To be eligible, any Child must be primarily dependent on you for maintenance and support. For purposes of the Fully-Insured Medical Programs, an Eligible Dependent also includes a child and any other dependent as defined under any applicable state law that applies to fully insured group insurance plans and health maintenance organizations. If you elected coverage under a Fully-Insured Medical Program, please see the applicable Insurer s Booklet for more information. If neither you nor your legal Spouse is enrolled in the Plan, your Children are not eligible for coverage under the Plan. Your Children are never eligible for coverage under the Medicare HRA. Determination of Tax Dependent Status You are solely responsible for determining whether your children are your Tax Dependents. A Child who is not your Tax Dependent is not eligible to participate in the Plan. In the event you enroll an individual who is not eligible, the value of the Plan benefits paid for the individual will be considered taxable income to you. It will be your responsibility to report these amounts to the Internal Revenue Service ( IRS ) and to pay any related income taxes and penalties. 11

24 Other Rules of Eligibility for the Plan If you are a Participant in the Plan, you (and your Eligible Dependents) may participate in only one Medical Program at a time, and, if the Medical Program has Coverage Options, only one Coverage Option at a time. Your Eligible Dependents must be enrolled in the same Coverage Option as are you. If you are an Eligible Retiree who is married to another Eligible Retiree, only one Eligible Retiree may elect to cover the Eligible Dependents who are Children. An Eligible Dependent may not be covered under the Plan while serving in the military. CONFIRMING ELIGIBLE DEPENDENT STATUS The Plan Administrator has the right to approve each Eligible Dependent s eligibility for coverage under the Plan or the HRA, as applicable. The Plan Administrator also may, from time to time, ask you to provide proof of continuing eligibility of the individuals you have enrolled in the Plan or your legal Spouse's continuing eligibility for Medicare HRA coverage. The Plan and the Medicare HRA have the right to seek restitution of benefits that have been paid to or on behalf of ineligible individuals or Spouses. You will be responsible for reimbursing the Plan or the Medicare HRA for these amounts. In addition, to assure compliance with Plan and Medicare HRA terms, the Company may periodically conduct audits of covered individuals to determine their continued eligibility for benefits under the Plan or the Medicare HRA. If the Company conducts such an audit, you will be required to provide supporting documentation to verify the eligibility of the individuals you have covered under the Plan or the Medicare HRA. This documentation may include, but is not limited to, birth and marriage certificates, tax returns and/or proof of residence. Any individuals who are determined to be ineligible, or for whom proof of coverage is not received timely, will be removed from the Plan or the Medicare HRA. You will be responsible for repaying the Plan or the Medicare HRA the cost of the health care claims or subsidy paid for or on behalf of any ineligible individuals. ENROLLING FOR COVERAGE UNDER THE PLAN If you first become an Eligible Retiree before you reach age 65 and before your Deemed Age 65 Date, you are eligible to participate in any Medical Program offered by the Plan provided that your home zip code falls within the service area of the specific Medical Program in which you wish to enroll. You are eligible to participate in the Out-of-Area Network Program if the CIGNA OAP / Aetna POS is unavailable in your area. 12

25 When you first become eligible to participate in the Plan, you will receive an enrollment worksheet. This worksheet will summarize the Plan s Medical Programs and Options available to you and the costs for those Programs and Options. You must enroll yourself and any Eligible Dependents you wish to cover within 31 calendar days after becoming eligible to participate in the Plan. You may elect Plan coverage for yourself only, you and your legal Spouse who has not reached age 65 nor his or her Deemed Age 65 Date, you and your eligible Children, or you and your family (which includes your legal Spouse who has not reached age 65 nor his or her Deemed Age 65 Date and your eligible Children). If you have other medical coverage, you may choose no medical coverage. If you do not enroll within this 31-day period, you will be deemed to have waived Plan coverage for yourself and your Eligible Dependents. IMPORTANT NOTE: You must enroll in the Plan when you first become eligible, or at such other time as unenrolled Eligible Retirees are offered an opportunity to enroll, and must continuously maintain coverage under the Plan. Read the following enrollment rules carefully: If you first become an Eligible Retiree before you reach age 65 and before your Deemed Age 65 Date: and you do not enroll in the Plan at that time, you will not be permitted to enroll in the Plan unless you become eligible for special enrollment due to an event described under Loss of Other Coverage below. Upon reaching your Deemed Age 65 Date you will be eligible for the Medicare HRA only assuming you are eligible for retiree medical benefits upon attaining age 65. Please refer to Appendix B for eligibility rules. and you enroll yourself in the Plan at that time, (1) you may also enroll your eligible Children in the Plan and (2) you may enroll your legal Spouse in the Plan if your legal Spouse is not yet age 65 or your legal Spouse will automatically be eligible for the Medicare HRA if he or she has reached his or her Deemed Age 65 Date assuming you are eligible for retiree medical benefits upon attaining age 65. Please refer to Appendix B for eligibility rules. If you first become an Eligible Retiree before you reach age 65 and before your Deemed Age 65 Date, and you enroll yourself in the Plan but do not enroll your Eligible Dependents in the Plan at that time, you will not be permitted to enroll such dependents in the Plan unless you have continuously maintained your enrollment in the Plan and such dependents become eligible for special enrollment due to an event described under Loss of Other Coverage below; or you acquire a new Dependent Child by birth, adoption or placement for adoption. 13

26 If you first become an Eligible Retiree on or after your Deemed Age 65 Date and you are eligible to receive retiree medical benefits upon attaining age 65: you will be eligible only for coverage under the Medicare HRA; you do not need to take any action to be covered under the Medicare HRA; if your legal Spouse has reached his or her Deemed Age 65 Date, your legal Spouse will be eligible only for coverage under the Medicare HRA; your legal Spouse does not need to take any action to be covered under the Medicare HRA; if your legal Spouse has not reached his or her Deemed Age 65 Date, you may enroll your legal Spouse in the Plan; if you enroll your legal Spouse in the Plan, you may also enroll any eligible Children in the Plan at the same time; when your legal Spouse reaches his or her Deemed Age 65 Date, your legal Spouse will no longer be eligible for coverage under the Plan and will be eligible for coverage under the Medicare HRA only, and your eligible Children will lose all eligibility for coverage under the Plan and will not be eligible for coverage under the Medicare HRA. If you reach your Deemed Age 65 Date while enrolled for coverage under the Plan, your eligibility under the Plan ends and you will be eligible for the Medicare HRA only as of your Deemed Age 65 Date, assuming you are eligible for retiree medical benefits upon attaining age 65. Please refer to Appendix B for eligibility rules. If your legal Spouse is enrolled in the Plan when you reach your Deemed Age 65 Date, but he or she has not reached his or her Deemed Age 65 Date, your legal Spouse may continue to be enrolled in the Plan; If your legal Spouse is not enrolled in the Plan when you reach your Deemed Age 65 Date and has not reached his or her Deemed Age 65 Date, you may enroll your legal Spouse and your eligible Children in the Plan at that time; if you do not enroll your legal Spouse in the Plan at that time, and do not keep your legal Spouse continuously enrolled in the Plan until your legal Spouse reaches his or her Deemed Age 65 Date, your legal Spouse will not be eligible for the Medicare HRA when he or she reaches his or her Deemed Age 65 Date; If your legal Spouse has reached his or her Deemed Age 65 Date, your legal Spouse will be eligible for coverage under the Medicare HRA at that time, regardless of whether your legal Spouse was covered under the Plan. This assumes you are eligible for retiree medical benefits upon attaining age 65. Please refer to Appendix B for eligibility rules. 14

27 If you first became an Eligible Retiree and were age 65 or older prior to January 1, 2013, and you were enrolled in either the Johns Manville group health plans or the Medigap Subsidy HRA as of December 31, 2012: you will be eligible only for coverage under the Medicare HRA as of January 1, 2013; you do not need to take any action to be covered under the Medicare HRA; if your legal Spouse was age 65 or older prior to January 1, 2013 and was enrolled in either the Johns Manville group health plans or the Medigap Subsidy HRA as of December 31, 2012; your legal Spouse will be eligible only for coverage under the Medicare HRA as of January 1, 2013; your legal spouse does not need to take any action to be covered under the Medicare HRA; if your legal Spouse was not yet age 65 prior to January 1, 2013 and was covered under the Plan up until his or her Deemed Age 65 Date, your legal Spouse will be eligible only for the Medicare HRA upon reaching his or her Deemed Age 65 Date; your legal Spouse does not need to take any action to be covered under the Medicare HRA; your eligible Children will lose all eligibility for coverage under the Plan and will not be eligible for coverage under the Medicare HRA. If you die while you are enrolled for coverage under the Plan or are eligible for coverage under the Medicare HRA, and your legal Spouse was enrolled for coverage under the Plan or eligible for coverage under the HRA at the time of your death, your legal Spouse may continue his or her coverage. If you die at a time when you are not enrolled for coverage under the Plan or are not eligible for coverage under the Medicare HRA, your legal Spouse may not enroll. If you die at a time when you are not enrolled for coverage under the Plan but your legal Spouse was enrolled for coverage under the Plan, your legal Spouse may continue his or her coverage. Your Children are never eligible for the Medicare HRA. Your Plan elections remain in effect throughout the calendar year. You will not be allowed to change your Plan elections until (1) the next annual enrollment period (see page 16) or (2) until you have an event that allows you to make a mid-year change to your election (such as a change in status or a QMCSO (see definition in Appendix A) (see page A-17). IDENTIFICATION CARD After you enroll in the Plan, you should receive an identification card from the insurance carrier or third party administrator of the Coverage Option of the Medical Program in which you enrolled. You should keep this card with you at all times. This card gives health care Providers important information about your coverage, including the Plan s identification number and the telephone number to call for Hospital Precertification. It also provides the address and the telephone number for the Claims Administrator. There are no identification cards for the Medicare HRA. 15

28 EFFECTIVE DATE OF PLAN COVERAGE FOR ELIGIBLE RETIREES If you are an Eligible Retiree, your participation in the Plan may begin on your Retirement Date, provided you have timely enrolled in the Plan. After you leave the Company, you must enroll within 31 calendar days upon becoming eligible for retiree medical coverage under the Plan. If you are or become eligible for the Medicare HRA, no enrollment is necessary and the subsidy will be available beginning on your Deemed Age 65 Date. EFFECTIVE DATE OF PLAN COVERAGE FOR ELIGIBLE DEPENDENTS In general, if you want your Eligible Dependents to be covered under the Plan, you must enroll them when you enroll upon first becoming an Eligible Retiree. You will not be able to enroll your Eligible Dependents at any other time unless they become eligible for enrollment due to an event described under Loss of Other Coverage or they are your new dependents acquired through birth, adoption or placement for adoption while you are enrolled in the Plan. Coverage for your Eligible Dependents is generally effective on the same date that your coverage under the Plan became effective - provided you enroll them when you enroll. If you are enrolling Eligible Dependents after you elected coverage for yourself, their coverage will be effective as explained below in the sections Annual Enrollment and Changing Your Coverage. EFFECTIVE DATE OF HRA COVERAGE Medicare HRA coverage, for those who are eligible, begins on the individual's Deemed Age 65 Date. Children are not eligible for coverage under the Medicare HRA. ANNUAL ENROLLMENT IN THE PLAN Annually, you will be given the opportunity to make changes to your health care elections under the Plan for the upcoming calendar year. The Company will provide you with enrollment information describing the Plan s Programs and Coverage Options and the cost of those Programs and Coverage Options. You also will be told when the annual enrollment period begins and ends. Re-enrollment in the Plan during the annual enrollment period is optional. If you do not follow the Plan s enrollment procedure to drop or change your Plan coverage, your existing elections for Medical Program Coverage Option coverage will continue into the next calendar year (if the Program and Coverage Option in which you are enrolled remains available). The cost for those Programs and Coverage Options, however, may change. If the Plan Programs or Coverage Options change, and the Program or Coverage Option you are enrolled in will not be available the next year, the Plan Administrator will tell you in the open enrollment materials what you must do to elect benefits. If you do not specify a different choice 16

29 during annual enrollment, the Plan Administrator may (1) enroll you (and your enrolled Eligible Dependents) in a Medical Program and Coverage Option that matches your current coverage most closely, (2) enroll you (and your enrolled Eligible Dependents) in a default Medical Program and Coverage Option or (3) default you to no coverage if you do not timely enroll. Plan coverage changes requested during the annual enrollment period are effective on the immediately following January 1. Annual enrollment does not apply to the Medicare HRA. (But remember: There are specific Medicare enrollment periods. If you fail to enroll in Medicare coverage during those periods, you might not be able to purchase coverage and, therefore, might not be able to use your Medicare HRA funds.) EFFECT OF DROPPING COVERAGE If you drop coverage under the Plan for yourself or your dependents, you will not be able to re-enroll yourself and/or your dependents in the Plan at a later date (except in very limited circumstances described below). Read the following information carefully: If you enroll in the Plan when you are first eligible after becoming an Eligible Retiree, and after enrolling in the Plan you drop coverage, you will not be permitted to re-enroll for coverage under the Plan unless you become eligible for special enrollment due to an event described under Loss of Other Coverage below. If you drop coverage for your dependents, you will not be permitted to re-enroll such dependents in the Plan unless such dependents become eligible for special enrollment due to an event described under Loss of Other Coverage below, or you reach your Deemed Age 65 Date and your dependents are otherwise eligible for coverage under the Plan. If you remain covered under the Plan, you will be eligible to enroll a new dependent acquired by birth, adoption or placement for adoption. CHANGING YOUR COVERAGE UNDER THE MEDICARE HRA An Eligible Retiree or a legal Spouse who is eligible only for the Medicare HRA is not eligible to enroll any other individuals in the Medicare HRA. CHANGING YOUR COVERAGE UNDER THE PLAN Unless you are eligible to make a change in your Plan coverage as described in this section, your coverage elections will remain in effect for a full calendar year. The following rules apply to coverage changes under the Plan and apply only if you are eligible for coverage under the Plan or your legal Spouse is eligible for coverage under the Plan. 17