Benefit Frequency Copay Coverage from a VSP Network Doctor Out-of-Network Reimbursement. $10 Covered in full Up to $50

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Warren Nash
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1 Vision Plan Vision Benefits At-A-Glance Type of Plan Who Pays the Cost Employee Eligibility Enrollment Period Plan Information Vision Plan for all eligible employees You share the cost of vision care coverage with Baker Hughes Employees on U.S.-based payroll who are: Regular full-time employees Benefits-eligible part-time employees New hires and employees transferring to a position with U.S. benefits, within 31 days of becoming eligible for coverage. If you do not enroll, you will not be able to elect coverage until the next Annual Enrollment period. There is no default coverage for employees who do not enroll. Employees can make changes during Annual Enrollment or if they have a change in status (see the Can I Make Changes After I Enroll? information located in the General Information section of this SPD). If you do not change the coverage in which you are enrolled during the Annual Enrollment period, you ll receive the same coverage you had the previous year. You may choose any provider, however, if you use doctors and facilities in the VSP network, your vision expenses are generally lower. Benefit Frequency Copay Coverage from a VSP Network Doctor Out-of-Network Reimbursement Eye Exam Lenses 12 months $10 Covered in full Up to $50 $25 materials copay (applies to lenses and frames) Single vision, lined bifocal, and lined trifocal lenses, Polycarbonate lenses for dependent children up to age 17 Frames* Up to $130 Up to $70 Contact Lenses* None Covered up to $125 Up to $125 Up to $50 for single vision lenses Up to $75 for lined bifocal lenses Up to $100 for lined trifocal lenses N/A When Coverage Begins Contact Enroll within 31 days of becoming eligible for coverage and begin coverage on your date of hire or date of transfer if you re a new hire or an existing employee transferring to a position with U.S. benefits. If you enroll during Annual Enrollment your coverage will begin the following January 1. VSP at VSP customer service at or (worldwide) myrewards at The Benefits Center at (toll-free in the U.S.) or (worldwide) *During a calendar year, you may receive either one pair of glasses or contact lenses, but not both. Note: Do not rely on this chart alone. It merely summarizes your benefits. Please read the following pages for a more complete explanation of your coverage. 116 What is the Cost of the Vision Plan? You and Baker Hughes share the cost of coverage provided under the Baker Hughes Incorporated Vision Program (the Vision Plan). To see your cost, log onto myrewards at or call the Benefits Center at You pay your portion of the cost with pre-tax dollars which means that your monthly premiums are deducted from your paycheck generally before Federal and state income and Social Security taxes are withheld. Because your premiums are not included in your taxable income, your taxable income is lower. Note: New Jersey does not allow before-tax deductions. In New Jersey, only your Federal taxable income would be reduced.

2 How Does the Vision Plan Work? The Baker Hughes Vision Plan is funded through an insurance policy issued by VSP and is designed to pay benefits to help you and your family take care of your vision needs. By encouraging regular vision exams and helping you pay for necessary vision expenses, the Vision Plan helps you maintain your vision at a reasonable cost. For Questions Contact: Website Telephone VSP or (worldwide) VSP operates a nationwide network of eye-care providers. Network doctors provide services at pre-negotiated fees, which are usually lower than the fees charged by non-network doctors. You and the Vision Plan share the cost when you receive vision care. You pay a copay or receive an allowance depending on the type of service you receive. Refer to the Vision Schedule of Benefits for more information. A copay is the flat dollar amount you pay when you use the VSP network. For example, you will be charged a $10 copay for an annual eye examination when you visit a VSP network doctor (the Vision Plan generally pays the remaining portion of the allowable cost). Copays must be paid each time a service is rendered or materials are prescribed and filled. An allowance is the set dollar amount the Vision Plan pays toward your eye care in a calendar year. You will be responsible for all charges over the Vision Plan allowance. You ll receive 20% off the amount over your allowance through VSP network providers. Refer to the Vision Schedule of Benefits. Remember If you re covered under the Vision Plan, you will not receive an identification card. If you use a VSP network provider, they will submit claims on your behalf. If you use a non-network provider, you will need to pay for care at the time of service and you will need to submit a claim form for reimbursement. Claim forms are available online via the Baker Hughes Intranet, at or by calling VSP at or (worldwide). myhealth Through the Vision Plan, you ll save on eye exams, prescription eyeglasses (lenses and frames), and contact lenses. Additionally, you ll receive extra discounts on additional pairs of eyeglasses and sunglasses, including lens options through VSP network doctors, and discounts on laser eye surgery through VSP contracted surgery facilities. You simply make an appointment to see any eye care provider when you need eye care, keeping in mind you ll receive the most value from VSP network doctors. If your provider is in the VSP network, you pay the applicable copay and expense based on the type of service you receive. Your VSP doctor will submit a claim electronically to VSP, which will pay your doctor for eligible services. If you choose a provider who is not in the VSP network, you must pay for care at the time of service and submit a claim form to VSP for reimbursement. The Vision Plan will reimburse you at the out-of-network reimbursement level minus the copays. All covered expenses are subject to provisions shown in the Vision Schedule of Benefits. Remember Flexible Spending Account participants may file a claim for reimbursement of out-of-pocket expenses not covered by the plan. See the Flexible Spending Account section of this SPD for more information. 117

3 Vision Network VSP has a national network of participating doctors and offers low, fixed prices for services. To locate a participating doctor: Ask your local doctor if he or she participates in the VSP network; Log onto the VSP website at and use the doctor search feature; or Call VSP member services at or (worldwide). Tip! If you or a covered dependent are away from home (for example, a child away at school) you can use any VSP network doctor in the United States. How the Process Works Using a VSP Preferred Provider When you make your appointment, identify yourself as a VSP member; provide your name and confirm your date of birth. The doctor s office will contact VSP for authorization and confirm the Vision Plan benefits and coverage amounts. The cost of a routine eye examination and standard lenses (single vision, lined bifocal, lined trifocal) are covered in full under the Vision Plan when provided through a VSP preferred provider or network doctor after you pay the necessary copays. When you arrive for your appointment, you ll pay the $10 copay for your routine eye examination. If the doctor prescribes corrective lenses for prescription eyeglasses, you ll be responsible for the additional $25 materials copay (lenses and frame). You ll receive a $130 allowance toward the purchase of your frames. You ll receive a 20% discount off the amount over your allowance. You will be responsible for paying any amount above the allowance. If the doctor prescribes contact lenses, you will receive a $125 allowance that can be applied toward the contacts and the contact lens exam (fitting and evaluation). You ll receive a 15% discount off the cost of the contact lens exam (fitting and evaluation). You will be responsible for paying any amount above the allowance. 118

4 Using your Benefits Outside the VSP Network If you choose a provider outside the VSP network, you are responsible for paying all charges at the time of your appointment. You will then be responsible for submitting an itemized statement of services to VSP for reimbursement under the Vision Plan. The reimbursement amounts are shown on the Vision Schedule of Benefits. You may contact VSP for instructions regarding your claim filing. Example: Before you make an appointment to see an eye care provider, take a look at the options you have and how the VSP process works whether you choose to obtain services from a VSP Preferred Provider or outside the network. myhealth You make an appointment to see Dr. Green for an annual eye exam. If Dr. Green is in the VSP network If Dr. Green is a non-network provider You make an appointment to see Dr. Green. Tell them you are covered by the Baker Hughes Vision Plan administered by VSP. You may be asked for your Social Security Number. Dr. Green s office will contact VSP before your appointment for authorization and your Vision Plan coverage amounts You pay a $10 copay at the time of service You make an appointment to see Dr. Green, knowing that non-network charges will apply You must pay the total fee for service during your visit with Dr. Green $55 You send your claim directly to VSP for processing (remember to make a copy for your records). VSP mails your allowance of $70 to your home address The network eye exam costs you $10 The non-network eye exam costs you $20 (the VSP eye exam allowance is up to $50). Note: Dollar amounts are for illustrative purposes only and do not reflect actual costs. 119

5 Vision Schedule of Benefits Benefit Frequency Copay Coverage from a VSP Network Doctor Out-of-Network Reimbursement Eye Exam Lenses 12 months $10 Covered in full Up to $50 $25 copay (applies to lenses and frames) Single vision, lined bifocal, and lined trifocal lenses are covered in full Polycarbonate are covered for dependents up to age 17 Up to: $50 for single vision lenses $75 for lined bifocal lenses $100 for lined trifocal lenses Frames* Covered up to $130 Up to $70 Contact Lenses* None Covered up to $125 $125 *Eye exams must be performed by an ophthalmologist or optometrist and must include a complete analysis of your eyes and related structures to identify diagnosis for glasses or contact lenses. **During a calendar year, you may receive either one pair of glasses or contact lenses, not both. You pay additional costs for the following: Blended lenses Contact lenses, except as noted above Oversize lenses Photochromic lenses, except Pink No. 1 and Pink No. 2 Progressive multifocal lenses Coating of the lens or lenses Laminating of the lens or lenses Frames that cost more than the allowance Note: When you receive care or services at a VSP network doctor location, you must pay any cost above your allowances under the Vision Plan, including sales tax and any non-covered expenses. Visually Necessary Visually necessary lenses are those needed following cataract surgery or to correct extreme visual activity problems that cannot be corrected with eyeglasses or lenses for certain eye conditions. (The conditions covered include aphakia, anisometropia, high anetropia, nystagmus, keratoconus, and other eye conditions that make contact lenses necessary.) When visually necessary contact lenses are obtained from a VSP network doctor, they will be covered in full minus the $25 materials copay when certain criteria is met. When visually necessary contact lenses are obtained from a provider outside the network, the Vision Plan will provide an allowance toward the cost as outlined below. Coverage for visually necessary contact lenses regardless of whether they are obtained from a VSP network doctor or not are subject to review to determine if certain conditions are met. VSP Network Doctor Non-VSP Network Doctor Professional fees and materials Covered in full Up to $

6 Exclusions No benefits are paid for services or materials connected with: Orthoptics or vision training and any associated supplemental testing Plano lenses (less than a +50 diopter power) Two pair of glasses instead of bifocals Lenses and frames previously paid for under the Vision Plan which are lost or broken will not be replaced except at the intervals when services are otherwise available Medical or surgical treatment of the eyes myhealth Any eye exam or corrective eyewear required by an employer as a condition of employment Corrective vision treatment of an experimental nature How Do I File a Vision Plan Claim? If you use a VSP Preferred Provider or network doctor, he or she will submit claims on your behalf. You re only responsible for applicable copays and amounts over your Vision Plan allowances. If you use a provider outside the network, you must submit a claim to VSP for reimbursement. To file a claim, send VSP the following information: An itemized statement of services you received; Include your name, address, phone number, date of birth, and employer name (Baker Hughes); and If the claim is for a dependent, your dependent s name, address, phone number, and your relationship to the covered dependent (such as spouse or child); and Copies of your receipts. Send your claim to: VSP P.O. Box Sacramento, CA File your claim directly with VSP as soon as possible after the date of treatment. Benefits will only be paid for those expenses incurred during the current or previous calendar year. Remember It s always a good idea to keep a copy of your claim form, receipts, and all supporting evidence for your records. Once your claim is processed and approved, you ll be reimbursed according to the Vision Schedule of Benefits. 121

7 Remember A participant advocacy service is available through the Benefits Center. The advocacy service assists you with Vision Plan access or claim issues that you have not been able to resolve on your own. Call the Benefits Center at (toll-free in the U.S.) or (worldwide) for more information. What If My Vision Plan Claim Is Denied? If your claim is denied, in whole or in part, you can call or write to VSP member services at to see if VSP member services can help you resolve your issues and questions regarding the denial without you having to file a formal appeal. This procedure is voluntary. You are not required to call VSP member services before filing a formal appeal. If VSP member services cannot resolve your issues with respect to the denial of your claim for benefits over the phone, you may file a formal appeal. Appealing a Denied Claim If you are not satisfied with the results of a decision regarding your claim, you may begin the appeals procedure as outlined below. You or your doctor may initiate an appeal within 180 days of an initial determination through the VSP Member Appeals Department. Appeals may be submitted orally or in writing to: VSP Member Appeals 3333 Quality Drive Rancho Cordova, CA You may submit written comments, documents, records, and any other information relating to your appeal regardless of whether this information was submitted or considered in the initial claim. You may obtain, upon request and free of charge, copies of all documents, records, and other information relevant to your appeal. Your appeal will be reviewed by a person who is neither the individual who made the initial determination that is the subject of the appeal nor the subordinate of that person. If you disagree with the resolution of your appeal, you have the right to a second level appeal. Within 60 days of receipt of VSP s final determination, you may submit your appeal along with any further documentation to the address listed above. VSP will respond within the appropriate time period for the type of claim. This response will include the reasons for the decision and references to the plan provisions on which the decision was based. If VSP fails to follow the claims appeals procedures as outlined above, you have the right to bring a civil action to court. Additional Resources Via the Baker Hughes Intranet Via Internet: Search for providers in the VSP network View your personalized eye-care coverage Access eye health and wellness information Customer Service:

8 Coordination of Benefits for the Vision Plan If you or your covered dependent(s) have coverage under another vision plan in addition to your coverage under the Baker Hughes Vision Plan, you may choose to receive separate services from each plan independently, or you may choose to have the plans pay for the same date of service. If you choose to have the plans pay for the same service, one of the plans will pay the benefits first, making that plan primary. The other plan(s) will pay benefits next. In this case, the other plan(s) will be the secondary payer. The rules below help determine which plan pays first. How Coordination Works myhealth If the Baker Hughes Vision Plan is primary, it will pay or provide its benefits as if the other plan(s) does not exist. If the Vision Plan is the secondary plan, you will receive allowances (exam, lenses, and frame) that will be used to pay up to, but not more than the billed amount. Only services used on the primary benefit may be used for coordinating services on the secondary benefit. Secondary allowances are applied first to the same service or product on the primary plan. Vision benefits may only be coordinated with services provided for vision care. How to Determine if Your Baker Hughes Vision Plan is Primary When you or your covered dependent(s) have coverage under another vision plan in additon to coverage under the Baker Hughes Vision Plan, VSP must determine the order of assignment. A plan that does not provide for coordination of benefits will pay its benefits first. A plan that covers a person as an employee will pay its benefits before the plan that covers the person as a dependent, and a plan that covers a person as an active employee is primary over a plan that covers a person who is laid off or a retiree. If you are a dependent child and are covered under both parents plans, the parent whose birth date falls first in the calendar year has the primary plan. If the parents are separated or divorced, the parent with custody has the primary plan, or the parent decreed by the court to be responsible has the primary plan. If a person whose coverage is provided under a right of continuation pursuant to a Federal or state law (e.g. COBRA) is also covered under another plan, the effect on benefits is as follows: The plan covering the person as an employee (or as the employee s dependent) will pay first, and The plan of continuation coverage will pay second. When the rules above do not apply, the plan which has covered the person for the longer period of time will pay its benefits first. For example, if you are a new employee as the result of an acquisition of a business by Baker Hughes and your vision plan coverage continues with your former employer for a period of time after the acquisition, your former employer s plan will pay first. A new plan is not established when coverage by one carrier is replaced within one day by that of another. 123

The Company offers the VSP Vision Plan. VSP provides the following benefits.

VSP VISION PLAN HIGHLIGHTS The Company offers the VSP Vision Plan. VSP provides the following benefits. Exams Lenses Frames Necessary contact lenses Elective contact lenses Participants may choose between