EatonBenefits.com. Summary Plan Description Effective January 1, 2018

Transcription

1 EatonBenefits.com Summary Plan Description Effective January 1, 2018

2 EATON EMPLOYEE BENEFIT PLANS OVERVIEW This Summary Plan Description (SPD) summarizes the main features of the Eaton health care and insurance benefit plans effective January 1, The front section has information about who is covered in the Plans and when coverage begins and ends, including: Eligibility for yourself and your dependents How to enroll in the Plans Making certain changes during the year What happens while you are away from work on a leave of absence When your coverage begins and ends How to continue coverage under COBRA The middle sections provide detailed information about each benefit plan: Medical (including prescription drug) Dental Vision Reimbursement Accounts (dental/vision and dependent care spending accounts; purchased vacation program) Work/Life Solutions and Adoption Reimbursement Benefits Life and Accidental Death & Dismemberment (AD&D) Short Term Disability (See updated information about this benefit at the end of this booklet) Long Term Disability (See updated appeals procedures for disability claims at the end of this booklet) The back section, Plan Administration, gives you details about how the Company administers the Plans, including coordination of benefits, claims appeals procedures and your ERISA rights. If you have any questions about your benefits, you can: Contact the claims administrator for the specific benefit plan (see the Plan Administration section) Contact the Eaton Service Center at Fidelity The intent of this booklet is to satisfy the Employee Retirement Income Security Act of 1974 (ERISA) requirement for a Summary Plan Description (SPD). The entire Plan and applicable group policies, not only this SPD, will be determinative in all matters pertaining to rights and obligations with respect to each Plan. The information in this booklet has been provided by Eaton and is the sole responsibility of Eaton. Eaton Corporation is sometimes referred to as Eaton or the Company in this booklet.

3 THE EATON SERVICE CENTER AT FIDELITY Eaton, as Plan Sponsor, has retained the services of Fidelity Employer Services Company, a division of Fidelity Investments Institutional Services Company, Inc., an independent contractor, to assist the Plan Administrator with certain administrative functions (other than claims administration) in connection with the Eaton Corporation Flexible Benefits Program. Fidelity Employer Services Company performs these services under the name Eaton Service Center at Fidelity. General information about your benefits is available by accessing the Fidelity web site or by calling the Eaton Service Center at Fidelity. The web site is generally available 24 hours a day, seven days a week. Phone service representatives are available weekdays, excluding holidays, from 8:30 a.m. to midnight, Eastern Time. Contacting the Eaton Service Center at Fidelity There are two ways to contact the Eaton Service Center at Fidelity: 1. By Computer: Fidelity Web Site You can access Fidelity s web site on the Internet. Go to: EatonBenefits.com or the EatonBenefits.com link on JOE Click on: Eaton Service Center at Fidelity Enter: Your Username (which is your Social Security number [SSN] or Customer ID number) and your Password 2. By Toll-free Telephone You can call the Eaton Service Center at Fidelity at EATON01 ( ) to speak with an Eaton phone service representative. Trained service representatives are available to answer your questions Monday through Friday (excluding holidays recognized by the New York Stock Exchange) from 8:30 a.m. to midnight, Eastern Time. Special Needs If you need language interpretation with immediate over-the-phone assistance, contact the Eaton Service Center at Fidelity and ask for Language Line translation. A service representative will conference in a translator to assist you with your call. If you need to contact the Eaton Service Center at Fidelity from outside the United States or Canada, log on to AT&T Direct ( to look up the country access code or download a free wallet card with access codes. You can also get the code by contacting an AT&T operator. When calling from outside the U.S., use this access code first and then dial To call with the assistance of TDD service for the hearing or speech impaired, dial Your Password You use your password to access personal information via Fidelity s web site or by telephone. Be sure to remember your password. If you need a new password, contact the Eaton Service Center at Fidelity to establish a new one. Confirmation of the new password will be sent to your home address in approximately three business days. If you receive a password confirmation that you did not authorize, contact the Eaton Service Center at Fidelity immediately. 2

4 Who s Covered and When WHO S COVERED AND WHEN WHO IS ELIGIBLE FOR COVERAGE... 4 Coverage for Yourself... 4 Coverage for Your Spouse/Domestic Partner... 4 Coverage for Your Children... 4 Coverage for a Disabled Child... 5 Proof of Dependent Eligibility... 5 Qualified Medical Child Support Orders (QMCSO) and National Medical Support Notices... 6 ENROLLING FOR COVERAGE... 6 Your Benefit Options... 7 If You Do Not Enroll... 9 Benefit Plans You Do Not Enroll In... 9 Couples Who Are Both Eligible for Eaton Benefits... 9 When Your Youngest Child Reaches Age Benefit Contributions, Social Security and Taxes WHEN COVERAGE STARTS CHANGING YOUR COVERAGE DURING THE YEAR Change in Status Events Certain Other Events Special Enrollment Rights for Medical, Dental and Vision Coverage BENEFITS COVERAGE WHILE YOU ARE NOT ACTIVELY AT WORK Non-Occupational or Occupational Short Term, Long Term or Extended Disability Leave of Absence Other Company-Approved Leaves of Absence Temporary Layoff CONTINUING REIMBURSEMENT ACCOUNT PARTICIPATION WHILE NOT ACTIVELY AT WORK Non-Occupational or Occupational Short Term, Long Term or Extended Disability Leave of Absence Unpaid FMLA Leave of Absence Other Unpaid Leave of Absence Paid Leave of Absence Temporary Layoff WHEN COVERAGE ENDS When Your Employee Coverage Ends When Dependent Coverage Ends Extended Dependent Coverage Period if You Die Continuing Coverage Certificate of Creditable Coverage CONTINUING COVERAGE THROUGH COBRA When You Become Eligible for COBRA (Qualifying Events) Starting with COBRA How Long COBRA Coverage Lasts Paying for COBRA Coverage When COBRA Coverage Can Be Terminated... 24

5 Who s Covered and When WHO IS ELIGIBLE FOR COVERAGE Coverage for Yourself You are eligible for the benefits plans described in this SPD if you are: A regular salaried or non-represented hourly employee of the Company or an affiliate in the United States, and Regularly scheduled to work 20 or more hours per week. If your employment is covered by a collective bargaining agreement, you are eligible for these benefit plans only if your collective bargaining agreement provides for it. Specific eligibility requirements and benefit terms may be stipulated by your bargaining agreement and are explained in the appropriate benefit sections. Leased and temporary employees are not eligible for coverage. Coverage for Your Spouse/Domestic Partner Your spouse/domestic partner is eligible for the Eaton Medical, Dental, Vision, Work/Life Solutions, and Life and AD&D Plans provided he or she is: Your spouse by a legally valid marriage (same or opposite sex). Your domestic partner (same or opposite sex) who: - is at least 18 years of age; - is not related to you; - has lived with you for at least six consecutive months; - you share an intimate, committed relationship with and intend for the relationship to last indefinitely; - you are in an exclusive relationship with and neither of you is legally married to or in a domestic partnership with anyone else; and - shares documented joint financial responsibility with you. For Life and AD&D. To insure your domestic partner under the Supplemental Life and AD&D Plan, the insurer also requires that you and your domestic partner have a mutually dependent relationship so that each has an insurable interest in the life of the other. Your domestic partner must satisfy the description above, or as an alternative, be registered as your domestic partner, civil union partner or reciprocal beneficiary with a government agency where such registration is available. Contributions for domestic partner coverage may have different tax consequences. Coverage for Your Children Medical, Dental, Vision and Work/Life Solutions Plans. Each of your children is eligible for the Medical, Dental and Vision Plans until the end of the year in which the child reaches age 26 provided: The child is your or your spouse s natural or adopted child (including a child placed for adoption), The child is a child for whom you (the employee) have legal guardianship or a similar court order that confers authority and the corresponding duty to care for the person and property of the child under applicable law, or You can claim the child as an exemption within the meaning of the U.S. Internal Revenue Code on your federal income tax return for the year of coverage and the child is: - your domestic partner s natural or adopted child (including a child placed for adoption), or - a child for whom your spouse or domestic partner has legal guardianship or a similar court order that confers authority and the corresponding duty to care for the person and property of the child under applicable law. 4

6 Who s Covered and When Exceptions for Tobacco Cessation Program and On-site Health Center To participate in the Tobacco Cessation Program, a dependent must be at least age 18. To access the Health Center, a dependent must be at least age 2 and enrolled in an Eaton Medical Plan. Life and AD&D Plan. The eligibility requirements for covering a child in the Life and AD&D Plan are somewhat different. To start, a child can be covered from birth until the end of the calendar year in which he or she reaches age 25. He or she must be unmarried. Your eligible children are then: Each of your children by birth, legal adoption or placement for adoption, including full-time students who do not live with you; Each of your spouse s or domestic partner s children by birth, legal adoption or placement for adoption provided: - the child s legal residence is with you, and - the child is a member of your household; and Each child for whom you (the employee) are the legally appointed guardian provided the child's legal residence is with you. To provide Life and AD&D Plan coverage, you must be able to validly claim any child listed above as an exemption, within the meaning of the U.S. Internal Revenue Code, on your federal income tax return for the year of coverage. If you can t, he or she is eligible for Life and AD&D Plan coverage if you are required under your divorce decree or similar court order to provide medical coverage for the child. Such a child is also eligible for coverage if: Your former spouse can validly claim the child as an exemption on his or her federal income tax return for the year of coverage, You and your former spouse provide more than one-half of the child s support for the calendar year, and The child is in your custody, or in the custody of your former spouse, for more than one-half of the calendar year. States set their own insurance laws, and certain states have an expanded definition of a child for Life insurance and AD&D insurance purposes. That means that certain states let you provide insurance for children who may not qualify as your dependents under the Internal Revenue Code (IRC). Coverage for a Disabled Child A totally and permanently disabled child described in the bulleted sections above who is totally and permanently disabled before his or her coverage would otherwise end because of age may qualify for continued coverage. To qualify, the disabled child must be unable to engage in any substantial gainful activity due to a medically determinable physical or mental condition that can be expected to result in death or to be of long, continued or indefinite duration. In addition, the child must be eligible to be claimed as an exemption, within the meaning of the U.S. Internal Revenue Code, on your federal income tax return for the year of coverage. You must submit evidence of your child s total and permanent disability to the Claims Administrator within 31 days of the date the child s coverage would otherwise end. You must provide proof of the child s continuing disability as requested. If you disagree with a determination that a child is not totally and permanently disabled, you can file an appeal under the claims appeal process. Proof of Dependent Eligibility When you enroll a dependent in a Plan, you are representing to the Claims Administrator that the dependent meets the eligibility requirements for the Plan. From time to time, the Plan Administrator may ask you to verify the eligibility of a dependent. You may need to provide his or her Social Security number and other documents. Other documents may include, but are not limited to, a marriage license, birth certificate and copies of federal tax returns. For example, a child s eligibility for coverage in any year may be based on whether you have validly claimed the child as an exemption on your most recent federal income tax return and your certification that you are able to do so for the current year. You will be given a reasonable amount of time to submit the requested information and documents. If you do not do so, coverage for the dependent will end. 5

7 Who s Covered and When Qualified Medical Child Support Orders (QMCSO) and National Medical Support Notices An employee s child who does not meet all the eligibility requirements for Plan coverage may be assigned the right to receive benefits by a qualified medical child support order (QMCSO). These orders are issued based on state domestic relations laws. The order may be issued by a court of competent jurisdiction or through an administrative process established by state law that has the force and effect of law. You will be notified when a support order is served on the Plan Administrator. Within a reasonable period of time you will then be informed if it is a QMCSO. State child support enforcement agencies are required to enforce health care coverage provisions in child support orders through the use of the National Medical Support Notice (NMSN). When completed properly, the NMSN is deemed to be a QMCSO. You may request a copy of the Plan s QMCSO procedures without charge by contacting QDRO Consultants Company at and identifying yourself as an Eaton employee. ENROLLING FOR COVERAGE Eaton provides you with an enrollment worksheet when you are first eligible to participate in the Eaton Flexible Benefits Program and before each annual enrollment. The personalized worksheet explains how to enroll and shows your: Plan options, Employee costs or credits, and Default coverage: the benefits and coverage levels Eaton assigns you if you don t actively make enrollment decisions. You can enroll over the phone or online through the Eaton Service Center at Fidelity. Enrollment periods are: Within 60 days of your date of hire, Within 60 days of the date you transfer to an eligible employee status, and During the annual enrollment period each fall. When you first enroll, your enrollment choices including default elections authorize the Company to take payroll deductions to pay the employee cost of your Plan options and coverage levels for the rest of the year. (The year is the Plan year, which is the same as the calendar year.) During annual enrollment, your elections authorize payroll deductions for the coming year. 6

8 Who s Covered and When Your Benefit Options When you enroll, you choose from the following benefits: Plan Options Description Paying for Coverage Health Care Plans Medical Enhanced Medical with HSA Basic Medical with HSA No coverage Dental Dental Plan No coverage Vision Vision Plan No coverage Reimbursement Accounts Dental/Vision Reimbursement Account (DVRA) No coverage Dependent Care Reimbursement Account (DCRA) No coverage Coverage levels (you can choose a different level for each plan): Employee only Employee and spouse/domestic partner Employee and child(ren) Employee and spouse/domestic partner and child(ren) You and your eligible dependents must be in the same medical option. For eligible dental and vision expenses For eligible child and elder care expenses Contribute between $10 - $208 per month ($120 - $2,496 per year) Contribute between $10 - $416 per month ($120 - $4,992 per year) You and Eaton share the cost of coverage in the Medical and Dental Plans. You pay the full cost of coverage in the Vision Plan. You pay your share with before-tax dollars, except you may pay after-tax for domestic partner coverage if he or she is not your dependent for tax purposes. You contribute before-tax dollars to a reimbursement account to pay eligible expenses that come up during the year. Use-it-orlose-it rule applies. 7

9 Who s Covered and When Plan Options Description Paying for Coverage Life and Accidental Death and Dismemberment (AD&D) Insurance Life Insurance Eaton pays for coverage equal to one times annual base pay (minimum of $25,000). AD&D Insurance Eaton pays for coverage equal to one times annual base pay. See page 114 to confirm coverage. Spouse/Domestic Partner Life and AD&D You can choose other life insurance amounts: Additional coverage equal to 1 to 7 times your annual pay level with rates based on age and, if you have AD&D coverage of 1 times annual base pay, tobacco user status ($10 million maximum) 25%, 50% or 75% of annual base pay and receive a credit toward other benefits You can choose other AD&D amounts: Additional coverage equal to 1 to 7 times your annual pay level ($10 million maximum) No coverage and receive a credit toward other benefits You can choose coverage for your spouse/domestic partner: Flat dollar amounts of $10,000 / $50,000 / $100,000 / $150,000 / $200,000 / $250,000 No coverage Eaton pays the cost of basic life and AD&D coverage as noted. Premiums for coverage of more than $50,000 are reported as imputed income. You pay for additional coverage with before-tax dollars. You pay with beforetax dollars for: Spouse AD&D Child AD&D Child Life and AD&D You can choose coverage for your eligible children: Flat dollar amounts of $10,000 / $15,000 / $20,000 / $25,000 No coverage Your cost is the same regardless of how many eligible children you have. You pay with aftertax dollars for: Spouse/domestic partner life insurance Child life insurance Domestic partner AD&D Disability Coverage Long Term Disability Plan Eaton pays for Option 1 coverage of 50% of your monthly base pay. Certain collectively bargained employees have other arrangements. See page 138 to confirm eligibility. You can choose additional coverage: Option 2 60% of monthly base pay Option 3 70% of monthly base pay Taxation of child AD&D coverage varies by state. See Paying for Child AD&D Insurance. Eaton pays the cost of Option 1 coverage. You pay for additional coverage with before-tax dollars. Long term disability benefits you receive from the Plan are taxable income. 8

10 Who s Covered and When If You Do Not Enroll As a newly eligible employee, if you do not enroll within the 60-day timeframe for new employees, you will be assigned the following coverage only: Plan Medical Long Term Disability Employee Life Employee AD&D Default Coverage Basic Medical with HSA for you only Option 1: 50% of monthly base pay One times annual base pay One times annual base pay The employee contribution for the Basic Medical with HSA plan option will be deducted from your paycheck. If you do not want Eaton medical coverage, you must elect Medical No Coverage when you enroll. In that case, you will have no medical or prescription drug coverage under the Eaton plan; you are certifying you have medical coverage elsewhere for example, through a health care program maintained by your spouse s employer. During the annual enrollment period, if you do not enroll, Eaton assigns you the same Plan options and coverage levels you have in place at the end of the year for the next year. Payroll deductions for your Plan options and coverage levels will continue for the coming year. If your option is not available for the next year, you will be assigned the default coverage shown on your enrollment worksheet. Benefit Plans You Do Not Enroll In You do not enroll in some benefit plans because Eaton pays the full cost of coverage. If you are eligible, you automatically participate in the: Short Term Disability Plan Work/Life Solutions Plan Couples Who Are Both Eligible for Eaton Benefits You and your spouse/domestic partner may both be eligible to enroll in Eaton-sponsored benefit plans. For example, you may both be active employees of Eaton or a participating subsidiary, or one may be a retiree. In this case, you have the following Medical, Dental and Vision Plan enrollment options: You and your spouse/domestic partner may each elect coverage under your own plan. Each of you may cover different eligible children, or one of you may cover all of the children. In this option, neither of you may be covered as a spouse/domestic partner; or One of you may enroll as the employee and the other as the spouse/domestic partner along with any eligible children. All members of the family must be in the same Medical Plan option. You may provide spouse/domestic partner Life and AD&D insurance for each other in addition to any employee life insurance you have through Eaton. Both of you may elect life and AD&D insurance for your eligible children. When Your Youngest Child Reaches Age 25 Children are eligible for Child Life Insurance and Child AD&D Insurance until their 25 th birthdays. If you have been purchasing insurance for your child(ren), you should elect the No Coverage option during annual enrollment in the fall of the year your youngest child reaches age 25. It is your responsibility to stop coverage when your youngest child reaches age 25; coverage does not end automatically. For example, if your youngest child turns age 25 on June 23, 2016, you must elect No Coverage during the annual election period for 2017 Child Life and AD&D benefits. Note that medical, dental, vision and Work/Life Solutions coverage is available until the end of the year in which your child reaches age 26. 9

11 Who s Covered and When Benefit Contributions, Social Security and Taxes Effective Date of Payroll Deductions. Increases or decreases in payroll deductions resulting from an enrollment or mid-year change in Plan coverage will go into effect as soon as administratively possible. Retroactive deductions will not be taken and retroactive refunds will not be made. Impact on Social Security Benefits. You generally do not pay Social Security taxes on the before-tax contributions you make for coverage in the Flexible Benefits Program. This means your Social Security benefits at retirement or during a period of disability may be slightly less if: You earn less than the Social Security wage base, or Your before-tax deductions reduce your taxable wages below the Social Security wage base. If your taxable wages are more than the Social Security wage base, your Social Security benefits are not affected. In most circumstances, your before-tax deductions for coverage do not affect other Eaton benefit plans such as life insurance, disability, savings plan and pension. Impact on Taxes. Before-tax Contributions The Eaton Corporation Flexible Benefits Program is a cafeteria plan under Section 125 of the Internal Revenue Code. Employee contributions are deducted from your paycheck on a before-tax basis as permitted under current federal tax law. Certain state and local taxes may apply. Credits in the Flexible Benefit Program Some employee life insurance and AD&D options provide less coverage than the Company-paid insurance amounts. If you choose one of these options, you receive a credit toward other benefits in the Flexible Benefits Program. If you do not use the credits, they are included in your regular paycheck as taxable income. Unused credits are not payable during any period you do not receive a paycheck but are still eligible for benefits. Paying for Domestic Partner Coverage If you cannot validly claim your domestic partner as an exemption within the meaning of the U.S. Internal Revenue Code on your federal income tax return, your contributions for coverage of your domestic partner are deducted from your paycheck on an after-tax basis. The monetary value of your partner s benefit coverage, less your after-tax contributions, is considered taxable income to you. Paying for Child AD&D Insurance States set their own insurance laws, and certain states have an expanded definition of a child for Life insurance and AD&D insurance purposes. As a result, certain states let you provide insurance for children who may not qualify as your dependents under the Internal Revenue Code (IRC). If you live in one of these states and choose child AD&D coverage, you must pay for coverage on an after-tax basis if you are covering more than one child and any one of them is not your IRC dependent. Contributions for child AD&D coverage are automatically taken from your pay on a before-tax basis. If any child you are covering does not qualify as an IRC dependent, you must contact the Eaton Service Center at Fidelity to request that your contributions for child AD&D coverage be made on an after-tax basis. If the contribution is not handled correctly, there may be tax consequences. If the dependent status of your children changes during annual enrollment or because of a mid-year change in family status and all of the children meet the definition of an IRC dependent, contact the Eaton Service Center at Fidelity again to request that your contribution for child AD&D coverage be switched back to a before-tax basis. 10

12 Who s Covered and When WHEN COVERAGE STARTS When you are newly eligible, your benefit plan coverage generally starts on the later of: Your date of employment, The date you transfer to eligible status, or The effective date of coverage for newly participating locations of Eaton or U.S. subsidiaries. Dependent coverage generally starts on the date you become eligible. However, if a dependent other than a newborn child is in the hospital or similar facility for medical care or treatment on that date, his or her life and AD&D coverage will not begin until he or she is released. Your initial benefit choices typically stay in effect until the end of the year. The benefit choices you make during annual enrollment typically start on the next January 1 and stay in effect for the year. Exceptions to these start dates are: If evidence of good health is required for increased coverage, the higher coverage does not become effective until the evidence of good health is submitted and approved. For short term disability, long term disability and life and AD&D coverage for yourself, you must be actively at work on the date your coverage is due to begin, or else coverage including any elections made during annual enrollment does not start until the day you return to active work. For short-term disability, any initial employment periods specified for production employees represented by a collective bargaining agent take precedence. Under certain circumstances, you can change your coverage option during the year if you have a qualified change in status or other event. See Changing Your Election during the Year for more information. Actively at Work Actively at work or active work means the performance of duties as required or assigned by the Company. You are considered to be actively at work for purposes of the Plan if you are on paid vacation or Company holiday on your initial effective date. 11

13 Who s Covered and When CHANGING YOUR COVERAGE DURING THE YEAR Internal Revenue Service (IRS) and Plan rules restrict the benefit plan changes you can make during the year. You may, though, be allowed to change your coverage during the year if certain events occur. These events are called change in status events, and the related IRS and Plan rules are extensive. The following is a brief summary. You can change your benefit plan elections for any reason during the next annual enrollment period, and the change will be effective at the start of the next calendar year. Change in Status Events You may be allowed to change your benefit plan coverage if you experience a change in status event that follows IRS and Plan rules. Your benefit changes must be consistent with the event, as determined by the Plan Administrator. For example, if you get married you can cancel your medical coverage only if your spouse is adding you under his or her medical plan. You must notify the Eaton Service Center at Fidelity of the change in status event and make allowable benefit changes within 31 days (unless noted otherwise) after the date of the event. Otherwise, you will need to wait until the annual enrollment period to make the change. Change in status events include the following, which may affect your participation in some or all of the Plans: Change in your legal marital status; Change in the number of your eligible dependents; Change in employment status for you, your spouse, your domestic partner or your dependent child; Your child or domestic partner satisfies (or no longer satisfies) dependent eligibility requirements; The start or end of adoption proceedings; Change in the permanent residence of your dependents from a foreign location to the U.S.; and For medical coverage, your, your spouse s/domestic partner s or your child s enrollment in a Health Insurance Marketplace medical plan due to a special enrollment or annual open enrollment period for the Marketplace plan. Plus, you may be able to change your Dependent Care Reimbursement Account (DCRA) election for the following events: A change in your dependent day care expenses, or A leave of absence or layoff. 12

14 Who s Covered and When Timing and Start Date for Dependent Eligibility Changes. When your change in status affects a dependent s eligibility for coverage, you may be able to add, remove or change coverage for you and your dependents, consistent with the event. The timeframes shown below apply. For medical coverage, you will also be able to change your medical option. Your change in coverage will start as shown below. Reason for Dependent Eligibility Change Dependent Gains Eligibility Legal guardianship or a similar arrangement that confers authority (and the corresponding duty) to care for the person and property of the child under applicable law Regaining dependent eligibility Marriage Reaching domestic partner eligibility Medical, Dental and Vision Plans: Change in permanent residence from outside the U.S. to inside the U.S. Birth Adoption or placement for adoption Dependent Loses Eligibility Divorce, annulment, legal separation Change in Coverage Starts on the Date* The court order becomes effective Your dependent again meets eligibility requirement Of marriage The person has lived with you for six consecutive months The dependent moves to the U.S. Of birth Child is placed in your residence Of divorce, annulment, legal separation You Must Notify the Eaton Service Center at Fidelity Within 31 days 60 days 31 days for LTD and Life and AD&D Insurance Six months 31 days Death Of death 31 days Covered child or domestic partner no longer meets eligibility requirements Dependent no longer meets eligibility requirements 31 days * Exceptions may apply for the start of Life and AD&D Insurance as well as LTD coverage for yourself. Employment Changes. If the change in status event that affects you, your spouse, your domestic partner or a dependent child relates to termination, start of employment or a change in work schedule, you may be able to change your coverage level and/or Plan options or enroll in benefits coverage to the extent the change is consistent with the event. Any allowable change starts as of the date of the applicable event if you notify the Eaton Service Center at Fidelity and make your new election within 31 days of the event. 13

15 Who s Covered and When Certain Other Events Certain other events may also occur that allow you to change your election in some or all Plans. For example: Taking a leave of absence under the Family and Medical Leave Act (FMLA) or because of qualifying military service, Certain court orders (such as qualified medical child support orders), Entitlement (or loss of entitlement) to Medicare, or A significant change in your spouse s or your domestic partner s benefits coverage or cost under another employer s plan. Any change to your election must be made with the Eaton Service Center at Fidelity within 31 days of the event and be consistent with the type of event you have experienced. Special Enrollment Rights for Medical, Dental and Vision Coverage If you do not enroll yourself or your dependents (including your spouse/domestic partner) because you have other medical, dental or vision coverage, you may be able to enroll yourself or your dependents in the Plan if your other coverage ends or the employer stops contributing to your or your dependents other coverage. For medical coverage, the Healthy Incentive program rules will still apply to you. You must contact the Eaton Service Center at Fidelity and make your enrollment election within 31 days of the date the other coverage ends or the employer stops contributing. In addition, if you gain a new dependent as a result of marriage, domestic partner eligibility, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents. You must request enrollment through the Eaton Service Center at Fidelity within 60 days after the marriage or the date of domestic partner eligibility, or within six months after the date of birth, adoption or placement for adoption. Rights Related to Medicare and Medicaid. If you or your dependent becomes covered by Medicare Parts A, B or C, you may be able to cancel medical coverage by contacting the Eaton Service Center at Fidelity within 31 days of becoming covered by Medicare. If you or your dependent loses eligibility for Medicare Part A, B or C, you may be able to enroll in medical coverage by contacting the Eaton Service Center at Fidelity within 31 days of losing Medicare eligibility. If you or your dependent becomes covered by Medicaid, you may be able to cancel medical coverage by contacting the Eaton Service Center at Fidelity within 60 days of becoming covered by Medicaid. If you or your dependent loses eligibility for Medicaid, you may be able to enroll in medical coverage by contacting the Eaton Service Center at Fidelity within 60 days of losing Medicaid eligibility. 14

16 Who s Covered and When BENEFITS COVERAGE WHILE YOU ARE NOT ACTIVELY AT WORK You can continue your Eaton benefit plan coverage while you are not actively at work on a Companyapproved leave of absence by paying the required employee contribution for coverage either by payroll deduction, monthly invoice or automatic bank withdrawal through the Eaton Service Center at Fidelity. If you are paying by monthly invoice or automatic bank withdrawal, you will not be charged for your Long Term Disability coverage. The amount of time you can continue benefits is determined by type of leave, as explained below. If you stop making the required contributions, your coverage ends at the end of the month for which the last required contribution was paid. There is a maximum continuation period of 18 consecutive months for Employee Life Insurance, Employee AD&D Insurance, Spouse/Domestic Partner Life Insurance, Spouse/Domestic Partner AD&D Insurance, Child Life Insurance and Child AD&D Insurance regardless of: The continuation period described for each type of leave, or Whether your absence consists of one or more than one type of leave. Unless noted otherwise, Short Term Disability Plan and Work/Life Solutions Plan coverage continues during an approved leave of absence. The cost of this coverage is paid by the Company. Because the reimbursement accounts operate under IRS provisions for a given tax year, the Dental/Vision Reimbursement Account (DVRA) and Dependent Care Reimbursement Account (DCRA) have separate rules for continuing participation while not at work. Please see the next section for details. Non-Occupational or Occupational Short Term, Long Term or Extended Disability Leave of Absence When a non-occupational or occupational illness, accidental injury or pregnancy prevents you from working and you are on a Company-approved disability leave of absence, you may continue coverage under the Medical, Dental, Vision, Life and AD&D Insurance, Short Term and Long Term Disability and Work/Life Solutions EAP Plans for the duration of your short term disability leave. You can extend coverage for an additional 12 months after your short term disability leave ends if you are receiving benefits from the Long Term Disability Plan. Other Company-Approved Leaves of Absence If you are on a Company-approved leave of absence, as listed below, you may continue your coverage under the Medical, Dental, Vision, Life and AD&D Insurance, Short Term and Long Term Disability and Work/Life Solutions EAP Plans during your leave. Personal or Educational Leave. If you are granted an unpaid personal or educational leave of absence, you may continue your coverage for up to six consecutive months. For a paid leave, you may continue coverage for the duration of the leave. Family and Medical Leave Act (FMLA) Leave of Absence. If you have been employed by Eaton for at least 12 months and have worked a minimum of 1,250 hours within the last 12 months, the FMLA entitles you to 12 weeks of unpaid, job-protected leave each year. Leaves are allowed for family and medical reasons specified in the FMLA. See your Human Resources Department for information concerning the FMLA. You may continue your coverage for the duration of an FMLA leave. Military Reserve Leave of Absence. If you are granted a military reserve leave of absence, you may continue your coverage for the duration of your leave. Active Military Leave of Absence. If you are called to active military duty, your benefit plan coverage continues under the provisions of the Company military leave policy. The length of time you may continue coverage varies by military conflict. Mandatory Unpaid Leave of Absence (MULA) or Voluntary Unpaid Leave of Absence (VULA). If you are required or volunteer to take an unpaid leave of absence, you may continue coverage for the duration of your leave. 15

17 Who s Covered and When Temporary Layoff If you are temporarily laid off, you may continue coverage under the Medical, Dental, Vision, Life and AD&D Plans for up to six consecutive months. Short Term Disability and Long Term Disability Plan coverage ends while you are on layoff. Note: If your employment is covered by a collective bargaining agreement, coverage under the Plan may be continued for a greater or lesser period of time than described above if a continuation period is specified by the collective bargaining agreement. Any continuation periods specified by a collective bargaining agreement take precedence over the applicable continuation provisions described here. CONTINUING REIMBURSEMENT ACCOUNT PARTICIPATION WHILE NOT ACTIVELY AT WORK You may be able to continue participating in the Dental/Vision Reimbursement Account (DVRA) and/or Dependent Care Reimbursement Account (DCRA) Plans even if you are not actively at work. If you are not working due to any of the situations described below, your annual election amount does not change. Reimbursement account deposits are collected through one or more of the following methods: Deductions continue to be made from your paycheck; You are billed for your deposits; or After you return to work from an unpaid leave of absence, the amount deducted from the remainder of the year s paychecks is increased so you will meet your annual election amount. You cannot be reimbursed for dependent care expenses you incur while you are not actively at work; for example, while you are on a leave of absence or layoff. Because this federal law affects DCRA reimbursements, you may make a mid-year change in your election amount. Non-Occupational or Occupational Short Term, Long Term or Extended Disability Leave of Absence When a non-occupational or occupational illness, accidental injury or pregnancy prevents you from working and you are on a Company-approved disability leave of absence, your deductions for reimbursement account deposits continue to be made from your paychecks. If you are not receiving disability benefits through the Eaton payroll system: You are billed for DVRA contributions during any full calendar month in which you are on leave. (You pay contributions for any partial month for which you are on leave through increased payroll deductions when you return to work, as described below.) Your DVRA coverage continues until the earlier of: - the end of the Plan year (calendar year), or - the end of the month before the first month for which you did not pay the monthly billed amount. If you return to work during the same calendar year, the amount deducted from the rest of your paychecks for the year is increased so you will meet your annual election amount. DVRA contributions paid through the monthly billing process are taken into account to determine your increased deduction amount. The increased deduction starts in your paychecks as soon as administratively possible after you return to work. See the example on page 96. You are not billed for Dependent Care Reimbursement Account contributions, and your Dependent Care Reimbursement Account participation continues until the end of the calendar year. If you are still on a leave at the beginning of a year, you cannot participate in either of the reimbursement accounts until you return to work and elect to participate during the applicable enrollment period. 16

18 Who s Covered and When Unpaid FMLA Leave of Absence If you are granted an unpaid FMLA leave of absence: You are billed for your DVRA contributions during any full calendar month in which you are on leave. (You pay contributions for a partial month through increased payroll deductions when you return to work, as described below.) Your DVRA coverage continues until the earlier of: - the end of the calendar year; or - the end of the sixth calendar month following the last day you were actively at work. You are not billed for Dependent Care Reimbursement Account contributions, and your Dependent Care Reimbursement Account participation continues until the end of the calendar year. During your leave you are not required to pay the contributions to the DVRA, and if you do not, the amount deducted from your future paychecks will be increased to recoup the difference. The increased deduction starts in your paychecks as soon as administratively possible after you return to work. Contact the Plan Administrator to determine the amount of the increase and the length of time during which the increased premiums will be deducted. If you are still on a leave at the beginning of a year, you cannot participate in the Dependent Care Reimbursement Account until you return to work and elect to participate during the applicable enrollment period. Other Unpaid Leave of Absence If you are granted an unpaid personal, educational, FMLA, active military or military reserve leave of absence, or a mandatory or voluntary unpaid leave of absence (MULA or VULA): You are billed for your DVRA contributions during any full calendar month in which you are on leave. (You pay contributions for any partial month for which you are on leave through increased payroll deductions when you return to work, as described below.) Your DVRA coverage continues until the earlier of: - the end of the Plan year (calendar year); - the end of the sixth calendar month following the last day you were actively at work if you are on personal, educational or military reserve leave; - the end of the contribution period if you are on active military leave (the length of the continuation period varies by military conflict); or - the end of the month before the first month for which you do not pay the monthly billed amount. You are not billed for Dependent Care Reimbursement Account contributions, and your Dependent Care Reimbursement Account participation continues until the end of the calendar year. If you return to work during the same calendar year, the amount deducted from the rest of your paychecks for the year is increased so you will meet your annual election amount. DVRA contributions paid through the monthly billing process are taken into account when determining the amount of the increased deduction. The increased deduction starts in your paychecks as soon as administratively possible after you return to work. See the example on page 96. If you are still on a leave at the beginning of a year, you cannot participate in either of the reimbursement accounts until you return to work and elect to participate during the applicable enrollment period. Paid Leave of Absence Personal, Educational, FMLA or Military Reserve Leave of Absence. If you are granted a paid personal, educational, FMLA or military reserve leave of absence, your reimbursement account deposits continue to be deducted from your paycheck. Active Military Leave of Absence. If you are called to active military duty, your reimbursement account deposits continue to be deducted from your paycheck as long as you remain eligible to participate in the Plan. The length of time you may continue to participate in the reimbursement accounts varies by military conflict. 17

19 Who s Covered and When Temporary Layoff If you are temporarily laid off: You are billed for your DVRA contributions during any full calendar month in which you are on layoff. (You pay contributions for any partial month for which you are on leave through increased payroll deductions when you return to work, as described below.) Your DVRA coverage continues until the earlier of: - the end of the Plan year (calendar year), - the end of the sixth calendar month following the last day you were actively at work, or - the end of the month before the first month for which you did not pay the monthly billed amount. You are not billed for Dependent Care Reimbursement Account contributions, and your Dependent Care Reimbursement Account participation continues until the end of the calendar year. If you return to work during the same calendar year, the amount deducted from the rest of your paychecks for the year is increased so you will meet your annual election amount. DVRA contributions paid through the monthly billing process are taken into account when determining the amount of the increased deduction. The increased deduction starts in your paychecks as soon as administratively possible after you return to work. See the example on page 96. If you are still on layoff at the beginning of a year, you cannot participate in either of the reimbursement accounts until you return to work and elect to participate during the applicable enrollment period. 18

20 Who s Covered and When WHEN COVERAGE ENDS When Your Employee Coverage Ends Unless you elect continuation coverage under COBRA, if eligible, your coverage under the Eaton health care and insurance Plans ends on the earliest of: The last day of the month in which your employment with Eaton ends, The last day of the month in which the period for which you are eligible to continue coverage while not actively at work expires, The last day of the month in which you are eligible to continue coverage under the terms of an Eaton severance plan or agreement, The date you transfer to a non-eligible employee status, or The date of your death. If you were an active employee when you died, your dependents may be able to continue their coverage as explained below. Dependent Care Reimbursement Account. Your participation under the Dependent Care Reimbursement Account ends: At the end of the calendar year in which: - your employment with Eaton ends, - you transfer to a non-eligible employee status, or - you die. Short Term Disability Plan. Your short term disability plan coverage ends on the earliest of: Your last day of active work immediately before the date your employment with Eaton ends, Your last day of active work immediately before the date you are laid off from the Company, Your last day of active work immediately before your retirement date, 11:59 p.m. on your last day of an approved period of leave if you do not return to active work, Your last day of active work immediately before the date you transfer to a non-eligible employee status, or The date of your death. Long Term Disability Plan. Your Long Term Disability Plan coverage ends on the earliest of the following dates: The date your employment with Eaton ends, The date you transfer to a non-eligible employee status, The date you go on temporary layoff, The last day of the month in which the period that you are eligible to continue coverage while not actively at work expires, or The date of your death. For all Eaton Plans, if you stop making the required contributions for coverage, your coverage ends at the end of the month for which the last required contribution was paid. Your coverage under the Plans is subject to termination or amendment by the Company at any time for any reason. 19

21 Who s Covered and When When Dependent Coverage Ends Unless continuation coverage is elected under COBRA (if eligible), your dependents coverage under the Eaton benefit plans they are enrolled in ends on the earliest of the following dates: The date on which your coverage ends for a reason other than death; The last day of the 12 th month following the month in which your death occurs (see below); The last day of the month for which you paid the required employee contribution for coverage; For your spouse, the date on which he or she is divorced or legally separated from you, or his or her marriage to you is annulled; or For each covered dependent child or a domestic partner, the date when such child or domestic partner no longer meets the definition of an eligible dependent. Extended Dependent Coverage Period if You Die If you die while you are an active employee, your surviving spouse/domestic partner and your eligible dependent children (whether or not there is a surviving spouse/domestic partner) are eligible for an extended period of benefit coverage. By paying the applicable employee contribution for coverage, they can continue their coverage in the Medical, Dental, Vision and/or Life and AD&D Insurance Plans. Coverage can continue for up to 12 months following the end of the month in which you died. Coverage for a dependent child ends during the 12-month period if he or she no longer meets the dependent eligibility requirements. If your surviving spouse/domestic partner marries any time after your death, the new spouse and his or her dependent children are not eligible to participate in the Plans. At the end of the 12-month extension period, if your surviving spouse/domestic partner and/or eligible dependent children are still enrolled, they may continue coverage through COBRA. They can continue coverage under COBRA for up to 36 consecutive calendar months following the end of the 12-month extension period. For the DVRA, your eligible dependents can continue coverage through the end of the calendar year if they pay the required monthly contributions. Continuing Coverage If your or your dependents coverage ends, you may be able to continue coverage in the group health plans through COBRA. The conversion and portability options in the Life and AD&D Insurance Plan allow you to continue coverage in an individual insurance policy unless your coverage ended because you did not pay your required contributions. Certificate of Creditable Coverage If your Medical Plan coverage ends, you will receive a certificate of prior creditable coverage. The certificate shows evidence of your Eaton medical coverage that you can apply toward a preexisting condition exclusion under another medical plan. For the certificate to be valid, you have 63 days from the date your Eaton plan coverage ends to enroll in another plan. Contact your state insurance department for further information. If you elect COBRA continuation coverage, a second certificate is issued when it ends. Contact the Eaton Service Center at Fidelity for further information. 20

22 Who s Covered and When CONTINUING COVERAGE THROUGH COBRA If you lose your eligibility for group health plan coverage for active employees, the Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you to continue your coverage at your own expense in certain situations. In many cases, your covered spouse and dependent children (your qualified beneficiaries) are also eligible. The Plans that are group health plans and eligible for COBRA coverage are: Medical Dental Vision Dental/Vision Reimbursement Account (DVRA) portion of the Reimbursement Account Plans Counseling Program, Eaton On-site Health Center and the Tobacco Cessation Program of the Work/Life Solutions Plan All references to Eaton group health coverage in this section refer to the Plans listed above. If you choose to continue coverage through COBRA, the Company must provide you the same coverage that similarly situated employees or family members receive. If Plan coverage changes for these similar beneficiaries, your coverage will also change. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The Company has retained the Eaton Service Center at Fidelity as its COBRA compliance administrator for its group health plans. Make sure the Eaton Service Center at Fidelity has the current addresses of your family members. You should also keep a copy, for your records, of any notices you send to the Eaton Service Center at Fidelity. When You Become Eligible for COBRA (Qualifying Events) You, your spouse and/or dependent children who are covered by Eaton group health coverage may continue coverage through COBRA if you lose your coverage because of your: Reduced hours of employment. Loss of employment (except for gross misconduct on your part). Your covered spouse and dependent children may also be able to continue coverage through COBRA if they lose their coverage because you: Die. Get divorced or legally separated. Become entitled to Medicare (under Part A, Part B or both). In addition, your covered dependent child can continue coverage through COBRA if he or she would lose coverage because of no longer meeting the definition of an eligible dependent. A child born to, adopted by or placed for adoption with you during the period of COBRA coverage is also eligible for COBRA coverage. 21

23 Who s Covered and When Starting with COBRA Notifying the Eaton Service Center at Fidelity. Depending on the event that causes you to lose eligibility, either you or Eaton is responsible for notifying the Eaton Service Center at Fidelity. Who Notifies the Eaton Service Center at Fidelity You, your covered spouse or covered dependents, within 60 days of: Divorce Legal separation Child losing dependent status You may need to provide documentation of the above events. If you do not notify the Eaton Service Center at Fidelity within 60 days, your rights to continue coverage end. Eaton, within 30 days of: Reduction in hours of employment Termination Death Medicare entitlement If you need help acting on behalf of a beneficiary who is deemed to be incompetent, contact the Eaton Service Center at Fidelity. After the Eaton Service Center at Fidelity has been notified, the Eaton Service Center at Fidelity will, in turn, notify you of your right to elect COBRA coverage. Enrolling for COBRA Coverage. Under the law, a qualified beneficiary has 60 days from either the date of loss of coverage or from the date of the notice, whichever is later, to choose COBRA coverage. If you do not choose COBRA coverage, your Eaton group health coverage ends. You can elect COBRA coverage on behalf of your spouse, and you or your spouse can elect COBRA coverage on behalf of your children. You do not have to show that you are insurable to choose COBRA coverage. DVRA If you elect to continue your DVRA and you want to use your Acclaris Visa card to pay for eligible expenses, you need to reactivate your card. Call the toll-free phone number on the card and enter the requested information. Alternatives to COBRA There may be other medical coverage options for you and your family through the Affordable Care Act s Health Insurance Marketplace. In the Marketplace, you could be eligible for a tax credit that lowers your monthly premiums right away. You can see what your premium, deductibles and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage or a tax credit through the Marketplace. Additionally, you may qualify for a special enrollment opportunity with another group health plan for which you are eligible (such as a spouse's plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days. 22

24 Who s Covered and When How Long COBRA Coverage Lasts For eligible Plans except DVRA. You, your covered spouse and your covered children can continue COBRA coverage up to the time period shown below. Qualifying Event How Long COBRA Coverage Lasts 18 months 29 months 36 months You lose coverage because of: Reduced work hours Employment ends for any reason other than gross misconduct You or your dependent is disabled (as defined by Title II or XVI of the Social Security Act) at any time during the first 60 days of COBRA coverage (see below) You die*, divorce or become legally separated You become entitled to Medicare, causing dependents to lose coverage Child no longer qualifies as a dependent Employee Spouse Children Employee Spouse Children Spouse (former spouse) Children Spouse Children Child * If you die while actively at work, the COBRA continuation period for your spouse and dependent children begins on the last day of the 12-month period following the month of your death. COBRA coverage may continue past 18 months in certain situations. If you, your covered spouse or your dependent becomes disabled. COBRA coverage can continue for up to an additional 11 months if Social Security determines the individual is disabled at any time during the first 60 days of COBRA coverage. To receive the extension, the Eaton Service Center at Fidelity must be notified within 60 days of the Social Security disability determination and before the end of the original 18-month period. The extension will end if the disability ends during the 11-month extension period. The Eaton Service Center at Fidelity must be notified within 30 days of any final determination that the individual is no longer disabled. If there is more than one qualifying event. COBRA coverage for your spouse or child may extend to 36 months if a second event (death, divorce, legal separation, Medicare entitlement or a dependent child no longer qualifies as a dependent under the Plan) occurs during the first 18-month period. For DVRA. If your eligibility ends because of a COBRA-qualifying event, you may continue to participate in the DVRA, but only until the end of the calendar year in which the COBRA event occurs. You contribute to the DVRA on an after-tax basis. 23

25 Who s Covered and When Paying for COBRA Coverage You pay 102% of the applicable cost of coverage for your COBRA coverage on an after-tax basis. This includes the full cost of coverage plus a 2% administration fee. The cost of the 11-month disability extension (does not apply to DVRA) will be: 150% of the applicable contribution if the disabled qualified beneficiary is covered, or 102% of the applicable contribution if only non-disabled qualified beneficiaries are covered. You have 45 days from the date you first elect COBRA coverage to pay: Your first monthly payment, and Any other payments that are due for periods of coverage that end before 45 days from the date of that election. You must make future payments in full within 30 days of each due date. Note: Some states offer financial aid to help certain individuals pay for COBRA coverage. Contact your appropriate state agency to see if this applies to you. When COBRA Coverage Can Be Terminated The law says that your COBRA continuation coverage may end before the full COBRA continuation period is up for any of the following reasons. If your continuation coverage ends for any reason, it cannot be reinstated. You become, after the date of your election, entitled to Medicare. You do not pay the contribution for your COBRA coverage by the due date, as required by the Plan. You extend coverage for up to 29 months due to disability and there has been a final determination that you are no longer disabled. Eaton no longer provides group health coverage to any of its employees. Although your coverage could legally end for the first and second reasons listed above, the Plan provisions do not include termination of coverage for these reasons. If you have questions about the Eaton Corporation Flexible Benefits Program or COBRA, contact the Eaton Service Center at Fidelity at EATON01. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA web site at or call their toll-free number at For more information about health insurance options available through a Health Insurance Marketplace, visit HealthCare.gov. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s web site.) 24

26 Medical Plan MEDICAL PLAN MEDICAL PLAN OVERVIEW HEALTHY INCENTIVES CREDITS Special Rules for Receiving Credits Notice Regarding Wellness Program Protections from Disclosure of Medical Information ANTHEM BLUE CROSS BLUE SHIELD ( ANTHEM BCBS ) THE HEALTH PLAN CLAIMS ADMINISTRATOR Health Plan Claims Administrators and Care Providers HOW TO USE YOUR NETWORK Selecting a Network Physician Precertification When You Travel PPO PROVIDER TYPE COMPARISON PPO and Traditional Indemnity Provider Listing COVERED SERVICES AND SUPPLIES: PREVENTIVE CARE Routine Physical Examinations Well-Woman Gynecological Examinations Well-Woman PAP Tests Well-Woman Mammograms Routine Eye Examinations Routine Hearing Screenings Immunizations and Flu Shots Colon Cancer Screenings Prostate Cancer Screenings Skin Cancer Screenings Cholesterol Screening Bone Density Testing Nutritional Counseling Well Child Care Blood Glucose Screening COVERED SERVICES AND SUPPLIES Physicians and Specialists Diagnostic X-Rays, Lab Tests and Procedures: Outpatient Mental Health/Substance Abuse (MH/SA) Treatment Pregnancy and Newborns Inpatient and Outpatient Surgery and Hospital Care Emergency and Urgent Care Care in Alternate Settings Therapy Specialized Treatments Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics Ambulance Services Additional Services and Programs Anthem Centers of Excellence Maximum Covered Price EXPENSES NOT COVERED DEFINITIONS AND IMPORTANT TERMS PAYMENT OF MEDICAL EXPENSE BENEFITS Filing Claims Filing Deadline Claims Processing Rules How Payments Are Made Procedure for Resolving an Issue Other than a Claims Appeal Claims Appeal Procedures... 57

27 Medical Plan PRESCRIPTION DRUG PROGRAM Purchasing Prescription Drugs Drug Categories Drug Coverage Chart Paying for Prescriptions Purchasing Drugs at a Retail Pharmacy Purchasing Drugs at a Non-Participating Pharmacy Mail Order Program Pay the Difference Program Preferred Drug Step Therapy Prior Authorization of Certain Drugs Preventive Care Drugs Diabetic Supplies Prescription Vitamins Specialty Medications and How to Obtain Them Personalized Medicine Exclusions Filing a Claim Under the Retail Card Program HEALTH SAVINGS ACCOUNT (HSA) Eligibility Opening Your HSA Contributing to Your HSA Using Your HSA The Amount Available to You for Payments Ways to Pay Your HSA When Your Employment Ends Naming a Beneficiary

28 Medical Plan MEDICAL PLAN OVERVIEW Your Share of the Cost of Covered Services Enhanced Medical Basic Medical Details Annual Deductible The amount you pay for covered expenses each year before the Plan starts to pay coinsurance. The deductible does not apply to in-network preventive services, which the Plan pays for in full. In-network Services Employee Employee + Others Out-of-Network Services Employee Employee + Others $1,700 $3,400 $3,400 $6,800 $2,700 $5,400 $5,400 $10,800 For Employee coverage, unless noted otherwise, all of your covered expenses during the year go toward satisfying the annual deductible. For Employee + Others coverage, the family deductible is satisfied by adding together one or more family members covered expenses for the year. One member s eligible expenses can be added together to satisfy the entire family deductible. Once the family deductible is met, the Plan begins to pay coinsurance for all family members. The annual deductible for in-network services is separate from the annual deductible for out-of-network services. The out-of-network deductible does not include: Amounts in excess of the maximum allowed amount, and Charges for service or supplies that are not medically necessary under the terms of the Plan or are not otherwise covered under the Plan. Coinsurance Once you meet the annual deductible, the percentage of the cost of covered services you and the Plan share. Coinsurance does not apply to in-network preventive services, which the Plan pays for in full. Some services require precertification (see page 32) or must be provided through an Anthem Center of Excellence (see page 46) to be covered by the Plan. In-network Out-of-network 20% 40% 20% 40% Unless noted otherwise, coinsurance applies to all covered services and supplies except for in-network preventive care. The Plan pays coinsurance for out-ofnetwork services based on maximum allowed amounts. Annual Out-of-Pocket Maximum The amount you pay (including your deductible) out of your own pocket before the Plan starts to pay 100% of your covered eligible expenses for the rest of the year. Certain exclusions apply, see page 48. In-network Employee Employee + Others Out-of-network Employee Employee + Others $4,000 $8,000 ($7,150 max for one individual) $8,000 $16,000 $5,000 $10,000 ($7,150 max for one individual) $10,000 $20,000 For Employee coverage, the individual out-of-pocket maximum is satisfied by adding together your deductible and coinsurance for the year. For Employee + Others coverage, the family out-of-pocket maximum is satisfied by adding together all family members deductibles and coinsurance for the year so far. However, no one family member will be required to pay more than $7,150 in-network before the Plan begins to pay all eligible expenses for that individual. The out-of-pocket maximum for in-network services is separate from the out-of-pocket maximum for out-ofnetwork services. The out-of-pocket maximum does not include: Amounts in excess of the maximum allowed amount, and Charges for service or supplies that are not medically necessary under the terms of the Plan or are not otherwise covered under the Plan. 27

29 Medical Plan How Expenses Are Paid In-network preventive care Most covered services and prescription drugs Non-emergency use of an emergency room Enhanced Medical Basic Medical You pay $0 (no deductible or coinsurance). You pay 100% up to the deductible, then you pay 20% until you reach the out-of-pocket maximum You pay 100% up to the out-of-network deductible, then you pay 40% of the maximum allowed amounts plus 100% of the difference between the maximum allowed amount and the actual charges. Details Find more details on covered preventive services starting on page 34. Find more details on other covered service starting on page 36. Find more details on prescription drug benefits starting on page 58. Health Savings Account (HSA) Eaton annual contribution Employee Only Coverage: $400 Employee + Others Coverage: $800 You receive this contribution if you are employed on January 1; otherwise the Eaton annual contribution will be prorated by hire date. Find more details on the HSA starting on page 68. HEALTHY INCENTIVES CREDITS You and your covered spouse/domestic partner can earn Healthy Incentives credits toward your monthly employee contribution to the Medical Plan by taking the following actions by the annual deadline: Register with Castlight: You must register with Castlight to be eligible to receive the Healthy Incentives credits described below. Once you register, you do not need to re-register each year. Tobacco Free credit: Register with Castlight and certify that you have been tobacco free for at least the last four months OR enroll in the Eaton Tobacco Cessation Program and complete four sessions. For 2018 the credit is $50/month. Know Your Numbers credit: Register with Castlight and have your important numbers reported by Quest Diagnostics AND complete the Health Assessment. For 2018 the credit is $25/month. The amount of the monthly credit for 2019 will be announced in July 2018 for the 2019 plan year. One of Eaton s core values and principles of ethical business conduct is to communicate openly and honestly and to be truthful in all documentation. We trust that employees and their spouses/domestic partners will be honest in communicating whether they are tobacco free or not. We would like to remind you that as an Eaton employee, you have the responsibility to never falsify any document or misrepresent the true nature of any transaction. Participation in the Health Assessment is voluntary and all information is strictly confidential. Special Rules for Receiving Credits The rules for receiving Healthy Incentives credits are different when you are a new employee. And specific rules apply to your spouse/domestic partner if he or she is new to the Eaton medical plan. You and your spouse/domestic partner automatically receive Healthy Incentives credits through December 2018 if you were hired August 1, 2017 or later. Your spouse/domestic partner automatically receives Healthy Incentives credits through December 2018 if you add your spouse/domestic partner to medical coverage: Due to marriage or another qualifying life event that occurred August 1, 2017 or later; or During annual enrollment for coverage effective January 1,

30 Medical Plan Although you re not required to take action this year, the Healthy Incentives programs are still available to you. For your own health and well-being, we encourage you and your spouse/domestic partner to register with Castlight, participate in the screening, take the Health Assessment and, if you use tobacco, enroll in the Tobacco Cessation Program. If you and/or your spouse/domestic partner are currently receiving automatic 2017 Healthy Incentives credits, you both must take action by the deadline to earn credits in Who Is Not Eligible. You are not eligible for Healthy Incentives credits if you are enrolled in COBRA coverage or you waive medical coverage. Healthy Incentives credits are not available to children regardless of whether or not you cover them in the Medical Plan. Healthy Incentives credits are not available to spouses/domestic partners not covered by the Medical Plan. You and your spouse/domestic partner are advised to take all of the actions described on the previous page even if you do not participate in the Eaton Medical Plan. An unexpected life event may cause you or your spouse/domestic partner to lose other medical coverage and need to enroll in the Eaton Plan during the year. Notice Regarding Wellness Program The Eaton Healthy Incentives Program is a voluntary wellness program available to all employees. 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 Healthy Incentives Program you will be asked to complete a voluntary health risk assessment or HRA 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 will be asked to complete a biometric screening, which will include a blood test for height, weight, blood pressure, blood glucose, cholesterol (HDL, LDL and total) and triglycerides. You will also be asked to attest that you are tobacco-free. If you are not tobacco-free you will be asked to participate in a free Tobacco Cessation Program. You are not required to complete the HRA or to participate in the blood test or other medical examinations. Employees who choose to participate in the Healthy Incentives Program will receive credits applied toward their medical contributions if they participate in the Eaton medical plan in Although you are not required to complete the HRA, participate in the biometric screening, attest tobacco-free or participate in the Tobacco Cessation Program, only employees who complete these activities will be eligible to receive Healthy Incentives credits. If you are unable to participate in any of the Healthy Incentives activities required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks. You also are encouraged to share your results or concerns with your own doctor. 29

31 Medical Plan Protections from Disclosure of Medical Information. We are required by law to maintain the privacy and security of your personally identifiable health information. Although Castlight and Eaton may use aggregate information it collects to design a program based on identified health risks in the workplace, Castlight/Jiff will never disclose any of your personal information either publicly or to Eaton, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the Healthy Incentives Program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the Healthy Incentives 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 Healthy Incentives Program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Healthy Incentives Program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the Healthy Incentives Program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information are the Quest teams that administer the biometric portion of 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 encrypted, and no information you provide as part of the Healthy Incentives 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 Healthy Incentives Program, Eaton or Castlight/Jiff will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the Healthy Incentives Program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Eaton Wellness at

32 Medical Plan ANTHEM BLUE CROSS BLUE SHIELD ( ANTHEM BCBS ) THE HEALTH PLAN CLAIMS ADMINISTRATOR Anthem BCBS is an independent corporation operating under a license with the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield service marks in the State of Ohio. The Company has retained Anthem BCBS to coordinate the administration of the Medical Benefits portion of the Eaton Medical Plan throughout the United States. Like all Blue Cross and Blue Shield licensees, Anthem BCBS participates in a program called BlueCard. Whenever covered persons access health care services outside the geographic area served by Anthem BCBS (Ohio), the claims are processed through BlueCard and presented to Anthem BCBS for payment. Under BlueCard, when covered persons receive health care services within the geographic area served by an on-site Blue Cross and/or Blue Shield licensee (called a Host Blue ), Anthem BCBS is responsible for the payment of claims, but it is the Host Blue that contracts with the participating providers in its network. Information about your medical claims, or what is covered under the Plan, is available by accessing the Anthem BCBS web site, or by calling Anthem BCBS. The web site is available 24 hours a day, seven days a week. Phone service representatives are available weekdays, excluding holidays. Contacting Anthem BCBS You can contact Anthem BCBS: 1. Online through EatonBenefits.com. On the web site you can: Print a claim form, Explanation of Benefits or temporary ID Card Request an Explanation of Benefits or a permanent ID card be mailed to you Find a participating doctor or specialist Check the status of a claim and view your claims history 2. By calling an Anthem BCBS service representative at EATON02 ( ) on Monday through Friday (excluding holidays). Health Plan Claims Administrators and Care Providers As described here, the Medical Plan includes coverage for hospital, physician and other medical care services through a Preferred Provider Organization (PPO), or network. Anthem Blue Cross Blue Shield ( Anthem BCBS ) is the Health Plan Claims Administrator for the PPO network and offers covered employees access to the BlueCard PPO network licensed by Blue Cross Blue Shield. Some states have different local networks, as follows: California: Select PPO; Georgia: Blue Open Access POS; Missouri: Blue Access Choice; Tennessee: Network S; and Wisconsin: Blue Preferred. Anthem BCBS also provides mental health/substance abuse treatment through your applicable network of psychiatrists, psychologists, social workers, treatment clinics and hospitals. Prescription drugs are provided through the Express Scripts, Inc. ( Express Scripts ) retail pharmacy network and mail order program. Express Scripts is the Health Plan Claims Administrator for the Prescription Drug Program. These Health Plan Claims Administrators are independent contractors that operate the respective provider networks available to Plan participants and process claims for covered services and supplies. Generally, health care providers are independent contractors and are not employees or agents of Eaton or the Health Plan Claims Administrators, except that under the mail order drug program, drugs are dispensed by mail order distribution centers owned and operated by Express Scripts Inc., and certain medical facilities are owned or partly owned by one or more of the Health Care Claims Administrators. Eaton expressly disclaims any warranty of the quality of care that may be provided by any health care provider, regardless of whether or not the provider participates in a network accessible under the Plan. The final decision about the treatment you receive and where you receive it is always between you and your physician, whether or not the treatment is determined to be covered under the terms of the Plan. In addition, Eaton expressly disclaims any warranty concerning the accuracy or completeness of any health, wellness or other information available from or distributed by any Health Plan Claims Administrator, including by its web site. 31

33 Medical Plan HOW TO USE YOUR NETWORK The networks are each made up of doctors, hospitals and other health care providers that have individual contracts with Blue Cross Blue Shield. The Medical Plan pays higher in-network benefits when you receive care from a member of your applicable network. The Plan gives you the flexibility to use providers who are not in the network, but benefits are paid at a lower out-of-network level. Selecting a Network Physician Precertification You do not have to sign up with a specific physician, and you do not need a referral to see a specialist. But it is your responsibility to use your network providers so you receive in-network benefits. Before you receive services, you should: Verify your physician is in your network by checking with his/her office or by calling Anthem BCBS Customer Service at EATON02; and Make sure the providers your network physician uses or refers you to are in your network as well by calling Anthem BCBS Customer Service. If you live in a state with a different local network as indicated on the previous page, make sure to use the correct network name when verifying provider status. If you receive covered services from a provider who is not in your network, benefits are paid at the out-of-network benefit level. Specialists. You receive in-network benefits for covered services when you see a specialist physician in your network. You do not need a referral to see a specialist. If an appropriate specialist is not available in your network, Anthem BCBS may authorize benefits at the in-network level for a non-participating specialist. However, authorization is unlikely since all of the networks include a variety of specialists. Contact Anthem BCBS at EATON02 for more information. You are responsible for having services approved in advance, or precertifying services. You must notify Anthem BCBS Managed Care at EATON02: At least two days before: - inpatient care in a hospital or another facility for an event other than childbirth - inpatient care in a medical rehabilitation facility or skilled nursing facility - intensive outpatient care, partial hospitalization, residential treatment center care and certain other outpatient services - receiving home health care, private duty nursing care, hospice care or home infusion therapy If the hospital stay for childbirth will be longer than 48 hours for a vaginal birth or 96 hours for a cesarean section delivery; Before receiving certain outpatient mental health/substance abuse services (see page 38); Before receiving high-dollar imaging and scanning procedures (see page 37); Before receiving certain radiology therapies (see page 37); Before receiving more than 60 physical therapy visits in a year; Before receiving certain orthopedic surgeries (see page 41); Before receiving certain cardiac procedures (see page 37); Before receiving bariatric surgery (see page 41); Before receiving gender reassignment surgery (genital) or other related surgery; When the patient has been medically evaluated and approved for an organ or tissue transplant; and When receiving genetic testing (recommended). If you are admitted to a facility on an emergency basis, contact Anthem BCBS Managed Care within 48 hours of your admission. When you precertify, Anthem BCBS Managed Care determines whether the services, treatments or supplies are medically necessary and, as a result, whether the Plan will cover them. The outcome of the review determines in advance the benefits the Plan will pay. If you fail to precertify and the treatment or 32

34 Medical Plan When You Travel services you received are later determined not to have been medically necessary, benefits will be denied. Of course, the final decision about the treatment you receive and where you receive it is always between you and your physician. The Health Plan Claims Administrator determines only whether services, treatments or supplies are medically necessary and covered under the Plan. Under federal law, group health plans may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours for a normal vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally allows an attending physician, after consulting with the mother, to discharge the mother and/or her newborn earlier than 48 hours (or 96 hours), if appropriate. In either case, plans may not require a provider to obtain authorization from the plan s utilization review organization for prescribing a length of stay not in excess of the above periods. Outside Your Network Service Area. While traveling outside your local network service area, the Plan covers true emergency services at the in-network benefit level whether or not providers are in the network. The Plan covers non-emergency or routine services you receive from any local BlueCard PPO network provider at the in-network level. If a network provider is not readily available, you must call Anthem BCBS Managed Care at EATON02. There you can request authorization to use a physician who is not in the BlueCard PPO network and have services covered at the in-network level. You may need to submit a claim and itemized bills for reimbursement. Outside the United States. When traveling outside the United States, BlueCard Worldwide gives you access to a network of providers around the world. For more information in the U.S., call BLUE. Outside the U.S. call collect at , or go online at PPO PROVIDER TYPE COMPARISON There are three types of PPO network providers. This chart compares key payment features to consider when choosing a health care provider. Benefit Level PPO Provider Paid at higher in-network benefits; you pay lower deductibles and coinsurance Traditional Indemnity Provider Paid at lower out-of-network benefits; you pay higher deductibles and coinsurance Reduced Fees Yes Yes No Medical Claim Filing Employee Responsible for Charges Exceeding Maximum Allowed Amounts Precertification Medical provider responsibility Medical provider responsibility No No Yes Provider responsible for inpatient admissions; you are responsible for precertifying all other services PPO and Traditional Indemnity Provider Listing Your responsibility Non-Participating Provider Paid at lower out-of-network benefits; you pay higher deductibles and coinsurance Employee responsibility Your responsibility You can obtain a listing of PPO network and/or traditional indemnity providers for your local area by calling Anthem BCBS Customer Service at EATON02 and requesting that a provider listing be mailed to you. You can also obtain information about PPO and/or traditional indemnity providers from the Internet: Go to: EatonBenefits.com or the EatonBenefits.com link on JOE Click on: Anthem medical on the left-hand side of the page 33

35 Medical Plan COVERED SERVICES AND SUPPLIES: PREVENTIVE CARE In addition to all preventive benefits described in this section, Eaton is in compliance with the Affordable Care Act (ACA) requirements. For a full list of preventive services covered under ACA visit HealthCare.gov. You receive in-network preventive care benefits at no cost. The annual deductibles do not apply to preventive services. On the other hand, benefits for preventive care services provided out-of-network are subject to the out-of-network annual deductible and out-of-network coinsurance. The Claims Administrator will also review the services supplied for medical necessity and charges are subject to maximum allowed amounts. Tests or examinations administered to diagnose, treat or monitor a suspected or identified injury or disease are not considered as preventive care and are covered as Diagnostic X-Rays, Lab Tests and Procedures. Exceptions are the suite of tests for Know Your Numbers in the Healthy Incentives Program including lipid panel, triglycerides and blood glucose and the first mammogram and colonoscopy in a calendar year. The Plan covers newborn care and well-baby care for children under age two. The preventive services listed here are for adults and children age two and older. If an office visit is associated with your preventive care service and any service provided during an office visit or screening is for non-preventive purposes, a charge for the office visit will apply. In-Network Benefits. When you see an in-network physician, you pay nothing. Out-of-Network Benefits. When you receive preventive care services out of the network, you must first meet the annual deductible. Then you pay 40% of the covered charges, which are subject to maximum allowed amounts. Routine Physical Examinations The Plan covers routine physical examinations including school, sports and camp physicals under the Plan for each adult and child age two and older. A routine physical examination is a medical examination given by a physician for a reason other than to diagnose or treat a suspected or identified injury or disease. Included as covered services are any tests performed and analyzed in the physician s office and billed by the same provider on the same day, and preventive x-ray and laboratory tests provided or analyzed outside the physician s office. Well-Woman Gynecological Examinations Well-woman gynecological examinations are covered under the Plan. Included as covered services are: IUDs or diaphragms and their insertion and removal, Depo-Provera injections, Any tests performed and analyzed in the physician s office and billed by the same physician on the same day, and Preventive x-ray and laboratory tests provided or analyzed outside the physician s office. Generic and single-source brand (i.e., brands without a generic equivalent) birth control medications are covered as preventive drugs under the Prescription Drug Program for women under the age of

36 Medical Plan Well-Woman PAP Tests The Plan covers laboratory and pathological examinations of well-woman PAP tests taken by a physician to detect cervical cancer. If one of the following specific medical conditions exists, the services are not considered to be preventive, and benefits are paid as described in Diagnostic X-Rays, Lab Tests and Procedures : Previous surgery for a vaginal, cervical or uterine malignancy; Presence of a suspect lesion in the vaginal, cervical or uterine areas as established through clinical examination; A positive PAP test leading to surgery and requiring a postoperative PAP test; or The presence of a diagnosed illness requiring such tests. Well-Woman Mammograms The Plan covers well-woman mammograms administered to detect breast cancer. After the first annual mammogram, benefits are paid as described in Diagnostic X-Rays, Lab Tests and Procedures for mammograms prescribed due to a diagnosed illness. Routine Eye Examinations The Plan covers routine eye examinations by an ophthalmologist or optometrist. The Plan does not cover refractive services, contact lenses, eyeglasses or fittings that may be prescribed as the result of the examination. Benefits are paid as described in Diagnostic X-Rays, Lab Tests and Procedures when these services are provided to treat a diagnosed illness. Routine Hearing Screenings The Plan covers routine hearing screenings; that is, unilateral or bilateral tests including a patient s case history, a visual inspection of the ear, a pure tone screening, speech audiometry and a self-assessment. The Plan does not cover hearing examinations, hearing aids or batteries and their fitting that may be prescribed as the result of the examination. Benefits are paid as described in Diagnostic X-Rays, Lab Tests and Procedures when these services are provided to treat a diagnosed illness. Immunizations and Flu Shots The Plan covers flu shots and immunizations, including those required for travel to a foreign country or for school admission, under both the medical and prescription drug programs. There are no restrictions on FDA-approved immunizations. See also preventive vaccines on page 64. Colon Cancer Screenings To detect colon cancer, the Plan covers all related laboratory tests, digital rectal examinations, sigmoidoscopies, colonoscopies and virtual colonoscopies. Removal of polyps and secondary procedures done in conjunction with a colonoscopy are not considered part of a routine screening. After the first annual colonoscopy, benefits are paid as described in Diagnostic X-Rays, Lab Tests and Procedures when the services are provided to treat a diagnosed illness. Prostate Cancer Screenings To detect prostate cancer, the Plan covers laboratory and pathological examinations or tests ordered by a physician. Benefits are paid as described in Diagnostic X-Rays, Lab Tests and Procedures when these services are provided to treat a diagnosed illness. 35

37 Medical Plan Skin Cancer Screenings To detect skin cancer, the Plan covers an annual examination by a dermatologist. Covered services include the office visit and any tests and examinations performed in the physician s office and billed by the same physician on the same day. Any services the physician orders that are performed or analyzed outside of the physician s office are subject to coverage as described in Diagnostic X-Rays, Lab Tests and Procedures. Cholesterol Screening The Plan covers laboratory blood tests ordered by a physician and performed and analyzed in a network lab whether provided as part of a routine exam or not to detect elevated cholesterol levels. Bone Density Testing The Plan covers bone density testing to detect osteoporosis. Covered tests include computerized tomography, dual energy x-ray absorptiometry (DXA) and dual photon absorptiometry. Benefits are paid as described in Diagnostic X-Rays, Lab Tests and Procedures for bone density testing prescribed due to a diagnosed illness. Nutritional Counseling Well Child Care During a calendar year, the Plan covers one nutritional counseling session per month for up to six sessions. The sessions must be with a registered dietitian (R.D.). Sessions are not limited when part of a pre- or post-bariatric surgery program. The Plan covers physician s visits for well child care/physical examinations and immunizations up to age 17, according to claims administrator guidelines. Blood Glucose Screening The Plan covers blood glucose screenings ordered by a physician and performed and analyzed in a network lab whether provided as part of a routine exam or not to detect whether you have a problem with your blood sugar control, even though you may not have any symptoms. COVERED SERVICES AND SUPPLIES The Medical Expense Benefits portion of the Plan covers the charges for medically necessary (subject to the maximum allowed amounts of each Plan option) services and supplies described in this section. An explanation of benefits for prescription drugs starts on page 58. Keep in mind, once you have reached your out-of-pocket maximum for the year, the Plan pays the remainder of covered, medically necessary, maximum allowed amount charges at 100%. Some services need to be precertified. See How to Use Your Network Precertification for more information. Unless stated otherwise, benefits are paid as follows: In-Network Benefits. You pay 20% of the negotiated network charges after you meet the annual in-network deductible. Out-of-Network Benefits. You must first meet the annual out-of-network deductible, and then you pay 40% of the covered charges, which are subject to maximum allowed amounts. Physicians and Specialists Office Visits. Covered services include the office visit, injections and tests when performed in a physician s office for an illness or injury. Also see LiveHealth Online on page 45. Specialty medications that are self-administered (such as medications treating MS) or infused to treat rare diseases (such as hemophilia) are only covered when provided by Accredo, the mail order specialty pharmacy (see page 66). Clinician-administered specialty medications (such as those that treat osteoporosis) are covered under the medical plan. Allergy Injections. The Plan covers allergy injections administered in a physician s office. Physician s In-Hospital Visits. The Plan covers physician s visits during a hospital stay. 36

38 Medical Plan Diagnostic X-Rays, Lab Tests and Procedures: Outpatient The Plan covers diagnostic x-rays, lab tests and procedures billed for, or ordered by, a physician if the services are directly related to the diagnosis of illness or injury. If these services are performed as part of a hospital stay, refer to Hospital/Facility Care later in this section. You must authorize in advance that a high-dollar diagnostic or imaging procedure is medically necessary and will be covered by the Plan. In addition, a Maximum Covered Price (see page 47) applies to MRIs and CT scans. For advanced authorization of the services listed below, please have your provider contact AIM first when one of the following procedures is ordered: Magnetic resonance imaging (MRI) for more information on the Maximum Covered Price Program for advanced radiology procedures, see page 47 Computer tomography (CT) for more information on the Maximum Covered Price Program for advanced radiology procedures, see page 47 Positron emission tomography (PET) Nuclear cardiology Sleep studies Stress and resting echocardiography Calcium scoring (EBCT and MDCT) Anthem s AIM Specialty Health service will inform you and your provider if the procedure is determined to be medically necessary and tell you about any locations close to you that offer the procedure at equal quality and a lower price. Services may be covered as preventive care if the physician orders them in conjunction with a routine physical exam or if hospital rules for patient care require them. Certain Radiation Therapies. The Plan covers certain radiation therapies. However, you should verify coverage and you must precertify these services. See How to Use Your Network Precertification. Intensity modulated radiotherapy (IMRT) Stereotactic body radiotherapy (SBRT) Proton beam proton therapy Cardiac Procedures. The Plan covers certain cardiac procedures. However, you should verify coverage and you must precertify these services. See How to Use Your Network Precertification. Coronary artery bypass graft Percutaneous coronary intervention In-Network Benefits. When you receive these cardiac procedures in a Center of Excellence facility that is part of a Blue Cross Blue Shield Association Anthem Blue Distinction Center or Blue Distinction Centers Plus, you pay 20% of the negotiated network charges after you meet the annual in-network deductible. Out-of-Network Benefits. If you receive these cardiac procedures at a network PPO provider that is not designated as an Anthem Blue Distinction Center, you pay 40% of the negotiated network charges after you meet the annual out-of-network deductible. The out-of-network annual out-of-pocket maximum applies. The Plan does not cover the above listed cardiac procedures or related services provided at an out-of-network facility. 37

39 Medical Plan Mental Health/Substance Abuse (MH/SA) Treatment The Plan covers treatment of mental health disorders and substance abuse provided to prevent, diagnose, correct, cure, alleviate or preclude deterioration of a diagnosable condition that threatens life, causes pain or suffering, or results in illness or infirmity. MH/SA services can be provided in alternate levels of care that serve as a transition from or an alternative to inpatient hospital treatment. Inpatient alternate levels of care include residential treatment centers. A residential treatment center is a provider licensed and operated by law and includes: Room, board and skilled nursing care (either an RN or LVN/LPN) available on-site at least eight hours daily with 24-hour availability; A staff with one or more doctors available at all times; Residential treatment that takes place in a structured facility-based setting; The resources and programming to adequately diagnose, care and treat a psychiatric and/or substance use disorder; and Facilities that are designated residential, subacute or intermediate care and may occur in care systems that provide multiple levels of care. The residential treatment center must be fully accredited by The Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF), the National Integrated Accreditation for Healthcare Organizations (NIAHO) or the Council on Accreditation (COA). The term residential treatment center/facility does not include a provider, or that part of a provider, used mainly for: Nursing care Rest care Convalescent care Care of the aged Custodial dare Educational care Alternate levels of care provided on an outpatient basis include intensive outpatient therapy (IOP) and partial hospitalization. The Plan covers an alternate level of care when the level of service provided is safe and treatment that is equally effective, more conservative and less costly is not available. The Health Care Plan Claims Administrator will authorize treatment in alternate levels of care only if it is individualized, specific, consistent with the symptoms and diagnosis, and provided at an appropriate level of care. Call Anthem BCBS at to precertify inpatient MH/SA care and alternate levels of care. A counselor will refer you to an appropriate hospital, facility or provider, and send written confirmation of the authorized services. Precertification is required for: All other outpatient services beginning with the first visit Inpatient MH/SA care Residential MH/SA care Intensive outpatient therapy (IOP) Partial hospitalization (PHO) Inpatient treatment, including detoxification See How to Use Your Network Precertification. 38

40 Medical Plan Employee Assistance Program When you or your household members need initial help or guidance with mental health or substance abuse issues, the EAP offers up to six visits with a certified professional at no charge. You and your household members can call the EAP at If additional assistance is needed, your EAP professional can help you with next steps. See the Work/Life Solutions and Adoption Reimbursement Benefits Plans section for more information about the EAP program. Mental Health Parity and Addiction Equity Act The Mental Health Parity and Addiction Equity Act provides for parity in the application of aggregate lifetime limits, annual dollar limits, financial requirements and treatment limitations (day or visit limits) on mental health and substance use disorder benefits with dollar limits, financial requirements or day/visit limits on medical/surgical benefits. In general, group health plans offering mental health and substance use disorder benefits cannot set annual dollar limits, lifetime dollar limits or day/visit limits on mental health or substance use disorder benefits that are lower than any such dollar limits or day/visit limits for medical and surgical benefits. A plan that does not impose annual dollar limits, lifetime dollar limits, or day/visit limits on medical and surgical benefits may not impose such dollar limits or day/visit limits on mental health and substance use disorder benefits offered under the plan. Also, the plan may not impose deductibles, copayment/coinsurance and out-of-pocket expenses on mental health and substance use disorder benefits that are more restrictive than deductibles, copayment/coinsurance and out-of-pocket expenses applicable to other medical and surgical benefits. Pregnancy and Newborns Obstetrical Care. The Plan covers obstetrical care, including regular office visits, delivery and one postpartum office visit. Hospital care is covered the same as any other inpatient admission. Newborn Care. The combined charges of the mother and newborn are charged to the mother s claim until the mother or child is discharged. If a physician other than the delivering physician or the physician who administered anesthesia during the delivery examines the newborn, the visit is charged as a physician s in-hospital visit. A newborn child remaining in the hospital after the mother is discharged becomes separately subject to the terms of the Plan. Expenses for the newborn of a covered dependent female child are processed under the dependent daughter s claim until the newborn is released from the hospital. Coverage for the grandchild ends when the mother (dependent daughter) is discharged from the hospital, or when the grandchild is discharged, if earlier. Circumcision is covered as surgery see Surgical Services in this section. Infertility Services. The Plan covers physician s services for the diagnosis and treatment of infertility, as well as medically necessary tests, facility charges and laboratory work related to covered services. Artificial insemination and/or super-ovulatory drug therapy for females diagnosed with infertility is limited to four cycles per birth. Benefits for artificial insemination and/or super-ovulatory drug therapy renew only after treatment results in a birth. Non-experimental-assisted reproduction (i.e., in vitro fertilization, GIFT, ZIFT) is covered up to two attempts per birth. Benefits for assisted reproduction renew only after treatment results in a birth. A physician must order the services and, as described in the paragraph below and in Expenses Not Covered, some services are not covered. The Plan does not cover the following services: more than four cycles of artificial insemination and/or super-ovulatory drug therapy per birth; more than two cycles of assisted reproduction per birth; sperm, ova or embryo acquisition, retrieval or storage; reversal of voluntary sterilization; and surrogate pregnancy and related obstetric/maternity benefits. 39

41 Medical Plan Inpatient and Outpatient Surgery and Hospital Care Hospital/Facility Care. The Plan covers the following inpatient and outpatient hospital services, as applicable: Semiprivate room accommodations (A private room is paid at the semiprivate room rate unless a private room is determined to be medically necessary for purposes of coverage under the Plan.) Intensive care Physician s visits Oxygen and other gas therapy Hemodialysis Use of operating, delivery and other surgical treatment rooms Anesthesia administered by an employee of the hospital Drugs and medicines Dressings and casts Physical, speech and occupational therapy Use of radium owned or rented by the hospital Laboratory and x-ray services Routine nursery care of the newborn infant during the hospital stay of the mother for maternity care Other ancillary services and supplies necessary for the treatment of the patient For inpatient care, general nursing services, rooms and meals are included in the hospital daily room service charge. Precertification is required for inpatient and some outpatient hospital services. See How to Use Your Network Precertification. Hospital Anesthesiologist/Pathologist/Radiologist. The Plan covers anesthesia, pathology and radiology services. If services are billed by an anesthesiologist and a nurse anesthetist, covered charges are processed based on the performance of a single procedure. Anesthesia charges must include the length of time administered, surgical procedure and type of anesthetic used. If anesthesia, pathology or radiology is performed by an out-of-network provider at an in-network hospital, or on an outpatient basis (even if the individual provider does not participate in the network), you pay 20% of the negotiated network charges after you meet the in-network deductible. Assistant Surgeon. The Plan covers medically necessary charges for an assistant surgeon during a major surgical procedure. If services are performed by an in-network assistant surgeon or by an out-of-network assistant surgeon assisting an in-network surgeon you pay 20% of the negotiated network charges after you meet the annual in-network deductible. See Surgical Services below. Surgical Services. The Plan covers all generally accepted operative and cutting procedures necessary for the diagnosis and treatment of diseases, injuries, fractures, dislocations, and certain reconstructive surgical procedures to correct deformities resulting from accidental injury or medically necessary surgery. Voluntary sterilization is also a covered expense. The payment for surgical services includes all related medically necessary preoperative and postoperative care by the physician. When a single incision is used to perform more than one surgical procedure, the Plan pays benefits based on maximum allowed amounts (see definition on page 54) for the most complex procedure the surgeon performs. The Plan does not pay for incidental procedures that is, procedures that are carried out at the same time through the same incision. If more than one incision is required and surgery is performed at different sites at the same time, the Plan pays benefits based on the most complex procedure performed and on 50% of the maximum allowed amount for each additional procedure performed. The patient is responsible for the denied office visit charge. Second Surgical Opinion for Elective Surgery. The Plan pays benefits if you seek a second surgical opinion before receiving care. If you have any questions, take advantage of the Expert Medical Opinion (see page 45). 40

42 Medical Plan Breast Reconstruction Surgery. The Plan covers medically necessary breast reconstruction surgery performed in connection with a mastectomy, including the following expenses: Reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prosthesis and physical complications for all stages of mastectomy, including lymphedemas. Orthopedic and Bariatric Surgery. Precertification is required for inpatient and outpatient services related to certain knee and spine orthopedic surgeries and bariatric surgery, as shown below: Total knee replacements Total hip replacements Discectomies Decompressions Spinal fusions See How to Use Your Network Precertification. In-Network Benefits. When you receive services in a Center of Excellence facility that is part of a Blue Cross Blue Shield Association Anthem Blue Distinction Center or Blue Distinction Centers Plus, you pay 20% of the negotiated network charges after you meet the annual in-network deductible. Out-of-Network Benefits. If you receive services at a network PPO provider that is not designated as an Anthem Blue Distinction Center, you pay 50% of the negotiated network charges after you meet the annual out-of-network deductible (for orthopedic surgery, you pay 40% of the negotiated network charge after you meet the annual out-of-network deductible). The out-of-network annual out-of-pocket maximum applies. The Plan does not cover the orthopedic surgeries listed above or bariatric surgery or related services provided at an out-of-network facility. Emergency and Urgent Care Emergency Room True Emergency. If you experience a true emergency, you should get care as soon as possible from the nearest source. All medically necessary and appropriate services required for treatment in a true emergency situation are paid on an in-network basis, even if you are treated in an out-of-network hospital emergency room. That means you pay 20% of the negotiated network charges after you meet the annual in-network deductible. You must notify Anthem BCBS Managed Care within 48 hours of an emergency admission. Emergency Room Non-Emergency. If you go to a hospital emergency room for treatment but do not have a true medical emergency, benefits are paid differently. See Definitions and Important Terms Medical Emergency for the definition of a true medical emergency. Whether you seek non-emergency treatment at a network or out-of-network hospital emergency room, you must first meet the annual out-of-network deductible, and then you pay 40% of the covered charges, which are subject to maximum allowed amounts. Urgent Care Centers. The Plan covers services provided by an urgent care center for a sudden serious or unexpected illness, injury or condition that is not an emergency but requires care to relieve pain or to diagnose or treat a non-life-threatening health problem. 41

43 Medical Plan Care in Alternate Settings Private Duty Nursing Services. The Plan covers private duty nursing care by a registered graduate nurse (R.N.) when prescribed by a physician. If the services of an R.N. cannot be obtained, care may be provided by a licensed practical nurse (L.P.N.). Custodial care is not a covered expense; the patient must be receiving skilled nursing services. Precertification is required for private duty nursing services. See How to Use Your Network Precertification. Private duty nurses charges must include the date, place, hours of duty, medical services performed and charge per hour or day. Skilled Nursing Facility. The Plan covers skilled nursing bed-patient care in a skilled nursing facility. Precertification is required for admission to a skilled nursing facility. See How to Use Your Network Precertification. Home Health Care. The Plan covers home health care when prescribed by a physician. Home health care covered services and supplies include nursing care, infusion drugs, physical therapy and laboratory tests. The patient may receive covered services and supplies other than professional nursing care from hospitals, skilled nursing facilities and, in certain circumstances, licensed community providers. Home health care coverage also includes payment of charges for home health aide visits when necessary. Custodial care is not a covered expense. The patient must be receiving medical treatment for an illness or injury while at home. Precertification may be required for home health care services. See How to Use Your Network Precertification. Hospice Care. The Plan covers hospice services for a terminal illness in a licensed hospice or other facility under the direction of a licensed hospice professional. An illness is considered to be terminal if the physician s prognosis is a life expectancy of six months or less. Charges for hospice care include the following services: Semiprivate room and board accommodations and hospice services while confined in a hospice facility. Services provided by a hospice facility on an outpatient basis. Pain-relief treatment, including drugs, medicines and medical supplies furnished by the hospice facility. Home health care services, including: - part-time or intermittent nursing care by or under the supervision of a registered nurse, by a licensed practical nurse or by a licensed visiting nurse; - part-time or intermittent services of a home health aide; - physical therapy, occupational therapy and speech therapy; - medical supplies, drugs and medicines, and laboratory services; and - rental of wheelchairs and other necessary durable medical equipment. Precertification is required for hospice care. See How to Use Your Network Precertification. Therapy Chiropractic and Physical Therapy. The Plan covers chiropractic care and physical therapy services performed in an office or other freestanding facility. Massage therapy is covered if it is prescribed by a doctor as part of a physical therapy program. In-network and out-of-network limits are combined. Chiropractic care is limited to 12 spinal manipulations per calendar year. X-rays are covered as described under Diagnostic X-Rays, Labs and Procedures (see page 37) and do not count toward the 12-visit limit. Outpatient physical therapy is covered for up to 60 visits per calendar year, provided charges are billed by a registered physical therapist. More than 60 visits per year require precertification (see page 32). See Hospital/Facility Care in this section for therapy services performed in the outpatient department of a hospital. 42

44 Medical Plan Speech, Occupational, Hearing and Vision Therapy. The Plan covers speech, occupational, hearing and vision therapy services performed in an office or other freestanding facility. The Plan covers certain speech therapy services when performed by a physician or when prescribed by, and under the direction of, a physician and performed by a registered speech therapist. The Plan limits combined speech, occupational, hearing and vision therapy benefits to 60 visits per calendar year. In-network and out-of-network limits are combined in the same 60-visit list. See Hospital/Facility Care in this section for therapy services performed in the outpatient department of a hospital. For speech therapy to be covered under the Plan, the following criteria must be met: The speech defect is a result of injury or illness, including Autism Spectrum Disorder; The speech defect is serious enough to interfere significantly with the patient s ability to communicate at an appropriate level; and The patient has the potential for useful speech. To be covered under the Plan, the length of treatment should not surpass the point at which: The patient has attained a level of verbal communication that is reasonably adequate for his or her age and mental status; or Little or no evidence of continuing improvement exists as determined by the Health Plan Claims Administrator. The Plan does not cover speech therapy for stuttering or stammering. Specialized Treatments Chemotherapy. The Plan covers chemotherapy treatment administered on an inpatient or outpatient basis at a hospital or, if approved by the Health Plan Claims Administrator, in the patient s home. Coverage includes the following categories of therapy: Parenteral, Infusion, Perfusion, and Intracavitary. Hemodialysis. The Plan covers outpatient hemodialysis for chronic kidney disease. If approved by the Health Plan Claims Administrator, treatment is also covered in the home including purchase or rental of equipment and training for the patient in the use of such equipment. Cardiac Rehabilitation. Inpatient cardiac rehabilitation treatment is covered by the Plan if prescribed by a physician and if covered expenses are incurred during confinement in a hospital. Formal cardiac rehabilitation treatment on an outpatient basis is covered if: Prescribed by and under the supervision of a physician, and The treatment takes place in a hospital or other licensed outpatient medical facility within three months of an episode of symptoms due to acute cardiovascular disease. The Plan does not cover general programs of counseling and exercise in health clubs or similar facilities, even if prescribed by a physician. 43

45 Medical Plan Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics Durable medical equipment, prosthetics, orthotic services and medical supplies not covered under the Prescription Drug Program are covered at the higher in-network benefit level, even if you use a provider who does not participate in the network. Coverage for durable medical equipment and orthotics is limited by the following: The expense for a piece of equipment or service should not exceed the cost of an alternative piece of equipment or service that is effective and medically necessary, as determined by the Health Plan Claims Administrator. Coverage for an item may be approved on a rental or a purchase basis, as determined by the Health Plan Claims Administrator. Prosthetics, including hair prostheses (i.e., wigs) for hair loss resulting from certain injuries, diseases or treatment of a disease. The Plan will not pay more than the cost of an alternative prosthetic or service that is effective and medically necessary for purposes of coverage under the terms of the Plan, as determined by the Health Plan Claims Administrator. Coverage for the replacement of an item is based on the Health Plan Claims Administrator s review of information from the prescribing physician indicating the patient s present condition and why the present equipment, orthotic or prosthetic is no longer adequate or therapeutic. Please note that orthopedic/therapeutic shoes are covered only when the shoe is an integral part of a brace. Covered persons may contact the Health Plan Claims Administrator for information regarding coverage for specific equipment and services. Additional Information About Out-of-Network Benefits You pay for covered supplies at the in-network level: 20%. The in-network deductible and out-of-pocket maximum apply. Ambulance Services The Plan covers independent ground ambulance services in a true emergency situation to the first hospital where treatment of disease or injury is received. Coverage is also available to hospital bed patients or for patients seen in the emergency room for ground ambulance transfer (one way or round-trip) from one hospital to another hospital within the region when: The transfer is medically necessary as determined by the Health Plan Claims Administrator; The first hospital lacks specialized treatment facilities, equipment or staff physicians; A physician prescribes the services that necessitate use of ambulance transportation; and The provider of the ambulance service meets Medicare criteria for approval (without regard to whether you are eligible for Medicare). The Plan also covers the ground ambulance transfer of a hospital bed patient to a licensed non-hospital facility for a diagnostic test covered under the Plan. The Plan covers air ambulance services when required as a result of the severity of the patient s illness or injury. This requirement means that the level of treatment needed is not available locally and that time is of the essence to save a life or to limit more severe adverse health consequences. In-Network and Out-of-Network Benefits. All ambulance services necessary to transport a covered person in a true emergency situation are covered in-network, regardless of whether the provider participates in the network. You pay 20% of the negotiated network charges after you meet the annual deductible. 44

46 Medical Plan Additional Services and Programs When you participate in any of the programs described below, Eaton s Health Care Partners Anthem BCBS, Advance Medical and Express Scripts will work together to coordinate your care. To get started with any of the programs, go to EatonBenefits.com and click on the Whom to Contact and More tab in the left-hand side navigation bar (or follow the instructions indicated below). To help you and your family stay on track with your health, Eaton offers: Disease and Care Management. This program helps to integrate the various programs of all of Eaton s Health Care Partners. A nurse or wellness coach works with you if you have a chronic or complex health condition such as heart disease or diabetes. You can get a better understanding of your condition, answers to medication questions, explanations of test results and support for making healthy lifestyle changes. Nurses will also help guide you through the hospitalization process, where applicable, and help you navigate the health care system. The nurse will serve as a point of contact for you and your family members and will refer you to other Health Care Partner programs based on your condition. Patient Decision Support. An Anthem Team member works with you and your doctor if you face tough treatment decisions for conditions like arthritis, chronic back pain, prostate cancer, obesity and coronary artery disease. The goal is to reach better informed decisions in collaboration with your physician. Maternity Management. A specially trained nurse guides you through your pregnancy and helps you understand your baby s needs. Nurse Line. You can get answers 24/7 to troubleshoot medical problems and identify next steps. LiveHealth Online. Register at livehealthonline.com to consult with a U.S. board-certified doctor 24/7 through your computer or mobile device. Doctors can answer questions, make a diagnosis and prescribe medication for issues such as cold and flu symptoms, allergies and sinus infections. After you meet your deductible, online visits are covered in full; you do not have to pay coinsurance. Expert Medical Opinion. Expert Medical Opinion gives you access to recognized experts in specific medical fields. You can use this resource to get answers to questions and concerns you have when faced with a medical diagnosis and/or treatment decisions. You work with a physician as your case manager. He or she spends as much time with you as needed to answer questions, collect medical documentation, access the medical experts, help you understand the expert s report, and speak with your treating physician, if you like. You and your immediate family (e.g., spouse/domestic partner and dependent children) can use this service, whether or not you are enrolled in an Eaton Medical Plan. The program is completely confidential and Eaton pays the full cost. Medical appointments and treatments remain your responsibility. Advance Medical is Eaton s partner in this program and you can reach them online as described above or phone them at

47 Medical Plan Anthem Centers of Excellence (also known as Anthem Blue Distinction Centers or Blue Distinction Centers Plus). Anthem BCBS s Centers of Excellence (COE) managed care department may refer you to a facility that is part of a Blue Cross Blue Shield Association (BCBSA) Blue Distinction Center (BDC) if you are under consideration for services related to: A human organ transplant Orthopedic surgery - knee replacements - hip replacements - discectomies - decompressions - spinal fusions Bariatric surgery Cardiac procedures - coronary artery bypass graft - percutaneous coronary intervention The COE network is comprised of certain hospitals and medical centers located across the United States that specialize in these procedures. The BCBSA contracts with these facilities to provide services, and your use of a BQC facility is strictly voluntary. Any physician or facility may contact the COE department to coordinate care at a network facility. If a participating PPO or a BDC facility is located so far from your home that daily travel is unreasonable (as determined by the Health Plan Claims Administrator), travel, meals and accommodations for the patient and a companion are covered at $125 per day, up to a $10,000 lifetime maximum benefit. Expenses paid for a companion and reimbursed meal expenses are considered taxable income for the participant. The Plan pays the cost for a semiprivate room. A private room is paid at the semiprivate room rate unless a private room is determined to be medically necessary. No benefits are paid for experimental or investigational procedures (see Expenses Not Covered ). For human organ transplant patients, benefits are provided for: Evaluation tests to determine donor compatibility and suitability for a covered patient who is confined on an inpatient basis in a hospital (or other covered facility) when such tests cannot be safely and effectively performed on an outpatient basis. Services performed by a physician to donors and potential donors for medically recognized human organ or tissue transplants as determined by the Health Plan Claims Administrator including evaluation tests and surgical removal of the donated part provided the donor or potential donor is not covered under any other health care program that provides benefits for such services. Hospital-billed expenses connected with organ and tissue procurement. Included in these expenses are charges for locating, removing and preserving the donated part, whether from a living or nonliving human donor. Transportation expenses are covered if billed by a service other than a hospital. Medical and hospital expenses of the donor are covered only when the recipient is covered under the Plan. Coverage is not available for treatment of medical complications that may occur to a donor who is not covered under the Plan. 46

48 Medical Plan Maximum Covered Price for Certain Non-Emergency MRIs and CT Scans. The Plan sets a maximum covered price for certain types of MRIs and CT scans that vary widely in price but not in quality. The maximum covered price is the most the Plan will consider for benefits for a covered procedure. The maximum covered price applies to MRIs and CT scans performed in-network only. If you receive an MRI or CT scan that is subject to the Maximum Covered Price (as described here) and the price is higher than the maximum covered price set by the Plan, you are responsible for paying: Your deductible and coinsurance on the amount charged up to the maximum covered price, plus The full amount charged that is above the maximum covered price. These amounts will not count toward your deductible but will count toward your out-of-pocket maximum. Please have your provider contact Anthem s High Tech Imaging Precertification number on the back of your ID card when an MRI or a CT scan is ordered to precertify the service. Also log in to Castlight to find prices at area locations that meet or are lower than the maximum covered price. Anthem s High Tech Imaging Precertification service will inform your provider if the procedure is determined to be medically necessary. Once approved, the service will contact you if they identify locations that offer the procedure at a lower cost and identify if you are below the Maximum Covered Price. However, it is your responsibility to ensure the provider requests precertification and that the service is approved as medically necessary in advance. It is also your responsibility to determine if the service you receive falls within the maximum covered price set by the Plan in your area. Exceptions. MRIs and CT scans for the following conditions or circumstances will not be subject to the Maximum Covered Price: When performed for dependents less than 18 years old When they take place while you are an inpatient For oncology cases During medical emergencies that take place in an ER or ambulance For magnetic resonance angioplasty procedures that involve the heart 47

49 Medical Plan EXPENSES NOT COVERED Some expense items are not covered under the Plan. These exclusions also apply to the Prescription Drug Program. Among these exclusions are: Any service or supply not prescribed by a qualified physician, a legally licensed or certified health care provider; or any charges for services or supplies not medically necessary for the diagnosis or treatment of an injury or illness as determined by the Health Plan Claims Administrator, even if prescribed by a physician; or services or supplies that are a convenience only, even if prescribed by a physician. Services, treatment or supplies not generally accepted in medical practice for the prevention, diagnosis or treatment of an illness or injury, as determined by the Health Plan Claims Administrator. Services for hospital confinement primarily for diagnostic studies. Charges billed by non-participating providers that are in excess of maximum allowed amounts. Work-connected injury or disease that includes a charge in connection with: - an injury arising out of, or in the course of, any work for wage or profit (whether or not with the Company); or - a disease covered, with respect to such work, by any Workers Compensation law, occupational disease law or similar law. A government plan charge. A charge for a service or supply: - furnished by or for the U.S. government or any other government, unless payment of the charge is required by law; - to the extent that the service or supply, or any benefit for the charge, is provided by any law or government plan under which the patient is or could be covered. This limitation does not apply to a state plan under Medicaid or to any law or plan when, by law, its benefits are in excess of any private insurance program or other non-government program; or - for treatment of illness or injury resulting from an act of war, military service or armed conflict. Those for or in connection with services or supplies that the Health Plan Claims Administrator determines to be experimental or investigational as explained under Definitions and Important Terms Experimental/Investigational. Charges for educational services or supplies to the extent it is determined by the Health Plan Claims Administrator to be educational. Charges for services or supplies furnished in connection with a service or supply that is educational are also not covered as explained under Definitions and Important Terms Educational. Services that do not involve direct patient care. Dental services, including: - surgical or anesthesia expenses (Hospital or outpatient surgical facility charges are covered if determined to be medically necessary under the Plan due to a concurrent medical condition, or for children under age six.); - doctor s services for x-ray examinations in conjunction with mouth conditions due to a periodontal or periapical disease, or any condition (other than a tumor) involving teeth, surrounding tissue or structure, the alveolar process or the gingival tissue; - removal of impacted wisdom teeth; and - treatment of an accidental injury to sound natural teeth more than one year from the date of the injury. Cosmetic surgery (including cosmetic surgery related to gender reassignment surgery) except for reconstructive surgery following a mastectomy or when medically necessary to correct damage caused by an accident or an injury, or to correct a congenital defect. Custodial care (see Definitions and Important Terms Custodial Care ). 48

50 Medical Plan Transportation or ambulance services, except as provided for emergency transportation and transfer of patients as explained under Medical Expense Benefits Covered Services and Supplies. Routine foot care, including: - care of corns, bunions, calluses, toenails, flat feet, fallen arches, weak feet and chronic foot strain; - symptomatic complaints of the feet except capsular or bone surgery related to bunions and hammertoes; and - orthotics for treatment of routine foot care services, treatment or supplies not generally accepted in medical practice for the prevention, diagnosis or treatment of an illness or injury, as determined by the Health Plan Claims Administrator. Admissions and treatment for weight reduction or diet control, unless determined by the Health Plan Claims Administrator to be medically necessary for purposes of coverage under the Plan. Eyeglasses, contact lenses or the fitting thereof except for lens replacement after cataract surgery. Hearing examinations and hearing aids, batteries and fittings. Charges incurred in any federal hospital, or expenses you are not legally obligated to pay, or for which no charge would be made in the absence of health care coverage. Radial keratotomy and other refractive eye surgery. Vitamins and minerals that do not require a prescription (see Prescription Drug Program ). Food supplements. Massage therapy except when billed by a licensed provider as a modality of physical therapy. Speech therapy for stuttering or stammering. Mental health/substance abuse services and treatments that are: - court-ordered, unless assessed and certified in accordance with the Health Plan Claims Administrator s definition of medically necessary; - for the purpose of maintaining employment or insurance; - required under law to be provided by the school system for a child; - for personal growth and development; - for adjudication of marital, child support and custody cases; - for chronic pain other than precertified psychotherapy, biofeedback or hypnotherapy performed in connection with a current DSM disorder; or - for work-related stress. Chemical dependency treatments that are nutritionally based, non-abstinence-based or involve aversion therapy. Psychotherapy, biofeedback or hypnotherapy treatment except for a DSM diagnosis. Treatment of temporomandibular joint (TMJ) disorders (and all other craniomandibular disorders), with the exception of: - joint and muscle injection therapy; - diagnostic CT, MRI or transcranial x-ray; - tomograms; - surgery; and - post-surgical physical therapy. Surrogate pregnancy and related obstetric/maternity services and newborn care. Routine care except for services listed under preventive care. 49

51 Medical Plan Vision perception training. Services and supplies for smoking deterrent/cessation programs that do not require a prescription (see Tobacco Cessation Programs in the Work/Life Solutions and Adoption Reimbursement Benefits Plans section of this booklet). Reversal of vasectomy or tubal ligation. Services or supplies provided by a member of your family or household. Fees or charges made by an individual, agency or facility operating beyond the scope of its license. Services for medical care for which no charge is made. Services for telephone consultations, charges for failure to keep a scheduled visit, charges for completion of a claim form, or charges for giving information concerning a claim. Separate charges by interns, residents, house physicians or other health care professionals who are employed by the covered facility that makes their services available. Services for recreational therapy. Acupuncture unless performed by a physician and determined to be medically necessary by the Health Plan Claims Administrator. Services of a Certified Acupuncturist or OMD are not covered. Electrical stimulation is not covered. Charges for treatment received before coverage under this Plan began or after coverage is terminated. Expenses you would not be required to pay if there was no health coverage. Expenses that you or a dependent has no legal obligation to pay. Alcohol wipes. Wearable cardioverter defibrillator (life vest). Other exclusions and/or limitations on benefits may be included in the specific benefit description. 50

52 Medical Plan DEFINITIONS AND IMPORTANT TERMS The following terms define specific words used in this Plan. These definitions should not be interpreted to extend coverage unless specifically provided for under the provisions of the Plan. Alternate Levels of Care. Mental health/substance abuse services can be provided in alternate levels of care that range from inpatient hospital treatment to less restrictive settings that serve as a transition from or an alternative to inpatient hospital treatment. These alternate levels of care are described below. Intensive outpatient services (IOPs) are significantly more intensive than outpatient psychotherapy and medication management. IOPs provide multidisciplinary, multimodal structured treatment in an outpatient setting. Typically, treatment is offered two to four hours per day, and three to five days per week. IOPs are less intensive than a partial hospitalization program/day treatment programs because they may not always include medical oversight and medication evaluation and management. Clinical interventions include modalities typically delivered in office-based settings such as individual, couple and family psychotherapy, group therapies, medication management, and psycho-educational services. Adjunctive therapies such as life planning skills (assistance with vocational, educational and financial issues) and special issue or expressive therapies may be provided. Active family/significant other involvement is important, unless contraindicated. Partial hospitalization programs provide clinical diagnostic and treatment services on the same level of intensity as an inpatient program, but for six to eight hours per scheduled day, and up to five days per week. Partial hospitalization is a nonresidential treatment program that may or may not be hospital based. The environment is highly structured with a staff-to-patient ratio sufficient to ensure necessary therapeutic services, professional monitoring, control and protection. Services include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, vocational counseling, rehabilitation recovery counseling, substance abuse evaluation and counseling, and behavioral plans. Psychiatric partial hospital treatment may be appropriate when a patient does not require the more restrictive and intensive environment of a 24-hour inpatient setting, but does need up to eight hours of clinical services. Partial hospitalization is used as a time limited response to stabilize acute symptoms. As such, it can be used both as a transitional level of care (i.e., step-down from inpatient) as well as a standalone level of care to stabilize a deteriorating condition and avert hospitalization. Detoxification programs provide a 24/7 inpatient residential program for individuals with substance abuse problems. Supervision is less intense than in an inpatient residential treatment program, and oversight is provided by a director who is a licensed clinician. Emergency psychiatric/medical services are available either on-site or by agreement. The program must be compliant with an overall after-care/continuing care treatment plan and provide or have access to a full range of educational, social and recreational therapies for transition to the activities of daily living. Residents are monitored for potential or suspected substance abuse through random urine drug screens. Family involvement in treatment is required or encouraged. Residential treatment programs provide 24/7 inpatient treatment in a controlled environment with a high degree of supervision and structure for individuals with severe and persistent psychiatric disorders. Physician visits are required at least weekly. Services include a wide range of diagnostic and treatment services as well as therapeutic intervention and specialized training in basic skills such as social skills and activities of daily living to transition to community living. The services are provided in the context of a comprehensive, multidisciplinary and individualized treatment plan that is frequently reviewed and updated based on the individual s clinical status and response to treatment. Treatment primarily provides social, psychosocial rehabilitative training and a focus on family or caregiver support. Active/significant involvement through family therapy is a key element of treatment and is strongly encouraged unless contraindicated. For inpatient care, rooms and meals are included in the daily room service charge. Precertification is required for inpatient and some outpatient hospital services. See How to Use Your Network Precertification. 51

53 Medical Plan Annual Deductible. The amount you pay out of your own pocket for an individual s or a family s medical services covered by the Plan before the Plan begins to pay benefits. Once the annual deductible is satisfied, coinsurance goes into effect and you and the Plan share the cost of the individual s or the family s eligible expenses for the balance of the year or until you reach the annual out-of-pocket maximum. Annual Out-of-Pocket Maximum. The limit on the total amount you pay each calendar year for an individual s or a family s covered services. Deductibles and coinsurance count toward the out-of-pocket maximum. Assistant Surgeon. A surgeon who assists the primary surgeon during major surgical procedures. The Plan covers medically necessary services for an assistant surgeon. Coinsurance. The percentage of the cost of covered health care services and supplies you and Eaton pay after you meet the annual deductible. Covered Person. An individual who meets the Plan s eligibility requirements and is enrolled under the Plan. Covered Services and Supplies. Services and supplies eligible for benefits. Custodial Care. Care given to a patient who is mentally or physically disabled and the disability is expected to continue and be prolonged; requires a protected, monitored and controlled environment whether in an institution or in the home; requires assistance to support the essentials of daily living; and is not under active and specific medical/surgical or psychiatric treatment that will reduce the disability to the extent necessary to enable the patient to function outside the protected, monitored or controlled environment. Durable Medical Equipment (DME). Medical equipment that can withstand repeated use without significant deterioration. DME is primarily and customarily used to serve a medical purpose, and generally is not useful to a person in the absence of an illness or injury. Durable medical equipment and orthotics (see Expenses Not Covered for exceptions) include certain disposable supplies, enteral feedings, glucose monitors and insulin pumps. (See Prescription Drug Program Diabetic Supplies for the coverage available for diabetic supplies under the Prescription Drug Program.) Educational. Services or supplies that are, as determined by the Health Plan Claims Administrator, educational. A service or supply is determined to be educational if its primary purpose is to provide the patient with training in the activities of daily living, instruction in scholastic skills (such as reading and writing), preparation for an occupation/vocation or treatment for learning disabilities. A service or supply is also determined to be educational if it is provided to promote development beyond any level of function previously demonstrated. Essential Health Benefits. As defined by federal law, categories of services an employer-sponsored plan must cover, including: Ambulatory patient services; Emergency services; Hospitalization; Maternity and newborn care; Mental health and substance use disorder services, including behavioral health treatment; Prescription drugs; Rehabilitative and habilitative services and devices; Laboratory services; Preventive and wellness services; and Chronic disease management and pediatric services, including oral and vision care. 52

54 Medical Plan Experimental/Investigational. Services or supplies that the Health Plan Claims Administrator determines to be experimental or investigational. A service (i.e., drug, device, procedure or treatment) is experimental or investigational if any one of four conditions exist. First, insufficient outcomes data is available from controlled clinical trials published in peer review literature to substantiate its safety and effectiveness for the disease or injury involved. Second, the FDA has not granted required approval for marketing the service. Third, a recognized national medical society or regulatory agency has determined, in writing, that it is experimental, investigational or for research purposes. Fourth, the written protocols or informed consent used by the treating facility or any facility studying substantially the same service state it is experimental, investigational or for research purposes. However, the Health Plan Claims Administrator or Plan Administrator, as applicable, acting upon the recommendation of one or more medical experts deemed appropriate for consultation by either Administrator may determine that a service is not considered experimental or investigational in two situations. One, the rarity of the medical condition the claim relates to makes it unreasonable to expect that outcomes data is available or that controlled clinical trials would be conducted. Two, the medical condition the claim relates to would, in the absence of the service in question, likely result in death. With regard to mental health and substance abuse, those services mainly for research or not in keeping with national standards of practice, including but not limited to, treatment of sexual addiction, codependency or any behavior without a current DSM diagnosis; and regressive or megavitamin therapy. Express Scripts Participating Retail Pharmacy. An independently licensed pharmacy or pharmacy organization that has entered into an agreement with Express Scripts under which the pharmacy agrees to provide services to covered persons. Half-way House. A 24/7 inpatient residential program for individuals with substance abuse problems. Supervision is less intense than in an inpatient residential treatment program. Health Care Practitioner. Any duly licensed non-physician lawfully performing a medical service in accordance with governmental licensing privileges and limitations. Only those health care practitioners holding the following degrees are considered for benefits: Doctor of Optometry (O.D.), Optician (L.O.), Registered Dietitian (R.D.), Certified Nurse Midwife (C.N.M.), Certified Registered Nurse Anesthetist (C.R.N.A.), Registered Physical Therapist (R.P.T.), Speech Therapist (M.S.C.C.C.), Occupational Therapist (O.T.), Registered Respiratory Therapist, Doctor of Dental Surgery (D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.), Doctor of Chiropractic (D.C.), Physician s Assistant (P.A.), Audiologist (M.A. C.C.C.-A, M.S. C.C.C.-A, Med. C.C.C.-A), Licensed Practical Nurse (L.P.N.), Licensed Vocational Nurse (L.V.N.), Registered Nurse (R.N.), Psychologist (a licensed individual who usually has a Ph.D. and is trained in methods of psychological analysis, therapy and research for treatment of mental disorders), Licensed Professional Counselor, Licensed Clinical Social Worker (LCSW) and Substance Abuse Counselor. Health Care Provider. A licensed physician, health care practitioner, hospital, laboratory, mental health/substance abuse facility, pharmacy, skilled nursing facility, sub-acute rehabilitation facility, birthing center, ambulatory surgical center, hospice, home health agency or medical supply/equipment vendor. Hospice. A facility that offers a coordinated program of home care and inpatient care for a terminally ill patient. The hospice provides supportive care to meet special needs that are often experienced during the final stages of terminal illness. Hospital. A place that: Mainly provides inpatient facilities for the surgical and medical diagnosis, treatment and care of impaired and sick persons. Is supervised by a staff of physicians. Provides 24-hour-a-day R.N. service. Is not mainly a place for rest, for the aged, for those with chemical or alcohol dependency, or a nursing home. Charges for its services. In-Network Benefits. Plan coverage received when a covered person receives covered services from a health care provider or practitioner that participates in your Anthem network or Express Scripts Retail Pharmacy network. The level of in-network benefits is generally higher than out-of-network benefits. 53

55 Medical Plan Maximum Allowed Amount. The most the Plan will pay for an out-of-network service or supply performed or provided by a non-participating provider. The Claims Administrator must first determine that an out-of-network service or supply is covered and medically necessary in accordance with pre-authorization, utilization management and other applicable Plan requirements. When you receive services from an in-network participating provider or a traditional indemnity provider (see page 33), the provider has agreed to accept the negotiated rate and maximum allowed amounts do not come into play. The Claims Administrator determines the maximum allowed amount it will pay for out-of-network covered services based on a variety of considerations. For example, the Claims Administrator may establish at its discretion an out-of-network fee schedule or rate, taking into account reimbursement amounts: Accepted by like/similar providers who are part of the network; Paid by the Centers for Medicare and Medicaid Services for the same services or supplies; or Determined using other industry cost, reimbursement and utilization data. The Plan pays out-of-network benefits based on these determinations. You are responsible for paying any amounts the provider charges that are more than the maximum allowed amount. These charges, fees and expenses can be significant and do not apply to the annual deductible or the annual out-of-pocket maximum. Medical Emergency. A true medical emergency is the sudden and, at the time, unexpected onset of a change in a person s physical or mental condition that, if the procedure or treatment was not performed right away could, as determined by the Health Plan Claims Administrator, reasonably be expected to result in: Loss of life or limb, Significant impairment to bodily functions, or Permanent dysfunction of a body part. In a true emergency situation, the covered person should get care as soon as possible from the nearest source. You must notify Anthem BCBS s Managed Care Program within 48 hours of an emergency admission. Medically Necessary. To be considered for reimbursement under the Plan, a charge for a service, prescription drug or supply must be for a covered service, drug or supply and must be determined to be medically necessary under the terms of the Plan. A service or supply furnished by a health care provider is medically necessary for purposes of coverage under the terms of the Plan if the Health Plan Claims Administrator determines it is appropriate for the diagnosis, care or treatment of a disease or injury, or constitutes preventive services covered under the Plan. To be appropriate, services, supplies or equipment provided by a health care provider must be: Consistent with the symptoms or diagnosis and treatment of the patient s medical condition, illness or injury; In accordance with standards of good medical practice; Not solely for the convenience of the patient, the family or the provider; and The most appropriate level of service that can be safely provided to the patient. The fact that a health care provider prescribes, recommends or approves a service, supply or equipment does not, in itself, make it medically necessary. In no event will the following services or supplies be considered medically necessary for the purpose of coverage under the Plan: Those that do not require the technical skills of a physician or health care provider; Those furnished mainly for the personal comfort or convenience of the person; any person who cares for him or her; any person who is part of his or her family; or any health care provider or health care facility; Those furnished solely because the person is an inpatient on any day on which the person s disease or injury could safely and adequately be diagnosed or treated while not confined; or Those furnished solely because of the setting if the service or supply could safely and adequately be furnished in a physician s office or other less costly setting. Charges for services or supplies that are not medically necessary do not apply to the annual deductible or to the annual out-of-pocket maximum and are the patient s responsibility to pay. 54

56 Medical Plan Medicare. Medicare is a federal health insurance program. Entitlement to Medicare benefits generally begins on the first day of the month in which you: Reach age 65, Are disabled in accordance with the Federal Social Security Act and have received disability benefits under the Act for at least 24 months, Have permanent kidney failure and are being treated with dialysis, or Receive a kidney transplant. Once you become eligible for Medicare, you may enroll in Medicare Parts A and B, also known as Original Medicare, and Part D prescription drug benefits. Part A. Hospital insurance that can help you pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care. Part B. Medical insurance that can help you pay for medically necessary doctors services, outpatient hospital services, emergency ambulance transportation, anesthesia, diagnostic tests, durable medical equipment, and many other services and supplies that are not covered by Medicare Part A. Part D. Prescription drug benefits through private insurers or private drug plans that are approved by the federal government. You can apply for Medicare and get more information about the program through your local Social Security Administration office. Mental Health Disorder. Mental disorders, mental illnesses, psychiatric illnesses, mental conditions and psychiatric conditions, whether of organic or non-organic, biological, non-biological, genetic, chemical or non-chemical origin, and irrespective of cause, basis or inducement. This includes, but is not limited to, psychoses, neurotic disorders, schizophrenic disorders, affective disorders, personality disorders, and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems. Includes disorders, conditions and illnesses listed in the Diagnostic and Statistical Manual of Mental Disorders. Negotiated Network Charge. The maximum amount a participating provider has agreed to charge for any service or supply for the purpose of calculating benefits under the Plan. Non-Participating Provider. Duly licensed facilities, physicians, practitioners and other health care providers who have no contractual arrangement with the network or Express Scripts. Except in emergency situations, lower out-of-network benefits apply if you use a non-participating provider. Out-of-Network Benefits. Plan coverage that applies when a covered person receives covered services from a health care provider who does not participate in your PPO network or Express Scripts retail pharmacy network. The level of out-of-network benefits is generally less than in-network benefits. Participating Pharmacy. A duly licensed retail pharmacy lawfully dispensing prescription drugs in accordance with governmental licensing privileges and limitations. The pharmacy must be under contract with Express Scripts to provide covered prescription drugs to covered persons under the Plan. Participating PPO Provider. Those duly licensed facilities, physicians, practitioners, mental health/substance abuse and other health care providers who participate in the network. These providers have contracted with Anthem BCBS to accept negotiated fees for medical care provided to covered persons and meet certain standards set by Blue Cross Blue Shield. Higher in-network benefits apply if you use a PPO provider for covered services. Physician. A duly licensed medical doctor (M.D.) or doctor of osteopathy (D.O.) lawfully performing a medical service in accordance with governmental licensing privileges and limitations. Retail Clinic. A health care clinic located in a retail store, supermarket or pharmacy that treats uncomplicated minor illnesses and provides preventive health care services. Skilled Nursing Facility. A licensed facility that provides 24-hour professional nursing services on an inpatient basis to persons convalescing from an injury or sickness. Skilled nursing facilities maintain a complete medical record on each service recipient and are supervised on a full-time basis by a physician. The facility must be licensed as a skilled nursing facility or be recognized as an extended care facility under Medicare. Custodial or domiciliary care is not a covered expense. The patient must be receiving regular medical treatment for an illness or injury while confined. 55

57 Medical Plan Substance Abuse. Any use of alcohol and/or drugs that produces a pattern of pathological use, causing impairment in social or occupational functioning or physiological dependency evidenced by physical tolerance or withdrawal. Traditional Indemnity Provider. Duly licensed facilities, physicians, practitioners and other health care providers who have contracted with Blue Cross Blue Shield to accept negotiated fees for medical care provided to covered persons. When you use a traditional indemnity provider, lower out-of-network benefits apply (unless it is an emergency situation), but you will not be responsible for any charges above maximum allowed amounts. Urgent Care Center. A duly licensed ambulatory health care facility, separate from a hospital, that specializes in the delivery of immediate, short-term medical care without an appointment. PAYMENT OF MEDICAL EXPENSE BENEFITS Filing Claims Always present your Medical Plan ID card to the provider of service (physician, hospital, clinic or other health care professional or facility). You should also present your ID card for coverage you may have through another source such as Medicare or a benefit plan provided through your spouse s employer. Benefits under this Plan are paid only if the Health Plan Claims Administrator decides that the applicant is entitled to them. Participating Providers. You generally do not have to file a claim when you use a network provider. You should not make a payment at the time of service. Here is how the process should work: Present your Anthem ID card. Give this card to the person behind the counter before you are seen by the doctor. It is best to wait to pay until the claim is processed by the Medical Plan so you get the benefit of our negotiated network discounts and receive credit for your deductible and out-of-pocket maximums. (Members may not want to use the HSA debit card at the doctor s office since the bill at the time may not reflect the negotiated rate. Wait until you receive your Explanation of Benefits.) If you need assistance, please contact Anthem customer service with the number on the back of your ID card. File a claim with Anthem BCBS. If you use network providers, your provider will file your claim. If you use out-of-network providers, you may need to submit your claim to Anthem BCBS. Review your Explanation of Benefits (EOB) from Anthem BCBS to make sure it reflects the care you received. Pay the final invoice from your provider. The EOB reflects the plan s negotiated rate. You pay only the amount listed on the EOB as out-of-pocket cost. Use your HSA to pay for expenses. You can cover your out-of-pocket cost using your HSA debit card or HSA checkbook or you can pay out of your own pocket and then use the HSA to reimburse yourself for the expense (up to the amount in your HSA). You are responsible for keeping all receipts to document your qualified medical expense. While unlikely, some doctors may still ask you to pay at the time of service. This is within their network contract agreement with Anthem BCBS and if they do so, you will need to pay the member out-of-pocket cost when asked. You can ask the provider to estimate the negotiated fee arrangement for the cost of the service in your area. Be sure to show your new Anthem ID card and ask the provider to allow you to pay only the local BCBS discounted fee for this service rather than the provider s normal charge. Also, confirm that your provider submits the claims to Anthem BCBS so that you will receive credit toward your deductible and out-ofpocket maximum. Please ask your provider to contact Anthem to determine your current deductible status and whether you are entering into the coinsurance phase. Non-Participating Providers. Each time you incur an expense with a non-participating provider, you must submit a claim form to the Health Care Claims Administrator at the address listed on your ID card. Complete your section of the claim form according to the instructions on the form. Be sure to answer all questions to avoid delay in payment of benefits. Your claim form must be submitted with itemized, original bills. Each bill or statement must include the name of the patient, nature of surgical or medical procedure, including mental health diagnosis as defined by the Diagnostic and Statistical Manual of Mental Disorders, and other services or supplies furnished, as well as the date and amount charged for each. 56

58 Medical Plan Filing Deadline Claim Forms. Claim forms are generally required when you or a dependent: Uses a non-participating provider, or Receives care while traveling outside the network service area. You can get claim forms by calling Anthem BCBS at EATON02. Or you can print them from your personal computer by going online: Go to: EatonBenefits.com or the EatonBenefits.com link on JOE Click on: Anthem medical on the left-hand side of the page The Health Plan Claims Administrator must receive all claims for benefit consideration within 12 months of when you incurred such charges for medical services or supplies. The Claims Administrator will not consider claims received after the deadline for benefit payment. Claims Processing Rules The Claims Administrator applies processing rules to your claim for benefits for covered services. Among other things, the claim is evaluated to determine the accuracy and appropriateness of the procedure and the diagnosis codes included in the claim. Even when a covered service is determined to be medically necessary, application of these rules can affect the maximum allowed amount if the submitted claim was inconsistent with procedure coding rules and/or reimbursement policies. For example, a provider may submit a claim using several procedure codes when a single code may exist that includes all of the procedures performed. In this event, the maximum allowed amount payable is based on the single procedure code rather than the maximum allowed amount for each separately billed code. Likewise, if your physician or health care professional performs multiple procedures on the same day, the Plan may reduce the maximum allowed amount it pays for secondary and subsequent procedures. Paying 100% of the maximum allowed amount for those procedures would represent a double payment for components of the primary procedure that may be considered incidental or inclusive. How Payments Are Made Benefit payments are usually sent directly to participating providers. Benefit payments for non-participating providers are sent to you. The Health Plan Claims Administrator sends you an Explanation of Benefits (EOB) after processing your claim. The EOB states how your benefit payment was calculated, where the payment was sent or whether your claim was denied. Note that some of the Health Plan Claims Administrators send you an EOB only if you owe the provider money after the Plan pays benefits. Procedure for Resolving an Issue Other than a Claims Appeal Other than a claims appeal, if you have a concern or problem relating to your medical coverage, precertification or a participating provider, please notify a Customer Service Representative at EATON02. With the involvement of the appropriate department at the Health Plan Claims Administrator, the Customer Service Department can resolve many types of issues in a timely manner. If the Customer Service Department does not resolve an issue to your satisfaction, the Customer Service Representative can explain the formal resolution procedure you should follow. Claims Appeal Procedures See Claims Appeal Procedure for a statement of the claims appeal procedures. 57

59 Medical Plan PRESCRIPTION DRUG PROGRAM The Plan covers charges for medically necessary federal legend drugs requiring a physician s written prescription through the Prescription Drug Program. Express Scripts, operating as an independent contractor, administers the Prescription Drug Program. The Prescription Drug Program described in this section is not available to employees who elect the No Coverage option. No warranty, expressed or implied, is given by Eaton or Express Scripts concerning any drug, whether or not it is included in the formulary. You and your doctor must make the final decision about which drug is best for your condition and medical treatment. Because of the volume of prescription drugs purchased through the Plan, the Plan qualifies for pricing discounts and rebates or refunds from pharmaceutical manufacturers paid through Express Scripts. Any such rebate or refund is paid to the Plan, which uses the funds to operate the Plan. Plan participants do not receive these payments. Coinsurance and deductible amounts do not reflect manufactures rebates. Purchasing Prescription Drugs Drug Categories Prescriptions drugs are covered under the Prescription Drug Program administered by Express Scripts. You receive in-network benefits by purchasing the drug from an Express Scripts participating retail pharmacy or through the mail order prescription drug program whether your prescription was written by an in-network or out-of-network provider. You pay the full Express Scripts discounted price for a prescription until you reach the annual deductible. After you meet the annual deductible, you pay 20% coinsurance, up to a maximum payment after the deductible of $500 per prescription filled. If you reach the annual out-of-pocket maximum, you pay nothing for all covered prescription drugs for the rest of the calendar year. You pay nothing for certain preventive medications. Plan coverage for prescription drugs is based on the drug category as described below and the benefit levels shown in the chart on the next page. Generic Drug. A generic drug has the same active chemical composition as its brand name equivalent but is no longer protected by a patent. Formulary Brand Drug. The formulary is a list of FDA-approved prescription drugs and supplies developed by Express Scripts Pharmacy and Therapeutics Committee. These drugs are chosen based on established criteria recognizing therapeutic and cost effectiveness. To obtain a list of the most commonly used formulary drugs (which changes periodically), call Express Scripts at the toll-free number listed on your ID card and request that a list be mailed to you. You can also find information about the formulary on the Express Scripts web site accessible through EatonBenefits.com. Using formulary brand drugs helps reduce overall Plan costs. Multi-source drugs. Brand name drugs that have a generic equivalent.` Non-Formulary Brand Drug. These drugs are brand name drugs that are not on the formulary list. Preventive Care Drugs. Preventive care drugs are defined by the Patient Protection and Affordability of Care Act. The Plan covers both Tier 1 and Tier 2 preventive drugs at 100% with no deductible, so you are not charged for these drugs (see pages 64 and 65). Single-source drugs. Brand name drugs that have no generic equivalent. Specialty Drugs. Specialty drugs are used to treat complex conditions; they are typically administered by injection or infusion and require special handling. These drugs are available only through Accredo, the mail-order specialty program (see page 66). 58

60 Medical Plan Drug Coverage Chart Drug Category Generic Formulary Brand Non-formulary Brand Tier 1 and Tier 2 Preventive Drugs (see page 64 and 65) How Benefit Works Until you reach the annual deductible You pay 0% You pay 100% After you reach the annual deductible and before you reach the annual out-of-pocket maximum (up to a 30-day supply at retail and up to a 90-day supply through mail order) You pay 20% Your maximum payment each time you fill a prescription is $500 (after you meet the annual deductible). Deductible does not apply. Covers only generics in Tier 1. (exceptions may apply to tobacco cessation medications, certain contraceptives and drugs to prevent invasive breast cancer) Additional charges may apply if you fill a prescription with a formulary or non-formulary drug when a generic equivalent is available (Pay the Difference program; see page 61), or if you fill a maintenance drug more than three times at a retail pharmacy (Mail Order program; see page 61). Additional charges may also apply if you don t use Accredo for specialty drugs (see page 66). Otherwise specialty drugs are covered the same as other drugs in the category they fall under (i.e., formulary brand or non-formulary brand). To visit the Express Scripts web site: After you reach the Plan s annual out-of-pocket maximum You pay no out-of-pocket cost for covered medications for the rest of the year. Go to: EatonBenefits.com or the EatonBenefits.com link on JOE Click on: Express Scripts Prescription Drugs on the left-hand side of the screen Covers only generics in Tier 2 unless a generic is not available in the category or class Paying for Prescriptions The information below and in the chart above provides an overview of how prescription costs are paid. Details on charges for specific types of prescriptions follow in this section. The Pay the Difference program (see page 61) and Mail Order program (see page 61) apply to all your purchases. You are charged the full Express Scripts discounted price for a drug until you reach the annual in-network deductible (see page 27). Then you pay coinsurance as described in the chart above. The maximum you pay for the fill of a prescription is $500 after you reach the deductible. This maximum, however, does not apply to your payment when a generic equivalent is available and the generic portion of the cost is capped (see Pay the Difference program). The $500 maximum payments also does not apply when, instead of using mail order, you fill a maintenance prescription more than three times at a retail pharmacy. If you reach the annual in-network medical/prescription drug out-of-pocket maximum, you pay nothing more for covered prescription drugs and medical expenses for the rest of the calendar year. The annual deductible, coinsurance amounts, penalties and additional amounts you pay as a result of the Pay the Difference program apply toward your annual deductible and out-of-pocket maximum. The Plan covers certain preventive generic drugs at 100%. You are not required you to meet the annual deductible, so these medications are provided at no cost to you. 59

61 Medical Plan You are expected to pay your pharmacist at the time of service. Here s how the process should work: Present your prescription drug ID card (Anthem or Express Scripts/Medco ID card, depending on your Medical Plan option). Give this card to the person behind the counter. This will give you the benefit of our negotiated network discounts and credit toward the deductible and out-of-pocket maximum, if applicable. Pay the pharmacy. Your cost will reflect the Plan s negotiated rate and your out-of-pocket cost. You will need to pay the pharmacy at the time of service. Use your HSA to pay for expenses. You can cover your out-of-pocket cost using your HSA debit card or HSA checkbook or you can pay out of your own pocket and then use the HSA to reimburse yourself for the expense (up to the amount in your HSA). File a claim with Express Scripts. If you use network providers, your pharmacist will file your claim. If you use out-of-network providers, you may need to submit your claim to Express Scripts. Purchasing Drugs at a Retail Pharmacy The Express Scripts retail card program covers charges for up to a 30-day supply per prescription or refill at a participating retail pharmacy. You need to present your Medco/ Express Scripts ID card so you will be charged correctly for each covered prescription. Participating pharmacies should automatically substitute a generic equivalent drug for a brand name, if one exists, unless the physician indicates dispense as written on the prescription or you request a brand name. Pharmacy Listing. Express Scripts maintains a national network of pharmacies under contract to dispense prescription drugs to covered persons. All participating retail pharmacies are independent contractors and are not employees or agents of Eaton or Express Scripts. You can obtain the names and locations of pharmacies that participate by calling the toll-free number listed on your ID card and giving them your zip code. The phone representatives will then give you the names of participating pharmacies in your area. You can also obtain information about participating pharmacies from the Express Scripts web site. Emergency Prescriptions While Traveling. If you are traveling away from home, you can call the Express Scripts toll-free number shown on your ID card to help locate the nearest Express Scripts participating retail pharmacy. Assistance by phone is available 24 hours a day, seven days a week (except Thanksgiving and Christmas). If a participating pharmacy is not available, you can call to request prior authorization to have the prescription filled at a non-participating pharmacy. You will need to pay the entire cost of the drug at the non-participating pharmacy and file a claim for reimbursement from Express Scripts. For unplanned medical treatment of an emergency or urgent nature, you are reimbursed as if you used a participating pharmacy as long as you receive prior authorization from Express Scripts. Mail Order Program for Maintenance Medications. If you elect to fill a maintenance drug through a retail pharmacy more than three times, you will be charged 100% of the cost of the drug starting with your fourth fill. No maximum applies to the charge. You can avoid paying the full cost of maintenance prescriptions by using the mail order program. Purchasing Drugs at a Non-Participating Pharmacy If you purchase prescription drugs from a pharmacy that does not participate with Express Scripts, you must pay the entire cost of the prescription at the time of purchase. You will need to file a claim for reimbursement with Express Scripts. Express Scripts reimburses you based on the Express Scripts discounted charge and the applicable coinsurance (see the chart on page 59). You are responsible for coinsurance plus any amount the non-participating pharmacy charges above the Express Scripts discounted charge. Only the Express Scripts approved discounted cost is applied to the annual deductible in the Consumer Health Plan options and to the out-of-pocket maximum in all Plan options. 60

62 Medical Plan Mail Order Program The mail order prescription drug program covers maintenance prescription drugs for up to a 90-day supply per prescription or refill. Maintenance drugs are drugs you take for long periods to treat chronic conditions such as hypertension or diabetes. You get specialty medications through Accredo, the mail order specialty pharmacy, as described on page 66. You can pay the applicable charge by check or money order, or you can bill it to your credit card or use your HSA debit card. To obtain mail order forms, call Express Scripts at the toll-free number listed on your ID card. Prescriptions must be written on a physician s prescription form. Mail order prescriptions will be sent U.S. mail unless you make other arrangements. For controlled drugs (such as narcotics regulated by the FDA), you must provide a complete street address, and an adult s signature may be required on delivery. Please note, prescription drugs cannot be mailed overseas or renewed more than 14 days before the prior dosage/prescription is to expire. Pay the Difference Program Many brand name drugs have generic equivalents, and the Pay the Difference program supports the use of these less expensive generic equivalents. If a generic equivalent is available and your prescription is filled with a formulary or non-formulary brand drug, you pay the applicable coinsurance for the generic version of the drug plus the difference in cost between the generic drug and the brand name drug. You pay more for the brand name drug even if your doctor indicates that you must use a brand name drug rather than the generic equivalent. If your prescription has a note from the doctor saying dispense as written, the pharmacist is required to fill the prescription with the brand name drug rather than a generic equivalent, and you will pay more. The choice of medication is always a decision to be made by you and your doctor, but you will always pay more for a brand name drug when there is a generic equivalent available. When a generic equivalent drug is available and you select a brand name drug instead: You pay the full Express Scripts discounted price for the brand name drug until you reach the annual deductible. After you meet the annual deductible, you pay 20% of the discounted cost of generic equivalent drug PLUS the difference in cost between the generic equivalent version of the drug and the brand name drug used to fill the prescription. The $500 maximum payment per filled prescription applies only to your share of the cost of the generic medication. Your coinsurance and additional costs for a formulary or non-formulary drug count toward your annual deductible and out-of-pocket maximum. If you reach the annual out-of-pocket maximum, you pay nothing for your eligible prescription drug costs, including penalties, for the rest of the calendar year. Here is an example of how Pay the Difference works for the brand name Prozac and the generic equivalent Fluoxetine. This example assumes that the deductible has already been met. Generic Brand Pay the Difference Drug Type Fluoxetine Prozac Gross Cost (30 days) $14.75 $ Coinsurance of Generic Cost PLUS Brand Generic Difference $2.94 (20%) $2.94 (20%) N/A You Pay $2.94 $ Eaton Pays (30 Days) $11.81 $

63 Medical Plan Preferred Drug Step Therapy The Preferred Drug Step Therapy Program requires you to try a preferred generic drug or preferred brand drug before the Plan will cover higher-cost non-preferred drugs unless special circumstances exist. The following categories of drugs are subject to preferred drug step therapy: Proton Pump Inhibitors (PPIs) for acid reflux Bisphosphonates for osteoporosis Intranasal steroids for allergies Inhaled corticosteroids and combination inhalers for asthma Hypnotics to aid sleep Triptans for migraine Angiotensin II Receptor Antagonists (ARBs) for blood pressure control Glaucoma therapy Insulin and DDP-4 oral products for diabetes Androgen therapy for hormone replacement Non-steroidal anti-inflammatory (NSAIDs) medications and tramadol for pain management Topical creams/ointments and oral antibiotics for acne treatment Topical corticosteroids for skin conditions Benign prostatic hyperplasia (BPH) therapies Fenofibrates and statins for high cholesterol Therapies for overactive bladder Alzheimer therapies Select seizure therapies Antidepressants Specialty therapies such as growth hormone, rheumatoid arthritis, prostate cancer, CAPS syndrome, and multiple sclerosis When a prescription for a non-preferred drug is entered at a participating retail pharmacy, Express Scripts sends an online message to the pharmacist. The pharmacist will notify you that the drug is non-preferred and therefore not covered, and that your physician will need to provide a new prescription for a preferred drug. At some participating pharmacies, the pharmacist may contact your physician on your behalf. If your physician feels the non-preferred drug is medically necessary for your treatment, he or she may contact Express Scripts for prior authorization. If you send a prescription for a non-preferred drug to the mail order pharmacy, Express Scripts will contact the prescribing physician for a new prescription for a preferred drug. This process may delay the delivery of your prescription. 62

64 Medical Plan Prior Authorization of Certain Drugs Prior authorization is needed before the Prescription Drug Program covers the medications listed below. In addition, quantity limits for coverage within a time period may apply. Specialty drugs including: - growth hormones - immune globulin - anti-interleukin therapy - infantile spasm therapy - PKU agents - PNH agents - cancer and blood disorder therapies - anemia treatments - viral infections for select conditions - multiple sclerosis therapy - high blood pressure in the pulmonary (lung) arteries treatment - rheumatoid arthritis, psoriasis, fibromyalgia or Crohn s Disease treatment - Gaucher disease therapy - Parkinson s disease therapy - some hormones and diagnostic agents - ophthalmic agents - cystic fibrosis therapy Non-specialty drugs to treat: - male impotency (most dosages limited to 8 tablets for 30 days or 24 tablets for 90 days) - allergies and asthma - sleeping disorders - migraines - nausea - osteoporosis - seizures and pain disorders - Attention Deficit Hyperactivity Disorder (ADHD) - pain management - Tretinoin and Tazorac for patients age 25 or older - weight loss - select androgens and anabolic steroids When a prescription for a drug that requires pre-authorization is entered at a participating retail pharmacy, Express Scripts sends an online message to the pharmacist. The pharmacist will notify you that additional information is needed from your physician before the prescription can be filled. You must contact your physician and request the physician s office call the Express Scripts toll-free prior authorization line at to provide information to authorize the drug s use for purposes of coverage under the Plan. (Please note, this phone number is for physician use only.) At some participating pharmacies, the pharmacist may contact the doctor on your behalf. 63

65 Medical Plan You have the option of paying the full cost for the prescription or waiting to see if authorization is received. If you pay for the prescription and the drug is subsequently authorized, you are refunded for the cost less your coinsurance by filing a claim with Express Scripts. If you wait for authorization before filling the prescription, the pharmacist will contact you when the prescription has been authorized or denied. If you are purchasing a drug that requires prior authorization through the mail order prescription service, delivery may be delayed during the authorization process. The mail order pharmacy will contact the prescribing physician for the required information. If coverage for the prescription is denied, you will be notified. If coverage is approved, you will be notified of the time period for which coverage is valid. Preventive Care Drugs In addition to all preventive benefits described in this section, Eaton is in compliance with the Affordable Care Act (ACA) requirements. For a full list of preventive services covered under ACA visit HealthCare.gov. The ACA classifies certain drugs as preventive care drugs. Because they are preventive, you do not have to pay the annual deductible, and the Plan pays the full cost of these medications when you use an Express Scripts retail pharmacy or the mail order program to fill your prescription. Tier 1 preventive care drugs are the following generic drugs: Aspirin prescribed for cardiovascular protection Aspirin (low-dose 81 mg/day) for women of childbearing age who are at increased risk of preeclampsia after 12 weeks gestation Folic acid prescribed in doses of 400 to 800 mcg/day for women who are pregnant or who are planning to become pregnant Fluoride prescribed for children to prevent dental cavities Liquid iron preparations for infants FDA-approved preventive vaccines such as seasonal influenza, pneumococcal pneumonia (Pneumovax), hepatitis B (Heptavax) and shingles (Zostavax) administered at Express Scripts network retail pharmacies (See also Immunizations and Flu Shots under preventive care on page 35.) Contraceptive medications generic, brands without generic equivalent and over-the-counter when filled through Express Scripts with a written prescription from your physician. For example, birth control pills, injectables, patches and Depo-Provera. Brands with a generic equivalent may also be covered, but only if your physician indicates it is medically necessary (DAW, dispense as written) on your prescription Vitamin D for ages 65 and over Bowel preparations Tobacco cessation products the prescription products Nicotrol NS, Nicotrol Inhaler, Zyban and Chantix are covered through Express Scripts only if you participate in the Active Health Management (AHM) tobacco cessation program. Over-the-counter products are covered through the AHM Tobacco Cessation program when you participate in it Drugs to prevent invasive breast cancer if you are over age 35 and do not have a history of breast cancer, ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS), request a copay review by Express Scripts to determine if you qualify to receive tamoxifen, raloxifene or Soltamox as a preventive drug at no cost 64

66 Medical Plan Tier 2 Preventive Drugs. In addition to the list above, the Plan covers Tier 2 generic medications for the following conditions at no cost to you. If a generic version is not available in the drug class or category, the brand name drug is covered as a preventive drug. Drugs Which Lower the level of bad cholesterol Lower blood pressure Reduce thinning of the bones (osteoporosis) Reduce stickiness of platelets in the blood Reduce excess stomach acid Lower estrogen levels To Prevent Drug Classification Generic Drug Examples (you pay $0) Heart attacks Heart attacks Bone fractures Heart attacks Ulcers Breast cancer Antihyperlipidemics HMG COA reductase inhibitors Antihypertensives ACE inhibitors, beta-blocking agents, calcium channel blocking agents, ARBs Bone resorption inhibitors Platelet aggregation inhibitors Proton pump inhibitors Aromatase inhibitors simvastatin, pravastatin, atorvastatin lisinopril, clonidine, amlodipine, metoprolol, losartan alendronate ticlopidine, clopidogrel omeprazole, lansoprazole anastrozole, letrozole, exemestane Brand Name Drug Examples (deductible & coinsurance applies) Crestor, Vytorin Norvasc, CoregCR, Covera HS, Teveten Boniva Brilinta, Effient Nexium, Aciphex Arimindex, Aromasin, Femara Because there are no generic alternatives, you pay $0 for the following brand name preventive prescription drugs purchased at an in-network retail pharmacy or through the mail order pharmacy. Drugs Which To Prevent Drug Classification Brand Name Drug Examples (you pay $0) Increase white blood cells Increase red blood cells Diabetic Supplies Infection Anemia Colony Stimulating Factors Erythropoiesis- Stimulating Agents Neulasta, Neumega Procrit, Epogen With a written prescription, you can obtain insulin under the Prescription Drug Program (see chart on page 59). Other diabetic supplies are covered as medical expenses. Prescription Vitamins The Prescription Drug Program covers vitamins that require a prescription. Folic acid prescribed in doses of 400 to 800 mcg/day for women who are pregnant or who are planning to become pregnant is covered as a preventive drug. 65

67 Medical Plan Specialty Medications and How to Obtain Them Specialty medications are drugs that are used to treat complex conditions and illnesses, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis. These drugs usually require special handling, special administration and/or intensive patient monitoring. Specialty medications that are self-administered (such as medications treating MS) or infused to treat rare diseases (such as hemophilia) are only covered when provided by Accredo, the mail order specialty pharmacy. The Plan does not cover charges for these specialty medications when billed by a physician s office or other provider. Any such prescription must be transferred to Accredo. If you purchase these medications from your doctor or another pharmacy or provider, you are responsible for their full cost. Clinician-administered specialty medications (such as those that treat osteoporosis) continue to be covered under the medical plan. Specialty drugs are usually filled with a 30-day supply, but the quantity may vary based on what is clinically appropriate. Accredo determines the clinically appropriate quantity, ranging from a 30- to a 90-day supply, for each specialty drug. If the most appropriate quantity is less than 90 days, your mail order coinsurance is prorated. Specialty drugs are covered the same as other drugs in the category they fall under (i.e., generic, formulary brand or non-formulary brand), and the maximum payments for fills of prescription drugs apply to specialty drugs (see chart on page 59). A list of the specialty medications subject to the program is available on the Express Scripts Web site or by calling the number on your prescription drug ID card. Medications on the list may change, so you should always check the list before you fill a prescription for a specialty medication. Medications used to treat diabetes (e.g., insulin) are not on the list of specialty medications. If you have any other questions, call Member Services at Personalized Medicine The Personalized Medicine program covers clinical testing programs (called pharmacogenomics) that enable a more precise approach to treatment. Cheek swab tests or simple blood tests give you and your physician a better understanding of how you are responding to a specific therapy. The Prescription Drug Program covers testing programs for the following drug therapies: Cardiovascular and drugs such as Warfarin and Plavix Oncology and drugs such as Gleevec, Tasigna and Sprycel Immunology and drugs such as Abacavir and Maraviroc A1c and lipid diabetes home testing kits Your physician will be notified if you are eligible for clinical testing. Alternatively, your physician may call to inquire about testing. 66

68 Medical Plan Exclusions The Prescription Drug Program does not cover the following: Over-the-counter products (drugs not requiring a written prescription from a physician to be purchased) unless the over-the-counter product is a preventive drug prescribed by your physician for certain conditions; Drugs used for cosmetic purposes; Yohimbine; Serums, toxins, or allergens; Injectable gold compounds; Vitamins and minerals that do not require a prescription; Food supplements; Therapeutic devices or appliances; Homeopathic medications; Charges for administration or injection of any drug; Experimental or investigational drugs (see Definitions and Important Terms ); and Drugs taken or administered while in a doctor s office, hospital, skilled nursing facility or medical facility. Filing a Claim Under the Retail Card Program When you present your prescription drug card at participating pharmacies, you typically do not need to file a claim form. If you fail to present your prescription drug card at a participating pharmacy or if you purchase drugs at a non-participating pharmacy, you must file a claim form to receive reimbursement. The address for filing claim forms is: Express Scripts P.O. Box Lexington, KY Telephone number: Prescription drug receipts should contain: name of patient, prescribing physician s name, prescription number, date of purchase, name of drug and cost of each prescription. Express Scripts will send an Explanation of Benefits (EOB) indicating how the benefit payment was calculated for each submitted claim. All claim forms must be submitted to Express Scripts for benefit consideration no later than December 31 of the calendar year following the year in which you or your covered dependent incurred charges for prescription drugs. Claim forms submitted after the deadline are not considered for benefit payment. You can get Express Scripts claim forms by calling the Express Scripts toll-free number. Please see Claims Appeal Procedure for a statement of the claims appeal procedures. The Prescription Drug Program is part of the Plan. Sections of the Medical Plan that do not apply to the Prescription Drug Program are How to Use Your Network, Medical Expense Benefits: Covered Services and Supplies, and Payment of Medical Expense Benefits. 67

69 Medical Plan HEALTH SAVINGS ACCOUNT (HSA) Eligibility The Eaton Medical Plan options and the Health Savings Account (HSA) are two separate components that work together to help you make the most of the money you budget and spend for health care. The HSA is an exempt trust or custodial account you set up with Fidelity Investments, a qualified HSA trustee, to save before-tax dollars to pay qualified medical expenses such as the deductible in the Medical Plan. Please note, the HSA is not part of the Eaton Corporation Group Insurance Plan for U.S. Employees and is not subject to the terms and conditions of the Plan described in this summary plan description. As a result, Eaton has no fiduciary responsibility with respect to the HSA, and claims with respect to the HSA are managed solely by Fidelity Investments. In addition, since the administration of an HSA is a taxpayer responsibility, you are encouraged to consult your tax advisor before opening an HSA. There are extensive IRS regulations and Plan rules relating to HSAs, and the following information is only a brief summary. You are also encouraged to review information available from the Internal Revenue Service (IRS) at Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans, and IRS Publication 502, Medical and Dental Expenses (including the Health Coverage Tax Credit). To help you off-set the cost of your annual deductible for 2018, if you are a regular employee as of January 1, 2018, Eaton will make a lump sum contribution to your account in early January of: $400 for Employee only coverage, or $800 for Employee + Others coverage. Note that Employee + Others coverage is defined as employee + spouse/domestic partner or employee + child(ren); and employee + spouse/domestic partner and child(ren). If you are hired after January 1, 2018, the Eaton HSA contribution will be prorated. You must open your Health Savings Account at Fidelity by the administrator s deadline in order to receive Eaton s lump sum contributions. To be eligible to establish an HSA, you must: Be covered under one of Eaton s Consumer Health Plan options, which are considered to be high deductible health plans. Not have other health coverage in a non-high deductible health plan such as through your spouse s employer or TRICARE. Not be enrolled in a health care flexible spending account (FSA) through your spouse. However, you can use the Eaton Dental/Vision Reimbursement Account (DVRA) ( limited purpose FSA) for dental and vision expenses. See the Reimbursement Account Plans section for more information. Not be enrolled in Medicare. Not be claimed as a dependent on someone else s tax return. You are not eligible to use payroll deductions to contribute to the Fidelity HSA if you are continuing your Eaton Consumer Health Plan option coverage under COBRA, and Eaton will not pay the administrative fee to maintain the HSA. You can continue to make after-tax deposits to the Fidelity HSA or open an HSA on your own. While you cannot have other non-high deductible health care coverage and contribute to an HSA, you can have additional insurance that provides benefits for liabilities incurred under workers compensation laws, tort liabilities, or liabilities related to ownership or use of property; a specific disease or illness; and a fixed amount per day (or other period) of hospitalization. You can also have coverage (whether provided through insurance or otherwise) for accidents, disability, dental care, vision care and long-term care. 68

70 Medical Plan Opening Your HSA You can elect HSA coverage and have it begin the first day of any month after you meet the eligibility requirements. To open your HSA, complete the HSA Online Application available through the Eaton Service Center at Fidelity. After you log on, click the Open link next to Health Savings Account. You can also order an HSA debit card and/or an HSA checkbook to pay your expenses when you open your HSA. If you do not have access to NetBenefits, please contact the Eaton Service Center at Fidelity for an application. Once your application is approved, you will receive a New Account Profile from Fidelity Personal Investments. At that time, you will be able to view your account on NetBenefits. Please note, if you elect employee payroll deductions, it may take up to three payroll cycles for your contributions to begin. If you enroll in the Medical Plan during annual enrollment: You can open your HSA as of January 1 of the next calendar year, and you are generally eligible to make HSA contributions (yours and the Company s combined) up to the full IRS limit. If you enroll in the Medical Plan during the year: You can elect to have your HSA coverage begin as of the first day of the month following the effective date of your medical coverage. If your coverage becomes effective on the first day of a month, your HSA can also start on that day. Your maximum annual contribution amount is prorated based on the number of months you are eligible. By following the IRS Last-Month Rule, you may be eligible for the full annual contribution limit if you are enrolled in the HSA on December 1 and continue coverage in a high deductible health care plan through December 31 of the following Plan year. Contributing to Your HSA You can contribute money to your HSA through convenient before-tax payroll deductions by setting up an amount to have deducted from your pay. You can start, change or stop your contributions anytime during the year, but the changes are subject to the Fidelity-Eaton payroll feed cycles. You can also contribute to your HSA through separate deposits you make by check or electronic fund transfer directly to your Fidelity HSA account. You can then claim the deposits as deductions on your annual tax return (to the extent that the total contributions to your account do not exceed your maximum annual contribution amount). However, unlike a payroll contribution, you will not receive credit for Medicare or Social Security taxes. Generally, you may make tax-deductible contributions until your federal tax filing deadline (not including extensions), typically April 15 of the following year. Limits on HSA Contributions. Because your contributions are not taxed, the government sets limits on the maximum amount you can contribute to an HSA each year. For 2018, the limits, which are based on your Consumer Health Plan option coverage level are: Employee only coverage: $3,450 Employee + Others coverage: $6,900 These limits are subject to adjustments for inflation; for updated rates, refer to your annual enrollment materials or go to All contributions from any source (you, the Company or any other third party) are added together to determine the annual contribution to your account. You are responsible for ensuring your HSA contributions do not exceed these limits during the year. If your contributions exceed the maximum allowed, any contributions above the maximum are considered taxable income and any of those amounts that remain in your account are subject to a 6% excise tax. You can avoid the excise tax by withdrawing the excess contributions (and any earnings on those contributions) by your federal tax filing deadline (including any extensions) for the applicable tax year. See IRS Publication 969 or the Department of Treasury Web site or contact your tax advisor for more detailed information. If you are not eligible for the HSA for the full calendar year, the maximum you can contribute for the year is calculated two different ways. The prorated maximum is based on the month you become eligible for the HSA. So, for example, if you are hired and your Consumer Health Plan option coverage becomes effective on June 15, your HSA is opened on July 1. You are eligible for the HSA for six months, or one half of the year, and as a result can contribute up to 50% of the maximum contribution amount for your coverage level. However, your maximum may be more if the IRS Last-Month Rule applies to you. 69

71 Medical Plan When you enroll in Medicare Parts A or B, your eligibility to make contributions to an HSA or to receive Company contributions ends on your Medicare effective date. To stop your payroll contributions and Company contributions, contact the Eaton Service Center at Fidelity. If your domestic partner or child(ren) is tax qualified, the contribution limit is the same as a spouse. If your domestic partner or child(ren) is not tax qualified, the employee s HSA cannot reimburse the domestic partner s or child(ren) s health care expenses. However the domestic partner/child(ren) can establish an HSA directly with the bank of his or her choice. Because both the employee and domestic partner/child(ren) are enrolled in employee + other, each can contribute the employee + other maximum to their HSA, which is limited to $6,900 based on 2018 IRS limits. Catch-up Contributions. You can make additional catch-up contributions up to $1,000 per year to your HSA if you are: At least 55 years old, Not enrolled in Medicare, and Otherwise an eligible individual. In the year you turn age 55, you can make the full $1,000 catch-up contribution for that tax year if you were enrolled in an HSA-eligible health plan on the first day of each month during the year. Otherwise, you must prorate the catch-up contribution amount based on the number of months you are eligible that year or follow the IRS Last-Month Rule. After-tax Contributions. You can make after-tax contributions directly with Fidelity at any time. When you file your tax return, you can claim this contribution as a deduction; however, unlike a payroll contribution, you will not receive credit for Medicare or Social Security taxes. Transfers. You may be able to transfer funds from another HSA. Complete and return to Fidelity a Transfer of Assets form, available on Fidelity.com, and Fidelity will verify eligibility of the transfer and coordinate the transfer from the other institution. The transfer is not considered a taxable event and is not reported to the IRS. Eligible transfers are not included when calculating your maximum annual contribution amount. Fidelity does not charge fees on this transaction, but you should always consult the fee schedule of your other HSA custodian to understand any fees or charges that may apply. IRA Rollover. You may also make a one-time contribution to an HSA from amounts distributed from an IRA as a direct trustee-to-trustee transfer. Consult with your tax advisor. 70

72 Medical Plan IRS Last-Month Rule Under the Last-Month Rule, if you are eligible for the HSA on the first day of the last month of your tax year (December 1 for most taxpayers), you are considered eligible for the entire year. You are treated as having the same Consumer Health Plan option coverage for the entire year as you had on the first day of the last month of the year. If the contributions to your HSA are based on your eligibility under the Last-Month Rule that is, they are higher than the amount you could have contributed if you prorated your contribution for the actual number of months you were eligible for the HSA the IRS applies a testing period. Your eligibility must continue during the testing period, which begins with the last month of your tax year and ends on the last day of the 12 th month following that month. For example, December 1, 2017 through December 31, Unless you die or become disabled, if your eligibility does not continue during the testing period, your additional contributions above the prorated amounts will become taxable as ordinary income in the year of the testing period and subject to a 10% additional tax. Example. Joe becomes an Eaton employee on July 1, He did not have coverage in a high deductible health plan before joining Eaton, but chooses Employee only coverage in the Consumer Health 80 Plan option when his Eaton employment starts. The maximum HSA contribution for Employee only coverage is $3,450 for 12 months, so on a prorated basis, half of that amount would be $1,725 ($3,450 x.50 = $1,725). Because Eaton is making discretionary contributions to employees HSAs in 2018, Joe will receive a prorated $200 contribution from Eaton ($400 contribution for 2018 plan year x.50 = $200). As a result, the prorated amount Joe could contribute to his HSA in 2018 based on the actual number of months he is eligible is $1,500 (.50 x $3,400 = $1,700 - $200 Eaton contribution = $1,500). Under the Last-Month Rule, however, Joe can contribute more to his HSA during Provided he still has Employee only coverage in the Medical Plan on December 1, 2019, contributions to his account can equal the annual maximum, or $3,450. That maximum is offset by the $200 that Eaton contributes, for a maximum HSA contribution on Joes part of $3,250 for Joe is subject to an IRS testing period from December 1, 2018 through December 31, As long as he remains eligible for an HSA throughout that time period, Joe has no negative tax consequences. But if he loses eligibility for an HSA for example, he terminates and does not have high deductible health coverage through December 31, 2019 the difference in the prorated contribution and the contribution using the Last-Month Rule becomes taxable income to him in That means he would be taxed on $1,725 in income in 2017 ($3,450 annual maximum - $1,725 prorated maximum = $1,725). This amount is also subject to a 10% additional tax. See IRS Publication 969 for more information. 71

73 Medical Plan Eaton s 2018 Contribution to Your HSA As an incentive to get your savings started, if you enroll in the Medical Plan in 2018, Eaton will make a contribution to your HSA. Eaton will contribute: $400 if you have Employee only coverage $800 if you have Employee + Others coverage Provided you have elected and opened an HSA with Fidelity, Eaton s contribution will be made to your HSA in January 2018, so it will be available to you for the full year. If you don t use the money, it remains in your account and rolls over for your future use. Also, while you are an active employee, Eaton will pay any monthly service fee associated with administering the Fidelity HSA. If you have a qualified change in status and switch your coverage from Employee only to Employee + Others, Eaton s contribution will be increased on a prorated basis to the higher contribution amount. For example, if you change to Employee and spouse coverage effective April 1, 2018, you will have that coverage for nine months, or 75% of the year. Eaton s total contribution to your account would be $700. That is, three months at Employee coverage and nine months at Employee + Others coverage, or (0.25 x $400) + (0.75 x $800) = $100 + $600 = $700. This additional contribution will be deposited in the employee s account as soon as administratively feasible (approximately 4 weeks after the employee requests the change in medical coverage). If you change to Employee only coverage from Employee and spouse coverage during the year, your balance is not affected. During 2018, newly hired employees who enroll in the Medical Plan will receive the Eaton contribution based on their level of coverage and prorated for the number of months they are eligible for an HSA that year. You receive the Eaton contribution if you are participating in the Medical Plan, except if: Your employment is terminated by Eaton due to your receiving Eaton Long Term Disability benefits, or You are continuing coverage under COBRA. Using Your HSA You own and control your HSA. You can use your HSA to pay for current expenses such as the deductible and coinsurance in the Medical Plan, as well as qualified dental and vision expenses. For your convenience, a list of most common eligible expenses is provided on EatonBenefits.com as well as NetBenefits. However, always check Publications 969 and 502 at for the most up-to-date information as well as consult with your tax advisor. Eligible medical expenses reimbursed from an HSA must have been incurred on or after the date the HSA was established, even if incurred during a prior tax year. For example, if you incurred an expense in 2017, you can use HSA funds in 2018 to reimburse yourself for the 2017 expense. You can use your HSA to cover expenses for you, your spouse and any tax dependent. If your domestic partner meets the IRS qualifications to be considered a tax dependent, you can use your HSA dollars to cover his/her eligible expenses. Any HSA balance you accumulate while you are working can supplement your retirement income. You can withdraw funds tax-free to pay Medicare premiums, deductibles, copays and coinsurance as well as retiree medical premiums for coverage through a former employer. Medigap insurance premiums are not considered to be qualified expenses. Like an Individual Retirement Account (IRA), after age 65 you can withdraw the money in your HSA for any purpose and the withdrawal will be taxed as ordinary income. The money in your HSA has the potential to grow with interest and/or investment earnings, and any remaining balance rolls over from year to year in your account. The money in your HSA is yours. You own it, even if you leave Eaton. If you use the money in your HSA to pay for qualified health care expenses, your withdrawals are tax-free. You can take a distribution from your HSA to pay for nonqualified expenses, but you ll have to pay ordinary taxes on the distribution and an additional 20% penalty if you re under age 65. See your tax advisor or financial institution for the most recent information about the tax treatment of HSAs. 72

74 Medical Plan The Amount Available to You for Payments Ways to Pay When contributions are made to your HSA, they are directed into your core position, an FDIC-insured account. The Fidelity HSA is a Fidelity brokerage account. You can choose to invest in a full range of Fidelity mutual funds, non-fidelity funds, and individual stocks and bonds. However, most Fidelity mutual funds require a minimum initial investment of $2,500, and $250 on any subsequent investment. Refer to Fidelity.com for additional information on minimum investments. Some investment options are available to you only if the balance in your HSA satisfies these minimums. Any earnings on your Fidelity HSA investments grow tax-free. The value of your account may increase or decrease at any time due to investment earnings or losses. You are only entitled to receive the value of your account as of the date of a distribution. That value will be determined as of the valuation date immediately before the distribution date and may be larger or smaller than the value determined as of any other valuation date. No party guarantees your account against investment losses. Distributions are taken only from your core position. Before requesting a distribution, you may need to transfer sufficient funds from your HSA investment funds into your core position. If the funds in your core position are less than your distribution request, your distribution is not processed. However, if money is available in other investments in your Fidelity HSA, you may move money from your investments into your core position and then resubmit your distribution request. You can use your HSA to pay for eligible medical expenses in three ways: Debit Card. You can use your HSA debit card to pay providers who accept debit card payments and for prescription drug expenses at a pharmacy. Checkbook. If you request an HSA checkbook, you can write a check to pay expenses to a provider or pharmacy, or to yourself to reimburse expenses you ve paid from your pocket. It is not recommended to write a check to a provider at the point of service since you should always wait for the claim to be processed so you know the exact amount you will be required to pay. Pay Out of Pocket and Be Reimbursed. You can pay the expense out of your own pocket and then request reimbursement from your HSA. You can receive the money in an Electronic Fund Transfer (EFT) from your HSA to your personal bank account or in a check mailed to you. Tracking and Reporting Your Distributions from Your HSA. Because taxes are not payable on HSA distributions you use to pay qualified medical expenses, you need to report any HSA distributions on Form 8889 when you file your federal taxes for the year. You must keep records showing how you ve used your HSA distributions, although you do not send records of your qualified medical transactions in with your tax returns. You are responsible for ordinary income taxes on distributions you do not use for qualified medical expenses plus an additional 20% penalty tax. The 20% penalty does not apply to distributions made if you become disabled, once you reach age 65, or after your death. The medical expenses you pay from your HSA cannot be taken as itemized deductions in any year. If a Distribution Is Made by Mistake. If you mistakenly take a distribution from your HSA for an expense that is not qualified, you may repay your account to avoid a penalty. Mistaken distributions include distributions intended for a qualified medical expense and later returned to you as overpayment by a health care provider. There are a few ways to repay your account: You can use the mistaken distribution to pay for another qualified medical expense for which you have not already paid or been reimbursed. If the original distribution was made on your HSA debit card, you can ask your health care provider to process the overpayment as a credit on your card. Finally, you may send a check and deposit slip to Fidelity indicating the amount is a mistaken distribution and request that it be treated as a 60-day rollover. Because it is a rollover contribution, it must be made within 60 days of the date that funds were withdrawn from your Fidelity HSA. Contact the Eaton Service Center at Fidelity for more information. 73

75 Medical Plan Your HSA When Your Employment Ends At the time your employment ends, you will receive a packet from Fidelity outlining how you can continue to contribute and make withdrawals from your HSA. Please note, you cannot make contributions, just withdrawals, to an HSA if you do not remain in a qualified high deductible health plan, and you cannot make HSA contributions after you reach age 65 just withdrawals. After you are no longer an active employee, you will be responsible for maintaining any monthly service fees associated with your account. Naming a Beneficiary Because you own your HSA, you can name a beneficiary for your account in the event of your death. If you are married and designate your spouse as your beneficiary, the account is treated as your spouse s HSA after your death. If you name another person as your beneficiary, the account stops being an HSA and its fair market value is taxed as ordinary income to your beneficiary. If your estate is the beneficiary, the value is included in your final income tax return. The Health Savings Account is a voluntary plan offered under the Company s Flexible Benefits Program and is subject to the terms and conditions of a separate contract between the Company and Fidelity Brokerage Services, LLC. The HSA program described in this booklet is not subject to ERISA, and this booklet is solely a source of information for employees about the HSA. The entire HSA plan is set forth in separate plan documents and not only this SPD. If there is any conflict between this SPD and the plan documents, the plan documents will be determinative. 74

76 Dental Plan DENTAL PLAN DENTAL PLAN OVERVIEW DELTA DENTAL: THE DENTAL PLAN CLAIMS ADMINISTRATOR USING THE DENTAL PLAN The Dental Networks Predetermination of Benefits COVERED SERVICES AND SUPPLIES Preventive Services Diagnostic and Restorative Services Prosthodontic and Major Restorative Services Orthodontic Services EXPENSES NOT COVERED DEFINITIONS AND IMPORTANT TERMS PAYMENT OF DENTAL BENEFITS Claim Forms Proof of Loss Filing Deadline How Payments Are Made... 83

77 Dental Plan DENTAL PLAN OVERVIEW The Dental Plan provides financial assistance for covered dental care services you and your covered dependents may need. This chart summarizes the Plan deductible, coinsurance and maximums that apply to each enrolled individual: Feature Annual Deductible Individual/Family Annual Maximum Plan Benefit $50 / $100 ($100 / $200 if you see a Premier network or non-network provider) $1,500 per individual Lifetime Orthodontic Maximum $1,500 per dependent up to age 19 Service Preventive X-rays 80% Fillings and simple extractions 80% Oral surgery/surgical extractions 50% Dentures/bridgework/crowns/root canals 50% Orthodontics for dependents to age 19 50% Plan Coinsurance 100% (no deductible applies) DELTA DENTAL: THE DENTAL PLAN CLAIMS ADMINISTRATOR Delta Dental is Eaton s claims administrator for dental services. The Plan is self-insured by Eaton. Contacting Delta Dental You can contact Delta Dental: 1. Online through EatonBenefits.com. On the web site you can: Print a temporary ID Card or claim form for filing out-of-network claims Find a participating dentist Check the status of a claim and view your claims history 2. By calling Delta Dental customer service toll free at EATON03 ( ) on Monday through Friday from 8:30 a.m. to 7:50 p.m. Eastern Time. 76

78 Dental Plan USING THE DENTAL PLAN The Dental Networks Delta Dental offers two networks of dental providers, Delta Dental PPO and Delta Dental Premier. A dental network is a group of dental care providers that have been screened for quality and have agreed to provide dental care services at a contracted rate. You pay the same coinsurance (based on the Dental Plan Benefits chart) whether you use providers in the Delta Dental PPO or Delta Dental Premier networks. Network providers have agreed to lower fees and generally accepted processing policies so you should expect to pay less when you use them. You will save the most on out-of-pocket costs when you receive treatment from a PPO member dentist because the PPO dentist has agreed to a set fee schedule that is typically lower than the fees charged by a Premier or non-network dentist. Plus, if you see a Premier or non-network dentist, you pay a higher deductible before the Plan starts to pay benefits (as shown on the Dental Plan Benefits chart). Predetermination of Benefits If a course of treatment can reasonably be expected to involve covered dental expenses of $200 or more, your dentist must file a description of the procedures to be performed and an estimate of charges with the Claims Administrator before the course of treatment begins. The Claims Administrator notifies the dentist and the patient (or the parent of a minor patient) of the benefits the Plan will pay based on each course of treatment. In determining the amount of benefits payable, the Claims Administrator considers alternate procedures, services or courses of treatment that may be performed for the dental condition concerned to accomplish the desired result. The amount included as covered dental expenses is the appropriate amount as determined in accordance with the provisions and limitations of the Plan. If a description of the procedures to be performed and an estimate of the dentist s charges are not submitted in advance, the Claims Administrator reserves the right to determine benefits taking into account alternate procedures, services or courses of treatment based on accepted standards of dental practice. To the extent verification of covered dental expenses cannot reasonably be made by the Claims Administrator, the benefits for the course of treatment may be for a lesser amount than would otherwise have been payable. Predetermined allowances are also subject to the following conditions: The patient must be eligible for benefits when the described services are performed. An expense is incurred when the service is performed, except that it is deemed to be incurred if performed at the following times: - in the case of dentures, when the dentures are delivered; - in the case of fixed bridgework, restorative crowns, inlays and onlays, when the bridgework, restorative crown, inlay or onlay is delivered (cemented); or - in the case of root canal therapy, when the canal is filled or the root canal is completed, regardless of the number of visits to the dentist or whether a separate charge is made for each visit. Total benefit payments for all treatment of a patient in any calendar year may not exceed the Plan maximum. The allowances may be reduced by an entitlement to other insurance or employer sponsored benefits, application of deductibles or a change in the Plan benefits before the service begins. This predetermination requirement does apply to courses of treatment under $200 or to emergency treatment, routine oral examinations, X-rays, prophylaxis and fluoride treatments. 77

79 Dental Plan COVERED SERVICES AND SUPPLIES Preventive Services Covered expenses are the allowable services and supplies that are necessary for treatment of a dental condition, but only for services and supplies provided in accordance with accepted standards of dental practice. Such expenses are only those incurred in connection with the following dental services that are provided by a dentist while the patient is covered by the Plan, except as otherwise provided in Expenses Not Covered. The Plan pays 100% of the maximum approved fee for the following covered dental services subject to the annual maximum benefit: Oral examinations/evaluations and prophylaxis (scaling and cleaning of teeth), up to two times per calendar year. Topical application of fluoride (to age 18). Space maintainers that replace prematurely lost teeth for children under 19 years of age. Emergency palliative treatment. Dental sealants for children ages 4 through 14. Brush biopsy to detect oral cancer. Diagnostic and Restorative Services After you meet your annual deductible, the Plan pays 80% of the maximum approved fee for the following covered dental services, subject to the annual maximum benefit: Dental X-rays, including full mouth X-rays (but not more than once in any 60-month period), supplementary bitewing X-rays (but not more than one time per calendar year), and other dental X-rays that are required in connection with the diagnosis of a specific condition requiring treatment. Simple extractions. Amalgam, silicate, acrylic, and composite filling restorations to restore diseased or accidentally broken teeth. Non-surgical treatment of periodontal and other diseases of the gums and tissues of the mouth. Injection of antibiotic drugs by the attending dentist. Prosthodontic and Major Restorative Services After you meet your annual deductible, the Plan pays 50% of the maximum approved fee for the following covered dental services, subject to the annual maximum benefit: Oral surgery or surgical therapy. For surgery performed at a medical facility, only provider charges are covered; the Dental Plan does not cover charges for the facility. General anesthetics/iv sedation when medically necessary and administered in connection with oral or dental surgery, including anesthesia administered at (but not billed by) a medical facility. Surgical extractions. Surgical treatment of periodontal and other diseases of the gums and tissues of the mouth. Endodontic treatment; that is, root canal therapy. Inlays and onlays to restore diseased or accidentally broken teeth (once per tooth in a five-year period), but only when the tooth, as a result of extensive cavities or fracture, cannot be restored with an amalgam, silicate, acrylic, synthetic porcelain or composite filling restoration. Implants. Initial installation of fixed bridgework (including inlays and crowns as abutments). Initial installation of partial or full removable dentures (including precision attachments and any adjustments during the six-month period following installation). 78

80 Dental Plan Repair or recementing of crowns, inlays, onlays, bridgework or dentures; or relining or rebasing of dentures more than six months after the installation of an initial or replacement denture, but not more than one relining or rebasing in any period of 36 consecutive months. Crown restorations to restore diseased or accidentally broken teeth (once per tooth in a five-year period), but only when the tooth, as a result of extensive cavities or fracture, cannot be restored with an amalgam, silicate, acrylic, porcelain, gold or composite filling restoration. Replacement of an existing partial or full removable denture or fixed bridgework by a new denture, by new bridgework or by the addition of teeth to an existing partial removable denture or to bridgework, but only if satisfactory evidence is presented to the Claims Administrator that: - the replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed; - the existing denture is an immediate temporary denture that cannot be made permanent, and replacement by a permanent denture takes place within 12 consecutive months from the date of initial installation of the immediate temporary denture; or - if the existing denture or bridgework cannot be made serviceable, replacement is a covered expense: when eight years have elapsed if benefits have been provided by the Plan for an initial placement or a replacement; or at any time while coverage is in force if no benefits have been provided by the Plan for an initial placement or a replacement. Normally, dentures are replaced by dentures, but if a professionally adequate result can be achieved only with bridgework, such bridgework is a covered dental expense. Appliances (and adjustments to appliances) prescribed for the treatment of temporomandibular joint (TMJ) disorders. Limitations on partial dentures. If a cast chrome or acrylic partial denture restores the dental arch satisfactorily, the Plan pays benefits based on that appliance. If you and your dentist choose a more elaborate or precision appliance, you can apply the benefit the Plan pays to that appliance. You are responsible for coinsurance and the difference in the cost between the appliances. Limitations on complete dentures. The Plan pays benefits for complete denture services. If, you and your dentist decide on personalized restorations or specialized techniques (as opposed to standard procedures), you can apply the benefit the Plan pays to that procedure. You are responsible for coinsurance and the difference in the cost of the procedures. Limitations on replacement of existing dentures. The Plan pays benefits for replacement of an existing denture only if it is unserviceable and cannot be made serviceable. The benefit the Plan pays is based on the cost of making the appliance serviceable. The Plan pays benefits for the replacement of prosthodontic appliances only if it has been at least eight years since they were initially installed or replaced under the Plan. Limitations on gold, baked porcelain restorations, crowns and jackets. If a tooth can be restored with a material such as amalgam, the benefit the Plan pays for the procedure is based on the use of that material. If you and your dentist choose another more expensive type of restoration, you can apply the benefit the Plan pays to that restoration. You are responsible for coinsurance and the difference in the cost between the restorations. Limitation on reconstruction. The Plan pays benefits for procedures necessary to eliminate oral disease or to replace missing teeth. The plan does not pay benefits for restorations to increase vertical dimension or restore occlusion; these procedures are considered optional and the cost is your responsibility. 79

81 Dental Plan Orthodontic Services After you meet your annual deductible, the Plan pays 50% of the allowed charges for orthodontic treatment for dependents until they reach age 19. Benefits payable for these services are subject to the lifetime maximum orthodontic benefit. Benefits for orthodontic treatment consist of the total allowable fee, the initial allowable banding fee and the number of months of treatment. For example: a total fee of $3,400; an initial banding fee of $1,000; and a treatment time of 24 months. To determine the monthly fee amount the Claims Administrator deducts the allowable initial fee from the allowable total fee and divides the balance by the number of months of treatment: $3,400 total fee - $1,000 initial banding fee = $2,400 divided by 24 months = $100 monthly fee. Benefits are then paid at 50% payable over the course of the treatment. Benefits stop when the lifetime maximum has been reached or when the patient reaches age 19, whichever occurs first. In this example the Plan will reach the lifetime maximum of $1,500 before the treatment time is completed. Example of Orthodontic Benefit Installment Payments This example assumes: Appliance is installed, and estimated length of treatment is 24 months. Total fee is $3,400. Initial banding fee is $1,000. Deductible is already satisfied. Patient has no other dental coverage. The Plan pays according to the following schedule: Initial banding fee Monthly fee x 20 months TOTAL AMOUNT PAID BY PLAN Charge Plan % Plan Benefit Payments end after 20 months when the lifetime maximum of $1,500 is reached. Limitations on orthodontia services. If orthodontic treatment ends for any reason before it is completed, the Plan only pays benefits to the date the treatment ends. If treatment begins again, any remaining benefits will continue to be paid until the lifetime maximum benefit is reached. The Plan pays benefit installments for orthodontic services only for charges you incur while Plan coverage is in effect. 80

82 Dental Plan EXPENSES NOT COVERED Listed below are expenses that are not covered by the Plan and for which no benefits are payable: Services provided by the Eaton Medical Plan. Treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride may be performed by a licensed dental hygienist if the treatment is rendered under the supervision and guidance of the dentist. Services or supplies that are cosmetic in nature, including charges for personalization or characterization of dentures. Prosthetic devices (including bridges and crowns) and the fitting thereof that were ordered while the individual was covered under the Plan, but are finally installed or delivered to the individual more than three consecutive months after coverage ended. Replacement of a lost, missing or stolen prosthetic device. Failure to keep a scheduled dental appointment. Replacement or repair of an orthodontic appliance. Services or supplies that are compensable under a Workers Compensation or employer s liability law. Services rendered through a medical department, clinic or similar facility provided or maintained by the patient s employer. Services or supplies for which no charge is made that the employee is legally obligated to pay, or for which no charge would be made in the absence of dental expense coverage. Services or supplies that are unnecessary, according to accepted standards of dental practice, or that are not recommended or approved by the attending dentist. Services or supplies that do not meet accepted standards of dental practice, including charges for services or supplies that are experimental in nature. Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared. Services or supplies from any governmental agency that are obtained by the patient without cost by compliance with laws or regulations enacted by any federal, state, municipal or other governmental body. Any duplicate prosthetic device or any other duplicate appliance. Any services to the extent for which benefits are payable under any health care program supported, in whole or in part, by funds of the federal government or any state or political subdivision thereof. Completion of any claim forms. Whitening of teeth. Oral hygiene and dietary instruction. Plaque control programs. Veneers. Non-tooth related services. Charges in excess of maximum approved fees. Other exclusions and/or limitations on benefits may be contained in the specific benefit description in this booklet to which they relate. 81

83 Dental Plan DEFINITIONS AND IMPORTANT TERMS Annual Deductible. The amount of covered dental expenses you pay each year before dental benefits are paid by the Plan. Each covered person is subject to the annual deductible every year. However, if you have enrolled for dependent coverage, two or more family members covered expenses in the calendar year can be added together to satisfy the maximum family annual deductible. When two or more covered family individuals, together, meet the family annual deductible, all enrolled family members are eligible for payment of their covered expenses without any further annual deductible being applied until the next calendar year. The annual deductible is waived for preventive services as described in Covered Services and Supplies. Coinsurance. The percentage amount of the covered expenses paid when you incur dental expenses. For example, if you incur charges for an extraction after the annual deductible has been met, the Plan pays 80% of the covered expense and you pay 20% plus any amount in excess of the maximum approved fee. Course of Treatment. A planned program of one or more services or supplies, whether rendered by one or more dentists, for the treatment of a dental condition diagnosed by the attending dentist as a result of an oral examination. The course of treatment begins on the date a dentist first renders a service to correct or treat the diagnosed dental condition. Dentist. A legally licensed dentist practicing within the scope of his or her license. As used herein, the term dentist also includes a legally licensed physician authorized by his or her license to perform the particular dental services rendered. Maximum Approved Fee. Charges, fees and expenses are considered covered expenses under the Plan only to the extent that they are reasonable and customary as determined by the Claims Administrator. The maximum approved fee for a service or supply in the Delta Dental Premier network is the amount the Claims Administrator determines to be the prevailing charge level made for the service in the geographic area where it is furnished. The maximum approved fee in the Delta Dental PPO is based on the PPO Fee Schedule for the service in the geographic area where it is furnished. In determining the maximum approved fee for a service or supply that is unusual; not often provided in the area; or provided by only a small number of providers in the area, the Claims Administrator may take into account factors, such as: The complexity, The degree of skill needed, The type of specialty of the provider, and The prevailing charge in other areas. If you use a provider who is not a part of the Delta Dental networks, you are responsible for charges, fees and expenses that are in excess of the maximum approved fees. These additional amounts do not apply to the annual deductible. Remember, only those charges, fees and expenses for services and supplies that are allowable, and necessary based on accepted standards of dental practice, are considered covered expenses. Maximum Benefit. There are two independent Dental Plan maximums. Each year, a maximum Plan benefit of $1,500 applies to you and each of your covered dependents for all dental benefits other than orthodontia. A lifetime maximum benefit of $1,500 for orthodontia treatment applies to each of your covered dependents up to age 19. The maximum benefits under this Plan include benefits paid under a prior Eaton dental plan, or by any other plan that is the primary source of dental coverage. Ordered. The term ordered means, in the case of dentures, that impressions have been taken from which the denture will be prepared; and, in the case of fixed bridgework, restorative crowns, inlays and onlays, that the teeth that will serve as abutments or support or that are being restored have been fully prepared to receive, and impressions have been taken from which will be prepared the bridgework, crowns, inlays or onlays; in the case of root canal therapy, when work on the tooth has begun. Orthodontic Treatment. Corrective treatment of dental irregularities that result from the anomalous growth and development of dentition and its related anatomic structures, or as a result of accidental injury, and that require repositioning (except for preventive treatment) of teeth to establish normal occlusion. 82

84 Dental Plan PAYMENT OF DENTAL BENEFITS Claim Forms Proof of Loss Filing Deadline If you contribute to the Dental/Vision Reimbursement Account (DVRA) be sure to use those funds first to pay eligible dental expenses. The DVRA has a use-it-or-lose-it rule, and you don t want to lose contributions for which you don t have equivalent expenses during the calendar year. You can also use money from your Health Savings Account (HSA) to pay for eligible dental expenses. See page 68 for more information. Keep in mind, your balance in the HSA rolls over from year to year. Benefits under this Plan are paid only if the Claims Administrator decides that the applicant is entitled to them. You or your dentist must file a claim with the Claims Administrator for benefits to be paid. The claim form must include the following information: Employee Information Name, date of birth, your Social Security number or alternate ID number, and address. Dependent Information Name, date of birth, address (if different from employee) and relationship to employee. Spouse s name, Social Security number, date of birth and employer (if applicable). Spouse s group dental coverage information (if applicable). Dependent children status (employed, student, etc.). Provider Information Dentist s name, address, telephone number, tax ID number and license number. Description and/or procedure code of the service rendered or proposed. Amount of charge for each service rendered or proposed. Date that each service was rendered. The claim form is also used to obtain a Predetermination of Benefits before any treatment begins that is expected to involve covered expenses of $200 or more. The Claims Administrator reserves the right to accept, or to require verification of, any alleged fact or assertion pertaining to any claim for benefits from the Plan. As part of the basis for determining benefits payable, the Claims Administrator may require X-rays and other appropriate diagnostic and evaluative materials. The Claims Administrator must receive all claims for benefit consideration no later than December 31 of the calendar year following the year in which you incurred such charges for dental services or supplies. The Claims Administrator will not consider claims received after the deadline for benefit payment. How Payments Are Made Benefit payment may be made to you or directly to the dentist. If you authorize direct payment of benefits (by so indicating on the claim form), the payment is sent to the dentist. The Claims Administrator s address is: Delta Dental P.O. Box 9085 Farmington Hills, MI The Claims Administrator sends you an Explanation of Benefits (EOB) after processing your claim. The EOB states how your benefit payment was calculated, where the payment was sent or whether your claim was denied. 83

85 Vision Plan VISION PLAN VISION PLAN OVERVIEW THE VISION PLAN NETWORK EYEMED VISION CARE THE VISION CARE PLAN ADMINISTRATOR COVERED SERVICES AND SUPPLIES Eye Examinations Eyewear Disease Detection Additional Programs and Discounts EXPENSES NOT COVERED DEFINITIONS AND IMPORTANT TERMS PAYMENT OF VISION BENEFITS Filing Claims in the EyeMed Network Filing Claims for Out-of-Network Services Resolving Problems... 92

86 Vision Plan VISION PLAN OVERVIEW The Vision Plan provides financial assistance for covered vision services and eyewear for you and your covered dependents. The Plan pays the benefits shown in the following chart once per year per covered person. Benefits under this Plan may not be used in conjunction with any other promotions or discounts. Vision Service/Supply In-Network Out-of-Network* Eyeglass examination: Includes contact lens examination, if desired Plan pays 100% after you pay $10 copay Plan pays up to $30 Contact Lenses Fit and Follow-up: Includes fit and two follow-up visits after comprehensive exam Standard Plan pays 100% for two follow-up visits Premium Plan pays $55, and you pay the balance over $55 Eyeglasses Frames Plan pays 100% up to $125, then you pay 80% of the balance over $125 Plan pays up to $25 Plan pays up to $35 Lenses (uncoated plastic) Plan pays up to: * Single vision $25 Bifocal Plan pays 100% after you pay $10 copay $40 Trifocal $55 Progressive Lenses Standard Plan pays 100% after you pay $75 copay Premium Other Lens Options You pay $75 copay and 80% of the charge less $120 Plan pays up to $40 Plan pays up to $40 Standard plastic scratch-resistance Plan pays 100% Plan pays up to $5 Standard UV coating Plan pays 100% after you pay $15 copay Standard tint (solid and gradient) Plan pays 100% after you pay $15 copay Standard polycarbonate Plan pays 100% after you pay $40 copay Standard anti-reflective coating Plan pays 100% after you pay $45 copay You pay 100% You pay 100% You pay 100% You pay 100% Other add-ons and services 20% off retail price You pay 100% Contact Lenses Conventional lenses (in lieu of eyeglasses) Disposable lenses (in lieu of eyeglasses) Medically necessary lenses Plan pays up to $105, then you pay 85% of the balance over $105 Plan pays up to $105, then you pay 100% of the balance over $105 You pay $10 copay, then Plan pays 100% Plan pays up to $90 Plan pays up to $90 Plan pays up to $200 * The out-of-network lens benefit is for two lenses. If only one lens is needed, the benefit will be one-half of the amount shown. 85

87 Vision Plan THE VISION PLAN NETWORK You may visit the eye care provider of your choice, but the Plan pays higher benefits when you use an EyeMed network provider. The EyeMed Vision Care Network is made up of: Optical retailers such as: - Sears Optical - Target Optical - LensCrafters - Most Pearle Vision locations Some private practice optometrists, ophthalmologists and opticians. Under their contract with EyeMed, some ophthalmologists provide eyeglass examinations only; they do not dispense eyewear. The Plan pays lower benefits if you use a provider who is not part of the EyeMed Vision Care Network. Eaton expressly disclaims any warranty of the quality of care that may be rendered by any vision care provider. The final decision about the vision care you receive and where you receive it is always between you and your vision care provider, whether or not the care is determined to be covered under the Vision Plan or an Eaton Medical Plan. EYEMED VISION CARE THE VISION CARE PLAN ADMINISTRATOR The Plan is insured by the Combined Insurance Company of America. EyeMed Vision Care operates the provider network and administers claims. Contacting EyeMed You can contact EyeMed: 1. Online through EatonBenefits.com or On the web site you can: Print a claim form, Explanation of Benefits or temporary ID Card Request an Explanation of Benefits or a permanent ID card be mailed to you Find a participating doctor or specialist Check the status of a claim and view your claims history 2. By calling EyeMed customer service toll free at on Monday through Saturday from 8 a.m. to 11 p.m. Eastern Time; and Sundays from 11 a.m. to 8 p.m. Eastern Time. You can: Ask questions regarding submitted claims for out-of-network services, Obtain assistance in identifying EyeMed participating providers in your area, Obtain information about the benefits available under the Vision Plan, Request claim forms for filing out-of-network claims, Report network-related service problems, and Ask other questions you may have about the EyeMed network. 86

88 Vision Plan COVERED SERVICES AND SUPPLIES Eye Examinations The Eaton Medical Plan and the Vision Plan both cover annual eyeglass examinations, and if you enroll in both plans, you can choose which Plan to cover an exam. The Vision Plan provides a benefit toward the cost of contact lens exams and eyewear, while the Medical Plan generally does not pay any benefit for these expenses. Eyeglass Examination. The Plan covers one eye examination, including dilation, each calendar year. In network, you pay a $10 copayment. The Plan pays up to $30 if you use an out-of-network provider, and you pay the rest of the charge. Contact Lens Examination. When you use an in-network provider, a contact lens examination is covered as part of the in-network eyeglass examination. See the Vision Expense Benefits chart for the contact lens fit and follow-up benefits available for both in-network and out-of-network. Eyewear Lenses. The Plan covers scratch-resistant plastic eyeglass lenses prescribed for vision correction once each calendar year. You pay a $10 copayment for eyeglass lenses if purchased from an EyeMed participating provider. You also pay a copayment for various lens options if purchased from an EyeMed participating provider. See the Vision Expense Benefits chart for more information on covered lens options as well as the out-of-network benefit available under the Plan for eyeglass lenses. Frames. The Plan covers eyeglass frames up to a retail value of $125 on an in-network basis (or up to $35 on an out-of-network basis) once each calendar year. You receive a 20% discount on the balance over $125. Contact Lenses. The Plan covers contact lenses up to the Plan s calendar year benefit for contact lenses. Benefits for contact lenses are in lieu of lenses covered under the Plan in the same calendar year. If the contact lenses are medically necessary, you pay a $10 copayment at EyeMed participating providers. Disease Detection During an eye examination, an optometrist or ophthalmologist may detect eye disease. An eye exam may also uncover abnormalities in the eye that are symptomatic of medical conditions such as diabetes or hypertension. Check your medical plan to see your coverage for additional physician visits, surgery for treatment of eye disease as well as diagnosis and treatment of other medical conditions. Additional Programs and Discounts Lens Options. Eyeglass lens options the Plan does not cover are available at a discount at EyeMed network providers. Additional eyewear. You can buy additional pairs of eyeglasses and contact lenses at a discount at EyeMed network providers after using your annual Vision Plan benefit. U.S. Laser Network. You can get laser vision correction surgery at a discount through EyeMed s U.S. Laser Network. Call LASER6 for information about discounts and participating network providers. Contact Lens By Mail. To ensure proper fit and follow-up care, you must buy your first pair of contact lenses from your eye care provider. After your first pair, you can buy replacement contact lenses through EyeMed s Contact Lens by Mail Program. This allows you to take advantage of competitive pricing and have the lenses mailed directly to your home. Your core benefit allowance or discount does not apply. To use the Contact Lens By Mail Program, go to You can also access details and the ordering site through the who to contact link on Fidelity NetBenefits Health & Insurance tab. 87

89 Vision Plan EXPENSES NOT COVERED Listed below are expenses that are not covered by the Plan and for which no benefits are payable: Orthoptic or vision training and any associated supplemental testing. Plano lenses. Charges above the allowance for eyeglass lens coatings. Two pair of glasses, in lieu of bifocals or trifocals. Medical or surgical treatment of the eyes, including laser vision correction. Any eyeglass examination, or any corrective eyewear, required by an employer as a condition of employment. Charges for services or supplies that are compensable under a Workers Compensation or employer s liability law. Charges above the allowance for no-line bifocal or progressive lenses. The additional charge for photochromic lenses. Sub-normal vision aids or non-prescription lenses. Charges incurred after: - the Plan ends, or - the patient s coverage under the Plan has ended. Experimental or non-conventional treatment or devices or any service or supply not listed in the section entitled Covered Services and Supplies. The additional charge for high index lenses of any material type. Charges for services or supplies for which no charge is made that the patient is legally obligated to pay, or for which no charge would be made in the absence of vision expense coverage. Charges for failure to keep a scheduled eye examination appointment. Eyeglass/routine vision examinations for which benefits are provided to the covered person under the Eaton Medical Plan. Other exclusions and/or limitations on benefits may be contained in the benefit description in this booklet or the group policy. 88

90 Vision Plan DEFINITIONS AND IMPORTANT TERMS Contact Lens Examination. Examination requirements for patients who wish to wear contact lenses include all of the standard eyeglass examination procedures as well as the following: Keratometry, Diagnostic lens testing (when applicable), Additional external examination (biomicroscopy) with and without contact lenses, and Series of follow-up visits to ensure compliance with maintenance and wearing schedules. Contact Lenses. Corrective eyewear worn directly on the eye. The most common types of contact lenses are: Daily wear contact lenses can be soft or rigid contact lenses made of different types of plastic, depending on the specific type of lens. Daily wear lenses are to be worn for periods of less than 24 hours at a time, and should be removed each night before the wearer goes to sleep. Lenses generally need to be replaced annually or biannually. Extended wear contact lenses are usually soft contact lenses, but are designed to be worn for 24 hours or more at a time. Some lenses are FDA-approved for up to 30 days of continuous wear, but most doctors recommend removing and cleaning the lenses at least weekly. Extended wear lenses have replacement schedules that vary significantly by the specific type of lens and length of continuous wear. Disposable contact lenses are soft contact lenses, either daily wear or extended wear, that are replaced on a seven- to 30-day cycle. Wearers generally purchase a supply of disposable lenses that will last six months to one year. Hard contact lenses are made from a rigid plastic resin, polymethylmethacrylate (PMMA). The lenses are more durable and easier to handle than soft contact lenses, but many people may find them uncomfortable. PMMA does not absorb water and does not allow for the transmission of oxygen through the lens to the eye. Hard contact lenses should be removed daily. Rigid gas permeable (RGP) contact lenses are made of a non-absorbent material that is oxygen permeable. RGP lenses are durable and easy to handle like hard contact lenses, but more comfortable to wear, though usually not as comfortable as soft contact lenses. Most RGP lenses are used for daily wear, but some lenses can be worn for extended periods of time. Toric lenses are either hard or soft contact lenses used to treat astigmatism, which cannot be corrected with traditional spherical contact lenses. Many soft and disposable contact lenses have a visibility tint, usually bluish, that makes them easier to see. This visibility tint makes the lenses easier to handle and easier to find if the wearer drops them. There is generally no additional charge for lenses with a visibility tint. Contact lenses can also be tinted to change or enhance the color of the wearer s eye. The lenses are generally made with a clear center so that the wearer s perception of color is not affected. Because these lenses are more complicated to manufacture, they are generally more expensive than contact lenses with a visibility tint. Copayment. The covered person s portion of the charge for an in-network eye examination, eyeglass lenses and medically necessary contact lenses. 89

91 Vision Plan Dilation. Dilation is the enlargement of the pupil diameter, which allows the ophthalmologist or optometrist to observe the internal eye more completely. It is not always part of a provider s standard examination procedure, but providers may perform dilation if any of the following conditions exist: Diabetes Myopia (nearsightedness) over six diopters Hypertension (high blood pressure) Retinal disease Sudden changes in vision Flashes or floaters Family or personal health history that predicts future ocular complications State law requiring dilation Eyeglass Examination. The standard examination includes at least the following: Case history, reason for examination, patient medical and eye history, current medications, etc. Recording of monocular (one eye) and binocular (both eyes) visual acuities at far and near, with and without present correction Pupil responses (neurological integrity) External examination findings (biomicroscopy) Internal examination findings (ophthalmoscopy) Present prescription (when applicable) Retinoscopy (when applicable) Subjective refraction Phorometry/binocular testing at far and near Tonometry Diagnosis/prognosis Specific recommendations Eyeglass Lenses. The most common types of eyeglass lenses are: Single vision lenses are uncoated, plastic lenses with a single prescription that corrects myopia, hyperopia or astigmatism. Standard bifocal lenses are uncoated, plastic lenses that correct both for distance and near vision in persons with presbyopia. The top of the lens corrects for distance vision. In the lower part of the lens there is a visible semicircle ground into the lens that corrects for near vision. Trifocal lenses are uncoated, plastic lenses that correct for vision at three distances. The top of the lens corrects for distance vision. In the lower part of the lens there is a visible semicircle ground into the lens that corrects for near vision. Just above this semicircle is an additional lens segment that corrects for distances of about an arm s length away. Lenticular lenses are designed to treat eye conditions that are more serious than myopia, hyperopia, presbyopia or astigmatism. They are often prescribed after cataract surgery for patients without intraocular implants. 90

92 Vision Plan Progressive lenses, also called no-line bifocals, are bifocal or trifocal lenses that have an invisible corridor of increasing power that leads from the distance portion of the lens down to the reading portion. Polycarbonate lenses are made of a material similar to standard plastic, but are lighter in weight and thinner than uncoated plastic lenses. They offer protection from surface abrasions like scratchresistant coated plastic lenses, and they do not shatter like glass or standard plastic lenses. Photochromic lenses are light-sensitive glass lenses. The glass contains silver halide crystals that darken when exposed to ultraviolet (UV) light and become clear when removed from the light. In their darkened state, photochromic lenses offer protection from UV rays. Transition lenses are light-sensitive plastic lenses, which makes them lighter in weight than photochromic glass lenses. They become darker when exposed to ultraviolet light and lighten when removed from the light. Transition lenses resist UV radiation both when light and dark, and the lenses are scratch-resistant. The additional expense for transition lenses is not covered by the Plan. Scratch-resistant coated lenses offer protection from most surface abrasions. The coating is included as a part of polycarbonate lenses, but available as an option that is applied to the surface of standard plastic lenses after the lenses are ground. Glass lenses are generally heavier than plastic lenses and resist scratching better than uncoated plastic lenses. The additional expense for glass lenses is not covered by the Plan. EyeMed Participating Provider. A vision care provider who has contracted to accept, as full payment, copayments from persons covered under the Plan for covered eye examinations, eyeglass lenses and medically necessary contact lenses. EyeMed participating providers also agree not to charge covered persons for eyeglass frames and elective contact lenses ordered by covered persons up to the amount of the covered person s unused benefits available under the Plan. Eyewear. Eyeglass lenses, eyeglass frames and contact lenses. In-Network. Plan coverage available when a covered person accesses an EyeMed participating provider for covered vision services. Medically Necessary Contact Lenses. Following certain surgeries, soft contact lenses are sometimes prescribed to act as a replacement for the front covering of the eye that has been removed or disturbed. Because these contact lens prescriptions are medically necessary they are covered differently than elective contact lenses under the Plan. Medically necessary contact lenses can also be prescribed for the treatment of certain eye diseases, including keratoconus. Ophthalmologist. A medical doctor (MD) or osteopath (DO) who specializes in the treatment of the eye and visual system. In addition to providing routine eye care, ophthalmologists can diagnose and treat eye disease using medical or surgical techniques. Optician. There are several types of opticians: A dispensing optician helps the patient with the selection of frames and also measures, adjusts and fits eyewear using prescriptions supplied by an optometrist or ophthalmologist. A laboratory optician can manufacture eyewear using prescriptions supplied by an optometrist or ophthalmologist. An optometric technician performs the same duties as a dispensing optician, but has also had two years of formal training or has passed the National Optometric Registration Exam for technicians. Optometrist. An eyecare professional who has completed four years of optometry school after graduating from college. Optometrists specialize in examination, diagnosis and treatment of conditions of the visual system, including prescribing and fitting eyeglasses and contact lenses. Optometrists are not authorized to use surgical techniques to treat eye disease. Out-of-Network. Plan coverage available when a covered person obtains covered eyeglasses or contact lenses from a non-participating vision care provider. 91

93 Vision Plan Prescription. Written by an ophthalmologist or optometrist following an eyeglass examination when one of the following conditions is detected: Myopia ( nearsightedness ) is a condition in which light refracted into the eye focuses at a point in front of the retina. Myopic individuals can see objects clearly at near and have trouble seeing at far. Myopia is correctable with eyeglasses or contact lenses. Myopic correcting lenses are concave, or thinner in the center than on the edge. Hyperopia ( farsightedness ) is a condition in which light refracted into the eye focuses at a point behind the retina. Hyperopic individuals can see objects clearly at far and have trouble seeing at near. Hyperopia is correctable with eyeglasses or contact lenses. Hyperopic correcting lenses are convex, or thicker in the center than on the edge. Presbyopia is the loss of focus ability due to the natural aging process. It is correctable with bifocal or trifocal lenses that reduce the need for the eye to focus when changing from far to near vision. Astigmatism is a condition in which an asymmetric cornea results in different visual irregularities in different parts of the eye. It is correctable with eyeglass lenses that are ground to a different thickness and curvature. Toric soft contact lenses or rigid contact lenses can also correct some cases of astigmatism. Vision Care Provider. A licensed ophthalmologist, optometrist or optician. PAYMENT OF VISION BENEFITS If you contribute to the Dental/Vision Reimbursement Account (DVRA) be sure to use those funds first to pay eligible vision expenses. The DVRA has a use-it-or-lose-it rule, and you don t want to lose contributions for which you don t have equivalent expenses during the calendar year. You can also use money from your Health Savings Account (HSA) to pay for eligible vision expenses. See page 68 for more information. Keep in mind, your balance in the HSA rolls over from year to year. Filing Claims in the EyeMed Network When you receive services or supplies from an EyeMed participating provider, present your Vision Plan ID card at the time of service. The EyeMed provider will file any claims for you. You pay only your copayments and any non-covered expenses at the time of your visit. Filing Claims for Out-of-Network Services You must submit a claim form to EyeMed Vision Care when you or a covered family member purchases eyewear or other services from a non-eyemed participating provider. Vision claim forms are available in the Reference Library on the Health & Insurance tab of Fidelity NetBenefits. You can also get vision claim forms by calling EyeMed s Customer Service Department at Mail out-of-network claims to: EyeMed Vision Care Attn: OON Claims P.O. Box 8504 Mason, OH A claim for out-of-network benefits will only be considered if EyeMed receives it by December 31 of the calendar year following the year in which the charge was incurred. EyeMed will send you an Explanation of Benefits (EOB) after processing your claim. Resolving Problems Out-of-network benefit payments are made payable to you and cannot be assigned to the service provider. Other than a claims appeal, if you have a concern or problem relating to your coverage or a participating provider, please notify an EyeMed Customer Service Representative at With the involvement of the appropriate department at EyeMed, many types of issues can be resolved in a timely manner. If your claim is not resolved to your satisfaction, you may file a Claims Appeal. See Claims Appeal Procedure for a statement of the claims appeal procedures. 92

94 Reimbursement Account Plans REIMBURSEMENT ACCOUNT PLANS REIMBURSEMENT ACCOUNT PLANS OVERVIEW ACCLARIS: THE REIMBURSEMENT ACCOUNT CLAIMS ADMINISTRATOR REIMBURSEMENT ACCOUNT DEPOSIT AMOUNTS Dependent Care Contribution Limits if You Are Married If You Miss Payroll Deductions During the Year REIMBURSEMENT ACCOUNT RULES EXPENSES YOU CAN PAY WITH REIMBURSEMENT ACCOUNT FUNDS Whose Eligible Health Care Expenses Can Be Paid Through the DVRA Whose Eligible Dependent Care Expenses Can Be Paid Through the DCRA USING THE DENTAL/VISION REIMBURSEMENT ACCOUNT Examples of Eligible Expenses in DVRA USING THE DEPENDENT CARE REIMBURSEMENT ACCOUNT Dependent Care Reimbursement Account or Tax Credit Eligible Expenses in the Dependent Care Reimbursement Account Examples of Eligible Expenses in the DCRA Expenses That Are Not Eligible for Reimbursement THREE WAYS TO PAY Using the Acclaris Visa Debit Card Filing Claims for Reimbursement Supporting Documents for Claims Reimbursement Payments Recovery of Fraudulent Payments Reimbursement Account Statements SUBMITTING CLAIMS AFTER PARTICIPATION ENDS PURCHASED VACATION PROGRAM Who Is Eligible for Coverage Effective Date of Coverage Purchasing Vacation Days Using Purchased Vacation Days

95 Reimbursement Account Plans REIMBURSEMENT ACCOUNT PLANS OVERVIEW The Reimbursement Account Plans help reduce your taxable income by allowing you to set aside before-tax dollars through payroll deduction to pay eligible dental and vision and dependent care expenses. You choose the reimbursement account contributions, if any, that you want each year. Then dollars are deducted from your pay before any federal, Social Security and, in most cases, state taxes are taken out. In addition, you can direct any credits you may receive under the Flexible Benefits Program into one or both of the reimbursement accounts. This chart outlines how the Dental/Vision and Dependent Care Flexible Spending Accounts work. Reimbursement Accounts What you do How it works Eligible expenses (what you can pay with account funds) Whose expenses are eligible How much you can deposit Dental/Vision You deposit before-tax dollars to pay for eligible dental and vision expenses for you and your family members during the year. You access the funds in your account using your Acclaris debit card when appropriate, or you submit claims. You are reimbursed up to the full amount of your annual deposit amount whether or not you have made those deposits to your account yet. Dental and vision expenses that your dental and vision plans do not cover such as eyeglasses, vision correction surgery and orthodontia. Expenses for you and any of your eligible dependents. Coverage under an Eaton dental or vision plan is not required. From $120 to $2,600 a year. The deposit amount you elect remains in effect for future years unless you change it: During annual enrollment, or As a result of a qualified change in status event. Dependent Care You deposit before-tax dollars to pay for eligible dependent care expenses that enable you and/or your spouse to work or look for work during the year. You submit claims and are reimbursed from your account, up to your current account balance. Many child care expenses not claimed for a federal dependent tax credit on your federal tax return such as day care center charges for dependent children or care of an elderly dependent, nursery school expenses, or Social Security and unemployment taxes paid on behalf of a care provider. Expenses for: Children under age 13, Handicapped children of any age, or A spouse or elderly parent incapable of self care. From $120 to $5,000 a year, depending on your tax filing status. The deposit amount you elect remains in effect for future years unless you change it: During annual enrollment, or As a result of a qualified change in status event. Find information on purchasing extra vacation days through the Purchased Vacation Program on page

96 Reimbursement Account Plans ACCLARIS: THE REIMBURSEMENT ACCOUNT CLAIMS ADMINISTRATOR Acclaris, Inc. is Eaton s claims administrator for reimbursement accounts. Contacting Acclaris You can contact Acclaris: 1. Online through EatonBenefits.com. You will need to enter your user name and password to check your account. If you have not yet registered, follow the instructions on the screen. On the web site you can: Submit claims for reimbursement Print a claim form to mail in or fax reimbursement requests Find information about eligible expenses Check your account balances and view your claims history 2. By calling Acclaris customer service toll free at ; non toll free at ; or TTY at ; Monday through Friday (excluding holidays recognized by the New York Stock Exchange) from 8:00 a.m. to 8:00 p.m. Eastern Time. REIMBURSEMENT ACCOUNT DEPOSIT AMOUNTS Federal law sets the minimum and maximum you can deposit in reimbursement accounts each year. Before-tax amounts are deducted from each of your paychecks during the year on a prorated basis. The minimum and maximum annual deposits are: Account Dental/Vision Reimbursement Account (DVRA) Dependent Care Reimbursement Account (DCRA) Minimum Annual Deposit* $120 $2,600 $120 $5,000** Maximum Annual Deposit* * The actual amount deducted from your paycheck depends on the frequency of your paychecks. ** During any given period, your before-tax deposits cannot be more than your total available compensation. In the DVRA, the total annual amount you choose to deposit is available starting the first day you participate in the Plan. You can use the total to pay for eligible expenses, regardless of whether your deposits to date are enough to cover them. In the DCRA, expenses up to the current balance in your account when your claim is received can be reimbursed. 95

97 Reimbursement Account Plans Dependent Care Contribution Limits if You Are Married If you are married, different limits may apply to your Dependent Care Reimbursement Account contributions. If this is your situation You or your spouse earns less than $5,000 a year Your spouse also participates in a DCRA Then your maximum annual DCRA contribution is The amount the lower-paid spouse earns $5,000 combined for both DCRAs You file separate federal income tax returns $5,000 If you and your spouse both work for Eaton, $2,496 Your spouse is a full-time student for at least five months of the year or incapable of caring for himself or herself No more than your earnings or your spouse s earnings, whichever is less, up to $4,992 Your spouse is deemed to have earnings of $250 per month ($416 if there are two or more dependents) for each month such status or condition continues If You Miss Payroll Deductions During the Year If you do not receive a paycheck(s) for any reason during the year, the annual amount you elected to deposit in a reimbursement account does not change. Instead, if you return to work in the same calendar year, the amount deducted from that year s remaining paychecks is increased so you meet your annual deposit amount. The increased deduction shows up in your paycheck as soon as possible after you return to work. While you are on an unpaid leave of absence, you may be billed for your contributions to a DVRA. Contributions you pay through the monthly billing process help offset the amount needed to meet your annual deposit amount when you return to work. See Continuing Reimbursement Account Participation While Not Actively At Work for more information about the billing process. Example You elect to contribute $1,200 for the year to your DVRA. That works out to a monthly contribution of $100. Contributions are deducted from your paycheck during the six-month period from January to June, for a total of $600 in your account. Then, in July you take a three-month unpaid leave of absence. When you return to work in October, your monthly contributions are increased so you will meet the $1,200 annual election. You have $600 left to contribute ($1,200 annual election - $600 contributed during the six months before your leave started = $600 contribution remaining) over the three-month period from October through December. Your contribution for those three months is $200 per month. ($600 contribution 3 months = $200 per month contribution). 96

98 Reimbursement Account Plans REIMBURSEMENT ACCOUNT RULES You fund a reimbursement account by making before-tax deposits from your paycheck. Based on your best estimate of next year s spending, you choose a deposit amount during the annual enrollment period. You access the funds to pay eligible expenses using your Acclaris debit card or by submitting claims to Acclaris. Because of the tax advantages reimbursement accounts offer, the Internal Revenue Service (IRS) has a number of rules that apply. Review the following list carefully because these rules can guide your decision on how much to deposit. The Use-It-or-Lose-It Rule. You forfeit any unused money remaining in your account after all claims have been processed for the Plan year. You cannot roll reimbursement account funds over from one year to the next. Any amount you forfeit goes to reduce costs related to the administration of the Plan. Expenses Must Be from the Current Year. You can only use your account for eligible dental or vision or dependent care expenses you incur during the year you are enrolled. You incur an expense on the date you receive a service, not when you are billed or pay for it. Expenses you incur before or after you are enrolled in the Plan, or for services you plan to receive in the future, are not eligible. Even if you pay for a service in advance, you can only file a claim for reimbursement after the services begins. You can submit claims for reimbursement until March 31 for expenses you incurred during the previous calendar year. If your participation in the Plan ends for any reason, you still have until March 31 of the next year to submit reimbursable expenses you incurred while you participated in the Plan. Each Account Is Separate. Dental/Vision and Dependent Care Reimbursement Accounts are separately elected and maintained. You cannot transfer money between accounts. As well, dental and vision expenses cannot be reimbursed from your dependent care account or vice versa. Keep a Record. If your taxes are audited, you are responsible to provide documents (for example, detailed receipts) that verify the nature, amount and date of your expenses. You should keep this information with your other tax records for the year. For the Dependent Care Reimbursement Account, you have to report the Social Security or tax ID number of your care provider when you file your federal income tax return. No Double Dipping. You can only use the funds in a reimbursement account to pay eligible expenses for which you have not and will not seek reimbursement from any other plan or source. You cannot take a deduction or a tax credit on your or your spouse s federal income tax return for any expense you pay for through your reimbursement accounts. Get Good Advice. Consult a tax advisor if you have any questions regarding your reimbursement accounts. 97

99 Reimbursement Account Plans EXPENSES YOU CAN PAY WITH REIMBURSEMENT ACCOUNT FUNDS In most cases, expenses you can pay or be reimbursed for from the Plan are expenses that would be eligible as deductions for federal income tax purposes. The IRS has published guidelines explaining what dental and vision or dependent care expenses are eligible for federal income tax deductions. You can request these guidelines from the IRS or find them online: Publication 502, Medical and Dental Expenses: Publication 503, Child and Dependent Care Expenses: Dental/Vision expenses that are eligible for reimbursement (assuming they satisfy all other requirements) must meet all of the following: They generally must be expenses that the IRS would allow you to deduct as health care expenses for income tax purposes. They must be expenses you do not claim on your or your spouse s tax return. They must be expenses for which you are not reimbursed under another plan covering you, your spouse or another dependent. If you have questions regarding the eligibility of a particular expense, you can contact the Claims Administrator or the IRS for assistance. Whose Eligible Health Care Expenses Can Be Paid Through the DVRA You can use your DVRA to pay eligible dental and vision expenses for: Yourself, and Other individuals who are your dependents for federal tax purposes, whether or not they meet the definition of an eligible dependent under the Eaton dental or vision plans. You can also use your DVRA to pay eligible dental and vision expenses incurred before the end of the calendar year in which a child reaches age 26 even if the child is not your federal tax dependent. Eligible expenses are those of: Your or your spouse s natural or adopted child, or A child for whom you (the employee) have legal guardianship or a similar arrangement giving you authority (and the corresponding duty) to care for the person and property of the child under applicable law. Only one person can claim the expenses of a qualifying child. If two people want to claim the same child s expenses, these rules apply: If one person is the child s parent and the other is not, the parent can claim the expenses. If both people are the child s parents, the parent with whom the child lives longest in the year can claim the expenses. If both people are the child s parents and the child lives equally with both during the year, the parent with the higher income can claim the expenses. If both people are not the child s parents, the person with the higher income can claim the expenses. You do not have to enroll in the Eaton s dental and vision plans to participate in the DVRA. 98

100 Reimbursement Account Plans Whose Eligible Dependent Care Expenses Can Be Paid Through the DCRA You can use a DCRA to pay the cost of eligible dependent care expenses provided to qualifying individuals so you can work. Generally, a qualifying individual is: Your child under age 13 who lives with you more than half the year and is considered your dependent for federal income tax purposes, Your parent or other dependent for federal income tax purposes who is mentally or physically incapable of caring for himself or herself and who lives with you more than half the year (the entire year if not related to you), or Your spouse, if he or she is mentally or physically incapable of caring for himself or herself and lives with you more than half the year. If you are divorced and have custody of your child, that child s dependent care expenses may be eligible for reimbursement even if you do not claim the child as a dependent on your income tax return. Check with your personal tax advisor. USING THE DENTAL/VISION REIMBURSEMENT ACCOUNT The Dental/Vision Reimbursement Account (DVRA) allows you to pay out-of-pocket dental and vision expenses with before-tax dollars. The chart below outlines charges you can pay with DVRA funds. You use payroll deductions to set aside funds in your DVRA. You can then choose to pay the out-ofpocket dental and vision charges you are responsible for with your Acclaris Visa debit card or by filing a Reimbursement Form. Another option is to file a claim online and pay your provider directly from your account. See the section Three Ways to Pay for more information. Examples of Eligible Expenses in DVRA Eligible Expenses Insurance Related Deductibles, coinsurance and copayments for dental and vision plans Amounts over maximum allowed amounts in dental and vision plans Charges for medically necessary services that exceed dental and vision plan annual maximums Dental Dental care Artificial teeth/dentures Braces, orthodontic services Vision Optometrist or ophthalmologist fees Eyeglasses Contact lenses and cleaning solutions Corrective eye surgery including radial keratotomy Ineligible Expenses All premiums/contributions for insurance coverage, including health, long-term care, loss of income and loss of life insurance Expenses paid by your dental or vision plan Expenses reimbursed through a reimbursement plan offered by your spouse s employer Teeth bleaching Tooth bonding that is not medically necessary Lens replacement insurance Warranties and protection plans 99

101 Reimbursement Account Plans USING THE DEPENDENT CARE REIMBURSEMENT ACCOUNT A Dependent Care Reimbursement (DCRA) reduces your taxable income because you can use the before-tax dollars in your account to pay expenses for the care of a dependent if that care is necessary for you to work. If you are married, you and your spouse must both work, or your spouse must be disabled or a full-time student, for you to be eligible for expense reimbursement. You pay dependent care expenses up front, and then file a Reimbursement Form to be reimbursed from your account. Only the actual balance in your Dependent Care Reimbursement Account at the time your claim is received will be available for reimbursement. Dependent Care Reimbursement Account or Tax Credit You can either be reimbursed for eligible expenses through your DCRA or, if you qualify, by taking a dependent care tax credit for the eligible dependent care expenses on your federal income tax return. However, you cannot be reimbursed through your reimbursement account and also take a dependent care tax credit for the same expenses. The approach that produces the greater tax savings for you depends on your personal situation, including your income and number of children. Any expenses you are reimbursed for through your DCRA reduce dollar-for-dollar the qualified expenses you can consider when computing the dependent care tax credit. This rule greatly reduces the possibility of being able to use both the DCRA and the dependent care tax credit. Remember, you cannot claim an expense through your DCRA and take a credit for the same expense on your or your spouse s federal income tax return. You will have to complete Form 2441 (or its equivalent) and provide on your federal income tax return the taxpayer identification numbers of any dependent care service providers you pay. (If the provider is a church or other tax-exempt organization, you need only show the name and address.) In addition, this form must be used to compute the proper exclusion from your income and/or any dependent care tax credit. Specific questions regarding the tax advantages of participating in the DCRA should be directed to your personal tax advisor. Eligible Expenses in the Dependent Care Reimbursement Account Expenses that are eligible for reimbursement from your DCRA (assuming they satisfy all other requirements) include: An individual caring for your child(ren) under age 13 while you and your spouse work or your non-working spouse attends school full-time or is incapable of self-care; Day care for a dependent, regardless of age, who is mentally or physically unable to care for himself or herself; who depends on you for more than one-half of his or her financial support; and who, if related to you, lives with you more than one-half the year (if not related, lives with you for the full year); A day care center; if the center provides care for more than six individuals and is paid for these services, it must meet all applicable state and local laws; A nursery school for your child(ren) including lunches and education if not itemized; and Summer day camp programs (other than educational or scholastic programs). 100

102 Reimbursement Account Plans Examples of Eligible Expenses in the DCRA Eligible Expenses Child Care After school programs Before school programs Babysitting (in your or someone else s home) Child care Nursery school Preschool Sick child care Summer day camp Elder Care Adult day care Elder care (in or outside your home) Senior day care Ineligible Expenses Dance lessons Language classes Sleep-away camp Educational services (other than preschool) Piano lessons Kindergarten Private school tuition (for kindergarten and up) Tutoring Day care nursing Medical care Nursing home care Expenses That Are Not Eligible for Reimbursement You cannot be reimbursed from the DCRA for: Amounts paid to your spouse, your child under age 19, or to an individual you claim as a dependent on your federal income tax return; Amounts paid through a DCRA offered by your spouse s employer; and Amounts paid for care that is not necessary for you to work. THREE WAYS TO PAY You have three ways to use the money in your reimbursement account to pay eligible expenses. You can: Use your Acclaris Visa debit card for dental or vision expenses. Pay dental/vision or dependent care expenses and then file a claim for reimbursement. Pay your provider directly from your reimbursement account using the online claim feature. Only expenses incurred while you are a Plan participant can be reimbursed. In addition, claims must be incurred in the same calendar year that you made deposits and submitted for reimbursement by March 31 of the following year. Claims received by the Claims Administrator after this date will not be considered for reimbursement. 101

103 Reimbursement Account Plans Using the Acclaris Visa Debit Card An Acclaris Visa debit card is mailed to you when you elect to contribute to the DVRA. When you use the debit card upfront, you do not have to pay expenses out of your own pocket, file claims or wait to be reimbursed. In the DVRA, you can use the debit card for deductibles, coinsurance or copayments for dental and vision services. When you use your card, select credit as this card does not require a personal identification number (PIN). Once you activate the card, it is loaded with the full amount you elected to contribute to the DVRA for the current year, less any reimbursements you might already have claimed. The debit card tracks your spending against your annual account election amount. If you have funds in your account but not enough to cover the expense for which you are using the card, it will be declined. You will need to file a Reimbursement Form by mail or fax, or filing an online claim to get any remaining money in your account. Save all receipts that describe exactly what you paid for with your card. You are required to reimburse your account for any purchases you cannot show to be eligible dental or vision expenses. If you choose not to activate your debit card or not to use it, you can submit a Reimbursement Form by mail or fax, or file an online claim to request the money from your account. Each year you continue to participate in the DVRA, your card will be loaded with your new annual contribution amount at the beginning of the year. Tips for Using Your Acclaris Visa Debit Card You can make using your Acclaris Visa debit card easier and have fewer requests for receipts by following these tips: Pay for each prescription separately. Pay for over-the-counter items (like contact lens supplies) separately from prescriptions. Do not use your debit card to pay for items that are not eligible for reimbursement. Use the card only to pay for services received during the current year, regardless of when the expense is charged. If several family members visit a service provider on the same day, pay each individual s charges in a separate transaction. Filing Claims for Reimbursement During the year, as you and your family members pay eligible dependent care and dental/vision expenses out of your pocket, you may submit claims for reimbursement in two ways: Reimbursement Form. Print out the Health Care or Dependent Reimbursement Form, as applicable, from the Acclaris web site, or request a form from the Eaton Service Center at Fidelity or from a Service Center representative (see page 94). Complete the form and mail or fax it to Acclaris at the fax number or address shown on the form. Make sure to include any required supporting documentation, as outlined below. Dependent care expenses and certain dental or vision expenses (for example, cosmetic or reconstructive dental treatments prescribed by a physician) can only be reimbursed using a Reimbursement Form. Online Claims on Acclaris Web Site. When you sign in to your account and go to the New Claim section, you will be able to choose or add the person to whom you would like the payment to be made yourself or your provider and upload the documentation needed to substantiate your claim. Reimbursements are generally processed within 10 business days. Each time Acclaris processes a reimbursement for you, you will receive an Explanation of Benefits (EOB). If you choose reimbursement to yourself, the check is made payable to you and sent to your home address. You also have the option of having your reimbursements deposited directly to your bank account. Contact the Claims Administrator for the necessary form to establish direct deposit. 102

104 Reimbursement Account Plans Supporting Documents for Claims You should keep supporting documents for all your purchases, including debit card purchases. In most cases, you will need to provide this documentation when you submit a claim form. Dental/Vision Expenses. Supporting documentation for dental or vision expenses must include either an itemized receipt, billing statement or EOB indicating the date of service or sale, patient, and the type and amount of the expense. Canceled checks are not acceptable as a receipt. Any dental or vision expense eligible for filing under your or your spouse s group dental or vision plans must first be submitted to the appropriate claims administrator or carrier for that plan. The EOB or receipt you receive in response supports your reimbursement account claim. The Claims Administrator will consider any portion of the expense your or your spouse s group dental or vision plans do not pay for reimbursement. Dependent Care Expenses. Supporting documentation for dependent care expenses must include an invoice or a signed claim form from your dependent care provider indicating the dates of service. Dependent care expenses are not reimbursed until after the services have been provided. Reimbursement Payments Dental/Vision Reimbursement Account. Claims incurred in the same calendar year in which you made deposits are paid as they are submitted, provided the claims do not exceed your total elected deposit amount. If your participation in the account ends, only eligible expenses you incurred while you were a participant will be paid. Dependent Care Reimbursement Account. Claims incurred in the same calendar year in which you made deposits are paid as they are submitted, as long as they do not exceed your actual deposits to the account. If you have insufficient deposits at the time you file a dependent care claim, the portion of your claim that cannot be paid at that time is automatically paid in subsequent periodic payments as additional contributions are made to your account. Recovery of Fraudulent Payments If you were reimbursed for claims based on fraudulent information you provided, the Plan will exercise all available legal rights, including its right to withhold payment of future benefits, until the overpayment is recovered. Reimbursement Account Statements Periodically, you will receive account balance statements from the Claims Administrator. These statements help you keep track of your account balance(s) so you know how much you have available to pay claims. SUBMITTING CLAIMS AFTER PARTICIPATION ENDS Under the Dental/Vision Reimbursement Account, you cannot be reimbursed for claims incurred after the date coverage ends. Under the Dependent Care Reimbursement Account, coverage continues until the end of the Plan year. In either account, you can file claims until March 31 of the next year to receive reimbursement for eligible expenses. 103

105 Reimbursement Account Plans PURCHASED VACATION PROGRAM Who Is Eligible for Coverage You are eligible to participate in the Purchased Vacation Program if you work at least 20 hours per week. If your employment is covered by a collective bargaining agreement, you are eligible for the Purchased Vacation Program, only if your collective bargaining agreement provides for it. Specific eligibility requirements and benefit terms may be stipulated by your bargaining agreement. Effective Date of Coverage You begin to participate in the program on the first day of the year after you choose to purchase vacation days during the annual enrollment period in the fall. Purchasing Vacation Days The Purchased Vacation Program allows you purchase vacation days in addition to your regular allocation of vacation benefits. During the annual enrollment period, you may elect to purchase one work week of additional vacation time to be used during the year following the annual enrollment period. For example, during fall 2017 annual enrollment, you may purchase vacation days for use during If you purchase vacation days, you pay with before-tax dollars and you authorize payroll deductions based on your election and your hourly rate of pay (or calculated hourly rate of pay) determined as of the August 1 before the plan year. The payroll deductions are taken in equal amounts from each payroll during the year. Changes to your compensation during the year, such as merit increases or promotions, will not affect your payroll deductions for the year. No Election Changes During the Year. Once you make an election under the Purchased Vacation Program, you cannot make any changes to your election during the plan year. However, the Plan Administrator may reduce your election at any time during the plan year in order to satisfy legal requirements relating to nondiscrimination under the Code, as applicable. Using Purchased Vacation Days You must use your accrued vacation days first, before using days you purchase under this program. Vacation time must be used in full-day increments. If you purchased days and do not use them within the plan year for which they were purchased, those vacation days will be forfeited and you will not be able to carry them over into the next year, unless required by applicable law. If your employment with Eaton ends or you are no longer eligible for this benefit, your election will be suspended immediately. In this case, you will be refunded for any unused purchased vacation days, as determined by the sole discretion of the Plan Administrator, at the hourly rate of pay (or calculated hourly rate of pay) determined as of the beginning of the plan year. 104

106 Work/Life Solutions and Adoption Reimbursement Benefits Plans WORK/LIFE SOLUTIONS AND ADOPTION REIMBURSEMENT BENEFITS PLANS BENEFITS FOR YOU AND YOUR FAMILY PAYING FOR PLAN SERVICES EMPLOYEE ASSISTANCE PROGRAM (EAP) Counseling Program Child and Elder Care Services Legal and Financial Consultation Wellness Information and Tools Convenience Services EATON CENTER ON-SITE HEALTH CENTER Services Available TOBACCO CESSATION PROGRAM ADOPTION REIMBURSEMENT BENEFITS PLAN Covered Expenses Filing a Claim for Adoption Reimbursement Benefits Taxes on Adoption Reimbursement Benefits Effect on Other Benefits

107 Work/Life Solutions and Adoption Reimbursement Benefits Plans BENEFITS FOR YOU AND YOUR FAMILY The Work/Life Solutions and Adoption Reimbursement Benefits Plans represent a comprehensive program of services designed to help you manage personal and family needs and balance work and personal responsibilities. Program/Features Employee Assistance Program Counseling: Confidential counseling on a short-term basis for personal issues such as: Marital and family matters Stress, anxiety and other emotional problems Grief Work-related concerns Personal growth and development Alcohol or drug abuse Legal assistance: Initial 30-minute consultation with an attorney (in-person or by phone), plus 25% discount on services beyond the initial consultation. Use the legal services for issues such as: Home buying and other housing and real estate issues Will and estate planning Family law issues such as adoption, divorce, child support, custody and visitation Bankruptcy Financial counseling: Unlimited phone consultations with qualified financial counselors and educators for issues such as: Family budgeting Mortgages College tuition planning Retirement planning Child care services: Child care information, including: Child care providers and summer care providers Emergency/backup care providers Adoption Parenting College search information Elder care services: Elder care information, including: Care products Health care and housing Legal and financial consulting matters Coping with the demands of caring for an elderly family member Convenience services: For help with arrangements for family, food or fun, including: Tourist and city information Tickets to sports events, theaters, concerts and other entertainment Airline tickets and hotel accommodations Restaurants Moving and relocation Home repair and maintenance services Pet care Wellness Information and Tools: On-site wellness activities and health awareness events Contact Information , 24/ , 8:30 a.m. to 8:00 p.m. Eastern Time login: Eaton Check your location for listings 106

108 Work/Life Solutions and Adoption Reimbursement Benefits Plans Program/Features On-Site Health Center at Eaton Center Health Center services: Preventive care services and regular exams Lab work, immunizations, vaccinations and allergy management Health coaching, health risk identification and wellness management programs Acute (urgent) care, including symptom treatment and management Referrals for specialized care and treatment programs Management of chronic conditions, such as high blood pressure and diabetes EAP services Prescriptions for any of the above, if determined to be medically necessary by Health Center staff Tobacco Cessation Program Support and resources to help you stop using tobacco using the Tobacco Cessation Program Adoption Reimbursement Benefits Plan Reimbursement of up to $10,000 in adoption expenses Contact Information Make an appointment or register a dependent as an Eaton Center building guest: , or EatonBenefits.com Eaton Service Center at Fidelity PAYING FOR PLAN SERVICES Eaton pays the full cost of providing the Work/Life Solutions Plan and the Adoption Reimbursement Benefits Plan. Your EAP includes unlimited financial consultations, a free 30-minute phone consultation with an attorney and up to six sessions per issue each year with an EAP counselor at no cost to you. You are responsible for the cost of other provider services you use. For example, child care search services are included as a Plan benefit, but you pay the cost of any child care provider services you use. The Health Center bills services according to the terms of your medical plan. Deductibles and coinsurance are the same as at another health care provider. If you are not in an Eaton Medical Plan, review your other plan coverage carefully as the Health Center may be considered out-of-network. In the Tobacco Cessation Program, you do not pay for consultations or for over-the-counter smoking cessation products you order through your specialist. The Tobacco Cessation Program itself does not cover prescription smoking cessation medications. But if you are in an Eaton Medical Plan, you do not pay for prescriptions filled through the Prescription Drug Program. If your primary care physician requires an office visit to issue the prescription, you are responsible for any other expense the Eaton Medical Plan does not pay for. 107

109 Work/Life Solutions and Adoption Reimbursement Benefits Plans EMPLOYEE ASSISTANCE PROGRAM (EAP) The EAP consists of several programs to help you and your household members manage the varying demands of your work life and family needs. Counseling Program The Counseling Program provides confidential professional assistance in dealing with personal issues that may affect your health, well-being or on-the-job effectiveness. You and your household members can call the EAP 24/7 to speak with a licensed mental health clinician. This person will assess your situation and identify possible solutions and available resources. The EAP network is staffed by professionals, including psychologists, social workers, mental health counselors and others with specific training. All information you share with the staff is confidential. Information is subject to applicable state and federal law, including HIPAA, and is not disclosed to anyone without your written authorization. EAP counseling is available by phone, in person or online via LiveHealthOnline EAP. You and your household members are eligible for up to six counseling sessions per issue per year. In California, state law allows three visits in a six-month period. If you or a member of your household requires short-term counseling, the EAP will provide you a list of counselors in your area that specialize in your specific needs. If you need specialized or long-term counseling, the EAP will work with you to determine your options when your short-term counseling ends. They will help you transition your treatment to your medical plan mental health benefits, if available. Child and Elder Care Services Counselors at the EAP work with you to evaluate your child or elder care needs and identify resources that fit your family situation. Child and elder care information services are available to you at no cost. You pay the cost of any services you eventually select. Child care information you can access includes information on: Child care providers, Summer care and emergency/backup care providers, Adoption, and Parenting. Elder care information available to you online includes: Information on elder care products, Information about health care and housing for the elderly, Counseling on elder care legal and financial matters, and Information and counseling on how to cope with the demands of caring for an elderly family member. College search information is available at this same site. Note: All child and elder care providers are independent contractors solely responsible for their services. 108

110 Work/Life Solutions and Adoption Reimbursement Benefits Plans Legal and Financial Consultation Legal Assistance. As part of the EAP's services, you will have access to our nationwide network of attorneys for one 30-minute legal consultation per issue. This can either be over the phone or face to face. When contacting the EAP, you will speak with a legal consultant who conducts an intake, confirms appropriateness and availability of a lawyer, and follows up to ensure caller satisfaction and resolution. Most common uses of the legal service are to address concerns related to: Divorce/custody issues Criminal issues Estate planning/wills/trusts Real estate Landlord/tenant Bankruptcy Personal injury/malpractice Small claims Adoption We offer two types of legal services to ensure that all legal needs are addressed in an appropriate manner: Telephone Advice: This level of service is appropriate when concerns can be resolved through a telephone call. The advice attorney will be located in your state of residence to ensure familiarity with varying state laws. Local Referral: You also have the option to meet with an attorney face-to-face. Our team contacts the local lawyer first to confirm their availability, their area of expertise and their willingness to accept the case before providing you the name. These local lawyers provide a free half-hour consultation, and agree to discount their hourly fees by 25% if additional assistance is required. The Anthem EAP website also offers access to over 90 legal forms on topics related to business and personal needs, including wills, power of attorney, home/landlord/tenant forms and more. *Please note, matters involving disputes or actions between you and your employer or other work-related issues, malpractice issues or issues involving Anthem or its parent company or affiliated companies are specifically excluded from this service. Also excluded are matters that in the opinion of the attorney lack merit. Court costs, filing fees, fines and costs incurred beyond the initial consultation are your responsibility. Financial Consulting. Through the EAP, you can be connected with qualified financial counselors and educators. You can receive a phone consultation without an appointment Monday through Friday during both day and evening hours with pre-scheduled sessions available on Saturday. Or you can make an appointment for a detailed consultation (usually lasting about one hour) regarding your most pressing financial issues. The most common financial issues addressed include: Bankruptcy Budgeting (to cope with reduction in household earnings, to reduce debt, to save and household budgeting) Buying a home for the first time Major life event planning (wedding, adoption, divorce) College fund planning Credit card debt (lowering rates, consolidating debt) Retirement planning Foreclosure prevention Decisions you make for financial investments are your responsibility. 109

111 Work/Life Solutions and Adoption Reimbursement Benefits Plans Wellness Information and Tools As a part of the EAP, some Eaton locations will periodically provide on-site wellness activities and health awareness events. Note: The medical information provided through on-site wellness events is not intended to be a substitute for professional medical advice. You should always seek the advice of your physician or other qualified health care provider regarding your health care. Convenience Services The EAP offers assisted work-life services to help with the demands of everyday life. You can speak with a work-life consultant who can do research for you on topics such as: Pet care Vacation planning Comparison shopping Moving and relocation Home repair services EATON CENTER ON-SITE HEALTH CENTER Services Available The Eaton Center On-site Health Center (Health Center) offers an on-site physician and nurse practitioner who provide the same medical services as those in a doctor s office. You can use the Health Center as your regular health care provider or as a supplement to your outside medical provider. The Health Center is located in the Eaton Center, 1000 Eaton Boulevard, Cleveland, Ohio You are eligible to use the Health Center if you work at Eaton Center or are visiting on Company business. Your dependents age 2 years and older can also use the Health Center if they are enrolled in an Eaton Medical Plan. The Health Center offers the following services: Preventive care services and regular exams Lab work, immunizations, vaccinations and allergy management Health coaching, health risk identification and wellness management programs Acute (urgent) care, including symptom treatment and management Referrals for specialized care and treatment programs Management of chronic conditions, such as high blood pressure and diabetes EAP services Prescriptions for any of the above, if determined to be medically necessary by Health Center staff. TOBACCO CESSATION PROGRAM The Tobacco Cessation Program is available to you and your eligible dependents. The Program offers support and resources to stop using tobacco. The Tobacco Cessation Program is a group health plan, and information you provide is protected under HIPAA. You may receive a combination of medication and telephone and online coaching to provide inspiration, motivation and support. Treatment may include prescription medications such as bupropion (Zyban, Wellbutrin ) and varenicline (Chantix ), and/or over-the-counter nicotine replacement therapy (nicotine gum, lozenges or patch). When you participate in both this Program and an Eaton Medical Plan option, you can receive prescription drugs for tobacco cessation at no cost. But if your physician requires an office visit to issue the prescription, you are responsible for any other medical charges not reimbursed by the Eaton Medical Plan. 110

112 Work/Life Solutions and Adoption Reimbursement Benefits Plans Employees on expatriate assignment who participate in the CIGNA International Medical Plan option or those living abroad are not eligible for the over-the-counter drug provisions of this Program. The Tobacco Cessation Program and treatment options are available for as long as you are an eligible Eaton employee. ADOPTION REIMBURSEMENT BENEFITS PLAN Covered Expenses One way Eaton recognizes the diversity of its employees and their families is by helping with the time and expense involved in the adoption process. The Adoption Reimbursement Benefits Plan helps cover certain adoption expenses. Adoption reimbursement benefits are payable when you adopt a child under age 18, but not your grandchild, stepchild or any other child related to you. The maximum benefit payable is $10,000 per adoption. Eligible adoption-related expenses the Plan covers are: Agency and placement fees; Legal and court costs; Medical expenses of the birth mother, but not in a surrogate arrangement; Temporary foster care costs, including orphanage fees in an international adoption; Immigration, immunization and translation fees; Transportation and lodging expenses for you, your spouse and the child; and Medical expenses for the child before the adoption. The Plan does not reimburse other expenses such as voluntary contributions and donations. Benefits are paid for eligible expenses you incur while you are covered by the Plan. You are not reimbursed for expenses you incur before the date coverage begins or after coverage ends. Benefits are paid whether or not you successfully complete the adoption process. The Plan pays benefits only once per adoption, even if both you and your spouse are Eaton employees. Filing a Claim for Adoption Reimbursement Benefits You file an adoption reimbursement benefits claim when the adoption process is complete even if the results were unsuccessful. Claim forms are available by contacting the Eaton Service Center at Fidelity. You must file your claim form with the Eaton Service Center at Fidelity by December 31 of the year after the year in which the adoption process is completed. Approved expenses are reimbursed in your paycheck. Social Security and applicable state and local taxes are withheld from the amount you receive, but federal taxes are not. Eaton Service Center at Fidelity will send you a separate explanation of benefits. 111

113 Work/Life Solutions and Adoption Reimbursement Benefits Plans Taxes on Adoption Reimbursement Benefits Adoption expenses reimbursed under this Plan are reported on your Eaton W-2 as earnings. Reimbursement for most expenses can be excluded from your taxable income on your federal tax return. However, for those expenses that are taxable, you are responsible for making income tax payments for those reimbursements. Internal Revenue Code Section 36C allows a federal income tax credit for adoption expenses. While you may be eligible for both Eaton adoption reimbursement benefits and the federal income tax credit, you cannot be reimbursed and claim a federal tax credit for the same expenses. You are responsible for coordinating the benefits you receive from Eaton with the federal tax credit, if you use both. For advice about the taxability of adoption expenses and reimbursements, you should consult with your tax professional. Effect on Other Benefits Reimbursement you receive from the Adoption Reimbursement Benefits Plan does not affect the amount of pay used to determine your other Eaton benefits such as life insurance, disability, pension or savings plan benefits. Coverage for Your Adopted Child Your adopted child becomes eligible for Eaton-sponsored health care, dependent life insurance and Work/Life Solutions coverage on the earlier of the date: Your child is legally placed in your home; or for international adoption, the date the child is placed in your care; or The adoption is finalized. 112

114 Life and Accidental Death and Dismemberment Plans LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLANS LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE OVERVIEW Coverage for You Buying Insurance for Your Dependents Expanded Eligibility for Your Dependent Children EVIDENCE OF GOOD HEALTH REQUIREMENTS WHEN LIFE INSURANCE BENEFITS ARE PAYABLE Employee Life Insurance Spouse/Domestic Partner and Child Life Insurance Accelerated Benefits Option Assignment of Benefits Travel Assistance Services WHEN AD&D BENEFITS ARE PAYABLE Additional AD&D Benefits Payable for You and Your Covered Dependents AD&D Benefits Payable for Your Survivors Exclusions LEGAL, FINANCIAL AND GRIEF COUNSELING WHEN EMPLOYEE LIFE INSURANCE COVERAGE IS TAXABLE HOW TO OBTAIN BENEFITS Claims for Benefits How Payments Are Made CONTINUING COVERAGE AFTER YOUR EATON ELIGIBILITY ENDS Conversion Portability How to Apply Retirement/Disability Beneficiary

115 Life and Accidental Death and Dismemberment Plans LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE OVERVIEW Coverage for You Life insurance needs differ according to family circumstances and personal financial needs. Eaton provides you with a basic level of Life Insurance and AD&D Insurance. You can choose to purchase additional coverage for yourself and your eligible family members and pay with convenient payroll deductions. Eaton provides you with Basic Life Insurance equal to the greater of one times your annual base pay or $25,000, and AD&D Insurance equal to one times your annual base pay. You can choose to have less coverage or purchase more, as shown below. Employee Group All employees You can choose less coverage and receive a credit toward buying other benefits under the Flexible Benefits Program Company-Paid Life Insurance The greater of one times annual base pay or $25,000 25% of annual base pay 50% of annual base pay 75% of annual base pay Company-Paid AD&D Insurance 1 times annual base pay No coverage You can buy additional coverage 1 times annual base pay 2 times annual base pay 3 times annual base pay 4 times annual base pay 5 times annual base pay 6 times annual base pay 7 times annual base pay 1 times annual base pay 2 times annual base pay 3 times annual base pay 4 times annual base pay 5 times annual base pay 6 times annual base pay 7 times annual base pay Buying Additional Insurance for Yourself. If you choose a higher level of Life and/or AD&D insurance than the Company provides, your cost of coverage is deducted from your paycheck on a before-tax basis. Your cost for each additional $1,000 of employee life insurance is based on: Your age, and Your tobacco user/non-tobacco user status as reported in the Healthy Incentives Program, except if you are a production employee represented by a collective bargaining agent in one of the following locations: - Bloomington, CA - Long Branch, NJ - Syracuse, NY Your age as of December 31 of the Plan year is considered to be your age throughout the Plan year. The maximum combined amount of Company-paid and employee-paid life insurance coverage you can have is $10 million. A $10 million maximum amount also applies to your combined amount of Companypaid and employee-paid AD&D insurance. If you choose employee life insurance or AD&D coverage that is less than the Company-paid amount, you will receive a credit you can use to purchase other benefits under the Flexible Benefits Program. 114

116 Life and Accidental Death and Dismemberment Plans Annual Base Pay Annual base pay is your earnings for a normal work week (not to exceed 40 hours) annualized. Annual base pay is exclusive of commissions, shift differentials, bonuses and overtime pay. To calculate life insurance and accidental death and dismemberment insurance coverage amounts, your annual base pay is multiplied by the level of coverage you choose and then rounded to the next higher $1,000 (if not already an even multiple of $1,000). For example, if your annual base pay is $29,500 and you elect coverage of three times annual base pay, your coverage amount is $89,000 (3 x $29,500 = $88,500, which is rounded up to $89,000). For newly hired employees, your base pay annualized on the date you become covered under this Plan determines your insurance coverage on that date. For other employees, your annual base pay as specified in your annual enrollment materials for the upcoming year determines your base pay for purposes of contributions under the Plan. For all options, insurance benefits are paid based on your annual base pay on your last day of active work before your death. Buying Insurance for Your Dependents Your Dependents Life Insurance AD&D Insurance Spouse/Domestic Partner $10,000 $50,000 $100,000 $150,000 $200,000 $250,000 No coverage Child or Children $10,000 $15,000 $20,000 $25,000 No coverage $10,000 $50,000 $100,000 $150,000 $200,000 $250,000 No coverage $10,000 $15,000 $20,000 $25,000 No coverage Spouse/Domestic Partner Insurance. You pay the full cost of insurance for your spouse/domestic partner. Contributions are deducted from your paycheck on an after-tax basis for spouse/domestic partner life insurance and domestic partner AD&D insurance. Contributions are deducted on a before-tax basis for spouse AD&D insurance. The amount you pay depends on the coverage option you elected and your age as of December 31 of the Plan year. You can choose spouse/domestic partner life insurance amounts and AD&D insurance amounts independent of each other. Child Insurance. You pay the full cost of insurance for your children. Whether you pay on a before-tax or after-tax basis depends on if your child is considered a dependent under the Internal Revenue Code (IRC). Contributions are deducted from your paycheck on an after-tax basis for child life insurance and generally on a before-tax basis for child AD&D insurance. However, if you live in one of the states listed below and choose child AD&D coverage (and life coverage in Texas), you must pay for coverage on an after-tax basis if you are covering more than one child and any one of them is not your IRC dependent. The amount you pay depends on the coverage option you elected. Your monthly cost is the same regardless of how many eligible children you have. You can choose child life insurance amounts and AD&D insurance amounts independent of each other. See Life Insurance Rates in the Reference Library at the Eaton Service Center at Fidelity for current rates on all types of insurance. 115

117 Life and Accidental Death and Dismemberment Plans Expanded Eligibility for Your Dependent Children While eligibility for the Plan is explained on page 4, the Plan s definition of a dependent child for AD&D insurance coverage is modified for employees living in the following states and additionally for Life Insurance in Texas: Louisiana. An eligible child also includes your grandchildren residing with you. The child or grandchild must be under age 26, regardless of marital, student or full-time employment status. You do not need to provide support for your natural child, adopted child, stepchild or grandchild under age 26 for him or her to qualify as an eligible child. In addition, marital status does not prevent or end the continuation of coverage for a mentally or physically handicapped child or grandchild age 26 or older. Minnesota. An eligible child also includes your grandchildren who are financially dependent on you and reside with you continuously from birth. The child or grandchild must be under age 25, regardless of student or full-time employment status. You do not need to provide support for your natural child, adopted child or stepchild under age 25 for him or her to qualify as an eligible child. Montana. An eligible child also includes a newborn infant born of any person covered by this Plan. The age limit for children is under age 25, regardless of student or full-time employment status. You do not need to provide support for your natural child, adopted child or stepchild under age 25 for him or her to qualify as an eligible child. New Mexico. The age limit for children is under age 25, regardless of the child s student status or full-time employment status. Your natural child, adopted child or stepchild will not be denied AD&D coverage under the Plan because he or she: Was born out of wedlock; Is not claimed as your dependent on your federal income tax return; or Does not reside with you. Texas. For AD&D insurance, an eligible child also includes your grandchildren whom you claimed as dependents for federal income tax purposes at the time you added your coverage. The child or grandchildren must be under age 25, regardless of student, full-time employment or military service status. You do not need to provide support for your natural child, adopted child or stepchild under age 25 for him or her to qualify as an eligible child. Texas. For life insurance, an eligible child also includes your grandchildren whom you claimed as dependents for federal income tax purposes at the time you added your coverage. The child or grandchild must be under age 25, regardless of student or full-time employment status. You do not need to provide support for your natural child, adopted child or stepchild under age 25 for him or her to qualify as an eligible child. Utah. The age limit for children is under age 26, regardless of the child s student or full-time employment status. You do not need to provide support for your natural child, adopted child or stepchild under age 26 to qualify as an eligible child. 116

118 Life and Accidental Death and Dismemberment Plans EVIDENCE OF GOOD HEALTH REQUIREMENTS You may be required to provide evidence of good health (sometimes referred to as evidence of insurability) satisfactory to the Insurance Company when you enroll in or increase coverage for yourself or your spouse/domestic partner. You do not have to provide evidence of good health to purchase accidental death and dismemberment coverage and life insurance coverage for your children. When it is necessary for you to submit evidence of good health for you or your spouse/domestic partner, the Eaton Service Center at Fidelity will provide you with a Statement of Health form. You must complete and submit the form to the Insurance Company within 31 days of the date shown on the form. Employee Life Insurance. You must provide the Insurance Company, at your own expense, with evidence of your good health if: You are a new employee and enroll for coverage that is more than five times your annual base pay (up to $2 million); or During annual enrollment you request to increase your coverage: - by more than one level if your current coverage is less than five times your annual base pay, - to any amount more than five times your annual base pay, or - to any level that results in insurance greater than $2 million. Examples An employee who is covered for one times annual base pay may increase coverage to two times annual base pay without providing evidence of good health. An employee who is covered for five times annual base pay is required to submit evidence of good health to increase coverage to six times annual base pay. If you fail to submit evidence of good health, or if your evidence of good health is not satisfactory to the Insurance Company, the increase in your employee life insurance is limited to the highest Plan option for which evidence of good health is not required. Spouse/Domestic Partner Life Insurance. You must provide evidence of good health for your spouse/domestic partner if: You are a new employee and you enroll your spouse/domestic partner for coverage of $50,000 or more. During annual enrollment you request to increase coverage for your spouse/domestic partner more than the Plan s next higher insurance amount. For example, if you previously elected No Coverage, you may only enroll in the $10,000 option without providing evidence of your spouse s/domestic partner s good health. A requested increase requiring evidence of good health will become effective the date the evidence of good health is approved if that is after January 1. You get married, or your domestic partner meets the eligibility requirements, and within 31 days you enroll your spouse/domestic partner for spouse/domestic partner life insurance coverage of $50,000 or more. You have any other change in status that allows you to enroll mid-year and you request to increase coverage for your spouse/domestic partner by more than the next higher Plan option. If you fail to submit evidence of good health for your eligible spouse/domestic partner, or the evidence of good health you provide is not satisfactory to the Insurance Company, the increase in spouse/domestic partner life insurance will be limited to one Plan option. 117

119 Life and Accidental Death and Dismemberment Plans WHEN LIFE INSURANCE BENEFITS ARE PAYABLE Employee Life Insurance If you die from any cause while covered under the Employee Life Insurance Plan, the full amount of your employee life insurance is paid to the person(s) you have designated as your beneficiary. If you have named more than one beneficiary, each shares the benefit equally unless you have specified otherwise. A person s rights as a beneficiary end if he or she dies before, at the same time as, or within 24 hours after your death. That person s share is then divided equally among the surviving beneficiaries, unless you have specified otherwise. If there is no beneficiary at your death, benefits are paid in a single sum to the first surviving class of the following classes of beneficiaries: Your spouse/domestic partner, Your children if there is no surviving spouse/domestic partner, Your parents, Your siblings, or Your estate. Naming a Beneficiary A beneficiary is the person you choose to receive any benefits payable because of your death. You may change your beneficiary at any time by requesting a beneficiary designation form from the Eaton Service Center at Fidelity. Instructions are included on the form. Once the change is recorded in your insurance records at the Eaton Service Center at Fidelity, it will take effect as of the date you signed the request, even if you are deceased when it is recorded. You do not need to have your beneficiary s consent to make a change. Spouse/Domestic Partner and Child Life Insurance If your spouse/domestic partner or child dies from any cause while covered under the Spouse/Domestic Partner or Child Life Insurance Plans, the full benefit amount is paid to you. If your covered spouse/domestic partner or child dies at the same time as you or within 24 hours after your death, benefits are paid to your estate. Accelerated Benefits Option If you or your spouse/domestic partner is diagnosed as terminally ill while covered under the Employee or Spouse/Domestic Partner Life Insurance Plan, you may have the option to receive a portion of the applicable life insurance benefits while you or your spouse/domestic partner is still living. Requirements. To be considered for accelerated life insurance benefits, you (or your spouse/domestic partner) must have a life expectancy of 12 months or less due to an illness or injury. A Doctor of Medicine (M.D.) or a Doctor of Osteopathy (O.D.) must certify in writing that these requirements are met. The proof provided must be satisfactory to the Insurance Company. The Insurance Company has the right to have you (or your spouse/domestic partner) examined by a doctor of its choice at its expense. Coverage. The Employee Life Insurance Plan or the Spouse/Domestic Partner Life Insurance Plan will pay accelerated benefits if: You apply or your legal representative applies while coverage is in effect; and You meet the requirements for terminal illness while covered under the Employee Life Insurance Plan or, in the case of your spouse/domestic partner, he or she meets the requirements for terminal illness while covered under the Spouse/Domestic Partner Life Insurance Plan. Accelerated benefits are payable only once for an individual. 118

120 Life and Accidental Death and Dismemberment Plans Payment of accelerated benefits reduces the amount of life insurance coverage for you and your spouse/domestic partner and the amount available for conversion to a personal life insurance policy as described under Conversion. Amount. The amount of the accelerated benefit payable is: Up to 100% of the coverage amount you elected under the Employee or Spouse/Domestic Partner Life Insurance Plan; but Not more than $1 million. The amount of the accelerated benefit payable is determined as of the date the Insurance Company accepts proof that the requirements for payment have been met. If you are within 12 months of a scheduled reduction in your life insurance amount, your accelerated benefit cannot be more than 80% of your reduced life insurance amount. After an accelerated benefit has been paid, the amount of your life insurance under the Employee Life Insurance Plan (or the amount of your spouse s/domestic partner s life insurance under the Spouse/Domestic Partner Life Insurance Plan) will be: The amount of coverage in effect on the date the Insurance Company accepts proof that you (or your spouse/domestic partner) meet the requirements for an accelerated benefit; less The amount of the accelerated benefit paid. Any required contributions for coverage are reduced to correspond with the amount of insurance coverage remaining. Exclusions. An accelerated benefit is not payable if you have assigned your life insurance (see Assignment of Benefits below). Taxation of Accelerated Benefits. You should consult with your personal tax advisor to determine the taxability of an accelerated benefit. Other Considerations. Receipt of an accelerated benefit may affect your (or your spouse s/domestic partner s) eligibility for Medicaid or other government benefits or entitlements. You should consult with your own counsel or legal advisor to determine how this may affect your situation. Some states prohibit a health care facility such as a nursing home or home care agency from requiring you to make an accelerated payment of life insurance as a condition of admission or for providing care. Assignment of Benefits An assignment is a right exercised by an employee in which he or she assigns or delivers ownership of his or her insurance coverage, including the right to name and change a beneficiary. You may make a gift assignment of your entire interest in your employee life and accidental death and dismemberment insurance under each Plan. You should consult with your personal legal and tax advisors who can assist you in determining the advantages and disadvantages of assigning your coverage. Neither the Eaton Service Center at Fidelity, the Company nor the Insurance Company accepts any responsibility if you assign your benefits without understanding the possible outcome. To assign benefits, you must complete an Absolute Assignment of Group Insurance form available from the Eaton Service Center at Fidelity. An assignment will not be honored unless the completed form has been returned to the Eaton Service Center at Fidelity and approved by the Insurance Company. Travel Assistance Services Travel assistance services for you and your dependents are included as part of your life insurance coverage. Services are provided through RedpointWTP LLC and are available 24 hours per day, 365 days a year for emergency assistance and transport when traveling 100 or more miles away from home. For service terms and conditions, and pre-trip information visit or call (in the U.S. and Canada) or (international). 119

121 Life and Accidental Death and Dismemberment Plans WHEN AD&D BENEFITS ARE PAYABLE The Accidental Death and Dismemberment (AD&D) Insurance Plan pays benefits when you or a covered dependent dies, is dismembered, is paralyzed, disappears, is subject to exposure, or suffers brain damage or a coma as the result of an accident. The accident must be the sole cause of the injury, and the injury the sole cause of death, dismemberment, paralysis, brain damage or coma. The death or dismemberment must occur no later than 365 days after the accident. The Insurance Company must receive satisfactory proof of the covered loss. As shown in the schedule below, the AD&D Insurance Plan pays benefits based on the coverage amount you selected for yourself, your spouse/domestic partner and/or your dependents. Loss Loss of life 100% Brain damage 100% Coma (after 12 months) 100% Any combination of loss of hand, foot or sight in one eye 100% Dismemberment Hand permanently severed at or above the wrist but below the elbow 50% Arm permanently severed at or above the elbow 50% Thumb (through or above the second joint from the tip) and index finger (through or above the third joint from the tip) of same hand permanently severed Foot permanently severed at or above the ankle but below the knee 50% Leg permanently severed at or above the knee 50% Loss of Sight, Hearing or Speech Speech and hearing 100% Sight in one eye (permanent and uncorrectable loss with visual acuity 20/200 or worse, or a field of vision less than 20 degrees) Speech (entire and irrevocable loss of speech) 50% Hearing (entire and irrevocable loss of hearing in both ears 50% Paralysis (loss of use of a limb determined by a physician to be permanent, complete and irreversible) Paralysis of both arms and both legs 100% Paralysis of both arms and one leg OR paralysis of both legs and one arm 75% Paralysis of one leg or both legs 50% Paralysis of the arm and leg on either side of the body 50% Paralysis of one arm or both arms 50% If you or your covered dependent sustains more than one loss as the result of a covered accident, the maximum amount the AD&D Plan pays is the full coverage AD&D amount. 25% 50% 120

122 Life and Accidental Death and Dismemberment Plans If you die because of a covered accident, the Plan pays the benefits to your beneficiary. If your dependent dies because of a covered accident, the Plan pays benefits to you. Payments to beneficiaries are made in the same manner as described in When Life Insurance Benefits Are Payable. Brain Damage. The Plan pays a benefit equal to 100% of the coverage amount if you or your covered dependent suffers brain damage in a covered accident. The brain damage must result directly and independently of all other causes from a covered accident. The benefit is payable if: Brain damage begins within 60 days after the date of the covered accident, The covered person is hospitalized for treatment of brain damage for at least seven days within the first 60 days following the accident, and Brain damage persists 12 consecutive months from the date of the accident. The lump sum benefit payment equals 100% of the coverage amount and is paid at the beginning of the 13 th month after the date of the covered accident. Coma. A coma is a state of deep sleep and total unconsciousness from which the comatose person cannot be aroused. If you or a covered dependent is injured and lapses into a coma within 365 days of a covered accident, the Plan starts paying the beneficiary a monthly benefit equal to 1% of the coverage amount (less any amounts payable as the result of the same accident) after the injured person has been in a coma for 31 days. The monthly benefit is paid for up to 100 months. If the covered person dies before all benefit payments have been made, the remaining amount is paid in a lump sum to his or her beneficiary. Disappearance. The AD&D Insurance Plan pays the loss of life benefit if your body or that of a covered dependent has not been found within one year after: The disappearance, forced landing, stranding, sinking or wrecking of a common carrier in which you or your covered dependent was an occupant; or Being reported missing to authorities if traveling in any other aircraft or vehicle. A common carrier is defined as a government-regulated business that transports fare-paying passengers. A common carrier does not include chartered or other privately arranged transportation, taxis or limousines. Exposure. The AD&D Insurance Plan pays a benefit if you or a covered dependent is unavoidably exposed to the elements and suffers a loss as the result of a covered accident. Additional AD&D Benefits Payable for You and Your Covered Dependents The AD&D Insurance Plan pays benefits in addition to those listed above in the following situations. Automobile Fatalities Benefit. An additional benefit is payable if you or a covered dependent was wearing a seatbelt and dies as a result of accidental injuries sustained in an automobile accident. The additional benefit equals 10% of the total AD&D coverage amount to a maximum benefit of $25,000. For purposes of the Plan, the deceased must have been driving or riding as a passenger in a private passenger car and wearing a seatbelt: Approved by the state or federal government for the individual s age and weight, and In the manner the vehicle s manufacturer prescribes. A police officer investigating the accident must certify that the seatbelt was properly fastened and a copy of the certification must be submitted to the Insurance Company with the claim for benefits. Airbag Benefit. An additional benefit is payable if you or a covered dependent dies as a result of accidental injuries sustained in an automobile accident and the deceased person was riding in a seat equipped with an airbag as well as wearing a properly fastened seatbelt at the time of the accident. The additional benefit equals 10% of the total AD&D coverage amount up to $10,000. A police officer investigating the accident must certify that the seatbelt was properly fastened and the seat in which the deceased was traveling was equipped with an airbag. A copy of the certification must be submitted to the Insurance Company with the claim for benefits. 121

123 Life and Accidental Death and Dismemberment Plans Dependent Child Loss Benefit. A benefit is payable if a covered child suffers a loss other than loss of life because of a covered accident. The total benefit payable for the loss is twice the amount that would otherwise be payable. New Spouse/Domestic Partner Benefit. If you do not have dependent life insurance when you are first married or your domestic partner first becomes eligible, the Company provides $3,000 of AD&D insurance coverage for your spouse/domestic partner during the first 31 days following the change in status event. Coverage continues only if you enroll your spouse/domestic partner in the Plan within 31 days of the change in status event. Newborn Benefit. The Plan provides $10,000 of AD&D insurance coverage for your first newborn dependent child through the first 31 days of life. Coverage continues if you enroll your newborn in the Plan within 31 days of his or her date of birth. AD&D Benefits Payable for Your Survivors The AD&D Insurance Plan pays additional benefits to your survivors if you (the employee) die in a covered accident and the following circumstances apply. Child Care Benefit. An additional child care benefit is payable for each of your eligible dependent children who at the time of the accident are: Under 13 years of age, and Enrolled at a legally licensed child care center on the date of the accident or within 12 months following the date of the accident. For each child who qualifies, the Plan pays an annual maximum benefit of $10,000 for up to six consecutive years. The maximum overall benefit the Plan pays is the lesser of 10% or $10,000 of your Company-paid coverage amount. Child Education Benefit. A higher education benefit is payable to your dependent children who: Are under age 25; Are enrolled at a school of higher learning before age 25, or at the 12th grade level and enroll as full-time students at a school of higher learning within one year following the date of your death; and Incur expenses for tuition, fees, books, transportation and any other costs that are paid directly to the school or the school approves and certifies. For each child who qualifies, the Plan pays an annual maximum benefit of $10,000 for up to four consecutive years. The maximum overall benefit the Plan pays is 20% of your Company-paid coverage amount. Workplace Felonious Assault Benefit. A benefit is payable if you suffer a loss as the result of a felonious assault committed at the Company s place of business, or if a felonious assault is committed while you are engaged in Company business, except if you are working at home or commuting to or from your regular place of employment. The additional benefit payment is 25% of your Company-paid coverage amount, to a maximum of $50,000, and is payable to you or your survivors, as appropriate. A felonious assault is one committed during a felony, as defined by the laws of the jurisdiction in which the felony is committed. The benefit is not payable if the felonious assault is committed by you, a member of your immediate family or an employee of the Company. Spouse/Domestic Partner Education Benefit. If you die as the result of a covered accident and your spouse/domestic partner is enrolled in an accredited school at the time of your death or enrolls within 12 months following your death the AD&D Insurance Plan pays a benefit toward his or her tuition charges. The amount paid is the lesser of the charge for tuition, $20,000 or 10% of your Company-paid coverage amount. Benefits are paid annually to your spouse/domestic partner when the Insurance Company receives proof that the tuition charges have been paid. Only expenses occurred within 30 months after the date of your death will be eligible for reimbursement. Monthly Medical Premium Payment Benefit. If you die as the result of a covered accident, the AD&D Insurance Plan pays a benefit toward the cost of continued medical coverage through COBRA for your surviving dependents. The Plan pays up to $5,000 per year for up to three consecutive years, subject to a maximum overall benefit of 15% of your total AD&D coverage amount. 122

124 Life and Accidental Death and Dismemberment Plans Exclusions Accidental Death and Dismemberment Insurance Plan benefits are not paid if the covered person s death or dismemberment is the result of: Self-inflicted injury, self-destruction or autoeroticism, whether sane or insane; Suicide or attempted suicide, whether sane or insane; Your participation in, or attempt to commit, a crime, assault, felony or any illegal activity, regardless of any legal proceedings thereto; Bodily or mental infirmity, illness or disease; The use of alcohol; The use of prescription drugs, non-prescription drugs, illegal drugs, medications, poisons, gases, fumes or other substances taken, absorbed, inhaled, ingested or injected unless taken or used as prescribed by a physician or an over-the-counter drug or medication taken as directed; Motor vehicle collision or accident where you are the operator of the motor vehicle and your blood alcohol level meets or exceeds the level at which intoxication is defined in the state where the collision or accident occurred, regardless of any legal proceedings thereto; Infection, other than infection occurring simultaneously with, and as a direct and independent result of, the accidental injury; Medical or surgical treatment or diagnostic procedures or any resulting complications, including complications from medical misadventure; Travel in or descent from any aircraft, except as a fare-paying passenger on a regularly scheduled commercial flight on a licensed passenger aircraft carrier; or War or any act of war, whether declared or undeclared. LEGAL, FINANCIAL AND GRIEF COUNSELING LifeWorks US, Inc. provides U.S. active employees covered under the group life insurance policy, and their spouses and dependents, access to counseling professionals and related resources and referrals concerning legal, financial and grief issues. Contact LifeWorks at or visit LifeWorks.com (user name: lfg, password: resources). Legal, financial and grief counseling includes: Comprehensive web and mobile resources Telephonic guidance and consultation with professionals in each area Thirty-minute face-to-face consultation with an attorney for each unique legal issue Assistance drafting and reviewing legal documents, including wills, power of attorney, living wills, health care directives and more Guidance from accredited financial consultants regarding credit management, budgeting, mortgage/refinancing, retirement/401(k) and basic estate planning Caring, confidential support with grief, anger or anxiety and access to community resources You can access these resources 24 hours a day/365 days a year. This legal, financial and grief counseling benefit is in addition to services provided through the Employee Assistance Program. 123

125 Life and Accidental Death and Dismemberment Plans WHEN EMPLOYEE LIFE INSURANCE COVERAGE IS TAXABLE If you are covered for more than $50,000 of employee life insurance, federal tax law may require that you report the value of a portion of your life insurance coverage as imputed income subject to FICA and federal income tax. State and local taxes may also apply. The first $50,000 of group term life insurance coverage is currently not subject to taxation under the imputed income rule. You may have imputed income if you elect coverage that is more than $50,000. Your imputed income will equal the value of the coverage you elected, less the value of the first $50,000 of coverage. The value is determined by an Internal Revenue Service Table that is provided below. Any imputed income that you have will be reflected on your Form W-2. The IRS Table for determining the value of a given amount of group term life insurance is available at irs.gov. The following table was current in Age* Monthly Value per $1,000 of Insurance * The IRS considers your age on December 31 to be your age for the entire tax year. For example, if you reach age 40 on December 15, 2018, the IRS considers you to be age 40 for the entire 2018 tax year. HOW TO OBTAIN BENEFITS Claims for Benefits Employee, Spouse/Domestic Partner and Child Life Insurance Benefits. As soon as reasonably possible following the date of death, you or your beneficiary must complete a claim form for life insurance benefits and return it to the Claims Administrator. A certified copy of the death certificate as shown in the records of the health department, county clerk or other public official must also be provided. If you want to apply for an accelerated benefit under the Accelerated Benefits Option, the Eaton Service Center at Fidelity can provide a form for you and your doctor (or your spouse s/domestic partner s doctor) to complete and return. The Eaton Service Center at Fidelity will forward your application to the Claims Administrator. Accidental Death or Dismemberment Insurance Benefits (Employee and Dependent). If the claim is for accidental death or dismemberment benefits, the Claims Administrator should be notified no later than 30 days after the accident that caused death or dismemberment. The Claims Administrator will then provide you or your beneficiary with forms to submit proof of the claim. If the Claims Administrator does not provide the forms within 15 days, you should submit your own proof describing the nature and extent of the event and the cause. Either way, proof satisfactory to the Claims Administrator must be provided within 90 days of the date of the loss or as soon as reasonably possible. If you or your beneficiary is claiming additional accidental death benefits for an automobile fatality, a copy of the police report indicating the correct position of the seatbelt as certified by the investigating officer must be submitted with the claim. While an accidental dismemberment claim is pending, the Insurance Company has the right to have you or your dependent examined by doctors of the Insurance Company s choice at its expense. In the case of an accidental death, the Insurance Company has the right to request an autopsy where permitted by law. 124

126 Life and Accidental Death and Dismemberment Plans You may not file a lawsuit to obtain AD&D benefits until you exhaust your claims and appeals rights set forth under Claims Appeals Procedure. In general, this means that you may not file a lawsuit until 60 days after proof is given, and you must file a lawsuit within three years after the date proof is given to the Claims Administrator. Travel Assistance Benefits. If you are traveling and need assistance with any of the services listed on page 119, you should call Redpoint, the Claims Administrator, directly at (in the U.S. and Canada) or (international). How Payments Are Made When a life insurance or accidental death or dismemberment claim has been approved and processed, the full insurance benefit, payable to you or your beneficiary, will be: Paid by check or direct deposit, or Paid by any other method that provides immediate access to the full benefit amount. Accelerated life insurance benefits are made payable to you by check or direct deposit. CONTINUING COVERAGE AFTER YOUR EATON ELIGIBILITY ENDS Conversion Portability If your Plan coverage or that of a dependent ends because your Eaton employment ends or you are no longer in an eligible group, you may continue your life insurance or life insurance for your spouse/domestic partner or children through Securian. One option is conversion; that is, switching any portion or all of your coverage to a personal policy. A second option is portability; that is, taking your optional group life insurance with you when your Eaton coverage ends. Provided you apply within the time frames described below, neither conversion nor portability require you to provide evidence of good health. When your Eaton coverage ends, you may convert employee life insurance, spouse/domestic partner life insurance and/or child life insurance coverage to an individual policy. When you convert your coverage, the amount of your personal life insurance policy cannot be more than the amount of your Eaton coverage when it ended. The individual policy will not include accidental death and dismemberment insurance and may not be a term life insurance policy. The amount of your premium depends on your or your dependent s age, risk class, policy form and amount. If Eaton ends this Plan and your coverage has been in effect for at least five years, the amount of the personal life insurance policy to which you convert will be $10,000, less the amount of life insurance for which you or your dependent(s) may be eligible under any group policy within 31 days. Application Period. To convert coverage to a personal policy, you (or your spouse/domestic partner or child) must apply in writing no later than 31 days after your Eaton coverage ends. Then your personal policy takes effect on the 32nd day after life insurance coverage under the Eaton Plan ends. If the covered person dies during the 31-day application period, the benefit paid will equal the maximum amount that could have been obtained under a personal life insurance policy. The portability option allows you to continue your optional employee group life insurance at your own cost. The amount of coverage cannot be more than the Eaton coverage you had when it ended (subject to state laws). Certain benefits may be different than your Eaton Plan benefits; they will be explained in your certificate of insurance. You may request portability provided that, on the date of your request: The Eaton Employee Life Insurance Plan is in effect; Securian has not received notice of any intent to end the Plan; and You have not applied to convert insurance coverage as described above. 125

127 Life and Accidental Death and Dismemberment Plans How to Apply Application Period. To take advantage of the portability option, you must apply in writing and pay the first premium within the applicable time period described here: If you receive written notice of your right to portability within 15 days before or after the date your insurance ends, you have 31 days from the date your coverage ends to submit your application. If you receive written notice of your right to portability more than 15 days after but within 90 days of the date your insurance ends, you have 45 days from the date you receive notice to submit your application. If you receive written notice of your right to portability more than 90 days after the date your insurance ends, you have 90 days from the date you receive notice to submit your application. To apply for continued life insurance coverage, please contact Securian Life Insurance Company at Retirement/Disability Beneficiary If your employee life insurance coverage under this Plan ends due to retirement or disability and you are eligible for coverage under another Eaton life insurance plan, you may continue your life insurance coverage up to the amount of the difference between your insurance coverage under this Plan and your insurance under the replacement Eaton life insurance plan. The provisions described in this section apply. When you apply to continue your insurance coverage, you must make a written beneficiary designation. If you become covered under the Eaton Employee Life Insurance Plan again, you must rename your beneficiary in writing. 126

128 Short Term Disability Plan SHORT TERM DISABILITY PLAN SHORT TERM DISABILITY Employee Groups Covered by the Plan Who Is Eligible for Coverage Effective Date of Coverage CONTINUING INCOME WHILE YOU ARE DISABLED FACTORS THAT AFFECT THE AMOUNT YOU RECEIVE Benefits Are Taxable Reduction of Benefit Payments Modified Duty Employment If You Retire Successive Periods of Disability THE PERIOD BENEFITS ARE PAID When Payments Begin When Payments End DISABILITIES THE PLAN COVERS Covered Disability Disabilities the Plan Does Not Cover HOW TO OBTAIN BENEFITS Reporting a Claim for Short Term Disability Benefits Reporting Deadline Requests for Information on Initial Claim Claims for Other Disability Benefits Medical Information Requirement to Update Medical Information How Payments Are Made

129 Short Term Disability Plan SHORT TERM DISABILITY Employee Groups Covered by the Plan The Short Term Disability Plan defines three groups of U.S. employees who are covered by the Plan. Different provisions may apply to the groups and to locations within the groups. The Corporate Standard group includes all Eaton employees except those who are: Eligible for the Eaton Hourly Short Term Disability Plan Eligible for any Eaton Union Short Term Disability Plan Production employees represented by a collective bargaining agent at Bloomington, CA; Hicksville, NY; or Long Branch, NJ The Hourly Standard group includes: Production employees represented by a collective bargaining agent at the following locations: - Americus, GA - Auburn, IN - Beaver, PA - Brooklyn, OH; - Eden Prairie, MN - Ellisville, MO - Elk Grove Village, IL - Euclid, OH - Horseheads, NY - Hutchinson, KS - Jackson, MI - Jackson, MS - Lincoln, IL - Meadowlands, PA - Pinckneyville, IL - Vicksburg, MS - Warwick, RI Production employees not represented by a collective bargaining agent at the following locations: - Beltsville, MD - Fitzgerald GA - Fort Worth, TX, including associated employees in Irvine, CA - Jackson, MI - Menomonee Falls, WI, including associated employees in Reynosa, Mexico - White City, OR - Williamsburg, VA - Williamsport, MD - Toccoa, GA - Former Cooper facilities in the U.S. (Note: employees at Greenwood, SC are in the Corporate Standard group) The Union group includes production employees represented by a collective bargaining agent at the following locations: Highland, IL Syracuse, NY Troy, IL 128

130 Short Term Disability Plan Who Is Eligible for Coverage The eligibility requirements for the Short Term Disability Plan are the same as for other Eaton benefit plans EXCEPT the hours-per-week of work requirement varies. Hours of Work Per Week Requirement for Eligibility CORPORATE STANDARD GROUP 20 or more hours per week HOURLY STANDARD GROUP 20 or more hours per week UNION GROUP Highland, IL Troy, IL 30 or more hours per week Syracuse, NY 40 or more hours per week Leased and temporary employees are not eligible for coverage. Your Human Resources Department can answer any questions you may have about eligibility for short term disability coverage. Effective Date of Coverage Your short term disability coverage becomes effective on the later of: The date you transfer to an eligible employee status; The effective date of coverage for newly acquired businesses, as specified by the Company; or When you are a new employee, as shown in the chart below: Short Term Disability Coverage Starts for New Employees CORPORATE STANDARD GROUP The first day of your employment HOURLY STANDARD GROUP The first day of your employment UNION GROUP Highland, IL Troy, IL The first day of your employment Syracuse, NY The date you complete four consecutive weeks of service with the Company You must be actively at work on the date your coverage begins. Otherwise, coverage will become effective on the day you return to active work. For the Short Term Disability Plan, actively at work or active work means the performance of duties as required or assigned by the Company. If you are on paid vacation or Company holiday on your initial effective date, you are considered to be actively at work for purposes of the Plan. You do not have to enroll to be covered by the Plan. 129

131 Short Term Disability Plan CONTINUING INCOME WHILE YOU ARE DISABLED The Short Term Disability Plan provides you with continuing income for up to 26 weeks if a covered disability prevents you from working. If you are disabled longer than 26 weeks, additional benefits may be available under the Eaton long term disability plan. During a period of covered disability, you will receive a percentage of your base pay using the rate in effect on the day immediately before your disability begins. The percentage you receive depends on your employee group. The short term disability benefit you receive is coordinated with certain other benefits to which you may be entitled. The percentage of base pay benefit payable under the Plan is reduced by certain other income you may be eligible to receive (see Amount of the Benefit You Receive Reduction of Benefit Payments ). Amount of Benefit and How Long it Continues CORPORATE STANDARD GROUP Your length of service is determined by the Eaton pension plan in which you participate. HOURLY STANDARD GROUP 60% of base pay for up to 26 weeks UNION GROUP Highland IL Troy, IL Length of service Less than 10 years 100% of base pay for: 60% of base pay for: 9 weeks 17 weeks 10 to 15 years 13 weeks 13 weeks 15 to 20 years 19 weeks 7 weeks 20 to 25 years 23 weeks 3 weeks 25 years or more 26 weeks 0 weeks 45% of base pay for up to 26 weeks Syracuse, NY 45% beginning with the second week of disability if you are drawing New York State Disability benefits. You can receive STD benefits from the Plan for up to 26 weeks in a 52-week period. Your Human Resources Department can answer any questions you may have about eligibility for short term disability coverage. 130

132 Short Term Disability Plan FACTORS THAT AFFECT THE AMOUNT YOU RECEIVE The base pay used to calculate your short term disability benefit is your pay rate before it is reduced by contributions or adjustments related to participation in the Eaton Corporation Flexible Benefits Program or any other Eaton program for which you have elected before-tax contributions. Your base pay does not include shift differential pay, overtime pay, bonuses or any other extra pay. If you have a change in your base pay, you must be actively at work for the change to become effective for Plan purposes. Your new base pay under the Plan will become effective on the date you return to active work. If you are on a paid vacation or Company holiday, you are considered to be actively at work. Benefits Are Taxable Short term disability benefits you receive from the Plan may be taxable income. Federal and applicable state and local taxes are withheld from benefit payments. Reduction of Benefit Payments Benefits paid under the Plan are reduced by the total amount of certain other income for which you may be eligible during any period of disability. These sources of other income are any: Pension or other retirement benefits you receive from any retirement plan sponsored by Eaton or any Eaton subsidiary company. Benefits for which you are eligible under Workers Compensation, occupational disease or other employer liability plan or plans. And, for all groups except Highland, IL; Troy, IL; and Syracuse, NY: - Disability benefits under any Company-sponsored program (but not benefits paid under the Accelerated Benefits Option of the Eaton Life Insurance Plan); - Disability and/or retirement benefits for which you are eligible under the federal Social Security laws, or under any other federal, state, county, municipal or other program either tax-supported or sponsored by any government. The reduction for Social Security includes primary and auxiliary benefit awards. Auxiliary benefits may be provided to your family members based on your Social Security benefit eligibility; and - Mandatory no fault automobile insurance work-loss payments. Your Short Term Disability Plan maximum benefit is reduced by the amount of the Social Security benefit for which you and your dependents are eligible on the date your disability benefit begins. During the period you receive Short Term Disability Plan benefits, your Plan benefit is adjusted to reflect increases or decreases in the Social Security benefits you receive. Modified Duty Employment If You Retire While you are receiving disability benefits, your health care provider or a health care provider selected by the Company or Claims Administrator may determine that you could return to work in your regular job if your duties were modified to accommodate your current health limitations. The Claims Administrator will work with you and your work location to determine if the suggested modifications can be reasonably accommodated. Your benefits end if you do not accept modified duty employment that has been designed for you. In modified duty employment, you work at your regular job with either restrictions on the work you do or a reduction in the number of hours you work. The Company does not create positions for the purpose of modified duty employment. Any permanent job restrictions are analyzed in accordance with the Americans with Disabilities Act. You receive your regular pay while working in modified duty employment. Modified duty employment may last up to 90 days. After 90 days, you must return to your regular job, go back on disability or receive an extension that has been approved by the Claims Administrator, Plan Administrator and the Company. If you begin receiving short term disability plan benefits again, the periods you receive benefits before and after your modified duty employment are added together to determine the length of time benefits continue. If you retire while receiving short term disability benefits, your Short Term Disability Plan benefits will end on your retirement date, and you will not be eligible for benefits under the Eaton Long Term Disability Plan. 131

133 Short Term Disability Plan Successive Periods of Disability If you return to work after a period of receiving short term disability benefits and you again become disabled from the same cause or cause related to your first disability within three months* following your return to work, the second disability is considered a continuation of the first. Your two periods of disability are added together to determine the percentage of your income that will be replaced and the date at which you reach the 26-week maximum short term disability benefit period. The disability is considered a new disability if you return to work for longer than three months* or if you experience a disability from a second, unrelated cause after at least one full workday. In that case, you are considered to have a second disability. Short term disability benefits become payable as of the first day of your subsequent covered disability case for up to 26 weeks. * 14 days for collectively bargained employees in Highland, IL; Syracuse, NY; and Troy, IL. THE PERIOD BENEFITS ARE PAID When Payments Begin When your short term disability benefits become payable depends on your employee group, as shown in this chart. CORPORATE STANDARD GROUP Benefits begin on the earliest of the listed dates First day you are not at work due to a covered disability, but only after you have completed a waiting period of seven consecutive calendar days First day you are confined to a hospital for 18 or more consecutive hours Day you undergo an outpatient surgical procedure HOURLY STANDARD GROUP The eighth consecutive calendar day you are unable to work First day you are confined to a hospital for 18 or more consecutive hours Day you undergo an outpatient surgical procedure UNION GROUP Highland, IL Troy, IL First day you undergo an outpatient surgical procedure, First day you are confined to a hospital for 24 consecutive hours, First day you are unable to work due to an injury or accident whether or not hospitalization is required, or Sixth consecutive calendar day you are unable to work because of a covered disability. Syracuse, NY The second week (eighth consecutive calendar day) of disability if you are receiving New York State Disability Benefits. 132

134 Short Term Disability Plan When Payments End Once you begin receiving short term disability benefits, your benefits continue until the earliest of the following events occurs: You no longer have a covered disability under the Plan. Either you are able to resume the essential duties of your regular position or, at the Company s sole discretion, to work in another Company position that accommodates your medical restrictions; The first day for which you are unable to provide satisfactory medical evidence of a covered disability; You do not follow the treatment plan ordered by your health care practitioner; You fail to cooperate with a scheduled independent medical examination (IME) or functional capacity evaluation (FCE); You begin work similar to your work with Eaton for wage or profit with another employer or through self-employment; You have received benefits for a 26-week period; You are incarcerated; Your employment ends for any reason, including retirement; You die; or The Plan terminates. You cannot substitute holiday pay or vacation pay for payment of disability benefits. Hourly Bargaining Employees in Syracuse, NY Once you begin receiving short term disability benefits, your benefits continue until the earliest of the following events occurs: You no longer have a covered disability under the Plan. Either you are able to resume the essential duties of your regular position or, at the Company s sole discretion, to work in another Company position that accommodates your medical restrictions; You are no longer receiving New York State Disability Benefits; Four weeks after your employment ends due to termination or lay off; You die; or The Plan terminates. You cannot substitute holiday pay or vacation pay for payment of disability benefits. The maximum benefit is 26 weeks in a 52-week period. 133

135 Short Term Disability Plan DISABILITIES THE PLAN COVERS Covered Disability You may be eligible for short term disability benefits if you are covered by the Plan and you: Have a covered disability as defined below; Are under the continuous care of a licensed health care practitioner; and Return a signed copy of the Overpayment Reimbursement Agreement provided by the Claims Administrator. Benefit payments are suspended until the Claims Administrator receives this form. You must be under the care of a health care practitioner who verifies, to the satisfaction of the Claims Administrator, that because of your disability you are unable to perform the essential duties of your employment with the Company. For purposes of the Plan, the term health care practitioner means a fully licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Dental Surgery (D.D.S.), Doctor of Podiatry Medicine (D.P.M.), Doctor of Chiropractic (D.C.), Psychologist, Physician s Assistant (P.A.), Nurse Practitioner (N.P.) or Certified Nurse Midwife (C.N.M.). If you cannot work due to mental illness or alcohol or chemical dependency, a psychiatrist or licensed psychologist must provide continuous care and verify, to the satisfaction of the Claims Administrator, your covered disability. For a disability resulting from alcohol or chemical dependency, you must be receiving treatment in an accredited residential or outpatient substance abuse treatment facility. You are considered to have a covered disability (see Disabilities the Plan Does Not Cover below for exceptions) under the Plan if an occupational or non-occupational illness or injury prevents you from performing the essential duties of your regular position with the Company or the duties of any suitable alternative position with the Company. This definition is different for bargaining employees in Syracuse, NY (see below). The Company, at its sole discretion, determines the availability and suitability of alternative positions at Eaton. Disabilities the Plan Does Not Cover The Plan does not pay benefits if your disability is the result of: Any attempt at suicide or intentionally self-inflicted injury, while sane or insane; Participation in (or as a consequence of prior participation in) the commission of a felony; Any act of war, declared or undeclared, service in the armed forces of any country, or performing police duties as a member of any military organization; or Cosmetic procedures. However, disability benefits will be paid for reconstructive surgery following a mastectomy; for surgery the Medical Plan determines to be medically necessary to correct damage caused by an accident, an injury or to correct a congenital defect; and for complications that prevent your return to work within the normal recovery period for a cosmetic surgery procedure. Hourly Bargaining Employees in Syracuse, NY You may be eligible for short term disability benefits if you are covered by the Plan and you return a signed copy of the Overpayment Reimbursement Agreement provided by the Claims Administrator. Benefit payments are suspended until the Claims Administrator receives this form. Employees who are drawing New York State Disability benefits will receive a supplement that will increase their total weekly benefit. Proof of New York State Disability benefit approval must be received by the Claims Administrator. You are considered to have a covered disability if you have been approved for New York State Disability Benefits and the Claims Administrator receives documentation of this approval. 134

136 Short Term Disability Plan HOW TO OBTAIN BENEFITS Reporting a Claim for Short Term Disability Benefits Reporting Deadline When you are absent from work, you need to notify your supervisor and local Human Resources Department as soon as possible regarding the reason for your absence. If your absence is due to a workrelated (occupational) injury or illness, it is important that you indicate this when you report your absence. Call the Claims Administrator at the phone number listed in Plan Administration Claims Administrator to file your claim for short term disability benefits: On the first day of absence due to an accident, outpatient surgery, or a hospital stay lasting 18 hours or longer; As soon as you know an illness will last seven consecutive days, or by the eighth day; or Two weeks before your due date if you are pregnant or before scheduled surgery. The Claims Administrator will send you several forms. You must sign and return the Authorization for Release of Medical Information form so the Claims Administrator can contact your health care practitioner if additional medical information is needed. You must also sign and return the Overpayment Reimbursement Agreement so benefit payments can start. The Claims Administrator will review your claim and either approve or deny benefits. To minimize the interruption in your income, report your absence to the Claims Administrator within eight consecutive days of your last day of active work. As shown in the chart, you have a limited amount of time to file a claim for Plan benefits. Reporting Deadline to File a Claim for Benefits CORPORATE STANDARD GROUP 180 days from your last day of active work before your absence due to illness, injury, surgery or pregnancy HOURLY STANDARD GROUP 180 days from your last day of active work before your absence due to illness, injury, surgery or pregnancy UNION GROUP Highland, IL Syracuse, NY Troy, IL Requests for Information on Initial Claim 31 days after your benefits are first payable Except for hourly bargaining employees in Syracuse, NY, the Claims Administrator may require additional medical or other information to evaluate your claim, and you will be notified in writing if additional information is needed. It is your responsibility to see that your health care practitioner submits any medical information the Claims Administrator needs. Claims for Other Disability Benefits Remember that your maximum short term disability benefit is reduced by the amount of benefits you are eligible to receive from other sources. 135

137 Short Term Disability Plan Medical Information You should apply for Social Security Disability benefits as soon as the Claims Administrator determines that you are eligible for them. The Claims Administrator will assign your case to a Social Security advocacy group that will work with you to get the benefits that you and your dependents may be entitled to because of your disability. If your initial application for Social Security Disability benefits is denied, the Plan requires you to reapply. In the event Social Security Disability benefits are denied upon re-application, the Plan requires you to appeal the denial before an Administrative Law Judge. If the Administrative Law Judge denies your application, your disability benefits will be reinstated retroactively. Your short term disability benefits are not reduced for Social Security payments until your application is approved. Objective findings of a disability are necessary to substantiate the period of time your health care practitioner indicates you are unable to work because of your disability. Objective findings are those your health care practitioner observes through objective means, not your description of the symptoms. Objective findings include: Physical examination findings (functional impairments/capacity); Diagnostic test results/imaging studies; Diagnoses; X-ray results; and Observation of anatomical, physiological or psychological abnormalities. Requirement to Update Medical Information If the Claims Administrator approves your claim, your health care practitioner may be required to submit updated medical information regarding your continuing disability as often as every two weeks. Payments will be suspended or terminated if the Claims Administrator does not receive updated information to reevaluate your claim within the timeframe shown in this chart. If you do not provide updated medical information within: 15 calendar days of the initial request 30 calendar days of the initial request Then: Benefit payments are suspended (for up to 15 days) effective the date the Claims Administrator determines you are no longer eligible for benefits. Benefit payments and your claim are denied effective the date the Claims Administrator determines you are no longer eligible for benefits. To appeal the termination of benefits, you need to follow the Claims Appeal Procedure that begins on page 151. You are responsible for the expense involved in obtaining updated medical information regarding your disability. Except for hourly bargaining employees in Syracuse, NY, the Claims Administrator may also require you to undergo an independent medical examination and/or a functional capacity test. If you do not cooperate with this request (for example, you fail to keep a scheduled appointment), your benefits will be terminated. (See Claims Appeal Procedure in this SPD.) If the Claims Administrator requests that you undergo an independent medical examination (IME) and/or a functional capacity evaluation (FCE), the charge for such examination will be at the Company s expense. How Payments Are Made Short term disability benefits are paid through Corporate Payroll at the same frequency as your regular paycheck. When benefits are payable for less than one week, the amount of your benefit for each day of the period is one-fifth of the weekly benefit. 136

138 Long Term Disability Plan LONG TERM DISABILITY PLAN LONG TERM DISABILITY PLAN OVERVIEW Who Is Not Covered Long Term Disability Contributions Increasing or Decreasing Coverage DISABILITIES THE PLAN COVERS Covered Disability Disabilities the Plan Does Not Cover AMOUNT OF THE BENEFIT YOU RECEIVE Maximum Monthly Long Term Disability Benefit Benefits Are Taxable Reduction of Maximum Long Term Disability Plan Benefit Minimum Monthly Long Term Disability Benefit WHEN PAYMENTS BEGIN AND HOW LONG THEY CONTINUE Successive Periods of Disability When Long Term Disability Benefits End Modified Duty Employment Rehabilitative Employment During Disability Vocational Rehabilitation HOW TO OBTAIN BENEFITS Claims for Long Term Disability Benefits Filing Deadline Deadline for Responding to Requests for Information Claims for Other Disability Benefits How Payments Are Made Medical Information Requirement to Update Medical Information

139 Long Term Disability Plan LONG TERM DISABILITY PLAN OVERVIEW The Long Term Disability Plan provides a continued source of income if you are sick or injured and cannot work for an extended period of time. During the first 26 weeks of a covered disability, you may be covered by an Eaton Short Term Disability (STD) Plan. If you remain disabled after that time, you may receive a benefit from the Long Term Disability Plan. This chart shows the maximum monthly benefit provided by each long term disability option. Month of Disability Weeks 1 26: Short Term Disability After 26 weeks until you are no longer disabled or you reach a specific age Disability Benefit The amount of your benefit and when it starts is determined by the STD plan that covers you The amount of income replaced depends on your LTD option in effect on the date your disability begins: Option 1: 50% of your monthly base pay Option 2: 60% of your monthly base pay Option 3: 70% of your monthly base pay Who Is Not Covered The monthly LTD benefits you receive are coordinated with certain other benefits you may be eligible for (see Amount of the Benefit You Receive Reduction of Maximum Long Term Disability Benefit ) so that 50%, 60% or 70% of your monthly base pay is replaced. The Long Term Disability (LTD) Plan is not offered to all employees. You are not covered by the Long Term Disability Plan if you are a production employee represented by a collective bargaining agent at the following facilities: Bloomington, CA Ellisville, MO Hicksville, NY Highland, IL Long Term Disability Contributions Long Branch, NJ Meadowlands, PA Syracuse, NY Troy, IL For new hires, the monthly base pay used to calculate contributions and credits is your monthly base pay on the date of hire. For other eligible employees, the monthly base pay used to calculate contributions and credits is your monthly base pay as of August 1 preceding the Plan year for which the contributions or credits apply. Contributions and credits are subject to review and change by the Company at any time. 138

140 Long Term Disability Plan Increasing or Decreasing Coverage Increasing Coverage by One Level. You may increase your long term disability coverage by one level, from Option 1 (50%) to Option 2 (60%), or from Option 2 (60%) to Option 3 (70%), without providing evidence of good health. You may increase your coverage by one level during the annual enrollment period held each fall. The increase will become effective at the start of the next year, provided you are actively at work (see page 11) on that day. If you are not actively at work, your increase in coverage becomes effective on the day you return to active work. You may also increase your coverage by one level if you experience a change in status event. You must request the increase within 31 days of a change in status event, and the increase will become effective on the date the approved change in status occurs. If you are not actively at work on that day, however, your increase in coverage becomes effective on the day you return to active work. Increasing Coverage by Two Levels from Option 1 to Option 3. You may request to increase your long term disability coverage by two levels during the annual enrollment period held each fall or within 31 days of a change in status event. To increase your coverage by two levels, you will need to provide, at your expense, a completed Statement of Health form providing evidence of your good health. The Company designates a third-party organization to review and approve all Statements of Health. If you fail to submit evidence of good health or if your evidence of good health is found to be unsatisfactory, the increase in your coverage is limited to Option 2 (60%). If you request a two-level increase during annual enrollment, you will receive a Statement of Health form with your enrollment confirmation statement. You must return the completed form before the date specified on the statement. The increase will become effective at the start of the next year provided: You are actively at work on that day, and The Company receives the necessary third-party approval of your evidence of your good health. If the approval has not been received by January 1, you will be covered under Option 2 (60%) from January 1 until the first day of the month following the date the Company receives approval of evidence of your good health. If you are not actively at work on that date, the increase to Option 3 (70%) will not become effective until the date you return to active work. If you request a two-level increase when you experience a change in status event, the Eaton Service Center at Fidelity will mail a Statement of Health form to you. You must return the completed form within 31 days of the change in status event. You will be covered under Option 2 (60%) from the date the change in status event occurs. The change from Option 2 to Option 3 (70%) will become effective on the first of the month following the date the Company receives third-party approval of the evidence of your good health. If you are not actively at work on that date, the increase to Option 3 (70%) will not become effective until the date you return to active work. Decreasing Your Coverage. You may decrease your coverage by one or two levels, but you cannot waive coverage in Option 1 (50%). You may decrease your coverage option during the annual enrollment period, and the decrease will be effective at the start of the next year. If you decrease your coverage when you experience a change in status event, the decrease becomes effective on the date of the approved change in status event. 139

141 Long Term Disability Plan DISABILITIES THE PLAN COVERS Covered Disability The Long Term Disability Plan provides you with continuing income if a covered disability prevents you from working for longer than 26 weeks. To be eligible for LTD benefits, you must be covered by the Plan and: Have a covered disability as defined below; Have exhausted any short term disability benefits you are receiving from a Company short term disability program; Be under the continuous care of a licensed health care practitioner; and Sign and return a copy of the Overpayment Reimbursement Agreement provided by the Claims Administrator. Benefit payments are suspended until the Claims Administrator receives this form. You must be under the care of a health care practitioner who verifies, to the satisfaction of the Claims Administrator, that because of your disability you are unable to perform the essential duties of your employment with the Company or any occupation (See Covered Disability ). For a physical disability, the term health care practitioner means a fully licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Dental Surgery (D.D.S.), Doctor of Podiatry Medicine (D.P.M.), Doctor of Chiropractic (D.C.), Psychologist, Physician s Assistant (P.A.), Nurse Practitioner (N.P.) or Certified Nurse Midwife (C.N.M.). If mental illness or alcohol or chemical dependency keeps you from working, you must be receiving continuous care from a psychiatrist or licensed psychologist. For alcohol or chemical dependency, you must be receiving treatment in an accredited residential or outpatient substance abuse treatment facility. Your psychiatrist or licensed psychologist must verify your disability to the satisfaction of the Claims Administrator. You are considered to have a covered disability (see Disabilities the Plan Does Not Cover below for exceptions) under the Plan if you are unable to work as the result of an occupational or non-occupational illness or injury. The work you are unable to do is defined differently over the course of a disability. You will be considered disabled: If During Months 1 23, including six months of short term disability Month 24 until you are no longer disabled or retire Your Disability Makes You Totally and continuously unable to perform the essential duties of your regular position or any suitable alternative position with the Company. Totally and continuously unable to engage in any occupation or perform any work for compensation or profit for which you are, or may become, reasonably well fit by reason of education, training or experience at Eaton or elsewhere. The Company, at its sole discretion, determines the availability and suitability of alternative positions at Eaton. Disabilities the Plan Does Not Cover The Plan does not pay benefits if your disability is the result of: Attempted suicide or intentionally self-inflicted injury, while sane or insane; Participation in (or as a consequence of prior participation in) the commission of a felony; Any act of war, declared or undeclared; service in the armed forces of any country; or performing police duties as a member of any military organization; Cosmetic procedures. However, the Plan will pay disability benefits related to reconstructive surgery following a mastectomy; surgery the Medical Plan determines to be medically necessary to correct damage caused by an accident, injury or congenital defect; or complications that prevent your return to work within the normal recovery period for a cosmetic surgery procedure; or A preexisting condition, or related to a preexisting condition, if the disability starts within the 12-month period after the date your long term disability coverage becomes effective. 140

142 Long Term Disability Plan Preexisting Condition Limitation You will not be covered under the Plan if, within 12 months of the initial effective date of your coverage, you become disabled due to a preexisting condition. A preexisting condition is any physical or mental condition, regardless of cause, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period immediately before your Long Term Disability Plan coverage became effective. This limitation does not apply to a period of disability resulting from an injury that occurs or a sickness that begins after your Long Term Disability Plan coverage becomes effective. If your employment with Eaton ends and you are rehired by Eaton, the preexisting condition limitation does not apply if: You were previously covered under the Plan for at least 12 months, and Your Plan coverage ended less than 12 months before your rehire date. AMOUNT OF THE BENEFIT YOU RECEIVE Maximum Monthly Long Term Disability Benefit The maximum monthly long term disability benefit the Plan pays you is based on: The long term disability option you elected and in effect on the date your disability starts; and Your monthly base pay on the day immediately before your disability starts. To calculate your long term disability benefit, the Plan uses monthly base pay rate, not including shift differential pay, overtime pay, bonuses or any other extra pay. Your base pay rate is not reduced by contributions or adjustments related to participation in the Eaton Corporation Flexible Benefits Program or any other Eaton program for which you have elected before-tax contributions. Benefits Are Taxable The Plan does not place a maximum on the monthly base pay it considers. Long term disability benefits are taxable income. Eaton pays for all or a portion of the coverage, and any of your contributions to the cost of coverage are made with before-tax dollars. Current tax law treats your benefit payments as taxable income. Federal taxes are withheld from benefit payments. State taxes will be withheld at your request when you submit the applicable tax form. Reduction of Maximum Long Term Disability Plan Benefit The 50%, 60% or 70% maximum benefit the Long Term Disability Plan pays for any period of disability is reduced by the total amount of certain other income for which you may be eligible. These sources of other income are any: Pension or other retirement benefits you receive from any retirement plan sponsored by Eaton or any Eaton subsidiary company; Taxable wages (such as bonuses) payable by Eaton or any of its subsidiaries; Disability and/or retirement benefits for which you are eligible under the federal Social Security laws, or under any other federal, state, county, municipal or other program either tax-supported or sponsored by any government. The reduction for Social Security includes primary and auxiliary benefit awards. Auxiliary benefits may be provided to your family members based upon your Social Security benefit eligibility; Mandatory no fault automobile insurance work-loss payments; and Benefits for which you are eligible under Workers Compensation, occupational disease or other employer liability plan or plans. 141

143 Long Term Disability Plan Example This example assumes: Your monthly base pay is $2,500 when you become totally disabled. You are eligible for a Social Security disability benefit of $700 per month. You have no other income that would reduce your Long Term Disability Plan maximum benefit. If you are covered under Option 2 at 60%, your long term disability benefit is determined as follows: 60% of $2,500 $1,500 maximum monthly disability income Less Social Security benefit Social Security benefit $ 800 Long Term Disability Plan payment The Long Term Disability Plan payment of $800 per month is subject to applicable taxes. Your Long Term Disability Plan maximum benefit is reduced by the amount of the Social Security benefit for which you and your dependents are eligible when your disability benefit begins. During the period you receive Long Term Disability Plan benefits, your Plan benefit is adjusted to reflect increases or decreases in the Social Security benefits you receive. If the Claims Administrator has not received documentation that substantiates your application for Social Security Disability benefits within 30 days of when your Long Term Disability Plan benefits start, the Claims Administrator will use an estimate to reduce your Plan benefit. For more information on the Social Security application process, see Claims for Other Disability Benefits. Minimum Monthly Long Term Disability Benefit The Plan pays a minimum monthly long term disability benefit regardless of the income you receive from other sources. The minimum benefit is determined by the Plan option in effect on the date your disability begins. Plan Option In Effect When Disability Begins Minimum Monthly Payment The minimum benefit may be used to recover long term disability benefits paid to you under the provisions of the Rights of Restitution and Reimbursement and Subrogation section. 142

144 Long Term Disability Plan WHEN PAYMENTS BEGIN AND HOW LONG THEY CONTINUE Long term disability benefit payments begin on the day immediately following a six-month period during which you have been absent from work due to a covered disability. You must submit a claim to be considered for benefits (see How to Obtain Benefits Claims for Long Term Disability Benefits ). Once your long term disability benefit payments start, they continue throughout your disability period until your recovery date or until the date shown in the chart below (subject to continuation of the Plan). Your Age When Disability Begins 60 or younger Your 65 th birthday Date Long Term Disability Benefits End 61 through 69 After 5 years or your 70 th birthday, whichever comes first 70 or older After 1 year After you are first approved, you must periodically submit updated medical information regarding your continuing disability. See How to Obtain Benefits Medical Information and How to Obtain Benefits Requirement to Update Medical Information for more information. Successive Periods of Disability The waiting period for the start of LTD benefits begins on the day you become disabled and continues for six months. During that time, you may be eligible for benefits under a Company short term disability program. If you return to work before LTD benefit payments begin. If you return to work for three months or less during the six-month LTD waiting period and you become disabled again, you do not have to start over to satisfy a new six-month waiting period. The days you were out on leave will count toward the six-month waiting period, but the days you were back at work will not. For this to be the case, your second period of disability must be from the same cause or a cause related to the first disability. The waiting period is handled differently if you return to work for longer than three months or you experience a disability from a second, unrelated cause. In that case, you are considered to have a new disability. The six-month waiting period starts again with the new disability. After LTD Benefits Payments Have Begun. If you return to work after receiving LTD benefits and you become disabled again within three months following your return the second period of disability is considered a continuation of the first. Long term disability benefits become payable as of the first day of your subsequent covered disability. For this to apply, your second period of disability must be from the same cause or a cause related to the first disability. Benefits are handled differently if you return to work for longer than three months or you experience a disability from a second, unrelated cause. In that case, you are considered to have a second disability. The six-month waiting period starts again with the new disability. 143

145 Long Term Disability Plan When Long Term Disability Benefits End If you have a covered disability and are receiving long term disability benefits, your benefits end when the earliest of the following events occurs: You no longer have a covered disability under the Plan, as determined by the Claims Administrator; The Company, at its sole discretion, offers you at your pre-disability base pay employment that accommodates any medical restrictions your health care practitioner orders; The first day for which you are unable to provide satisfactory evidence of a covered disability; You do not follow the treatment plan ordered by your health care practitioner; You fail to cooperate with a scheduled independent medical examination (IME) or functional capacity evaluation (FCE); You begin work for wage or profit with any employer or through self-employment, unless the work is rehabilitative employment (see below) approved by the Claims Administrator; The applicable period of benefit payments ends based on your age (see chart on page 143); You complete the vocational rehabilitation program developed for you, or you decline to participate in the program or fail to complete it; You are incarcerated; You die; or The Plan terminates. You cannot substitute holiday pay or vacation pay for payment of disability benefits. Modified Duty Employment While you are receiving disability benefits, it may be determined that you could return to work in your regular job if your duties were modified to accommodate your current health limitations. Such a determination is made by your health care provider or a health care provider selected by the Company or Claims Administrator. The Claims Administrator will work with you and your work location to determine if the suggested modifications can be reasonably accommodated. Your benefits end if you do not accept modified duty employment that has been designed for you. In modified duty employment, you work at your regular job with either restrictions on the work you do or a reduction in the number of hours you work. The Company does not create positions for the purpose of modified duty employment. Any permanent job restrictions are analyzed in accordance with the Americans with Disabilities Act. You receive your regular pay while working in modified duty employment. Modified duty employment may last up to 90 days. After 90 days, you must return to your regular job, go back on disability or receive an extension that has been approved by the Claims Administrator, Plan Administrator and Company. Rehabilitative Employment During Disability If you are eligible to receive LTD benefits but believe that you may be able to return to active work either with another employer or in a self-employed arrangement, you may request approval for a rehabilitative employment period. If approved, you will be eligible for long term disability benefits for up to a three-month period of rehabilitative employment. The LTD benefit you would otherwise receive is reduced by 50% of the gross income you earn from rehabilitative employment. You may request additional three-month periods of rehabilitative employment, up to a maximum period of 24 months for any one disability. Contact the Claims Administrator for an application and additional information. 144

146 Long Term Disability Plan Vocational Rehabilitation If you become eligible to receive long term disability benefits under the Plan, the Claims Administrator will evaluate your potential job skills and physical capacity for a vocational rehabilitation program. If the Claims Administrator determines retraining will prepare you to hold a job, in a similar or another occupation, a vocational rehabilitation program may be developed for you. A vocational rehabilitation program means any reemployment program selected by the Claims Administrator, in its sole discretion, as appropriate for the claimant. This may include vocational or placement counseling, skills training, placement assistance or vocational training. Long term disability benefits will end if you refuse to participate in a program that the Claims Administrator has identified as appropriate for you. Payment of expenses, for the vocational rehabilitation program, will be mutually agreed upon by the Plan and participant. HOW TO OBTAIN BENEFITS Claims for Long Term Disability Benefits Filing Deadline You are required to complete and submit certain forms to receive Long Term Disability Plan benefits. If you are receiving disability benefits from the Short Term Disability Plan, the Claims Administrator will mail the Long Term Disability Plan forms to you at the end of your fourth month of disability. You must complete the forms and return them to the Claims Administrator within 30 days of when you receive them. The forms to receive benefits from the Long Term Disability Plan must be completed and returned to the Claims Administrator within one year of your last day of active work with the Company. If you do not meet this filing deadline, you will not be eligible to receive long term disability benefits. Deadline for Responding to Requests for Information In addition to the standard forms, the Claims Administrator may require additional medical or other information to evaluate your claim. If the Claims Administrator requests additional information, you must respond within 30 days of the initial request. If you do not respond by this deadline, your claim will be denied. It is your responsibility to see that your health care practitioner submits any requested medical information within this 30-day period. Claims for Other Disability Benefits Remember that the maximum long term disability benefit is reduced by the amount of benefits you are eligible to receive from other sources. You must apply for Social Security Disability benefits as soon as the Claims Administrator determines you are eligible for them. The Claims Administrator will assign your case to a Social Security advocacy group that will work with you to get the benefits you and your dependents may be entitled to because of your disability. If you fail to participate in this advocacy process, your LTD benefits will be reduced by an estimate of the expected Social Security award until the Claims Administrator receives documentation of your Social Security application. If your initial application for Social Security Disability benefits is denied, the Plan requires you to reapply. In the event Social Security Disability benefits are denied upon re-application, the Plan requires you to appeal the denial before an Administrative Law Judge. If the Administrative Law Judge denies your application, your disability benefits will be reinstated retroactively. If a determination of your Social Security Disability benefit has not yet been made within the first 30 days of the start of your Long Term Disability Plan benefits, the Claims Administrator will reduce your Plan benefit using an estimated Social Security amount. 145

147 Long Term Disability Plan How Payments Are Made Medical Information Long term disability benefits are paid monthly. Benefits are prorated for any period of disability lasting less than a month. If amounts from another source for which the Plan reduces benefits are paid to you in a lump sum, the Claims Administrator considers those benefits as if they were paid in monthly installments prorated over the period the lump sum was intended to cover. Objective findings of a disability are necessary to substantiate the period of time your health care practitioner indicates you are disabled. Objective findings are those that can be observed by your health care practitioner through objective means, not from your description of the symptoms. Objective findings include: Physical examination findings (functional impairments/capacity); Diagnostic test results/imaging studies; Diagnoses; X-ray results; and Observation of anatomical, physiological or psychological abnormalities. Requirement to Update Medical Information If your claim is approved by the Claims Administrator, your health care practitioner will periodically be requested to submit updated medical information regarding your continuing disability. Payments will end if information required to revalidate your claim is not received within 30 days of the initial request. You are responsible for the expense involved in obtaining updated medical information regarding your disability. The Claims Administrator may require you, from time to time, to undergo an independent medical examination (IME) and/or a functional capacity evaluation (FCE). If you do not cooperate with this request (for example, you fail to keep a scheduled appointment), your benefits will end. If the Claims Administrator requests that you undergo an independent medical examination and/or a functional capacity test, the examination is made at the Company s expense. 146

148 Plan Administration PLAN ADMINISTRATION COORDINATION OF BENEFITS Which Plan Pays First How COB Works for Medical (Including Medicare), Dental and Vision Expenses Coordination of Benefits Examples CLAIMS APPEAL PROCEDURE Claims and Claims Filing General Overview and Explanations Claim Denials or Adverse Benefit Determinations FILING AND APPEALING CLAIMS Step 1: You File a Claim with the applicable Claims Administrator Step 2: Claims Administrator Makes an Initial Decision on Your Claim Step 3: You Appeal a Denial of Your Initial Claim First-Level Appeal Step 4: Claims Administrator Reviews Your Appeal and Makes a Decision Step 5: Your Options if Your First-Level Appeal Is Denied Step 6: Second Level of Appeal for Claims Step 7: External Review Process Step 8: You File Suit in Federal Court RECOVERY OF BENEFITS RIGHTS OF RESTITUTION AND REIMBURSEMENT AND SUBROGATION ACCESS TO RECORDS ADMINISTRATION AND OTHER INFORMATION Plan Name, Type, Funding and Number Plan Administrator Employer and Plan Sponsor Employer Number Agent for Service of Legal Process Type of Administration No Contract of Employment Non-Assignment of Rights Plan Amendment and Termination Claims Administrators and Suppliers Other Third Party Administrators Plan Year Alternate Payee Provision Reliance on Documents and Information No Waiver Physician/Patient Relationship Intention of the Dental Plan to Be Grandfathered USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION UNDER HIPAA STATEMENT OF ERISA RIGHTS Receive Information About Your Plan and Benefits Continue Group Health Plan Coverage Prudent Actions by Plan Fiduciaries Enforce Your Rights Assistance with Your Questions ERISA RIGHTS DO NOT APPLY TO CERTAIN PROGRAMS PLAN INTERPRETATION COLLECTIVE BARGAINING AGREEMENT

149 Plan Administration COORDINATION OF BENEFITS Eaton uses a coordination of benefits (COB) process to determine benefit payments from the Medical, Dental and Vision Plans. COB applies when benefits for the same expenses for you or any of your covered dependent are payable from another group health plan. Other group health plans include government plans, employer-sponsored plans and HMOs. COB helps to avoid double payments and control costs. Which Plan Pays First When expenses are eligible for coverage from more than one plan, the plan identified as the primary plan pays benefits first, based on its plan rules. Then the secondary plan determines what it will pay, if anything. This section explains how the plans decide which plan is primary. For Employees. If Primary Plan Secondary Plan You are covered by more than one group health plan You are an active Eaton employee and you have a second job that provides coverage The other group health plan does not have a COB clause The other plan is motor vehicle liability or uninsured/ underinsured coverage The plan that covers the patient as an active employee The plan that covers the patient as an active employee The plan that covers the patient as a retiree The plan that has covered you the longest The other group health plan The motor vehicle liability or uninsured/underinsured coverage The plan that covers the patient as a dependent The plan that covers the patient as a retiree The plan that covers the patient as a dependent The plan that has covered you for the least amount of time The Eaton Plan The Eaton plan For Dependent Children Covered by Both Parents Plans. If Primary Plan Secondary Plan The parents are not divorced or legally separated The parents are divorced or legally separated A parent who has legal custody remarries A parent is assigned financial responsibility for a child s medical care expenses The plan of the parent whose birthday comes first in the calendar year* Plan of the parent who has legal custody Plan of the parent with legal custody Plan covering that parent (For a stepchild, the divorce decree determines the primary plan.) Other parent s plan Other parent s plan The plan of the stepparent is secondary. The plan of the natural parent without custody pays third. The other parent s plan * For example, if your birthday is May 1 and your spouse s birthday is December 5, your medical plan pays first. The year of each parent s birth is not a factor. If both parents have the same birthday, the plan of the parent who has been covered the longest pays first. 148

150 Plan Administration Eaton Medical Plan and Medicare. In most cases, the Eaton Medical Plan is the primary plan when a person is covered in the Plan and also eligible for Medicare. The Eaton Plan pays benefits first and Medicare is the secondary payer when: You are actively working and you or a dependent (excluding domestic partners) is covered by the Eaton Medical Plan and also eligible for Medicare. You are an active employee age 65 or older. You can choose to have Medicare be the primary payer. During the first 30 months the person covered by the Eaton Medical Plan qualifies for Medicare because of end stage renal disease (ESRD). You cover your domestic partner under the Eaton Medical Plan and he or she is Medicare-eligible because of disability or during the first 30 months of ESRD. The Federal Secondary Medicare Payer Program identifies Medicare as the primary payer: After the person covered under the Eaton Medical Plan has qualified for ESRD for 30 months. The 30-month period starts on the earlier of the month in which the covered person: - begins a regular course of renal dialysis, or - receives a kidney transplant without first beginning dialysis. You cover your domestic partner under the Eaton Medical Plan and he or she qualifies for Medicare based on age (unless he or she has coverage through his or her own employer). When Medicare is the primary payer and the covered person enrolls in Medicare Advantage, the Eaton Plan stops paying benefits for him or her. To avoid paying for Eaton Plan coverage, you must waive coverage through the Eaton Service Center at Fidelity. If you later reenroll in Medicare Parts A and B, you can start your Eaton Plan coverage again by contacting the Eaton Service Center at Fidelity within 31 days of the date Medicare Parts A and B become effective. Other COB Rules. If the COB procedures described above fail to determine which plan is primary, then the plan covering the patient for the longest period of time pays first. However, if a plan covers a person as the dependent of a retired employee, the benefits of that plan are secondary to a plan that covers the person as the dependent of an active employee. (If the other plan does not have this provision, this exception does not apply to that plan.) Regardless of any COB provisions, the plan does not cover a dependent unless he or she meets the requirements under Eligibility for Your Dependents. How COB Works for Medical (Including Medicare), Dental and Vision Expenses When the Eaton Medical, Dental or Vision Plan is primary, the Plan calculates and pays benefits as if there is no other plan. When the Eaton Plan pays second, the Claims Administrator determines the benefits the Eaton Plan will pay as follows. Step 1: Step 2: Step 3: The Claims Administrator calculates your benefit as if the Eaton Plan paid first. The Claims Administrator compares that amount to the primary plan s benefit. If the Eaton Plan would have paid a bigger benefit than the primary plan, the Eaton Plan makes a payment toward the remaining eligible expenses. The amount the Eaton Plan pays is the difference between what it would have paid and what the primary plan already paid. The payment is made subject to all Plan provisions, and the total paid will not be more than what the Eaton Plan would have paid if it paid first. If the Eaton Plan would have paid the same or a smaller benefit than the primary plan, you receive no benefit from the Eaton Plan. This same process applies when Medicare is the primary payer and the Eaton Medical Plan is secondary. Eaton Plan benefits are reduced to reflect the Medicare Parts A and B benefits payable whether or not the covered person is enrolled. If Medicare is your primary plan, make sure to enclose the Explanation of Medicare Benefits (EOMB) when you submit expenses to the Health Plan Claims Administrator for payment. 149

151 Plan Administration Coordination of Benefits Examples Medical Example. Assume a primary care physician office visit. The charges are: Office visit charge $65 Health Plan Claims Administrator s negotiated network charge (participating physician) $55 Maximum allowed amount $60 In-Network Consumer Health 80 Plan Option Eaton Plan Is Secondary Primary Plan Paid $43 $55 Negotiated network charge x 80% Plan coinsurance $44 Eaton Plan payment if primary - $43 Paid by primary plan $ 1 Benefit payable by Eaton Plan Out-of-Network $60 Eligible charge (maximum allowed amount) x 60% Plan coinsurance $36 Eaton Plan payment if primary - $43 Paid by primary plan $ 0 Benefit payable by Eaton Plan Note: Example assumes the annual deductible has been met. The out-of-pocket payment applies to the annual out-of-pocket maximum. When the Eaton Plan is secondary, participating providers are not obligated to honor the negotiated network charge. Dental Example. Assume a covered dental expense of $250 for a crown restoration. The annual deductible has already been met. Eaton Plan Is Primary Dentist s Charge $250 Reasonable & customary expense x 50% Plan coinsurance $125 Benefit paid by Eaton Plan Employee/Patient Responsibility $125 ($250 less $125) Eaton Plan Is Secondary Dentist s Charge $250 Reasonable & customary expense $100 Primary plan payment Eaton Plan as secondary pays $25 ($25 is the difference between the Eaton Plan as primary [benefit of $125 available] and payment made by primary plan when Eaton is secondary) $100 From the primary plan + 25 From the Eaton Plan, as secondary $125 Total from both plans Employee/Patient Responsibility $125 ($250 less $125) Plan Administration $25 Applied Toward Annual Maximum 150

152 Plan Administration CLAIMS APPEAL PROCEDURE If you disagree with the Claims Administrator s decision on a claim you submitted, the Plan provides a claims appeal process. You must complete the appropriate steps in the process that is, you must exhaust your administrative remedies before you can file suit in state or federal court. This section of the SPD describes the Plan s claims appeal procedure in detail. Note that at each point in the claims process, you will receive the relevant information about your right to appeal a decision. The Claims Administrators are listed under Administration and Other Information Claims Administrator and Service Providers. The addresses for filing claims with the applicable Claims Administrator are also listed. Claims and Claims Filing General Overview and Explanations A claim is a request for benefits for items or services that is made by or on behalf of a Plan participant to the Claims Administrator. Claims must be filed according to the Plan s procedure for the applicable benefit claims. The group health plans distinguish among four types of claims: Urgent care claims are claims on which a decision must be made as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the claim is filed. The 72-hour period applies because a longer time period for processing: - could seriously jeopardize your life, health or ability to regain maximum function; or - in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that can be adequately managed only with the care or treatment requested in the claim. Concurrent care decisions relate to treatment provided on an ongoing basis over a period of time or approved for a specified number of treatments. A request to extend the course of treatment beyond the approved time period or number of treatments requires a concurrent care decision by the Claims Administrator. Benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review. Pre-service claims are claims for treatments or services that require pre-authorization as a precondition for payment of benefits or for payment of the largest benefit available. Pre-service claims differ from urgent care claims because an emergency situation does not exist. Post-service claims are claims for care that you have already received. These claims involve only the decision to approve payment to the provider or reimburse you for the cost of the services. An example of a post-service claim is paying the full price for a prescription drug at a retail pharmacy and then requesting reimbursement from the Plan. All welfare plan claims are considered to fall in this category as follows: the Dental/Vision Reimbursement Account Plan, Dependent Care Reimbursement Account Plan, Work/Life Solutions Plan, Adoption Reimbursement Benefits Plan, Disability Plan and Employee Life Insurance Plan. You must file all claims in writing except urgent care claims, which can be filed over the telephone. Your claim is considered to be filed on the date the Claims Administrator receives it. You may authorize a personal representative to act on your behalf in the claim filing and appeal process by completing and signing the form specified by the Claims Administrator. For an urgent care claim, a health care professional with knowledge of your health condition is permitted to act as your authorized representative until you are able to make a written authorization. You or your dependent for whom a claim is filed may be referred to as a claimant in some correspondence. For purposes of this claims procedure section, use of the word you means the claimant. 151

153 Plan Administration Claim Denials or Adverse Benefit Determinations The terms claims denial, denied claim and adverse benefit determination are interchangeable and refer to a claim for Plan benefits that is: Denied, Reduced, Terminated, or Fails to provide or make payment in whole or in part for the service or treatment requested. A rescission of coverage under the group health plans is also considered an adverse benefit determination. An adverse benefit determination may be based on any of the following reasons: A determination that you are not eligible to participate in the Plan, The application of utilization review, A determination that the item or service requested is experimental or investigational, or A determination that the item or service requested is not medically necessary or not appropriate. Claim denials are made in writing and can be appealed. The claim denial that you receive from the Claims Administrator will explain the next step in the appeals process. FILING AND APPEALING CLAIMS There are several steps in the claims filing and appeal process. You must complete the applicable steps for your type of claim as outlined here to exhaust your administrative procedures. Step 1: You File a Claim with the applicable Claims Administrator You can find the process for filing a claim for services toward the back of each benefit section of this booklet. Step 2: Claims Administrator Makes an Initial Decision on Your Claim After reviewing your claim, the Claims Administrator sends you an explanation of benefits (EOB) showing what the Plan will pay for the services requested in the claim and/or information about the claim, such as if it is incomplete. Required Time Frames. If you filed your claim properly, the type of claim you filed determines the amount of time the Claims Administrator has to make an initial decision on your claim. A decision as to whether your claim is accepted or denied is made as soon as possible but at least within the times shown here: Time Frames for Initial Decision on Your Claim Type of Claim Initial Decision Extension (see Extensions for Claims on the next page) Urgent care claim and urgent concurrent care decision Concurrent care decision (not urgent), pre-service (not urgent) and dental non urgent care claims Post-service for medical, dental and vision; DVRA (Dental/Vision Reimbursement Account) claims 72 hours (24 hours for urgent dental concurrent care if the claim is made at least 24 hours before the expiration of the prescribed period or number of treatments) NA 15 days 15 days 30 days 15 days for medical, prescription drug, DVRA 152

154 Plan Administration Time Frames for Initial Decision on Your Claim Disability claim 45 days 30 days; additional 30 day extension for Long Term Disability Plan Work/Life Solutions Plan and Adoption Reimbursement Benefits Plan Dependent Care Reimbursement Account (DCRA) 60 days NA 90 days 60 days Life and AD&D Plan 60 days 60 days These timeframes do not determine the date the claim is paid. Incomplete or Improperly Filed Urgent Care or Pre-Service Claims. The Claims Administrator will notify you within 24 hours of when they receive your urgent care claim if you did not: Follow the Plan s procedures for filing an initial urgent care claim, or Provide enough information in your claim for the Claims Administrator to determine whether, or to what extent, benefits are covered or payable under the Plan. Unless you request it in writing, this notice may be provided orally and will explain the proper procedures to follow and/or the specific information needed. If specific information is required, you will be given a reasonable amount of time (taking into account the medical circumstances, but at least 48 hours) to provide it. For an urgent care claim, the Claims Administrator will notify you of the benefit determination within 48 hours of whichever of the following is earlier: The date the Claims Administrator receives the specified information, or The end of the period in which you had to supply the information. The same procedures apply for a pre-service claim as for an urgent care claim, except that the Claims Administrator has five days to notify you that the pre-service claim was filed improperly or did not contain complete information. Extensions for Claims. The Claims Administrator may extend the time for its response to your initial claim by up to the days specified in the chart above under Extension for matters beyond its control, including an incomplete claim. You must be notified in writing of the extension before the initial decision period ends (15, 30, 45 or 90 days respectively), including the reasons for the extension and a description of any additional information you need to supply to complete your claim. You have 45 days (30 days for the Disability Plan) from the date the Claims Administrator sends the notification to supply the specified information. Once you provide the additional information, the Claims Administrator will notify you of the benefit determination on your initial claim within 15 days of the earlier of: The date the Claims Administrator receives the specified information, or The end of the period in which you had to supply the information. The Plan may secure independent medical or other advice and require other evidence it deems necessary to decide your claim. For the LTD Plan, if the Claims Administrator determines that, because of reasons beyond the control of the Claims Administrator, a decision cannot be reached within the 30-day extension period, the determination period may be extended for up to an additional 30 days. The Claims Administrator must notify you before the end of the first 30-day extension period, telling you the reason for the extension and the expected decision date. Decision on Your Claim. If your initial claim is denied, in whole or in part, you will receive a written notice that contains the information listed in the Required Content of Adverse Benefit Determination Notifications box on page 154. This may come in the form of an EOB. Please note that an EOB form usually meets the legal definition of a claim denial because deductibles, coinsurance and other cost-sharing charges that are normally your responsibility to pay mean that the Plan does not cover the claim at 100%. As a result, even though the percentage of the charge you must pay is defined by the Plan s cost-sharing features, the EOB will include information about your right to appeal. 153

155 Plan Administration Required Content of Adverse Benefit Determination Notifications The Claims Administrator will send you a written or electronic notification of adverse benefits determination that includes the following: Information sufficient to identify the claim involved (including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability upon request of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning). The specific reason or reasons for the denial (including the denial code and its corresponding meaning as well as a description of any standard that was used in denying the claim). Reference to the specific Plan provisions on which the determination is based. A description of any additional material or information necessary for you to perfect the claim and an explanation of why such material or information is necessary. A description of the Plan s internal appeals and external review procedures and the time limits applicable to these procedures, including a statement of your right to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on final review by the Claims Administrator. If an internal rule, guideline, protocol or other similar criterion ( internal rule ) was relied on in making the adverse determination, either the internal rule itself or a statement that such an internal rule was relied on in making the adverse benefit determination and that a copy of that internal rule will be provided to you free of charge upon request. If an adverse benefit determination is based on a medical necessity, experimental treatment or similar exclusion or limit, the notification will inform you that an explanation of the scientific or clinical judgment for the determination will be provided free of charge upon request. For health care claims, the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman who may assist you with the internal claims appeals and external review processes. For urgent care claims, a description of the expedited review process applicable to such claims. If your appeal of a claim is denied, the notification of denial will also include, if applicable: A statement describing any additional mandatory or voluntary appeal procedures offered by the Plan, including the opportunity for you to request an external review by an independent review organization. A statement that You and your Plan may have other voluntary dispute resolution options such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state insurance regulatory agency. An explanation of your right to request in writing reasonable access to and copies of all documents, records and other information relevant to your claim without charge. In the case of a second level appeal denial, the description of the Plan s standard, if any, used in denying the claim must include a discussion of the decision. Step 3: You Appeal a Denial of Your Initial Claim First-Level Appeal If you do not agree with the Claims Administrator s determination, you have 180 days (60 days for Life and AD&D Plan) from the date you receive the written denial of your initial claim to appeal the decision. Your claim appeal must be in writing and filed with the Claims Administrator at the address listed in the materials they send you (see box above). If you do not appeal within 180 days (60 days for Life and AD&D Plan), you lose your right to appeal the denial, and because you failed to exhaust your internal administrative appeal rights, you lose your right to file suit in court. For the Disability Plan, you must file your appeal of the initial claim denial within 30 days of receipt of the written notification to avoid termination of your employment. 154

156 Plan Administration Step 4: Claims Administrator Reviews Your Appeal and Makes a Decision When you appeal a claim denial, the Claims Administrator reviews your claim again and makes a decision based on all comments, documents, records and other information you have submitted. The following rules apply in group health plan review of a claim appeal: For health care benefits, someone other than the original reviewer and who does not report to the original reviewer reviews the claim decision. If the denial was based, in whole or in part, on a medical judgment, the reviewer will consult with a health care professional who has appropriate training and experience in the medical field involved. The health care professional cannot be the same person who made the original denial decision nor someone who reports to that person. The identity of medical or vocational experts who were consulted in the initial claim denial must be disclosed to you regardless of whether their advice was relied on in making the claim determination. For an urgent care claim, the review process is expedited and you can submit your request for a review orally or in writing. Necessary information may be transmitted between you and the Plan by phone, fax or any other similarly expeditious method. The review of the appeal cannot defer to the initial denial of your claim; that is, the review must stand on its own and not use the previous decision to support the decision on appeal. The Claims Administrator will send you, at no extra charge, any new or additional evidence or rationale that is considered, relied on or generated in connection with your appeal of the claim. This information must be provided to you as soon as possible so you have a reasonable amount of time to respond before the date of the final determination of the claim. Required Time Frames. Based on the type of claim, the Claims Administrator must review your appeal within a reasonable amount of time but at least within the periods shown here: Type of Claim Time Frames for Decision on Your Appeal of a Denied Claim Urgent care claim and urgent concurrent care decision Concurrent care decision (not urgent) for prescription drug and dental claims; preservice claim (not urgent) for prescription drug; and dental non urgent care claims Pre-service claim (not urgent) and concurrent care decision (not urgent) for medical; post-service claim for dental and vision; and Dental/Vision Reimbursement Account (DVRA) claims First Level Appeal Decision 72 hours NA 15 days NA Extension 30 days 15 days for vision No extension available for dental and DVRA Disability claim 45 days 45 days Post-service claim for medical, Dependent Care Reimbursement Account, Work/Life Solutions Plan, Adoption Reimbursement Benefits Plan, Life and AD&D Plan claims 60 days 60 days No extension available for Medical, Work/Life Solutions Plan and Adoption Reimbursement Benefits Plan If your claim appeal is denied, in whole or in part, the Claims Administrator will send you a written notice that contains the information listed in the Required Contents of Adverse Benefit Determination Notifications box on page 154. Extensions. The Claims Administrator may extend the time for its response to your first level appeal claim by up to the days specified in the chart above for matters beyond its control, including an incomplete claim. You must be notified in writing of the extension before the appeal decision period ends, including the reasons for the extension and a description of any additional information you need to supply to complete your claim. 155

157 Plan Administration Step 5: Your Options if Your First-Level Appeal Is Denied If the Claims Administrator denies your claim after a first-level appeal for Dependent Care Reimbursement Account and Work/Life Solutions Plan claims, you may file suit in court (see Step 8). For all other benefits, if the Claims Administrator denies your claim after a first-level appeal, you have these options available to you: For medical claims: - file a voluntary second-level appeal with the Health Plan Administrator (see Step 6), - in certain circumstances, you may request an external review by an independent review organization (may be done at the same time as filing for a voluntary appeal) (see Step 7), or - file suit in court (see Step 8). For prescription drug claims: - urgent care claims, request an expedited external review by an independent review organization (see Step 7) or file suit in court (see Step 8). - non-urgent drug claims, you must file a second-level appeal with the Health Plan Claims Administrator (see Step 6). For dental claims: - urgent care claims, request a voluntary second-level appeal with the Plan Administrator (see Step 6). - all other dental claims, you must file a second-level appeal with the Plan Administrator (see Step 6). For vision and DVRA claims, you must file a second-level appeal with the Plan Administrator (see Step 6). For Disability Plan claims, you must file a second-level appeal with the Claims Administrator (see Step 6). For Life and AD&D claims, file suit in court (see Step 8). Step 6: Second Level of Appeal for Claims. Mandatory Second-Level Appeal. If the Claims Administrator denies your claim for prescription drug, non-urgent care dental, vision, DVRA, disability and life benefits in your first-level appeal and you do not agree with the determination, you must appeal the decision (file a second-level appeal) with the Claims or Plan Administrator for a final determination as follows: For prescription drug non-urgent drug claims, you must file a second-level appeal with the Health Plan Claims Administrator within 90 days from the date you receive the written denial For all dental except urgent care claims: you must file a second-level appeal with the Plan Administrator within 60 days from the date you receive the written denial For vision claims, you must file a second-level appeal with the Plan Administrator within 60 days from the date you receive the written denial For DVRA claims, you must file a second-level appeal with the Plan Administrator within 30 days from the date you receive the written denial For Disability Plan claims, you must file a second-level appeal with the Claims Administrator within 180 days from the date you receive the written denial If you do not appeal within the times specified above, you lose your right to appeal the denial, and you lose your right to file suit in court because you failed to exhaust your internal administrative appeal rights. In reviewing the denial of your appeal, the Administrator must comply with the same standards in Step 4. A decision will be made within 15 days (30 days for post-service dental, vision and DVRA claims, 45 days for Disability Plan claims (with possible extension of 45 days), of when the Administrator receives your appeal. You will be notified in writing of the decision on your appeal. If your claim is denied, you may file a suit in federal court (see Step 8) or in certain circumstances, you may request an external review (see Step 7). 156

158 Plan Administration Voluntary Second-Level Appeal for Medical and urgent care Dental Claims. If the Claims Administrator denies your medical claim appeal and you do not agree with the determination, you may file a voluntary appeal with the Plan Administrator. Your appeal must be in writing and filed with the Plan Administrator at the address listed under Administration and Other Information Plan Administrator within 45 days for medical claim and 60 days for dental Plan claim of receiving the Claims Administrator s determination of your first appeal. At the same time as you file the voluntary appeal, you may file a suit in federal court (see Step 8) or, in certain circumstances for a medical claim, you may request an external review (see Step 7). The Plan Administrator will not assert a failure to exhaust administrative remedies if you elect to pursue a claim in court after the first-level appeal, rather than through the voluntary level of appeal or external review process. The running of any statute of limitations applicable to pursuing your claim in court will be suspended during the period of the voluntary appeal process. Your decision on whether to pursue a voluntary appeal with the Plan Administrator has no effect on your right to any other benefits under the Plan. The Plan Administrator has 30 days (with the option to extend by an additional 30 days) for the Medical Plan or 10 days for the Dental Plan to review your voluntary appeal and make a decision. Because the appeal is voluntary, you do not have to complete this step. You may file a suit in federal court (see Step 8) or in certain circumstances, you may request an external review for medical claims (see Step 7) at the same time as requesting a voluntary appeal. Step 7: External Review Process You may request an external review by an Independent Review Organization (IRO) when you receive a denial of: Your initial urgent care claim, Your first-level appeal of a non-urgent medical claim, or Your second-level appeal of a non-urgent prescription drug claim. Your claim is eligible for external review if: You are or were covered under the Plan when the health care item or service was requested or provided; The claim or appeal denial was based on medical judgment or was a rescission of coverage; You have exhausted all of the Plan s claims and appeal processes up to the external review process if it is a non-urgent care claim; and You have provided all information and forms required to process the external review. Your request for an external review must be in writing and filed with the Claims Administrator within four months of receiving your claim denial. Although it is not required, you may include issues, comments, documents, records and other information relating to your claim that you want considered in the external review. Standard (non-expedited) External Review. Within five days of receiving your request, the Claims Administrator must determine if your claim appeal is eligible for an external review. The Claims Administrator will notify you in writing within one day of the decision on your claim s eligibility for an external review. If your request is complete but not eligible for an external review, the notice will include the reasons your request is ineligible and contact information for the Employee Benefits Security Administration. If your request is incomplete, the notice will describe the information needed to complete the request. You will have until the later of the end of the four-month period you had to file the request for an external review or the 48-hour period after you receive the notice to provide the missing information. The Claims Administrator assigns eligible claims to an independent review organization (IRO). The IRO notifies you when the review process is beginning, and you will have 10 business days following receipt of the notice to provide the IRO with additional information to consider in your appeal. The IRO will provide written notice of the final external review decision within 45 days after it receives your request for external review. 157

159 Plan Administration The IRO will not defer to the decisions made during the internal appeal process and will consider all the information and documents that it receives in a timely manner when making its decision. Expedited External Review. You may request an expedited external review for an urgent care claim at the same time you request a first-level appeal of a denied claim by the Claims Administrator. For other claims, you may request an expedited external review if your claim is denied after the first-level appeal, and: The time for completing the standard external review process would jeopardize your life, health or ability to regain maximum function; or The denial of the first-level appeal concerned the admission, availability of care, continued stay or health care item or service for which you received emergency services, and you have not yet been discharged from a facility. In general, the same rules that apply to a standard external review apply to an expedited external review, except that the time frame for decisions and notifications is shorter. The Claims Administrator will immediately conduct a preliminary review to determine if your claim is eligible for an external review. After the preliminary review is complete, the Claims Administrator will immediately notify you of its determination. If your claim is eligible for an expedited external review, your claim will be assigned to an IRO. The IRO will provide you its final decision as expeditiously as your medical condition or circumstances require, but in no event will the notification be provided later than 72 hours after the IRO receives the request for expedited external review. If you receive a verbal notice, a written notice will follow no more than 48 hours later. External Review Decision Is Final. All claim decisions of the external IRO are final. If the IRO reverses the denial of your claim, the decision will be final and the Plan must immediately provide coverage or payment. Step 8: You File Suit in Federal Court You have the right to file suit in federal court under ERISA Section 502(a) if the Claims Administrator denies your: Initial urgent care claim First-level appeal of a pre-service, concurrent or post-service medical claim, Dependent Care Reimbursement Account, Work/Life Solutions Plan, Adoption Reimbursement Benefits Plan and Life and AD&D Plan claims Second-level appeal of a prescription drug claim, dental (except for urgent care), vision, DVRA and disability claims Voluntary appeal In these cases, you are considered to have exhausted the administrative review process. You must file suit within one year after the date of the claim determination. Any suit must be filed in Ohio state court or in the United States District Court for the Northern District of Ohio and no other. The running of the one-year time period may be suspended during a voluntary appeal for urgent care claims. 158

160 Plan Administration RECOVERY OF BENEFITS The Company has the right to recover benefits payments that are made in error. It may do on its own behalf or through the Claims Administrator or other third party administrators. For health care plans, payments made in error include, but are not limited to, payments that are: More than the amount allowed under a Plan. Made incorrectly on behalf of a dependent. Made for services the Plan does not cover. Recovery may be made from any person or health care provider to whom the payments were made or from future benefits the covered person is entitled to. For disability plans, payments made in error include, but are not limited to, payments that are: Wrong. Made for any period you fail to provide satisfactory evidence of a covered disability. Not reduced by the total amount of certain other sources of income as listed in the Eaton Short Term Disability Plan and Long Term Disability Plan. Retroactive payments you receive from any of the listed sources of other income must be immediately disclosed to the Claims Administrator. Excess payments will be recovered directly from you, or if necessary, from future benefit payments or from your estate, to the extent permitted by law. 159

161 Plan Administration RIGHTS OF RESTITUTION AND REIMBURSEMENT AND SUBROGATION If the Plan provides or pays benefits to treat an injury or sickness: Caused by the act or omission of another party; Covered by no fault or employers liability laws; Covered by Workers Compensation if disabling; Available or required to be furnished by or through national or state governments or their agencies; or Sustained on the property of a third party that has premises liability insurance available, then: The Plan, or Claims Administrator on behalf of the Plan, has the equitable right to recover the value of services and payments made under the Plan as well as an equitable lien on any moneys that might be owed to you for the injury or sickness. This right is by restitution and reimbursement or subrogation, and exists because the benefit payable under the Plan is the net amount of covered claims after taking all other forms of recovery into account. The right of restitution and reimbursement means you or a covered dependent must repay the Plan at the time a recovery is made. Accordingly, if you receive benefits under any of the circumstances listed, you must repay the Plan the amount of the benefits you receive from another source up to the amount you have received from the Plan because the Plan has an equitable lien in that amount. Recovery includes all amounts received by you or a covered dependent from any persons, organizations or insurers by way of settlement, judgment, award or otherwise on account of such injury or sickness. The right of subrogation means that the Plan, the Claims Administrator or another third party acting on behalf of the Plan may make claim in your or your covered dependent s name or the Plan s name against any persons, organizations or insurers on account of such injury or sickness. The rights of restitution and reimbursement or subrogation apply whether or not you or a covered dependent has been fully compensated for his or her losses or damages by any recovery of payments. If a covered person settles a claim against a third party, he or she is deemed to have been made whole by such settlement and the Plan, or the Claims Administrator or other third party acting on behalf of the Plan, is entitled to immediately collect the present value of its subrogation rights as the first priority claim from said settlement or judgment. The Plan is entitled to the first dollars recovered. No attorney s fees will be payable from any subrogation recovery unless the Plan has been notified of the attorney s proposed representation in advance, and unless the Plan has agreed in writing to the representation of the Plan s interests by that attorney. Under certain circumstances, a covered person will be required to hold the Company and the Plan harmless against future claims for covered expenses pertaining to the injury or sickness for which a settlement is reached. These rights of restitution and reimbursement or subrogation apply to any type of recovery from any third party, including but not limited to recoveries from tort-feasors, underinsured motorist coverage, uninsured motorist coverage, other substitute coverage or any other right of recovery, whether based on tort, contract, equity or any other theory of recovery. Any amounts a covered person receives from such a recovery must be held in trust for the Plan s benefit to the extent of the Plan s restitution and reimbursement or subrogation claims. Covered persons must cooperate fully in every effort by the Plan, the Claims Administrator or another third party acting on behalf of the Plan to enforce the Plan s rights of restitution and reimbursement or subrogation. Covered persons must not do anything to interfere with those rights. The Plan has the right to discontinue the payment of benefits if the covered person fails to cooperate. The Plan also has the right to seek reimbursement from the covered person for the amount of benefits paid related to that loss. Covered persons agree to promptly inform the Claims Administrator in writing of any situation or circumstance that may allow it to invoke the Plan s rights under this section. ACCESS TO RECORDS By filing a claim for benefits and/or enrolling for coverage under the Plan (including the assignment of default coverage if you do not actively enroll), you authorize the Plan Administrator, Claims Administrator, other third party administrators and their representatives (collectively the Administrators ) to have access to any health records and medical information held by any health care provider who delivers services to you under the Plan. For a disability claim, you further allow access to any health records or medical information held by any health care provider and employment information held by any employer. You also authorize the Administrators to use your health records and medical information for claims processing (including, without limitation, claims for restitution and reimbursement or subrogation under the Plan), health care, dental or disability claims data evaluation, quality of care assessment, health service utilization review and evaluation of potential or actual claims against the Administrators. 160

162 Plan Administration ADMINISTRATION AND OTHER INFORMATION Plan Name, Type, Funding and Number Plan Name Plan Type Plan Funding* Plan Number Eaton Corporation Group Insurance Plan for U.S. Employees, which includes: Medical Expense Benefits Prescription Drug Program Dental Plan Eaton Corporation Group Insurance Plan for U.S. Employees, which includes: Vision Plan Group health plan Group health plan The Plan is self-insured. Contributions to cover the cost of the Plan are made by enrolled active employees, other covered persons and the Company. Plan benefits are funded by the Company in whole or in part through a voluntary employee benefits association ( VEBA ) Trust for which Key Trust Company of Ohio, NA, serves as Trustee. The Trustee s address is Key Center, 127 Public Square, Cleveland, OH If the Trust is terminated and residual assets remain after all liabilities and all expenses of the Plans funded by the VEBA and the Trust have been satisfied, the Trustee will, at the direction of the Company, apply those assets to provide (directly or through the purchase of insurance) life, sickness, accident or other permissible benefits to employees, former employees or their eligible dependents under the plans. The Plan is fully insured under a group insurance contract with Combined Insurance Company of America (Combined). EyeMed Vision Care, Inc. reviews and pays claims on behalf of Combined. Premiums are paid by enrolled active employees through payroll deduction and by other covered persons to Combined

163 Plan Administration Plan Name Plan Type Plan Funding* Plan Number HSA Eaton Corporation Flexible Benefits Program, which includes: Eaton Corporation Health Care Reimbursement Account Plan Eaton Corporation Dependent Care Reimbursement Account Plan (DCRA) Purchased Vacation Program Eaton Corporation Group Insurance Plan for U.S. Employees (also known as the Eaton Work/Life Solutions Plan and Adoption Reimbursement Benefits Plan), which includes: Employee Assistance Program Eaton Center On-site Health Center Wellness Information and Tools Program Tobacco Cessation Program Legal Assistance Program Adoption Reimbursement Benefits Plan Eaton Corporation Group Insurance Plan for U.S. Employees, which includes: Short Term Disability Plan (STD Plan) Long Term Disability Plan (LTD Plan) A trustee account administered by Fidelity Brokerage Services, LLC A cafeteria plan under Section 125 of the Internal Revenue Code. The Health Care Reimbursement Account Plan is a group health plan. The Dependent Care Reimbursement Account Plan is a dependent care plan under Section 129 of the Internal Revenue Code and is not subject to ERISA. Welfare plan offering group health benefits through the Personal Counseling Program, Eaton Center On-site Health Center (Health Center) and the Tobacco Cessation Program; and group legal benefits through the Legal Assistance Program Welfare plan offering disability benefits The Company reserves the right to change Health Savings Account contributions at any time for any reason. Contributions are made by the Company and employees. It is not subject to ERISA. Employees elect before-tax payroll deductions (see pages 7 and 8) to receive benefits under the Plans. Benefits (reimbursement of eligible expenses) are paid from employee contributions and Eaton s general assets. The DCRA is self-insured. Except for the Adoption Reimbursement Benefits Plan, Wellness Information and Tools Program, Tobacco Cessation Program, and Health Center, the Work/Life Solutions Plan is fully insured through a contract with the EAP provider. The Company pays the full cost of the insurance for these insured programs. The Company pays the full cost of the Adoption Reimbursement Benefits Plan, Wellness Information and Tools Program, Tobacco Cessation Program and Health Center out of its general assets. The STD Plan is self-insured. Coverage is provided at no cost to eligible employees. Benefits are paid by the Company from its general assets. The LTD Plan is self-insured. Benefits are funded by employees and the Company, in whole or in part, from its general assets

164 Plan Administration Plan Administrator Plan Name Plan Type Plan Funding* Plan Number Eaton Corporation Group Insurance Plan for U.S. Employees, which includes: Employee Life Insurance Plan Employee Accidental Death and Dismemberment Insurance Plan Spouse/Domestic Partner Life Insurance Plan Child Life Insurance Plan Spouse/Domestic Partner Accidental Death and Dismemberment Insurance Plan Child Accidental Death and Dismemberment Insurance Plan Welfare plan offering life and accidental death and dismemberment benefits Eaton Health and Welfare Administrative Committee c/o Eaton 1000 Eaton Boulevard Cleveland, OH Telephone number: Employer and Plan Sponsor Employer Number The Employer and Plan Sponsor is: Eaton Corporation 1000 Eaton Boulevard Cleveland, OH Telephone number: The Employer Identification Number is The Plans are fully insured through a group insurance contract with Securian. Securian reviews and pays claims. Premiums for the Companypaid Employee Life and Accidental Death and Dismemberment Insurance Plans are paid by the Company out of its general assets. Premiums for additional coverage under the Employee Life and Accidental Death and Dismemberment Insurance Plans, and the Spouse/Domestic Partner and Child Life and Accidental Death and Dismemberment Insurance Plans are paid through employee contributions

165 Plan Administration Agent for Service of Legal Process The agent for service of legal process is: Senior Vice President and Secretary Eaton 1000 Eaton Boulevard Cleveland, OH Telephone number: Service of legal process may also be made upon the Plan Administrator. For disputes arising under the Eaton Work/Life Solutions Plan (except for the Tobacco Cessation Program, Wellness Information and Tools, and Health Center), service of legal process may be made upon Anthem EAP at 700 Broadway, Denver, CO For disputes arising under the Life Insurance Plan insurance policy, service of legal process may be made upon Securian at one of its local offices, or upon the supervisory official of the Insurance Department in the state in which you reside. Type of Administration Eaton, as Plan Sponsor, has retained the services of Fidelity Employer Services Company, a division of Fidelity Investments Institutional Services Company, Inc., an independent contractor, to assist the Plan Administrator with certain administrative functions (other than claims administration) in connection with most benefits in the Eaton Plans. Fidelity Employer Services Company performs these services under the name Eaton Service Center at Fidelity. The Health and Welfare Administrative Committee, as Plan Administrator, is responsible for certain administrative functions as described in this booklet and as required by ERISA. Claims for benefits are administered by the applicable claims administrators. The Health Savings Account is a trustee account administered by Fidelity Brokerage Services, LLC. Participation in an HSA is a taxpayer responsibility and you are strongly encouraged to consult your tax advisor before opening an HSA. You are also encouraged to review information available from the Internal Revenue Service (IRS) for taxpayers, which can be found on the IRS Web site at Anthem EAP administers the programs offered under the Work/Life Solutions Plan (except for the Tobacco Cessation Program, Wellness Information and Tools, and Health Center) under the terms of its contract with Eaton. Anthem administers the Tobacco Cessation Program and Wellness Information and Tools under a separate contract with Eaton. Take Care Employer Solutions, LLC administers the Health Center under the terms of a separate contract with Eaton. The Life Insurance Plan is fully insured. Benefits are provided under a group insurance contract entered into between the Company and Securian. Securian is responsible for reviewing and paying claims. No Contract of Employment The Eaton Plans and offer of enrollment options are not intended to be and may not be construed as constituting a contract or other arrangement between an employee and the Company to the effect that an employee will be employed for a specific period of time. 164

166 Plan Administration Non-Assignment of Rights No benefit, right or interest of any person covered under any Eaton Plan is assignable. Nothing contained in the Plan or this booklet shall be construed to make the Plan or the Company liable for treatment or services. Plan Amendment and Termination Although the Company s present intent is to continue the Plans described here indefinitely, you should be aware that the Company retains the right to substitute other coverage or change contributions, or to amend, change, modify or completely terminate the Plan and any programs or options under it, for any or all groups of employees at any time for any reason. Neither this booklet nor any other writing regarding the Plan or the Flexible Benefits Program grants or confers any vested or other rights to any employee, retiree, dependent or any other person for future benefits beyond covered expenses incurred while the applicable Plan, program or option is in effect. The Company may amend the provisions of any Eaton Plan at any time by written action of an officer of the Company or any individual designated in writing by that officer as authorized to take such action. Designees include (but are not limited to) the employees holding the following positions at the Company s World Headquarters: the Vice President, Compensation and Benefits and the Vice President, Benefits. Amendment will be effective at the time designated in the amendment itself. The Company may discontinue or terminate any Eaton Plan, in whole or in part, at any time for any reason by written action of an officer of the Company. If an Eaton Plan is terminated, no future benefits will be paid from that Plan, except benefits for covered services received before the Plan s termination date or benefits for disabilities beginning before the plan s termination date. Claims Administrators and Suppliers Benefit Claims Administrator Claims Filing Address Medical Expense Benefits, including MH/SA Prescription Drug Program Castlight Health Fidelity Investments Brokerage Services, LLC Anthem Blue Cross Blue Shield 85 Crystal Run Road Middletown, NY EATON02 ( ) Utilization Review Express Scripts 8111 Royal Ridge Parkway Irving, TX Castlight Health 150 Spear Street, Suite 400 San Francisco, CA NA Claims filing: Anthem Blue Cross Blue Shield P.O. Box Atlanta, GA Appeals: Anthem Blue Cross Blue Shield Grievances and Appeals P.O. Box Atlanta, GA EATON02 ( ) Anthem Managed Care P.O. Box 5076 Middletown, NY EATON02 Express Scripts P.O. Box Lexington, KY NA Fidelity Brokerage Services, LLC 900 Salem Street Smithfield, RI

167 Plan Administration Benefit Claims Administrator Claims Filing Address Dental Plan Vision Plan Eaton Corporation Flexible Benefits Program, which includes: Eaton Corporation Health Care Reimbursement Account Plan Eaton Corporation Dependent Care Reimbursement Account Plan Purchased Vacation Program Counseling Program, Legal/Financial Consultation, Convenience, Child and Elder Care Services Wellness Information and Tools Program, Tobacco Cessation Program, and Eaton Center On-site Health Center Adoption Reimbursement Benefits Plan For written inquiries: Delta Dental P.O Lansing, MI EATON03 ( ) EyeMed Vision Care LLC ATTN: Vision Care Department 4000 Luxottica Place Mason, Ohio Acclaris, Inc Purchased Vacation Program Eaton Service Center at Fidelity EATON01 ( ) Anthem EAP 700 Broadway Denver, CO Eaton Health and Welfare Administrative Committee 1000 Eaton Boulevard Cleveland, OH Eaton Service Center at Fidelity EATON01 ( ) Claims filing and initial appeal: Delta Dental P.O Farmington Hills, MI Second Appeal: Eaton Health and Welfare Administrative Committee c/o Eaton 1000 Eaton Boulevard Cleveland, OH EyeMed Vision Care LLC ATTN: Quality Assurance Department 4000 Luxottica Place Mason, Ohio Claims filing and initial appeal: Acclaris, Inc. P.O. Box Lehigh Valley, PA Fax: Second Appeal: Eaton Health and Welfare Administrative Committee 1000 Eaton Boulevard Cleveland, OH Purchased Vacation Program: Eaton Service Center at Fidelity EATON01 ( ) Anthem EAP 700 Broadway Denver, CO Eaton Health and Welfare Administrative Committee 1000 Eaton Boulevard Cleveland, OH Eaton Service Center at Fidelity EATON01 ( ) 166

168 Plan Administration Benefit Claims Administrator Claims Filing Address Eaton Corporation Disability Plan, which includes: Short Term Disability Plan (STD Plan) Long Term Disability Plan (LTD Plan) General Correspondence: Sedgwick P.O. Box Lexington, KY Initial and second appeals: Sedgwick P.O. Box 1981 Chicago, IL Eaton Corporation Employee Life Insurance Plan, which includes: Employee Life Insurance Plan Employee Accidental Death and Dismemberment Insurance Plan Spouse/Domestic Partner Life Insurance Plan Child Life Insurance Plan Spouse/Domestic Partner Accidental Death and Dismemberment Insurance Plan Child Accidental Death and Dismemberment Insurance Plan Travel Assistance Plan Securian Life Insurance Company 400 Robert Street North St. Paul, MN Redpoint LLC 1875 South Grant Street, Suite 960 San Mateo, CA (U.S. and Canada) (International) The life insurance plan is insured under policy number 70231, and the voluntary accidental death and dismemberment plan is insured under policy number issued to the Company by Securian. Claims and Appeals Correspondence: Securian Attn: Group Division Claims P.O. Box St. Paul, MN NA Other Third Party Administrators COBRA/Billing Services Administrator. The Eaton Service Center at Fidelity Telephone number: EATON01 ( ) Qualified Medical Child Support Order (QMCSO) Administrator. QDRO Consultants Company Telephone number: Plan Year All Plan records are compiled on an annual basis from January 1 through December 31 the calendar year. The Plan Year is referred to as the year or the calendar year in this booklet. 167

169 Plan Administration Alternate Payee Provision Under normal conditions, Eaton Medical, Dental and Vision Plan benefits are payable to you and can only be paid directly to another party upon signed authorization from you. If conditions exist under which a valid release or assignment cannot be obtained, the Plan may make payment to any individual or organization that has assumed the care or principal support for you and is equitably entitled to payment. The Plan must make payments to your separated/divorced spouse, state child support agencies or Medicaid agencies if required by a qualified medical child support order (QMCSO) or state Medicaid law. The Plan may also honor benefit assignments made prior to your death in relation to remaining benefits payable by the Plan. Any payment made by the Plan in accordance with this provision will fully release the Plan of its liability to you. Reliance on Documents and Information No Waiver Information required by the Plan Administrator may be provided in any form or document that the Plan Administrator considers acceptable and reliable. The Plan Administrator relies on the information provided by you and your dependents seeking coverage when evaluating coverage and benefits under the Plan. All such information must be accurate, truthful and complete. The Plan Administrator is entitled to conclusively rely upon, and is protected for any action taken in good faith when relying upon, information you or others provide. Any act, practice or omission that constitutes fraud or any intentional misrepresentation of material fact may result in the denial of the claim, cancellation or rescission of coverage, or any other legal remedy available to the Plan. Inadvertent omissions or unintentional misrepresentations are not grounds for rescission of coverage. The failure of the Plan Administrator to enforce strictly any term or provision of this Plan will not be construed as a waiver of such term or provision. The Plan Administrator reserves the right to enforce strictly any term or provision of this Plan at any time. Physician/Patient Relationship This Plan is not intended to disturb the relationship between a physician or other health care provider and the patient. Physicians and other health care providers are not agents or delegates of the employer, Plan Administrator or the Health Plan Claims Administrator. Nothing contained in this Plan requires you or your dependent to commence or continue medical treatment by a particular provider. Further, nothing in this Plan limits or otherwise restricts a physician s judgment with respect to the physician s ultimate responsibility for patient care in the provision of medical services to you or your dependent. Intention of the Dental Plan to Be Grandfathered The Eaton Corporation Dental Plan (the Plan) believes the Plan is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that our dental plan may not include certain consumer protections of the Affordable Care Act that apply to other plans. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. It should be noted that the Plan does provide many of the benefits and protections required for non-grandfathered plans. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Plan Administrator at the Eaton Service Center at Fidelity EATON01 ( ). You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or This web site has a table summarizing which protections do and do not apply to grandfathered health plans. 168

170 Plan Administration USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION UNDER HIPAA The Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA), is a federal law that requires health plans to protect the confidentiality of your private health information. Private health information, or protected health information, is referred to as PHI. Your rights under HIPAA are described in the Plan s Notice of Privacy Practices. You can find the Notice along with Frequently Asked Questions in the Reference Library under the Health & Insurance tab on Fidelity NetBenefits. The Notice is also available from the Eaton Service Center at Fidelity. STATEMENT OF ERISA RIGHTS As a participant in the Eaton Plans, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants will be entitled to: Receive Information About Your Plan and Benefits You are entitled to examine at no charge at the Plan Administrator s office and at other specified locations, all documents governing the Plan, including insurance contracts and collective bargaining agreements, if applicable. You may also examine at no charge a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. You may obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, if applicable, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan Administrator may make a reasonable charge for the copies. You are entitled to receive at no charge a summary of the Plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of the summary annual report. Continue Group Health Plan Coverage You may continue health care coverage for yourself, your spouse or your dependents if you or your dependent(s) lose coverage under the Plan because of a qualifying event. You or your dependents may have to pay for such coverage. Review your Summary Plan Description and the documents governing the Plan on the rules of COBRA continuation coverage rights. Your group health plan or health insurance issuer should provide you with a certificate of creditable coverage at no charge when: You lose coverage under the Plan, You become entitled to elect COBRA continuation coverage, and/or Your COBRA continuation coverage ends. If you do not receive the certificate of creditable coverage, you must request the certificate within 24 months of losing coverage. Having creditable coverage from another plan may reduce or eliminate any exclusionary periods of coverage for preexisting conditions under your group health plan. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after you enroll in your coverage. Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining your welfare benefit or exercising your rights under ERISA. 169

171 Plan Administration Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial, all within certain time schedules. Under ERISA, you can take steps to enforce the above rights. For example, you can file suit in a federal court if you: Request a copy of Plan documents or the latest annual report from the Plan and do not receive it within 30 days. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. Exhaust the claims procedures described in this Summary Plan Description and your claim for benefits is denied or ignored, in whole or in part. (You may also file a claim in state court.) Disagree with the Plan s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order. Are discriminated against for asserting your rights. (You may also seek assistance from the U.S. Department of Labor.) You may also seek assistance from the U.S. Department of Labor or file suit in a federal court if it should happen that the Plan fiduciaries misuse the Plan s money. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact: The nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory; or The Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue N.W. Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA web site at or call their toll-free number at For more information about health insurance options available through a Health Insurance Marketplace, visit HealthCare.gov. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s web site.) 170

172 Plan Administration ERISA RIGHTS DO NOT APPLY TO CERTAIN PROGRAMS Your Health Savings Account is not an ERISA covered plan. As a result, Eaton has no fiduciary responsibility under ERISA with respect to the HSA, and claims with respect to the HSA are managed solely by Fidelity Investments. Other programs not subject to ERISA include: Expert Medical Opinion Dependent Care Reimbursement Account (DCRA) Purchased Vacation Program Paid Parental Leave PLAN INTERPRETATION Benefits under the Eaton Plans will be paid only if the Plan Administrator and/or the appointed Claims Administrator decides that the applicant is entitled to them under the terms of the Plan. The Plan Administrator and/or the Claims Administrator has discretionary authority to determine eligibility for benefits and to construe any and all terms of the Plan, including but not limited to any disputed or doubtful terms. The Plan Administrator and/or Claims Administrator also has the power and discretion to determine all questions arising in connection with the administration, interpretation and application of the Plan. Any and all determinations by the Plan Administrator and/or Claims Administrator will be conclusive and binding on all persons, except to the extent reviewable by a court with jurisdiction under ERISA after giving effect to the time limits described in the Claims Appeal Procedure section of this booklet. COLLECTIVE BARGAINING AGREEMENT If your employment is covered by a collective bargaining agreement that specifically allows for your participation in the Plans described in this booklet, your participation is subject to the terms and conditions of the collective bargaining agreement and the Plans. Participants and beneficiaries may obtain a complete list of the Plan s sponsoring organizations by writing to the Plan Administrator at the address shown under Administration and Other Information Plan Administrator. As a covered employee, you may obtain a copy of your respective collective bargaining agreement by writing to the Plan Administrator at the address shown under Administration and Other Information Plan Administrator. The Company may charge you a reasonable amount for the copy. As a covered employee, provided you give reasonable advance notice of your visit, you may also examine a copy of your respective collective bargaining agreement at Eaton at that same address or at the union office during normal business hours. Participants and beneficiaries may obtain a complete list of the Plan s sponsoring organizations by writing to the Plan Administrator at the address shown under Administration and Other Information Plan Administrator. 171

173 THE EATON CORPORATION GROUP INSURANCE PLAN FOR U.S. EMPLOYEES Summary of Material Modifications Summarized below are important changes to The Eaton Corporation Group Insurance Plan for U.S. Employees (the "Plan"). This Summary of Material Modifications is intended to supplement the Summary Plan Description for the Plan. Because this is only a summary, it is not meant to interpret, extend or change the actual provisions of the Plan in any way. The provisions of the Plan are definitively set forth in the Plan document. Effective as of January 1, 2017: Short Term Disability Plan Reduction of Benefit Payments Benefits paid under the Plan are reduced by the total amount of certain other income for which you may be eligible during any period of disability. These sources of other income are any: Pension or other retirement benefits you receive from any retirement plan sponsored by Eaton or any Eaton subsidiary company. Benefits for which you are eligible under Workers Compensation, occupational disease or other employer liability plan or plans. And, for all groups except Highland, IL; Troy, IL; and Syracuse, NY: - Disability benefits under any Company-sponsored program (but not benefits paid under the Accelerated Benefits Option of the Eaton Life Insurance Plan); - Disability benefits for which you are eligible under the federal Social Security laws, or under any other federal, state, county, municipal or other program either tax-supported or sponsored by any government. The reduction for Social Security Disability Insurance includes primary benefit awards only. This offset of Social Security Disability Insurance does not include Social Security retirement benefits; and - Mandatory no fault automobile insurance work-loss payments. Your Short Term Disability Plan maximum benefit is reduced by the amount of the Social Security Disability Insurance benefit for which you are eligible on the date your disability benefit begins. During the period you receive Short Term Disability Plan benefits, your Plan benefit is adjusted to reflect increases or decreases in the Social Security Disability Insurance benefit you receive. Effective Date of Coverage Only for hourly, union employees at Troy, IL & Highland, IL locations: Effective January 1, 2017 your short term disability coverage becomes effective on the first day of your employment. SMM-1

174 Effective as of January 1, 2018: Plan Administration Claims Administrators and Suppliers Benefit Claims Administrator Claims Filing Address Eaton Corporation Disability Plan, which includes: Short Term Disability Plan (STD Plan) Long Term Disability Plan (LTD Plan) General Correspondence: Sedgwick P.O. Box Lexington, KY Initial and Second Appeals: Sedgwick P.O. Box 1981 Chicago, IL Once you have exhausted the administrative review process under the Plan, you have the right to file suit in federal court under ERISA Section 502(a) within one year after the date of the claim determination. Any suit must be filed in Ohio state court or in the United States District Court for the Northern District of Ohio and no other. Effective as of April 2, 2018: Plan Administration CLAIMS APPEAL PROCEDURE If you disagree with the Claims Administrator s decision on a claim you submitted, the Plan provides a claims appeal process. You must complete the appropriate steps in the process that is, you must exhaust your administrative remedies before you can file suit in state or federal court. This section of the SPD describes the Plan s claims appeal procedure in detail. Note that at each point in the claims process, you will receive the relevant information about your right to appeal a decision. The Claims Administrators are listed under Administration and Other Information Claims Administrator and Service Providers. The addresses for filing claims with the applicable Claims Administrator are also listed. Claims and Claims Filing General Overview and Explanations A claim is a request for benefits for items or services that is made by or on behalf of a Plan participant to the Claims Administrator. Claims must be filed according to the Plan s procedure for the applicable benefit claims. The group health plans distinguish among four types of claims: Urgent care claims are claims on which a decision must be made as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the claim is filed. The 72-hour period applies because a longer time period for processing: - could seriously jeopardize your life, health or ability to regain maximum function; or - in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that can be adequately managed only with the care or treatment requested in the claim. SMM-2

175 Concurrent care decisions relate to treatment provided on an ongoing basis over a period of time or approved for a specified number of treatments. A request to extend the course of treatment beyond the approved time period or number of treatments requires a concurrent care decision by the Claims Administrator. Benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review. Pre-service claims are claims for treatments or services that require pre-authorization as a precondition for payment of benefits or for payment of the largest benefit available. Pre-service claims differ from urgent care claims because an emergency situation does not exist. Post-service claims are claims for care that you have already received. These claims involve only the decision to approve payment to the provider or reimburse you for the cost of the services. An example of a post-service claim is paying the full price for a prescription drug at a retail pharmacy and then requesting reimbursement from the Plan. All welfare plan claims are considered to fall in this category as follows: the Dental/Vision Reimbursement Account Plan, Dependent Care Reimbursement Account Plan, Work/Life Solutions Plan, Adoption Reimbursement Benefits Plan, Disability Plan and Employee Life Insurance Plan. You must file all claims in writing except urgent care claims, which can be filed over the telephone. Your claim is considered to be filed on the date the Claims Administrator receives it. You may authorize a personal representative to act on your behalf in the claim filing and appeal process by completing and signing the form specified by the Claims Administrator. For an urgent care claim, a health care professional with knowledge of your health condition is permitted to act as your authorized representative until you are able to make a written authorization. You or your dependent for whom a claim is filed may be referred to as a claimant in some correspondence. For purposes of this claims procedure section, use of the word you means the claimant. Claim Denials or Adverse Benefit Determinations The terms claim denial, denied claim and adverse benefit determination are interchangeable and refer to a claim for Plan benefits that is: Denied, Reduced, Terminated, or Fails to provide or make payment in whole or in part for the service or treatment requested. A rescission of coverage under the group health plans, or effective for disability claims filed on or after April 2, 2018, the disability plans, is also considered an adverse benefit determination. An adverse benefit determination may be based on any of the following reasons: A determination that you are not eligible to participate in the Plan, The application of utilization review, A determination that the item or service requested is experimental or investigational, or A determination that the item or service requested is not medically necessary or not appropriate. Claim denials are made in writing and can be appealed. The claim denial that you receive from the Claims Administrator will explain the next step in the appeals process. Filing and Appealing Claims There are several steps in the claims filing and appeal process. You must complete the applicable steps for your type of claim as outlined here to exhaust your administrative procedures. Step 1: You File a Claim with the applicable Claims Administrator You can find the process for filing a claim for services toward the back of each benefit section of this booklet. SMM-3

176 Step 2: Claims Administrator Makes an Initial Decision on Your Claim After reviewing your claim, the Claims Administrator sends you an explanation of benefits (EOB) showing what the Plan will pay for the services requested in the claim and/or information about the claim, such as if it is incomplete. Required Time Frames. If you filed your claim properly, the type of claim you filed determines the amount of time the Claims Administrator has to make an initial decision on your claim. A decision as to whether your claim is accepted or denied is made as soon as possible but at least within the times shown here: Time Frames for Initial Decision on Your Claim Type of Claim Initial Decision Extension (see Extensions for Claims on the next page) Urgent care claim and urgent concurrent care decision Concurrent care decision (not urgent), pre-service (not urgent) and dental non urgent care claims Post-service for medical, dental and vision; DVRA (Dental/Vision Reimbursement Account) claims 72 hours (24 hours for urgent dental concurrent care if the claim is made at least 24 hours before the expiration of the prescribed period or number of treatments) NA 15 days 15 days 30 days 15 days for medical, prescription drug, DVRA Disability claim 45 days 30 days; additional 30 day extension for Long Term Disability Plan Work/Life Solutions Plan and Adoption Reimbursement Benefits Plan Dependent Care Reimbursement Account (DCRA) 60 days NA 90 days 60 days Life and AD&D Plan 60 days 60 days These timeframes do not determine the date the claim is paid. Incomplete or Improperly Filed Urgent Care or Pre-Service Claims. The Claims Administrator will notify you within 24 hours of when they receive your urgent care claim if you did not: Follow the Plan s procedures for filing an initial urgent care claim, or Provide enough information in your claim for the Claims Administrator to determine whether, or to what extent, benefits are covered or payable under the Plan. Unless you request it in writing, this notice may be provided orally and will explain the proper procedures to follow and/or the specific information needed. If specific information is required, you will be given a reasonable amount of time (taking into account the medical circumstances, but at least 48 hours) to provide it. For an urgent care claim, the Claims Administrator will notify you of the benefit determination within 48 hours of whichever of the following is earlier: The date the Claims Administrator receives the specified information, or The end of the period in which you had to supply the information. The same procedures apply for a pre-service claim as for an urgent care claim, except that the Claims Administrator has five days to notify you that the pre-service claim was filed improperly or did not contain complete information. SMM-4

177 Extensions for Claims. The Claims Administrator may extend the time for its response to your initial claim by up to the days specified in the chart above under Extension for matters beyond its control, including an incomplete claim. You must be notified in writing of the extension before the initial decision period ends (15, 30, 45 or 90 days respectively), including the reasons for the extension and a description of any additional information you need to supply to complete your claim. You have 45 days (30 days for the Disability Plan) from the date the Claims Administrator sends the notification to supply the specified information. Once you provide the additional information, the Claims Administrator will notify you of the benefit determination on your initial claim within 15 days of the earlier of: The date the Claims Administrator receives the specified information, or The end of the period in which you had to supply the information. The Plan may secure independent medical or other advice and require other evidence it deems necessary to decide your claim. For the LTD Plan, if the Claims Administrator determines that, because of reasons beyond the control of the Claims Administrator, a decision cannot be reached within the 30-day extension period, the determination period may be extended for up to an additional 30 days. The Claims Administrator must notify you before the end of the first 30-day extension period, telling you the reason for the extension and the expected decision date. Decision on Your Claim. If your initial claim is denied, in whole or in part, you will receive a written notice that contains the information listed in the Required Content of Adverse Benefit Determination Notifications box below. This may come in the form of an EOB. Please note that an EOB form usually meets the legal definition of a claim denial because deductibles, coinsurance and other cost-sharing charges that are normally your responsibility to pay mean that the Plan does not cover the claim at 100%. As a result, even though the percentage of the charge you must pay is defined by the Plan s cost-sharing features, the EOB will include information about your right to appeal. Required Content of Adverse Benefit Determination Notifications The Claims Administrator will send you a written or electronic notification of adverse benefits determination that includes the following: For health care claims, information sufficient to identify the claim involved (including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability upon request of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning). The specific reason or reasons for the denial (including, for health care claims, the denial code and its corresponding meaning as well as a description of any standard that was used in denying the claim). Reference to the specific Plan provisions on which the determination is based. A description of any additional material or information necessary for you to perfect the claim and an explanation of why such material or information is necessary. A description of the Plan s internal appeals and external review procedures and the time limits applicable to these procedures, including a statement of your right to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on final review by the Claims Administrator and for disability claims filed on or after April 2, 2018, a statement that any civil action under section 502(a) of ERISA must be filed in the United States District Court for the Northern District of Ohio within one year after the date of the claim determination. For health care claims, if an internal rule, guideline, protocol or other similar criterion ( internal rule ) was relied on in making the adverse determination, either the internal rule itself or a statement that such an internal rule was relied on in making the adverse benefit determination and that a copy of that internal rule will be provided to you free of charge upon request. For disability claims filed on or after April 2, 2018, either the internal rule or standard, or a statement that such internal rule or standard does not exist. If an adverse benefit determination is based on a medical necessity, experimental treatment or similar exclusion or limit, the notification will inform you that an explanation of the scientific or clinical judgment for the determination will be provided free of charge upon request. SMM-5

178 For disability claims filed on or after April 2, 2018, a discussion of the decision, including an explanation of the basis for disagreeing with or not following: (i) the views presented by you to the plan of health care professionals treating you or vocational professionals who evaluated you, (ii) the views of medical or vocational experts whose advice was obtained on behalf of the plan in connection with your adverse benefit determination, without regard to whether the advice was relied upon in making the determination, and (iii) a disability determination regarding you presented by you to the plan made by the Social Security Administration. For disability claims filed on or after April 2, 2018, a statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of, all documents, records, and other information relevant to your claim for benefits. For health care claims, the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman who may assist you with the internal claims appeals and external review processes. For urgent care claims, a description of the expedited review process applicable to such claims. If your appeal of a claim is denied, the notification of denial will also include, if applicable: A statement describing any additional mandatory or voluntary appeal procedures offered by the Plan, including the opportunity for you to request an external review by an independent review organization. A statement that You and your Plan may have other voluntary dispute resolution options such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state insurance regulatory agency. An explanation of your right to request in writing reasonable access to and copies of all documents, records and other information relevant to your claim without charge. In the case of a second level appeal denial, the description of the Plan s standard, if any, used in denying the claim must include a discussion of the decision. Step 3: You Appeal a Denial of Your Initial Claim First-Level Appeal If you do not agree with the Claims Administrator s determination, you have 180 days (60 days for Life and AD&D Plan) from the date you receive the written denial of your initial claim to appeal the decision. Your claim appeal must be in writing and filed with the Claims Administrator at the address listed in the materials they send you (see box above). If you do not appeal within 180 days (60 days for Life and AD&D Plan), you lose your right to appeal the denial, and because you failed to exhaust your internal administrative appeal rights, you lose your right to file suit in court. For the Disability Plan, you must file your appeal of the initial claim denial within 30 days of receipt of the written notification to avoid termination of your employment. Step 4: Claims Administrator Reviews Your Appeal and Makes a Decision When you appeal a claim denial, the Claims Administrator reviews your claim again and makes a decision based on all comments, documents, records and other information you have submitted. The following rules apply in group health plan review of a claim appeal: For health care benefits, someone other than the original reviewer and who does not report to the original reviewer reviews the claim decision. If the denial was based, in whole or in part, on a medical judgment, the reviewer will consult with a health care professional who has appropriate training and experience in the medical field involved. The health care professional cannot be the same person who made the original denial decision nor someone who reports to that person. The identity of medical or vocational experts who were consulted in the initial claim denial must be disclosed to you regardless of whether their advice was relied on in making the claim determination. For an urgent care claim, the review process is expedited and you can submit your request for a review orally or in writing. Necessary information may be transmitted between you and the Plan by phone, fax or any other similarly expeditious method. SMM-6

179 The review of the appeal cannot defer to the initial denial of your claim; that is, the review must stand on its own and not use the previous decision to support the decision on appeal. The Claims Administrator will send you, at no extra charge, any new or additional evidence or rationale that is considered, relied on or generated in connection with your appeal of the claim. This information must be provided to you as soon as possible so you have a reasonable amount of time to respond before the date of the final determination of the claim. Required Time Frames. Based on the type of claim, the Claims Administrator must review your appeal within a reasonable amount of time but at least within the periods shown here: Type of Claim Time Frames for Decision on Your Appeal of a Denied Claim Urgent care claim and urgent concurrent care decision Concurrent care decision (not urgent) for prescription drug and dental claims; preservice claim (not urgent) for prescription drug; and dental non urgent care claims Pre-service claim (not urgent) and concurrent care decision (not urgent) for medical; post-service claim for dental and vision; and Dental/Vision Reimbursement Account (DVRA) claims First Level Appeal Decision 72 hours NA 15 days NA Extension 30 days 15 days for vision No extension available for dental and DVRA Disability claim 45 days 45 days Post-service claim for medical, Dependent Care Reimbursement Account, Work/Life Solutions Plan, Adoption Reimbursement Benefits Plan, Life and AD&D Plan claims 60 days 60 days No extension available for Medical, Work/Life Solutions Plan and Adoption Reimbursement Benefits Plan If your claim appeal is denied, in whole or in part, the Claims Administrator will send you a written notice that contains the information listed in the Required Contents of Adverse Benefit Determination Notifications box above. Extensions. The Claims Administrator may extend the time for its response to your first level appeal claim by up to the days specified in the chart above for matters beyond its control, including an incomplete claim. You must be notified in writing of the extension before the appeal decision period ends, including the reasons for the extension and a description of any additional information you need to supply to complete your claim. Step 5: Your Options if Your First-Level Appeal Is Denied If the Claims Administrator denies your claim after a first-level appeal for Dependent Care Reimbursement Account and Work/Life Solutions Plan claims, you may file suit in court (see Step 8). For all other benefits, if the Claims Administrator denies your claim after a first-level appeal, you have these options available to you: For medical claims: - file a voluntary second-level appeal with the Health Plan Administrator (see Step 6), - in certain circumstances, you may request an external review by an independent review organization (may be done at the same time as filing for a voluntary appeal) (see Step 7), or - file suit in court (see Step 8). SMM-7

180 For prescription drug claims: - urgent care claims, request an expedited external review by an independent review organization (see Step 7) or file suit in court (see Step 8). - non-urgent drug claims, you must file a second-level appeal with the Health Plan Claims Administrator (see Step 6). For dental claims: - urgent care claims, request a voluntary second-level appeal with the Plan Administrator (see Step 6). - all other dental claims, you must file a second-level appeal with the Plan Administrator (see Step 6). For vision, DVRA and Disability Plan claims, you must file a second-level appeal with the Claims Administrator (see Step 6). For Life and AD&D claims, file suit in court (see Step 8). Step 6: Second Level of Appeal for Claims. Mandatory Second-Level Appeal. If the Claims Administrator denies your claim for prescription drug, non-urgent care dental, vision, DVRA, disability and life benefits in your first-level appeal and you do not agree with the determination, you must appeal the decision (file a second-level appeal) with the Claims or Plan Administrator for a final determination as follows: For prescription drug non-urgent drug claims, you must file a second-level appeal with the Health Plan Claims Administrator within 90 days from the date you receive the written denial For all dental except urgent care claims: you must file a second-level appeal with the Plan Administrator within 60 days from the date you receive the written denial For vision claims, you must file a second-level appeal with the Plan Administrator within 60 days from the date you receive the written denial For DVRA claims, you must file a second-level appeal with the Plan Administrator within 30 days from the date you receive the written denial For Disability Plan claims, you must file a second-level appeal with the Claims Administrator within 180 days from the date you receive the written denial If you do not appeal within the times specified above, you lose your right to appeal the denial, and you lose your right to file suit in court because you failed to exhaust your internal administrative appeal rights. In reviewing the denial of your appeal, the Administrator must comply with the same standards in Step 4. A decision will be made within 15 days (30 days for post-service dental, vision and DVRA claims, 45 days for Disability Plan claims (with possible extension of 45 days), of when the Administrator receives your appeal. You will be notified in writing of the decision on your appeal. If your claim is denied, you may file a suit in federal court (see Step 8) or in certain circumstances, you may request an external review (see Step 7). Voluntary Second-Level Appeal for Medical and urgent care Dental Claims. If the Claims Administrator denies your medical claim appeal and you do not agree with the determination, you may file a voluntary appeal with the Plan Administrator. Your appeal must be in writing and filed with the Plan Administrator at the address listed under Administration and Other Information Plan Administrator within 45 days for medical claim and 60 days for dental Plan claim of receiving the Claims Administrator s determination of your first appeal. At the same time as you file the voluntary appeal, you may file a suit in federal court (see Step 8) or, in certain circumstances for a medical claim, you may request an external review (see Step 7). The Plan Administrator will not assert a failure to exhaust administrative remedies if you elect to pursue a claim in court after the first-level appeal, rather than through the voluntary level of appeal or external review process. The running of any statute of limitations applicable to pursuing your claim in court will be suspended during the period of the voluntary appeal process. SMM-8

181 Your decision on whether to pursue a voluntary appeal with the Plan Administrator has no effect on your right to any other benefits under the Plan. The Plan Administrator has 30 days (with the option to extend by an additional 30 days) for the Medical Plan or 10 days for the Dental Plan to review your voluntary appeal and make a decision. Because the appeal is voluntary, you do not have to complete this step. You may file a suit in federal court (see Step 8) or in certain circumstances, you may request an external review for medical claims (see Step 7) at the same time as requesting a voluntary appeal. Step 7: External Review Process You may request an external review by an Independent Review Organization (IRO) when you receive a denial of: Your initial urgent care claim, Your first-level appeal of a non-urgent medical claim, or Your second-level appeal of a non-urgent prescription drug claim. Your claim is eligible for external review if: You are or were covered under the Plan when the health care item or service was requested or provided; The claim or appeal denial was based on medical judgment or was a rescission of coverage; You have exhausted all of the Plan s claims and appeal processes up to the external review process if it is a non-urgent care claim; and You have provided all information and forms required to process the external review. Your request for an external review must be in writing and filed with the Claims Administrator within four months of receiving your claim denial. Although it is not required, you may include issues, comments, documents, records and other information relating to your claim that you want considered in the external review. Standard (non-expedited) External Review. Within five days of receiving your request, the Claims Administrator must determine if your claim appeal is eligible for an external review. The Claims Administrator will notify you in writing within one day of the decision on your claim s eligibility for an external review. If your request is complete but not eligible for an external review, the notice will include the reasons your request is ineligible and contact information for the Employee Benefits Security Administration. If your request is incomplete, the notice will describe the information needed to complete the request. You will have until the later of the end of the four-month period you had to file the request for an external review or the 48-hour period after you receive the notice to provide the missing information. The Claims Administrator assigns eligible claims to an independent review organization (IRO). The IRO notifies you when the review process is beginning, and you will have 10 business days following receipt of the notice to provide the IRO with additional information to consider in your appeal. The IRO will provide written notice of the final external review decision within 45 days after it receives your request for external review. The IRO will not defer to the decisions made during the internal appeal process and will consider all the information and documents that it receives in a timely manner when making its decision. Expedited External Review. You may request an expedited external review for an urgent care claim at the same time you request a first-level appeal of a denied claim by the Claims Administrator. For other claims, you may request an expedited external review if your claim is denied after the first-level appeal, and: The time for completing the standard external review process would jeopardize your life, health or ability to regain maximum function; or The denial of the first-level appeal concerned the admission, availability of care, continued stay or health care item or service for which you received emergency services, and you have not yet been discharged from a facility. SMM-9

182 In general, the same rules that apply to a standard external review apply to an expedited external review, except that the time frame for decisions and notifications is shorter. The Claims Administrator will immediately conduct a preliminary review to determine if your claim is eligible for an external review. After the preliminary review is complete, the Claims Administrator will immediately notify you of its determination. If your claim is eligible for an expedited external review, your claim will be assigned to an IRO. The IRO will provide you its final decision as expeditiously as your medical condition or circumstances require, but in no event will the notification be provided later than 72 hours after the IRO receives the request for expedited external review. If you receive a verbal notice, a written notice will follow no more than 48 hours later. External Review Decision Is Final. All claim decisions of the external IRO are final. If the IRO reverses the denial of your claim, the decision will be final and the Plan must immediately provide coverage or payment. Step 8: You File Suit in Federal Court You have the right to file suit in federal court under ERISA Section 502(a) if the Claims Administrator denies your: Initial urgent care claim First-level appeal of a pre-service, concurrent or post-service medical claim, Dependent Care Reimbursement Account, Work/Life Solutions Plan, Adoption Reimbursement Benefits Plan and Life and AD&D Plan claims Second-level appeal of a prescription drug claim, dental (except for urgent care), vision, DVRA and disability claims Voluntary appeal In these cases, you are considered to have exhausted the administrative review process. You must file suit within one year after the date of the claim determination. Any suit must be filed in Ohio state court or in the United States District Court for the Northern District of Ohio and no other. The running of the one-year time period may be suspended during a voluntary appeal for urgent care claims. For health care claims and for disability claims filed on or after April 2, 2018, if the Claims Administrator does not comply with all of the procedures described above, you will generally be treated as though you have exhausted the internal appeals process. As a result, you may request an external review or bring a suit against the plan even though you have not completed all required levels of appeal. However, if the violation of these procedures is de minimus, you will not be treated as though you have exhausted the internal appeals process. The violation will be considered de minimus if it is not likely to cause prejudice or harm to your claim, it was for good cause or due to matters beyond the plan s control and was in the context of an ongoing, good faith exchange of information between you and the plan. More Information Please retain this Summary of Material Modifications with your Summary Plan Description. Should you need a copy of the Summary Plan Description or have questions relating to the Plan, you may log on to Fidelity NetBenefits at or call the Fidelity Benefits Service Center at business days (excluding holidays recognized by the New York Stock Exchange) between 8:30 A.M. to 8:30 P.M., Eastern Time and speak to a Spanish-speaking service representative. April 2, 2018 SMM-10

183 2018 Eaton Health and Insurance Plans All Rights Reserved Eaton Printed in USA 1000 Eaton Boulevard June 2018 Cleveland, OH /18 3.EA-H-364H.111