retiree benefits enrollment guide · 2019. 11. 21. · insurance coverage sponsored by a new...

Retiree Benefits Enrollment Guide

Plan Year | 2020

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We have designed a retiree benefit program for individuals under and over Medicare retirement age (currently 65). The program includes medical insurance, including our direct 24/7 access primary care model, dental insurance, and life insurance. This program is intended to cover our valued employees and their covered spouses with insurance for the duration of life, unless terminated. If you gain other coverage through another benefit plan, you are no longer eligible for the J M Smith Corporation Retiree Insurance Program. Please read this outline closely so you understand the benefit provisions and cost and make the best decision for you and your spouse, if applicable. The cost of the programs are subject to change each calendar year. Employees and covered spouses must also sign a affidavit each year proving other coverage. If you have any questions, please do not hesitate to call Human Resources at 864-542-9419. Sincerely, J M Smith Corporation

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Requirements: 1. The Employee must be at least age 62 to retire. 2. The Employee must have a minimum 10 years of service to retire. Effective January 1, 2020, to be eligible for retiree medical insurance an employee must be age 62 or greater and have at least ten (10) years of continuous service to the Company. If the employee has a combined total score of “75” using age and years of service the em-ployee is eligible to continue benefits at a discount. If the employee does not have a com-bined total score of “75” using age and years of service, but still meets the minimum age to retire (62) and at least 10 years of services, then the base cost applies. Example: 62 years of age and 10 years of service = 72 base cost 62 years of age and 13 years of service = 75 discounted cost *Only whole years will be used for age and years of service

Prior to age 65: Discounted Discounted Base Base Cost: 75 75 65-74 65-74 Monthly Plan A or B Plan C Plan A or B Plan C Per Enrollee $ 310 $ 210 $525 $460 Coverage: Coverage mirrors that of an active employee. If enrollee chooses Plan C – they will automatically be enrolled in Proactive MD. Age 65 and above: Cost:________________________________________________________________ Monthly Medical Plan C/Medical Medical Plan C/Medical Reimbursement Reimbursement Reimbursement Reimbursement

Per Enrollee $ 85 $ 60 $160 $110 Coverage: For enrollees (who are 65 or older) the coverage is secondary to Medicare. The plan coordinates benefits with Medicare A and B. Over age 65 will not have drug benefits. J M Smith will sponsor a medical reimbursement account to cover co-pays and donut holes not covered by Medicare D program, which enrollees over 65 must be enrolled in. If enrollee chooses Plan C – they will automatically be enrolled in Palmetto Proactive. Prescription Coverage: Enrollee must have a Medicare Part D policy in place upon the over 65 retiree insurance effective date. JMS will sponsor a medical reimbursement account to cover co-pays and donut holes not covered by Medicare D program.

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Open Enrollment: A retiree eligible for the J M Smith Retiree Medical Plan has one opportunity to elect retiree benefits in this plan and can only extend the benefit tier enrolled in under their active employee status. Open Enrollment will not be ongoing for the retiree plans, unless there are qualifying events or change in other insurance coverages. If there are any changes to the retiree medical plan, JM Smith Corporation will communicate those to the retirees during Annual Open Enrollment each year. Please remember that if you decide to drop your coverage, you cannot come back onto the plan. JM Smith Retiree Medical Plan: The JM Smith Corporation Retiree Medical Plan is your primary insurance program, outside of participants over Medicare age with Medicare A, B, and D. If at any time you are eligible for other insurance coverage sponsored by a new employer, you will no longer be eligible for the JM Smith Corporation Retiree Medical Plan. Termination of Coverage: If the enrollee does not pay the premium within 60 days of due

date If the enrollee passes away If the enrollee gets other qualified coverage after retirement

(another job, another marriage with eligible coverage) Refer to www.jmsmithbenefits.com for more information and forms.

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Table of Contents

Introduction.......................................................................................................... 4

How to Use This Guide ........................................................................................ 6

Making Your Choices .......................................................................................... 6

Eligibility .............................................................................................................. 7

Changing Your Benefits ....................................................................................... 8

Benefit Website ................................................................................................... 9

Medical Coverage.............................................................................................. 10

Plan Choice, 10

Medical Plan Comparison, 11-16

Prescription Drug Coverage Under Age 65 ........................................................ 17

Prescription Medications Not Covered, 18

MaxorPlus, 18

Narrow Networks……………………………………………………………………….18

Over Age 65 Medical Reimbursement Plan…………………………………………19

Over Age 65 Drug Reimbursement Plan……….……………………………………20

Dental Coverage ............................................................................................... 21

Wellness for Life ................................................................................................ 23

Life Management .............................................................................................. 24

Identification Card......................................................................................... 26-27

Important Notices .............................................................................................. 28

2020 Benefits Enrollment ............................................................................. …..29

Plan Exclusions……………………………………………………………………..30-31

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Throughout this booklet, you will find Healthy Notes which will provide helpful hints on your benefit plans as well as guidelines for a healthier lifestyle for you and your family.

How to Use This Guide This document has been designed to provide you with information about the J M Smith Corporation’s retiree plan program and to guide you through the choices you have in each benefit area. We understand that you can always use a little help in navigating your way through these benefit decisions. So, throughout this guide you will find helpful hints that will answer your questions, emphasize important points, or guide you to additional information. Look for these icons:

Making Your Choices At J M Smith Corporation, you have the flexibility to choose from many benefit and coverage options so you can create a benefit package that meets your individual needs. It is important that you take time to review this guide and make the choice that works best for you and your dependents.

Note! Special points to consider as you are using the J M Smith Corporation’s retiree benefits.

Q&A Frequently asked questions and answers that will help you understand how each benefit works.

Right for you? Tips to help you decide which benefit options are right for you and your family.

Website Reminder that more information can be found on J M Smith ’s benefit website.

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Eligibility You must be at least 62 years old to be eligible for retirement. You must also have a minimum 10 years of service to qualify for the retirement plan. Retirees can only extend coverage they are currently enrolled in under their active employee status. Examples:

Single Coverage would only extend to Single Retiree Coverage

Employee & Spouse Coverage could extend to Single Retiree Coverage or Retiree & Spouse Coverage

Cost of Retiree Plans The cost of the Retiree Medical Insurance will be dependent on your total score. Your score is determined by your age plus years of service. The Employee’s score must equal at least 75 at a minimum to receive the discounted premium. If the employee has a combined total score of “75” using age plus years of service, they are eligible to continue benefits at a discount. If the employee does not have a combined total score of “75” using age and years of service, but still meets the minimum age to retire (62) and at least 10 years of service, then the base cost applies. Example:

62 years of age + 13 years of service = 75 (discounted cost)

62 years of age + 10 years of service = 72 base cost

Coverage Your coverage varies, depending on your age:

Age 65 and older

Under Age 65 If you are age 65 or older and your spouse is under age 65 (or vice versa), you may want to review both types of coverage and associated costs since they may both apply. For enrollees prior to 65. Coverage mirrors that of an active employee. If enrollee chooses Plan C—they will automatically be enrolled in Palmetto Proactive. For enrollees (who are 65 or older) the coverage is secondary to Medicare. The plan coordinates benefits with Medicare A and B. Over age 65 will not have drug benefits. J M Smith will sponsor a medical reimbursement account to cover co-pays and donut holes not covered by Medicare D program, which employees over 65 must be enrolled in. Please note: The 65 or older enrollee must be enrolled in Part A, B, and D of Medicare. If enrollee chooses Plan C, they will automatically be enrolled in Palmetto Proactive.

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Changing Your Benefits Due to Life Events The benefits you elect become effective the first day of the month following your retirement date or by January 1 and will remain in effect through December 31. During the year, you can make changes only if you have a qualifying event which means a change in one of the following:

Becoming eligible for Medicare

Legal marital status: Events that change your legal marital status, including marriage, death of spouse, divorce, legal separation or annulment

Number of Dependents: Events that change your number of dependents, including birth, adoption, placement for adoption, qualified medical child support order (QMCSO), or death of a dependent

Employment status: A commencement of employment by you, your spouse or your dependent

Eligibility of a dependent: An event that causes your dependent to satisfy or cease to satisfy the requirements for coverage due to an attainment of age or any similar circumstance as provided in the health plan under which the dependent receives coverage

Any other event determined to be a qualified change in status by the Plan Administrator In any of the cases listed below, you MUST provide supporting documentation in order to add dependents to your health coverage. If you do not provide this documentation, your dependent will NOT be added to your coverage.

You may not add newly acquired dependents if, at the time of your retirement, you were married or had eligible dependents but you had individual health insurance coverage on your last day of active employment.

As a retiree, you may add newly acquired dependents to your health insurance plan if you were single when you retired.

You may add newly acquired dependents if you had Employee + Child, Employee + Spouse, or Family coverage when you retired, and had all eligible dependents covered.

In the event of a retiree’s death, a covered spouse may continue health coverage indefinitely or until remarriage. All other covered dependents may remain covered as long as they are eligible under the plan guidelines for eligibility.

Note: Should the dependent spouse remarry, he/she cannot add dependents to the plan. Also, if the dependent spouse has qualified coverage through a job or the remarriage, they must terminate the plan.

If you have Family coverage, Employee + Child, or Employee + Spouse coverage, you may cancel your coverage or drop a dependent at any time.

If you have a qualifying event, contact your Human Resources representative. Any benefit changes must be made within 31 days of the event and must be consistent with the qualifying event.

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Benefit Website J M Smith Corporation has devised a website to aid you and your dependents with questions and access to forms. The internet address for this site is www.jmsmithbenefits.com. This site gives you access 24 hours a day to information about your benefits, from work or from home. It also makes it easy for you to obtain frequently used forms so you can keep your payroll and benefits information up to date. For example:

Medical and Dental Insurance: Go to www.southcarolinablues.com to view medical claim information. Go to www.deltadentalsc.com to view dental claim information.

Health-Related Issues: Get helpful information on numerous health-related issues by going to the Helpful Links page.

Take a minute to explore www.jmsmithbenefits.com and see how it can make it easier for you to manage your benefits.

Note! You have

24/7 access to review your benefit plans throughout the year whether from your home or office.

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Deductible is the initial payment that you must pay before you receive your benefits. Your plan has a deductible for certain services and will be owed before the insurance will pay their portion of the coinsurance. Coinsurance is the split between the health plan and you. For example, your plan may have an 70% / 20% split (in network). This means the health plan will pay 70% of your medical bill (once your deductible is met) and you are responsible for 20% up to an out of pocket maximum.

Medical Coverage J M Smith Corporation offers multiple medical plans from which to choose. Keep in mind that all of the options encourage you to seek care through our Preferred Provider Organizations (PPO). If you choose our PPO network for your treatment, then you will receive a higher level of benefit. Your PPO acts as a contract between you and your healthcare providers. The PPO network and your plan benefits will ensure you get the best possible price. You may choose to utilize providers outside the network. However, you have no “contract” protection and may receive a lower level of benefit. Prior to Age 65: Plan A (deductible) Plan A (deductible) offers the highest level of out of pocket expense protection.

Lowest deductibles

Lowest maximum out of pockets This plan pays 70% of charges with participating providers after you reach your deductible, with a maximum out of pocket amount. The majority of all medical benefits are covered this way under this plan. Plan B (copay) Plan B (copay) offers co-payments for physician visits (up to a maximum). All other benefits are subject to the deductible and coinsurance. This plan has a higher deductible and out-of-pocket maximum than Plan A (deductible). Plan C (Proactive MD Plan) - Available to enrollees with access to Proactive MD physicians in local area Plan C (deductible) offers the most innovative insurance plan option with direct primary care access in local areas only, as well as the lowest deductible and cost. Age 65 and Above: This is the same plan for all retirees. It is designed to coordinate with Medicare Parts A, B, and D. YOU MUST have Medicare Parts A, B, and D to participate in this plan. Note: Part D coverage will be co-pays and “donut hole’ reimbursements only.

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Medical Benefits – PLAN A Benefit In Network Out of Network

Deductible – Individual Policy $1,500 per Calendar Year $2,500 per Calendar Year

Deductible – Family Policy $3,000 per Calendar Year $5,000 per Calendar Year

Coinsurance (after satisfying the deductible) 70% (Insurance pays 70%, you pay 30%)

50% (Insurance pays 50%, you pay 50%)

Out-of-Pocket Maximum – Individual Policy $2,850 per Calendar Year in addition to deductible

$4,950 per Calendar Year in addition to deductible

Out-of-Pocket Maximum – Family Policy $5,700 per Calendar Year in addition to deductible

$9,900 per Calendar Year in addition to deductible

Lifetime Maximum (per person) No Lifetime Max

Physician Office Visits – Primary Care Physi-cians (PCP), Pediatrician, OB-Gyn, Internist (includes lab, x-ray and ancillary charges billed by the physician)

70% after deductible 50% after deductible

Specialist Office Visit – Includes lab, x-ray and ancillary charges billed by the physician 70% after deductible 50% after deductible

Prescription Drugs Patient responsible for 40% of the prescription cost except for

generic drugs. Patient pays $4 for multisource gener-

ics. Patient pays $10 for single source

generics. Not subject to a deductible.

Not covered

Prescription Drugs Out of Pocket Maximum - Applies to in and out of network pharmacy cost. Retail and home delivery co-pays apply to the Pharmacy Out of Pocket.

$3,500 Individual $7,000 Family

Not Covered

Preventive Care for Employees and Covered Spouses See page 22 Not covered

Preventive Care for covered children – Immunizations, Routine Physicals 100% of covered expenses Not covered

Allergy Testing Allergy Serum and Injections



Routine Physician Maternity Services – Rou-tine Prenatal, Delivery and Postnatal Care 70% after deductible 50% after deductible

Urgent Care 70% after deductible 50% after deductible

Emergency Room – Co-pay is waived in case of injury, life threatening illness, or if admitted as inpatient

$200 co-pay then 70% after deductible

$200 co-pay then 50% after deductible

Ambulance Services 70% after deductible 70% after deductible

Inpatient Services – Physician, Maternity, Nursery Room, Surgical, Anesthesia, Lab and X-ray Charges/Interpretation


Inpatient Hospital Services - Per admission co-payment is waived when a PPO hospital is used or admission occurs directly from Emergency Room

70% after deductible $500 per admission co-payment then

50% after deductible

Semi-Private Room Rate Reimbursement Amount: If the hospital only has private room facilities then private room charge will be considered as the semi-private.

70% Semi– Private Room Rate 50% Semi-Private Room Rate

Intensive Care Unit 70% Reimbursement Amount 50% Reimbursement Amount

The Medical Plan comparison chart explains the benefit levels available in each of the plans offered. You are responsible for knowing the benefits available in your medical plan, including deductibles, co-payments, prior authorization requirements and benefit exclusions. A summary plan description which contains complete details of the plan provisions is available on-line under the medical section.

Visit our benefit website at

jmsmithbenefits.com.

Please see Exhibit A at the back of this booklet for a listing of key Plan Exclusions.

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Medical Benefits – PLAN A – Continued

Refer to www.jmsmithbenefits.com for administrative questions and participating providers. This site will also provide you with a link to www.southcarolinablues.com for claims inquiries.

Note!!

You will have two identification cards for your medical and pharmacy benefits. Please keep your card with you at all times. Additional cards can be requested at the website or customer service number on the card.


Benefit In Network Out of Network

Mental Disorders: Inpatient 70% after Deductible $500 copay, then

50% after Deductible

Mental Disorders: Outpatient 70% after Deductible 50% after Deductible

Substance Abuse: Inpatient 70% after Deductible $500 copay, then


Substance Abuse: Outpatient 70% after Deductible 50% after Deductible

Outpatient Services – Hospital, Physician, Surgical, Anesthesia, Lab and X-ray Charges/interpretation

70% after Deductible 50% after Deductible

Outpatient Therapy – Physical, Speech and Occupational


Outpatient Therapy – Renal Dialysis, Chem-otherapy and Radiation


Durable Medical Equipment 70% after Deductible 50% after Deductible

Home Health Care 70% after Deductible with a 60 visit

maximum per year 50% after Deductible with a 60

visit maximum per year

Skilled Nursing Facility 70% after Deductible with a 120 day

maximum per calendar year 50% after Deductible with a 120 day maximum per calendar year

Outpatient Private Duty Nursing 70% after Deductible 50% after Deductible

Hospice Care 70% after Deductible 50% after Deductible

Transplant Services – Lung, Pancreas, Liver, Heart, Cornea, Kidney, Bone Marrow, Heart/Lung


Infertility Services Not covered Not covered

LASIK Eye Surgery 50% after deductible with a maximum of $1,000 per eye and $2,000 lifetime

maximum Not covered

TMJ 70% after Deductible 50% after Deductible

Accident Benefit

Pays 100% of the first $500 then subject to 70% of the remaining amount (not sub-ject to the deductible); Charges must be incurred within 90 days of such accident

Pays 100% of the first $250 then subject to 50% of the remaining

amount (not subject to the deducti-ble); Charges must be incurred within 90 days of such accident

Chiropractic Services / Acupuncture Services

Subject to the deductible then a maximum payment of $15 per visit; $1,000 maximum

per calendar year

Subject to the in-network deductible then a maximum payment of $15

per visit; $1,000 maximum per calendar year

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Medical Benefits – PLAN B

Q & A

What happens if I have a claim at the end of year and don’t submit it by December 31? You will have time after the end of the year to file claims for eligible expenses that you incurred during this year. We recommend submitting claims by March 31 of the following year.


jmsmithbenefits.com. to see the status of your claims.



Deductible – Individual Policy $1,700 per Calendar Year $2,500 per Calendar Year

Deductible – Family Policy $3,400 per Calendar Year $5,000 per Calendar Year

Coinsurance (after satisfying the deductible)



Out-of-Pocket Maximum – Individual Policy $3,250 per Calendar Year in addition to

Deductible $4,950 per Calendar Year in addition to

Deductible

Out-of-Pocket Maximum – Family Policy $6,500 per Calendar Year in addition to

Deductible $9,900 per Calendar Year in addition to

Deductible


Physician Office Visits – Primary Care Phy-sicians (PCP), Pediatrician, OB-Gyn, Intern-ist (includes lab, x-ray and ancillary charges billed by the physician)

Subject to $45 co-payment per visit then paid at 100% of covered expenses


Specialist Office Visit – Includes lab, x-ray and ancillary charges billed by the physician

Subject to $55 co-payment per visit then paid at 100% of covered expenses


Prescription Drugs

Patient responsible for 40% of the prescription cost except for generic

drugs. Patient pays $4 for multisource generics.

Patient pays $10 for single source generics.

Not subject to a Deductible

Not covered



Not Covered

Preventive Care for Employees and Covered Spouses

See page 23 Not covered

Preventive Care for other children – Immun-izations, Routine Physicals 100% of covered expenses Not covered

Allergy Testing and Allergy Serum and Injections $55 co-payment for Specialists, then

100% 50% after Deductible

Routine Physician Maternity Services – Routine Prenatal, Delivery and Postnatal Care 70% after deductible 50% after Deductible

Urgent Care Subject to $45 co-payment per visit then

paid at 100% 50% after Deductible


$200 co-pay then 70% after Deductible $200 co-pay then 70% after Deductible

Ambulance Services 70% after Deductible 70% after Deductible



Inpatient Hospital Services - Per admission co-payment is waived when a PPO hospital is used or admission occurs directly from Emergency Room

70% after Deductible $500 per admission co-payment then


Semi-Private Room Rate Reimbursement Amount: If the hospital only has private room facilities then private

room charge will be considered as the semi-private. 70% Semi– Private Room Rate 50% Semi-Private Room Rate

Intensive Care Unit 70% Reimbursement Amount 50% Reimbursement Amount

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Medical Benefits – PLAN B – Continued

Refer to www.jmsmithbenefits.com for administrative questions and participating providers. This site will also provide you with a link to www.southcarolinablues.com for claims inquiries.

Q & A

What benefits are provided if I use a non-participating provider? If you use a non-participating provider, then you may have to pay your bill in full for the services you receive and request reimbursement later by completing a claim form.


jmsmithbenefits.com. for a claim form.













Outpatient Therapy – Renal Dialysis, Chemo-therapy and Radiation




maximum per year 50% after Deductible with a 60 visit

maximum per year


maximum per calendar year 50% after Deductible with a 120 day

maximum per calendar year






LASIK Eye Surgery 50% after deductible with a maximum of $1,000 per eye and $2,000 lifetime maxi-

mum Not covered


Accident Benefit

Pays 100% of the first $500 then subject to 70% of the remaining amount (not

subject to the deductible); Charges must be incurred within 90 days of such

accident


amount (not subject to the deducti-ble); Charges must be incurred with-

in 90 days of such accident


Subject to the deductible then a maximum payment of $15 per visit; $1,000 maximum

per calendar year

Subject to the in-network deductible then a maximum payment of $15 per visit; $1,000 maximum per calendar

year

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Medical Benefits – PLAN C


Deductible – Individual Policy $1,000 $2,500

Deductible – Family Policy $2,000 $5,000

Coinsurance (after satisfying the Deductible) 70% (Plan pays 70%, you pay 30%) 50% (Plan pays 50%, you pay 50%)

High Performing Network - Special contracts with high quality providers 100% N/A

Out-of-Pocket Maximum – Individual Policy $3,250 per Calendar Year in addition to

Deductible $4,950 per Calendar Year in addition

to Deductible

Out-of-Pocket Maximum – Family Policy $6,500 per Calendar Year in addition to

Deductible $9,900 per Calendar Year in addition

to Deductible


Physician Office Visits – Primary Care Physi-cians (PCP) and Pediatrician (includes lab, x-ray and ancillary charges performed by, or under the direction of the Proactive MD physi-cians)

Proactive MD physician—No charge Non-Proactive MD physician -


Non-Proactive MD physician 10% after Deductible

Specialist Office Visit – Includes OB-GYN and Internist (Includes lab, x-ray and ancillary charges with the same service date)


Prescription Drugs

Patient responsible for 40% of the pre-scription cost except for generic drugs. Patient pays $4 for multisource gener-

ics. Patient pays $10 for single source ge-

nerics. Not subject to a Deductible.

Not covered



Not Covered

Preventive Care for Employees and Covered Spouses See page 23 Not covered

Preventive Care for covered children – Immunizations, Routine Physicals 100% of covered expenses Not covered

Allergy Testing Allergy Serum and Injections


Routine Physician Maternity Services – Rou-tine Prenatal, Delivery and Postnatal Care 70% after Deductible 50% after Deductible

Urgent Care 70% after Deductible 50% after Deductible


$200 co-pay, 70% after Deductible $200 co-pay, 50% after Deductible

Ambulance Services 70% after Deductible 70% after Deductible



Inpatient Hospital Services - Per admission co-payment is waived when a PPO hospital is used or admission occurs directly from Emer-gency Room

70% after Deductible $500 per admission co-pay then


Semi-Private Room Rate

Reimbursement Amount: If the hospital only has private room facilities then private room charge will be considered as the semi-private.

Semi–Private Room Rate: Semi-Private Room Rate: 70% after Deductible 50% after Deductible

Intensive Care Unit 70% after Deductible 50% after Deductible

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Medical Benefits – PLAN C Continued












Outpatient Therapy – Renal Dialysis, Chemotherapy and Radiation




maximum per year 50% after Deductible with a 60 visit

maximum per year


maximum per calendar year 50% after Deductible with a 120 day

maximum per calendar year






LASIK Eye Surgery 50% after Deductible with a maximum of

$1,000 per eye and $2,000 lifetime maximum

Not covered


Accident Benefit

Pays 100% of the first $500 then subject to 70% of the remaining amount (not subject to the Deductible); Charges

must be incurred within 90 days of such accident


amount (not subject to the Deducti-ble); Charges must be incurred with-

in 90 days of such accident


Subject to Deductible; Maximum payment of $15 per visit; $1,000 maximum per

calendar year

Subject to In-Network Deductible; Maximum payment of $15 per visit; $1,000 maximum per calendar year

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Prescription Drug Coverage Under Age 65 When you elect medical coverage, you are automatically covered under the prescription drug plan. This coverage allows you to fill your prescriptions at participating retail pharmacies.

There are multiple categories of drugs under the plan. The differences between these categories are described below: A generic drug is one that meets the same standards as name brand drugs for safety,

purity, strength and effectiveness. Generic drugs are less expensive than name brand drugs.

A multisource generic drug is a generic drug with multiple manufacturers. A single source generic drug is a generic drug with exclusive

manufacturing rights. A single source drug is a name brand drug (patent protected) with no generic

available. A multisource drug is a name brand drug (patent expired) with a generic available.

Under this plan, you have the opportunity to lower the amount you pay by choosing a generic whenever possible. Be sure to discuss this option with your physician when he or she writes your prescription.

If you request a brand name drug when a generic is available, you will be responsible for paying the difference in price between the brand name and

the generic drug added to the generic copayment.

Only prescriptions obtained from participating pharmacies are covered by your prescription

plan.

Participating Pharmacy Preferred Pharmacy Network Performance 90 Network

Maximum Supply Allowed 30 Days 90 Days

Multi-source Generic Copay Single-Source Generic Copay

$4 $10

Brand Copay 40% of cost 40% of cost

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Prescription Medications Not Covered Over-the-counter medications; injectables except insulin; fertility medications; vitamins except prenatals; anti-obesity; ostomy supplies; smoking deterrents; non-insulin syringes; cosmetic drugs; diagnostics; diabetic supplies; medical supplies and apparatus; experimental and investigational drugs; medications administered while admitted to a medical facility; medications covered by worker’s compensation or similar government program.

MaxorPlus MaxorPlus is a national pharmacy benefit management (PBM) company founded with the goals of managing prescription benefit costs while providing better customer service than anyone in the industry. If you have any questions or just want to know if your local pharmacy is participating, please call MaxorPlus Customer Service at (800) 687-0707. You may also visit their website at https://maxorplus.com. Narrow Networks There may be times when your physician refers you to another provider for diagnostic testing or treatment. J M Smith Corporation has developed a network of providers who can offer negotiated cost savings while providing high-quality care to our retirees and their covered family members. These providers are referred to as a "narrow network providers." When you are referred for these services (including x-ray, ultrasound, MRI, CT Scan, physical therapy, mammography and colonoscopy), explain that you are going to use your employer's narrow network and ask your physician for the physician order. It is your responsibility to contact the narrow network provider to initiate service. When arranging for the appointment, be sure to identify yourself as a J M Smith retiree or covered family member and be sure to take your physician's order for the test/treatment with you to that appointment. Retirees and their covered family members are eligible to take advantage of the J M Smith narrow network regardless of the medical coverage plan (A,B or C) they enrolled in. For information on which providers are in the J M Smith narrow network, please contact Pam Watson 866-270-2316, extension 5483 or JMS Corporate Benefits Coordinator at 864-542-9419, extension 5436. You may choose to use providers outside the J M Smith Corporation narrow network, however, this will result in a higher out of pocket expense for you.

Generic drugs have a long history of safety and effectiveness. Generic manufacturers must demonstrate that the generic drug has the same medical effect as its name brand equivalent by measuring the rate and extent of drug absorption. Because generic drug companies do not have to spend millions of dollars on research and advertising, they can sell the generics for a lot less. These manufacturers compete against each other which keeps the prices affordable year after year.

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Over Age 65 Medical Reimbursement Plan For enrollees (who are 65 or older) the coverage is secondary to Medicare. The plan coordinates with Medicare A and B. The Medical Reimbursement Plan will cover approved Medicare expenses, such as the Medicare A and B deductibles as shown in the chart below. Example: Skilled nursing facility coverage under Medicare is limited 30 days after hospital stay. If enrollee chooses Plan C – they will automatically be enrolled in Palmetto Proactive Health.

Note: Even if Medicare covers a service or item, you generally have to pay deductibles, coinsurance, and copayments. Some of the items and services that Medicare doesn't cover include: Most dental care Eye Examinations related to prescribing glasses Dentures Cosmetic surgery Acupuncture Hearing aids and exams for fitting them Long term care If you have Original Medicare, visit Medicare.gov/coverage, or call 1-800-Medicare (1-800-633-4227) to find out if Medicare covers an item or service you need.

Benefits Over Age 65 Medical Reimbursement

Plan

Medicare Part A: Coinsurance and hos-pital costs (up to an additional 365 days

after Medicare benefits are used) 100%

Medicare Part B: Coinsurance or Copay-ment:

100%

Blood (first 3 pints) 100%

Part A Hospice Care coinsurance or copay-ment

100%

Skilled nursing facility care coinsurance 100%

Part A deductible 100%

Part B Deductible 100%

Part B Excess Charges 100%

Foreign Travel emergency (up to plan limits)

70%

Note!

You must sign up for Medicare Parts A, B,

and D. Sign up for Parts A and B at your

local Social Security Office.

Note!

In reviewing your Medigap options, you may want to consider

all plans, including traditional and

advantage plans before making your choice for coverage under the J M Smith retiree plan over age

65.

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Over Age 65 Prescription Drug Reimbursement Plan The plan for individuals over age 65 does not cover prescription medications. You must enroll in a Medicare D (Drug) plan. The J M Smith plan will cover co-payments and donut holes not covered by your Medicare D program through medical reimbursement. J M Smith will reimburse co-pays and donut hole expenses you incur that are NOT covered by the Medicare D program you choose. There is no annual plan maximum benefit. If you have co-pay or donut hole cost, you will be responsible to pay the providers and submit a paper claim form for full reimbursement. You can submit claims as often as you would like. All claims must be submitted within 12 months of date of service. Claim forms can be found at www.jmsmithbenefits.com, or call HR at 864-542-9419 and we can e-mail you the forms.

Note! In reviewing your Medigap options, you may want to consider all plans, including traditional and advantage plans before making your choice for coverage under the J M Smith retiree plan over age 65.

Note! How do you find a Medicare D program? Blue Cross Blue Shield, AARP, United Health Care, and many other insurance companies sell stand alone Medicare D programs.

21

Premium Dental Plan There are dental benefit coverages available at J M Smith Corporation. Please review the following information regarding the covered procedures in each dental category so you will have an understanding of your benefits.

Annual Deductible $50 per person

Annual Maximum Non-orthodontic care Orthodontic care

$2,000 (per calendar year) $2,000 (lifetime maximum)

Preventive Services do NOT accumulate towards the annual maximum.

Preventive Services Plan pays 100% of the allowable charges; You pay 0%

Oral exams (2 exams per12 months) Waiting Period for Benefits to begin: None Cleanings (2 exams per 12 months) Bitewing x-rays (2 every 12 months) Full set of x-rays (every 36 months) Space maintainers for dependent children under the age of 16 Fluoride treatments for dependent children under the age of 18 (2 each calendar year) Sealants for dependent children under the age of 18 once per tooth in any 36 months

Basic Services Plan pays 80% of the allowable charges; You pay 20% {Subject to the deductible if not already met}

Fillings, other then gold Extractions Periodontics Oral Surgery Anesthesia Laboratory tests

Waiting Period for Benefits to begin: Late Entrants Only - The 1st 6 months of the covered person’s coverage

Major Services Plan pays 50% of the allowable charges; You pay 50% {Subject to the deductible if not already met}

Crowns Dentures Bridgework Repairs to crowns, bridges and dentures Dental Implants


Orthodontic Services Plan pays 50% of the allowable charges; You pay 50%

Benefit is available for adults and children Waiting Period for Benefits to begin: Late Entrants Only - The 1st 24 months of the covered person’s coverage

Q & A

What happens if I have a claim at the end of year and don’t submit it by December 31? You will have time after the end of the year to file claims for eligible expenses that you incurred during this year. We recom-mend submitting claims by March 31 of the following year.

Q & A I have

medical and dental insurance. Which one will cover the extraction of wisdom teeth? If the teeth are fully impacted, then the extraction will be covered under the medical plan subject to the deductible. If partially impacted, then it will be covered under the dental plan under the Basic Services.

Brush your teeth thoroughly twice per day. If possible brush immediately after a meal. This can prevent plaque buildup on your teeth. Discuss with your dentist about the use of water picks and electric toothbrushes and what is the best approach for you. Daily flossing is the best way to prevent gum disease. Floss gets rid of the buildup of plaque between your teeth and under the gum line. Regular brushing and flossing regimens will go a long way toward the health of your teeth and gums.

22

Basic Dental Plan There is dental benefit coverage available at J M Smith Corporation. Please review the following information regarding the covered procedures in each dental category so you will have an understanding of your benefits.

Annual Deductible $50 per person

Annual Maximum

$1,000 (per calendar year)

Preventive Services Plan pays 100% of the allowable charges; You pay 0%

Oral exams (2 exams per12 months) Waiting Period for Benefits to begin: None Cleanings (2 exams per 12 months) Bitewing x-rays (2 every 12 months) Full set of x-rays (every 36 months) Space maintainers for dependent children under the age of 16 Fluoride treatments for dependent children under the age of 18 (2 each calendar year) Sealants for dependent children under the age of 18 once per tooth in any 36 months

Basic Services Plan pays 80% of the allowable charges; You pay 20% {Subject to the deductible if not already met}

Fillings, other then gold Extractions Periodontics Oral Surgery Anesthesia Laboratory tests


Major Services Plan pays 50% of the allowable charges; You pay 50% {Subject to the deductible if not already met}

Crowns Dentures Bridgework Repairs to crowns, bridges and dentures Dental Implants


Q & A

What happens if I have a claim at the

end of year and don’t submit it by

December 31? You will have time

after the end of the year to file claims for

eligible expenses that you incurred during

this year. We recom-mend submitting

claims by March 31 of the following year.

Q & A

I have medical and dental insurance. Which one will cover the

extraction of wisdom teeth?

If the teeth are fully impacted, then the

extraction will be covered under the

medical plan subject to the deductible.

If partially impacted, then it will be covered under the dental plan

under the Basic Services.

Brush your teeth thoroughly twice per day. If possible brush immediately after a meal. This can prevent plaque buildup on your teeth. Discuss with your dentist about the use of water picks and electric toothbrushes and what is the best approach for you. Daily flossing is the best way to prevent gum disease. Floss gets rid of the buildup of plaque between your teeth and under the gum line. Regular brushing and flossing regimens will go a long way toward the health of your teeth and gums.

23

Wellness For Life JM Smith Corporation wants to encourage employees and their covered spouses to take care of their health. Your health is of great value to JM Smith. All preventive care is covered under our plan 100%, including an annual physical, if rendered by a PPO provider. See below for Preventive Care Services that are covered 100% by JM Smith Corporation in addition to your annual physical.

There are some tests performed in a physician's office that do not qualify under the JMSC preventive measure coverage of 100%. There is coverage for these tests, however they may be subject to the deductible and coinsurance. Such tests include but are not limited to: X-Rays, EKGs, and anything resulting in a diagnostic procedure. The plan will cover these services each year if the enrollee so chooses.


jmsmithbenefits.com for additional information.

Mammograms: The American Cancer Society and the Mayo Clinic advise

women to begin having annual mammograms at age 50. Women in their 20s and 30s are advised to have a clinical

breast exam about every three years. Women 50 and older also should have an

annual clinical breast exam. If your mother had breast cancer, it is

recommended that you get a mammogram in your 30s.

Pap Tests: Women should get screened for cervical cancer about 3

years after they start having vaginal sex, according to the American Cancer

Society. They should also get a screening no later than 21 years old.

PSA (Prostate): Certain people are more at risk for prostate cancer, including African Americans and those who have a family history of the disease. A prostate exam is recommended once a man is at age 55. Major risk factors for prostate cancer include age, race, and family history.

Annual Physical

Colonoscopy: Adhering to colon cancer screening guidelines is one of the best ways to prevent colon cancer. In general, your risk of developing colon cancer increases as you age. If this is your only risk factor, you are considered "average risk." Other factors in your personal and family medical history may increase your risk. The simplest way for average-risk individuals to prevent colon cancer is to receive colon cancer screening starting at age 50 and continuing through age 75.

http://coloncancer.about.com/od/glossaries/g/Colon_Cancer.htm

http://coloncancer.about.com/od/preventiveactions/qt/Medical_History.htm

http://coloncancer.about.com/od/preventiveactions/qt/FamilyHistory.htm

24

Life Management At J M Smith Corporation, we strive to be a “healthy company.” The health and wellness of all J M Smith Corporation retirees and their families is important to us. Our comprehensive medical coverage and wellness programs help retirees and their families achieve personal health success. If you have diabetes, hypertension, hyperlipidemia, or CAD, you and/or covered spouse are eligible to enter a voluntary education and improvement program. If you are “compliant” with the program you receive medications at a discount - Generics - free Brand - You pay 20%, Plan pays 80% How to be compliant*: You must set up monthly appointments with the Healthcare Professional at your location (regional employees: with the Healthcare Professional that has been assigned to you). It is YOUR responsibility to initiate these monthly appointments. If you do not comply with your monthly appointments, you will NOT receive free medications. You and your Healthcare Professional will set goals once you initiate your first appointment. *Compliancy is tracked once a quarter. For example: If you do NOT make your MONTHLY appointments for January, February and March (all three months, not one, not two) - you will NOT receive your FREE medications for April, May, June. Together, we can accomplish these goals by learning about healthy lifestyles choices, taking advantage of annual physicals, wellness checkups, and working to control the costs associated with our medical insurance program. It is important that you understand from the start, J M Smith Corporation will not have access to your medical records. You will maintain strict privacy between you and your healthcare professional and health coach. If it is unreasonably difficult for you to participate, please contact HR, and we will work with you to find an alternate .

25

BACK OF THE CARD

FRONT OF THE CARD

Medical Identification Card You will have separate ID cards for medical, pharmacy, and dental. Please keep the cards with you at all times so that you will have it available when you need medical or dental services. The card identifies your plans and gives instructions for providers on where to send claim information. How To Read Your Identification (ID) Card

Medical Group Number

26

Pharmacy Identification Card You have will separate ID cards for medical, pharmacy, and dental. Please keep the cards with you at all times so that you will have it available when you need medical or dental services. The card identifies your plans and gives instructions for providers on where to send claim information. How To Read Your Identification (ID) Card

BACK OF THE CARD

FRONT OF THE CARD

27

Dental Identification Card You will have separate ID cards for medical, pharmacy, and dental. Please keep the cards with you at all times so that you will have it available when you need medical or dental services. The card identifies your plans and gives instructions for providers on where to send claim information. How To Read Your Identification (ID) Card

BACK OF THE CARD

FRONT OF THE CARD

28

Important Notices The following are required notices as established by the Patient Protection and Affordable Care Act. They may or may not apply to you. Please read them in their entirety. If you have questions, please contact your plan administrator. Lifetime Limit Notice The lifetime limit on the dollar value of benefits under all JM Smith Corporation Health Plans no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment. For more information contact Glynda Karabinos (864) 542-9419, Ext. 5416. Non-Grandfathered Health Plan Notice As of January 1, 2012 our plan was “non-grandfathered” and subject to the provisions of the Patient Protection and Affordability Act (PPCA). Preventive Care as mandated by the Patient Protection and Affordable Act will be paid at 100% with no maximum. You may go to www.healthcare.gov to see a listing of procedures covered. Preventive Care benefits not mandated will be subject to plan specifications. Notice of Opportunity to Enroll in connection with Extension of Dependent Coverage to Age 26 Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in JM Smith Corporation’s Health Plan. Individuals may request enrollment for such children for 30 days from the date of notice. For more information contact Glynda Karabinos (864) 542-9419, Ext. 5416. Children’s Health Insurance Reauthorization Act - allows employees and dependents who are eligible for healthcare coverage under the group plan, but are not enrolled, will be permitted to enroll in the plan if they lose eligibility for Medicaid or CHIP coverage or become eligible for a premium assistance subsidy under Medicaid or CHIP. Individuals must request coverage under the plan within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.

Annual Notice Women’s Health and Cancer Rights Act -

Federal law requires that all plan participants be notified at enrollment or annually of their rights under the “Women’s Health and Cancer Rights Act”. This notice is being furnished to you in compliance with the requirements of the law.

The law requires that all group health plans that provide coverage for a surgically removed breast must also:

Provide reconstruction of the surgically removed breast;

Provide coverage for surgery and reconstruction of the other breast to produce a symmetrical appearance; and

Provide coverage for a prostheses and any physical complications that may occur in any stage of a mastectomy, including lymph edemas (swelling associated with the removal of lymph nodes.)

Coverage for breast reconstruction and any related services will be subject to ay plan deductibles and covered percentage amounts that apply to other covered medical benefits of the Plan.

A Final Note This booklet is intended to provide an easy-to-read overview of the benefits available at J M Smith Corporation. Should there be any conflict between the explanations in this booklet and the actual terms of the plan documents and contracts, the terms of the plan documents and contracts will govern in all cases. You will not gain any new rights or benefits because of a misstatement or omission in this booklet.

Summary Plan Descriptions for the benefit plans are available by accessing the benefit website at www.jmsmithbenefits.com.

J M Smith Corporation reserves the right to amend, modify, sus-pend or terminate any benefit at any time.

29

2020 BENEFITS ENROLLMENT WORKSHEET

Note that all contributions are monthly.

____ Employee Only $40.61

____ Employee & Family $94.76

Dental Coverage - Premium Plan (contributions are monthly)

Medical Coverage (contributions are monthly) Age 65 and above

Discounted 75 Plan A or B

Discounted 75 Plan C

Base 65-74 Plan A or B

Base 65-74 Plan C

____ Per Enrollee $310 $210 $525 $460

Medical Coverage (contributions are monthly) Prior to Age 65

Discounted 75 Medical Reimbursement

Discounted 75 Plan C/Medical Reimbursement

Base 65-74 Medical Reimbursement

Base 65-74 Plan C/Medical Reimbursement

____ Per Enrollee $85 $60 $160 $110

____ Employee Only $32.50

____ Employee & Family $75.80

Dental Coverage - Basic Plan (contributions are monthly)

30

EXHIBIT A - Plan Exclusions Please note this is a PARTIAL listing of Plan Exclusions. For a FULL listing of Medical, Dental, and Prescription Drug Exclusions, please reference your Summary Plan Booklet online at www.jmsmithbenefits.com.

1. Abortion. Services, supplies, care or treatment in connection with an abortion unless the life of the mother is endangered. 2. Alcohol. Services, supplies, care or treatment to a Covered Person for an Injury or Sickness which occurred as a result of that Covered Person's illegal use of alcohol. The arresting officer's determination of inebriation will be sufficient for this exclusion. Expenses will be covered for Injured Covered Persons other than the person illegally using alcohol and expenses will be covered for Substance Abuse treatment as spec-ified in this Plan. This exclusion does not apply if the Injury resulted from an act of domestic violence or a medical (including both physical and mental health) condition. 3. Complications arising from non-covered services or treatments. No benefits are payable for any care, treatment, services or supplies, whether or not prescribed by a Physician, for complications from a non-covered condition. This Exclusion does not apply to complications from a non-covered abortion or Complica-tions of Pregnancy for a covered Dependent daughter. 4. Cosmetic surgery (elective) or other services and supplies that improve, alter or enhance appear-ance, whether or not for psychological reasons. 5. Custodial care. Services and supplies, including confinement, that are provided to an individual primarily to assist with his/her daily living activities. Custodial Care includes assisting in activities of daily living such as walking, getting in and out of bed, bathing, dressing, eating and taking medication. 6. Experimental and/or Investigational means services, supplies, care and treatment which does not constitute accepted medical practice properly within the range of appropriate medical treatment, under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant seg-ment of the practicing physicians in the covered employer’s geographic area. A. The Plan Administrator must make an independent evaluation of the experimental/non -

experimental standings of specific technologies. The Plan Administrator shall be guided by a rea-sonable interpretation of Plan provisions. The decisions shall be made in good faith and rendered following a detailed factual background investigation of the claim and the proposed treatment. The Plan Administrator will be guided by the following principles:

1. The medical condition must be life-threatening, desperate, life-shortening or one that leads to paralysis or severe loss of bodily or motor functions. 2. Conventional therapy does not exist or has failed. 3. The risk-benefit ratio of patient outcome must be as favorable as that of established disease or condition being treated. 4. The technology must be appropriate, in level of service and intensity, to the nature of the disease or condition being treated. 5. Public policy would support the procedure(s) as a valid and ethical course of treat ment. 6. The technology is judged to be reasonably clinically effective according to reports in peer reviewed scientific literature and/or preponderant expert medical opinion.

B. If a technology does not meet the above criteria, in whole or in significant part, it will be deemed Experimental and/or Investigational. The decisions of the Plan Administrator will be final and binding on the Plan.

C. Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved by the Food and Drug Administration for general use. 7. Family counseling other than bereavement counseling as provided under Hospice benefits. 8. Hazardous Hobby or Activity. Care and treatment of an injury or sickness that results from engag-ing in a hazardous hobby or activity. The following hobbies/activities are considered to be hazardous: A. Skydiving D. Bungee jumping B. Auto/motorcycle racing E. Motorcycle/ATV riding without a helmet C. Hang gliding (regardless of State Law)

http://www.jmsmithbenefits.com

31

EXHIBIT A - Plan Exclusions Please note this is a PARTIAL listing of Plan Exclusions. For a FULL listing of Medical, Dental, and Pre-scription Drug Exclusions, please reference your Summary Plan Booklet online at www.jmsmithbenefits.com.

9. Illegal acts. Charges for services received as a result of Injury or Sickness occurring directly or indirectly, as a result of a Serious Illegal Act, or a riot or public disturbance. For purposes of this exclusion, the term "Serious Illegal Act" shall mean any act or series of acts that, if prosecuted as a criminal offense, a sentence to a term of imprisonment in excess of one year could be imposed. It is not necessary that criminal charges be filed, or, if filed, that a conviction result, or that a sentence of imprisonment for a term in excess of one year be imposed for this exclusion to apply. Proof beyond a reasonable doubt is not required. This exclusion does not apply if the Injury or Sickness resulted from an act of domestic violence or a medical (including both physical and mental health) condition. 10. Illegal drugs or medications. Services, supplies, care or treatment to a Covered Person for Injury or Sickness resulting from that Covered Person's voluntary taking of or being under the influence of any controlled substance, drug, hallucinogen or narcotic not administered on the advice of a Physi-cian. Expenses will be covered for Injured Covered Persons other than the person using controlled substances and expenses will be covered for Substance Abuse treatment as specified in this Plan. This exclusion does not apply if the Injury resulted from an act of domestic violence or a medical (including both physical and mental health) condition. 11. Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a part of the treatment plan for another Sickness. Medically Necessary charges for Morbid Obesity will be covered for adults (patients 18 years of age or older) under very strict guidelines:

A. FDA approved Bariatric surgery (to include, but not limited to Gastric bypass,

forms of Lab-Band and Gastric Sleeve procedures) for morbid obesity may be covered under the JM Smith program if all the following conditions are met:

B. The surgery is medically appropriate for the patient; C. The patient is well informed, motivated, an acceptable operative risk, and is able to participate in treatment and long-term follow-up;

D. The patient has a body mass index (BMI) of 35 kg/m2 or greater; E. A letter of medical necessity from the surgeon explaining the patient's illnesses and the conditions aggravated by the obesity; and F. The surgery is an integral and necessary part of a course of treatment for a pa-tient with one of the following life threatening or disabling co-morbid conditions:

1. Poorly controlled type II diabetes mellitus; 2. Poorly controlled dyslipidemia; 3. Poorly controlled hypertension; 4. Serious cardiopulmonary disorder (e.g. coronary artery disease, cardiomyop

thy, pulmonary hypertension); 5. Obstructive sleep apnea; 6. Severe arthropathy of weight-bearing joints (treatable but for the obesity); or 7. Pseudotumor cerebri

G. JM Smith is not covering FDA approved Bariatric surgery (to include, but not limited to Gastric bypass, forms of Lap-Band and Gastric Sleeve procedures) in patients who only have the diagnosis of obesity and not one of these other conditions. The sur-gery must be performed by highly qualified surgeons who are members of the American College of Surgeons and the American Society for Bariatric Surgery.

12. Self-Inflicted. Any loss due to an intentionally self-inflicted Injury. This exclusion does not apply if the Injury resulted from an act of domestic violence or a medical (including both physical and mental health) condition.

13. Sexual Dysfunctions. Charges for services due to sexual dysfunctions, sex transformation, non-congenital transsexualism, gender dysphoria or sexual reassignment or change are excluded. This Exclusion includes, but is not limited to, medications, implants, hormone therapy, surgery, medial or psychiatric treatment, sex therapy programs or psychotherapy for problems related to sexual dys-function.

http://www.jmsmithbenefits.com

J M Smith Corporation 101 West Saint John St., Suite 305

Spartanburg, SC 29306 (800) 428-7281

www.jmsmithbenefits.com

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