A Summary of Material Modification (SMM) notice, pertaining to benefits in this SPD, is included at the end of this electronic file.

Transcription

1 IMPORTANT NOTICE A Summary of Material Modification (SMM) notice, pertaining to benefits in this SPD, is included at the end of this electronic file. Please review this notice carefully as it may impact your benefits.

2 working together to live well Health Benefits Summary Plan Description

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4 Table of Contents BenefitsPlus Health Benefits General Information 1 Summary Plan Description 1 General Plan Information 2 Introduction 2 Eligibility 3 Enrolling for Coverage 5 When Coverage Begins 7 Paying the Cost of Coverage 7 BenefitsPlus Medical Program 9 Summary of Coverage Options 9 How You Receive Care and Benefits 12 The Blue Cross Blue Shield PPO Network 12 How You and the Plan Pay for Treatment 14 Annual Deductible 14 Payment Percentage and Coinsurance 15 Annual Out-of-Pocket Maximum 16 Copayment 17 Health Savings Account (HSA) & the MedicalPlus Option 17 Lifetime Maximum Benefit 17 Pre-Certification of Treatment 17 Covered Services and Eligible Medical Charges 19 Special Benefits and Limits 22 Prescription Drugs 29 Services Not Covered 31 BenefitsPlus Employee Assistance Program 35 Summary of Benefits 35 BenefitsPlus Dental Program 36 Summary of Coverage 36 How You Receive Care and Benefits 36 How You and the Plan Pay for Treatment 36 Payment Percentage and Coinsurance 37 Annual Maximum Benefit 38 Covered Services and Eligible Dental Charges 38 Services Not Covered 40 BenefitsPlus Vision Program 41 Summary of Coverage 41 How You Receive Care and Benefits 42 Copayment 42 Using the VSP Network 42 Using an Out-of-Network Provider 43 Covered Services 43

5 Table of Contents Services Not Covered 44 Cosmetic Materials 44 BenefitsPlus Flexible Spending and Health Savings Accounts Program 45 Summary of Coverage 45 How You Use the Program 47 Health Savings Account (HSA) Coverage Option 47 Health Care FSA Coverage Option 49 Limited Use FSA Coverage Option 50 Special Rules for Health Care FSA and Limited Use FSA 51 Eligible Health Care Expenses 51 Health Care Expenses Not Eligible 52 When You Have an HSA and a Limited Use FSA 54 Dependent Care FSA Coverage Option 54 Special Rules Applicable to Plan Benefits 58 Rebates and Other Payments 58 Filing Claims and Appeals 58 Extensions of Timeframes 61 Health Care Claims 61 Your Right to Appeal 64 Coordinating Benefits with Other Plans 66 When Others Should Pay Your Expenses 67 Right to Recover Overpayments 68 When You Have a Leave of Absence 68 Rules for Choosing Medicare or Plan Coverage 68 Qualified Medical Child Support Order 69 When Coverage Ends 71 Continuing Coverage Under COBRA 71 Certificates of Creditable Coverage 81 Coverage for Reconstructive Surgery Following Mastectomy 82 Maternity Minimum Stay Provisions 83 Health Insurance Portability and Accountability Act (HIPAA) 83 HIPAA Non-Discrimination Rules 83 Michelle s Law 84 Administrative Information 85 Plan Administrator 85 Plan Information 86 Your ERISA Rights 88 Other Important Information 90

6 Table of Contents Appendix A Location/Classification Schedules 91 Burlington Operations 91 Burlington Bargaining Unit 92 Field Service Operations 93 Houston Operations 94 Worcester Operations 95 Olean Operations 96 Olean Bargaining Unit 96 Painted Post Operations 97 Painted Post Bargaining Unit 97 Wellsville Operations 98 Wellsville Bargaining Unit 98 Appendix B Qualifying Status Changes 99

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8 Health Benefits BenefitsPlus Health Benefits General Information NOTE This summary plan description (SPD) describes the health and flexible spending accounts benefits (consisting of medical, dental, vision, employee assistance, and flexible spending accounts benefits) for salaried, non-represented hourly, and union employees identified in Appendix A and replaces all other SPDs. All of these benefits reflect prevailing Dresser-Rand programs. No reliance should be placed on any statements previously made in any other SPD. Summary Plan Description This summary plan description (SPD) provides an overview of the BenefitsPlus coverage options for eligible salaried, non-represented hourly, and union-represented employees of Dresser-Rand Company (Company). The term BenefitsPlus is used to describe the medical, dental, vision, employee assistance, and flexible spending accounts benefits available to eligible salaried, non-represented hourly, and union employees of the Company as provided under the Dresser-Rand Company Welfare Benefit Plan (Plan). There are a few important things to note about this SPD: This information is provided to you in accordance with the Employee Retirement Income Security Act of 1974 (ERISA). This SPD does not create a contract of employment between Dresser-Rand Company and any employee. Nothing in this SPD prevents Dresser-Rand from terminating or changing the terms of an employee s employment. The Plan is expected to be continued indefinitely. However, Dresser-Rand reserves the right to amend, suspend, or terminate the Plan at any time. If you have questions after reviewing this document, please contact your Human Resources Representative. Only the claims administrator(s) and the Dresser-Rand Human Resources Staff are authorized to answer questions and provide information about the Plan. However, the Plan s terms cannot be modified by oral or written statements to you from Human Resources Representatives, other personnel, or individuals. No answer or statement by a Human Resources Representative, other employee, claims administrator, or insurance company may be relied on if it differs from the terms set forth in the Plan document. 1

9 Summary Plan Description continued Benefits described in this booklet may not automatically apply to employees at all locations, in all classifications, and/or to employees covered under a collective bargaining agreement. General Plan Information Plan Amendment or Termination The Company reserves the right to reduce, increase, or otherwise change the level of benefits offered under the Plan and to amend, modify, or terminate the Plan at any time for any reason, according to the terms of the Plan document and subject to any collective bargaining agreements. The Plan document is available for review during normal business hours by contacting Human Resources Shared Services. Plan Interpretation In the case of any conflict between the documents provided by an insurance company and this SPD, the provisions of the applicable insurance company documents will govern with respect to benefits provided by the insurance companies and this SPD will govern in all other respects. In the case of any conflict between this SPD and the Plan document, the Plan document shall govern. Introduction Welcome to BenefitsPlus Dresser-Rand s package of employee benefits providing certain health and flexible spending benefits to eligible salaried, non-represented hourly, and union-represented employees of the Company. BenefitsPlus consists of five main programs of benefits, including: NOTE The Plan Administrator has full discretionary authority to determine eligibility for Plan benefits and to construe the terms of the Plan, including any ambiguities in Plan language, except that each insurance company providing benefits under the Plan has full discretionary authority to construe the terms of the Plan for the determination and payment of all Plan benefit claims submitted to it. Medical (self-insured benefits provided as access to certain networks sponsored by various preferred provider organizations); Dental (self-insured benefits); Vision (insured benefits); Employee Assistance; and Flexible Spending Accounts. BenefitsPlus also contains limited Health Savings Account (HSA) interaction which may be available if you choose certain Medical program options described in this SPD. It is important to note that the HSA is administered by an independent trustee/custodian and the Company s role is limited to allowing you to contribute to your HSA on a before-tax basis. It is important to note that all programs may not be available to eligible employees at all locations, in all employee classifications, and/or to employees covered under a collective bargaining agreement. 2

10 Health Benefits BenefitsPlus Call Center Getting Connected is Easy! Telephone Call the BenefitsPlus Call Center at Representatives are available Monday through Friday from 9:00 a.m. to 6:00 p.m. Eastern time who can: Answer your questions about benefit provisions, eligibility rules and explain how your coverage works. Help you enroll for benefits coverage. Assist if you have a Qualifying Status Change. Provide additional benefit information. Online Go to benefits 7 days a week/24 hours a day to: Enroll online. Review your current benefit elections, contribution rates and coverage. Verify your dependent and beneficiary information. Access modeling tools to help you identify the lowest cost medical option and calculate potential expenses and tax savings available through the Flexible Spending Accounts (FSAs) and Health Savings Account (HSA). benefit questions to d-r@empyreanbenefits.com. Live Chat Option Live chat instant messaging is available with customer service representatives when you link to your online enrollment information, Monday through Friday 9:00 a.m. to 6:00 p.m. Eastern time. Introduction continued The plans and programs in BenefitsPlus are an important part of your total compensation. If you have questions about any of the rules and descriptions in this booklet, please contact your Human Resources Representative. Eligibility Eligible Employees Only eligible employees of the Company are eligible to participate in the BenefitsPlus portion of the Plan. A detailed description of which employees are eligible and other important information applicable to specific employee locations/classifications are found in the Location/Classification Schedule in Appendix A at the end of this SPD. This means that some employees of the Company are not eligible for BenefitsPlus, or they are eligible for different benefits or programs than those included in this SPD. Some programs also offer coverage to eligible family members of eligible employees. Leased employees, temporary employees, independent contractors, agency employees, persons performing services pursuant to contracts under which they are designated independent contractors regardless of whether they might be deemed common law employees by a court, governmental agency or otherwise, and persons employed by employers other than the Company, are not eligible to participate in the Plan. The Company s classification of a person for purposes of the Plan shall be conclusive. No reclassification of a person s status with the Company for any reason, without regard to whether it is initiated by a court, governmental agency, or otherwise and without regard to whether or not the Company agrees to such reclassification, shall result in the person being considered an eligible employee for Plan purposes. Collectively Bargained Employees If you are covered by a collective bargaining agreement (CBA), you are an eligible employee only if your bargaining unit has negotiated for participation in the Plan. If there is a CBA applicable to you that requires coverage under this Plan, look to the terms of that CBA for your plan benefits and reimbursement rate (to the extent it does not conflict with the Employee Retirement Income Security Act [ERISA] or the Internal Revenue Code). The Location/Classification Schedule found in Appendix A at the end of this SPD identifies your agent and CBA. You and your family members covered by this Plan may examine the CBA at your collective bargaining agent s principal office or meeting hall, or the Human Resources Shared Services office during normal business hours. A copy of the agreement may also be obtained upon written request to Human Resources Shared Services. If there is not a CBA applicable to you, your eligibility requirements are listed on the applicable Location/ Classification Schedule found in Appendix A. Consult your collective bargaining agreement or your Dresser-Rand Human Resources Representative if you have a question about your participation in this Plan. 3

11 Collectively Bargained Employees continued Coverage under the programs described in this booklet will begin on the first of the month after your date of hire. Additional waiting periods apply to some programs, and they are described in this booklet. Records for Eligibility Employment records used to determine eligibility for Plan participation are maintained by the Company s Human Resources group, as well as other records relating to the Plan s self-insured benefits. Eligible Family Members Certain programs will allow you to cover your eligible family members. They are: Your spouse of the opposite sex, by marriage or common-law (when recognized by state law); Your dependent children, including biological, adopted, and other children who live with you in a parent-child relationship and depend on you for more than one-half of his or her annual financial support (e.g., step-child, legal ward), to age 19; or Your children who are full-time students, at an educational organization which normally maintains a regular faculty and curriculum and normally has a regularly enrolled body of students in attendance at the place where its educational activities are regularly carried on (School), until such children reach age 25 (you may be required to provide proof of your child s enrollment from time to time), provided that the child depends on you for more than one-half of his or her financial support. This category will be administered so that your child will remain an eligible family member during a School s regularly scheduled break if such child is enrolled as a full-time student at a School in the semesters immediately before and immediately following the break unless the break follows the month where your child completes all requirements to graduate from the School (Completes School). In the month in which your child Completes School, your child will cease to be an eligible family member at the end of that month in which he/she Completes School unless he/she is enrolled in a School by the end of such month in which he/she Completes School. Medical leave of absence (LOA) exception If your dependent does not meet the full-time student requirements listed above due to being on a physician-certified medical leave of absence, your dependent may remain eligible for benefits if proper documentation is provided. If your dependent meets these criteria, you may be required to provide medical documentation to ensure continuation of coverage. Your children of any age who are totally and permanently disabled (as determined by Blue Cross Blue Shield of Illinois based on the disability criteria described on page 5), and such determination is made during a time when such child would otherwise have been an eligible family member under the Plan and who depends on you for more than one-half of his/her annual financial support. 4

12 Health Benefits Eligible Family Members continued Disability criteria means that such child is unable to engage in any substantial gainful activity by reason of a medically-determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. You may be required to provide proof of continued disability from time to time. Enrolling for Coverage General Enrollment Information for BenefitsPlus If you are an eligible employee enrolling in BenefitsPlus, you have several decisions to make based on what program(s) and benefits you are eligible for under the Plan. For instance, when you enroll in the Medical program, you must choose one of the following two available benefit coverage options: PPO Option; or MedicalPlus Option. Both options are described in greater detail in the Medical Program section of this SPD. The benefits and restrictions associated with different benefits provided under BenefitsPlus are discussed in greater detail in the main sections dealing with the specific program options. What If My Spouse and I Both Work for Dresser-Rand? The Plan does not allow double coverage. Only one of you may choose coverage for your eligible children. And if you choose an enrollment category that covers your spouse, your spouse will not be eligible to also choose duplicative coverage under any Companysponsored Plan or program. Please note that the Medical program coverage option you choose applies to all your covered eligible family members. You may change from one Medical program coverage option to another only during a re-enrollment period. If you choose no coverage for the Medical program and you later want to have this coverage, you must wait until the next re-enrollment period, or until you have a qualifying status change, to have this coverage begin. Enrollment Categories Enrollment categories determine which of your eligible family members are covered by a program. You can choose from these enrollment categories for the Medical, Dental, and Vision programs: Employee only; Employee + one; or Employee + family. You may choose a different enrollment category for each of the three programs (Medical, Dental, and Vision). Confirming Your Enrollment Choices Once you have enrolled, you will receive a written confirmation statement of your enrollment choices and of the eligible family members you enrolled for each program. If you find an error on your written confirmation, or if all your eligible family members are not listed, you need to contact your Human Resources Representative immediately. You may not add or drop family members or change benefit options or enrollment categories after your enrollment deadline described in the section entitled When You Enroll. 5

13 When You Enroll For the programs described in this booklet, you must enroll in order for their coverage to begin. There are four times when you may enroll: Initial enrollment period the 30-day period starting on the day you are first hired by Dresser-Rand. Re-enrollment period the annual enrollment period, announced each fall. Qualifying status change enrollment period the 30-day period beginning when you or your eligible family member has a qualifying status change, described below. Special enrollment when you gain a new dependent by marriage, birth, adoption, or placement for adoption: the 30-day period beginning from the marriage, birth, adoption, or placement for adoption. If you are rehired within the same Plan Year and are eligible for the Plan, then you may make new elections, provided that you are rehired more than 30 days after you terminated employment. If you are rehired within 30 days or less during the same Plan Year, then your prior elections will be reinstated. Where Can I Get Updates on Coverage and Enrollment Rules? During each annual reenrollment period, you will receive communications that describe the most significant changes for the coming year. Those re-enrollment materials are Plan communications and are incorporated by reference into this document. Qualifying Status Changes With the exception of HSA benefits (for which prospective election changes generally are allowable), you generally cannot change your elections during the Plan Year. This is known as the irrevocability rule. Of course, you can change your elections for benefits and salary reductions during the reenrollment period, but those election changes will apply only for the following Plan Year. However, during the Plan Year, there are several exceptions to the irrevocability rule. For a summary of these rules, please see Appendix B of this SPD. Please note that the Plan Administrator may also reduce your contributions during the Plan Year if you are a key employee or highly compensated individual as defined by the Internal Revenue Code, if necessary to prevent the Plan from becoming discriminatory within the meaning of Federal income tax law. Additionally, if a mistake is made as to your eligibility or participation, the allocations made to your account, or the account of benefits to be paid to you or another person, then the Plan Administrator shall, to the extent that it deems administratively possible and otherwise permissible under applicable law, allocate, withhold, accelerate, or otherwise adjust such amounts as will in its judgment, accord the credits to the account or distributions to which you are, or such other person is, properly entitled under the Plan. Such action by the Plan Administrator may include withholding of any amounts due from your compensation. You may add or drop coverage for any eligible family member during an annual re-enrollment period or when you have a qualifying status change. However, you may change medical coverage options only during an annual re-enrollment period. Information on how to enroll in Dresser-Rand benefits is available on the Web at or you may contact your local Human Resources Representative. 6

14 Health Benefits How Do I Keep My Child Covered At Age 19? If your child is a full-time student (as described on page 4): Change your child s status within 30 days before his/her 19th birthday. Report the status change on the Web at com/benefits, or contact the BenefitsPlus Call Center for assistance. If your child is not a full-time student: Coverage ends on the last day of the month of his/ her 19th birthday. To continue the child s Medical, Dental, or Vision coverage for up to 36 months, your child must choose COBRA; see page 71 for information about COBRA coverage. Request Changes Within 30 Days When you have a qualifying status change, you must request any change in your coverage choices within 30 calendar days of the event. When you gain a new eligible family member, you must add that person within 30 days in order to begin that person s coverage. You must add a newborn s Social Security number within 60 days in order to continue the child s coverage. If you do not enroll a new eligible family member during this 30-day period, you must wait until the next re-enrollment period to begin that person s coverage, unless you have another qualifying status change. Review the confirmation statement you receive from the Plan, and your payroll deductions, to ensure your eligible family member s enrollment is complete. When Coverage Begins When coverage under any program under the Plan begins depends on when you or your eligible family member enroll for that program. People you enroll during your initial enrollment period have coverage beginning on the first day of the month after you become an eligible employee and have begun working (if you become an eligible employee on the first day of the month, your coverage begins on the first day of the following month). People you enroll during a re-enrollment period, rather than when they are first eligible, have coverage beginning on the following January 1. People you enroll during a qualifying status change enrollment period have coverage beginning on the date of their qualifying status change. Paying the Cost of Coverage While you are an active employee, you and the Company share the cost of coverage under the Plan. Contribution rates for non-union participants will be determined for each calendar year by the Company and communicated to the participants during the annual re-enrollment period prior to the calendar year to which the amounts apply. The materials containing these communications are made a part of this SPD by this reference. If you are part of a bargaining unit, your costs are determined by your collective bargaining agreement. For the programs described in this SPD, your contributions generally come from your pay on a before-tax basis. Before-tax contributions come from your pay before Federal income taxes, FICA (Social Security and Medicare) taxes, and most state and local income taxes are figured. Because your taxes are calculated on a lower amount of taxable income, you pay less tax. This has the effect of reducing the cost of your coverage. When you reduce the amount of your pay that is subject to Social Security taxes, you may also reduce your Social Security benefit. Any benefit reduction, however, should be only slight, and it will likely be more than offset by your reduced taxes. 7

15 Paying the Cost of Coverage continued This chart shows how you and the Company contribute toward the cost of each BenefitsPlus program in this booklet, and whether your contributions come from your pay on a before-tax or after-tax basis. Plan Eligible Employees Company Contribution Your Contribution Medical Yes Before-tax* Dental Yes Before-tax* Vision No Before-tax* Health Care FSA Only if you choose MedicalPlus and you are eligible for Medicare Before-tax* Limited Use FSA None Before-tax* Health Savings Account Yes Before-tax* Dependent Care FSA None Before-tax* * Although such contributions are generally on a before-tax basis, special circumstances may require after-tax contributions to the Plan (such as COBRA payments, Plan operational issues and leaves of absence). 8

16 Health Benefits BenefitsPlus Medical Program This summary is an overview of the BenefitsPlus medical options (Medical program) of the Plan. Do I Have to Choose Medical Coverage? You are not required to be covered by the Medical program, but Dresser-Rand strongly encourages you to have medical coverage from some source at all times. If you choose no coverage under the Medical program, you must wait until the next re-enrollment period to begin coverage unless you have a qualifying status change. For example, you may decline coverage under the Medical program because you have medical coverage through your spouse s employer. If your spouse s job ends and you lose that plan s coverage, you have a qualifying status change and you may enroll in the Dresser-Rand Medical program within 30 days after the date you lost coverage. Please note: In order to be eligible for certain retiree medical coverage, you must be enrolled in a medical coverage option under the Plan on the day before you retire. The eligibility rules for retiree medical coverage are in the section titled Does the Medical Program Cover Retirees? on page 11. You can contact your Human Resources Representative for more information. Summary of Coverage Options The Medical program has two coverage options, both offering separate benefit levels for in-network and out-of-network treatment. The PPO Option provides traditional-style coverage, while the MedicalPlus Option combines high-deductible medical coverage with a health savings account (HSA). When you enroll, you choose one of these options for you and all your covered eligible family members. Medical benefits under both coverage options are administered by Blue Cross Blue Shield of Illinois (BCBS). Prescription drug benefits under both coverage options are administered by Caremark Inc. (Caremark). 9

17 Summary of Coverage Options PPO Option MedicalPlus In-Network Out-of-Network In-Network Out-of-Network Annual Deductible Medical only: $300 per person $700 per family Medical only: $600 per person $1,400 per family Medical and prescription drugs: $2,500 per person $5,000 per family Medical and prescription drugs: $3,000 per person $6,000 per family Annual Out-of-Pocket Maximum (includes your deductible and coinsurance for most covered services) $2,000 per person $4,000 per family $4,000 per person $8,000 per family $3,000 per person $6,000 per family $5,000 per person $10,000 per family Physician s Office Visit (primary care and specialty physicians, nurse practitioners, and physician assistants) Program pays 80% after deductible; you pay 20% coinsurance Program pays 60%* after deductible; you pay 40%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 70%* after deductible; you pay 30%* coinsurance Preventive Care (based on published schedule of treatments) No deductible applies Program pays 100% Not covered No deductible applies Program pays 100% Not covered Inpatient Hospital Care (includes pre-admission testing and coordinated home care; requires pre-certification) Program pays 80% after deductible; you pay 20% coinsurance Program pays 60%* after deductible; you pay 40%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 70%* after deductible; you pay 30%* coinsurance Outpatient Surgery and Diagnostic Tests (performed in a physician s office, hospital, or free-standing facility) Program pays 80% after deductible; you pay 20% coinsurance Program pays 60%* after deductible; you pay 40%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 70%* after deductible; you pay 30%* coinsurance Emergency Care (you pay $150 penalty for using a hospital emergency room for nonemergency care) Program pays 80% after deductible; you pay 20% coinsurance Program pays 80%* after deductible; you pay 20%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 90%* after deductible; you pay 10%* coinsurance Inpatient Mental Health or Chemical Dependency (requires pre-certification or $500 benefit penalty applies) Program pays 80% after deductible; you pay 20% coinsurance Program pays 60%* after deductible; you pay 40%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 70%* after deductible; you pay 30%* coinsurance Outpatient Mental Health or Chemical Dependency Program pays 80% after deductible; you pay 20% coinsurance Program pays 60%* after deductible; you pay 40%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 70%* after deductible; you pay 30%* coinsurance Medical/Surgical Care Program pays 80% after deductible; you pay 20% coinsurance Program pays 60%* after deductible; you pay 40%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 70%* after deductible; you pay 30%* coinsurance Extended Care Facility (skilled nursing facility requires pre-certification) Program pays 80% after deductible; you pay 20% coinsurance Program pays 80%* after deductible; you pay 20%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 90%* after deductible; you pay 10%* coinsurance Hospice Care Program pays 80% after deductible; you pay 20% coinsurance Program pays 60%* after deductible; you pay 40%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 70%* after deductible; you pay 30%* coinsurance * Subject to reasonable and customary (R&C) charge as determined by BCBS. 10

18 Health Benefits Summary of Coverage Options PPO Option MedicalPlus In-Network Out-of-Network In-Network Out-of-Network Chiropractic Care (limited to $500 per year) Program pays 80% after deductible; you pay 20% coinsurance Program pays 80% after deductible; you pay 20% coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 90%* after deductible; you pay 10%* coinsurance Podiatric Care (treatment of the feet) Program pays 80%, no deductible; you pay 20% coinsurance Program pays 80%,* no deductible; you pay 20%* coinsurance Program pays 90%, no deductible; you pay 10% coinsurance Program pays 90%,* no deductible; you pay 10%* coinsurance Outpatient Therapies (occupational, physical, and speech; limited to $5,000 per year, per therapy) Program pays 80% after deductible; you pay 20% coinsurance Program pays 60%* after deductible; you pay 40%* coinsurance Program pays 90% after deductible; you pay 10% coinsurance Program pays 70%* after deductible; you pay 30%* coinsurance Prescription Drugs PPO No deductible applies MedicalPlus Deductible and out-of-pocket maximum apply, same as any other medical charge Brand Name Retail You pay 35% up to $150, program pays the rest (30-day supply) Generic Retail You pay $10 copayment, program pays the rest (30-day supply) You pay 100% of retail price at the pharmacy, plan reimburses 65% After deductible, you pay 10%, program pays 90% (30-day supply) After deductible, you pay 100% of retail price at the pharmacy, plan reimburses 65% Brand Name Mail Order You pay 25% up to $300, program pays the rest (90-day supply) None After deductible, you pay 10%, program pays 90% (90-day supply) None Generic Mail Order You pay $20 copayment, program pays the rest (90-day supply) Annual Prescription Out-of-Pocket Maximum** (includes your prescription copayments and coinsurance) $1,250 per person $2,500 per family None No separate prescription maximum prescription drug expenses apply to medical out-of-pocket maximum Lifetime Maximum Benefit $5 million (combined medical and pharmacy) * Subject to reasonable and customary (R&C) charge as determined by BCBS ** Separate from medical out-of-pocket maximum Does the Medical Program Cover Retirees? If you are a salaried/non-bargaining unit employee who is not an IR Retiree*, separate Medical program may be offered to you at retirement if, on January 1, 1998, you: Were actively employed by Dresser-Rand; Were age 45 or older; Had completed at least five years of service; and Your age plus your whole years of service totaled at least 65. In addition, when you retire, you must be: Age 55 or older and have at least 10 years of service; and Covered by a Dresser-Rand Medical program coverage option on the day before you retire. If you are covered by the Wellsville collective bargaining agreement, you are eligible for a separate Medical program at retirement if, on January 1, 2006, you: Were age 58 or older; Had completed at least five years of service; and Your age plus your whole years of service totaled at least 75. In addition, when you retire, you must be: Age 60 or older and have at least 10 years of service; and Not be an IR Retiree who, on October 31, 2004, was age 60 or older and had at least 10 years of service with Dresser-Rand. * An IR Retiree is someone who was employed by Dresser-Rand on October 31, 2004 and who, on October 31, 2004, was age 55 or older and had at least 15 years of service with Dresser-Rand. 11

19 Summary of Coverage Options continued Does the Medical Program Cover Retirees? If you are covered by the Painted Post collective bargaining agreement, you are eligible for a separate medical program at retirement if, on August 1, 2007, you: Were age 55 or older; Had completed at least five years of service; and Your age plus your whole years of service totaled at least 75. In addition, when you retire, you must: If you are covered by the Olean collective bargaining agreement, you are eligible for a separate medical program at retirement if, on April 1, 2008, you: Were age 58 or older; and Had completed at least fifteen years of service. In addition, when you retire, you must not be an IR Retiree. An IR Retiree is someone who was employed by Dresser-Rand on October 31, 2004 and who, on October 31, 2004, was age 55 or older and had at least 15 years of service with Dresser-Rand. Be age 55 or older and have at least 15 years of service, and Not be an IR Retire. An IR Retiree is someone who was employed by Dresser-Rand on October 31, 2004 and who, on October 31, 2004, was age 55 or older and had at least 15 years of service with Dresser-Rand. How You Receive Care and Benefits Both the PPO and MedicalPlus Options cover the same medical treatments (eligible medical charges) and services provided by laboratories, hospitals, and physicians. They differ primarily in the amount of benefit they provide. All treatment must be medically necessary in order to be an eligible medical charge and covered by the Medical program. The fact that a doctor has prescribed, ordered, recommended, or approved some type of care does not, in itself, make it medically necessary. If you have questions about the necessity of a treatment, please call BCBS before you agree to treatment. BCBS is solely responsible for determining whether any treatment, service, or supply is medically necessary. The Blue Cross Blue Shield PPO Network Blue Cross Blue Shield of Illinois and the larger Blue Cross Blue Shield organization have established a network of health care providers doctors, hospitals, clinics, laboratories, etc. who have agreements to care for BCBS patients at discounted charges. These Blue Card PPO providers are located all across the country. To find a member of the Blue Card PPO network, see the Web site for Blue Cross Blue Shield of Illinois at: and choose the Provider Finder link. Or you may call BCBS at

20 Health Benefits How Are Pre-Existing Conditions Affected by the Medical Program? The Medical program does not exclude pre-existing conditions from coverage. Neither you nor your eligible family member needs to present a certificate of creditable coverage in order to be covered by the Medical program. What Coverage Information Do I Give to a Provider? Each employee covered by the Medical program gets an identification card from BCBS. It has the information providers need to confirm your coverage and file claims for both medical care and prescription drugs. How Does the Program Cover Inpatient Specialist Care? In-Network Providers Using an in-network provider may save you money. The Medical program s benefits are highest when you use a provider in the Blue Card PPO network; they are described in the in-network column of the Summary of Coverage Options chart beginning on page 10. In-network providers negotiate with BCBS and agree on the fees they will charge for Blue Card PPO network patients. The provider bills you for your share of the negotiated amount only. This means you generally will not receive bills for any additional eligible medical charges when you use an in-network provider. You may also save time by using an in-network provider. Just present your ID card, and the provider uses it to contact BCBS to verify your eligibility and to file your claim with the Medical program. Out-of-Network Providers Providers who are not in the Blue Card PPO network are out-of-network providers. The Medical program pays its lower, out-of-network benefit for care from these providers; they are described in the out-of-network column of the Summary of Coverage Options chart beginning on page 10. Benefits for out-of-network providers are based on the reasonable and customary (R&C) charge for the treatment as determined by BCBS. The Medical program s benefits for out-of-network providers are limited to the R&C level. Many out-of-network providers are contracting providers, meaning they have an agreement with some Blue Cross Blue Shield organization, but not with the Blue Card PPO network. Contracting providers agree not to bill more than the R&C charge and file claims for Blue Card PPO network patients. Out-of-network providers who are not contracting providers may require you to pay them directly for your treatment. You will then need to file a claim to receive your benefits from the Medical program. Your benefits will be based on the R&C charge for your treatment, as determined solely by BCBS, based on charges for covered services in the same geographic area. If your provider s charges are more than the R&C level, you are responsible for paying those excess amounts, in addition to your deductible and coinsurance. Amounts you pay above R&C do not count toward your annual out-of-pocket maximum (Note: terms in italics described on the following pages). If you use an in-network hospital and doctor for inpatient care, all covered physician charges will be eligible for in-network benefits, even for radiologists, anesthesiologists, and pathologists who are not in-network providers. 13