Introduction ORNL BENEFITS

PO Box 2008, MS 6465 Oak Ridge, TN 37831-6465

(865) 576-7766 | ornlbenefits@ornl.gov

July 24, 2018

Dear Retiree/Spouse:

Your Retiree Benefits Summary Plan Description (SPD) outlines the benefits available to you as a retiree. Because of the many legal and plan design changes, the SPD has now been updated with current plan information.

The retiree SPD is available to view or download at http://benefits.ornl.gov/rspd/default.aspx. You may also request a free CD or print copy by contacting ornlbenefits@ornl.gov.

Please discard the older versions of Your Book of Benefits issued as a three-ring binder or CD and refer to the most current Web-based edition.

If you have any questions or need assistance, contact the ORNL Benefits Office at 865-576-7766.

Sincerely yours,

G. Scott McIntyreManager, Employee Benefits

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This Notice applies only to UT-Battelle, LLC’s group health plan and any health program that receives financial assistance from the Department of Health and Human Services

UT-Battelle, LLC (UT-Battelle) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

UT-Battelle does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

• UT-Battelle: o Provides free aids and services to people with disabilities to communicate

effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic

formats, other formats) o Provides free language services to people whose primary language is not English,

such as: Qualified interpreters Information written in other languages

If you need these services, contact Deborah Bowling, Civil Rights Coordinator, P.O. Box 2008, MS 6217, Oak Ridge, TN 37831-6217, Telephone - 865-574-9846.

If you believe that UT-Battelle has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Deborah Bowling, Civil Rights Coordinator, P.O. Box 2008, MS 6217, Oak Ridge, TN 37831-6217, Telephone - 865.574.9846, Fax - 865.574.4441, Email -bowlingdm@ornl.gov. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Deborah Bowling, Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1.800.368.1019, 800.537.7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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Tagline Informing Individuals with Limited English Proficiency of Language Assistance Services Spanish

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1.865.574.9846.

Arabic

(رقم 61.865.574.984اتصل برقم إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. ملحوظة: ھاتف الصم والبكم: .

Chinese

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1.865.574.9846。

Vietnamese

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số

1.865.574.9846.

Korean

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1.865.574.9846 번으로 전화해 주십시오.

French

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés

gratuitement. Appelez le 1.865.574.9846.

Laotian

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1.865.574.9846.

Amharic

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1.865.574.9846.

German

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1.865.574.9846.

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Gujarati

�ચુના: જો તમે �જુરાતી બોલતા હો, તો િન:�લુ્ક ભાષા સહાય સેવાઓ તમારા માટ� ઉપલબ્ધ છે. ફોન કરો 1.865.574.9846.

Japanese

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

1.865.574.9846 まで、お電話にてご連絡ください。

Tagalog

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1.865.574.9846.

Hindi

ध्यान द�: य�द आप �हदं� बोलते ह� तो आपके �लए मुफ्त म� भाषा सहायता सेवाएं उपलब्ध ह�। 1.865.574.9846 पर कॉल कर�।

Russian

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1.865.574.9846.

Persian (provided in Farsi language)

: اگر بھ زبان فارسی گفتگو می کنید، تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. باتوجھ تماس بگیرید. 1.865.574.9846

Contents

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1 About Your Benefits .......................................................................................... 1—1

Highlights .............................................................................................................1—2 Eligibility and Cost ................................................................................................1—3

Determining Eligibility and Cost .......................................................................................................... 1—3 Company Service Date prior to April 1, 2012 ...................................................................................... 1—4 Company Service Date on or after April 1, 2012 ................................................................................. 1—5

Medical and Dental Plans Coverage Rules ...........................................................1—6 Under Age 65 Medical (including Prescription Drug and Vision) and Dental Plans ............................. 1—6 Over Age 65 Medical and Dental Plans .............................................................................................. 1—6

Eligibility for Dependents ......................................................................................1—7 Medical and Dental Eligibility for Your Dependents ............................................................................ 1—7 Eligibility … At a Glance ..................................................................................................................... 1—8

When You May Change Your Elections ................................................................1—9 When You May Change Your Elections .............................................................................................. 1—9 Qualifying Life Events ......................................................................................................................... 1—9

How Changes Affect Your Benefits ..................................................................... 1—10 Steps to Take If You Get Married .................................................................................................... 1—10 Steps to Take If You Get Divorced ................................................................................................... 1—10 Steps to Take If You Are Expecting or Adopting a Child ................................................................... 1—11 Steps To Take at Death .................................................................................................................... 1—11 Steps To Take If You Lose a Spouse or Child .................................................................................. 1—11 Steps To Take If You or Your Spouse is Admitted to a Long-Term Care Facility .............................. 1—12 What Happens to Your Benefits If You Die ....................................................................................... 1—12

When Coverage Begins ...................................................................................... 1—13 When Coverage Ends ........................................................................................ 1—14

2 Medical Plans ..................................................................................................... 2—1 Highlights .............................................................................................................2—2 Prime Select and Consumer Choice with HSA Medical Plans Overview ...............2—3

How the Prime Select and Consumer Choice with HSA Medical Plans Work .......2—4 National Network of Providers ............................................................................................................ 2—4 Selecting a Physician ......................................................................................................................... 2—4 Preventive Care .................................................................................................................................. 2—4 Direct Access to Obstetricians and Gynecologists .............................................................................. 2—5 Coinsurance, Copayments, Deductibles, and Out-of-Pocket Maximum .............................................. 2—5 If You Have an Emergency ................................................................................................................. 2—6 The Network Credentialing Process ................................................................................................... 2—6 If You Need Care While Traveling Outside Your Network Area .......................................................... 2—6 Residing in Another Location .............................................................................................................. 2—6 Out-of-Network Benefits ..................................................................................................................... 2—7 Mental Health/Alcohol and Substance Abuse Treatment .................................................................... 2—7 UnitedHealthcare Member Services ................................................................................................... 2—8

UnitedHealthcare Prime Select Plan .....................................................................2—9 How the UnitedHealthcare Prime Select Plan Works .......................................... 2—10

In-Network Benefits .......................................................................................................................... 2—10

Contents (cont.)

RETIREE UT-B Introduction vi 1/1/2018

Summary of Benefits: UnitedHealthcare Prime Select Plan ................................ 2—11 UnitedHealthcare Consumer Choice with HSA Plan ........................................... 2—19 How the UnitedHealthcare Consumer Choice with HSA Plan Works .................. 2—20

In-Network Benefits .......................................................................................................................... 2—20 Summary of Benefits: UnitedHealthcare Consumer Choice with HSA Plan ........ 2—22 UnitedHealthcare Indemnity Plan ....................................................................... 2—31 How the UnitedHealthcare Indemnity Plan Works .............................................. 2—32

Medicare-Based Maximum Reimbursement Charge (MRC) ............................................................. 2—32 The Family Deductible ...................................................................................................................... 2—32 The Out-of-Pocket Maximum ............................................................................................................ 2—33

Summary of Benefits: UnitedHealthcare Indemnity Plan ..................................... 2—34 Information for All Medical Plans ............................................................................................. 2—37

Information for All Medical Plans ........................................................................ 2—38 Certification Requirements ............................................................................................................... 2—38 Preadmission Certification/Continued Stay Review for Hospital Confinement................................... 2—38 Outpatient Certification Requirements .............................................................................................. 2—39 Diagnostic Testing and Outpatient Procedures ................................................................................. 2—39 Prior Authorization/Pre-Authorized ................................................................................................... 2—39 Emergency Hospitalization ............................................................................................................... 2—39 Expenses Not Covered ..................................................................................................................... 2—40 Filing Claims ..................................................................................................................................... 2—42 Coordination of Benefits ................................................................................................................... 2—42

Other Important Information ................................................................................ 2—45 Right to Reimbursement (Subrogation)............................................................................................. 2—46 Newborns’ and Mothers’ Health Protection Act of 1996 .................................................................... 2—47 Medical Insurance After Age 65—During Active Service .................................................................. 2—47 Dependent Coverage In the Event of Your Death ............................................................................. 2—47 Continuation of Medical Coverage (COBRA) .................................................................................... 2—47 Coverage for Reconstructive Surgery Following Mastectomy ........................................................... 2—48 Medical Claims Review and Appeal Procedures ............................................................................... 2—48

3 Prescription Drug Plan ...................................................................................... 3—1 Highlights .............................................................................................................3—2 How the Prescription Drug Benefit Works .............................................................3—3

Prescription Drug Benefits .................................................................................................................. 3—3 Quantity Limits .................................................................................................................................... 3—3 Prior Authorization .............................................................................................................................. 3—3 Step Therapy: The Right Medication at the Right Cost ....................................................................... 3—3 Member Pays the Difference .............................................................................................................. 3—3 Retail Refill Allowance ........................................................................................................................ 3—3 Extended Payment Program ............................................................................................................... 3—3 Automatic Refills ................................................................................................................................. 3—4 Specialty Medications ......................................................................................................................... 3—4 Copayment/Patient Assistance Programs and Accredo ...................................................................... 3—4 Preventive Care Drugs ....................................................................................................................... 3—4 Infertility Drug Coverage ..................................................................................................................... 3—5

Contents (cont.)

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Summary of Benefits ............................................................................................3—6 Other Important Information ..................................................................................3—7

Prescription Drug Claims Review and Appeal Procedures .............................................................. 3—7

4 Vision Care ......................................................................................................... 4—1 Highlights .............................................................................................................4—2 How the Vision Service Plan Works ......................................................................4—3 Summary of Benefits ............................................................................................4—4

Necessary Contact Lenses ................................................................................................................. 4—4 Low Vision Benefit .............................................................................................................................. 4—4 Out-of-Network Provider Benefit ......................................................................................................... 4—4 Diabetic Eyecare Benefit .................................................................................................................... 4—5 TruHearing Hearing Aid Discount Program ......................................................................................... 4—5

Other Important Information ..................................................................................4—5 Vision Services Claims Review and Appeal Procedures ..................................................................... 4—5

5 Over 65 Medicare Supplement Program .......................................................... 5—1 Highlights .............................................................................................................5—2 How the Over 65 Medicare Supplement Program Works ......................................5—3 Your Prescription Drug Benefits ...........................................................................5—4 Health Reimbursement Arrangement ...................................................................5—5 Other Important Information ..................................................................................5—7

Prescription Drug Claims Review and Appeal Procedures ................................................................. 5—7 HRA Claims Procedures ................................................................................................................... 5—13 Medicare Supplement Plan Claims ................................................................................................... 5—14

6 Dental Plans ....................................................................................................... 6—1

Highlights .............................................................................................................6—2 Some Facts to Remember About Your Dental Plans ............................................6—2 MetLife Dental Plan ..............................................................................................6—3

How the MetLife Dental Plan Works .....................................................................6—4 Network Provider ................................................................................................................................ 6—4 Non-Network Provider ........................................................................................................................ 6—4 Annual Deductible .............................................................................................................................. 6—4 Maximum Benefits .............................................................................................................................. 6—4

MetLife Dental Plan—Summary of Benefits ..........................................................6—5 MetLife Dental Plan—Covered Expenses .............................................................6—6

Type A—Preventive and Diagnostic Services ..................................................................................... 6—6 Type B—Oral Surgery and Restorative Services ................................................................................ 6—6 Type C—Prosthodontic Services ........................................................................................................ 6—6 Type D—Orthodontic Services ........................................................................................................... 6—7

Predetermination of Benefits ................................................................................6—7 Alternative Course of Treatment ...........................................................................6—8

Contents (cont.)

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Exclusions ............................................................................................................6—8 Extended Dental Care Benefits ............................................................................6—9 Treatment in Progress ..........................................................................................6—9 Claiming Benefits .................................................................................................6—9 Coordination of Benefits ..................................................................................... 6—10 Other Company Benefits .................................................................................... 6—10 Claims Review and Appeal Procedures .............................................................. 6—10

Initial Determination .......................................................................................................................... 6—10 Appeals Procedure ........................................................................................................................... 6—11

Delta Dental Plan ............................................................................................... 6—13

How the Delta Dental Plan Works....................................................................... 6—14 Eligibility and Enrollment .................................................................................................................. 6—14 Choosing a Dentist ........................................................................................................................... 6—14 Participating vs. Nonparticipating...................................................................................................... 6—14 Annual Deductible ............................................................................................................................ 6—14 Maximum Benefits ............................................................................................................................ 6—14 Emergency Dental Care ................................................................................................................... 6—14 Limitations ........................................................................................................................................ 6—15 Types of Dental Services .................................................................................................................. 6—15

Delta Dental Plan—Summary of Benefits ........................................................... 6—15 Delta Dental Plan Schedule of Benefits .............................................................. 6—16

Class I—Preventive and Diagnostic Services ................................................................................... 6—16 Class II—Basic Services .................................................................................................................. 6—16 Class III—Major Services ................................................................................................................. 6—16 Class IV—Orthodontic Services ....................................................................................................... 6—17

Predetermination of Benefits .............................................................................. 6—17 Optional Services ............................................................................................... 6—17 Exclusions and Limitations ................................................................................. 6—18 General Provisions ............................................................................................. 6—20 Extended Dental Care Benefits .......................................................................... 6—21 Claims Review and Appeal Procedures .............................................................. 6—21

7 Long-Term Care ................................................................................................. 7—1 Highlights .............................................................................................................7—2 About Long-Term Care Benefits ...........................................................................7—3 How the Plan Works .............................................................................................7—3

Eligibility ............................................................................................................................................. 7—3 Premium Payments ............................................................................................................................ 7—3 When Benefits Are Paid ..................................................................................................................... 7—4 Waiting Period .................................................................................................................................... 7—4 What the Plan Pays ............................................................................................................................ 7—4

Contents (cont.)

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Coordination of Benefits ..................................................................................................................... 7—5 Concurrent Review ............................................................................................................................. 7—5 Changing Your Selections .................................................................................................................. 7—5 Inflation Increases .............................................................................................................................. 7—5 Reinstatement .................................................................................................................................... 7—5

Covered Services .................................................................................................7—5 Initial Care Planning Visit .................................................................................................................... 7—5 Nursing Home Care ............................................................................................................................ 7—5 Assisted Living Facility Services ......................................................................................................... 7—6 Home Care Services .......................................................................................................................... 7—6 Respite Care Services ........................................................................................................................ 7—6 Transition Benefit ............................................................................................................................... 7—6

Claiming Benefits Once You Are Authorized ........................................................7—7 What The Plan Does Not Cover ...........................................................................7—7 When Coverage Ends ..........................................................................................7—8

Continuation Coverage ....................................................................................................................... 7—8 Certificate of Insurance ....................................................................................................................... 7—9

8 Life Insurance..................................................................................................... 8—1 Highlights .............................................................................................................8—2 Basic Life Insurance (for Bargaining Unit Employees and Salaried Employees

hired prior to 4/1/2012 ......................................................................................8—3 Supplemental Life Insurance ................................................................................8—5 Other Important Information ..................................................................................8—6

Naming Your Beneficiary .................................................................................................................... 8—6 Tax Consequences ............................................................................................................................ 8—6 When Coverage Ends ........................................................................................................................ 8—6

Conversion and Portability ....................................................................................8—7 Conversion Privileges ......................................................................................................................... 8—7 Portability ........................................................................................................................................... 8—7 If Your Benefits Terminate .................................................................................................................. 8—7

9 Pension Plan ...................................................................................................... 9—1 Highlights .............................................................................................................9—2 Receiving Benefit Payments .................................................................................9—3

If You are Receiving Benefit Payments............................................................................................... 9—3 If Your Benefit Has Not Started .......................................................................................................... 9—3 Pension Benefit Amount ..................................................................................................................... 9—3 Employee Contributions ..................................................................................................................... 9—3

Normal Forms of Payment ....................................................................................9—3 For Married Employees ...................................................................................................................... 9—3 For Single Employees ........................................................................................................................ 9—3

Optional Forms of Payment ..................................................................................9—4 Life Annuity Option for Married Employees ......................................................................................... 9—4 50% Survivor Benefit Option ............................................................................................................... 9—4

Contents (cont.)

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Level Income Option........................................................................................................................... 9—4

Social Security ......................................................................................................9—5 Reemployment After Retirement ..........................................................................9—5 Other Important Information ..................................................................................9—5

Withholding Taxes .............................................................................................................................. 9—5 Change of Address ............................................................................................................................. 9—5

10 Savings Plan................................................................................................... 10—1

Highlights ........................................................................................................... 10—2 Your Savings Plan Account ................................................................................ 10—3 The Savings Plan Information Sources ............................................................... 10—3

Working with the Plan ....................................................................................................................... 10—3

Your Investment Options .................................................................................... 10—4 Investment Earnings ......................................................................................................................... 10—4

Investment Option Summary .............................................................................. 10—4 Transaction Processing .................................................................................................................... 10—4

Withdrawals from Your Deferred Account ........................................................... 10—6 Plan Payouts ...................................................................................................... 10—6

Request a Payout ............................................................................................................................. 10—6 Naming Your Beneficiary .................................................................................................................. 10—7

Taxation of Withdrawals and Final Payouts ........................................................ 10—7 Before Age 59½ .............................................................................................................................. 10—7 At Age 59½ or Later ......................................................................................................................... 10—7 Roth Contributions ............................................................................................................................ 10—7 Rollovers and Withholding ................................................................................................................ 10—8

Transfer of Assets for ORNL Participants ........................................................... 10—8 Your Quarterly Statement ................................................................................... 10—8

Claiming Benefits ............................................................................................................................. 10—8

Other Important Information ................................................................................ 10—9 Change of Address ........................................................................................................................... 10—9 Voting Your Shares .......................................................................................................................... 10—9 Investment Fees and Expenses ....................................................................................................... 10—9 Responsibility for Investment Decisions .......................................................................................... 10—9 Confidentiality of Investment Directions ............................................................................................ 10—9 Plan Funding .................................................................................................................................... 10—9 Tax Treatment .................................................................................................................................. 10—9

11 Glossary and Acronyms ................................................................................ 11—1 Glossary ............................................................................................................. 11—2 Acronyms and Abbreviations .............................................................................. 11—8

12 Administrative Information............................................................................ 12—1

Plan Sponsor and Administrator ......................................................................... 12—2

Contents (cont.)

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Employer Identification Number .......................................................................... 12—2 Plan Documents ................................................................................................. 12—2 Claiming Benefits ............................................................................................... 12—3 Health Claims Review and Appeal Procedures .................................................. 12—3 Other Claims Review and Appeal Procedures

(non-Health and non-Disability claims) ........................................................... 12—3 Other Claims Appeal ........................................................................................................................ 12—3 Notice of Adverse Benefit Determination for Other Claims ................................................................ 12—3 Notification on Other Claim Decisions .............................................................................................. 12—3 Other Claim Appeal of an Adverse Benefit Determination ................................................................ 12—3 Notification of Other Claims Decision on Appeal ............................................................................... 12—4

Legal Process ..................................................................................................... 12—4 Plan Termination and Amendment ..................................................................... 12—4 Special Pension and Savings Provisions ............................................................ 12—5

Assets Upon Termination ................................................................................................................. 12—5 Pension Benefit Guaranty Corporation ............................................................................................. 12—5 Assignment or Alienation of Benefits ................................................................................................ 12—5 Qualified Domestic Relations Order .................................................................................................. 12—6

Qualified Medical Child Support Order ............................................................... 12—6 Health Insurance Portability and Accountability Act (HIPAA) .............................. 12—6 Other Administrative Facts ................................................................................. 12—7 Your Rights Under COBRA ................................................................................ 12—8

COBRA Participation ........................................................................................................................ 12—8 COBRA Continuation Period ............................................................................................................ 12—9 Choosing COBRA ............................................................................................................................ 12—9 Cost of Participation ....................................................................................................................... 12—10 Notification ..................................................................................................................................... 12—10 When COBRA Ends ....................................................................................................................... 12—10

Your Rights Under ERISA ................................................................................ 12—11 Continue Group Health Plan Coverage........................................................................................... 12—11 Prudent Actions by Plan Fiduciaries ............................................................................................... 12—11 Enforce Your Rights ....................................................................................................................... 12—11 Assistance With Your Questions..................................................................................................... 12—12

13 Contact Information ....................................................................................... 13—1