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JACAM Chemical Company 2013, LLC.

2014-2015 Benefits Overview























































The Power of Share
JACAM Chemical Company 2013, LLC. | 2014-2015


Eligibility

If you are a JACAM Chemical Company 2013, LLC. full-time employee (working 30 or more hours per week) and have
successfully completed your waiting period, you are eligible to enroll in the benefits described in this guide.

New hires are eligible for benefits on the first of the month following 30 days of the first date of employment.

Benefits

Medical
Dental
Voluntary Vision
Life and AD&D Insurance
Voluntary Life Insurance
Voluntary Long Term Disability
Voluntary Short Term Disability
Voluntary Critical Illness, Cancer & Accident
401k Retirement Plan
Voluntary Legal Protection
Flexible Spending Account


K
Welcome to your 2014-2015 Benefits!

At JACAM Chemical Company 2013, LLC., our employees are our most valuable asset.

We recognize the importance of your familys financial security and understand the significance of offering you
a comprehensive benefits package. We invest many hours each year evaluating our plans. The Affordable Care Act (ACA) has
forced benefit changes and added additional financial responsibility to JACAM in the form of fees and taxes. However, we feel
we are continuing to achieve our goal of meeting your needs and expectations.

This Benefits Overview is a snapshot of the benefits available and is intended for illustrative purposes only. Please refer to the
Summary Plan Descriptions or Plan Certificates for further details, which can be provided by Human Resources. We hope you
find this overview useful and will participate in the benefits to the fullest extent possible. If you have any questions regarding
these plans, please contact the Human Relations Department.

The following benefits are effective May 1, 2014 through April 30, 2015.

Thank you,
Jason West


















JACAM Chemical Company 2013, LLC. | 2014-2015

Medical Insurance
CoreSource, a Trustmark Company

You have the freedom to choose from 2 plans. Plan summaries are illustrated on the next page.

Both plans include:
Access to either Cigna or First Health national networks.
o To find Cigna providers, search www.cigna.com
o To find First Health providers, search www.firsthealth.com
Affordable Care Act benefits that are covered under the plan include:
o Preventive care services are covered by the plan at 100% with no office visit copay or deductible responsibility
o Unlimited Lifetime Maximum with No Pre-Existing Conditions, for all ages
o Dependents covered until age 26
JACAM Chemical Company 2013, LLC. reserves the right to perform a dependent eligibility audit on
covered spouses and children to verify eligibility at any time during the plan year.
o Womens Care Preventive Services
Many generic contraceptives are covered at 100% with no copay
Breastfeeding support, supplies and counseling
o Tobacco Cessation Treatment Programs
Once enrolled in the medical insurance, register at www.myCoreSource.com to create an account. This will allow you to have
24/7 access to check on claims status, find a doctor, access plan documents and print a temporary ID card.

Monthly Medical & Pharmacy Premiums:

Traditional Health Plan Option 1 Employee
Employee/
Child(ren)
Employee/
Spouse
Family
$1,000 Individual Deductible /
$2,000 Family Deductible
20% Member Coinsurance
$2,000 Individual Out-of-Pocket Max /
$4,000 Family Out-of-Pocket Max
$25 Office Visit Copays
$250 Emergency Room Copay
(the only plan change from 2013/2014 plan)
$15/30/45 Prescription Copays
$114.45 $232.30 $245.67 $364.00
High Deductible Health Plan Option 2 Employee
Employee/
Child(ren)
Employee/
Spouse
Family
$3,000 Individual Deductible /
$6,000 Family Deductible
$3,000 Individual Out-of-Pocket Max /
$6,000 Family Out-of-Pocket Max
Rx - Deductible then $15/30/45 Copays
$95.47 $176.90 $158.10 $258.99
JACAM Chemical Company 2013, LLC. | 2014-2015

This is a summary description of benefits. All plan provisions are subject to the covered charges, limitations and exclusions set forth in the plan document. If this summary and the plan
document are contradictory, the plan document takes precedence. The employer reserves the right to modify or terminate these benefits for any reason at any time.
Medical Plan Benefits
Traditional Plan
Option 1

High Deductible Health Plan
Option 2
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
WELLNESS (Routine Care)
Physical Exams 100% 60% (deductible applies) 100% 80% (deductible applies)

Well Child Care (Including
Immunizations) 100% 60% (deductible applies) 100% 80% (deductible applies)
Mammogram (Test and Reading) 100% 60% (deductible applies) 100% 80% (deductible applies)
Pap Smears (Test and Reading) 100% 60% (deductible applies) 100% 80% (deductible applies)
Prostate Blood Test (Test and Reading) 100% 60% (deductible applies) 100% 80% (deductible applies)

Colonoscopy and Sigmoidoscopy (Test
and Reading) 100% 60% (deductible applies) 100% 80% (deductible applies)
MAJOR MEDICAL

Deductible
(combined in/out of network) $1,000/Individual $1,000/Individual $3,000/Individual $3,000/Individual

$2,000/Family $2,000/Family $6,000/Family $6,000/Family
Plan Payment (Coinsurance) 80% 60% 100% 80%

Member Payment (Coinsurance) 20% 40% 0% 20%

Out-of-Pocket Maximum
(combined in/out of network) $2,000/Individual $2,000/Individual $3,000/Individual $5,000/Individual

(Includes Deductible) $4,000/Family $4,000/Family $6,000Family $10,000/Family
Lifetime Maximum per Family Member Unlimited Unlimited Unlimited Unlimited
HOSPITAL BENEFITS

In-Patient



80%
(deductible applies)
60%
(deductible applies)
100%
(deductible applies)
80%
(deductible applies)

Emergency Room (must be medical
emergency)
$250 copay
(deductible applies-
copay waived if
admitted) then 80%
$250 copay
(deductible applies-
copay waived if
admitted)
then 80%

100%
(deductible applies)
100%
(deductible applies)

SURGICAL BENEFITS
In-Patient
80%
(deductible applies) 60% (deductible applies)
100%
(deductible applies) 80% (deductible applies)
Out-Patient
80%
(deductible applies) 60% (deductible applies)
100%
(deductible applies) 80% (deductible applies)
PHYSICIANS OFFICE VISITS
$25 Copay,
then 100%
60% (deductible applies)
100%
(deductible applies) 80% (deductible applies)
EYE EXAM (one exam per benefit
period)
$25 Copay,
then 100%
60% (deductible applies)
100%
(deductible applies)
80% (deductible applies)
URGENT CARE
$25 Copay,
then 100%
60% (deductible applies)
100%
(deductible applies)
80% (deductible applies)
SPECIALIST COPAY
$25 Copay,
then 100%
60% (deductible applies)
100%
(deductible applies)
80% (deductible applies)
OUTPATIENT DIAGNOSTIC X-RAY
/LABORATORY SERVICES
100% up $300 max
then subject to
ded/co-ins
60% (deductible applies)
100%
(deductible applies)
80% (deductible applies)
PRESCRIPTION DRUG CARD

Retail (30 day supply) $15/$30/$45
Deductible then
$15/$30/$45
Deductible
Then Copays
$15/$30/$45
Deductible Then Copays
$15/$30/$45

Mail Order (90 day supply) $37.50/$75/$112.50 $37.50/$75/$112.50
Deductible
Then Copays
$37.50/$75/$112.50
Deductible Then Copays
$37.50/$75/$112.50



JACAM Chemical Company 2013, LLC. | 2014-2015

Vision Premiums Per Month
Employee $9.77
Employee + 1 $14.16
Employee + 2 or more $25.39

Dental Premiums Per Month
Employee $23.67
Employee + Spouse $46.96
Employee + Child(ren) $50.89
Family $73.59

Dental
Delta Dental
To find PPO or Premier Network
providers: www.deltadentalks.com
100% Diagnostic and Preventative Services
(cleanings & exams: one per six months).
$25 individual deductible / $75 family
deductible (waived for diagnostic &
preventative services)
80% Basic Services (fillings, oral surgery,
endodontics, periodontics)
50% Major Services (crowns, dentures,
bridges, implants)
No waiting period on any service
Maximum Benefit for all covered services
(diagnostic, basic & major) for each Enrollee in
any one Calendar Year is $1,000
100/80/50% Out-of-Network Benefits for Non-
Participating Delta Premier Providers
Orthodontics Not Covered
Dependents eligible until the end of the
month of which they turn age 26











Vision
VSP
To find VSP providers, visit www.vsp.com
o VSP Choice Network
Comprehensive eye exam (includes
refraction and dilation) every 12 months
after $10 copay
Frames: $130 allowance every 12 months
after $25 copay with 20% off any amount
over your allowance
Lenses: Choose from standard, premium, or
custom progressive lenses. Allowance
ranges from $55-$175 depending on type of
lenses after $25 copay.
Contacts in lieu of glasses ($130
allowance per year elective contacts,
$250 if medically necessary). Copay does
not apply.
20% discount for additional glasses and
sunglasses within 12 months of last exam











JACAM Chemical Company 2013, LLC. | 2014-2015

Life and Disability
Assurant Employee Benefits

Life & AD&D (employer paid)
$65,000 benefit paid 100% by JACAM
Chemical Company 2013, LLC. for
benefit-eligible employees

Voluntary Life Insurance (employee paid)
Supplement the employer-paid benefit by
purchasing:
o Up to 5 times your annual earnings up to
$500,000 for yourself in increments of
$10,000 with a minimum of $20,000
o Up to $250,000 for your spouse in
increments of $5,000
o $10,000 for your children (no underwriting)
Evidence of Insurability (medical underwriting)
is required if this is not your first time eligible.
o Increase current benefit amount by
$10,000 without Evidence of Insurability
Rates based on election amount and age

Voluntary Long Term Disability (employee paid)
Elect up to 60% of monthly earnings to $6,000
Benefits begin 90 days after disability
Payable to the later of age 65 or 24 months
Rates based on election amount and age

Voluntary Short Term Disability (employee paid)
Elect up to 60% of weekly earnings to $2,500
Benefit payable on 8
th
day of accident,
sickness or pregnancy
Payable for 12 weeks
Pre-existing conditions limitation of 12
months for medical conditions treated by a
physician, including prescriptions taken,
within the last 6 months of applying for
coverage
Rates based on election amount and age


Voluntary Worksite Benefits
Allstate
Critical Illness High & Low Option (employee paid)
Lump Sum coverage for Heart Attack/ Stroke/
Cancer/ Renal Failure and more
Wellness benefit pays $50 per year per person
Premium locked in at current age and no
reduction of benefits
Family gets 50% of benefit amount
Each Critical Illness paid only once and must be
separated by 90 days
Benefits paid directly to you, not to provider
Cancer (employee paid)
Cash benefits for cancer and 29 specified
diseases and related surgeries & services
Wellness benefit pays $50 per year per person
Elect coverage for you or your entire family
No Evidence of Insurability at initial enrollment
Waiver of premium after 90 days of disability
due to cancer
Benefits paid directly to you, not to provider
Accident High & Low Option (employee paid)
24-hour off-the-job coverage

Initial hospital confinementpays
1x/person

Hospital confinement (per day) pays per
accident for up to 90 days
Medical expenses pays based on actual
bill (before insurance pays)
Outpatient Physicians Treatment pays for
any visit outside hospital for any reason 2
per year (employee only)/4 per year
(family)
Physical Therapy 6 per accident

Accident follow up treatments 2 per
accident


Paid in addition to any other benefits and
paid directly to employee, not to provider






JACAM Chemical Company 2013, LLC. | 2014-2015

401k Retirement Plan
Nationwide

JACAM Chemical Company 2013, LLC. allows eligible
employees to contribute up to 75% of compensation
to a 401k plan through payroll deduction.

JACAM Chemical Company 2013, LLC. will make
matching contributions equal to 100% of your eligible
elective deferrals, up to 4% of compensation.

You have the ability to select from investment
choices provided under the Plan. The Plan is intended
to be an ERISA Section 404(c) plan, which means you
exercise control over some or all of the
investments in your Plan

















Legal Protection
Legal Shield (employee paid)
Legal Advice unlimited issues
Letters/calls made on your behalf
Contracts & documents reviewed up to 10 pages
Mortgage document preparation
Uncontested Separation, Divorce, Name Change &
Adoption
Wills, Living Wills & Healthcare Power of Attorney
prepared by Lawyers
Traffic-Related Issues (Speeding Tickets, Accidents)
Trial Defense (Pre-Trial, Representation at trial)
IRS Audit Assistance
24/7 Emergency Access for Covered Situations
Online Legal Forms
Coverage for yourself, spouse and dependents (under 21
living at home or 23 for full-time college students,
never married)
Identity Theft Legal Shield
Credit Report
Personal Credit Score with Analysis
Continuous Monitoring with Activity Alerts
Identity Restoration Service
Flexible Spending Account (FSA)
ADP

Reduce your taxes and increase your take-home
pay while paying for expenses with pre-tax
dollars.

There are 2 types of FSA plans to contribute:
Unreimbursed Medical
o Elect up to $2,500 per year
o Pay for medical expenses including
copays, vision & dental
Dependent Care
o Contribute up to $5,000 per year to pay
for the care of dependents under the
age of 13



Contact Information
Power Group Companies
(for all benefit questions)
Enrollment Call Center:
1-877-277-7209
Amy Zeller: 913-754-5934
Diana Loera: 913-754-5941

CoreSource: 1-800-990-9058
Delta Dental: 1-800-733-5823
VSP: 1-800-852-7600
Assurant: 1-800-556-7994
Allstate: 1-800-521-3535
Nationwide: 1-877-669-6877
FSA: www.flexdirect.adp.com
Legal Shield: 1-316-687-0101

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