national oilwell varco · 2020. 10. 8. · national oilwell varco 2021 retiree health & welfare...

VERPS, Varco Lifers

National Oilwell Varco

2021 Retiree Health & Welfare Open Enrollment

2020 has brought us a new set of challenges. Difficult economic conditions persist in the oilfield markets we

serve, a global pandemic has impacted nearly every industry, and healthcare costs continue to rise. In these

uncertain times, we strive to help you stay healthy and safe. To retain a high level of benefits coverage, we

have made some modifications to the medical plans and their premiums. These changes will allow us to keep

your costs as low as possible while still providing a robust retiree benefits.

Medical Plan Changes:

Effective 01/01/2021, we have made changes to all three medical plans. The PPO and Consumer Plan + HSA

plan designs have been updated with new deductibles, copays, and out-of-pocket maximums. Due to the

increased deductible amount, the 800 PPO plan has been renamed as follows:

1000 PPO Plan (formerly the 800 PPO Plan)

Additional plan changes and details can be found in the enclosed documents. You may find additional

information, including the complete open enrollment packet including annual notices, online at

www.varipro.com/NOV2021, or you may contact Varipro to have one mailed or emailed to you.

No Vision Changes:

VSP will remain the vision insurance provider. Your current coverage will be continued unless you contact

Varipro to discontinue participation in the plan.

No Dental Changes:

The NOV Dental Plan provided through Cigna will not be changed. Your current coverage will be continued

unless you contact Varipro to discontinue participation in the plan.

New ID cards:

New medical ID cards will be issued to those enrolled in the PPO plans.

This will be a passive annual enrollment which means if you’re satisfied with your current insurance

coverage, there’s no need to take additional action. If you are currently enrolled in the 800 PPO Plan, you

will be enrolled in the 1000 PPO Plan for 2021, unless you make a change.

Please review your annual enrollment materials and changes carefully, as it is important for you to take an

active role in determining the best plan for you and your family.

If you have any questions regarding your billing, enrolling in the automatic payment option or change in

spouse or dependent status, please contact Varipro at 1-800-732-3412 or email [email protected] and a

representative will be happy to assist you.

Sincerely,

National Oilwell Varco

http://www.varipro.com/NOV2021mailto:[email protected]

2021 Monthly Cost

Medical Plans

Tier level Consumer Plan + HSA 1000 PPO Plan 1400 PPO Plan

EE Only $69.33 $164.67 $104.00

EE + Spouse $164.67 $463.67 $266.50

EE + Child(ren) $140.83 $359.67 $231.83

EE + Family $257.83 $667.33 $442.00

Tier level Dental PPO Plan Vision

EE Only $15.17 $0.00

EE + Spouse $32.50 $0.00

EE + Child(ren) $30.33 $0.00

EE + Family $47.67 $0.00

National Oilwell Varco 2021 Benefits Contact List

Benefit and Vendor Telephone Website

Blue Cross Blue Shield of Texas (Medical) 1-855-212-1613 www.bcbstx.com

CVS Caremark (Prescription drugs) 1-855-310-2475 www.caremark.com

Virtual Visits (Powered by MD Live) 1-888-681-4083 www.MDLIVE.com/nov

Cigna (Dental) 1-800-244-6224 www.cigna.com

VSP (Vision) 1-800-877-7195 www.vsp.com

Airrosti (Muscle and Joint Pain Treatment) 1-800-404-6050 www.airrosti.com

Discovery (COBRA) 1-866-451-3399 www.discoverybenefits.com

http://www.bcbstx.com/http://www.caremark.com/http://www.mdlive.com/novhttp://www.cigna.com/http://www.vsp.com/http://www.discoverybenefits.com/

U.S. annual enrollment guide

2021

Explore Your Benefits

Medical plan comparison

$1,750 / $3,500* $3,500 / $7,000*

$3,500 / $7,000* $7,000 / $14,000*

$1,000 / $2,000**

$4,250 / $8,500**

$3,000 / $6,000**

$8,500 / $17,000** $4,500 / $9,000** $9,000 / $18,000**

$44 before deductible, $35 after deductible $30 copay $35 copay

$30 copay

$40 copay

$35 copay

$65 copay

Up to $20 copay after deductible



Up to $20 copay

Up to $60 copay

Up to $100 copay

Up to $20 copay

Up to $60 copay

Up to $100 copay

You pay:


$30 copay or 25% after deductible, whichever is greater

$50 copay or 30% after deductible,

Up to $10 copay

$30 copay or 25%, whichever is greater

$50 c$50 copay or 30%, opay or 30%,

Plan featuresConsumer Plan + HSA 1000 PPO Plan 1400 PPO Plan

In-network EE only/Other tiers

Out-of-network EE only/Other tiers

In-network Individual/Family

Out-of-network Individual/Family

In-network Individual/Family

Out-of-network Individual/Family

Annual deductible $1,400 / $2,800** $4,200 / $8,400**

Annual out-of-pocket maximum (OOPM)

You pay: You pay:

Preventive care visit Covered in full 50% after deductible Covered in full 50% after deductible Covered in full 50% after deductible

Virtual Visits Powered by MDLIVE

Primary care visit 20% after deductible 50% after deductible 50% after deductible 50% after deductible

Specialist visit 20% after deductible 50% after deductible 50% after deductible 50% after deductible

Prescription drugs: Retail (up to a 30-day supply)

Generic drugs

Preferred drugs

erred drugs whichever is greater

Specialty drugs 30% after deductible up to $200

Prescription drugs: Mail order (up to a 90-day supply)

Generic drugs

Preferred drugs

Non-preferred drugs

*All coverage tiers with the exception of employee only have an aggregate deductible and OOPM. This means that any one person or combination of family members covered by the plan can meet the family deductible and OOPM. ** All coverage tiers with the exception of employee only have an embedded deductible and OOPM. This means that you will have both an individual and a family deductible and OOPM. No individual will satisfy more than the

individual deductible or OOPM.

1

Up to $10 copay

$30 copay or 25%, whichever is greater

$50 c$50 copay or 30%, opay or 30%, whichever is greater

30% up to $200

whichever is greater

30% up to $200

DentalNOV offers Cigna dental coverage using the Total Cigna DPPO network. You may visit any dentist you choose; however, you will save money by accessing care from a network provider. To find a network provider, visit cigna.com.

Plan treatment Plan detailsDeductibleWhat do I pay before my plan pays for eligible services?

You pay $50 per person or $100 for a family. However, the deductible is waived for preventive services.

CoinsuranceHow much do I pay for covered services?

You pay 0% for preventive services.Once you meet your deductible, you pay:

20% for basic services 50% for major services 50% for orthodontic services

Benefit maximumWhat is the maximum my plan will pay for services during the plan year?

$2,000 per person

Orthodontia coverageDoes my plan cover orthodontia?

Yes, the plan pays 50% up to $2,000 lifetime for adults and children.

Vision NOV offers a robust vision plan through VSP. You must enroll to elect coverage. To find a network provider, visit vsp.com.

Employee premium

Plan treatmentPlan details

In-network Out-of-network

Copays & allowances How much do I pay for services and materials?

Exam: $25 copay Lenses: covered after exam copay

Frames: up to $160Contacts: up to $150

Exam: $50 after exam copayLenses: $50-$100 after exam copay

Frames: $70 after exam copayContacts: $105 after exam copay

Benefit maximumHow often can I receive services?

Exams, lenses, or contacts: once every 12 monthsFrames: once every 24 months (once every 12 months for dependent children)

$0. Your vision coverage is paid by NOV at no cost to you.

2

http://cigna.comhttp://vsp.com

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021 – 12/31/2021 National Oilwell Varco, L.P.: Consumer Plan + HSA Coverage for: Individual + Family | Plan Type: HSA

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-855-212-1613 or at www.bcbstx.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or

other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

For In-Network: $1,750 Individual / $3,500 Family

For Out-of-Network: $3,500 Individual / $7,000 Family

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.

Are there services covered before you meet your deductible?

Yes. In-Network preventive care is covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes. Per occurrence: $500 Out-of-Network inpatient admission. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

What is the out-of-pocket limit for this plan?

For In-Network: $3,500 Individual / $7,000 Family

For Out-of-Network: $7,000 Individual / $14,000 Family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met.

What is not included in the out-of-pocket limit?

Premiums, preauthorization penalties, balanced-billed charges, and healthcare this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See www.bcbstx.com or call 1-855-212-1613 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

http://www.bcbstx.com/https://www.healthcare.gov/sbc-glossary/https://www.healthcare.gov/coverage/preventive-care-benefits/http://www.bcbstx.com/

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* For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information

In-Network Provider (you will pay the least)

Out-of-Network Provider

(you will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

20% coinsurance after plan deductible


Virtual visits are available, please refer to your plan policy for more details.

Specialist visit 20% coinsurance after plan deductible


None

Preventive care/screening/immunization

No Charge; deductible does not apply


You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work) 20% coinsurance after plan deductible


None

Imaging (CT/PET scans, MRIs) 20% coinsurance after plan deductible


None

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http://www.caremark.com/ or by calling 1-855-310-2475

Generic drugs $10 Retail $20 Mail Order;

Must file for reimbursement. Retail copay will apply.

After deductible is met. Coverage is limited to a 30 day supply at retail and a 90 day supply at mail order.

Preferred brand drugs $30 or 25% whichever is greater - Retail $60 - Mail Order;


Non-preferred brand drugs $50 or 30% whichever is greater - Retail $100 - Mail Order;


Specialty drugs 30% up to $200; Not Covered After deductible is met. Specialty drugs are limited to a 30 day supply.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)



None

Physician/surgeon fees 20% coinsurance after plan deductible


None

http://www.bcbstx.com/http://www.caremark.com/http://www.caremark.com/

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What You Will Pay





If you need immediate medical attention

Emergency room care 20% coinsurance after plan deductible


None

Emergency medical transportation 20% coinsurance after plan deductible


Balance bill charges may apply. Ground and air transportation covered.

Urgent care 20% coinsurance after plan deductible


None

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance after plan deductible


Additional $500 per admission deductible applies Out-of-Network. Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.



None

If you need mental health, behavioral health, or substance abuse services

Outpatient services 20% coinsurance after plan deductible


Certain services must be preauthorized; refer to your benefit booklet* for details. Virtual visits are available, please refer to your plan policy for more details.

Inpatient services 20% coinsurance after plan deductible



If you are pregnant

Office visits 20% coinsurance after plan deductible


Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery professional services



Childbirth/delivery facility services 20% coinsurance after plan deductible



http://www.bcbstx.com/

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What You Will Pay





If you need help recovering or have other special health needs

Home health care 20% coinsurance after plan deductible


Limited to 60 visits per calendar year. Preauthorization is required.

Rehabilitation services 20% coinsurance after plan deductible


None

Habilitation services 20% coinsurance after plan deductible


None

Skilled nursing care 20% coinsurance after plan deductible


Limited to 60 days per calendar year. Preauthorization is required.

Durable medical equipment 20% coinsurance after plan deductible


None

Hospice services 20% coinsurance after plan deductible


Preauthorization is required.

If your child needs dental or eye care

Children’s eye exam 20% coinsurance after plan deductible


None

Children’s glasses Not Covered Not Covered None

Children’s dental check-up Not Covered Not Covered None

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture

• Cosmetic surgery

• Dental care (Adult and children)

• Infertility treatment

• Long-term care

• Private-duty nursing

• Routine foot care (except with diagnosis of diabetes)

• Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Bariatric surgery (only covered at Blue Distinction Center)

• Chiropractic care (limited to 35 visits per calendar year)

• Hearing aids (limited to 1 per ear per 36-month period)

• Non-emergency care when traveling outside the U.S.

• Routine eye care (Adult and children)


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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at 1-855-212-1613, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Cross and Blue Shield of Texas at 1-855-212-1613 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-855-212-1613. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-212-1613.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-855-212-1613.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-212-1613.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

http://www.dol.gov/ebsa/healthreformhttp://www.cciio.cms.gov/http://www.healthcare.gov/http://www.bcbstx.com/http://www.dol.gov/ebsa/healthreformhttp://www.texashealthoptions.com/

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The plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture (in-network emergency room visit and follow

up care)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

◼ The plan’s overall deductible $1,750 ◼ Specialist coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing

Deductibles $1,750

Copayments $10

Coinsurance $500

What isn’t covered

Limits or exclusions $60

The total Peg would pay is $2,320

◼ The plan’s overall deductible $1,750 ◼ Specialist coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)


In this example, Joe would pay:

Cost Sharing

Deductibles $1,750

Copayments $100

Coinsurance $1,000



The total Joe would pay is $2,870

◼ The plan’s overall deductible $1,750 ◼ Specialist coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)


In this example, Mia would pay:

Cost Sharing

Deductibles $1,750

Copayments $10

Coinsurance $200



The total Mia would pay is $1,960

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

.

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/http://www.hhs.gov/ocr/office/file/index.html

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021 – 12/31/2021 National Oilwell Varco, L.P.: 1000 and 1400 PPO Plans Coverage for: Individual + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-855-212-1613 or at www.bcbstx.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other

underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

In-Network:

$1,000, $1,400 Individual / $2,000, $2,800 Family

Out-of-Network:


Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Services that charge a copay, prescription drugs, and In-Network preventive care and diagnostic tests are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes. Per occurrence: $500 Out-of-Network inpatient admission. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

What is the out-of-pocket limit for this plan?

In-Network:


Out-of-Network:


The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, preauthorization penalties, balanced-billed charges, and healthcare this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See www.bcbstx.com or call 1-855-212-1613 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

www.bcbstx.com.http://www.healthcare.gov/sbc-glossary/https://www.healthcare.gov/coverage/preventive-care-benefits/http://www.bcbstx.com/

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\

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.



What You Will Pay Limitations, Exceptions, & Other

Important Information In-Network Provider

(you will pay the least) Out-of-Network Provider (you will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$30 copay/visit for 1000 PPO Plan $35 copay/visit for 1400 PPO Plan; deductible does not apply


None

Specialist visit $40 copay/visit for 1000 PPO Plan $65 copay/visit for 1400 PPO Plan; deductible does not apply


None

Preventive care/screening/immunization

No Charge; deductible does not apply


You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work)

Applicable office visit copay or No Charge for outpatient services; deductible does not apply


None

Imaging (CT/PET scans, MRIs)

Applicable office visit copay; deductible does not apply or 20% coinsurance after plan deductible for outpatient services


None


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If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http://www.caremark.com/ or by calling 1-855-310-2475

Generic drugs $10 Retail $20 Mail Order; deductible does not apply


Coverage is limited to a 30 day supply at retail and a 90 day supply at mail order.

Preferred brand drugs

$30 or 25% whichever is greater - Retail $60 - Mail Order; deductible does not apply


Non-preferred brand drugs

$50 or 30% whichever is greater - Retail $100 - Mail Order; deductible does not apply


Specialty drugs 30% up to $200; deductible does not apply

Not Covered Specialty drugs are limited to a 30 day supply.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)



None



None


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If you need immediate medical attention

Emergency room care 20% coinsurance after plan deductible


None

Emergency medical transportation



Balance-bill charges may apply. Ground and air transportation covered.

Urgent care 20% coinsurance after plan deductible


None

If you have a hospital stay

Facility fee (e.g., hospital room)


$500 deductible per admission, plus 50% coinsurance after plan deductible

Preauthorization is required; $250 penalty if not preauthorized Out-of-Network.



None

If you need mental health, behavioral health, or substance abuse services

Outpatient services



Certain services must be preauthorized; refer to benefits booklet for details. Virtual visits are available, please refer to your plan policy for more details.

Inpatient services 20% coinsurance after plan deductible



If you are pregnant

Office visits $30 PCP / $40 SPC for 1000 PPO Plan $35 PCP / $65 SPC for 1400 PPO Plan copay/visit; deductible does not apply


Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services



Childbirth/delivery facility services





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If you need help recovering or have other special health needs

Home health care 20% coinsurance after plan deductible


Limited to 60 visits per calendar year. Preauthorization is required.

Rehabilitation services



None

Habilitation services



None

Skilled nursing care 20% coinsurance after plan deductible


Limited to 60 days per calendar year. Preauthorization is required.

Durable medical equipment



None

Hospice services 20% coinsurance after

plan deductible


Preauthorization is required.


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If your child needs dental or eye care

Children’s eye exam $30 PCP / $40 SPC for 1000 PPO Plan $35 PCP / $65 SPC for 1400 PPO Plan copay/visit; deductible does not apply


None

Children’s glasses Not Covered Not Covered None

Children’s dental check-up Not Covered Not Covered None

Excluded services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture

• Cosmetic surgery

• Dental care (Adult and children)

• Infertility treatment

• Long-term care

• Private-duty nursing

• Routine foot care (except with diagnosis of diabetes)

• Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Bariatric surgery (only covered at Blue Distinction Center)

• Chiropractic care (limited to 35 visits per calendar year)

• Hearing aids (limited to 1 per ear per 36-month period)

• Non-emergency care when traveling outside the U.S.

• Routine eye care (Adult and children)


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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at 1-855-212-1613, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Cross and Blue Shield of Texas at 1-855-212-1613 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-855-212-1613. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-212-1613.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-855-212-1613.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-212-1613.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

http://www.dol.gov/ebsa/healthreformhttp://www.cciio.cms.gov/http://www.healthcare.gov/http://www.bcbstx.com/http://www.dol.gov/ebsa/healthreformhttp://www.texashealthoptions.com/

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The plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture (in-network emergency room visit and follow

up care)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

◼ The plan’s overall deductible $1,000 ◼ Specialist copayments $40 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)


In this example, Peg would pay:

Cost sharing

Deductibles $1,000

Copayments $40

Coinsurance $700



The total Peg would pay is $1,800

◼ The plan’s overall deductible $1,000 ◼ Specialist copayments $40 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)


In this example, Joe would pay:

Cost sharing

Deductibles $800

Copayments $500

Coinsurance $900



The total Joe would pay is $2,220

◼ The plan’s overall deductible $1,000 ◼ Specialist copayments $40 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)


In this example, Mia would pay:

Cost sharing

Deductibles $1,000

Copayments $200

Coinsurance $200



The total Mia would pay is $1,400

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

.

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/http://www.hhs.gov/ocr/office/file/index.html

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Notice of privacy practices for protected health information

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THE NATIONAL OILWELL VARCO WELFARE BENEFITS PLAN (REFERRED TO AS THE HEALTH PLAN) AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

A. UNDERSTANDING YOUR HEALTH INFORMATION

Each time you visit a hospital, physician, or other healthcare provider, information is documented about you and your symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment. The Health Plan, which pays for care provided to you, also uses this information. For example, the health information may be used as:

• A legal document describing the care you received;

• A means to verify that services billed were actually provided;

• An information tool for underwriting, premium rating, and other activities related to creating a contract for health care payment;

• A source of information for determining eligibility and/or coverage under the Health Plan; or

• A data resource for utilization review, such as pre-certification and preauthorization for services.

Understanding what is in your medical record and how your health information is used helps you to:

• Ensure the accuracy of your record;

• Better understand who, what, when, where, and why others may access your health information; and

• Make more informed decisions when authorizing disclosure to others.

B. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Although the National Oilwell Varco Health Plan may use health information about you in carrying out its payment and administrative functions, that information belongs to you. You have the following rights regarding your health information:

• Right to Request Restrictions. You have the right to request a restriction on how we use and disclose the health information we receive about you to carry out our payment and health care operations activities and how we disclose health information to persons involved in paying for your care, such as relatives or close friends. You may request a restriction by writing to the Privacy Officer. We must comply with your request if (i) the disclosure is to a health plan for purposes of payment or health care operations (not for

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out payment and healthcare operations, and for other purposes that are permitted or required by law. It also sets out our legal obligations concerning your protected health information. Additionally, this Notice describes your rights to access and control your protected health information.

purposes of carrying out treatment), and (ii) the health information pertains solely to a health care item or service for which the health care provider has been paid out-of-pocket in full. The Health Plan may opt to honor requests for restriction for other reasons, but it is not required to agree to such a restriction.

• Right to Request Confidential Communications. You can request that we communicate with you about your health information only in the way that you ask us to. For example, you may request that we communicate with you only at work or only by mail. We will try to follow your request, if it is reasonable. Requests must be made in writing to the Privacy Officer.

• Right to Access, Inspect, and Copy Your Health Information. You have the right to inspect and/or obtain a copy of the health information that we have about you, except for information that we are allowed to withhold by law. You have the right to request a readily-producible form in which your health information may be delivered. You may also request a summary or an explanation of your health information. Requests for access or a summary or explanation of your health information must be made in writing to the Privacy Officer. The request should indicate the form or format in which you would like to see your health information. We may charge you a fee to copy and mail the information to you or to prepare a summary or explanation. In certain situations, we may deny your request to see your health information. You may be entitled to have a licensed health care professional review that denial. If the Health Plan uses or maintains an electronic health record with respect to your health information, you may obtain a copy of this health information in an electronic format, and, if you choose, direct the health plan to transmit a copy of the electronic health record directly to a third party you designate clearly and specifically. The fee charged for an electronic copy will be limited to labor costs in responding to your request for a copy.

• Right to Amend Your Health Information. You have the right to request changes to the health information we have about you. Requests for changes must be made in writing to the Privacy Officer and must explain why you think the change is needed. We may decide that the change you request does not need to be made, for example, if the health information is already correct and complete.

• Right to Receive an Accounting of Disclosures. You have the right to receive a listing of how we disclosed your health information to other people or organizations. There are certain disclosures that are not included in the listing, for example, disclosures we make to

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you about your own health information or disclosures that you give us permission to make. Disclosures that are made for payment and health care operations purposes listed below also are not included. A request for a listing of disclosures must be made in writing to the Privacy Officer. The request must include the dates for the disclosures you want. The first list is free of charge, but there may be a charge for more listings you request within the same 12 months.

• We will provide you an accounting of disclosures of health information made by the Health Plan for the six years prior to the date on which the accounting is requested, and either an accounting of disclosures of health information by all business associates acting on its behalf or a list of business associates acting on its behalf, including contact information, from whom you may request an accounting of disclosures they have made.

• Right to Receive a Paper Copy of This Notice. You have the right to request and receive a paper copy of this Notice of Privacy Practices, even if you agreed to receive this Notice electronically. You may obtain a copy of this Notice by contacting the Privacy Officer.

• Right to Restrict Certain Disclosures to Health Plans: You have the right to restrict certain disclosures of protected health information to the Health Plan when you pay out-of-pocket in full for health care items or services.

• Right to Notice of Breach of Unsecured Protected Health Information. You have the right to receive notice in the event that unsecured protected health information identifying you has been, or is reasonably believed to have been used, accessed, acquired or disclosed in an unauthorized manner.

C. OUR RESPONSIBILITIES WITH RESPECT TO YOUR HEALTH INFORMATION

We are required by law to keep your health information confidential, to provide you with this Notice of our legal duties and privacy practices with respect to your health information, and to notify you following a breach of unsecured protected health information. We will abide by the terms of the Notice as it is currently in effect.

We reserve the right to change the practices described in this Notice and to apply the new provisions to all the health information we maintain, regardless of when created or received. If we revise our privacy practices, we will send you a copy of the revised notice. You may also request a copy of the revised notice on or after the date that it takes effect.

D. ROUTINE USES AND DISCLOSURES OF HEALTH INFORMATION

Except for the situations described below, we will not use or disclose your private health information without your authorization or permission. If you give us permission to disclose your private health information to someone, you have the right to revoke that permission so that we will not disclose the information to that person or organization in the future. The revocation will not affect any uses or disclosures that we made with your permission before it was revoked. Also, if you gave us permission to disclose your information in order to obtain health care coverage, you may not revoke it if other law allows the insurer to contest a claim under the policy or to withdraw or otherwise terminate the policy itself.

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Following are situations where the law allows us to make a use or disclosure of your health information without obtaining your permission:

Uses and Disclosures for Payment and Health Care Operations

We will use or disclose your health information for payment purposes. For example, a bill may be sent to us to pay for your health care. The bill may contain or be accompanied by information that identifies you, your health condition, and the treatment you received. We may use your health information to be sure that the bills we pay for your health care are correct. We may also allow certain other health care organizations to see your health information so that they also can arrange payment for care that was provided to you.

We will use or disclose your health information for health care operations. For example, we may use your health information for underwriting or to help us determine the premium rates for the Health Plan. We may also allow another health care organization to see your health information for its own health care operations. But we will do so only if that other organization has a relationship with you and is required by law to protect the privacy of your information. Also, the information we give to that other organization can only be for specific purposes, such as quality assessment and improvement, evaluation and review of health care professionals, case management, care coordination, and health plan performance.

Uses and Disclosures to Business Associates

In some instances, we may contract with business associates for the payment and health care operations services we provide. For example, we may use an outside company to administer and manage the Health Plan. We may disclose your health information to our business associates so that they can perform the work that we ask them to perform. However, to protect your health information, we require that our business associates protect the privacy of your information.

Uses or Disclosures Required or Permitted by Law

We may use or disclose health information if the law requires us to use or disclose it for certain reasons. We may also disclose health information if a state law requires us to for auditing or monitoring situations and for licensing or certifying health care facilities or professionals.

Disclosures for Public Health Activities

Public Health Authorities We may disclose your health information to public health authorities that need the information to prevent or control disease, injury, or disability or handle situations where children are abused or neglected.

Food and Drug Administration (FDA) We may disclose health information when there are problems with a product that is regulated by the FDA. For instance, when the product has harmed someone, is defective, or needs to be recalled, we may disclose certain information.

Communicable Diseases We may disclose health information to a person who has been exposed to a communicable disease or may be at risk of spreading or contracting a disease or condition.

Employment-Related Situations We may disclose health information to an employer when the employer is allowed by law to have that information for work-related reasons. We may also disclose health information for workers’ compensation programs.

Disclosures About Victims of Abuse, Neglect, or Domestic Violence

We may disclose health information to appropriate authorities if we have reason to believe that a person has been a victim of abuse, neglect, or domestic violence.

Disclosures for Health Care Oversight

We may disclose health information so that government agencies can monitor or oversee the health care system and government benefit programs and be sure that certain health care entities are following regulatory programs or civil rights laws like they should.

Disclosures for Judicial or Administrative Proceedings

We may disclose health information in a court or other type of legal proceeding if it is requested through a legal process, such as a court order or a subpoena.

Disclosures for Law Enforcement Purposes

We may disclose health information to law enforcement if it is required by law; if needed to help identify or locate a suspect, fugitive, material witness, or missing person; if it is about an individual who is or is suspected to be the victim of a crime; if we think that a death may have resulted from criminal conduct; or if we think the information is evidence that criminal conduct occurred on our premises.

Uses or Disclosures in Situations Involving Decedents

We may use or disclose health information to coroners, medical examiners, or funeral directors so that they can carry out their responsibilities.

Uses or Disclosures Relating to Organ Donation

We may use or disclose health information to organizations involved in organ donation or organ transplants.

Uses or Disclosures Relating to Research

We may use or disclose health information for research purposes if the privacy of the information will be protected in the research.

Uses or Disclosures to Avert Serious Threat to Health or Safety

We may use or disclose your health information to appropriate persons or authorities if we have reason to believe it is needed to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Uses or Disclosures Related to Specialized Government Functions

We may use or disclose health information to the federal government for military purposes and activities, national security and intelligence, or so it can provide protective services to the U.S. President or other official persons.

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Uses or Disclosures for Law Enforcement Custodial Situations

We may disclose health information about a person in a prison or other law enforcement custody situation for health, safety, and security reasons.

Uses or Disclosures to Those Involved in Paying for Your Care

We may disclose health information to a family member, other relative, close personal friend, or any other individual you identify if that information is relevant to their involvement in paying for your health care. If possible, we will inform you in advance and allow you to prohibit or limit the disclosure of information to such persons.

Disclosures to Plan Sponsor

We may disclose health information to National Oilwell Varco L.P., as the plan sponsor of the Health Plan.

Disclosure of Genetic Information

The Health Plan is prohibited from using or disclosing your protected health information that is considered genetic information for underwriting purposes.

E. USES OF PROTECTED HEALTH INFORMATION REQUIRING AUTHORIZATION

For uses and disclosures beyond treatment, payment and operations purposes, and for reasons not included in one of the exceptions described above, the Health Plan is required to have your written authorization. Your authorizations can be revoked at any time to stop future uses and disclosures, except to the extent that the Health Plan has already undertaken an action in reliance upon your authorization.

Marketing

The Health Plan must obtain authorization for all treatment and health care operations communications where it receives financial remuneration for making the communications from a third party whose product or service is being marketed.

Sale of Protected Health Information

The Health Plan must obtain an authorization for any disclosure which is a sale of protected health information. Such authorization must state that the disclosure will result in remuneration to the Health Plan.

Psychotherapy Notes

Communications of health information containing psychotherapy notes generally require your authorization, except: to carry out the following treatment, payment, or health care operations: (i) use by the originator of the psychotherapy notes for treatment; (ii) use or disclosure by the Health Plan for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or (iii) use or disclosure by the Health Plan to defend itself in a legal action or other proceeding brought by an individual who is the subject of that information. The Health Plan may also use or disclose health information containing psychotherapy notes for health care oversight purposes, as required by law, for oversight of the originator of the psychotherapy notes, as those disclosures relate to decedents, or to avert a serious threat to health or safety, as each of those circumstances is described above.

F. FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions regarding anything contained in this Notice and would like additional information or would like to exercise any of your rights listed above, you may contact Mary Birk Jones, the Privacy Officer, by email at [email protected] or 1-713-815-3513.

If you feel that your privacy rights with respect to your health information have been violated, you may file a complaint with us by contacting the Privacy Officer. You may also file a complaint with the Secretary of Health and Human Services. There will be no retaliation against you for filing a complaint.

G. STATEMENT ON COMPLIANCE

We strive to protect your health information to the extent required under the law. Under federal law, we may be required to allow the Secretary of Health and Human Services access to your health information for investigations regarding our compliance with the federal privacy requirements for health information.

H. EFFECTIVE DATE

This Notice, as amended and restated, is effective as of August 19, 2013.

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Women’s health and cancer rights act (WHCRA)NOV’s medical plans, as required by the Women’s Health and Cancer Rights Act of 1998, provide benefits for mastectomy - related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema. Call your insurance carrier at the toll-free number listed on your ID card for more information.

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Notice of special enrollment rightsIf you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in an NOV plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 31 days after you or your dependents’ other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact the NOV benefits service center at 1-877-668-2363.

Important Notice from National Oilwell Varco, L. P. About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with National Oilwell Varco, L. P. (the “Company”) and about your options under Medicare’s prescription drug coverage, if you meet the eligibility requirements. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (such as a HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. The Company has determined that the prescription drug coverage offered by the National Oilwell

Varco Group Welfare Plan (the “Plan”) is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

__________________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Plan coverage will not be affected. You can keep this coverage if you elect Part D and this plan will coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current Plan coverage, be aware that you and your dependents may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage under the Plan, and you do not join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable

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coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the entity listed below for further information. NOTE: You’ll get this notice each year. You will also receive it before the next period you can join a Medicare drug plan, and if this coverage through Plan changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy

of the “Medicare & You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October 15, 2020 Name of Entity/Sender: National Oilwell Varco Contact Office: Corporate Benefits Department Address: 7909 Parkwood Circle Dr., Houston, TX 77036 Phone Number: 713-346-7500

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2020. Contact your State for more information on eligibility –

ALABAMA – Medicaid COLORADO – Health First Colorado

(Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program HIBI Customer Service: 1-855-692-6442

ALASKA – Medicaid FLORIDA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268

ARKANSAS – Medicaid GEORGIA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

CALIFORNIA – Medicaid INDIANA – Medicaid Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx Phone: 916-440-5676

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

IOWA – Medicaid and CHIP (Hawki) MONTANA – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

KANSAS – Medicaid NEBRASKA – Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

KENTUCKY – Medicaid NEVADA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: [email protected] KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

LOUISIANA – Medicaid NEW HAMPSHIRE – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218

MAINE – Medicaid NEW JERSEY – Medicaid and CHIP Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: -800-977-6740. TTY: Maine relay 711

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MINNESOTA – Medicaid NORTH CAROLINA – Medicaid Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

OREGON – Medicaid VERMONT– Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462

Website: https://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282

RHODE ISLAND – Medicaid and CHIP WASHINGTON – Medicaid

Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIP Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002

TEXAS – Medicaid WYOMING – Medicaid

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/ Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.

MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 1/31/2023)

national oilwell varco · 2020. 10. 8. · national oilwell varco 2021 retiree health & welfare...

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