ABC Company Benefit Guide

EMPLOYEE BENEFIT GUIDE

ELIGIBILITY BENEFITS RUN JULY 1, 2023 –JUNE 30, 2024 As a ABC Companyemployee, you are eligible for benefits if you work at least 30 hours per week. Benefits are effective on your first day of employment. You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include: • Your legal spouse • Your domesticpartner • Your children up to the age of 26 (Children will be This guide is a brief summary of benefits offered to your group and covered until the last day of the month in which they does not constitute a policy. ABC Company reserves to itself, turn26) pursuant to its sole and exclusive discretion, the right to change, amend or terminate the benefits program at any time. The Once your benefit elections become effective, they remain insurance companies plan descriptions will contain the actual in effect until June 30, 2024. You may only change your detailed provisions of your benefits. If there are any discrepancies benefits within 30 days of a qualified life event. between the information in the guide and the insurance company’s plan descriptions, the language in the insurance companiesplandescriptionswillalways prevail. 2// 2023 Employee BenefitGuide

BENEFIT COSTS Deducted from your paycheck bi-weekly Benefit Employee Only Employee + Spouse Employee + Child(ren) Family Medical $18.66 $161.19 $116.97 $182.90 Dental $0.98 $8.98 $8.32 $11.70 Vision, HRA, Basic life & Disability, BenefitHub, $0 Gradfin & Compt Voluntary Life Age banded 401(k), FSA & DCA Employee contributions vary

MEDICAL PLAN Preferred Blue PPO $2,000 In-Network Out-of-Network BCBS Plan Deductible $2,000 individual / $4,000 family $2,000 individual / $4,000 family Your Deductible Responsibility $500 individual / $1,000 family $500 individual / $1,000 family ABC’s HRA Deductible Contribution $1,500 individual / $3,000 family $1,500 individual / $3,000 family Out-of-Pocket Maximum Medical - $5,450 individual / $10,900 family Medical - $5,450 individual / $10,900 family Rx - $1,000 individual / $2,000 family Rx - $1,000 individual / $2,000 family Preventive Visit $0 $0 PCP Office Visit $15 $15 Specialist Visit $15 $15 Telehealth Visit $15 $15 Emergency Room Visit $150 $150 Behavioral Health Visit $15 $15 Acupuncture (up to 12 visits/calendar year) $15 $15 Diagnostic Tests & High-Tech Imaging $0 after deductible $0 after deductible Inpatient Hospitalization $0 after deductible $0 after deductible Outpatient/Day Surgery $0 after deductible $0 after deductible Prescriptions Tier 1 $15 retail / $30 mail $15 retail / $30 mail Tier 2 $30 retail / $60 mail $30 retail / $60 mail Tier 3 $50 retail / $150 mail $50 retail / $150 mail 4// 2023 Employee BenefitGuide download: medical summary of benefits and coverage (SBC) | medical summary of benefits (SOB) visit: BCBS eKit

MEDICAL PLAN EDUCATION BCBS MyBlue Member App Watch: SmartShopper – Get Rewarded! - track claims & benefits - check deductible balances - find a doctor - view your member ID card - contact member services scan QR learn more How to Save on Costs - Using a doctor, facility, or other provider from the BCBS of MA - The SmartShopper tool offers you incentives for using network will mean a lower bill for you. The Find a Doctor tool lets you the cost-effective in-network option search for doctors or check to see if yours is in-network. Get discount prescription drugs by using GoodRx to search for drugs you or your family members are prescribed to - Make sure you’re choosing the most cost-effective option for finding care. Check out this easy guide for where to go when you’re sick or member login phone support telehealth SmartShopper find a doctor glossary injured so you aren’t paying too much out-of-pocket 5// 2023 Employee BenefitGuide

BCBS MEMBER PERKS Telehealth Learn to Live Receive treatment and prescriptions Help coping with stress/anxiety/worry, (when necessary) from home for a variety depression, social anxiety, insomnia and of common ailments through the Well- substance use through self-paced, online Connection telehealth platform programs. Unlimited coaching is available Fitness Reimbursement ahealthyme Rewards Get up to $150 annually towards gym fees, Download the virgin pulse mobile app and home fitness equipment, fitness classes, or start tracking your health activities! You online workout programs can earn up to $400 annually for your healthy habits. Register here Weight Loss Reimbursement Blue365 Discounts Get up to $150 annually towards in-person Access exclusive discounts on things like or online weight loss programs like gym memberships, fitness gear, healthy Weight Watchers, or hospital-based eating options, and more – only for BCBS programs members 6// 2023 Employee BenefitGuide

NEW IN 2023 FROM BCBS PillarRx Reproductive Health Virtual Provider CVS Caremark Travel Benefit Networks Pillar RX is BCBS’s new BCBS of will reimburse Carbon Health& Firefly BCBS’s new Pharmacy cost share assistance you and one companion Healthare the two new Benefit Manager is CVS program for specialty if necessary for certain in-network virtual Caremark. To pay the meds based on expenses related to provider. PCP, urgent least for care, make sure manufacturer’s coupon travel for reproductive care, and mental health your prescriptions are programs. Learn more health services. Learn services are provided filled at a pharmacy here. more here. virtually for a $0 office within their network. visit copay. Learn more here. 7// 2023 Employee BenefitGuide

HEALTH REIMBRUSEMENT ARRANGEMENT Members of the ABC medical plan are automatically enrolled in the HRA The HRA is an account Employees will pay the Copays and When you do incur a that ABC Company first portion of their coinsurance are not deductible expense funds to help deductible, and ABC deductible expenses, so that is HRA eligible, the employees enrolled in Company will pay the you will still have to pay expense will the HRA medical plan remainder. These those when applicable. automatically be paid pay for expenses that amounts are outlined by HRC Total Solutions apply towards their below. and appear in your deductible. account. BCBS HRA Plan Deductible You Pay Up to This Amount First Then ABC Company Pays the Remaining $2,000 $500 $1,500 $4,000 $1,000 $3,000 8// 2023 Employee BenefitGuide

HEALTHCARE FLEXIBLE SPENDING ACCOUNT (FSA) Maximum Annual Eligible Expenses Plan Administrator How to Use Funds Funds Rollover Contribution Medical, Dental, and Vision. HRC Total Solutions Use your HRC Total You may rollover up to $3,050 Search eligible expenses Solutions debit card at the $610 of unused Healthcare point of sale, or submit FSA funds into the next receipts for reimbursement plan year through the member portal Enrolling in the FSA Watch: Everything You Need to Know About FSAs - You are required to re-enroll in the Healthcare Flexible Spending Account annually to contribute to the account, per IRS regulations - Once you enroll, you will need to elect the amount you would like to contribute for the entire year - On the first day of the plan, your entire annual election is available to use. Your deductions will be taken out bi-weekly for the remainder of the plan year 9// 2023 Employee BenefitGuide

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (DCA) MaximumAnnual Contribution You may contribute up to $5,000 annually per family ($2,500 if married filing separately) Eligible Expenses Childcare andeldercare. Click here to search eligible expenses. PlanYear January 1, 2023 – December 31, 2023 Administrator HRC Total Solutions is the plan administrator How to UseFunds You will submit receipts for reimbursement through the HRC Total Solutions memberportal. FundsDo NotRollover There is no rollover; unused funds are forfeited. Claims incurred during the 2023 plan year must be submitted for reimbursement by 9/30/2024. Enrolling in the DCA The IRS requires you to re-enroll in the FSA annually. Once you enroll, you will need to elect your contribution for the upcoming Your funds are only available to use as they are plan year. distributed into your FSA from your paycheck. 10// 2023 Employee BenefitGuide

DENTAL PLAN Dental Blue Freedom In-Network& Out-of-Network Deductible $50 member / $150 family Calendar YearMax $1,500 / year PreventiveCare 100% Covered; deductible does not apply to preventive services BasicCare 85%Covered* MajorCare 55%Covered* Orthodontia 50% Covered for children up to age 19 up to the lifetime max of $1,500 Accumulated MaximumRollover If your claims do not exceed $700 during the plan year, BCBS will rollover $500 towards your calendar year maximum to use next year and beyond. The rolloverbalance is capped at $1,500 *afterdeductiblehas been met 11 // 2023 Employee BenefitGuide download: dental summary of benefits (SOB) visit: BCBS eKit

DENTAL PLAN EDUCATION BCBS MyBlue Member App Watch: Seeing the Dentist is Good For Your Health - track claims & benefits - check deductible balances - find a doctor - view your member ID card - contact member services scan QR learn more Your Dental Benefits - Your plan allows you two free dental - When you see a BCBS of MA network dentist, benefits cleanings a year, and one routine x- are covered at the in-network level – you will enjoy the ray every 12 months. greatest savings. Click here to find an in-network dental - All services you receive at the provider. dentist fall under preventive, basic, or major. Preventive services are fully covered even before the deductible has been met member login phone support learn more 12 // 2023 Employee BenefitGuide

VISION PLAN VSP CHOICE NETWORK In-Network Out-of-NetworkReimbursement EyeExam $10copayfor yearly examination Routine Retinal Screening no more than $39 Frames Allowance $200frame allowance; 20% savings on balance after allowance Lenses &Enhancements SingleVision $20copay LinedBifocal $20 copay Lined TrifocalLenses $20copay StandardProgressive Progressive Premium Tiers 1 – 3 Progressive Premium Tier 4 ContactLenses DisposableContacts ConventionalContacts Medically NecessaryContacts 13 // 2023 Employee BenefitGuide download: vision summary of benefits (SOB)

VISION PLAN EDUCATION VSP On the GoApp Watch: Reasons to Enroll in a VisionPlan - track claims & benefits - check deductible balances - find a doctor - view your member IDcard - contact memberservices scan QR Your Vision Perks - Get 20% savings on additional pairs When you see a VSP network eye doctor, benefits are of glasses and sunglasses, covered at the in-network level – you will enjoy the greatest including lens enhancements, from savings. Click here to find an in-network vision provider. any VSP provider within 12 months of your last WellVision exam - No more than a $39 copay on routine retinal screening - Average 15% off the regular price or memberlogin support learnmore 5% off the promotional price of laser vision correction at contracted facilities 14// 2023 Employee BenefitGuide

LIFE, AD&D AND DISABILITY Basic Life AD&D Short-Term Disability Long-Term Disability Coverage Pays 1x your base annual earnings up Coverage Pays you 60% of your pre- Pays you 60% of your pre-disability Amount to a maximum of $250,000 Amount disability weekly base salary up monthly base salary up to $15,000 per to $2,500 per week month No medical questions asked up to Pays up to age 65 when you are limited Guaranteed the guaranteed issue amount of Pays up to 12 weeks after a 7- to performing the material and Issue & Age $250,000. Benefit reduces to 65% at Benefit Period day benefit waiting period substantial duties of your regular Reduction age 65, occupation after a 90-day benefit and to 55% at age 70 waiting period IRC section 79 provides an exclusion for the first $50,000 of group-term A Pre-Existing Condition is any sickness or Injury life insurance coverage provided for which you received medical treatment, under a policy carried directly or Pre-Existing consultation, care, or services, including diagnostic Disclaimer indirectly by an employer. The Condition None procedures, or took prescribed drugs or medicines imputed cost of coverage in excess of Exclusion within 3 months prior to your effective date of 12 $50,000 must be included in income, coverage. Disabilities that occur during the first using the IRS Premium Table, and months of coverage due to a pre-existing are subject to social security and condition are excluded from coverage Medicare taxes 15 // 2023 Employee BenefitGuide download: basic life summary | short-term disability summary | long-term disability summary

VOLUNTARY LIFE AND ACCIDENT Voluntary Supplemental Life and AD&D Voluntary Accident Insurance Employee Spouse Dependent Child Employee, Spouse or Dependent Child Coverage Overview Elect up to $500,000in Elect up to $250,000 or 50% Elect up to 10,000 for Pays a fixed, lump-sum benefit for coverage or 5x your annual of employee’s voluntary children aged 6 months and injuries resulting from a covered earningsin increments of coveragein increments of older accident $10,000 $5,000 Additional Guaranteed Issueis Guaranteed Issueis Guaranteed Issueis Employees must be under age 70 at Information $100,000 $25,000 $10,000 date of application. Benefit schedule specifies payment amounts Benefit Cost per $1k Age Cost per $1k of Age Cost per $1k of Benefit Cost per $1k of Benefit Amount Examples: of coverage coverage coverage coverage < 29 $0.067 50-54 $0.368 Ambulance $100 ground, $500 air Transportation 30-34 $0.072 55-59 $0.586 Emergency Treatment $150 35-39 $0.095 60-64 $0.868 $0.1025 Physical $25/session (6 max) Therapy 40-44 $0.141 65-69 $1.653 Concussion $100 45-49 $0.224 70+ $3.189 Dental Injury $150 crown; $50 extraction Voluntary AD&D: $0.048 16// 2023 Employee BenefitGuide download: voluntary life summary | voluntary accident summary

401(k) RETIREMENT PLAN Watch: Can You Afford to Wait? Saving for Retirement Employees can contribute up to $22,500 pre-tax annually to their 401(k)-retirement plan. You may contribute an additional $7,500 if you are age 50+ in an annual "catch-up contribution". ABC will match your first 3% in contributions 100%, then match your next 1% in contributions 50%. Enrollment & Account Access You can enroll in the plan, access your account, or get more information any time by: • Logging in to the ADP Retirement Portal • Calling 1-866-794-2268 Monday through Friday from 8:30am –7:00pm ET. Up to $22,500 annually. You may • Downloading the Empower Retirement mobile app Maximum contribute an additional $7,500 Contribution “catch-up contribution” annually if How much do you need to save for retirement? you are age 50+ That depends on your expenses. Use this calculator from ADP to determine Company Match ABC will match 50% of your first 6% in how much you should be saving now to be comfortable in your retirement. contributions their handy calculators here, including calculators You can also view all of specific to spending, planning, and overall financial wellness. Eligibility You are eligible to contribute to the Plan if you are at least 21 years old Withdrawals & You may withdraw money from your Loans account in certain situations and take up to one loan at a time. 17// 2023 Employee BenefitGuide Plan Administrator ADP Retirement Services

HOLIDAYS & TIME OFF Holidays ABC Company offers twelve paid holidays every year, which includes two floating holidays. Full-time team members will be paid for the following 2023 holidays: New Year’s Day January 2 Thanksgiving Day November 23 MLK Jr. Day January 16 Day after Thanksgiving November 24 Patriot’s Day April 17 Christmas Eve December 22 Memorial Day May 29 Christmas Day December 25 Independence Day July 4 Floating Holiday Your choice Labor Day September 4 Floating Holiday Your choice Sick time Employees receive 40 hours per year. There is no carryover of unused sick time. Sick time requests are submitted and approved through ADP. Vacation Time Employees accrue 4.62 hours per pay period. You may carryover up to 40-hours of unused vacation time each year, with a cap of 180-hours of vacation time per year. Vacation time requests are submitted and approved through ADP. 18// 2023 Employee BenefitGuide

EDUCATION Gradfin Student Loan Services ABC provides employees with free access to Gradfin. Gradfinhelps tackle student debt through financial education, expert loan analysis, and more. It is personalized student loan advice with smart technology. www.gradfin.comfor more details. Visit Tuition Reimbursement ABC reimburses employees for pre-approved, job related and career related courses, up to $5,250 per year. Eligible items include tuition, registration, books and exam fees. You must receive a passing grade of “C” or above to qualify, or complete a certification program. 19// 2023 Employee BenefitGuide

BENEFITHUB DISCOUNTS Benefits that engage everyday All ABC Company employees have access to BenefitHub. You can select from the world’s largest selection of Employee Discounts, Rewards, Lifestyle and Voluntary benefits. Its easy and convenient, choose what you want, and it’s free! Enrollment & Account Access You can enroll in the BenefitHub any time by: • ABC BenefitHub PortalReferral Code: E24GXM • Calling 1-866-664-4621 • [email protected] • Monday –Friday 8:30 a.m. to 8:30 pm ET • User FAQ'S –BenefitHub Help Center (zendesk.com) 20// 2023 Employee BenefitGuide

RELIANCE MATRIX PERKS Travel Assistance ID Theft Protection Employee Assistance Program Get 24/7 support while traveling Protect, identify, and resolve ID theft All covered employees & family members The Travel Assistance Program is available 24 The Identity Theft Protection Program provides ABC provides a no-cost EAP to all Eligible Employees hours a day to help protect employees from the employees with information to protect and their Family Members. The EAP is designed to unpredictable, whenever they travel 100 miles or themselves and step-by-step coaching to help provide prompt, confidential help with a range of more from home for less than 90 consecutive identify and resolve identity theft. Benefits personal or family issues. Benefits include: days. Key services include: include: • Medical support • Lost wallet assistance • up to three no-cost face-to-face counseling • Transportation for medical treatment • Credit information review sessions per separate issue • Medication/glasses replacement • Three-bureau fraud alert placement assistance • support for life improvement and goal setting, • Emergency message relay • ID theft affidavit assistance addictions, stress or anxiety, financial and legal • Emergency cash • Translation services while traveling concerns, and more. • Stolen item location assistance • Emergency cash advance while traveling with • Legal assistance/bail repayment guarantee Visit http://myassistanceprogram.com/rsl/for more info • Interpretation/translation services or Call (855) 775-4357 21// 2023 Employee BenefitGuide

CONTACTS & WEBSITES Benefit Carrier & Login Phone Medical & Dental BCBS of Massachusetts 1-888-630-2583 Vision VSP 1-800-877-7195 Life & Disability Reliance Matrix 1-800-435-7775 HRA, FSA & DCA HRC Total Solutions 1-603-647-1147 ext. 1 Retirement ADP 1-800-695-7526 Employee Discounts BenefitHub 1-866-664-4621 Student Loan Assistance Gradfin 1-844-472-3346 Health & Wellness Stipend Compt Employee Assistance Program Reliance Matrix 1-888-937-4783 22// 2023 Employee BenefitGuide

HEALTH PLAN NOTICES Special Enrollment Rights - If you are declining enrollment for yourself or same deductibles and co-insurance applicable to other medical and surgical your dependents (including your spouse) because of other health benefits provided under the ABC Company Health Plan. If you would like more insurance or group health plan coverage, you may be able to enroll yourself information on WHCRA benefits, please call your Plan Administrator and your dependents in this plan if you or your dependents lose eligibility Notice Regarding Lifetime and Annual Dollar Limits - In accordance with for that other coverage(or if the employer stops contributing toward your or applicable law, any lifetime dollar limits and annual dollar limits set forth in the your dependents’ other coverage). However, you must request enrollment Plan shall not apply to “essential health benefits,” as such term is defined under within 30 days after your or your dependents’ other coverage ends (or after Section 1302(b) of the Affordable Care Act. The law defines “essential health the employer stops contributing toward the other coverage). In addition, if benefits” to include, at minimum, items and services covered within certain you have a new dependent as a result of marriage, birth, adoption, or categories including emergency services, hospitalization, prescription drugs, placement for adoption, you may be able to enroll yourself and your rehabilitative and habilitative services and devices, and laboratory services. A dependents. However, you must request enrollment within 30 days after determination as to whether a benefit constitutes an “essential health benefit” the marriage, birth, adoption, or placement for adoption. To request special will be based on a good faith interpretation by the Plan Administrator of the enrollment or obtain more information, contact the Plan Administrator. guidance available as of the date on which the determination is made. Grandfathered Status -The Plan believes that none of the group health Patient Protection Disclosure - You have the right to designate any plans available under the Plan are “grandfathered health plans” as participating primary care provider who is available to accept you or your described under the Patient Protection and Affordable Care Act (the family members (for children, you may designate a pediatrician as the primary “Affordable Care Act”). care provider). For information on how to select a primary care provider and for Special Rule for Maternity and Infant Coverage -Group health plans and a list of participating primary care providers, contact the Plan Administrator. health insurance issuers generally may not, under Federal law, restrict You do not need prior authorization from the Plan or from any other person, benefits for any hospital length of stay in connection with childbirth for including your primary care provider, in order to obtain access to obstetrical or the mother or newborn child to less than 48 hours following a vaginal gynecological care from a health care professional; however, you may be delivery, or less than 96 hours following a cesarean section. However, required to comply with certain procedures, including obtaining prior Federal law generally does not prohibit the attending provider or authorization for certain services, following a pre-approved treatment plan, or physician, after consulting with the mother, from discharging the mother procedures for making referrals. For a list of participating health care or her newborn earlier than 48 hours (or 96 hours, as applicable). professionals who specialize in obstetrics or gynecology, contact the health Special Rule for Women’s Health Coverage (WHCRA) -If you have had or are plan. going to have a mastectomy, you may be entitled to certain benefits under Michelle’s Law - Michelle’s Law provides continued health and dental insurance the Women's Health and Cancer Rights Act of 1998 (WHCRA). For benefits under the Plan for dependent children who are covered under the individuals receiving mastectomy-related benefits, coverage will be Plan as a student but lose their student status in a post-secondary school or provided in a manner determined in consultation with the attending college because they take a medically necessary leave of absence from school. physician and the patient, for: all stages of reconstruction of the breast on If your child is no longer a student because he or she is out of school because of which the mastectomy was performed; surgery and reconstruction of the a medically necessary leave of absence, your child may continue to be covered other breast to produce a symmetrical appearance; prostheses; and under the Plan for up to one year from the beginning of the leave of absence. treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the

HEALTH PLAN NOTICES Affordable Care Act Consumer Protections -(a.) Coverage for Children Up to The Genetic Information Nondiscrimination Act (GINA) - GINA prohibits the Plan Age of 26. The Affordable Care Act of 2010 requires that the Plan must make from discriminating against individuals on the basis of genetic information in dependent coverage available to adult children until they turn 26 regardless providing any benefits under the Plan. Genetic information includes the results of if they are married, a dependent, or a student. genetic tests to determine whether someone is at increased risk of acquiring a (b.) Prohibition of Lifetime Dollar Value of Benefits: the Affordable Care Act condition in the future, as well as an individual’s family medicalhistory. of 2010 prohibits the Plan from imposing a lifetime limit on the dollar Wellness -Your health plan is committed to helping you achieve your best health. If value ofbenefits. your Plan includes a Wellness program that provides rewards or surcharges based (c.) Your Health Insurance Cannot be Rescinded -The Affordable Care Act on your ability to complete an activity or satisfy an initial health standard, and if you of 2010 prohibits the Plan, or any insurer, from rescinding your health think you might be unable to meet a standard for a reward under the wellness insurance coverage except as permitted under theAct. program, you might qualify for an opportunity to earn the same reward by different means. Contact the Plan Administrator and we will work with you (and, if you wish, (d.) Prohibition of Pre-Existing Conditions - No insurance plan can reject with your doctor) to find a wellness program with the same reward that is right for you, charge you more, or refuse to pay for essential health benefits for any you in light of your healthstatus. condition you had before your coveragestarted. YourRightsand ProtectionsAgainstSurpriseMedicalBills (e.) Prohibition of Restrictions on Annual Limits on Essential Benefits - The Whenyougetemergencycareorgettreatedbyanout-of-networkprovideratan Affordable Care Act of 2010 prohibits the Plan, or any insurer, effective in-networkhospital orambulatorysurgicalcenter,youare protectedfromsurprise January 1, 2014 from placing annual limits on the value of essential health billingorbalancebilling. benefits. (f) Notice of Marketplace/Exchange -You have the option to purchase health What is “balance billing” (sometimes called “surprisebilling”)? insurance at the Health Insurance Marketplace. The Marketplace offers When you see a doctor or other health care provider, you may owe certain out-of- "one-stop shopping" to find and compare private health insurance options pocket costs, such as a copayment, coinsurance, and/or a deductible. You may as well as a premium tax credit or a cost sharing reduction for certain have other costs or have to pay the entire bill if you see a provider or visit a health qualified individuals. If you purchase a health plan through the Marketplace, care facility that isn’t in your health plan’s network. you will lose any employer contribution toward the cost of your health “Out-of-network” describes providers and facilities that haven’t signed a contract coverage. Employer contributions to employer-provided coverage may be with your health plan. Out-of-network providers may be permitted to bill you for the excludable for federal income tax purposes. The Marketplace can help you difference between what your plan agreed to pay and the full amount charged for a evaluate your coverage options, including your eligibility for coverage service. This is called “balance billing.” This amount is likely more than in-network through the Marketplace and its cost. Please visit www.Healthcare.gov for costs for the same service and might not count toward your annual out-of-pocket more information and contact information for a Health Insurance limit. Marketplace in yourarea. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-networkprovider.

HEALTH PLAN NOTICES You are protected from balance billing for: Your health plan generallymust: Emergency services -If you have an emergency medical condition and get  Cover emergency services without requiring you to get approval for services emergency services from an out-of-network provider or facility, the most the in advance (priorauthorization). provider or facility may bill you is your plan’s in-network cost-sharing amount  Cover emergency services by out-of-networkproviders. (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable  Base what you owe the provider or facility (cost-sharing) on what it would condition, unless you give written consent and give up your protections not pay an in-network provider or facility and show that amount in your to be balanced billed for these post-stabilization services. explanation of benefits. Certain services at an in-network hospital or ambulatory surgical center -  Count any amount you pay for emergency services or out-of-network When you get services from an in-network hospital or ambulatory surgical services toward your deductible and out-of-pocket limit. center, certain providers there may be out-of-network. In these cases, the If you believe you’ve been wrongly billed, you may contact the Centers for most those providers may bill you is your plan’s in-network cost-sharing Medicare & Medicaid Serviceshttps://www.cms.gov/nosurprises amount. This applies to emergency medicine, anesthesia, pathology, Visit https://www.cms.gov/nosurprises/Policies-and-Resources/Overview-of- radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist rules-fact-sheetsfor more information about your rights under federallaw. services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. When balance billing isn’t allowed, you also have the following protections: You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

HEALTH PLAN NOTICES 11. Important Notice About Your Prescription Drug Coverage and When Can You Join A Medicare Drug Plan? Medicare You can join a Medicare drug plan when you first become eligible for Please read this notice carefully and keep it where you can find it. This Medicare and each year from October 15th to December 7th. However, if notice has information about your current prescription drug coverage you lose your current creditable prescription drug coverage, through no with your employer and about your options under Medicare’s fault of your own, you will also be eligible for a two (2) month Special prescription drug coverage. This information can help you decide Enrollment Period (SEP) to join a Medicare drug plan. whether or not you want to join a Medicare drug plan. If you are What Happens To Your Current Coverage If You Decide to Join A considering joining, you should compare your current coverage, Medicare Drug Plan? including which drugs are covered at what cost, with the coverage and Your current coverage pays for other health expenses, in addition to costs of the plans offering Medicare prescription drug coverage in your prescription drugs. If you are actively employed and decide to join a area. Information about where you can get help to make decisions Medicare drug plan, your current medical coverage will not be affected; about your prescription drug coverage is at the end of this notice. There you can keep this coverage if you elect part D and this plan will are two important things you need to know about your current coordinate with Part D coverage. coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to If you are actively employed and you decide to join a Medicare drug plan everyone with Medicare. You can get this coverage if you join a and drop your current medical coverage, be aware that you and your Medicare Prescription Drug Plan or join a Medicare Advantage Plan dependents may be able to get this coverage back at the next open (like an HMO or PPO) that offers prescription drug coverage. All enrollment period or upon a qualifying status change if you remain Medicare drug plans provide at least a standard level of coverage set by otherwise eligible to enroll in the Plan. Medicare. Some plans may also offer more coverage for a higher If you are no longer actively employed and you decide to join a Medicare monthly premium. drug plan and drop your current coverage, be aware that you and your 2.Your employer has determined that the prescription drug coverage dependents will not be able to get this coverage back. offered by the employer sponsored medical plans are, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and are 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.

HEALTH PLAN NOTICES When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug For More Information About Your Options Under Medicare Prescription Plan? Drug Coverage… You should also know that if you drop or lose your current coverage and More detailed information about Medicare plans that offer prescription don’t join a Medicare drug plan within 63 continuous days after your drug coverage is in the “Medicare & You” handbook. You’ll get a copy of current coverage ends, you may pay a higher premium (a penalty) to the handbook in the mail every year from Medicare. You may also be join a Medicare drug plan later. contacted directly by Medicare drug plans. If you go 63 continuous days or longer without creditable prescription For more information about Medicare prescription drug coverage: drug coverage, your monthly premium may go up by at least 1% of the • Visit www.medicare.gov Medicare base beneficiary premium per month for every month that • Call your State Health Insurance Assistance Program (see the inside you did not have that coverage. For example, if you go nineteen back cover of your copy of the “Medicare & You” handbook for their months without creditable coverage, your premium may consistently telephone number) for personalized help 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 • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877- have Medicare prescription drug coverage. In addition, you may have to 486-2048. wait until the following October to join. If you have limited income and resources, extra help paying for Medicare For More Information About This Notice Or Your Current Prescription prescription drug coverage is available. For information about this extra Drug Coverage… help, visit Social Security on the web at www.socialsecurity.gov, or call Contact the plan administrator for further information. them at 1-800-772-1213 (TTY 1-800-325-0778).

HEALTH PLAN NOTICES 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 apremium 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, visitwww.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.govto 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, www.askebsa.dol.govor call 1-866-444- contact the Department of Labor at EBSA(3272).

HEALTH PLAN NOTICES Alabama Colorado Minnesota Website: http://myalhipp.com/ Health First Colorado Website: https://mn.gov/dhs/people-we-serve/children- Phone: 1-855-692-5447 https://www.healthfirstcolorado.com/ and-families/health-care/health-care- Health First Colorado Member Contact Center: programs/programs-and-services/other- Alaska 1-800-221-3943/ State Relay 711 insurance.jsp The AK Health Insurance Premium Payment CHP+: Phone: 1-800-657-3739 Program https://www.colorado.gov/pacific/hcpf/child- Website: http://myakhipp.com/ health-plan-plus Missouri Phone: 1-866-251-4861 CHP+ Customer Service: 1-800-359-1991/ State Website: Email: [email protected] Relay 711 http://www.dss.mo.gov/mhd/participants/pages/ Medicaid Eligibility: Health Insurance Buy-In Program (HIBI): hipp.htm http://dhss.alaska.gov/dpa/Pages/medicaid/defa https://www.colorado.gov/pacific/hcpf/health- Phone: 573-751-2005 ult.aspx insurance-buyprogram HIBI Customer Service: 1-855-692-6442 Montana Arkansas Website: Website: http://myarhipp.com/ Florida http://dphhs.mt.gov/MontanaHealthcareProgra Phone: 1-855-MyARHIPP (855-692-7447) Website: ms/HIPP https://www.flmedicaidtplrecovery.com/flmedic Phone: 1-800-694-3084 California aidtplrecovery.com/hipp/index.html Website: Health Insurance Premium Payment Phone: 1-877-357-3268 Nebraska (HIPP) Program Website: http://www.ACCESSNebraska.ne.gov http://dhcs.ca.gov/hipp Georgia Phone: 1-855-632-7633 Phone: 916-445-8322 Website: https://medicaid.georgia.gov/health- Lincoln: 402-473-7000 [email protected] insurance-premium-payment-program-hipp Email: Omaha: 402-595-1178 Phone: 678-564-1162 ext2131 Nevada Massachusetts Medicaid Website: http://dhcfp.nv.gov Website: https://www.mass.gov/info- Medicaid Phone: 1-800-992-0900 details/masshealthpremium-assistance-pa Phone: 1-800-862-4840

HEALTH PLAN NOTICES New Hampshire Oregon Vermont Website: https://www.dhhs.nh.gov/oii/hipp.htm Website: Website: http://www.greenmountaincare.org/ Phone: 603-271-5218 http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-250-8427 Toll free number for the HIPP program: 1-800-852- http://www.oregonhealthcare.gov/index-es.html 3345, ext5218 Phone: 1-800-699-9075 Virginia New Jersey Website: https://www.coverva.org/en/famis- Medicaid Website: Pennsylvania select http://www.state.nj.us/humanservices/dmahs/clien Website: https://www.coverva.org/en/hipp ts/medicaid/ https://www.dhs.pa.gov/providers/Providers/Pages/Me Medicaid Phone: 1-800-432-5924 Medicaid Phone: 609-631-2392 dical/HIPP-Program.aspx CHIP Phone: 1-800-432-5924 CHIP Website: Phone: 1-800-692-7462 http://www.njfamilycare.org/index.html Washington CHIP Phone: 1-800-701-0710 Rhode Island Website: https://www.hca.wa.gov/ Website: http://www.eohhs.ri.gov/ Phone: 1-800-562-3022 New York Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Website: Share Line) West Virginia https://www.health.ny.gov/health_care/medicaid/ Website: http://mywvhipp.com/ Phone: 1-800-541-2831 South Carolina Toll-free phone: 1-855-MyWVHIPP (1-855-699- Website: https://www.scdhhs.gov 8447) North Carolina Phone: 1-888-549-0820 Website: https://medicaid.ncdhhs.gov/ Wisconsin Phone: 919-855-4100 South Dakota Website: Website: http://dss.sd.gov https://www.dhs.wisconsin.gov/badgercareplus North Dakota Phone: 1-888-828-0059 /p-10095.htm Website: Phone: 1-800-362-3002 http://www.nd.gov/dhs/services/medicalserv/medic Texas aid/ Website: http://gethipptexas.com/ Wyoming Phone: 1-844-854-4825 Phone: 1-800-440-0493 Website: https://health.wyo.gov/healthcarefin/medicaid/ Oklahoma Utah programs-and-eligibility/ Website: http://www.insureoklahoma.org Medicaid Website: https://medicaid.utah.gov/ Phone: 1-800-251-1269 Phone: 1-888-365-3742 CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

HEALTH PLAN NOTICES To see if any other states have added a premium assistance program, or for Paperwork Reduction ActStatement more information on special enrollment rights, contact either: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no U.S. Department of Labor persons are required to respond to a collection of information unless such Employee Benefits Security Administration collection displays a valid Office of Management and Budget (OMB) control www.dol.gov/agencies/ebsa number. The Department notes that a Federal agency cannot conduct or 1-866-444-EBSA (3272) 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 U.S. Department of Health and Human Services not required to respond to a collection of information unless it displays a Centers for Medicare & Medicaid Services currently valid OMB control number. See 44 U.S.C. 3507. Also, www.cms.hhs.gov notwithstanding any other provisions of law, no person shall be subject to 1-877-267-2323, Menu Option 4, Ext. 61565 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 four 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, 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.