ABC Company Sectioned Benefit Summary

DENTAL PRINCIPAL –ABC PAYS 75% 2022 EMPLOYEE BENEFIT SUMMARY Individual Deductible $50 Family Deductible $150 Calendar Year Max $1,250 / member MEDICAL & HRA Preventive Care Covered 100% & Deductible BCBS OF MA –ABC PAYS 75% does not apply HMO BLUE NE $2,000 Basic Care Covered 80% Deductible* $2,000 / $4,000 Major Care Covered 50% PCP Office Visit $25 Covered 50% for children up to Orthodontia the orthodontia lifetime max of Specialist & Urgent Care Visit $45 $1,000 Emergency Room Visit $150 Diagnostic Visit $35 / $135* (x-ray) $35 / $70* (labs) VISION High-tech Imaging $500* for hospitals PRINCIPAL –ABC PAYS 75% $50* for other facility Outpatient Surgery $0 / $1,000* for HCH Exam $10 copay Every 12 months Inpatient Admission $0 / $1,000* for HCH Lenses PREFERRED BLUE PPO $2,500 Every 12 months $25 copay Deductible* $2,500 / $5,000 Frames Covered up to $130 allowance; PCP Office Visit $35 Every 24 months 20% off remaining balance Specialist & Urgent Care Visit $45 Contacts (instead of glasses) - Every 12 months Emergency Room Visit $250 Elective Contacts Covered up to $130 allowance Diagnostic Visit $50 for hospitals Contact Fitting & Up to $60 copay $0 for other facilities Evaluation High-tech Imaging $400 for hospitals Necessary Contacts Covered in full after $25 copay $150 for other facilities Outpatient Surgery $500* LIFE & DISABILITY Inpatient Admission 10% coinsurance* PRINCIPAL –ABC PAYS 100% PRESCRIPTION DRUGS –HMO & PPO Rx Retail $10/$45/$150/$225 Pays 2x your annual base earnings up to Rx Mail Order $20/$90/$300/$675 Basic Life $350,000. Benefit reduces to 65% at age and AD&D 65, and to 50% at age 70 *after deductible combined with HRA all costs shown are in-network. For out-of-network costs, refer to your plan document. Preventive care always $0 in-network. HRA –SENTINEL BENEFITS* Short- Pays you 66.67% of your weekly base Term salary, up to $2,400/week. Benefit begins ABC pays the below portion of each employee’s Disability on the 15th day and lasts up to 11 weeks medical deductible through the Health Reimbursement Arrangement (HRA). Individual Family Long- Pays you 66.67% of your monthly base Term salary, up to $10,000/month. Benefit HMO Second $1,000 Second $1,000 Disability begins on the 91st day and lasts up to Social Security Normal Retirement Age PPO Second $1,500 Second $3,000