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Effective December 1, 2024 through November 30, 2025 Medical Dental Vision MASA LTD Colonial Life

TABLE OF CONTENTS Eligibility Medical Benefit Options RECURO—Telemedicine Dental Benefits Vision Benefits MASA LTD - UNUM Colonial Life Products BCBS Extra Benefits Medical SBCs GET READY! New Benets Choices Are Coming Your Way Silsbee Ford Inc. is pleased to offer its employees an excellent benefits program. These benefits are designed to protect you and your family while you are an active employee. The benefit choices you make should be tailored to your personal needs. After the open enroll-ment period ends, you may not add, delete, or change the coverage you have selected for yourself or your dependents until the next open enrollment period. Make sure to review this guide to learn about your options. Outside of open enrollment, changes to insurance coverage can only be made within 30 days of a Qualifying Family Status Change, which are as follows: • Marriage • Birth or adoption of a dependent child • Change in custody of a dependent child • Death of a spouse or dependent child • Your spouse has a change of employment or status affecting benefits coverage • Your change of employment status • You experience an involuntary loss of other group benefits coverage • Or within 60 days if the Qualifying Event is relative to Medicaid or CHIP Eligibility • Employees or Dependents become eligible or lose eligibility with state Medicaid or CHIP subsidies (Special Enrollment Rights Offered) PRE- TAX ADVANTAGE One of the advantages of your Employee Benefit Program is that your premium contributions are deducted from your paycheck on a pre-tax basis. When you pay for your premiums with pre-tax dollars, you are actually reducing your taxable income. Instead of paying This booklet is intended for illustrative and information purposes only. Not all plan provisions, limitations, and exclusions are included in this publication. In the event of any conflict between the information contained in this publication and the plan provisions, the Plan Documents and insurance cont racts will govern.

ELIGIBILITY Eligibility: You are eligible for benefits if you are classified as an active, full-time employee working 30 hours a week or more. Your coverage is effective the first of the month following 60 days. Dependent Eligibility: If you wish, your dependents may also be covered under the medical, dental, vision and supplemental plans. Newborns must be enrolled within 30 days from the date of birth. Eligible Dependents include: * Legal spouse, as defined by the Federal Law * Dependent children MEDICAL - Your children up to the end of the month in which they turn age 26, regardless of marital status, financial dependency, residency with the Eligible Employee, student status, employment status, or eligibility for other coverage. DENTAL – Dependent children are eligible until the end of the month in which they turn 26, regardless of whether or not they are dependent on the employee or whether they are a full-time or part-time student. VISION – Dependent children are eligible until the end of the month in which they turn 26, regardless of whether or not they are dependent on the employee or whether they are a full-time or part-time student. CLARIFICATION ON ELIGIBILITY FOR DEPENDENT COVERAGE Plans that offer dependent coverage must offer coverage to enrollees’ adult children until age 26, even if the young adult no longer lives with his or her parents, is not a dependent on a parent’s tax return, is no longer a student, or is married. This booklet is intended for illustrative and information purposes only. Not all plan provisions, limitations, and exclusions are included in this publication. In the event of any conflict between the information contained in this publication and the plan provisions, the Plan Documents and insurance cont racts will govern.

PPO HSA PlanBlue Essentials Co-Pay Plan (PCP Required)PPO Co-Pay PlanDesign (in-network)MTBCP008H MTBEE031 MTBCB031Network BCBS BCBS BCBSDeductible (Individual/Family)$6,000.00/$12,000.00 $3,500.00/$10,500.00 $3,500.00/$10,500.00Coninsurance After Deductible100% 80% 80%Out of Pocket Maximum (Individual/Family)$6,000.00/$12,000.00 $7,900.00/$15,800.00 $7,900.00/$15,800.00MEDICAL (in-network)Preventative Care Covered 100% Covered 100% Covered 100%Physician Office Visits Deductilbe then 100% Coinsurance $35.00 $35.00Specialst Office Visits Deductilbe then 100% Coinsurance $70.00 $70.00Lab/X-Ray at Office Visits Deductilbe then 100% Coinsurance Deductible then 80% Coinsurance Deductible then 80% CoinsuranceComplex Imaging Deductilbe then 100% Coinsurance Deductible then 80% Coinsurance Deductible then 80% CoinsuranceUrgent Care Center Deductilbe then 100% Coinsurance $75.00 $75.00ER Facility Fee Only Deductilbe then 100% Coinsurance $500.00 $500.00Outpatient Surgery Deductilbe then 100% Coinsurance Deductible then 80% Coinsurance Deductible then 80% CoinsuranceInpatient Surgery Deductilbe then 100% Coinsurance Deductible then 80% Coinsurance Deductible then 80% CoinsuranceRX (in-network)Retail Preferred PharmacyDeductilbe then 100% Coinsurance $0/$10/$50/$100/$150/$250 $0/$10/$50/$100/$150/$250Retail Non Preferred PharmacyDeductilbe then 100% Coinsurance $10/$20/$70/$120/$150/$250. $10/$20/$70/$120/$150/$250Mail OrderDeductilbe then 100% Coinsurance $0/$30/$150/$300/N/A/N/A $0/$30/$150/$300/N/A/N/ANotesPlan Type PPO HMO- BLUE ESSENTIALS NETWORK PPOMEDICAL - BCBS OF TXPPO HSA PlanBlue Essentials Co-Pay Plan (PCP Required)PPO Co-Pay PlanPLAN NAME MTBCP008H MTBEE031 MTBCB031Employee Portion 52 Deductions Per Year - Paid WeeklyEmployee Only $75.38 $92.88 $114.64Employee + Child(ren) $245.70 $282.30 $327.80Employee + Spouse $292.07 $333.88 $385.84Employee + Family $445.53 $504.55 $577.8924 Deductions Per Year - Paid Bi-MonthlyEmployee Only $163.32 $201.25 $248.40Employee + Child(ren) $532.35 $611.66 $710.24Employee + Spouse $632.83 $723.41 $835.99Employee + Family $965.32 $1,093.19 $1,252.10The above highlights are intended as an overview. In any discrepancy between the hightlights and the master contract, the master contract will govern. These hightlights do not guarantee benefits or eligibility. All terms, provisions, conditions, limitations and exclusions showin in the booklet certificate and master policy will apply.Silsbee Ford and Lake Country Chevy12/1/2024-11/30/2025 Medical Plan BenefitsBlueCross BlueShield of Texas* Retail is limited to a 30 day supply. Mail order is up to a 90 day supply except specialty drugs. Mail order specialty drugs are limited to a 30 day supply.*

Search online via Provider Finder® to nd a reward-eligible location for your procedure or service.Receive a cash reward by check, which will be mailed directly to your home, after your claim is paid and the location is veried as reward-eligible.How it worksShop online with Provider Finder by visiting bcbstx.com, register or log in to Blue Access for MembersSM and select “Find Care.” If you need help, call the Customer Service number on the back of your member ID card.Step 1 Step 3Get the procedure or service at your chosen reward-eligible location.Step 2Healthy You, Healthy Wallet!Member Rewards helps you compare costs, save money and earn cash rewards.Costs for the same medical care can vary.With Member Rewards, you can shop and earn cash rewards for procedures and services, which can vary based on location. It is quick and easy to shop in-network for scans, colonoscopies, surgeries and more. The Member Rewards program is part of your health plan benets and administered by Sapphire Digital – part of Zelis.759558.0922Sapphire Digital is an independent company that has contracted with Blue Cross and Blue Shield of Texas (BCBSTX) to administer the Member Rewards program for members with coverage through BCBSTX. Reward-eligible options and reward amounts are subject to change. Eligibility for rewards is subject to terms and conditions of the Member Rewards program. Amounts received through Member Rewards may be taxable. BCBSTX does not provide tax advice. Members that have primary coverage with Medicaid or Medicare are not eligible to receive incentive rewards under the Member Rewards program.BCBSTX makes no endorsement, representations or warranties regarding third-party vendors and the products and services offered by them.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Getting StartedCare ServicesVirtual Urgent Care• Acne / Rash• Allergies• Cold / Flu• GI Issues• Ear Problems• Fever• Insect Bites• Nausea• Pink Eye• Respiratory• UTI's• And More...Example Conditions Treatedcustomerservice@recurohealth.com | 855.6RECURO | Scan QR Code to Download $0Copay010203ActivateAccess your Recuro Care benefit by:Mobile App: Android or ApplePhone: 1.855.673.2876Online: member.recurohealth.comCreate LoginCreate your login credentials by entering your email, name, and date of birth, then create your username and password.Request a ConsultYou’re now ready to request a consult with a Doctor.Or visit: “member.recurohealth.com"Scan here or search for “Recuro Care” in your app store.Activate Now

BlueCare DentalSM Plan ID: DTNHR01 This information only provides a summary of the benefits for this Dental Plan. Please refer to your Dental Benefit Booklet for additional benefit information. The Deductibles, Coinsurance and Benefit Period Maximum shown below are subject to change as permitted by applicable law. Benefit Period Maximum $3,000 Deductible $25 Individual/$75 Family No Annual Maximum No Annual Maximum Diagnostic Evaluations Periodic oral evaluations Problem focused oral evaluations Comprehensive oral evaluations 100% (Deductible does not apply) Preventive Services Prophylaxis (cleanings) Topical fluoride applications 100% (Deductible does not apply) Diagnostic Radiographs Full-mouth and panoramic films Bitewing films Periapical films 100% (Deductible does not apply) Miscellaneous Preventive Services Sealants Space maintainers 100% (Deductible does not apply) Basic Restorative Dental Services Amalgams Resin-based composite restorations 80% Non-Surgical Extractions Removal of retained coronal remnants Removal of erupted tooth or exposed root 80% Non-Surgical Periodontal Services Periodontal scaling and root planing Full-mouth debridement Periodontal maintenance procedures 80% Adjunctive Services Palliative treatment (emergency) Deep sedation / general anesthesia 80% Endodontic Services Therapeutic pulpotomy and pulpal debridement Root canal therapy Apexification/recalcification 80% Program Basics Summary of Dental Benefits Covered Services

730311.0917 Oral Surgery Services Surgical tooth extractions Alveoloplasty and vestibuloplasty Excision of benign odontogenic tumor/cyst Excision of bone tissue Incision and drainage of an intraoral abscess 80% Surgical Periodontal Services Gingivectomy or gingivoplasty and gingival flap procedures Clinical crown lengthening Osseous surgery Osseous grafts Soft tissue grafts/allografts Distal or proximal wedge procedure Anatomical crown exposures 80% Major Restorative Services Single crown restorations Gold foil and inlay/onlay restorations Labial veneer restorations Crowns placed over implants 50% Prosthodontic Services Complete and removable partial dentures Denture reline/rebase procedures Fixed bridgework Prosthetics placed over implants Implants 50% Miscellaneous Restorative and Prosthodontic ServicesPrefabricated crowns Recementations Post and core, pin retention and crown/bridge repairs Adjustments 50% Orthodontic Services Orthodontic Diagnostic Procedures and Treatment Lifetime Maximum per Participant 50% $2,000 (Deductible does not apply) The above is a listing of common services available through your network of Participating Dentists. The Member's share of the cost is determined by whether care is received from a Participating or Non-Participating Dentist. Services from non-participating providers will be subject to reasonable and customary allowances, as determined by the Company. Amounts in excess of these allowances will be the full responsibility of the insured. This plan includes BlueCare Dental Enhanced BenefitSM. The Enhanced Benefit provides additional dental benefits, such as an extra cleaning and 100% coverage for periodontal cleanings to members with specific health issues at no additional cost. Please refer to your Dental Benefit Booklet for additional benefit information. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Covered Services (continued)Orthodontic Services

ExaminationLenses or Contact LensesFramesAdditional benefits are described in your Group Plan bookletPlease NotePremium Progressive Lenses (price varies by tier)FramesConventionalDisposableFrames/Contact LensesMembers also receive a 40% discount off complete pair of eyeglass purchases and a 15% discount off conventional contact lenses once the provided benefit has been used.FrequencyOnce in 24 MonthsOnce in 12 MonthsAdditional Pairs Benefit (In-Network Only)N/A15% Off RetailIn NetworkOut of Network$65 Reimbursement$130 AllowancePremiumRetinal Imaging Benefit Laser Vision Correction***10% DiscountMedically Necessary$104 Reimbursement$104 ReimbursementVision Benefit SummarySILSBEE FORD, INC. Effective: December 01, 2024ExamIn NetworkOut of NetworkExam with Dilation as NecessaryEyeglass LensesIn NetworkOut of Network$10 Copay$30 ReimbursementSingle VisionBifocalTrifocal$25 Copay$15 Reimbursement$25 Copay$5 ReimbursementLenticularStandard Progressive LensesNA$0 Copay, Paid in FullUp to $3915% Off RetailOnce in 12 Months*Out of Network is a reimbursement amount. Member reimbursement for services completed out of network will be thelesser of the listed amount or the member's actual cost from the out of network provider. In certain states, members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see EyeMed's online provider locator to determine which participating providers have agreed to the discounted rate.EyeMed Insight Network$210 ReimbursementUp to $40NAStandardContact Lens Fitting/Follow Up**In NetworkOut of Network$130 Allowance$15 Reimbursement$33 Reimbursement$33 Reimbursement$15 Reimbursement$110 to $135 Copay$25 Copay$25 Copay$90 Copay$130 Allowance

**Contact Lens fitting and 2 follow up visits are available once a comprehensive eye exam has been completed.***When Lasik or PRK from U.S. Laser Network is used.The above highlights are intended as an overview. In any discrepancy between the highlights and the master contract, the master contract will govern. These highlights do not guarantee benefits or eligibility. All terms, provisions, conditions, limitations and exclusions shown in the booklet-certificate and master policy will apply.*Out of Network is a reimbursement amount. Member reimbursement for services completed out of network will be the lesser of the listed amount or the member's actual cost from the out of network provider. In certain states, members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see EyeMed's online provider locator to determine which participating providers have agreed to the discounted rate.

EMERGENT PLUS MEMBERSHIP BENEFITSContact Your Representative, to learn more:Emergency Air Ambulance Coverage1MASA MTS covers out-of-pocket expenses associated with emergency air transportation to a medical facility for serious medical emergencies deemed medically necessary for you or your dependent family member. Emergency Ground Ambulance Coverage1MASA MTS covers out-of-pocket expenses associated with emergency ground transportation to a medical facility for serious medical emergencies deemed medically necessary for you or your dependent family member. Hospital to Hospital Ambulance Coverage1MASA MTS covers out-of-pocket expenses that you or a dependent family member may incur for hospital transfers, due to a serious emergency, to the nearest and most appropriate medical facility when the current medical facility cannot provide the required level of specialized care by air ambulance to include medically equipped helicopter or fi xed-wing aircraft. Repatriation to Hospital Near Home Coverage1MASA MTS provides services and covers out-of-pocket expenses for the coordination of a Member’s non-emergency transportation by a medically equipped, air or ground ambulance in the event of hospitalization more than one hundred (100) miles from the Member’s home if the treating physician and MASA MTS’ Medical Director says it’s medically appropriate and possible to transfer the Member to a hospital nearer to home for continued care and recuperation. A MASA MTS Membership provides the ultimate peace of mind at an aff ordable rate for emergency ground andair transportation assistance expenses within the continental United States, Alaska, Hawaii, and while travelingin Canada, regardless of whether the provider is in or out of your group healthcare benefi ts network. After thegroup health plan pays its portion, MASA works with providers to make certain our Members have no out-of-pocketexpenses~ for emergency ambulance transportation assistance and other related services.MASAEP_CB_FLR_14_032422are sent to the emergency room through ground or air ambulance every year*.Insurance companies may not may not cover all air and ground ambulance expenses which can result in max in-network out-of-pocket** costs of:DID YOU KNOW?MILLIONPEOPLE25$8,700 Individual $17,400 FamilyGround ambulance out-of-network out-of-network transportation costs may be even transportation costs may be even higher than in-networkhigher than in-network since the No Surprises Act does not apply to ground ambulance at this time.$14/MONTHStephanietexasfinancialcenter.com409-224-2012

1250 S. Pine Island Rd., Suite 500,Plantation, FL 33324800-643-9023 I www.masamts.comThe information provided in this product information sheet is for informational purposes only. The benefi ts listed and the descriptions thereof do not represent the full terms and conditions applicable for usage and may only be off ered in some memberships. Premiums and benefi ts vary depending on the benefi ts selected. Commercial air and Worldwide coverage are not available in all territories. For a complete list of benefi ts, premiums, and full terms, conditions, and restrictions, please refer to the applicable member services agreement for your territory. MASA MTS products and services are not available in AK, NY, WA, ND, and NJ. MASA MTS utilizes third-party transportation service providers for all transportation services. MASA Global, MASA MTS and MASA TRS are registered service marks of MASA Holdings, Inc., a Delaware corporation. Void where prohibited by law.~If a member has a high deductible health plan that is compatible with a health savings account, benefi ts will become available under the MASA membership for expenses incurred for medical care (as defi ned under Internal Revenue Code (“IRC”) section 213 (d)) once a member satisfi es the applicable statutory minimum deductible under IRC section 223(c) for high-deductible health plan coverage that is compatible with a health savings account. COVERAGE TERRITORIES:1. All coverage provided by this membership is limited to the continental United States, Alaska, Hawaii, and Canada, and must originate and conclude therein.SOURCES:*ACEP NOW 2014** Patient Protection and Aff ordable Care Act; HHS Notice of Benefi t and Payment Parameters for 2022 and Pharmacy Benefi t Manager Standards. May 5, 2021.MASAEP_CB_FLR_14_032422

Unum | Long Term Disability Insurance 911114EN-1978 FOR EMPLOYEES (3-22) How does it work?This coverage provides a monthly benefit if you have a covered illness or injury and you can’t work for a few months — or even longer.You’re generally considered disabled if you’re unable to do important parts of your job — and your income suffers as a result. Why is this coverage so valuable?You can use the money however you choose. It can help you pay for your rent or mortgage, groceries, out-of-pocket medical expenses and more.Long Term Disability InsuranceConsider your expensesUtilities $Housing $Groceries $Transportation $Child care/Elder care $Medical/Personal care $Education $Insurance $Long Term Disability Insurance can replace part of your income if a disability keeps you out of work for a long period of timeWhat else is included?Survivor Benefit If you die while you’ve been disabled and receiving benefits for at least 180 days, your family could get a benefit equal to 3 months of your gross disability payment.Waiver of premiumIf you’re disabled and receiving benefit payments, Unum waives your cost until you return to work.Work-life balance Employee Assistance Program Get access to professional help for a range of personal and work-related issues, including counselor referrals, financial planning and legal support.Worldwide emergency travel assistance One phone call gets you and your family immediate help anywhere in the world, as long as you’re traveling 100 or more miles from home. However, a spouse traveling on business for his or her employer is not covered.

Unum | Long Term Disability Insurance 911114EN-1978 FOR EMPLOYEES (3-22) Billed amount may vary slightly. Your rate is based on your age and will increase as you move to the next age band. If you didn’t get coverage when you were first eligible, you’ll have to answer health questions now. If you‘re newly eligible, you may not have to answer health questions. If you already have coverage, you can increase it up to the maximum available. You may have to answer health questions. New coverage may be subject to pre-existing condition limitations.Elimination period (EP)Your elimination period is 90 days. This is the number of days that must pass after a covered accident or illness before you can begin to receive benefits.Benefit duration (BD)This is the maximum length of time you can receive benefits while you’re disabled. You can receive benefits up to the Social Security (SS) normal retirement age.How much coverage can I get?You*You are eligible for coverage if you are an active employee in the United States working a minimum of 30 hours per week. Cover 60% of your monthly income, up to a maximum payment of $10,000. The monthly benefit may be reduced or offset by other sources of income. *See the Legal Disclosures for more information.This plan does not cover pre-existing conditions. See the disclosure section to learn more.Calculate your cost • Use $200,000 if your annual earnings exceed this amount. This is the maximum coverage amount offered in this plan. • Multiply by your rate.Use the rate table to find the rate based on your age.(Choose the age you will be when your coverage becomes effective on 11/01/2023.)Age Rates15-24$0.12025-29$0.16030-34$0.29035-39$0.47040-44$0.80045-49$1.13050-54$1.51055-59$1.83060-64$1.77065-69$1.29070+$1.030Disability worksheet1Enter your annual earnings and calculate your maximum monthly benefit available.$________ ÷ 12 = $_______ x 60% = $__________Your annual earningsYour monthly earnings(Max % of income covered) Max monthly benefit available 2Calculate your cost per paycheck $_______ ÷ 100 = $_______ x $_____ = $_______ ÷ 12 = $__________Your annual earningsRate Number of paychecks per yearTotal cost per paycheck

Unum | Long Term Disability Insurance 911114EN-1978 FOR EMPLOYEES (3-22) Exclusions and limitationsActive employeeYou are considered in active employment, if on the day you apply for coverage, you are being paid regularly by your employer for the required minimum hours each week and you are performing the material and substantial duties of your regular occupation.Delayed effective date of coverageInsurance coverage will be delayed if you are not an active employee because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.Benefit duration (BD)The duration of your benefit payments is based on your age when your disability occurs. Your Long Term Disability benefits are payable while you continue to meet the definition of disability. Please refer to your plan document for the duration of benefits under this policy.Definition of disabilityYou are considered disabled when Unum determines that:• You are limited from performing the material and substantial duties of your regular occupation due to sickness or injury; and• You have a 20% or more loss of indexed monthly earnings due to the same sickness or injuryAfter 24 months, you are considered disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.You must be under the regular care of a physician in order to be considered disabled.The loss of a professional or occupational license or certification does not, in itself, constitute disability.“Substantial and material acts” means the important tasks, functions and operations that are generally required by employers from those engaged in your usual occupation and that cannot be reasonably omitted or modified.Unless the policy specifies otherwise, as part of the disability claims evaluation process, Unum will evaluate your occupation based on how it is normally performed in the national economy, not how work is performed for a specific employer, at a specific location or in a specific region.Pre-existing conditionsYou have a pre-existing condition if:• You received medical treatment, consultation, care or services including diagnostic measures for the condition, or took prescribed drugs or medicines for it in the 3 months just prior to your effective date of coverage; and• The disability begins in the first 12 months after your effective date of coverage.Deductible sources of incomeYour disability benefit may be reduced by deductible sources of income and any earnings you have while you are disabled, including such items as group disability benefits or other amounts you receive or are entitled to receive:• Workers’ compensation or similar occupational benefit laws, including a temporary disability benefit under a workers’ compensation law• State compulsory benefit laws• Automobile liability insurance policy• No fault motor vehicle plan• Third-party settlements• Other group insurance plans• A group plan sponsored by your employer• Governmental retirement system• Salary continuation or sick leave plans, if applicable• Retirement payments• Social Security or similar governmental programsExclusions and limitationsBenefits will not be paid for disabilities caused by, contributed to by, or resulting from:• Intentionally self-inflicted injuries;• Active participation in a riot;• War, declared or undeclared or any act of war;• Commission of a crime for which you have been convicted;• Loss of professional license, occupational license or certification; or• Pre-existing conditions (See the disclosure section to learn more).The loss of a professional or occupational license does not, in itself, constitute disability.Unum will not pay a benefit for any period of disability during which you are incarcerated.Termination of coverageYour coverage under the policy ends on the earliest of the following:• The date the policy or plan is cancelled• The date you no longer are in an eligible group• The date your eligible group is no longer covered• The last day of the period for which you made any required contributions• The last day you are in active employment except as provided under the covered layoff or leave of absence provision.Unum will provide coverage for a payable claim that occurs while you are covered under the policy or plan.Unum’s LTD contracts standardly include a provision called the Social Security Claimant Advocacy Program. With this feature, claimants can receive expert advice and assistance from us regarding their Social Security Disability claim during the application and appeal process. Social Security advocacy services are provided by GENEX Services, LLC or Brown & Brown Absence Services Group. Referral to one of our advocacy partners is determined by Unum.Worldwide emergency travel assistance services are provided by Assist America, Inc. Work-life balance employee assistance program services are provided by HealthAdvocate. Services are available with select Unum insurance offerings. Terms and availability of service are subject to change and prior notification requirements. Service providers do not provide legal advice; please consult your attorney for guidance. Services are not valid after coverage terminates. Please contact your Unum representative for details.This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form C.FP-1 et al. or contact your Unum representative.Underwritten by:Unum Life Insurance Company of America, Portland, Maine© 2022 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

Voluntary Benefits Colomal Life. ■ ■ ■MBg■ w■ ■ To make su you get the covege you need, schedule your 1-to-1 benets counseling session today.

Group Accident for TX - discounted ratesApplicable to policy forms GACC1.0-P & GACC1.0-Cl Plan 2 - On/off job ISSUE AGE17-99NAMED INSURED$2.78EMPLOYEE & SPOUSE$4.55ONE-PARENT FAMILY$5.27TWO-PARENT FAMILY$7.06l Plan 3 - On/off job ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY17-99 $5.47 $8.95 $9.87 $13.36Individual Disability - ISTD3000 for TX AAA Risk ClassApplicable to policy form Individual DisabilitylOff Job Accident & Off Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,400* $2,400* $4,000* $6,500**monthly benefit amount7 days Accident/7 days Sickness 17-49 $3.96 $7.92 $13.57 $22.62 N/A50-64 $4.56 $9.11 $15.62 $26.03 N/A65-74 $5.52 $11.05 $18.94 $31.57 N/A14 days Accident/14 days Sickness 17-49 $2.67 $5.33 $9.14 $15.23 $24.7550-64 $2.97 $5.94$10.19 $16.98 $27.6065-74 $3.81 $7.62 $13.07 $21.78 $35.406 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,400* $2,400* $4,000* $6,500**monthly benefit amount7 days Accident/7 days Sickness 17-49 $5.01 $10.02 $17.17 $28.62 N/A50-64 $6.54 $13.08 $22.43 $37.38 N/A65-74 $8.51 $17.03 $29.19 $48.65 N/A14 days Accident/14 days Sickness 17-49 $3.46 $6.91 $11.85 $19.75 $32.1050-64 $4.36 $8.72$14.95 $24.92 $40.5065-74 $5.82 $11.63 $19.94 $33.23 $54.0030 days Accident/30 days Sickness 17-49 $2.18 $4.36 $7.48 $12.46 $20.2550-64 $3.34 $6.69$11.46 $19.11 $31.0565-74 $4.26 $8.53 $14.62 $24.37 $39.60Underwritten by Colonial Life & Accident Insurance CompanyRates Per Weekly Pay PeriodIndividual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$1500 Hospital Confinement Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $4.15 $7.90 $5.65 $9.4050-59 $5.83 $11.07 $7.33 $12.5760-64 $7.98 $15.16 $9.48 $16.6665-75 $10.64 $20.20 $12.14 $21.70

Underwritten by Colonial Life & Accident Insurance CompanyIndividual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$2500 Hospital Confinement Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $7.48 $14.18 $10.48 $17.1850-59 $10.37 $19.73 $13.37 $22.7360-64 $14.18 $26.93 $17.18 $29.9365-75 $18.90 $35.88 $21.90 $38.88Group Critical Care Applicable to policy forms GCC1.0-P & GCC1.0-Cl Full CI Benefit, with Subsequent Diagnosis, $50 Health Screening Benefit, HSA Compliant Non-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 16-29 $1.20 $1.80 $1.25 $1.8730-39 $1.62 $2.45 $1.69 $2.5240-49 $2.63 $3.99 $2.70 $4.0450-59 $4.29 $6.69 $4.36 $6.7460-74 $6.67 $10.34 $6.72 $10.39Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 16-29 $1.71 $2.59 $1.78 $2.6330-39 $2.59 $3.88 $2.63 $3.9240-49 $4.62 $6.95 $4.66 $6.9950-59 $7.94 $12.35 $8.01 $12.4260-74 $12.67 $19.64 $12.74 $19.69Group Critical Care with Cancer Diagnosis - NEWl Full CI Benefit, with Subsequent Diagnosis, Diagnosis of Cancer Benefit, $100 Health Screening Benefit, HSA Compliant Non-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 16-29 $2.36 $3.64 $2.50 $3.7730-39 $3.24 $4.93 $3.35 $5.0440-49 $5.13 $7.79 $5.27 $7.9350-59 $8.25 $12.66 $8.38 $12.8060-74 $12.51 $19.17 $12.68 $19.31Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 16-29 $2.89 $4.42 $3.01 $4.5430-39 $4.18 $6.34 $4.30 $6.4540-49 $7.32 $11.07 $7.46 $11.2150-59 $12.40 $19.07 $12.54 $19.2160-74 $19.67 $30.17 $19.83 $30.34GCC with Cancer can not be combined with the Individual Cancer Assist

Whole Life Plus (IWL5000) for TXlAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $2.12 $4.25 $6.37 $8.49 $10.6235 $2.89 $5.78 $8.67 $11.55 $14.4445 $4.59 $9.18 $13.77 $18.35 $22.9455 $7.49 $14.98 $22.47 $29.95 $37.4465 $13.33 $26.65 $39.98 $53.31 $66.63Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $3.71 $7.41 $11.12 $14.83 $18.5435 $4.51 $9.02 $13.53 $18.05 $22.5645 $6.72 $13.43 $20.15 $26.87 $33.5955 $11.32 $22.65 $33.97 $45.29 $56.6165 $19.36 $38.73 $58.09 $77.46 $96.82Underwritten by Colonial Life & Accident Insurance CompanylDependent Child Base Plan Paid-Up at Age 70ISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,0002 $1.42 $2.84 $4.26 $5.68 $7.105 $1.45 $2.90 $4.35 $5.80 $7.2510 $1.68 $3.35 $5.03 $6.71 $8.3815 $2.05 $4.09 $6.14 $8.19 $10.2317 $2.19 $4.37 $6.56 $8.75 $10.93Jamie Pope | jamie@colonialtx.com | (409) 782-1910Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $25,000 $50,000 $75,000 $100,000 $150,00025 $2.48 $2.43 $3.18 $3.94 $5.4535 $3.05 $2.67 $3.54 $4.42 $6.1745 $4.20 $5.03 $7.08 $9.13 $13.2455 $9.03 $10.69 $15.57 $20.46 $30.2365 $14.20 $27.48 $40.76 $54.03 $80.59Tobacco RatesISSUE AGE $25,000 $50,000 $75,000 $100,000 $150,00025 $4.66 $4.20 $5.84 $7.48 $10.7635 $5.37 $4.76 $6.68 $8.59 $12.4345 $7.78 $10.49 $15.27 $20.05 $29.6255 $18.19 $24.47 $36.24 $48.02 $71.5665 $23.92 $46.93 $69.93 $92.93 $138.94

Talk with your Colonial Life benefits counselor to learn more. You can't predict an illness, but you can be prepared With this covege: ■ ■ ■  guanteed-sue covege is available, u won't have to answer health questionJ L For mo details, talk wi your Colonial Life bene counselo J ■Available with or without Cancer Diagnosis Benefit

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationWondrTMCoach-Led Digital Program for Wellbeing Management and Health Advocacy SolutionsFunding Types: Fully Insured (FI), Administrative Services Only (ASO) | Minimum Premium Program (MPP) | Blue Balanced Funded (BF) Segments: Large Group (ASO, Custom Fully Insured, Standard Fully Insured) | Small Group | Mid-MarketNetworks: Preferred Provider Organization (PPO) | Health Maintenance Organization (HMO)

759577.0622As part of the Wellbeing Management and Health Advocacy Solutions packaging, Blue Cross and Blue Shield of Texas (BCBSTX) oers a valuable coaching option, with no extra charge to members. You can now provide to your employees digital educational opportunities for metabolic syndrome1 reversal with Wondr. This supplemental remote program can be done in the comfort of the member’s own home.Wondr – Metabolic Syndrome Reversal ProgramWondr is a behavioral counseling program for metabolic syndrome reversal and weight management. Features include:• Twelve weeks of counseling (personalized for skill building); twelve weeks (customized for skill reinforcement); 28 weeks (customized for skill maintenance).• Weekly self-paced, informative, online video sessions (including mobile app for on-the-go access, skill reinforcement and habit formation).• Interactions with health coaches and online community for social support.• Customized communication materials.• Employer reporting available for enrollment, participation and weight loss. EligibilityTo support the program, Wondr Health™ will receive a weekly le of eligible members. Because metabolic conditions are not always identiable through a claims screen, BCBSTX provides Wondr Health with the entire membership eligibility. 1. NationalInstitutesofHealthguidelinesdenemetabolicsyndromeashavingatleastthreeofthefollowingvetraits(ortakingmedicationtocontrolthem):largewaistcircumference;hightriglyceridelevel;reducedHDL(good)cholesterol;increasedbloodpressure;elevatedfastingbloodsugar.WondrHealthisanindependentcompanythathascontractedwithBlueCrossandBlueShieldofTexastoprovideametabolicsyndromereductionprogramformemberswithcoveragethroughBCBSTX.BCBSTXmakesnoendorsement,representationsorwarrantiesregardingthird-partyvendorsandtheproductsandservicesoeredbythem.On enrollment, member completes a brief health assessment to determine full eligibility for the program.

HINGEHEALTH.COM/BCBSTXTo learn more and apply, visit:Conquer back or joint pain without drugs or surgeryAs a member of Blue Cross and Blue Shield of Texas, you get access to a new innovative digital program for chronic back, knee, hip, shoulder, and neck pain at no cost to you. This program, provided by Hinge Health, includes:- A tablet and wearable sensors- Unlimited 1-on-1 health coaching- Personalized exercise therapyOver 80,000 participants have enrolled in their programs so far, and cut their pain by over 60%!*Questions? Call the number on the back of your member ID card.Hinge Health is an independent company that provides an online musculoskeletal program for Blue Cross and Blue Shield of Texas. Hinge Health is solely responsible for the products and services that it provides.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association*Source: Hinge Health 2017-2019 Outcomes Analysis755006.1120

756318.0621Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationFor Standard Plans 2-150 MembersBlue Cross and Blue Shield of Texas oers an exciting coaching option, with no extra charge to members. Your employees could benet from digital educational opportunities for reducing the risk of type 2 diabetes and heart disease with Omada. This supplemental remote care can be done in the comfort of the member’s own home.Omada – Diabetes Prevention SolutionOmada, a behavioral medicine program, inspires and enables people who are at risk for chronic conditions like type 2 diabetes and heart disease to change the habits that put them most at risk. The program combines data-powered human coaching, connected devices and a tailored curriculum to eectively improve overall health and reduce the risk of diabetes and cardiovascular disease. Features include:• Professional health coach to provide ongoing digital support and guidance• Weekly lessons to empower healthier habits around food, activity, sleep and stress • Cellular-connected scale that automatically uploads readings to a member’s account • Small online group for real-time motivation from a community of peers• Simple employer reporting for enrollment, engagement and outcomes EligibilityTo support the program, Omada will receive a weekly le of eligible members. Because all risks for diabetes and cardiovascular disease are not identiable through a claims screen, BCBSTX provides Omada with the entire membership eligibility. On enrollment, members complete a brief health assessment to determine full eligibility for the program. In addition, for groups that also implement Omada’s Hypertension program, BCBSTX screens prior claims to identify members with hypertension (HTN) and identies those members within Omada’s eligibility le. Omada will only outreach for HTN program to identied members. Members without prior claims can self-identify as having HTN when they enroll in that program.Omada is an independent company that provides a Diabetes Prevention Solution and Hypertension programs for Blue Cross and Blue Shield of Texas. Omada is solely responsible for the products and services that it provides. Blue Cross and Blue Shield of Texas makes no endorsement, representations or warranties regarding third-party vendors and the products and services oered by them.Omada®Coach-Led Digital Program for Diabetes Prevention

Blue Cross and Blue Shield of Texas (BCBSTX) is providing coaching for hypertension through Livongo, at no extra cost to members.Livongo® for HypertensionA Coach-Led Digital Program for Members with Hypertension For Standard Plans 2-150

Livongo is an independent company that provides chronic condition management solutions for Blue Cross and Blue Shield of Texas. Livongo is solely responsible for the products and services that it provides. BCBSTX makes no endorsement, representations or warranties regarding third-party vendors and the products and services oered by them. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationHypertension Management SolutionLivongo for Hypertension combines personalized health insights with clinical expertise to modify behavior and drive change. Members are motivated every step of the way, so they can reach their blood pressure goals and live healthier lives through:757384.0921To support the program, Livongo will receive a weekly le of eligible members. BCBSTX screens prior claims to identify members with diabetes and/or hypertension and provides only those members to Livongo. Members without prior claims can self-identify as having a covered condition when they enroll in the Livongo program and will be subsequently included in eligibility les.• Individualized, live 1:1 coaching, as needed.• 24/7 coaching on nutrition and weight, stress and blood pressure management• A cellular-connected monitor that enables uploading blood pressure measurements directly to the Livongo cloud platform, without needing to connect to a Wi-Fi network• Notications for high blood pressure readings and reminders to check blood pressure• Tools and resources to help monitor blood pressure, better manage nutrition and understand blood pressure reading trends• A mobile app to easily track progress and receive personalized coaching, weight management advice and alerts and daily reminders to check blood pressure

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2024 – 06/30/2025 : MTBCP008H Blue Choice PPOSM HSA 008H Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7The 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, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-800-521-2227. 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 QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $6,000 Individual/$12,000 FamilyOut-of-Network: $12,000 Individual/$24,000 FamilyGenerally, 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. In-Network preventive care services 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 www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $6,000 Individual/$12,000 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe 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, balance billing charges, and health care 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/go/bcppo or call 1-800-810-2583 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.SLMR Pharmacy No 0000012 0891C :doireP egarevo 1 4202/10/2 -1 5202/03/1C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illnessNo Charge after deductible30% coinsuranceVirtual visits are available. See your benefit booklet* for details.Specialist visitNo Charge after deductible30% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not apply30% coinsuranceYou 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.Diagnostic test (x-ray, blood work)No Charge after deductible30% coinsuranceIf you have a testImaging (CT/PET scans, MRIs)No Charge after deductible30% coinsuranceInpatient: Certain services may require preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.Generic drugs (Preferred)No Charge after deductibleRetail - No Charge after deductible plus 50% additional chargeGeneric drugs (Non-preferred)No Charge after deductibleRetail - No Charge after deductible plus 50% additional chargeBrand drugs (Preferred)No Charge after deductibleRetail - No Charge after deductible plus 50% additional chargeBrand drugs (Non-preferred)No Charge after deductibleRetail - No Charge after deductible plus 50% additional charge Specialty drugs (Preferred)No Charge after deductibleNo Charge after deductible plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsSpecialty drugs (Non-preferred)No Charge after deductibleNo Charge after deductible plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional charge will not apply to any deductible or out-of-pocket amounts.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.0000012 0891

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 3 of 7 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationFacility fee (e.g., ambulatory surgery center)No Charge after deductible30% coinsuranceIf you have outpatient surgeryPhysician/surgeon feesNo Charge after deductible30% coinsuranceCertain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.Emergency room careNo Charge after deductibleNo Charge after deductibleNoneEmergency medical transportationNo Charge after deductibleNo Charge after deductibleIf you need immediate medical attentionUrgent careNo Charge after deductible30% coinsuranceNoneFacility fee (e.g., hospital room)No Charge after deductible30% coinsuranceIf you have a hospital stayPhysician/surgeon feesNo Charge after deductible30% coinsurancePreauthorization required. Preauthorization penalty: $250 out-of-network. See your benefit booklet* for details.Outpatient servicesNo Charge after deductible30% coinsuranceCertain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.If you need mental health, behavioral health, or substance abuse servicesInpatient servicesNo Charge after deductible30% coinsurancePreauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.Office visitsNo Charge after deductible30% coinsuranceChildbirth/delivery professional servicesNo Charge after deductible30% coinsuranceIf you are pregnantChildbirth/delivery facility servicesNo Charge after deductible30% coinsuranceCost sharing does not apply to preventive services. Depending on the type of services, a deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).If you need help recovering or have other special health Home health careNo Charge after deductible30% coinsurance60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in 0000012 0891

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 7 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important Informationbenefits not to exceed $500. See your benefit booklet* for details.Rehabilitation servicesNo Charge after deductible30% coinsuranceHabilitation servicesNo Charge after deductible30% coinsuranceFor Outpatient, limited to combined 35 visits per year, including Chiropractic.Skilled nursing careNo Charge after deductible30% coinsurance25-day maximum per calendar year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. Durable medical equipmentNo Charge after deductible30% coinsuranceNoneneedsHospice servicesNo Charge after deductible30% coinsuranceInpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.Outpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Children’s eye examNot CoveredNot CoveredNoneChildren’s glassesNot CoveredNot CoveredIf your child needs dental or eye careChildren’s dental check-upNot CoveredNot CoveredNone0000012 0891

Page 5 of 7Excluded 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.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult and Child) Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (Child) Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care (Outpatient - Max.35 visits/year combined with habilitation and rehabilitation services) Hearing aids (Limited to one hearing aid per ear every 36 months) Infertility treatment (Invitro and artificial insemination are not covered unless shown in your plan document) Routine eye care (Adult) Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)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: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. 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: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. 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.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.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, 0000012 0891

Page 6 of 7CHIP, 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 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.0000012 0891

Page 7 of 7About 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. The plan’s overall deductible $6,000 Specialist $0 Hospital (facility) $0 Other $0This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost$12,700In this example, Peg would pay:Cost SharingDeductibles$6,000Copayments$0Coinsurance$0What isn’t coveredLimits or exclusions$60The total Peg would pay is$6,060 The plan’s overall deductible $6,000 Specialist $0 Hospital (facility) $0 Other $0This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter)Total Example Cost$5,600In this example, Joe would pay:Cost SharingDeductibles$2,300Copayments$300Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$2,620 The plan’s overall deductible $6,000 Specialist $0 Hospital (facility) $0 Other $0This EXAMPLE event includes services like:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example Cost$2,800In this example, Mia would pay:Cost SharingDeductibles$2,800Copayments$0Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,800The 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)Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)Mia’s Simple Fracture(in-network emergency room visit and follow up care)0000012 0891

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2024 – 06/30/2025 : MTBEE031 Blue EssentialsSM 031 Coverage for: Individual/Family | Plan Type: HMOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7The 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, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-877-299-2377. 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 QuestionsAnswersWhy This Matters:What is the overall deductible?$3,500 Individual/$10,500 FamilyGenerally, 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. Network office visits, prescription drugs, preventive care services, and Urgent care services 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 www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?Yes. ER $500. 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?$7,900 Individual/$15,800 FamilyThe 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, balance billing charges, and health care 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/go/be or call 1-877-299-2377 for a list of Participating 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?Yes.This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.SLMR Pharmacy No 0000043 0891C :doireP egarevo 1 4202/10/2 -1 5202/03/1C :rof egarevo I ylimaF + laudividn | P :epyT nal H OM

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedParticipating Provider (You will pay the least)Non-Participating Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$35 copayment/visit; deductible does not applyNot CoveredVirtual visits are available. See your benefit booklet* for details.Specialist visit$70 copayment/visit; deductible does not applyNot CoveredReferral required.If you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not applyNot CoveredYou 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.Diagnostic test (x-ray, blood work)20% coinsuranceNot CoveredIf you have a testImaging (CT/PET scans, MRIs)20% coinsuranceNot CoveredNoneGeneric drugs (Preferred)Retail - Preferred - No ChargeNon-Preferred - $10 copayment/prescriptionMail - No Charge;deductible does not applyNot CoveredGeneric drugs (Non-preferred)Retail - Preferred – $10 copayment/prescriptionNon-Preferred – $20 copayment/prescriptionMail – $30 copayment/prescription; deductible does not applyNot CoveredIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsBrand drugs (Preferred)Retail - Preferred – $50 copayment/prescriptionNon-Preferred - $70 copayment/prescriptionMail - $150 copayment/prescription; deductible does not applyNot CoveredLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.0000043 0891

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 3 of 7 What You Will PayCommon Medical EventServices You May NeedParticipating Provider (You will pay the least)Non-Participating Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Non-preferred)Retail - Preferred - $100 copayment/prescriptionNon-Preferred - $120 copayment/prescriptionMail - $300 copayment/prescription; deductible does not applyNot Covered Specialty drugs (Preferred)$150 copayment/prescription; deductible does not applyNot CoveredSpecialty drugs (Non-preferred)$250 copayment/prescription;deductible does not applyNot CoveredFacility fee (e.g., ambulatory surgery center)20% coinsuranceNot CoveredIf you have outpatient surgeryPhysician/surgeon fees20% coinsuranceNot CoveredFor Outpatient Infusion Therapy, see your benefit booklet* for details.Emergency room care$500 copayment/visit plus 20% coinsurance$500 copayment/visit plus 20% coinsurancePer Occurrence Deductible waived if admitted.Emergency medical transportation20% coinsurance20% coinsuranceIf you need immediate medical attentionUrgent care$75 copayment/visit; deductible does not applyNot CoveredNoneFacility fee (e.g., hospital room)20% coinsuranceNot CoveredIf you have a hospital stayPhysician/surgeon fees20% coinsuranceNot CoveredNoneOutpatient services$35 copayment/office visit; deductible does not apply or 20% coinsurance for other outpatient servicesNot CoveredNoneIf you need mental health, behavioral health, or substance abuse servicesInpatient services20% coinsuranceNot CoveredNone0000043 0891

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 7 What You Will PayCommon Medical EventServices You May NeedParticipating Provider (You will pay the least)Non-Participating Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationOffice visitsPrimary Care: $35 copayment/initial visitSpecialist: $70 copayment/initial visit; deductible does not applyNot CoveredChildbirth/delivery professional services20% coinsuranceNot CoveredIf you are pregnantChildbirth/delivery facility services20% coinsuranceNot CoveredCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to 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).Home health care20% coinsuranceNot CoveredNoneRehabilitation services20% coinsuranceNot CoveredHabilitation services20% coinsuranceNot CoveredNoneSkilled nursing care20% coinsuranceNot Covered60-day maximum per calendar year.Durable medical equipment20% coinsuranceNot CoveredNoneIf you need help recovering or have other special health needsHospice services20% coinsuranceNot CoveredNoneChildren’s eye examPrimary Care: $35 copayment Specialist: $70 copayment; deductible does not applyNot CoveredEye screenings only. Does not include refractions. One visit per year for members ages 17 and younger.Children’s glassesNot CoveredNot CoveredIf your child needs dental or eye careChildren’s dental check-upNot CoveredNot CoveredNone0000043 0891

Page 5 of 7Excluded 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.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture Bariatric surgery Children's dental check-up Children's glasses Cosmetic surgery Dental care (Adult) Long-term care Non-emergency care when traveling outside the U.S. Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care (Preauthorization required) Hearing aids (Limited to one hearing aid per ear every 36 months) Infertility treatment (Invitro not covered) Private-duty nursing (Only when ordered or authorized by the Primary Care Physician) Routine eye care (Adult - One visit every two years for members ages 18 and older) Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)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: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. 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: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. 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.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.0000043 0891

Page 6 of 7Does 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 1-877-299-2377.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-299-2377.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377.To see examples of how this plan might cover costs for a sample medical situation, see the next section.0000043 0891

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2024 – 06/30/2025 : MTBCB031 Blue Choice PPOSM Basic 031 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The 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, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-800-521-2227. 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 QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $3,500 Individual/$10,500 FamilyOut-of-Network: $10,000 Individual/$20,000 FamilyGenerally, 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. Network office visits, prescription drugs, preventive care services, Urgent care services and Hospice services 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 www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $7,900 Individual/$15,800 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe 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, balance billing charges, and health care 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/go/bcppo or call 1-800-810-2583 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.SLMR Pharmacy No 0000008 0890C :doireP egarevo 1 4202/10/2 -1 5202/03/1C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$35 copayment/visit; deductible does not apply50% coinsuranceVirtual visits are available. See your benefit booklet* for details.Specialist visit$70 copayment/visit; deductible does not apply50% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not apply50% coinsuranceYou 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.Diagnostic test (x-ray, blood work)20% coinsurance50% coinsuranceIf you have a testImaging (CT/PET scans, MRIs)20% coinsurance50% coinsuranceInpatient: Certain services may require preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.Generic drugs (Preferred)Retail - Preferred - No ChargeNon-Preferred - $10 copayment/prescriptionMail - No Charge;deductible does not applyRetail - $10 copayment/prescription;deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsGeneric drugs (Non-preferred)Retail - Preferred – $10 copayment/prescriptionNon-Preferred – $20 copayment/prescriptionMail – $30 copayment/prescription; deductible does not applyRetail - $20 copayment/prescription;deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional charge will not apply to any deductible or out-of-pocket amounts.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-0000008 0890

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 3 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Preferred)Retail - Preferred – $50 copayment/prescriptionNon-Preferred - $70 copayment/prescriptionMail - $150 copayment/prescription; deductible does not applyRetail – $70 copayment/prescription;deductible does not apply plus 50% additional chargeBrand drugs (Non-preferred)Retail - Preferred - $100 copayment/prescriptionNon-Preferred - $120 copayment/prescriptionMail - $300 copayment/prescription; deductible does not applyRetail - $120 copayment/prescription;deductible does not apply plus 50% additional charge Specialty drugs (Preferred)$150 copayment/prescription; deductible does not apply$150 copayment/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Non-preferred)$250 copayment/prescription;deductible does not apply$250 copayment/prescription;deductible does not apply plus 50% additional chargeday supply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)20% coinsurance50% coinsuranceIf you have outpatient surgeryPhysician/surgeon fees20% coinsurance50% coinsuranceCertain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.Emergency room care$500 copayment/visit plus 20% coinsurance$500 copayment/visit plus 20% coinsuranceCopayment waived if admitted.Emergency medical transportation20% coinsurance20% coinsuranceIf you need immediate medical attentionUrgent care$75 copayment/visit; deductible does not apply50% coinsuranceNoneIf you have a hospital Facility fee (e.g., hospital 20% coinsurance50% coinsurancePreauthorization required. Preauthorization 0000008 0890

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important Informationroom)stayPhysician/surgeon fees20% coinsurance50% coinsurancepenalty: $250 out-of-network. See your benefit booklet* for details.Outpatient services$35 copayment/office visit; deductible does not apply or 20% coinsurance for other outpatient services50% coinsuranceCertain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services20% coinsurance50% coinsurancePreauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.Office visitsPrimary Care: $35 copayment/initial visitSpecialist: $70 copayment/initial visit; deductible does not apply50% coinsuranceChildbirth/delivery professional services20% coinsurance50% coinsuranceIf you are pregnantChildbirth/delivery facility services20% coinsurance50% coinsuranceCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to 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).Home health care20% coinsurance50% coinsurance60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Rehabilitation services20% coinsurance50% coinsuranceHabilitation services20% coinsurance50% coinsuranceFor Outpatient, limited to combined 35 visits per year, including Chiropractic.Skilled nursing care20% coinsurance50% coinsurance25-day maximum per calendar year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. If you need help recovering or have other special health needsDurable medical equipment20% coinsurance50% coinsuranceNone0000008 0890

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 5 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationHospice servicesNo Charge; deductible does not apply50% coinsuranceInpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.Outpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Children’s eye examNot CoveredNot CoveredNoneChildren’s glassesNot CoveredNot CoveredIf your child needs dental or eye careChildren’s dental check-upNot CoveredNot CoveredNone0000008 0890

Page 6 of 8Excluded 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.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult and Child) Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (Child) Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care (Outpatient - Max.35 visits/year combined with habilitation and rehabilitation services) Hearing aids (Limited to one hearing aid per ear every 36 months) Infertility treatment (Invitro and artificial insemination are not covered unless shown in your plan document) Routine eye care (Adult) Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)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: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. 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: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. 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.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.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, 0000008 0890

Page 7 of 8CHIP, 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 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.0000008 0890

Page 8 of 8About 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. The plan’s overall deductible $3,500 Specialist copayment $70 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost$12,700In this example, Peg would pay:Cost SharingDeductibles$3,500Copayments$40Coinsurance$1,800What isn’t coveredLimits or exclusions$60The total Peg would pay is$5,400 The plan’s overall deductible $3,500 Specialist copayment $70 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)Total Example Cost$5,600In this example, Joe would pay:Cost SharingDeductibles$900Copayments$700Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,620 The plan’s overall deductible $3,500 Specialist copayment $70 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)Total Example Cost$2,800In this example, Mia would pay:Cost SharingDeductibles$2,100Copayments$600Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,700The 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)Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)Mia’s Simple Fracture(in-network emergency room visit and follow up care)0000008 0890

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This brochure highlights the main features of Silsbee Ford Inc. and Lake Country Chevrolet’s employee benets program. It does not include all plan rules, details, limitaons, and exclusions. The terms of your benet plans are governed by legal documents, including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents, the plan documents are nal authority. Silsbee Ford Inc. and Lake Country Chevrolet reserve the right to change or disconnue the employee benets plans at any me. Prepared by Texas Financial Center 150 W. Gibson Street Jasper, Texas 75951 Phone: 409.384.4441 Fax: 409.384.7800 stephanie@texasfinancialcenter.com