Custom Commodities Employee Benefit Guide.PUB : simplebooklet.com

C ustom Commodities, Inc is pleased to provide a variety of insurance benefits. You may select the insurance that best fits your needs. You are eligible for benefits if you are a regular, full-time employee working an average of 30 hours per week. Your coverage is effective the first of the month after you have completed 60 days of full-time employment. Enrollment must be completed within 31 days of the date of eligibility. Once your enrollment is completed, no changes will be allowed until the next annual open enrollment period unless you have a Qualifying Life Event or your hours worked per week drop below the minimum. The policy year runs from January 1, 2024 to December 31, 2024; however, the company reserves the right to make changes to the policies at anytime as well as the right to require appropriate documentation to prove your dependent relationship status including marriage, birth, tax returns and other legal documents. You may also enroll eligible dependents for benefits coverage. The cost to you for dependent coverage will vary depending on the number of dependents you enroll in the plan and the particular plans you choose. When covering dependents, you must select the same plans for your dependents as you select for yourself. Eligible Dependents include:  Your legal spouse Children under the age of 26, regardless ofstudent status, dependency or marital status* Natural Child* Legally Adopted Child* Step child* Child for who you or your spouse are the legalguardian as long as you have the sole legalright and obligation to provide support andmedical care Children who are fully dependent on you forsupport due to a mental or physical disability andwho are indicated as such on your federal taxreturn; may continue coverage past age 26 A child of a child who is dependent for federalincome tax purposes at the time application forcoverage of the child is madeQualifying Life Events Once you elect your benefit options, they will remain in effect for the entire plan year until the following Open Enrollment. You may only change coverage during the plan year if you have a Qualifying Life Event, and you must do so within 30 days of the event. You may NOT drop coverage due to financial hardship or dissatisfaction with the plan. Qualifying Life Events include:  Marriage, divorce, legal separation or annulment Birth, adoption or placement for adoption of aneligible child Death of a spouse or child Change in your spouse’s employment that affectsbenefits eligibility Change in your child’s eligibility for benefits(reaching the age limit) Change in residence that affects your eligibilityfor coverage Significant change in coverage or cost in your,your spouse’s or child’s benefit plans FMLA Leave, COBRA event, Court Judgment orDecree  Becoming eligible for Medicare or Medicaid Receiving a Qualified Medical Child SupportOrderIf you have a Qualifying Life Event and want to request a mid-year change, you must notify Human Resources and complete your election changes within 30 days following the event. Be prepared to provide documentation to support the Qualifying Life Event. Eligibility5

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C ustom Commodities is offering 2 medical plans, provided by UMR. All plans are PPO plans. Preferred Provider Organization (PPO) PPO plans offers the freedom to see any provider when you need care. When you use providers within the UMR network, you will receive benefits at the discounted network cost. If you use out-of-network providers, you may pay more for services. Health Saving Account (HSA) If you enroll in the EPO High Deductible Health Plan (HDHP), you are eligible to open a Health Savings Account (HSA). An HSA is a personal saving account which you can use to pay qualified out-of-pocket medical expenses with pretax dollars. You own and control the money in your health savings account. The money in your account (including interest and investment earnings) grows tax-free, and as long as the funds are used to pay for qualified medical expenses, they are spent tax-free. HSA Eligibility You are eligible to open & contribute to an HSA if you: Are not covered by other non-HDHPs: such asyour spouse’s health plan, Health Care FlexibleSpending Account or Health ReimbursementArrangement Are not eligible to be claimed as a dependent onsomeone else’s tax return Are not enrolled in Medicare or TRICARE Have not received Veterans AdministrationbenefitsYou can use the money in your HSA to pay for qualified medical expenses now or in the future. Your HSA can be used for your expense and those of your spouse and dependents, even if they are not covered by the HDHP. Contributions Your contributions to your HSA may not exceed the amount established by the IRS. The annual contribution maximum, including the company’s contribution, is based on the coverage option you elect.  Individual: $4,150 Family (filing jointly): $8,300Employees age 55 and older are allowed to make an additional annual “catch-up” contribution of up to $1,000. Opening an HSA When you enroll in the UMR HSA plan, you will also need to open a HSA administered by HSA Bank. Once your account is established, you will receive a debit card from HSA Bank for managing your HSA account reimbursements. Funds available for reimbursement are limited to the balance in your HSA. You, NOT the company, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit. Please note: You may open an HSA at any financial institution of your choice. However, payroll deductions are available only for HSAs openend through HSA Bank.Medical Coverage Information 6

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Medical Plan Summary This is only a brief summary of benefits. Please refer to certificate of coverage for your complete plan description. UMR Name of Plan HSA Base Plan Buy Up Plan Available Network Choice Plus Annual Deductible In Network Out of Network In Network Out of Network Individual $6,200 $12,000 $4,000 $10,000 Family $12,400 $24,000 $8,000 $20,000 Out of Pocket Maximum(Includes deductible) Individual $6,200 $24,000 $8,000 $20,000 Family $12,400 $48,000 $16,000 $40,000 Co-insurance 100% 50% 70% 50% Professional Services Physician Office Visit 100% after Deductible Ded + 50% $15; $0 for persons less than age 19 Ded + 50% Specialist Office Visit 100% after Deductible Ded + 50% Designated Net-work: $50 Network: $100 Ded + 50% Preventive Care Covered 100% Ded + 50% Covered 100% Ded + 50% Urgent Care 100% after Deductible Ded + 50% $25 Ded + 50% Virtual Visit - HealthJoy $0 Ded + 50% $0 Ded + 50% Diagnostic Procedures Outpatient Lab, X-Ray, Complex Imaging 100% after Deductible Ded + 50% Ded + 30% Ded + 50% Hospital Care In Patient 100% after Deductible $300 + Ded + 40% Ded + 30% $300 + Ded + 40% Outpatient 100% after Deductible $300 + Ded + 40% Ded + 30% $300 + Ded + 40% Emergency Room $300 copay per visit + Ded + 20% $300 copay per visit + Ded + 20% Pharmacy Tier 1 100% after Deductible $20 Tier 2 100% after Deductible $50 Tier 3 100% after Deductible $85 Tier 4 100% after Deductible $250 Mail Order Mandatory Mail Order on all Maintenance Drugs 100% after Deductible 2.5X Copay for 90 day supply Employee Weekly Payroll Deduction Employer will contribute $20 week into HSA account Employee $22.00 $27.50 Employee + Spouse $125.00 $135.00 Employee + Child(ren) $90.00 $95.00 Family $200.00 $220.00 7

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PLAN YEAR DEDUCTIBLES AND MAXIMUMS IN-NETWORK OUT-NETWORKType AWaived WaivedType B & C DeductibleIndividual$50 $50Family3 times Individual 3 times IndividualAnnual Maximum$1,500 $1,500Orthodontia Lifetime Maximum$1,500 $1,500The same expenses may be used to satisfy both the In-Network and Out-Network deductible.COVERED SERVICES IN-NETWORK OUT-NETWORKType A Services100% 100%· Examinations/Evaluations· Bitewing X-rays· All Other X-Rays· Fluoride Treatments· Cleaning/Prophylaxis· Sealants· Space Maintainers· Brush Biopsy/Cancer Screening· Full Mouth X-rays, Panoramic FilmType B Services80% 80%· Palliative Treatment· Periodontal Maintenance· Fillings· Stainless Steel Crowns· Simple Extractions· Oral Surgery· Endodontics· Surgical Extractions· General Anesthesia or I.V. Sedation· Surgical Periodontics· Non-Surgical PeriodonticsType C Services50% 50%· Full or Partial Removable Dentures· Repair of Full or Partial Removable Dentures· Adjustments, Tissue Conditioning, Rebasing orRelining of Full or Partial Removable Dentures· Bridges· Repair/Recementation of Bridges· Cast Crowns, Inlays, Onlays, Labial Veneers· Repair/Recementation of CastCrowns/Inlays/Onlays/Labial Veneers· ImplantsOrthodontia - All Insured Persons50% 50%· Harmful Habit Appliances1) The plan pays the percentage shown after the deductible is satisfied up to the maximum. Additional information about thebenefits and covered services of this plan will be included in the certificate booklet, which you will receive after enrolling forthis coverage. Please contact your employer or benefits administrator if you have questions prior to enrolling.2) The plan provides the same coverage levels for both In-Network and Out-Network services. However, because In-Networkproviders offer their services at predetermined fees, out-of-pocket expenses may be lower for plan members when receivingcovered services from an In-Network provider.3) The Maximum Allowance for Out-Network Services is based on the 90th Percentile as determined by Mutual of Omaha.Charges that exceed the Maximum Allowance (as defined in the certificate booklet) for any covered dental service are notconsidered.ANNUAL OPEN ENROLLMENT PERIODThe plan has an Annual Open Enrollment Period. Any Benefit Waiting Periods or Late Entrant Waiting Perods will bewaived during this time period.10

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LIMITATIONSInformation about the limitations and exclusions for this plan will be included in the certificate booklet, which you willreceive after enrolling for this coverage. Please contact your employer or Benefits Administrator if you have anyquestions prior to enrolling.· Exams – 2 services in a 12 month period.· Bitewing X-rays – 4 films in a 12 month period.· Full Mouth X-rays or Panoramic Film – 1 in any 36 month period.· Fluoride – For dependent children up to age 14. 2 services in a 12 month period.· Harmful Habit Appliance – For dependent children up to age 14.· Cleaning – 2 services in a 12 month period. An additional 2 services if required for documented medical reasons.· Sealants – For dependent children up to age 14; one per permanent bicuspid or molar tooth in any 36 month period.· Brush Biopsy/Cancer Screen – 2 services in a 12 month period.· Space Maintainers – For dependent children up to age 14, includes recementations and removal.· Fillings – Composite fillings allowed on all teeth. Replacement once in a 12 month period.· Stainless Steel Crowns – For dependent children up to age 16; one per tooth per lifetime. Not for temporaryrestoration.· Periodontal Maintenance – 2 services in a 12 month period in addition to routine cleaning. Following activeperiodontal treatment only.· Cast Crowns, Inlays, Onlays, Labial Veneers – Replacement allowed once in 10 years.· Bridges – Replacement allowed once in 10 years.· Dentures – Replacement allowed once in 10 years.· Implants – 1 per tooth per lifetime.· Orthodontia – Includes case workup, all appliances and one set of retainers.SERVICESHearing DiscountProgramThe Hearing Discount Program provides you and your family discounted hearingproducts, including hearing aids and batteries. Call 1-888-534-1747 or visitwww.amplifonusa.com/mutualofomaha to learn more.PREMIUM AMOUNTS AND ENROLLING FOR COVERAGECoverage TierPremium Amount(52 Payroll Deductions Per Year)Employee/Member $6.84Employee/Member + Spouse $13.68Employee/Member + Child(ren) $17.86Employee/Member + Family $27.24To enroll for dental coverage:1) Using the table above, first identify the tier of coverage you wish to enroll for. Options are available that provide coverage foryou (the employee) only, or for you and your family. The amount listed in the Premium Amount column is the cost perpaycheck for each tier of coverage.2) Locate the Voluntary Dental Coverage election section on your enrollment form. Place a √ or an x in the Yes box next to thetier of coverage you wish to enroll for, then insert the Premium Amount for the tier you select into the Premium Amountcolumn (if the premium amount is not already available on the form).3) If you are enrolling for coverage for your dependents, complete the Dependent Information section of the enrollment form.11

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Created for Custom Commodities Inc The VSP Advantage Plan is a basic full-service plan that offers choice, flexibility, and value through a VSP Advantage Network Provider. Save up to $3,000 Get up to $250 back $1,000 savings on LASIK With Exclusive Member Extras, members can save more than $3,000 with special offers and deals through VSP and other leading industry brands. Members can save big with VSP exclusive mail-in rebates on eligible popular contact lens brands l Bausch + Lomb. Members can save up to $1,000 on LASIK at LasikPlus, NVISION Eye Center, TLC Laser Eye Centers and The LASIK Vision Institute. LEARN MORE. VISIT VSP.COM/OFFERS Benefits through a VSP Network Provider Exam Services ● Comprehensive WellVision Exam® covered in full* ● Routine retinal screening covered after a no more than $39 copay Lenses • Glass or plastic single vision, lined bifocal, lined trifocal, or lenticular lenses are covered in full* Lens Enhancements ● Most popular lens enhancements are covered after a copay, saving our members an average of 20-25% Lens Enhancement Anti-reflective coating Polycarbonate - Adult Polycarbonate - Children Progressive Photochromic Scratch-resistant coating Single Vision $41 $35 Covered N/A $75 $17 Multifocal $41 $35 Covered $55 $75 $17 Prices above reflect standard lens enhancement selections; premium or custom lens enhancements may also be available at an additional cost Frame • Frames covered in full* up to the elected retail allowance. • Members who select a featured frame brand, including bebe, Calvin Klein, Cole Haan, Dragon, Flexon, Longchamp, Nike and more, will receive an extra $20 toward their frame allowance Featured frame brands subject to change • 20% off any amount above the retail allowance • Members can choose from all frames available on the market today 12

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Additional Pairs of Glasses ● Within 12 months of exam: 20% off unlimited additional pairs of prescription glasses and/or non-prescription sunglasses from any VSP doctor Elective Contact Lenses • Contact lens exam (fitting and evaluation): Standard and Premium fits are covered in full after copay. Member receives 15% off of contact lens exam services and member's copay will never exceed $60 • Prescription contact lens materials are covered in full up to the elected retail allowance. (in lieu of frame & lenses) • Members can choose from any available prescription contact lens materials . VSP Laser VisionCareSM Program • Discounts average 15-20% off or 5% off a promotional offer for laser surgery, including PRK, Custom PRK, LASIK, Custom LASIK, SMILE, and Contoura Discounts are only available from VSP-contracted facilities. Also custom LASIK coverage only available using wavefront technology, other LASIK procedures may be performed at an additional cost to the member Out-of-Network Schedule We offer a generous reimbursement schedule for services from other providers Exam Lenses: Single vision Lined bifocal Lined trifocal Frame Elective contact lenses (in lieu of lenses and frame) $45 $30 $50 $60 $50 $105 Monthly Rates: Fully Insured—Risk Rates Frequency 12/12/24 12/12/12 Exam/Lens/Frame Copay Frame/Lens Allowance Plan Enhancements $20/20 $130/130 N/A $20/20 $200/200 2nd Pair Employee Only $5.00 $15.08 Employee + One $10.00 $30.15 Employee + Children $10.75 $32.36 Employee + Family $16.98 $51.36 13

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45103Term Life InsuranceWe’ve Got You CoveredAs an active employee of Custom Commodities, Inc., you haveaccess to a life insurance policy from United of Omaha LifeInsurance Company.It replaces the income you would have provided, and helps payfuneral costs, manage debt and cover ongoing expenses.How much insurance is enough?When determining how much life insurance you need, thinkabout the expenses you may encounter now and through everystage of your life.Coverage guidelines and benefits are outlined in the chart below.ELIGIBILITY - ALL ELIGIBLE EMPLOYEESEligibility Requirement You must be actively working a minimum of 30 hours per week to be eligible forcoverage.Premium Payment The premiums for this insurance are paid in full by the policyholder. There is nocost to you for this insurance.BENEFITSLife InsuranceBenefit AmountFor You: $25,000In the event of death, the benefit paid will be equal to the benefit amount after any age reductionsless any living care/accelerated death benefits previously paid under this plan.AccidentalDeath &Dismemberment(AD&D) BenefitAmountFor You: The Principal Sum amount is equal to the amount of your life insurance benefit.FEATURESLiving Care/AcceleratedDeath Benefit80% of the amount of the life insurance benefit is available to you if terminally ill, not to exceed$20,000.14

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If it is determined that you are totally disabled, your life insurance benefit will continue withoutpayment of premium, subject to certain conditions.In addition to basic AD&D benefits, you are protected by the following benefits:- Childcare - Child Education - Seat Belt- Airbag - Spouse Education - Common CarrierAllows you to continue this insurance program should you leave your employer for any reason,without having to provide evidence of insurability (information about your health). You will beresponsible for the premium for the coverage.If your employment ends, you may apply for an individual life insurance policy from Mutual ofOmaha without having to provide evidence of insurability (information about your health). You willbe responsible for the premium for the coverage.The Travel Assistance program is an added benefit that provides assistance for your travels over100 miles away from home or outside the country.The Hearing Discount Program provides you and your family discounted hearing products,including hearing aids and batteries. Call 1-888-534-1747 or visitwww.amplifonusa.com/mutualofomaha to learn more.We work with Willing® to offer employees an online will prep tool. In just a few clicks you cancomplete a customized plan to protect your family and property (valid in all 50 states). To getstarted visit www.willing.com/mutualofomahaInsurance benefits and guarantee issue amounts are subject to age reductions:- At age 65, amounts reduce to 65%- At age 70, amounts reduce to 40%- At age 75, amounts reduce to 25%Information about the AD&D exclusions for this plan will be included in the summary of coverage, which you will receiveafter enrolling.Please contact your employer if you have questions prior to enrolling.Who is eligible for this insurance?What is Guarantee Issue?What is Evidence of Insurability?Can I take this insurance with me if I change jobs/am no longer a member of thisgroup?Are there any limitations, reductions or exclusions?15

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Within the coverage guidelines defined above, you select the amount of life insurance coverageyou want.This plan includes the option to select coverage for your spouse and dependent children.Children include those, up to age 26.In the event of death, the benefit paid will be equal to the benefit amount after any age reductionsless any living care/accelerated death benefits previously paid under this plan.You have the option to elect AD&D coverage for yourself, your spouse and your dependentchild(ren). If coverage is elected, the Principal Sum amount is equal to the amount of the lifeinsurance benefit.AD&D coverage is available if you or your dependents are injured or die as a result of an accident,and the injury or death is independent of sickness and all other causes. The benefit amountdepends on the type of loss incurred, and is either all or a portion of the Principal Sum.80% of the amount of the life insurance benefit is available to you if terminally ill, not to exceed$240,000.If it is determined that you are totally disabled, your life insurance benefit will continue withoutpayment of premium, subject to certain conditions.If you enroll for even the minimum amount of coverage during your initial enrollment, you have theability to enroll for additional coverage at your next enrollment by up to $10,000, provided the totalamount of insurance does not exceed your maximum benefit amount. This feature allows you tosecure additional life insurance protection in the event your needs change (ex. you get married orhave a child).In addition to basic AD&D benefits, you are protected by the following benefits:- Childcare - Child Education - Seat Belt- Airbag - Spouse Education - Common CarrierAllows you to continue this insurance program for yourself and your dependents should you leaveyour employer for any reason, without having to provide evidence of insurability (information aboutyour health). You will be responsible for the premium for the coverage.If your employment ends, you may apply for an individual life insurance policy from Mutual ofOmaha without having to provide evidence of insurability (information about your health). You willbe responsible for the premium for the coverage.The Travel Assistance program is an added benefit that provides assistance for your travels over100 miles away from home or outside the country.The Hearing Discount Program provides you and your family discounted hearing products,including hearing aids and batteries. Call 1-888-534-1747 or visitwww.amplifonusa.com/mutualofomaha to learn more.AbsenceProSM helps employees manage FMLA-related leaves of absence. This robust leaveadministration tool provides employees with both administrative and consultative services.We work with Willing® to offer employees an online will prep tool. In just a few clicks you cancomplete a customized plan to protect your family and property (valid in all 50 states). To getstarted visit www.willing.com/mutualofomahaInsurance benefits and guarantee issue amounts are subject to age reductions:- At age 65, amounts reduce to 65%- At age 70, amounts reduce to 40%- At age 75, amounts reduce to 25%Spouse coverage terminates when you reach age 70.Life insurance benefits will not be paid if the insured’s death is the result of suicide within two years from the datecoverage begins. If this occurs, the sum of the premiums paid will be returned to the beneficiary. The same applies forany future increases in coverage under this plan.Information about the AD&D exclusions for this plan will be included in the summary of coverage, which you will receiveafter enrolling.Please contact your employer if you have questions prior to enrolling.17

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Minimum WeeklyBenefit$25Partial DisabilityBenefitsIf you become disabled and can work part-time (but not full-time), you may be eligiblefor partial disability benefits, which will help supplement your income until you are ableto return to work full-time.DEFINITIONSDefinition ofDisabilityDisability and disabled mean that because of an injury or illness, a significant change inyour mental or functional abilities has occurred, for which you are prevented fromperforming at least one of the material duties of your regular job and are unable togenerate current earnings which exceed 99% of your weekly earnings from your regularjob. You can be totally or partially disabled during the elimination period.Definition ofWeekly EarningsWeekly earnings is the average gross weekly income received during the calendar yearimmediately prior to the year in which disability begins, as shown in the income box ofthe W-2 form. If employed for part of the previous calendar year, weekly earnings is theaverage gross weekly income received for the weeks worked.FEATURESVocationalRehabilitationBenefitIf you become disabled and participate in the vocational rehabilitation program, you willbe eligible for a monthly benefit increase of 5%.PortabilityThe portability feature allows you to apply for disability insurance through a trust policyshould your employment end, without having to provide evidence of insurability. Youwill be responsible for paying the premium for coverage.ReasonableAccommodationProvides a benefit to the employer to assist in covering costs incurred to make workplacemodifications for you to return to work.SERVICESHearing DiscountProgramThe Hearing Discount Program provides you and your family discounted hearingproducts, including hearing aids and batteries. Call 1-888-534-1747 or visitwww.amplifonusa.com/mutualofomaha to learn more.VOLUNTARY SHORT-TERM DISABILITY PREMIUM CALCULATIONUse the rates in the Age/Premium Factor Table to calculate your premium for voluntary short-term disability coverage in theworksheet below, using the example as a guide.AGE PREMIUM FACTORWEEKLY PREMIUM CALCULATIONEXAMPLE(42-year-old employeeearning $40,000 a year)< 30 0.010827730 - 34 0.010190835 - 39 0.0079615List your weekly earnings $ $769.2340 - 44 0.0086262(Maximum is $2,500)45 - 49 0.0096231Multiply by the premium factor0.008626250 - 54 0.0102600Your Estimated Weekly Premium**$ $6.6455 - 59 0.015632360+ 0.0196200**This is an estimate of premium cost. Actual deductions may vary slightly due torounding and payroll frequency.20

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45104 G000B6VHVoluntary Long-Term Disability InsuranceWe’ve Got You CoveredAs an active employee of Custom Commodities, Inc., you haveaccess to a disability income insurance policy from United ofOmaha Life Insurance Company.A lengthy disability can be devastating, and is more commonthan you might think. It may lead to a loss of income,independence and financial security.A disability income insurance policy can help provide securitywhen you need it most. It pays you cash benefits when you’resick or hurt and can’t work.Coverage guidelines and benefits are outlined in the chart below.ELIGIBILITY - ALL ELIGIBLE EMPLOYEESEligibilityRequirementYou must be actively working a minimum of 30 hours per week to be eligible forcoverage.PremiumPaymentThe premiums for this insurance are paid in full by you.BENEFITSEliminationPeriodYour benefits begin on the later of 90 calendar days after the onset of your disablinginjury or illness or the date your short-term disability ends.Monthly BenefitYour benefit is equivalent to 60% of your before-tax monthly earnings, not to exceed theplan’s maximum monthly benefit amount less other income sources.The premium for your long-term disability coverage is waived while you are receivingbenefits.MaximumMonthly Benefit$6,000Minimum MonthlyBenefit$50Maximum BenefitPeriodIf you become disabled prior to age 68, benefits are payable for two years. At age 68,benefits are payable to age 70. At age 69 (and older), benefits are payable for one year.21

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Partial DisabilityBenefitsIf you become disabled and can work part-time (but not full-time), you may be eligiblefor partial disability benefits. Additional benefits for child care expenses for eligibledependent children are also available while receiving partial disability benefits.DEFINITIONSOwn Occupation2 YearsOwn OccupationEarnings Test99%Definition ofMonthly EarningsMonthly earnings is the average gross monthly income received during the calendar yearimmediately prior to the year in which disability begins, as shown in the income box ofthe W-2 form. If employed for part of the previous calendar year, monthly earnings is theaverage gross monthly income received for the months worked.FEATURESVocationalRehabilitationBenefitIf you become disabled and participate in the vocational rehabilitation program, you willbe eligible for a monthly benefit increase of 5%.Survivor BenefitIf you pass away while receiving disability benefits, a lump sum equal to 3 times yourmonthly benefit will be paid to your eligible survivor.ReasonableAccommodationProvides a benefit to the employer to assist in covering costs incurred to make workplacemodifications for you to return to work.SERVICESHearing DiscountProgramThe Hearing Discount Program provides you and your family discounted hearingproducts, including hearing aids and batteries. Call 1-888-534-1747 or visitwww.amplifonusa.com/mutualofomaha to learn more.VOLUNTARY LONG-TERM DISABILITY PREMIUM CALCULATIONUse the rates in the Age/Premium Factor Table to calculate your premium for voluntary long-term disability coverage in theworksheet below, using the example as a guide.AGE PREMIUM FACTORWEEKLY PREMIUM CALCULATIONEXAMPLE(42-year-old employeeearning $40,000 a year)< 30 0.000592630 - 34 0.000740835 - 39 0.0009817List your monthly earnings $ $3,333.3340 - 44 0.0012005(Maximum is $10,000)45 - 49 0.0017806Multiply by the premium factor0.001200550 - 54 0.0023497Your Estimated Weekly Premium**$ $4.0055 - 59 0.003011560+ 0.0028551**This is an estimate of premium cost. Actual deductions may vary slightly due torounding and payroll frequency.22

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MASAMTS_WhyYouNeedMASA_EMP_V2_FLR_2_031722TWO PLANS TO PROTECT YOU AND YOUR FAMILYThe issue of out-of-pocket ambulance expenses isn’t going away, and we’ll all continue to require these services. A MASA MTS Membership bridges the gap in ambulance transport coverage at an aﬀ ordable rate for emergency ground and air transportation within the continental United States, Alaska, Hawaii and while traveling in Canada, regardless of whether the provider is in or out of the group healthcare beneﬁ ts network.While our critical beneﬁ ts are included in both memberships, Platinum members enjoy additional services. Whether you’d like to protect your clients and their family from costly emergency ambulance transports or provide overall peace of mind, MASA MTS has them covered.Emergency Air Ambulance CoverageEmergency Ground Ambulance CoverageHospital to Hospital Ambulance CoverageRepatriation to Hospital NearHome CoveragePatient Return Transportation CoverageCompanion Transportation CoverageHospital Visitor Transportation CoverageMinor Return Transportation CoverageVehicle & RV Return CoveragePet Return Transportation CoverageOrgan Retrieval & Organ Recipient Transportation CoverageMortal Remains Transportation CoverageEmergent Plus Membership Payroll Deduction: $3.23Platinum Membership Payroll Deduction: $9.00333333311122222226

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MASAMTS_WhyYouNeedMASA_EMP_V2_FLR_2_0317224 Ways You Can End Up With Out-Of-Pocket CostsOUT-OF-NETWORK PROVIDERSAccording to a 2021 IBIS World market research report, there are over 27,000 ambulance services in the United States, yet your health insurance policy may only cover a limited number of in-network providers. However, when emergencies happen, you can’t be choosy, and there’s no guarantee that you will be picked up by an in-network provider for a ground ambulance. According to Consumer Reports, 79% of all ground ambulance rides could result in an out-of-network bill. Essentially, that means your chances of being responsible for a majority of the bill are pretty high.THE REASON FOR YOUR TRIPHealth insurance policies will only pay for an ambulance trip deemed “Medically Necessary.” Medical necessity is established when any other method of transportation (besides an ambulance) would endanger the patient’s life. For example, let’s say you’re experiencing symptoms commonly associated with a heart attack and take an ambulance to the hospital. If your health insurance carrier decides that the cause of your symptoms (perhaps indigestion, heartburn, or a panic attack) doesn’t meet their requirements for an ambulance, they could deny your claim and leave you on the hook for thousands of dollars.USUAL, CUSTOMARY & REASONABLE RATEIf picked up by an out-of-network ground ambulance provider, and even if the insurance accepts the claim, we know that generally, at best, to expect that the carrier will only pay the Usual, Customary, and Reasonable Rate. This rate is commonly only a fraction of the overall charges, creating a potential balance bill responsibility.COPAYS & DEDUCTIBLESEven if your bills fall within the Usual, Customary and Reasonable Rate, most insurance plans have copays and deductibles. Copays are set fees attached to certain medical services. A deductible is a set amount you must pay before insurance coverage kicks in. Depending on your health insurance plan, some deductibles can be as high as $8,000. So, regardless of other variables, if you need a ground ambulance ride, you could automatically be responsible for hundreds to thousands of dollars just to fulﬁ ll the requirements of your insurance plan.EYE-OPENING STATISTICSHere are some interesting statistics related to the average cost of medical costs in the United States:Many people assume that their health insurance policy will cover them for ambulance rides and other emergency transportation. Unfortunately, this is often not the case. During the last ten years, huge gaps have opened in most insurance plans, which can leave you exposed to unexpected out of pocket expenses for ground and air ambulances, particularly when emergency transportation is involved.Modern Health Insuranceis Leaving You Exposed65.5% OF PEOPLEwho ﬁ le for bankruptcy cite medical issues as a key contributor to their ﬁ nancial downfall.- CNBC 201940%OF AMERICANSonly have enough savings to cover a $400 emergency expense.Federal Reserve, 2019530,000 FAMILIESﬁ le for bankruptcy each year because of medical bills. - CNBC 2019OVER 200 MILLIONmedical claims are denied every year.- AARP 2009Medical bills are a leading cause for bankruptcy in the U.S.- METLIFE 2021Unexpected medical bills rank as the #1 concern for Americans KFF - Kaiser Family Foundation, 202027

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MASAMTS_WhyYouNeedMASA_EMP_V2_FLR_2_031722The MASA MTS Beneﬁ tsAfter the group health plan pays its portion, MASA MTS works hand-in-hand with the beneﬁ ts administrators and transport providers to make certain our Members have no out-of-pocket expenses* for emergency ambulance transportation assistance and other related services. See the full list of Beneﬁ ts available based on plan chosen below.Emergency Air Ambulance CoverageMASA 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 CoverageMASA 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 CoverageMASA 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 CoverageMASA MTS provides services and covers out-of-pocket expenses for the coordination of a Member’s non-emergency transportation by a medically equipped, air 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. Patient Return Transportation CoverageMASA MTS provides services and covers the out-of-pocket expenses associated with coordinating a Member’s transportation when hospitalized more than one hundred (100) miles from home, after discharge from the medical facility, by a regularly scheduled commercial airline to the commercial airport nearest the Member’s home. Companion Transportation CoverageMASA MTS provides services associated with the coordination of transportation for the Member’s spouse, other family member, or companion to accompany the Member’s emergency transport by a medically equipped, rotary (i.e., helicopter) or ﬁ xed-wing aircraft, giving due priority to the medical personnel and/or equipment and the welfare and safety of the patient. Hospital Visitor Transportation Coverage MASA MTS provides services and covers air transportation expenses associated with coordinating a round-trip, regularly scheduled, commercial airfare for Member’s spouse, other family Member or companion to join the Member in the event of in-patient hospitalization more than one hundred (100) statute miles from Member’s home. Minor Return Transportation Coverage MASA MTS provides services and covers out-of-pocket expenses associated with minor return transportation to a parent, legal guardian, or another person that can be responsible for the minor in the event that the minor is unattended as a result of Member’s Emergency Air or Ground Ambulance, Hospital to Hospital Ambulance, Repatriation to Hospital Near Home, or Mortal Remains Transportation coverages. MASA MTS also provides for a qualiﬁ ed attendant to accompany the minor during travel when the minor’s age and/or medical condition may require such care. Vehicle & RV Return Coverage MASA MTS provides services and covers the out-of-pocket expenses associated with vehicle return transportation for one (1) a safe operational car, truck, van, motorcycle, travel trailer, or motor home to the Member’s home. This service is available when a Member uses Emergency Air or Ground Ambulance, Hospital to Hospital Ambulance, Repatriation to Hospital Near Home, Patient Return Transportation or Mortal Remains Transportation Coverages. MASA MTS pays the cost of fuel, oil and driver.Pet Return Transportation Coverage MASA MTS provides services and covers out-of-pocket expenses for the return transportation to a Member’s home for up to two (2) pet(s) belonging to the Member that includes either a dog, cat or other small animal(s). This service is available when a Member uses Emergency Air or Ground Ambulance, Hospital to Hospital Ambulance, Repatriation to Hospital Near Home, Patient Return Transportation or Mortal Remains Transportation Coverages. Organ Retrieval & Organ Recipient Transportation CoverageMASA MTS provides services and covers air transportation expenses associated with coordinating transportation for an organ when the Member requires an organ transplant. MASA MTS will also provide service and cover transportation costs of Member and Member’s spouse, other family Member or a companion should the Member need to travel to the location where the procedure will occur. If medically necessary, the organ will be transported by a medically equipped ﬁ xed-wing aircraft; otherwise, the organ is delivered by a commercial airline to the suitable airport nearest the location of the operation. Mortal Remains Transportation CoverageMASA MTS covers the air transportation expense for a Member’s mortal remains in the event of their death when it occurs more than one hundred (100) statute miles from home. Remains are transported by a regularly scheduled commercial airline to the commercial airport nearest a Member’s home. 28

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TOP 4 REASONSto become a MASA MTS Member14 . 32The information provided in this information sheet is for informational purposes only. The beneﬁts listed, and the descriptions thereof, do not represent the full terms and conditions applicable for usage and may only be oﬀered in some memberships. Premiums and beneﬁts vary depending on the beneﬁts selected. Commercial Air and Worldwide coverage are not available in all territories. For a complete list of beneﬁts, 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, beneﬁts will become available under the MASA membership for expenses incurred for medical care (as deﬁned under Internal Revenue Code section 213 (d)) once a member satisﬁes the statutory minimum deductible under Internal Revenue Code section 223(c) for high deductible health plan coverage that is compatible with a health savings account. MASA MTS provides over 2 million members with coverage for BOTH Ground and Air Ambulance transport out-of-pocket costs* regardless of the ambulance provider because MASA MTS is a PAYER and NOT a provider. MASA MTS gives you the peace of mind knowing out-of-pocket costs* associated with emergency transport for deductibles, co-pays, or co-insurance are covered.MASA MTS protects you and your family from unexpected out-of-pocket costs* regardless of any balance billing associated with ground ambulance in addition to the co-pays, co-insurance, and deductibles for both ground and air ambulance with: • One Low Monthly Fee• NO Age LImits• NO Health Questions• Easy Claims ProcessVER: ROAD_EMP_1SHEET_TOPREASONS_US_V2_031722MASA MTS protects our members and their families from the gaps in group health beneﬁts for emergency transport expenses within the continental United States, Alaska, Hawaii, and while traveling in Canada, regardless of in or out-of-network. Worldwide coverage is available with a Platinum Membership for lifesaving transportation at home and far away.29

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BEST VALUEFLEET PLATINUM FLEET GOLD$6.91 $4.60PER WEEK PER WEEK• $0 Covered Violaons• $295 Pre-Exisng Ticket Handling Fee*• CSA Challenges for Fleet and Drivers• $10,000 AD&D Policy• Most Driver Rewards• Safety Bonus• Personal Passenger Roadside Assistance (driver and spouse)• $125 Handling Fee for Covered Violaons• $295 Pre-Exisng Ticket Handling Fee*• CSA Challenges for Fleet and Drivers• $5,000 AD&D Policy• Driver Rewards• No Safety Bonus• Personal Passenger Roadside Assistance (driver and spouse)$29.95 PER MONTH $19.95 PER MONTHFLEET SILVER$2.52PER WEEK• $225 Handling Fee for Covered Violaons • $395 Pre-Exisng Ticket Handling Fee*• CSA Challenge for Fleet and Drivers ($25 each)• No AD&D Policy• No Driver Rewards• No Safety Bonus• Personal Passenger Roadside Assistance (driver and spouse)$10.95 PER MONTH*Tickets received prior to membership start dateOur ServicesPRO DRIVERS CHOOSE TVC PRO-DRIVERServing professional drivers for more than 30 years means we know how important it is to keep your drivers on the road. Traic violations, court time, CSA ratings and growing insurance rates can weigh a fleet down and reduce revenue. Let us help.866-709-2159 eetsales@prodriver.com 14313 N. May Avenue, Oklahoma City, OK 7313430

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401(k) Accounts Contribuon of up to 3% for 2024! Your 401k rerement savings plan at Custom Commodies is one of the best ways to save for your rerement. Custom Commodies encourages you to take full advantage of your 401k plan and all the beneﬁts that it oﬀers you, so that you can look forward to a more secure ﬁnancial future. YOU HAVE TO ENROLL FOR 2020 TO GET MATCHING CONTRIBUTIONS: Enrolling in the 401k plan is quick and easy! Once you enroll (you can enroll online see HR), your salary deferrals are deducted automacally from your pay, which makes saving in the plan convenient. You can elect from a wide range of investment opons under the 401k plan. Your own deferrals plus the matching contribuons made by Custom Commodies can help you achieve your goal for a more comfortable rerement. By parcipang in the 401k plan sooner rather than later, you also have the potenal to beneﬁt signiﬁcantly over me from compound earnings. Compounding enables you to build rerement savings not only from your own deferrals and company matching contribuons, but also from all reinvested dividends! YOUR MATCH GOES IN AS OFTEN AS YOUR DEFERRALS: Custom Commodies will be making a matching contribuon to your parcipant account as oen as you defer – in other words, as oen as you get paid – weekly! Custom Commodies will match dollar for dollar up to 3% of your gross payroll that you contribute. Take a look at the following examples: Weekly Salary Contribuon Percent Weekly Dollar Total Employee Contribuon Company Matching Contribuon $1,000 1% $10.00 $10.00 $1,000 2% $20.00 $20.00 $1,000 3% $30.00 $30.00 $60,000 3% $1,800.00 $1,800.00 The examples above are examples of Money Market only investments and do not take into account potenal gains or losses that might occur over me based on investment choices by the parcipant. Please note: If you are not deferring into the 401k plan, you cannot take advantage of the company matching contribuon! A VESTING SCHEDULE APPLIES TO COMPANY MATCHING CONTRIBUTIONS: You are always 100% “vested” in your own deferrals into the 401k plan. That means that your own deferrals (plus any earnings on those deferrals) belong to you at all mes – and you can take them with you when you rere or otherwise leave your employment at Custom Commodies. A vesng schedule does apply to the matching contribuons that you receive from Custom Commodies, Inc. The amount of money in your match account that you may take with you if you leave depends on the period of me that you have been employed with Custom Commodies (i.e., your “years of service”). Please see the following vesng schedule: 31

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Coordinate care with your doctor(s) - Over 95% of recommendations made by Tria Health were accepted by an individual’s physician.Tria Health’s Pharmacy Advocate Program is available for employees and/or dependents on Custom Commodities' health insurance. Tria Health is a free and confidential benefit that will support you in managing your health, medications and healthcare budget. Talk to a pharmacist over the phone and receive the personalized care you deserve. 1. Tria Health BOB & Patient Satisfaction SurveySchedule Your Appointment!visit www.triahealth.com/scheduleCall 1.888.799.8742 or Who We AreTria Health®smarter. medication. management. • Asthma/COPD• Diabetes• Heart Disease• High Blood PressureWho Should Participate?Tria Health is recommended for members who have any of the following conditions: Your Tria Pharmacist Can Help:11•Answer any questions you have about your health.•Help you save money - Tria saves patients an average $250 per year! •Make sure your medications are working as intended. •• High Cholesterol• • Migraines• OsteoporosisMental HealthParticipants will receive discounted copays on select medications used to treat targeted chronic conditions. You are not required to change your medications, pharmacy or doctor to receive this benet. Our goal is to improve your health and save you money! Save Money on Your MedicationsFree Blood Glucose & Blood Pressure DevicesSelect participants with diabetes and/or high blood pressure will have access to a FREE blood glucose meter and testing supplies and/or a blood pressure monitor for easy monitoring at home. All readings will be monitored by a clinician and can easily be shared with any physician.Choose to LoseProgramQualied participants will have access to a health and tness app and be assigned a designated health coach and clinical pharmacist. Apply at: www.triahealth.com/CTL-CustomCommodities35

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Frequently Asked QuestionsHow do I use the Program?To gain access to our services, register online at CancerCAREprogram.net, or call us at 1-877-640-9610. Once you are registered in our system, a nurse will be assigned to your case andthey will help you for the rest of your cancer journey. Do I have to pay for CancerCARE?The CancerCARE Program is an additional service included in the health plan oered by your company. Registration and program features are covered by your health plan. Contact your HR representative for more information. What if I am already being treated for cancer?You can join CancerCARE at any point during your treatment. Once registered, we are able to collaborate with your local oncologist and give them access to resources they may not have at their facility. We will also review your treatment plan to ensure everything is evidence-based quality care.I don’t have cancer, do I still need to register?Registration is only required if you have been diagnosed with cancer. If you had cancer in the past and are now cancer-free, you can still register as a survivor and we will help you deal with any long-term issues and concerns. Covered dependents can also register for CancerCARE.+1 877 640 9610 cancermanagement@cancercareprogram.netcancercareprogram.net37

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1 You can use your HSA to pay for a wide range of IRS-qualified medical expenses, including many that aren’t typically covered by health insurance plans. This includes deductibles, co-insurance, prescriptions, dental and vision care, and more. Go to irs.gov or hsabank.com/QME for a list of IRS-qualified medical expenses.2 HSA Bank has set daily limits on debit card transactions for fraud protection. These limits are listed in your Health Savings Account Custodial Agreement.© 2022 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC. Plan Administrative Services and Benet Services are administered by Webster Servicing LLC. . How_To_Use_Your_HSA_032922Visit hsabank.com or call the number on the back of your debit card for more information. Deposit funds into your HSATo maximize tax and savings benets, fund your HSA as soon as you can. There are a few convenient ways to contribute.• Payroll deduction – Money is deducted from yourpaychecks, pre-tax, and transferred to your HSA.Talk to your employer to sign up.• Online transfer – Visit the Member Website to transferfunds from your personal checking or savings account toyour HSA.• Check – Mail your personal check and completedcontribution form found on the Member Website to:HSA Bank, PO Box 939, Sheboygan, WI 53082Pay for healthcare expensesWhether you want to reimburse yourself for an IRS-qualied medical expense paid out of pocket or pay directly from your HSA, there are a few ways to get your funds.1 NOTE: Transactions are limited to your available cash balance.• HSA Bank Health Benets Debit Card – Access your HSAfunds when you use your debit card at qualied merchantsor ATMs for withdrawals.2 You can add your debit card toyour mobile wallet using Apple Pay or Samsung Pay.• Online transfer – Visit the Member Website or use themobile app to reimburse yourself for out-of-pocketexpenses. Schedule a one-time or recurring onlinetransfer from your HSA to your personal checking orsavings account.• Online bill pay – Use this feature to pay medical providersdirectly from your HSA.42

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This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificatebooklet for a full explanation of the plan’s benefits, exclusions, limitations and reductions. Should there be any discrepancy between thecertificate booklet and this summary, the certificate booklet will prevail. Benefits availability is subject to final acceptance and approval ofthe group application by the underwriting company. Disability income insurance is underwritten by United of Omaha Life InsuranceCompany, 3300 Mutual of Omaha Plaza, Omaha, NE 68175, 1-800-769-7159. United of Omaha Life Insurance Company is licensednationwide, except in New York. Policy form number G2018MP.SHORT-TERM DISABILITY INSURANCEWho is eligible for this insurance?You must be actively working (performing all normal duties of your job) at least 30 hours per week.How long will my benefits be paid?Benefits begin after the end of the elimination period and can be payable up to the maximum benefit period as long as youremain disabled.Will my benefits be reduced by other sources of income?Yes, depending on the type of income you receive. Your benefit amount may be reduced by other sources of income such asretirement/government plans, other group disability plans, salary continuance/sick leave, settlements on payments received andno-fault benefits.Does this plan cover me if I become disabled due to an injury at work?No, your STD insurance only provides benefits for off-the-job coverage for disabilities due to injury or sickness.Are there any limitations or exclusions?The benefits payable are subject to the following:· Your plan is subject to a pre-existing condition limitation. A pre-existing condition is one for which you have received medicaltreatment, consultation, care or services including diagnostic measures, or if you were prescribed or took prescriptionmedications in the predetermined time frame prior to your effective date of coverage. The pre-existing condition under thisplan is 3/12 which means any condition that you receive medical attention for in the 3 months prior to your effective date ofcoverage that results in a disability during the first 12 months of coverage, would not be covered.· Benefits are not payable for any disability or loss that:- Results from an act of declared or undeclared war or armed aggression- Results from participation in a riot or commission of or attempt to commit a felony- Results from elective or cosmetic surgery or procedure, or resulting complications, unless such surgery or procedure ismedically necessary for the appropriate diagnosis and treatment of your injury or illness- Arises out of or in the course of employment with the policyholder for benefits under any workers’ compensation oroccupational disease law, or receives any settlement from the workers’ compensation carrier- Results, whether the insured person is sane or insane, from an intentionally self-inflicted injury or illness, or attempted suicide- Occurs while incarcerated or imprisoned for any period exceeding 31 days- Is solely a result of a failed drug test- Is solely a result of a loss of a professional license, occupation license or certificationAll exclusions may not be applicable, or may be adjusted, as required by state regulations.Can I take this insurance with me if I change jobs/am no longer a member of this group?In the event this insurance ends due to a change in your employment/membership status with the group, or for certain otherreasons, you have the right to port your coverage to a group trust plan, subject to certain conditions.47

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This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificatebooklet for a full explanation of the plan’s benefits, exclusions, limitations and reductions. Should there be any discrepancy between thecertificate booklet and this summary, the certificate booklet will prevail. Benefits availability is subject to final acceptance and approval ofthe group application by the underwriting company. Disability income insurance is underwritten by United of Omaha Life InsuranceCompany, 3300 Mutual of Omaha Plaza, Omaha, NE 68175, 1-800-769-7159. United of Omaha Life Insurance Company is licensednationwide, except in New York. Policy form number G2018MP. LONG-TERM DISABILITY INSURANCEWho is eligible for this insurance?You must be actively working (performing all normal duties of your job) at least 30 hours per week.How long will my benefits be paid?Benefits begin after the end of the elimination period and can be payable up to the maximum benefit period as long as youremain disabled.Will my benefits be reduced by other sources of income?Yes, depending on the type of income you receive. Your benefit amount may be reduced by other sources of income such asretirement/government plans, other group disability plans, paid family leave, salary continuance/sick leave, settlements onpayments received and no-fault benefits.Does this plan cover me if I become disabled due to an injury at work?Yes, your LTD insurance provides benefits for both on-the-job and off-the-job coverage for disabilities due to injury or sickness.Are there any limitations or exclusions?The benefits payable are subject to the following:· Disabilities related to alcohol and drug abuse are only payable for up to 24 months while insured under the policy.· Disabilities related to mental disorders are only payable for up to 24 months while insured under the policy.· Your plan is subject to a pre-existing condition limitation. A pre-existing condition is one for which you have received medicaltreatment, consultation, care or services including diagnostic measures, or if you were prescribed or took prescriptionmedications in the predetermined time frame prior to your effective date of coverage. The pre-existing condition under thisplan is 3/12 which means any condition that you receive medical attention for in the 3 months prior to your effective date ofcoverage that results in a disability during the first 12 months of coverage, would not be covered.· Benefits are not payable for any disability or loss that:- Results from an act of declared or undeclared war or armed aggression- Results from participation in a riot or commission of or attempt to commit a felony- Results from elective or cosmetic surgery or procedure, or resulting complications, unless such surgery or procedure ismedically necessary for the appropriate diagnosis and treatment of your injury or illness- Results, whether the insured person is sane or insane, from an intentionally self-inflicted injury or illness, or attempted suicide- Results from alcohol and drug abuse and/or substance abuse, except as noted above- Results from a mental disorder, except as noted above- Is caused by alcohol and drug abuse and/or substance abuse, while not being actively supervised by and receiving continuingtreatment from a rehabilitation center or designated institution approved for such treatment by an appropriate body in thegoverning jurisdiction- Occurs while incarcerated or imprisoned for any period exceeding 31 days- Is solely a result of a failed drug test- Is solely a result of a loss of a professional license, occupation license or certificationAll exclusions may not be applicable, or may be adjusted, as required by state regulations.48

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VIRTUAL MSK THERAPYOptimized for AdherenceConvenient - Our program is more convenient than alternatives, like in-person physical therapy. Members can access the program from home or on-the-go, from their mobile device or a desktop, and it only requires 15 minutes out of their day. Equipment or sensors aren’t needed to complete any of the exercises.1Coach-Led - Every program participant is matched with a personal coach who will assign them a personalized program and support them throughout. The coach helps to ensure participant adherence and results. On average, members interact with their coach 40+ times throughout the program.23Cost-Effective - Our program costs just $800* per participant, which is less than half the cost of a round of in-person physical therapy. Since the employer covers the cost of the program, it’s completely free to employees so they have no barriers to getting the care they need.*1:1 ROI Guarantee: HealthJoy will refund or credit the difference between your estimated Program Savings and Fees if the Total Savings are lower.“My doctor told me that my only option left was surgery. I was losing hope. I’ve gone from 100% getting surgery to 100% NOT getting surgery. I can’t believe I went from ‘I may never run again’ to actually rejoining my running group. I’m just so excited.”43-YEAR-OLD FEMALE COLLEGE PROFESSOR WHO PARTICIPATED IN THE PROGRAM51

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General Medical FAQsWhen should I use General Medical services?Can Teladoc Health handle emergency situations?Will I talk with a real doctor?Does the doctor review my medical history before a visit?Can I request a specic doctor?You should choose General Medical any time you want to talk to a doctor in minutes about non-emergency health issues like sinus problems, respiratory infections, allergies, u symptoms, rashes, and many other illnesses. Doctors are available 24/7 within the HealthJoy app. Your doctor will diagnose your symptoms and provide a treatment plan, which may or may not include a prescription.You should not use Teladoc Health if you are experiencing a medical or mental health emergency. In the event of a medical emergency, please call 911. In the event of a mental health emergency, call 988.The providers in our General Medical care offering are board-certied internists, family doctors, psychiatrists, dermatologists, and pediatricians licensed to practice medicine in the US. When you request a visit, Teladoc Health will connect you with a doctor licensed in your state or province. All providers can diagnose, treat, and prescribe medications for common, non-emergency health issues by phone or video.You will complete a brief medical history prior to requesting your rst visit. This is similar to lling out forms before an in-person doctor visit. You can update your medical history at any time within the HealthJoy app. Your medical history is stored on Teladoc Health’s HIPAA-compliant, encrypted central server. Before each visit, the doctor will review your medical history with a specic focus on chronic illnesses, current medications, allergies, and changes in your medical condition.Depending on the plan your employer is on, you may be able to select a specic doctor for your visit. All Teladoc Health doctors are board-certied and state licensed. To become an ofcial Teladoc Health doctor, all providers must undergo a thorough credentialing process. All Teladoc Health doctors are thoroughly trained on how to provide the best virtual care experience.54

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Women’s Health and Cancer Rights Act of 1998 In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following benefits: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications of the mastectomy, including lymphedema. Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan. Special Enrollment Rights This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time. Loss of Other Coverage or Becoming Eligible for Medicaid or a state Children’s Health Insurance Program (CHIP) If you are declining coverage for yourself or your dependents because of other health insurance or group health plan coverage, you may be able to later enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must enroll within 31 days after your or your dependents’ other coverage ends (or after the employer that sponsors that coverage stops contributing toward the other coverage). If you or your dependents lose eligibility under a Medicaid plan or CHIP, or if you or your dependents become eligible for a subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents in this plan. You must provide notification with 60 days after you or your dependent is terminated from, or determined to be eligible for such assistance. Marriage, Birth or Adoption If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 31 days after the marriage, birth, or placement for adoption. For More Information or Assistance To request special enrollment or obtain more information, contact: Custom Commodities, Inc. Human Resources 408 N Trinity Gilmer, TX 75644 903-843-2648 Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Custom Commodities, Inc. and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to enroll in a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. If neither you nor any of your covered dependents are eligible for or have Medicare, this notice does not apply to you or the dependents, as the case may be. However, you should still keep a copy of this notice in the event you or a dependent should qualify for coverage under Medicare in the future. Please note, however, that later notices might supersede this notice. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that offers prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Custom Commodities, Inc. has determined that the prescription drug coverage offered by the Custom Commodities, Inc. medical plan is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered Creditable Coverage. Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare prescription drug plan, as long as you later enroll within specific time periods. You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare. If you decide to wait to enroll in a Medicare prescription drug plan, you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15 through December 7 but as a general rule, if you delay your enrollment in Medicare Part D, after first becoming eligible to enroll, you may have to pay a higher premium (a penalty). You should compare your current coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have a copy, you can get one by contacting Custom Commodities, Inc. at the phone number or address listed at the end of this section. If you choose to enroll in a Medicare prescription drug plan and cancel your current Custom Commodities, Inc. prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. To regain coverage, you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description to determine if and when you are allowed to add coverage. If you cancel or lose your current coverage and do not have prescription drug coverage for 63 days or longer prior to enrolling in the Medicare prescription drug coverage, your monthly premium will be at least 1% per month greater for every month that you did not 55

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have coverage for as long as you have Medicare prescription drug coverage. For example, if nineteen months lapse without coverage, your premium will always be at least 19% higher than it would have been without the lapse in coverage. For more information about this notice or your current prescription drug coverage: Contact the Human Resources Department at 903-843-2648. NOTE: You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage and if this coverage changes. You may also request a copy. For more information about your options under Medicare prescription drug coverage: More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov.Call your State Health Insurance Assistance Program (see theinside back cover of your copy of the “Medicare & You” handbookfor their telephone number) for personalized help.Call 1-800-MEDICARE (1-800-633-4227). TTY users should call877-486-2048.If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you can call them at 800-772-1213. TTY users should call 800-325-0778. Remember: Keep this Creditable Coverage notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty). January 1, 2024Custom Commodities, Inc. Human Resources 408 N Trinity Gilmer, TX 75644 903-843-2648Notice of HIPAA Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Effective Date of Notice: January 1, 2023 Company’s Plan is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about: 1. the Plan’s uses and disclosures of Protected Health Information(PHI);2. your privacy rights with respect to your PHI;3. the Plan’s duties with respect to your PHI;4. your right to file a complaint with the Plan and to the Secretary of theU.S. Department of Health and Human Services; and 5. the person or office to contact for further information about thePlan’s privacy practices.The term “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, electronic). Section 1 – Notice of PHI Uses and Disclosures Required PHI Uses and Disclosures Upon your request, the Plan is required to give you access to your PHI in order to inspect and copy it. Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate or determine the Plan’s compliance with the privacy regulations. Uses and disclosures to carry out treatment, payment and health care operations. The Plan and its business associates will use PHI without your authorization to carry out treatment, payment and health care operations. The Plan and its business associates (and any health insurers providing benefits to Plan participants) may also disclose the following to the Plan’s Board of Trustees: (1) PHI for purposes related to Plan administration (payment and health care operations); (2) summary health information for purposes of health or stop loss insurance underwriting or for purposes of modifying the Plan; and (3) enrollment information (whether an individual is eligible for benefits under the Plan). The Trustees have amended the Plan to protect your PHI as required by federal law. Treatment is the provision, coordination or management of health care and related services. It also includes but is not limited to consultations and referrals between one or more of your providers. For example, the Plan may disclose to a treating physician the name of your treating radiologist so that the physician may ask for your X-rays from the treating radiologist. Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims processing, subrogation, reviews for medical necessity and appropriateness of care, utilization review and preauthorizations). For example, the Plan may tell a treating doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan. Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts. It also includes case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. However, no genetic information can be used or disclosed for underwriting purposes. For example, the Plan may use information to project future benefit costs or audit the accuracy of its claims processing functions. Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use or release. Unless you object, the Plan may provide relevant portions of your protected health information to a family member, friend or other 56

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person you indicate is involved in your health care or in helping you receive payment for your health care. Also, if you are not capable of agreeing or objecting to these disclosures because of, for instance, an emergency situation, the Plan will disclose protected health information (as the Plan determines) in your best interest. After the emergency, the Plan will give you the opportunity to object to future disclosures to family and friends. Uses and disclosures for which your consent, authorization or opportunity to object is not required. The Plan is allowed to use and disclose your PHI without your authorization under the following circumstances: 1. For treatment, payment and health care operations.2. Enrollment information can be provided to the Trustees.3. Summary health information can be provided to the Trustees for thepurposes designated above.4. When required by law.5. When permitted for purposes of public health activities, includingwhen necessary to report product defects and to permit productrecalls. PHI may also be disclosed if you have been exposed to acommunicable disease or are at risk of spreading a disease orcondition, if required by law.6. When required by law to report information about abuse, neglect ordomestic violence to public authorities if there exists a reasonablebelief that you may be a victim of abuse, neglect or domesticviolence. In which case, the Plan will promptly inform you that such adisclosure has been or will be made unless that notice would cause arisk of serious harm. For the purpose of reporting child abuse orneglect, it is not necessary to inform the minor that such a disclosurehas been or will be made. Disclosure may generally be made to theminor’s parents or other representatives although there may becircumstances under federal or state law when the parents or otherrepresentatives may not be given access to the minor’s PHI.7.The Plan may disclose your PHI to a public health oversight agencyfor oversight activities required by law. This includes uses ordisclosures in civil, administrative or criminal investigations;inspections; licensure or disciplinary actions (for example, toinvestigate complaints against providers); and other activitiesnecessary for appropriate oversight of government benefit programs(for example, to investigate Medicare or Medicaid fraud).8. The Plan may disclose your PHI when required for judicial oradministrative proceedings. For example, your PHI may be disclosedin response to a subpoena or discovery request.9.When required for law enforcement purposes, including for thepurpose of identifying or locating a suspect, fugitive, material witnessor missing person. Also, when disclosing information about anindividual who is or is suspected to be a victim of a crime but only ifthe individual agrees to the disclosure or the Plan is unable to obtainthe individual’s agreement because of emergency circumstances.Furthermore, the law enforcement official must represent that theinformation is not intended to be used against the individual, theimmediate law enforcement activity would be materially andadversely affected by waiting to obtain the individual’s agreement anddisclosure is in the best interest of the individual as determined by theexercise of the Plan’s best judgment.10. When required to be given to a coroner or medical examiner for thepurpose of identifying a deceased person, determining a cause ofdeath or other duties as authorized by law. Also, disclosure ispermitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent. 11. When consistent with applicable law and standards of ethicalconduct if the Plan, in good faith, believes the use or disclosureis necessary to prevent or lessen a serious and imminentthreat to the health or safety of a person or the public and thedisclosure is to a person reasonably able to prevent or lessenthe threat, including the target of the threat.12. When authorized by and to the extent necessary to complywith workers’ compensation or other similar programsestablished by law.Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to your right to revoke such authorization. Uses and disclosures that require your written authorization. Other uses or disclosures of your protected health information not described above will only be made with your written authorization. For example, in general and subject to specific conditions, the Plan will not use or disclose your psychiatric notes; the Plan will not use or disclose your protected health information for marketing; and the Plan will not sell your protected health information, unless you provide a written authorization to do so. You may revoke written authorizations at any time, so long as the revocation is in writing. Once the Plan receives your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation. Section 2 – Rights of Individuals Right to Request Restrictions on Uses and Disclosures of PHI You may request the Plan to restrict the uses and disclosures of your PHI. However, the Plan is not required to agree to your request (except that the Plan must comply with your request to restrict a disclosure of your confidential information for payment or health care operations if you paid for the services to which the information relates in full, out of pocket). You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official. Right to Request Confidential Communications The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations if necessary to prevent a disclosure that could endanger you. You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official. Right to Inspect and Copy PHI You have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as the Plan maintains the PHI. If the information you request is in an electronic designated record set, you may request that these records be transmitted electronically to yourself or a designated individual. Protected Health Information (PHI) 57

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Includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form. Designated Record Set Includes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for the Plan; or other information used in whole or in part by or for the Plan to make decisions about individuals. Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set. The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained off site. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. You or your personal representative will be required to submit a written request to request access to the PHI in your designated record set. Such requests should be made to the Plan’s Privacy Official. If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial, a description of how you may appeal the Plan’s decision and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services. The Plan may charge a reasonable, cost-based fee for copying records at your request. Right to Amend PHI You have the right to request the Plan to amend your PHI or a record about you in your designated record set for as long as the PHI is maintained in the designated record set. The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI. Such requests should be made to the Plan’s Privacy Official. You or your personal representative will be required to submit a written request to request amendment of the PHI in your designated record set. Right to Receive an Accounting of PHI Disclosures At your request, the Plan will also provide you an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting will not include PHI disclosures made: (1) to carry out treatment, payment or health care operations; (2) to individuals about their own PHI; (3) pursuant to your authorization; (4) prior to April 14, 2003; and (5) where otherwise permissible under the law and the Plan’s privacy practices. In addition, the Plan need not account for certain incidental disclosures. If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided. If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting. Such requests should be made to the Plan’s Privacy Official. Right to Receive a Paper Copy of This Notice Upon Request You have the right to obtain a paper copy of this Notice. Such requests should be made to the Plan’s Privacy Official. A Note About Personal Representatives You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms: 1. a power of attorney for health care purposes;2. a court order of appointment of the person as the conservator orguardian of the individual; or3.an individual who is the parent of an unemancipated minor childmay generally act as the child’s personal representative (subjectto state law).The Plan retains discretion to deny access to your PHI by a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect. Section 3 – The Plan’s Duties The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with notice of the Plan’s legal duties and privacy practices. This Notice is effective September 23, 2013, and the Plan is required to comply with the terms of this Notice. However, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy practice is changed, a revised version of this Notice will be provided to all participants for whom the Plan still maintains PHI. The revised Notice will be distributed in the same manner as the initial Notice was provided or in any other permissible manner. If the revised version of this Notice is posted, you will also receive a copy of the Notice or information about any material change and how to receive a copy of the Notice in the Plan’s next annual mailing. Otherwise, the revised version of this Notice will be distributed within 60 days of the effective date of any material change to the Plan’s policies regarding the uses or disclosures of PHI, the individual’s privacy rights, the duties of the Plan or other privacy practices stated in this Notice. Minimum Necessary Standard When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. When required by law, the Plan will restrict disclosures to the limited data set, or otherwise as necessary, to the minimum necessary information to accomplish the intended purpose. However, the minimum necessary standard will not apply in the following situations: 1. disclosures to or requests by a health care provider for treatment;2. uses or disclosures made to the individual;3. disclosures made to the Secretary of the U.S. Department ofHealth and Human Services;4.uses or disclosures that are required by law; and58

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5. uses or disclosures that are required for the Plan’s compliance withlegal regulations.De-Identified Information This notice does not apply to information that has been de-identified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. Summary Health Information The Plan may disclose “summary health information” to the Trustees for obtaining insurance premium bids or modifying, amending or terminating the Plan. “Summary health information” summarizes the claims history, claims expenses or type of claims experienced by participants and excludes identifying information in accordance with HIPAA. Notification of Breach The Plan is required by law to maintain the privacy of participants’ PHI and to provide individuals with notice of its legal duties and privacy practices. In the event of a breach of unsecured PHI, the Plan will notify affected individuals of the breach. Section 4 – Your Right to File a Complaint With the Plan or the HHS Secretary If you believe that your privacy rights have been violated, you may complain to the Plan. Such complaints should be made to the Plan’s Privacy Official. You may file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, D.C. 20201. The Plan will not retaliate against you for filing a complaint. Section 5 – Whom to Contact at the Plan for More Information If you have any questions regarding this notice or the subjects addressed in it, you may contact the Plan’s Privacy Official. Such questions should be directed to the Plan’s Privacy Official at: Custom Commodities, Inc. Human Resources 408 N Trinity Gilmer, TX 75644 903-843-2648Conclusion PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations. Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs. If you or your children are not eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or go to www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask your State if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, 2021. Contact your State for more information on eligibility. ALABAMA – MEDICAID Website: http://www.myalhipp.com/ Phone: 1-855-692-5447 ALASKA – MEDICAID The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx ARKANSAS – MEDICAID Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (1-855-692-7447) CALIFORNIA – MEDICAID Website: Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp Phone: 916-445-8322 Email: hipp@dhcs.ca.gov COLORADO – MEDICAID AND CHP+ Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 FLORIDA – MEDICAID Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268 GEORGIA Website: www.medicaid.georgia.gov Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA – MEDICAID Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ 59

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Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 IOWA – MEDICAID Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website:http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp HIPP Phone: 1-888-346-9562 KANSAS – MEDICAID Website: http://www.kancare.ks.gov Phone: 800-792-4884 KENTUCKY – MEDICAID Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov LOUISIANA – MEDICAID Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)MAINE – MEDICAID Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711 MASSACHUSETTS – MEDICAID Website: http://www.mass.gov/info-details/masshealth-premium-assistance-pa Phone: 1-800-862-4840 MINNESOTA – MEDICAID Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739 MISSOURI – MEDICAID Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 MONTANA – MEDICAID Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 NEBRASKA – MEDICAID Website: http://www.ACCESSNebraska.ne.gov Phone: 855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178 NEVADA – MEDICAID Website: http://dhcfp.nv.gov Phone: 1-800-992-0900 NEW HAMPSHIRE – MEDICAID Website: http://www.dhhs.nh.gov/ombp/nhhpp/ Phone: 603-271-5218 Hotline: NH Medicaid Service Center at 1-888-901-4999 NEW JERSEY – MEDICAID AND CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK – MEDICAID Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – MEDICAID Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100 NORTH DAKOTA – MEDICAID Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 OKLAHOMA – MEDICAID Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON – MEDICAID AND CHIP Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA – MEDICAID Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462 RHODE ISLAND – MEDICAID Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347 SOUTH CAROLINA – MEDICAID Website: https://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - MEDICAID Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – MEDICAID Website: http://gethipptexas.com/ Phone: 1-800-440-0493 UTAH – MEDICAID AND CHIP Medicaid Website: https://medicaid.utah.gov CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669 VERMONT– MEDICAID Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA – MEDICAID Website: https://www.coverva.org/en/famis-select Website: https://www.coverva.org/en/hipp Medicaid and CHIP Phone: 1-800-432-5924 WASHINGTON – MEDICAID Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 WEST VIRGINIA – MEDICAID Website: http://mywvhipp.com/ Toll Free Phone: 1-855-MyWVHIPP (1-855-699-8447) WISCONSIN – MEDICAID 60

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