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EMPLOYEE BENEFITS2025 Message
2The Amplify Energy Annual Legal Notices can be found on the ADP Portal.• Women’s Health Cancer Act of 1998 (WHCRA) Notice• Newborns and Mothers’ Health Protection Act Notice• Notice of Special Enrollment Rights• Notice Regarding Wellness Rights• Statement of ERISA Rights• Medicare Part D Participant Notice• CHIPRA Notice• New Health Insurance Marketplace Coverage options and Your Health Coverage• Notice of Privacy PracticeTABLE OF CONTENTSWELCOME TO OPEN ENROLLMENT ............................. 3BENEFITS ELIGIBILITY AND ENROLLMENT............4ENROLLMENT INSTRUCTIONS .......................................... 5AMPLIFY ENERGY WELLNESS PROGRAM ............... 6MEDICAL BENEFITS ................................................................... 7BCBS MEMBER RESOURCES ............................................... 8VIRTUAL VISITS ............................................................................. 9TRANSPARENCY TOOLS FOR BCBS OF TX ...........10PRESCRIPTION DRUG COVERAGE ................................ 11DENTAL BENEFITS .................................................................... 12VISION BENEFITS....................................................................... 13HEALTH SAVINGS ACCOUNT—HSA .......................14-15FLEXIBLE SPENDING ACCOUNTS ................................. 16LIFE AND AD&D........................................................................... 17DISABILITY BENEFITS ............................................................ 18CANCER INSURANCE.............................................................. 19WORKSITE BENEFITS .....................................................20-21ADDITIONAL PROGRAMS AND BENEFITS ... 22-23IMPORTANT CONTACTS ....................................................... 24BENEFIT RESOURCE CENTER ......................................... 25
BENEFITS ENROLLMENTAmplify Energy’s benefit program is designed with flexibility in mind so you can select the benefits that best meet your specific needs and those of your loved ones. Your total compensation package includes a competitive benefits program designed to assist with the physical, mental, financial, and legal needs of your family.Each year at Amplify Energy, we assess our benefit offerings to make sure we are providing you with the best value possible. This also allows us to review our costs and ensure that we can continue to provide you and your loved ones with benefits to help you live a healthy life.WHAT IS OPEN ENROLLMENT?Open Enrollment is your annual opportunity to make changes to your benefits and choose which dependents you would like to cover. This year, Amplify Energy is hosting a passive enrollment. This means if you are satisfied with your current benefit elections, no action is required and you will automatically roll over as-is in 2025. The only exception is if you are interested in participating in the Health Care FSA or Dependent Care FSA, you are required to make an annual election for 2025.WHAT IS NEW IN 2025?Amplify has teamed up with UNUM to expand additional voluntary insurance benefits:• Accident• Hospital Indemnity, and• Critical IllnessAmplify Health Plan SavingsSlight increase of $100 to the individual deductible.Traditional PPOOutpatient Lab/X-Ray are subject to 20% coinsurance after deuctible has been met.ADDITIONAL RESOURCESFor more information on your benefit options, please go to HR Sharespoint.3WELCOME TO OPEN ENROLLMENTTHE DEADLINE TO ENROLL OR MAKE CHANGES FOR 2025 BENEFITS IS NOVEMBER 8TH!
4WHO IS ELIGIBLE?Employees who work at least 30 hours per week and their qualified dependents can participate in the plans. The following family members are eligible for medical, dental, vision, voluntary accident, critical illness (Unum), hospital insurance, and voluntary life coverage:• Legal spouse or domestic partner• Natural children, legally adopted children, children placed for adoption, or stepchildrenGrandchildren who are entitled to be claimed as your dependents for federal income tax purposes Children are eligible for coverage from birth to age 26. If a child is mentally or physically disabled, the child’s coverage may continue as long as the child remains disabled and dependent upon you for support (annual verification required).Please Note: It is important that you enroll eligible dependents only. Be prepared to provide documentation to verify those that you wish to cover meet the plan’s definition of eligibility. Contact the Human Resources Department for a list of acceptable documentation.BENEFITS ELIGIBILITY AND ENROLLMENTMAKING CHANGESTo make changes outside of your initial enrollment period, you must incur an IRS-approved qualifying status change. The table below lists the approved status change events and the allowable changes associated with them.LIFE STATUS EVENTREQUIRED DOCUMENTATIONBENEFIT START AND END DATECHANGES ALLOWEDMEDICAL/ DENTAL/VISIONHCFSA/ DCFSAVOLUNTARY LIFEMarriage or adding a Domestic PartnerMarriage license or affidavitStart: First of Month following or coinciding with event End: End of Month following eventMay add spouse or DP; add or terminate self and any new or current dependentsMay add, change or terminateEmployees can decrease or terminate coverage at any time. To add a new dependent, employees must have been enrolled in Voluntary Life or wait for next Open Enrollment.Divorce Divorce Decree Start: First of Month following or coinciding with event End: End of Month following eventMay terminate spouse; add or terminate self and any new or current dependentsMay add, change or terminateAdding Child (Birth, Custody, Adoption, Legal Guardianship)Birth certificate, adoption paperwork, verification of birth from hospitalStart: Date of Event May add dependentMay add or increaseLoss of other CoverageCertificate of creditable coverage or documentation proving loss (COBRA paperwork)Start: First of Month following or coinciding with eventMay add self, spouse, and any eligible dependentsMay add or increaseGain of other CoverageProof of other coverageEnd: End of Month following the eventMay terminate self, spouse and any current dependentsMay add or increaseWatch Video
5REMEMBER!If you think you may have a qualifying status change, you MUST notify Human Resources within 31 days of the event. Failure to make timely notice would require you to wait until the next Open Enrollment period for changes to be made effective January 1, 2026.days31 ENROLLMENT INSTRUCTIONSYOUR ENROLLMENT TASKS MAY INCLUDE: Review Your Personal Information Review Your Dependents and Beneficiaries Enroll in a Plan Review Your Benefit Enrollments Selections View Waived Plans Change Your Enrollment Details View Your EnrollmentsSTEPS TO ENROLLMENT SUCCESS1. Log on to: https://workforcenow.adp.com2. Starting Point: Myself > Benefits > Enrollments3. On the Enrollments page, click on Start and follow the instructions on each screen.4. After reviewing all plans and making your selections5. Submit EnrollmentQUESTIONS?HUMAN RESOURCES HR@AMPLIFYENERGY.COM
6WELLNESS PROGRAM INCENTIVES:• Premium Differential: Completion of the physician engagement form and a preventive physical exam with an approved healthcare provider, will earn employees who are enrolled in an Amplify medical plan a $50/month discount on medical contributions for the 2026 plan year.• Amplify Healthy Living Incentives: Amplify will reimburse employees 50% of the cost for participation in approved health-related memberships and/or activities up to a maximum of $300.What if I don’t participate?If you choose not to participate in the Amplify Wellness Program, you will not be eligible for the program incentives.Is the program mandatory?No. We hope you participate willingly to improve your health and well-being, but participation in the program is completely voluntary. Is there a new hire provision?If you are eligible for benefits on or after October 1, 2025, you will be grandfathered into the program and will receive the premium differential incentive.When is the discount effective?For the plan year starting 1/1/2026. AMPLIFY ENERGY WELLNESS PROGRAMFOR MORE INFORMATIONContact the Wellworks team for details on the program, including requirements, eligibility, deadlines and more.Wellworks 800.425.4657ADDITIONAL RESOURCESInformation and forms are also available on the Amplify HR SharePoint site.Amplify wants you to be well and recognizes you perform at your best when you are healthy. Our goal is to encourage you to connect with your primary care physician (PCP) to help you discover and manage any medical conditions you may currently have. That’s why we are continuing our wellness program centered around physician engagement.All employees are eligible to complete the Amplify Energy Wellness Program regardless of if you are enrolled in an Amplify Energy medical plan. Watch Video
7MEDICAL BENEFITSMEDICAL PLAN HIGHLIGHTS SIDE BY SIDE1 Out-of-Pocket Maximum includes deductible, copays, coinsurance and all copays, including medical & pharmacy.The above illustration includes the in-network benefits only. Out-of-network benefits are available for the two BCBSTX plans, but your out of pocket dollars will be lower if you seek treatment from a contracted provider.TRADITIONAL PPO AMPLIFY HEALTH SAVINGS PLAN (AHSP)CARRIER BCBSTX BCBSTXNetworkBlue Choice Blue ChoiceHealth Savings Account (HSA) • Individual / FamilyNot applicableEmployer Contributions $1,000 / $2,000Annual Deductible • Individual / Family$1,000 / $2,000 $3,300 / $5,400Out-of-Pocket Maximum1 Includes Deductible, %, Copays • Individual / Family$3,500 / $7,000 $5,000 / $10,000Physician Oce Visit • Primary Care • Virtual / Telehealth • Specialist $25 copay $25 copay $50 copay 20% after deductible 20% after deductible 20% after deductiblePreventive CareCovered at 100% Covered at 100%Inpatient Hospital Care20% after deductible 20% after deductibleOutpatient Hospital Care20% after deductible 20% after deductibleEmergency Room • Facility • Physician 20% after $250 copay 20% after deductible 20% after deductible 20% after deductibleUrgent Care$75 copay 20% after deductibleRetail Prescription Drugs • Generic Drug • Preferred Brand Name Drug • Non-Preferred Brand Name Drug • Specialty Rx$20 copay $35 copay $70 copay Same as retail copay$10 copay after deductible $35 copay after deductible $60 copay after deductible Same as retail copayMONTHLY DEDUCTIONS PPO AHSPEmployee Only$161 $110Employee + Spouse$340 $243Employee + Child(ren)$298 $214Employee + Family$468 $332Contributions illustrated on the left do not include the $50/month discount for completing the wellness program requirements. The 2025 discount will be granted to anyone who satisfied the program requirements by January 15, 2025. Please note: all employees will need to complete the program again in 2025 to be eligible for the discount in 2026. Please refer to page 6 for more information.Watch Video
8BCBS MEMBER RESOURCESARE YOUR DOCTORS IN-NETWORK?How can you keep your medical costs down and get the most out of your benefits? The first step is to verify your doctors and the facilities that treat you are considered in the plan’s network.It is your responsibility to be an informed consumer, so do your research before going to the doctor.Both medical plans with BlueCross BlueShield of Texas utilize the BlueChoice PPO Network!CALL MEMBER SERVICES AT 800-521-2227 ORACCESS A PROVIDER DIRECTORY ONLINE AT WWW.BCBSTX.COM.Amplify Energy medical plans are designed to cover a wide variety of medical services, including preventive care, office visits, prescription drugs and inpatient care. The plans differ in coverage and the level of benefits they provide.24/7 NURSELINEHave a medical question? Bilingual nurses are available to identify options when you or your family member has a health problem or concern. Call 800-581-0393, 24/7!CLICK HERE TO LEARN HOW TO READ AN EXPLANATION OF BENEFITS “EOB”BLUE ACCESS FOR MEMBERSIt’s easy to manage your medical benefits with Blue Access for Members and Blue Access Mobile (BAM).• Register by visiting www.bcbstx.com• Click “Sign Up or Log In”• Click “Register Now”, and use the information on your BCBSTX ID card to complete the registration processWITH BAM YOU CAN:• View coverage details• Access ID cards• Check claims status• Find a doctor• Access general health informationThe Blue Access Mobile app is available for both Apple and Android users.
9Getting sick is never convenient, and finding time to get to the doctor can be hard. MDLIVE provides you and your covered dependents access to care for non-emergency medical issues through MDLIVE. Virtual visits can also be a better alternative than going to the emergency room or urgent care center.Whether you’re at home or traveling, access to a board-certified doctor is available 24 hours a day, seven days a week. If you are enrolled in the PPO, the cost for this program is the same as your office visit copay. Those who enroll in the HSA plan will be responsible for the contracted rate of $40-$60 and subject to the plan deductible.MDLIVE doctors can help treat the following conditions and more:• Allergies• Asthma• Nausea• Sinus infections• Cold/Flu• Ear problems• Pinkeye REGISTER TODAY AND TAKE ADVANTAGE OF THIS BENEFIT!WWW.MDLIVE.COM 888-680-8646CLICK HERE TO LEARN MORE ABOUT WHERE TO GO FOR CAREVIRTUAL VISITSWatch Video
10TRANSPARENCY TOOLS FOR BCBS OF TXWHERE YOU GET CARE MAY AFFECT YOUR HEALTH AND YOUR WALLETBe a Smart Health Care Shopper with Help from Blue Cross and Blue Shield of Texas (BCBSTX).There is a lot to think about when deciding where to go for health care. Just take a look at how much prices differ for the same procedure in the same area.Note: costs are examples and may not apply to every member’s situation.Being informed does not have to be tricky, and there are resources available for helping you make the best decision.Use “Find Care”® to help make more informed health care choices by:Checking costs before your appointment: We’re here to help you find quality contracted health care providers that may cost less and to help you understand what you may need to pay based on your plan’s copay, coinsurance, deductible and other benefits.Finding out how doctors in your area compare:• Find a doctor in your network.• Check if your facility has been recognized for providing quality care.• Or read reviews and ratings from other members and share your own.GO ONLINELog in to Blue Access for Members (BAM) at www.bcbstx.com, anytime, day or night.Click Find Care to compare costs and find providers in-network.GET THE APPGo to the App Store or Google Play.Use the app to find all kinds of information to help you choose a provider and save money.*Message and data rates may applyPROCEDURE PROVIDER A1 PROVIDER B1 DIFFERENCEMRI of the Brain$513 $4,073 $3,560Hysterectomy$7,433 $35,039 $27,606Hernia Repair$3,170 $10,723 $7,553Knee Replacement$17,003 $61,930 $44,927Watch Video
11Your prescription drug coverage through MyPrimeoffers many options, resources and advantagesincluding: cost savings, convenience and time savings.At MyPrime.com, you will find a variety of tools that can help you learn more about your medicines,estimate prescription drug costs and help you bettercommunicate with your doctor about your options.USE MYPRIME.COM TO:• Find out if a drug is on your plan’s drug listor formulary Use the pharmacy locator tool• See a list of generic options for a brand drugand learn more about• generic drugs. Using generic drugs can oftensave you money.• Prescription History• Calculate your estimated cost for a 30-dayor 90-day supply of a covered drugPRESCRIPTION DRUGCOVERAGETO GET STARTED, JUSTFOLLOW THESE STEPS:1. Go to www.bcbstx.com2. Log in to Blue Access for Members3. Click on Pharmacy under Coverageand Benefits.This will direct you to MyPrime.com, the member site of BCBSTX pharmacybenefits manager.Watch Video
12Your dental benefits are provided through MetLife. The plan allows you the freedom to select any dentist, but you will pay less out-of-pocket when you choose an in-network provider.The chart below provides a brief summary of the dental benefits available through MetLife. For a complete listing of the benefits and restrictions, please refer to your certificate of coverage.DENTAL BENEFITSTo find a dental provider, visit metlife.com and on the homepage select “Support>Find a Dentist”.You may also contact Employee Customer Services at 1-800-GetMet8.METLIFE MEMBER RESOURCESOnce you’re enrolled you may take advantage of online self-service capabilities with MetLife.www.mybenefits.metlife.comDENTAL BENEFITS* PPO PLANAnnual Deductible$50 individual / $150 familyAnnual Maximum Benefit$2,250 per individualType A: Preventive** Type B: Basic Restoration Type C: Major RestorationCovered at 100%, deductible waived 20% after deductible 50% after deductibleType D: Orthodontia (Adult and Child)50%Orthodontia Lifetime Maximum$2,000Out-of-Network Benefit90th Percentile Usual & CustomaryDENTAL MONTHLY DEDUCTIONSEmployee Only$10.00Employee + Spouse$22.00Employee + Child(ren)$24.00Employee + Family$36.00*For more information regarding the dental service category and frequency refer to your benefit summary which can be found under Resource > Company Information > Tool/Resources section on ADP.**Oral examinations & cleanings are covered twice in 12 months.Watch Video
13EQUITABLE MEMBER RESOURCESOnce you’re enrolled you may take advantage of online self-service capabilities with www.equitable.com. 866-274-9887VISION BENEFITSVISION BENEFITS IN-NETWORK BENEFITSExamsCovered in full after $10 copayFramesUp to $130 allowance then 20% off balance after $25 eyewear copayStandard Corrective Lenses Single, Bifocal, Trifocal, Lenticular Contact Lenses (in lieu of eye glasses) Fitting and evaluation Conventional/Medically Necessary$25 copay $60 copay maximum Up to $130 allowance/Covered in fullFREQUENCY OF SERVICESEye ExaminationOnce every 12 monthsLensesOnce every 12 monthsFramesOnce every 12 monthsOUT-OF-NETWORK BENEFITS ARE SUBJECT TO A REIMBURSEMENT SCHEDULEAmplify Energy has developed a separate Prescription Safety Glasses Policy for any employee requiring prescription protective eyewear to conduct your job duties. Please contact HR for additional information on how to apply for this $150 reimbursement.VISION MONTHLY DEDUCTIONSEmployee Only$6.61Employee + Spouse$13.22Employee + Child(ren)$14.14Employee + Family$21.56Don’t forget to view special offers from VSP by visiting: www.vsp.com/specialoffersThe vision plan is offered through Equitable. This is a full-service vision plan that has a copayment schedule for in-network services, as well as out-of-network reimbursements for exams and services. To find a vision provider, visit equitable.com and on the homepage select “Search for Vision Providers” to search by location. You may also contact Member Services at 866-274-9887.Employees can simply use their Social Security number to verify coverage with their provider. If you prefer, easily download a Member Vision Card through www.equitable.com or directly from VSP (www.vsp.com).Refer to your certificate of coverage for additional information regarding this benefit.Watch Video
14A Health Savings Account “HSA” is a tax-advantaged savings account you establish exclusively for the purpose of paying for qualified medical expenses. HSAs are only available to individuals who are enrolled in the Amplify Health Savings Plan (AHSP). HSA dollars can be used to pay for medical and prescription drug expenses that are applied toward deductibles, over-the-counter medications if purchased with a prescription, and other out-of-pocket expenses for your medical, dental and vision expenses, all subject to IRS guidelines. The HSA is administered through Bank of America.CHANGING YOUR CONTRIBUTIONSOnce you establish your HSA, you can change your contributions at any time during the year. This flexibility enables you to contribute as much as your budget allows (up to the IRS annual maximums listed above) and adjust your contributions to fit your household budget throughout the year.CLICK HERE TO LEARN MORE ABOUT HOW TO OPTIMIZE YOUR HSAHEALTH SAVINGS ACCOUNT—HSAHERE’S HOW AN HSA WORKSSTART IT After you enroll in the AHSP Plan, Amplify will set up your account on your behalf, you will receive an email from Bank of America once this has been completed. After you open an HSA, your employer may make a contribution to your account.BUILD IT Your contributions to your HSA are pre-tax through payroll contributions. Limits apply (see below). You can change the amount you contrib-ute at any time.USE IT You can use the money in your HSA to pay for covered health care for you and your qualified dependents (like the deductible and coinsurance). Withdrawals from your HSA (for qualified medical expenses) are also tax-free!GROW IT Unused money in your account will roll over to the next year. Your account will earn interest and grow over time.KEEP IT You always own the money in your HSA, including contributions from Amplify Energy and any inter-est and other investment earnings. You can take the account with you if you are no longer em-ployed by the company.COVERAGE LEVEL 2025 ANNUAL LIMIT EMPLOYER CONTRIBUTIONYOUR CONTRIBUTION MAXIMUMEmployee Only$4,300 $1,000 $3,300Employee + Spouse$8,550 $2,000 $6,550Employee + Child(ren)$8,550 $2,000 $6,550Employee + Family$8,550 $2,000 $6,550Catch-up contribution: The annual catch-up contribution for individuals ages 55 or older remains $1,000Watch Video
15USE YOUR FUNDS WITH A DEBIT CARDYour HSA works like a savings account. You decide whether to use the funds to pay for health care expenses out of your pocket or from your HSA using a convenient debit card provided by Bank of America.HEALTH SAVINGS ACCOUNT—HSAKEEP YOUR RECEIPTS!Since your HSA is tax-advantaged, it is subject to IRS regulations and a possible audit. Always make sure to keep your receipts.QUALIFIED EXPENSESFor a full list of qualified expenses, visit: www.irs.gov/pub/irs-pdf/p502.pdfAdditional ResourcesBOA Phone: 800-718-6710 | Website: myhealth.bankofamerica.comHSA BY THE NUMBERS100% How much of your HSA balance automatically rolls over year-to-year. 100% How much of your HSA balance you can take with you if you leave the company. 100% How much of the money in your HSA grows tax-free. $0 Taxes you pay on the money you contribute to the HSA or withdraw for qualified expenses.WHO WILL PAY FOR YOUR HEALTH CARE IN RETIREMENT? CLICK HERESEE HOW OTHERS ARE USING THEIR HEALTH SAVINGS ACCOUNTS (HSA) CLICK HEREWatch Video
16FSAs allow you to have pre-tax money deducted from your paycheck to pay for certain unreimbursed medical expenses and dependent care costs. Since contributions are made through payroll deductions with pre-tax dollars, you decrease your taxable income and increase your take home pay by taking advantage of this benefit. Amplify Energy offers two types of accounts, a Health Care FSA and a Dependent Care FSA. If you are enrolled in the Amplify Health Savings Plan (AHSP) and participate in the HSA, you are not eligible for the Health Care FSA program. CLICK HERE TO LEARN MORE ABOUT FSA CLICK HERE TO LEARN MORE ABOUT DEPENDENT CARE FSA CLICK HERE TO LEARN HOW TO OPTIMIZE YOUR FSAFLEXIBLE SPENDING ACCOUNTS“BENEFITS BY WEX” MOBILE APPYour FSA accounts are now accessible on the go. Through the “Benefits by WEX” mobile app, you can get instant notifications of the status of claims, upload claim documentation, report a card lost or stolen, check balance and activity, and much more.COVERAGE LEVEL WHY WOULD I USE IT? MAXIMUM CONTRIBUTION AMOUNTSHealth Care FSA• Pays the uncovered portions of medical, dental, and vision expenses (including copays and deductible).• Contributions are pre-tax, so it increases your non-taxable take-home pay. • Covers expenses incurred by you or an eligible dependent.$3,300 per plan year• Up to $660 of unused funds may carry into the next plan year. • Any amount over is forfeited.• The account is pre-funded, meaning you can access your total annual contribution amount (less any monies already spent) at any time, even before the money is deposited.Dependent Care FSA• Pays for daycare for eligible dependents. • You (and your spouse, if married) work outside the home and require dependent care to allow you to work full-time.• You claim the dependent on your income tax return.• Contributions are pre-tax, so it increases your non-taxable take home pay. $5,000 per plan year ($2,500 if married and filing separately)• There is no carryover of fund associated with this account, so estimate your needs conservatively.• The account is NOT pre-funded, meaning that after you file a claim, you may only receive reimbursement for amounts that are currently in the account.
17LIFE AND AD&DBASIC LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)Amplify Energy provides Basic Life and AD&D Insurance at no cost to you through Unum. Your benefit is 2x your annual earnings (as defined by the Plan Document) up to $500,000. This benefit will be paid to your designated beneficiary in the event of your death while covered under the plan. Age reduction schedule applies.VOLUNTARY LIFE/AD&DFor an added layer of protection, you also have the opportunity to purchase additional Life and AD&D Insurance for yourself and your covered dependents. You must enroll yourself in coverage in order to enroll your spouse and/or children. Age reduction schedule applies.IMPORTANT! WHAT YOU NEED TO KNOW... • The spouse’s rate is based on his or her age.• You will be required to provide Evidence of Insurability (EOI) if:• You initially elect an amount over the Guarantee Issue amount or elect to so during open enrollment periods.• You decline voluntary life during your initial eligibility then elect coverage during a future open enrollment.• Your life insurance benefit is subject to the following age reduction schedules:• 65% of the original benefit at age 65• 50% of the original benefit at age 70• Employees must be actively at work to elect coverage.• A spouse or dependent child must not be confined in a hospital, rehabilitation or convalescence center, custodial care facility or confined to his/her home under the care of a physician.• Portability and Conversion Privileges applyVOLUNTARY LIFE AND AD&D BENEFITSEmployeeYou can purchase units of $1,000 to a maximum of the lesser of 7x your annual earnings (as defined by the plan document) or $500,000. Guarantee Issue: $130,000SpouseYou may elect units of $5,000 to a maximum of $250,000, not to exceed 100% of the employee’s election. Guarantee Issue: $30,000ChildrenYou may elect units of $2,000 to a maximum of the lesser of $10,000 or 100% of the employee’s election. (Benefit for children live birth to age 6 months is $1,000 VOLUNTARY LIFE AND AD&D BENEFITSAGE<24 25-29 30-34 35-39 40-44 45-59 50-54 55-59 60-64 65-69 70-74 75+Rate$.094 $.113 $.119 $.149 $.197 $.293 $.477 $.815 $1.294 $2.151 $3.727 $6.163Employee AD&D: $.040 Spouse AD&D: $.020 Child Life/AD&D: $.098 / $.010Watch Video
Amplify Energy provides Short Term and LongTerm Disability (LTD) insurance at no cost toyou through Unum. If you prefer, you can electto pay the LTD premium on a voluntary basisthrough post-tax payroll deductions. Doing soallows you to receive benefit payments tax-free if you file a claim. The cost for enrollmentis $0.25 per $100 of your covered payroll. Theexact calculation will be provided during theonline enrollment process. Please refer to yourcertificate of coverage for additional detailsregarding this benefit.DISABILITYBENEFITSWHAT IS SHORT TERMAND LONG TERM DISABILITY?Learn more about Short TermLearn more about Long TermTHE UNUM MOBILE APPNeed to file a claim or check on the status ofpayment? Use the Unum Customer mobile appto help manage your Life, AD&D, and Disabilitybenefits.With this free app you can submit documents,register for and manage direct deposit, verifyyour personal information or access Unum’scontact center.The app is available forApple and Android devices.SHORT TERM DISABILITY INSURANCEWeekly Benefit60% of your weekly earningsBenefit Maximum$2,500 per weekElimination Period7 days for injury or sicknessMaximum Benefit DurationUp to 25 weeksPre-existing condition limitNoneLONG TERM DISABILITY INSURANCEMonthly Benefit60% of your monthly earningsBenefit Maximum$12,000 per monthElimination Period180 daysMaximum Benefit DurationUp to Social Security NormalRetirement AgePre-existing condition limit3-month lookback /12-month exclusion18
19While major medical insurance can help with the cost of cancer treatment, you may still have out-of-pocket expenses that are not covered by your major medical insurance, including travel, food, lodging, child care and household help. Meanwhile, living expenses such as car payments, mortgage or rent payments and utility bills continue whether or not you are able to work. And if a family member has to stop working to take care of you, the loss of income may be doubled. At no cost to you, Amplify is covering you for up to $10,000 and your spouse for up to $5,000.*Note: Coverage is 100% for invasive cancer and 25% for non-invasive cancer.HOW DOES CANCER INSURANCE WORK?Cancer coverage provides a fixed benefit for the early detection, incidence and treatment of cancer as well as related expenses. The benefit is paid directly to you unless you choose otherwise. You can use the benefit any way you choose — to pay your mortgage, clear debts or replace lost income — you do not have to use the benefit to pay for treatment. This means you will have additional resources to help with the financial consequences of cancer that may not be covered by major medical insurance.If a member has a pre-existing condition that is diagnosed or symptoms occurred in the 12 months prior to the policy effective date, no benefits will be paid for the first 12 months of the policy effective date. Refer to the certificate of coverage for specific pre-existing limitations.Additional Resources For more information on your benefit options, please go to HR Sharepoint.CANCER INSURANCEWHAT IS SHORT TERM AND LONG TERM DISABILITY?Learn more about Short TermLearn more about Long TermADDITIONAL OCCURRENCE BENEFITOnce benefits have been paid under the ManhattanLife policy for a Critical Illness, an additional benefit is eligible to be paid when:1) The date of Diagnosis for the new Critical Illness is separate from the prior Critical Illness by at least six (6) consecutive months,2) the new Critical Illness is not caused by a Critical Illness for which benefits have been paid, and3) a benefit is not paid for more than one Critical Illness within a six (6) month period.Watch Video
20WORKSITE BENEFITSACCIDENT INSURANCE (24 HOUR COVERAGE)Accident insurance is an excellent benefit for those who have active lifestyles or children involved in sports or other extracurricular activities. The accident plan is designed to pay benefits directly to you based on treatment received and injuries sustained as a result of a covered accident. There is no waiting period for coverage to begin and payment will be in addition to any other insurance you have.HOSPITAL INSURANCEHospital Indemnity insurance can help you be better prepared by providing you with a payment tobe spent as you see fit if you experience one of the below covered events and meet the policy and certificate requirements. These benefits are portable, which means you can keep them even if you change employers and these benefits are paid directly to you, not the doctor or the hospital, regardless of whatever insurance coverage you may have.ACCIDENT BENEFITUNUMBenefit ReimbursementWellness Benefit $50 per calendar yearDeath (Employee / Spouse / Child)$50,000 / $25,000 / $12,500Appliances (ie. Crutches) Up to $200X-Ray / Complex Imaging $50 / $200 (1)Follow Up Treatment $75 (2)Fractures / Dislocations up to $4,500Physical Therapy up to $20 (15)Lacerations up to $600Concussion $200Hospital / ICU Admission $1,000 / $2,000 (24 hr)Hospital / ICU Confinement $200 / $300 (15)Outpatient Surgery $300Ambulance (Air / Ground) $1,000 / $300Eye Injury $200Pain Management / Anesthesia $100 / $250Prosthetic Device up to $1,500HOSPITAL INDEMNITY UNUMBenefit ReimbursementHospital Coverage (Accident)Hospital Admission (per admission)$1,000 (non-ICU) / $2,000 (ICU)Hospital Confinement (per day)$100 (non-ICU 365) / $200 (ICU 30)Hospital Coverage (Sickness)Hospital Admission (per admission)$1,000 (non-ICU) / $2,000 (ICU)Hospital Confinement (per day)$100 (non-ICU 365) / $200 (ICU 30)ProvisionsGuarantee Issue YesPre-Existing Waiting Period NoPre-Existing Pregnancy CoveredYesVOLUNTARY ACCIDENT MONTHLY PREMIUMSEmployee Only $13.45Employee & Spouse $23.70Employee & Child/ren $25.66Employee & Family $35.91VOLUNTARY HOSPITAL INDEMNITY MONTHLY PREMIUMSEmployee Only $15.11Employee & Spouse $36.08Employee & Child/ren $23.04Employee & Family $44.01To file claims, access certificates of insurance, and more: Visit www.unum.com/employees or contact 800-635-5597Rates include Annual $50 Be Well Benefit (payable to policyholder after wellness exam / physical)
21WORKSITE BENEFITSCRITICAL ILLNESS INSURANCEAvailable to you and your family*. Pays you a lump sum benefit if you are diagnosed with sudden illnesses (i.e., heart attack, cancer, stroke) to help pay other related expenses such as lost income, childcare, travel to and from treatment, high deductibles, and copays. UNUM will send you a check for the amount you elected. Please see the brochure for more information.CRITICAL ILLNESS UNUMBenefit Covered Illness ProvisionsYour Choice of a lump sum paid directly to the policyholder: Employee: $10,000, $20,000 or $30,000Spouse: 50% of Employee AmountChild(ren) under age 26: 50% of Employee Amount More than 25 listed conditions with partial or full benefit coverageMost Common full-benefit diagnosis Include: Invasive Cancer, Heart Attack, Stroke, Major Organ Transplant, Kidney Failure, Alzheimer’s DiseaseGuarantee Issue & No Pre-Existing Waiting PeriodDierent Illness Diagnosis: 0-month separationSame Illness Diagnosis: 6-month separation (Cancer / Heart Attack / Stroke)INCLUDES ANNUAL$50 BE-WELL BENEFIT(IN ADDITION TO ANY OTHER PLAN INCENTIVES)*OptionsBase Mid HighEmployee $10,000Add Spouse $5,000Employee $20,000Add Spouse $10,000Employee $30,000Add Spouse $15,000< 25 $4.08 $2.98 $6.28 $4.08 $8.48 $5.1825 - 29 $4.78 $3.33 $7.68 $4.78 $10.58 $6.2330 - 34 $5.68 $3.78 $9.48 $5.68 $13.28 $7.5835 - 39 $6.88 $4.38 $11.88 $6.88 $16.88 $9.3840 - 44 $9.18 $5.53 $16.48 $9.18 $23.78 $12.8345 - 49 $13.08 $7.48 $24.28 $13.08 $35.48 $18.6850 - 54 $18.98 $10.43 $36.08 $18.98 $53.18 $27.5355 - 59 $25.78 $13.83 $49.68 $25.78 $73.58 $37.7360 - 64 $44.48 $23.18 $87.08 $44.48 $129.68 $65.7865 - 69 $59.58 $30.73 $117.28 $59.58 $174.98 $88.4370 - 74 $80.58 $41.23 $159.28 $80.58 $237.98 $119.9375 - 79 $108.38 $55.13 $214.88 $108.38 $321.38 $161.6380 - 84 $144.28 $73.08 $286.68 $144.28 $429.08 $215.4885+ $208.98 $105.43 $416.08 $208.98 $623.18 $312.53TO FILE CLAIMS, ACCESS CERTIFICATES OF INSURANCE, AND MORE:Visit: www.unum.com/employees or contact 800-635-559721
22ADDITIONAL PROGRAMS AND BENEFITSEMPLOYEE ASSISTANCE PROGRAM (EAP)With your Employee Assistance Program through Health Advocate provides confidential assistance is as close as your phone or computer.Your EAP is designed to help you lead a happier and more productive life at home and at work. You will have confidential access to a licensed professional counselor who can help you. This benefit is available at no cost to you.A LICENSED PROFESSIONAL COUNSELOR CAN HELP YOU WITH:• Family concerns• Relationships• Stress• Anxiety• Depression• Grief• Drug and alcohol concerns• Work-related issues• Work/life balanceASK OUR SPECIALISTS ABOUT:• Child/Elder Care• Legal Questions• Identity Theft• Financial Services• Debt Management• Substance Abuse,• gambling and• other dependenciesWHO IS COVERED?Health Advocate’s EAP services are available to all eligible employees, their spouses or domestic partners, dependent children, parents and parents-in-law.HOW DO I ACCESS THE EAP?Toll Free 24/7: 866-799-2485 (multi-lingual)Email: answers@HealthAdvocate.comWeb: HealthAdvocate.com/membersHELP IS EASY TO ACCESS:• Licensed Professional Counselor: Up to 5 one-hour, in-person or via phone per issue per year.• Legal Attorney Consultation: One half-hour phone or in-person consultation, with 25% discount on standard fees if retained.• Certified Financial Specialist: One half-hour phone or in-person consultation per issue, no limit on number of matters addressed.• Online resources and planning tools are available.Watch Video
23ADDITIONAL PROGRAMS AND BENEFITSTRAVEL ASSISTANCEAssist America, Inc. provides help should you experience an emergency while away from home.Whether you’re traveling for business or personal reasons, Unum’s worldwide emergency travelassistance program goes with you. Help is just a phone call away, 24 hours a day, if you, your spouseor your dependent children need immediate assistance anywhere in the world. Call 800-872-1414 for more information. You may also download the Assist America mobile app or visitwww.assistamerica.com.Services are available for simple to extreme emergencies:• Help replacing lost prescriptions and passports• Referrals to Western-trained,English-speaking medical providers• Hospital admission assistance• Emergency medical evacuation
24IMPORTANT CONTACTSCOVERAGE CONTACT REFERENCE NUMBER PHONE / WEBSITEMedicalBlueCross BlueShield of Texas# 219389 PPO # 219390 AHSP800-521-2227 www.bcbstx.comFlexible Spending AccountWEX, Inc. # 20524866-451-3399 customerservice@wexhealth.comHealth Savings AccountBank of America800-718-6710 myhealth.bankofamerica.comDental PPOMetLife # 5397460800-GetMet8 (800-438-6388) www.mybenefits.metlife.comVisionEquitable # 6052866-274-9887 www.equitable.comLife / AD&D and Disability Vol. Life / AD&DUnum# 604581 # 604581File a claim online, mobile app, or via paper form 866-679-3054 www.unum.comEmployee Assistance ProgramHealth Advocate866-799-2485 www.healthadvocate.com/members Send an email: answers@healthadvocate.comTravel AssistanceAssist America Inc.Reference # 01-AA-UN-762490800-872-1414 609-986-1234 (Outside U.S) medservices@assistamerica.com401(k)Merrill # 202182800-228-4015 www.benefits.ml.comWorksite Unum800-635-5597 www.unum.com/employeesMedicareConsultingTracy Miller713-507-4729 MyBenefitAdvisor.com Send an email: tracy.miller@mybenefitadvisor.comEscalated Claims or Benefit Concerns?Toll Free: 855-874-0110BRCSouthwest@usi.comOur Benefits Specialists can assist you Monday through Friday, 8am to 5pm EST & CSTContact the Benefit Resource Center (“BRC”)!Watch Medicare Video
Escalated Claims orBenefit Concerns?Toll Free: 855-874-0110BRCSouthwest@usi.comOur Benefits Specialists can assist you Monday through Friday,8am to 5pm EST & CSTContact the Benefit Resource Center (“BRC”)!25