Bill Clark Benefit Booklet : simplebooklet.com

BCBS Plan Name Plan Type Deductible Out OfPocket Individual Family Individual Family Coinsurance MTBCP025 3 000 Plan PPO In 3 000 9 000 3 500 10 500 100 Out 6 000 18 000 Unlimited Unlimited 70 MTBCP044 6 000 Plan PPO In 6 000 15 800 8 150 16 300 80 Out 10 000 20 000 Unlimited Unlimited 50 MTBAB014 1 500 Plan HMO In 1 500 4 500 4 500 13 500 80 Out No Coverage No Coverage No Coverage No Coverage No Coverage PCP Specialty Urgent Care Emergency Room Inpatient Care Copays Outpatient Surgery Lab X Ray Advanced Imaging CT PET Scans MRIs Preferred Rx Non Preferred RX 35 30 After CYD 70 75 500 Visit 30 After CYD 30 After CYD AS INN No Charge After CYD 30 After CYD No Charge After CYD 30 After CYD No Charge No Charge 30 After CYD 30 After CYD No Charge After CYD 30 After CYD 0 10 50 100 150 250 10 20 70 120 150 250 40 80 75 500 CP CYD Coins CYD Coinsurance CYD Coinsurance No Charge No Charge 50 After CYD 50 After CYD 50 After CYD AS INN 50 After CYD 50 After CYD 50 After CYD 50 After CYD CYD Coinsurance 50 After CYD 0 10 50 100 150 250 10 20 70 120 150 250 35 70 75 500 CP CYD Coins CYD Coinsurance CYD Coinsurance CYD Coinsurance CYD Coinsurance No Coverage No Coverage No Coverage AS INN No Coverage No Coverage No Coverage No Coverage CYD Coinsurance No Coverage 0 10 50 100 150 250 10 20 70 120 150 250 3

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Summary of Benefits and Coverage What this Plan Covers What You Pay for Covered Services MTBCP025 Blue Choice PPOSM 025 CCoovveerraaggeePPeerrioiodd 0110 0 10 12 0220424 1029 3310 22002245 CovCeoravegreagfoer foInr dIinvdidivuidaul al FFaammiillyy PPllaann TTyyppee PPPPOO The Summary of Benefits and Coverage SBC document will help you choose a health plan The SBC shows you how you and the plan would share the cost for covered health care services NOTE Information about the cost of this plan called the premium will be provided separately This is only a summary For more information about your coverage or to get a copy of the complete terms of coverage visit www bcbstx com member policy forms 2024 or by calling 1 800 521 2227 For general definitions of common terms such as allowed amount balance billing coinsurance copayment deductible provider or other underlined terms see the Glossary You can view the Glossary at www healthcare gov sbc glossary or call 1 855 756 4448 to request a copy Important Questions Answers Why This Matters What is the overall deductible Network 3 000 Individual 9 000 Generally you must pay all of the costs from providers up to the deductible amount before this plan Family begins to pay If you have other family members on the plan each family member must meet their Out of Network 6 000 own individual deductible until the total amount of deductible expenses paid by all family members Individual 18 000 Family meets the overall family deductible Yes Network office visits with a Are there services covered before you meet your deductible copayment prescription drugs and This plan covers some items and services even if you haven t yet met the deductible amount But a preventive care services and copayment or coinsurance may apply For example this plan covers certain preventive services services with a copayment are without cost sharing and before you meet your deductible See a list of covered preventive services covered before you meet your at www healthcare gov coverage preventive care benefits deductible Are there other deductibles for specific No services You don t have to meet deductibles for specific services Network 3 500 What is the out of pocket Individual 10 500 Family limit for this plan Out of Network Unlimited Individual Unlimited Family The out of pocket limit is the most you could pay in a year for covered services If you have other family members in this plan they have to meet their own out of pocket limits until the overall family out of pocket limit has been met What is not included in the out of pocket limit Premiums balance billing charges and health care this plan Even though you pay these expenses they don t count toward the out of pocket limit doesn t cover Will you pay less if you use a network provider Yes See www bcbstx com go bcppo or call 1 800 810 2583 for a list of network providers This plan uses a provider network You will pay less if you use a provider in the plan s network You will pay the most if you use an out of network provider and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays balance billing Be aware your network provider might use an out of network provider for some services such as lab work Check with your provider before you get services Do you need a referral to see a specialist No You can see the specialist you choose without a referral SLMR Pharmacy No 5 Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8

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All copayment and coinsurance costs shown in this chart are after your deductible has been met if a deductible applies Common Medical Event Services You May Need Primary care visit to treat an injury or illness If you visit a health care provider s office or clinic Specialist visit Preventive care screening immunization Diagnostic test x ray blood work If you have a test Imaging CT PET scans MRIs If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www bcbstx com rxdrugs drug lists drug lists Generic drugs Preferred Generic drugs NonPreferred What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most 35 visit deductible does not apply 30 coinsurance 70 visit deductible does not apply 30 coinsurance No Charge deductible does not apply 30 coinsurance No Charge deductible does not apply 30 coinsurance No Charge after deductible 30 coinsurance Retail Preferred No Charge Non Preferred 10 prescription Mail No Charge deductible does not apply Retail Preferred 10 prescription Non Preferred 20 prescription Mail 30 prescription deductible does not apply Retail 10 prescription deductible does not apply plus 50 additional charge Retail 20 prescription deductible does not apply plus 50 additional charge Limitations Exceptions Other Important Information Virtual visits are available See your benefit booklet for details None You may have to pay for services that aren t preventive Ask your provider if the services needed are preventive Then check what your plan will pay for Inpatient Certain services may require Preauthorization for out of network failure to preauthorize may result in 250 reduction in benefits Outpatient Certain services may require Preauthorization for out of network failure to preauthorize may result in 50 reduction in benefits not to exceed 500 see your benefit booklet for details Limited to a 30 day supply at retail or a 90 day supply at a network of select retail pharmacies Up to a 90 day supply at mail order Specialty drugs limited to a 30 day supply except for certain FDA designated dosing regimens Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available Additional charge will not apply to any deductible or out of pocket amounts Cost sharing for insulin included in the drug list 6 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2024 Page 2 of 8

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Common Medical Event Services You May Need Brand drugs Preferred Brand drugs Non Preferred Specialty drugs Preferred If you have outpatient surgery Specialty drugs NonPreferred Facility fee e g ambulatory surgery center Physician surgeon fees If you need immediate medical attention If you have a hospital stay Emergency room care Emergency medical transportation Urgent care Facility fee e g hospital room Physician surgeon fees What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most Retail Preferred 50 prescription Non Preferred 70 prescription Mail 150 prescription deductible does not apply Retail 70 prescription deductible does not apply plus 50 additional charge Retail Preferred 100 prescription Non Preferred 120 prescription Mail 300 prescription deductible does not apply Retail 120 prescription deductible does not apply plus 50 additional charge 150 prescription deductible does not apply 150 prescription deductible does not apply plus 50 additional charge 250 prescription deductible does not apply 250 prescription deductible does not apply plus 50 additional charge No Charge after deductible 30 coinsurance No Charge after deductible 30 coinsurance 500 visit No Charge after deductible 75 visit deductible does not apply No Charge after deductible No Charge after deductible 500 visit No Charge after deductible 30 coinsurance 30 coinsurance 30 coinsurance Limitations Exceptions Other Important Information will not exceed 25 per prescription for a 30day supply regardless of the amount or type of insulin needed to fill the prescription Certain services may require preauthorization for out of network failure to preauthorize may result in 50 reduction in benefits not to exceed 500 For Outpatient Infusion Therapy see your benefit booklet for details Copayment waived if admitted None Preauthorization required Preauthorization penalty 250 out of network See your benefit booklet for details 7 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2024 Page 3 of 8

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Common Medical Event Services You May Need If you need mental health behavioral health or substance abuse services Outpatient services Inpatient services If you are pregnant Office visits Childbirth delivery professional services Childbirth delivery facility services Home health care If you need help recovering or have other special health needs Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most 35 office visit deductible does not apply or No Charge after deductible for other outpatient services 30 coinsurance No Charge after deductible 30 coinsurance Primary Care 35 initial visit Specialist 70 initial visit deductible does not apply No Charge after deductible No Charge after deductible 30 coinsurance 30 coinsurance 30 coinsurance No Charge after deductible 30 coinsurance No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible No Charge deductible 30 coinsurance 30 coinsurance 30 coinsurance 30 coinsurance 30 coinsurance Limitations Exceptions Other Important Information Certain services must be preauthorized failure to preauthorize at least two business days prior to service will result in 50 reduction in benefits not to exceed 500 refer to benefit booklet for details Preauthorization required out of network failure to preauthorize at least two business days prior to admission will result in 250 reduction in benefits Copayment applies to first prenatal visit per pregnancy Cost sharing does not apply to preventive services Depending on the type of services copayment or deductible may apply Maternity care may include tests and services described elsewhere in the SBC i e ultrasound 60 visits year Preauthorization may be required for out of network Failure to preauthorize may result in 50 reduction in benefits not to exceed 500 See your benefit booklet for details For Outpatient limited to combined 35 visits per year including Chiropractic 25 day maximum per calendar year Preauthorization may be required for out ofnetwork Failure to preauthorize may result in 250 reduction in benefits See your benefit booklet for details None Inpatient Preauthorization may be required for 8 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2024 Page 4 of 8

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Excluded Services Other Covered Services Services Your Plan Generally Does NOT Cover Check your policy or plan document for more information and a list of any other excluded services Abortion Except for a pregnancy that as Dental care Adult and Child Private duty nursing certified by a physician places the woman in Long term care Routine eye care Child danger of death or a serious risk of substantial Non emergency care when traveling outside the Weight loss programs impairment of a major bodily function unless an U S abortion is performed Acupuncture Bariatric surgery Cosmetic surgery Other Covered Services Limitations may apply to these services This isn t a complete list Please see your plan document Chiropractic care Outpatient Max 35 visits year combined with habilitation and Infertility treatment Invitro and artificial insemination are not covered unless shown in rehabilitation services your plan document Hearing aids Limited to one hearing aid per ear Routine eye care Adult every 36 months Routine foot care Only covered in connection with diabetes circulatory disorders of the lower extremities peripheral vascular disease peripheral neuropathy or chronic arterial or venous insufficiency Your Rights to Continue Coverage There are agencies that can help if you want to continue your coverage after it ends The contact information for those agencies is For group health coverage contact the plan Blue Cross and Blue Shield of Texas at 1 800 521 2227 or visit www bcbstx com For group health coverage subject to ERISA contact the U S Department of Labor s Employee Benefits Security Administration at 1 866 444 EBSA 3272 or www dol gov ebsa healthreform For non federal governmental group health plans contact Department of Health and Human Services Center for Consumer Information and Insurance Oversight at 1 877 267 2323 x61565 or www cciio cms gov Church plans are not covered by the Federal COBRA continuation coverage rules If the coverage is insured individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law Other coverage options may be available to you too including buying individual insurance coverage through the Health Insurance Marketplace For more information about the Marketplace visit www HealthCare gov or call 1 800 318 2596 Your Grievance and Appeals Rights There are agencies that can help if you have a complaint against your plan for a denial of a claim This complaint is called a grievance or appeal For more information about your rights look at the explanation of benefits you will receive for that medical claim Your plan documents also provide complete information to submit a claim appeal or a grievance for any reason to your plan For more information about your rights this notice or assistance contact For group health coverage subject to ERISA Blue Cross and Blue Shield of Texas at 1 800 521 2227 or visit www bcbstx com the U S Department of Labor s Employee Benefits Security Administration at 1 866 444 EBSA 3272 or www dol gov ebsa healthreform and the Texas Department of Insurance Consumer Protection at 1 800 252 3439 or www tdi texas gov For non federal governmental group health plans and church plans that are group health plans Blue Cross and Blue Shield of Texas at 1 800 521 2227 or www bcbstx com or contact the Texas Department of Insurance Consumer Protection at 1 800 252 3439 or www tdi texas gov Additionally a consumer assistance program can help you file your appeal Contact the Texas Department of Insurance s Consumer Health Assistance Program at 1 800 252 3439 or visit www cms gov CCIIO Resources Consumer Assistance Grants tx html Does this plan provide Minimum Essential Coverage Yes Minimum Essential Coverage generally includes plans health insurance available through the Marketplace or other individual market policies Medicare Medicaid 10 Page 6 of 8

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About these Coverage Examples This is not a cost estimator Treatments shown are just examples of how this plan might cover medical care Your actual costs will be different depending on the actual care you receive the prices your providers charge and many other factors Focus on the cost sharing amounts deductibles copayments and coinsurance and excluded services under the plan Use this information to compare the portion of costs you might pay under different health plans Please note these coverage examples are based on self only coverage Peg is Having a Baby 9 months of in network pre natal care and a hospital delivery The plan s overall deductible Specialist copayment Hospital facility Other 3 000 70 0 0 This EXAMPLE event includes services like Specialist office visits prenatal care Childbirth Delivery Professional Services Childbirth Delivery Facility Services Diagnostic tests ultrasounds and blood work Specialist visit anesthesia Total Example Cost In this example Peg would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Peg would pay is 12 700 3 000 0 0 60 3 060 Managing Joe s Type 2 Diabetes a year of routine in network care of a wellcontrolled condition The plan s overall deductible Specialist copayment Hospital facility Other 3 000 70 0 0 This EXAMPLE event includes services like Primary care physician office visits including disease education Diagnostic tests blood work Prescription drugs Durable medical equipment glucose meter Total Example Cost In this example Joe would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Joe would pay is 5 600 800 700 0 20 1 520 Mia s Simple Fracture in network emergency room visit and follow up care The plan s overall deductible Specialist copayment Hospital facility Other 3 000 70 0 0 This EXAMPLE event includes services like Emergency room care including medical supplies Diagnostic test x ray Durable medical equipment crutches Rehabilitation services physical therapy Total Example Cost In this example Mia would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Mia would pay is 2 800 2 500 200 0 0 2 700 12 The plan would be responsible for the other costs of these EXAMPLE covered services Page 8 of 8

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Summary of Benefits and Coverage What this Plan Covers What You Pay for Covered Services MTBCP044 Blue Choice PPOSM 044 CCoovveerraaggeePPeerrioiodd 0170 0 10 12 0220424 0069 3300 22002255 CovCeoravegreagfoer foInr dIinvdidivuidaul al FFaammiillyy PPllaann TTyyppee PPPPOO The Summary of Benefits and Coverage SBC document will help you choose a health plan The SBC shows you how you and the plan would share the cost for covered health care services NOTE Information about the cost of this plan called the premium will be provided separately This is only a summary For more information about your coverage or to get a copy of the complete terms of coverage visit www bcbstx com member policy forms 2024 or by calling 1 800 521 2227 For general definitions of common terms such as allowed amount balance billing coinsurance copayment deductible provider or other underlined terms see the Glossary You can view the Glossary at www healthcare gov sbc glossary or call 1 855 756 4448 to request a copy Important Questions Answers Why This Matters What is the overall deductible Network 6 000 Individual 15 800 Family Out of Network 10 000 Individual 20 000 Family Generally you must pay all of the costs from providers up to the deductible amount before this plan begins to pay If you have other family members on the plan each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible Yes Network office visits Are there services covered before you meet your deductible prescription drugs preventive care This plan covers some items and services even if you haven t yet met the deductible amount But a services Hospice services Urgent copayment or coinsurance may apply For example this plan covers certain preventive services care services and Diagnostic without cost sharing and before you meet your deductible See a list of covered preventive services services are covered before you at www healthcare gov coverage preventive care benefits meet your deductible Are there other deductibles for specific No services You don t have to meet deductibles for specific services Network 8 150 What is the out of pocket Individual 16 300 Family limit for this plan Out of Network Unlimited Individual Unlimited Family The out of pocket limit is the most you could pay in a year for covered services If you have other family members in this plan they have to meet their own out of pocket limits until the overall family out of pocket limit has been met What is not included in the out of pocket limit Premiums balance billing charges and health care this plan Even though you pay these expenses they don t count toward the out of pocket limit doesn t cover Will you pay less if you use a network provider Yes See www bcbstx com go bcppo or call 1 800 810 2583 for a list of network providers This plan uses a provider network You will pay less if you use a provider in the plan s network You will pay the most if you use an out of network provider and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays balance billing Be aware your network provider might use an out of network provider for some services such as lab work Check with your provider before you get services Do you need a referral to see a specialist No You can see the specialist you choose without a referral SLMR Pharmacy No 15 Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8

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All copayment and coinsurance costs shown in this chart are after your deductible has been met if a deductible applies Common Medical Event Services You May Need Primary care visit to treat an injury or illness If you visit a health care provider s office or clinic Specialist visit Preventive care screening immunization Diagnostic test x ray blood work If you have a test Imaging CT PET scans MRIs If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www bcbstx com rxdrugs drug lists drug lists Generic drugs Preferred Generic drugs Nonpreferred What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most 40 copayment visit deductible does not apply 50 coinsurance 80 copayment visit deductible does not apply 50 coinsurance No Charge deductible does not apply 50 coinsurance No Charge deductible does not apply 50 coinsurance 20 coinsurance 50 coinsurance Retail Preferred No Charge Non Preferred 10 copayment prescription Mail No Charge deductible does not apply Retail Preferred 10 copayment prescription Non Preferred 20 copayment prescription Mail 30 copayment prescription deductible does not apply Retail 10 copayment prescription deductible does not apply plus 50 additional charge Retail 20 copayment prescription deductible does not apply plus 50 additional charge Limitations Exceptions Other Important Information Virtual visits are available See your benefit booklet for details None You may have to pay for services that aren t preventive Ask your provider if the services needed are preventive Then check what your plan will pay for Inpatient Certain services may require preauthorization for out of network failure to preauthorize may result in 250 reduction in benefits Outpatient Certain services may require preauthorization for out of network failure to preauthorize may result in 50 reduction in benefits not to exceed 500 see your benefit booklet for details Limited to a 30 day supply at retail or a 90 day supply at a network of select retail pharmacies Up to a 90 day supply at mail order Specialty drugs limited to a 30 day supply except for certain FDA designated dosing regimens Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available Additional charge will not apply to any deductible or out of pocket amounts Cost sharing for insulin included in the drug list will not exceed 25 per prescription for a 30 16 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2024 Page 2 of 8

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Common Medical Event Services You May Need Brand drugs Preferred Brand drugs Non preferred Specialty drugs Preferred If you have outpatient surgery Specialty drugs Nonpreferred Facility fee e g ambulatory surgery center Physician surgeon fees What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most Retail Preferred 50 copayment prescription Non Preferred 70 copayment prescription Mail 150 copayment prescription deductible does not apply Retail 70 copayment prescription deductible does not apply plus 50 additional charge Retail Preferred 100 copayment prescription Non Preferred 120 copayment prescription Mail 300 copayment prescription deductible does not apply Retail 120 copayment prescription deductible does not apply plus 50 additional charge 150 copayment prescription deductible does not apply 150 copayment prescription deductible does not apply plus 50 additional charge 250 copayment prescription deductible does not apply 250 copayment prescription deductible does not apply plus 50 additional charge 20 coinsurance 50 coinsurance 20 coinsurance 50 coinsurance Limitations Exceptions Other Important Information day supply regardless of the amount or type of insulin needed to fill the prescription Certain services may require preauthorization for out of network failure to preauthorize may result in 50 reduction in benefits not to exceed 500 For Outpatient Infusion Therapy see your benefit booklet for details Emergency room care 500 copayment visit plus 20 coinsurance 500 copayment visit plus 20 coinsurance Copayment waived if admitted If you need immediate medical attention Emergency medical transportation Urgent care 20 coinsurance 20 coinsurance None 75 copayment visit deductible does not apply 50 coinsurance 17 If you have a hospital Facility fee e g hospital 20 coinsurance 50 coinsurance Preauthorization required Preauthorization For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2024 Page 3 of 8

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Common Medical Event Services You May Need stay room Physician surgeon fees If you need mental health behavioral health or substance abuse services Outpatient services Inpatient services If you are pregnant Office visits Childbirth delivery professional services Childbirth delivery facility services If you need help recovering or have other special health needs Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most 20 coinsurance 50 coinsurance 40 copayment office visit deductible does not apply or 20 coinsurance for other outpatient services 50 coinsurance 20 coinsurance 50 coinsurance Primary Care 40 copayment initial visit Specialist 80 copayment initial visit deductible does not apply 20 coinsurance 50 coinsurance 50 coinsurance 20 coinsurance 50 coinsurance Limitations Exceptions Other Important Information penalty 250 out of network See your benefit booklet for details Certain services must be preauthorized failure to preauthorize at least two business days prior to service will result in 50 reduction in benefits not to exceed 500 refer to benefit booklet for details Preauthorization required out of network failure to preauthorize at least two business days prior to admission will result in 250 reduction in benefits Copayment applies to first prenatal visit per pregnancy Cost sharing does not apply to preventive services Depending on the type of services a copayment coinsurance or deductible may apply Maternity care may include tests and services described elsewhere in the SBC i e ultrasound 20 coinsurance 20 coinsurance 20 coinsurance 20 coinsurance 20 coinsurance 50 coinsurance 50 coinsurance 50 coinsurance 50 coinsurance 50 coinsurance 60 visits year Preauthorization may be required for out of network Failure to preauthorize may result in 50 reduction in benefits not to exceed 500 See your benefit booklet for details For Outpatient limited to combined 35 visits per year including Chiropractic 25 day maximum per calendar year Preauthorization may be required for out ofnetwork Failure to preauthorize may result in 250 reduction in benefits See your benefit booklet for details None 18 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2024 Page 4 of 8

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About these Coverage Examples This is not a cost estimator Treatments shown are just examples of how this plan might cover medical care Your actual costs will be different depending on the actual care you receive the prices your providers charge and many other factors Focus on the cost sharing amounts deductibles copayments and coinsurance and excluded services under the plan Use this information to compare the portion of costs you might pay under different health plans Please note these coverage examples are based on self only coverage Peg is Having a Baby 9 months of in network pre natal care and a hospital delivery The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 6 000 80 20 20 This EXAMPLE event includes services like Specialist office visits prenatal care Childbirth Delivery Professional Services Childbirth Delivery Facility Services Diagnostic tests ultrasounds and blood work Specialist visit anesthesia Total Example Cost In this example Peg would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Peg would pay is 12 700 6 000 40 1 100 60 7 200 Managing Joe s Type 2 Diabetes a year of routine in network care of a wellcontrolled condition The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 6 000 80 20 20 This EXAMPLE event includes services like Primary care physician office visits including disease education Diagnostic tests blood work Prescription drugs Durable medical equipment glucose meter Total Example Cost In this example Joe would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Joe would pay is 5 600 800 800 0 20 1 620 Mia s Simple Fracture in network emergency room visit and follow up care The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 6 000 80 20 20 This EXAMPLE event includes services like Emergency room care including medical supplies Diagnostic test x ray Durable medical equipment crutches Rehabilitation services physical therapy Total Example Cost In this example Mia would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Mia would pay is 2 800 2 100 600 0 0 2 700 22 The plan would be responsible for the other costs of these EXAMPLE covered services Page 8 of 8

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Summary of Benefits and Coverage What this Plan Covers What You Pay for Covered Services MTBAB014 Blue Advantage HMOSM 014 CoverraaggeePPeerrioiodd 010 0 10 12 0220424 1029 310 22002245 CovCeoravgereafgoer foInr dIinvdidivuidaul al FFaammiillyy PPllaann TTyyppee HHMMOO The Summary of Benefits and Coverage SBC document will help you choose a health plan The SBC shows you how you and the plan would share the cost for covered health care services NOTE Information about the cost of this plan called the premium will be provided separately This is only a summary For more information about your coverage or to get a copy of the complete terms of coverage visit www bcbstx com member policy forms 2024 or by calling 1 877 299 2377 For general definitions of common terms such as allowed amount balance billing coinsurance copayment deductible provider or other underlined terms see the Glossary You can view the Glossary at www healthcare gov sbc glossary or call 1 855 756 4448 to request a copy Important Questions Answers Why This Matters Generally you must pay all of the costs from providers up to the deductible amount before this plan What is the overall deductible 1 500 Individual 4 500 Family begins to pay If you have other family members on the plan each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible Are there services covered before you meet your deductible Yes Network office visits prescription drugs and preventive care services are covered before you meet your deductible This plan covers some items and services even if you haven t yet met the deductible amount But a copayment or coinsurance may apply For example this plan covers certain preventive services without cost sharing and before you meet your deductible See a list of covered preventive services at www healthcare gov coverage preventive care benefits Are there other deductibles for specific services Yes ER 500 There are no other You must pay all of the costs for these services up to the specific deductible amount before this plan specific deductibles begins to pay for these services What is the out of pocket The out of pocket limit is the most you could pay in a year for covered services If you have other limit for this plan 4 500 Individual 13 500 Family family members in this plan they have to meet their own out of pocket limits until the overall family out of pocket limit has been met What is not included in the out of pocket limit Premiums balance billing charges and health care this plan Even though you pay these expenses they don t count toward the out of pocket limit doesn t cover Will you pay less if you use a network provider Yes See www bcbstx com go bahmo 1 877 299 2377 for a list of Participating Providers or call This plan uses a provider network You will pay less if you use a provider in the plan s network You will pay the most if you use an out of network provider and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays balance billing Be aware your network provider might use an out of network provider for some services such as lab work Check with your provider before you get services Do you need a referral to see a specialist Yes This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist SLMR Pharmacy No 25 Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7

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All copayment and coinsurance costs shown in this chart are after your deductible has been met if a deductible applies Common Medical Event Services You May Need Primary care visit to treat an injury or illness If you visit a health care provider s office or clinic Specialist visit Preventive care screening immunization If you have a test Diagnostic test x ray blood work Imaging CT PET scans MRIs Preferred generic drugs If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www bcbstx com rxdrugs drug lists drug lists Non preferred generic drugs Preferred brand drugs What You Will Pay Participating Provider You will pay the least Non Participating Provider You will pay the most 35 visit deductible does not apply Not Covered 70 visit deductible does not apply Not Covered No Charge deductible does not apply Not Covered 20 coinsurance Not Covered 20 coinsurance Retail Preferred No Charge Non Preferred 10 prescription Mail No Charge deductible does not apply Retail Preferred 10 prescription Non Preferred 20 prescription Mail 30 prescription deductible does not apply Retail Preferred 50 prescription Non Preferred 70 prescription Mail 150 prescription deductible does not apply Not Covered Not Covered Not Covered Not Covered Limitations Exceptions Other Important Information Virtual visits are available See your benefit booklet for details Referral required You may have to pay for services that aren t preventive Ask your provider if the services needed are preventive Then check what your plan will pay for None Limited to a 30 day supply at retail or a 90 day supply at a network of select retail pharmacies Up to a 90 day supply at mail order Specialty drugs limited to a 30 day supply Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available Cost sharing for insulin included in the drug list will not exceed 25 per prescription for a 30day supply regardless of the amount or type of insulin needed to fill the prescription 26 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 2 of 7

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Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health behavioral health or substance abuse services Services You May Need Non preferred brand drugs Preferred specialty drugs Non preferred specialty drugs Facility fee e g ambulatory surgery center Physician surgeon fees Emergency room care Emergency medical transportation Urgent care Facility fee e g hospital room Physician surgeon fees Outpatient services Inpatient services What You Will Pay Participating Provider You will pay the least Non Participating Provider You will pay the most Retail Preferred 100 prescription Non Preferred 120 prescription Mail 300 prescription deductible does not apply Not Covered 150 prescription deductible does not apply Not Covered 250 prescription deductible does not apply Not Covered 20 coinsurance 20 coinsurance 500 visit plus 20 coinsurance Not Covered Not Covered 500 visit plus 20 coinsurance 20 coinsurance 20 coinsurance 75 visit deductible does not apply Not Covered 20 coinsurance Not Covered 20 coinsurance 35 office visit deductible does not apply or 20 coinsurance for other outpatient services Not Covered Not Covered 20 coinsurance Not Covered Limitations Exceptions Other Important Information For Outpatient Infusion Therapy see your benefit booklet for details Per Occurrence Deductible waived if admitted None None None None 27 If you are pregnant Office visits Primary Care 35 initial visit Specialist 70 initial visit deductible does not apply Not Covered For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 3 of 7

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Common Medical Event Services You May Need Childbirth delivery professional services Childbirth delivery facility services If you need help recovering or have other special health needs If your child needs dental or eye care Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services Children s eye exam Children s glasses Children s dental check up What You Will Pay Participating Provider You will pay the least Non Participating Provider You will pay the most 20 coinsurance Not Covered 20 coinsurance Not Covered 20 coinsurance 20 coinsurance 20 coinsurance 20 coinsurance 20 coinsurance 20 coinsurance Primary Care 35 Specialist 70 deductible does not apply Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Limitations Exceptions Other Important Information Copayment applies to first prenatal visit per pregnancy Cost sharing does not apply to preventive services Depending on the type of services copayment coinsurance or deductible may apply Maternity care may include tests and services described elsewhere in the SBC i e ultrasound None None 60 day maximum per calendar year None None Eye screenings only Does not include refractions One visit per year for members ages 17 and younger None 28 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 4 of 7

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Excluded Services Other Covered Services Services Your Plan Generally Does NOT Cover Check your policy or plan document for more information and a list of any other excluded services Abortion Except for a pregnancy that as certified by a physician places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed Acupuncture Bariatric surgery Children s dental check up Children s glasses Cosmetic surgery Dental care Adult Long term care Non emergency care when traveling outside the U S Weight loss programs Other Covered Services Limitations may apply to these services This isn t a complete list Please see your plan document Chiropractic care Preauthorization required Hearing aids Limited to one hearing aid per ear every 36 months Infertility treatment Invitro not covered Private duty nursing Only when ordered or authorized by the Primary Care Physician Routine eye care Adult One visit every two years for members ages 18 and older Routine foot care Only covered in connection with diabetes circulatory disorders of the lower extremities peripheral vascular disease peripheral neuropathy or chronic arterial or venous insufficiency Your Rights to Continue Coverage There are agencies that can help if you want to continue your coverage after it ends The contact information for those agencies is For group health coverage contact the plan Blue Cross and Blue Shield of Texas at 1 877 299 2377 or visit www bcbstx com For group health coverage subject to ERISA contact the U S Department of Labor s Employee Benefits Security Administration at 1 866 444 EBSA 3272 or www dol gov ebsa healthreform For non federal governmental group health plans contact Department of Health and Human Services Center for Consumer Information and Insurance Oversight at 1 877 267 2323 x61565 or www cciio cms gov Church plans are not covered by the Federal COBRA continuation coverage rules If the coverage is insured individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law Other coverage options may be available to you too including buying individual insurance coverage through the Health Insurance Marketplace For more information about the Marketplace visit www HealthCare gov or call 1 800 318 2596 Your Grievance and Appeals Rights There are agencies that can help if you have a complaint against your plan for a denial of a claim This complaint is called a grievance or appeal For more information about your rights look at the explanation of benefits you will receive for that medical claim Your plan documents also provide complete information to submit a claim appeal or a grievance for any reason to your plan For more information about your rights this notice or assistance contact For group health coverage subject to ERISA Blue Cross and Blue Shield of Texas at 1 877 299 2377 or visit www bcbstx com the U S Department of Labor s Employee Benefits Security Administration at 1 866 444 EBSA 3272 or www dol gov ebsa healthreform and the Texas Department of Insurance Consumer Protection at 1 800 252 3439 or www tdi texas gov For non federal governmental group health plans and church plans that are group health plans Blue Cross and Blue Shield of Texas at 1 877 299 2377 or www bcbstx com or contact the Texas Department of Insurance Consumer Protection at 1 800 252 3439 or www tdi texas gov Additionally a consumer assistance program can help you file your appeal Contact the Texas Department of Insurance s Consumer Health Assistance Program at 1 800 252 3439 or visit www cms gov CCIIO Resources Consumer Assistance Grants tx html Does this plan provide Minimum Essential Coverage Yes Minimum Essential Coverage generally includes plans health insurance available through the Marketplace or other individual market policies Medicare Medicaid CHIP TRICARE and certain other coverage If you are eligible for certain types of Minimum Essential Coverage you may not be eligible for the premium tax credit 29 Page 5 of 7

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About these Coverage Examples This is not a cost estimator Treatments shown are just examples of how this plan might cover medical care Your actual costs will be different depending on the actual care you receive the prices your providers charge and many other factors Focus on the cost sharing amounts deductibles copayments and coinsurance and excluded services under the plan Use this information to compare the portion of costs you might pay under different health plans Please note these coverage examples are based on self only coverage Peg is Having a Baby 9 months of in network pre natal care and a hospital delivery The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 1 500 70 20 20 This EXAMPLE event includes services like Specialist office visits prenatal care Childbirth Delivery Professional Services Childbirth Delivery Facility Services Diagnostic tests ultrasounds and blood work Specialist visit anesthesia Total Example Cost In this example Peg would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Peg would pay is 12 700 1 500 40 2 200 60 3 800 Managing Joe s Type 2 Diabetes a year of routine in network care of a wellcontrolled condition The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 1 500 70 20 20 This EXAMPLE event includes services like Primary care physician office visits including disease education Diagnostic tests blood work Prescription drugs Durable medical equipment glucose meter Total Example Cost In this example Joe would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Joe would pay is 5 600 900 700 0 20 1 620 Mia s Simple Fracture in network emergency room visit and follow up care The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 1 500 70 20 20 This EXAMPLE event includes services like Emergency room care including medical supplies Diagnostic test x ray Durable medical equipment crutches Rehabilitation services physical therapy Total Example Cost In this example Mia would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Mia would pay is 2 800 1 500 600 100 0 2 200 31 The plan would be responsible for the other costs of these EXAMPLE covered services Page 7 of 7

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Why Virtual Visits 24 7 access to an independently contracted board certified doctor or therapist Access via phone online video or mobile app from almost anywhere Average wait time of less than 20 minutes Doctors can send e prescriptions to your local pharmacy The Virtual Visits benefit is a convenient alternative for treatment of more than 80 health conditions including Allergies Cold Flu Fever Headaches Nausea Sinus infections Virtual Visits sessions with licensed behavioral health therapists are available by appointment Get virtual care for Depression Eating disorders ADHD Substance use disorders Trauma and PTSD Autism spectrum disorder First call your doctor s office they may also offer telehealth consultations by phone or online video If you have any questions about this or any other BCBSTX benefit please call the number on the back of your ID card Activate your Virtual Visits account today Call 888 680 8646 Go to MDLIVE com bcbstx Text BCBSTX to 635 483 Download the app Virtual Visits may be limited by plan For providers licensed in New Mexico and the District of Columbia Urgent Care service is limited to interactive online video Behavioral Health service requires video for the initial visit but may use video or audio for follow up visits based on the provider s clinical judgment Behavioral Health is not available on all plans MDLIVE is a separate company that operates and administers Virtual Visits for Blue Cross and Blue Shield of Texas MDLIVE is solely responsible for its operations and for those of its contracted providers MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE Inc and may not be used without permission Blue Cross Blue Shield and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 36 9100009 1222

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BCBS Preferred Pharmacy s Pharmacy Walgreens 6583 Walgreens 3271 HEB Pharmacy Walgreens 3796 Walgreens 3821 HEB Pharmacy Walgreens 3081 Walgreens 12355 Walgreens 03507 Walgreens 3958 Walmart Pharmacy 10 0449 HEB Pharmacy Walgreens 5375 Walgreens 10139 Walgreens 11275 BCBS Network Urgent Care Provider AFC Urgent Care Beaumont Urgent Care Eastex Urgent Care Next Level Urgent Care Immediate Medical Care Dowlen Urgent Care Promptu Immediate Care Peoples Urgent Care Bestmed Urgent Care Bestmed Urgent Care Next Level Urgent Care Wellfast Health Urgent Care Mid County Urgent Care First Urgent Care Bestmed Urgent Care Aceso Urgent Care Silsbee Hardin County Urgent Care Total Care Medical First Response Urgent care Orange County Urgent Care Peoples Urgent Care Total Care Port Arthur Total Care Medical Address 3885 N Dowlen Rd Beaumont TX 77706 3990 East Lucas Drive Beaumont TX 77708 3025 N Dowlen Beaumont TX 77706 6795 Calder Rd Beaumont TX 77706 3605 College St Beaumont TX 77701 3590 College Street Beaumont TX 77701 1408 N 16th St Orange TX 77630 1790 Texas Ave Bridge City TX 77611 2126 Nall Street Port Neches TX 77651 4930 Gulfway Drive Port Arthur TX 77642 4999 Twin City Hwy Port Arthur TX 77642 480 Hwy 365 Port Arhtur TX 77642 3700 Hwy 365 Port Arhtur TX 77642 1305 N Main Vidor TX 77662 4746 Twin City Hwy Groves TX 77619 Address 3195 Dowlen Rd Ste 105 Beaumont TX 77706 3650 N Major Dr Ste A Beaumotn TX 77713 4310 Dowlen Rd Beaumont TX 77706 6342 Phelan Blvd Beaumont TX 77706 4795 College St Beaumont TX 77707 2342 Dowlen Rd Beaumont TX 77706 4046 Dowlen Rd Beaumont TX 77706 3255 N Major Dr Ste F Beaumont TX 77706 1105 N Main Vidor TX 77662 114 S LHS Dr Lumberton TX 77657 1031 Nederland TX 77627 1509 S Hwy 69 Nederland TX 77627 1908 Hwy 365 Nederland TX 77627 3620 FM HWY 365 Ste 400 Port Arthur TX 77642 8465 Memorial Blvd Ste 300 Port Arthur TX 77642 205 E Ave J Silsbee TX 77656 655 S Main St Lumberton TX 77657 1650 Texas Ave Bridge City TX 77611 434 LHS Dr Ste 500 Lumberton TX 77657 220 Strickland Dr Orange TX 77630 1509 S Hwy 69 Nederland TX 77627 1650 Texas Ave Ste E Bridge City TX 77611 101 South Prarie St Dayton TX 77535 Phone 409 899 8697 409 924 7570 409 860 4212 409 860 3909 409 832 7374 409 813 8452 409 883 0876 409 792 0597 409 727 1426 409 982 1654 409 963 2182 409 722 4066 409 724 1914 409 769 1171 409 960 6394 Phone 409 860 1888 409 333 1272 409 299 4407 281 783 8162 409 842 5444 409 861 0000 855 481 8400 409 554 0326 409 422 4380 409 227 0053 409 783 8162 409 722 9355 409 729 1900 409 344 4557 409 227 0053 409 242 6418 409 227 4084 409 344 9277 409 344 4557 409 330 4704 409 519 8045 409 792 5521 409 344 9277 37

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BlueCare DentalSM Plan ID DTXHR30 This information only provides a summary of the benefits for this Dental Plan Please refer to your Dental Benefit Booklet for additional benefit information The Deductibles Coinsurance and Benefit Period Maximum shown below are subject to change as permitted by applicable law Summary of Dental Benefits Program Basics Benefit Period Maximum Deductible Covered Services Diagnostic Evaluations Periodic oral evaluations Problem focused oral evaluations Comprehensive oral evaluations Preventive Services Prophylaxis cleanings Topical fluoride applications Diagnostic Radiographs Full mouth and panoramic films Bitewing films Periapical films Miscellaneous Preventive Services Sealants Space maintainers Basic Restorative Services Amalgams Resin based composite restorations Non Surgical Extractions Removal of retained coronal remnants Removal of erupted tooth or exposed root Non Surgical Periodontal Services Periodontal scaling and root planing Full mouth debridement Periodontal maintenance procedures Adjunctive Services Palliative treatment emergency Deep sedation general anesthesia Endodontic Services Therapeutic pulpotomy and pulpal debridement Root canal therapy Apexification recalcification Contracting Dentist Non Contracting Dentist 5 000 25 Individual 75 Family No Annual Maximum 25 Individual 75 Family No Annual Maximum 100 Deductible does not apply 100 Deductible does not apply 100 Deductible does not apply 100 Deductible does not apply 100 Deductible does not apply 100 Deductible does not apply 100 Deductible does not apply 100 Deductible does not apply 80 80 80 80 80 80 80 80 80 80 38

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Contracting Dentist Non Contracting Dentist Covered Services continued Oral Surgery Services Surgical tooth extractions Alveoloplasty and vestibuloplasty Excision of benign odontogenic tumor cyst Excision of bone tissue Incision and drainage of an intraoral abscess Surgical Periodontal Services Gingivectomy or gingivoplasty and gingival flap procedures Clinical crown lengthening Osseous surgery Osseous grafts Soft tissue grafts allografts Distal or proximal wedge procedure Major Restorative Services Single crown restorations Inlay onlay restorations Labial veneer restorations Crowns placed over implants Prosthodontic Services Complete and removable partial dentures Denture reline rebase procedures Fixed bridgework Prosthetics placed over implants Implants Miscellaneous Restorative and Prosthodontic Services Prefabricated crowns Recementations Post and core pin retention and crown bridge repairs Adjustments Orthodontic Services Orthodontic Services Orthodontic Diagnostic Procedures and Treatment Lifetime Maximum per Participant Adult coverage and dependent children to age 19 80 80 80 80 50 50 50 50 50 50 50 50 50 2 000 Deductible does not apply The above is a listing of common services available through your network of Contracting Dentists The Member s share of the cost is determined by whether care is received from a Contracting or Non Contracting Dentist Benefits for covered services received from a Contracting Dentist are based on the Allowable Amount and such Dentist cannot balance bill for charges in excess of this Allowable Amount Benefits for covered services received from a Non Contracting Dentist will be based upon an Allowable Amount determined by BCBSTX where non contracting Allowable Amount will be not less than the amount BCBSTX would have paid for the same covered service supply or procedure if performed or provided by a Contracting Dentist and it is possibl e that such Dentist will balance bill for amounts above this This plan includes BlueCare Dental Enhanced BenefitSM The Enhanced Benefit provides additional dental benefits such as an extra cleaning for members with specific health issues Please refer to your Dental Benefit Booklet for additional benefit information Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and 39 758536 1022

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Summary of Vision Benefits PLAN 8 12 12 24 130 Frequency Examination Lenses or contact lenses Frame Contact lens eval fitting Once every 12 months Once every 12 months Once every 24 months N A Vision Care Services Exam with dilation as necessary Contact lens fit and follow up In Network Member Cost 10 copay Up to 40 for standard 10 off retail price for premium Frames Any available frame at provider location 0 copay 130 allowance 20 off balance over 130 Standard Lenses Single vision Bifocal Trifocal Lenticular Standard progressive lens Premium progressive lens 25 copay 25 copay 25 copay 25 copay 90 copay See table on page 2 Lens Options Tint solid and gradient Scratch resistant coating Polycarbonate lenses Ultraviolet coating Anti reflective coating High index lenses Polarized lenses Photochromic transitions plastic 15 0 0 kids 40 adults 15 See table on page 2 20 off retail 20 off retail 75 Contact Lenses in lieu of spectacle lenses Conventional 0 copay 130 allowance 15 off balance over 130 Disposable 0 copay 130 allowance plus balance over 130 Medically necessary 0 copay paid in full Other Laser vision correction Additional pairs benefit Amplifon hearing discount Additional discounts 15 retail price or 5 off promotional price 40 off purchase of complete pair of eyeglasses and a 15 off conventional contact lenses once the funded benefit has been used 40 off hearing exams and low price guarantee on discounted hearing aids 20 off non covered items with limitations Eligibility All active full time employees as defined by your employer Dependent coverage is available to age 26 Out of Network Reimbursement Up to 30 N A Up to 65 Up to 25 Up to 40 Up to 55 Up to 55 Up to 40 Up to 40 N A Up to 5 Up to 5 kids N A N A N A N A N A Up to 104 Up to 104 Up to 210 N A N A N A N A Additional discounts 40 OFF Complete pair of prescription eyeglasses 20 OFF Non prescription sunglasses 20 OFF Remaining balance beyond plan coverage These discounts are not insured benefits and are for in network providers only Take a sneak peek before enrolling For a complete list of in network providers near you visit eyemedvisioncare com bcbstxvis or call 1 855 556 8796 For LASIK providers call 1 877 5LASER6 Vision Care Insurance products issued by Dearborn Life Insu4r1ance Company 701 E 22nd St Suite 300 Lombard IL 60148

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Summary of Benefits Continued Progressive Price List2 Member Cost In Network Standard progressive 90 copay Premium Progressives3 as Follows Tier 1 110 copay Tier 2 120 copay Tier 3 135 copay Tier 4 90 copay 80 of charge less 120 allowance Anti Reflective Coating Price List2 Standard anti reflective coating Member Cost In Network 45 Premium anti reflective3 coatings as follows Tier 1 57 Tier 2 68 Tier 3 80 of charge Other Add ons Price List Photochromic Polarized Member Cost In Network 75 80 of charge Plan Exclusions 1 Orthoptic or vision training subnormal vision aids and any associated supplemental testing aniseikonic lenses 2 Medical and or surgical treatment of the eye eyes or supporting structures 3 Any eye or vision examination or any corrective eyewear required by a Policyholder as a condition of employment safety eyewear 4 Services provided as a result of any Workers Compensation law or similar legislation or required by any governmental agency or program whether federal state or subdivisions thereof 5 Plano non prescription lenses and or contact lenses 6 Non prescription sunglasses 7 Two pair of glasses in lieu of bifocals 8 Services rendered after the date an insured person ceases to be covered under the policy except when vision materials ordered before coverage ended are delivered and the services rendered to the insured person are within 31 days from the date of such order 9 Services or materials provided by any other group benefit plan providing vision care 10 Lost or broken lenses frames glasses or contact lenses will not be replaced except in the next benefit frequency when vision materials would next become available 1Member Reimbursement Out of Network will be the lesser of the listed amount or the member s actual cost from the out of network provider In certain states members may be required to pay the full retail rate 2Blue Cross Blue Shield of Texas Vision Care reserves the right to make changes to the products on each tier and the member out of pocket costs Fixed pricing is reflective of brands at the listed product level All providers are not required to carry all brands at all levels 3Premium progressives and premium anti reflective designations are subject to annual review by EyeMed s Medical Director and are subject to change based on market conditions Fixed pricing is reflective of brands at the listed product level All providers are not required to carry all brands at all levels Not available in all states Some provisions benefits exclusions or limitations listed herein may vary For employee use This piece is for illustrative purposes only and is not a contract It is intended to provide only a brief summary of the type of policy and insurance coverage advertised The policy provides the actual terms of coverage including any exclusions conditions and limitations to coverage All plans are based on a 48 month contract term and 48 month rate guarantee Premium is subject to adjustment even during a rate guarantee period in the event of any of the following events changes in benefits employee contributions the number of eligible employees or the imposition of any new taxes fees or assessments by Federal or State regulatory agencies Benefits may not be combined with any discount promotional offering or other group benefit plans Benefit allowance provides no remaining balance for future use with the same benefits year Fees charged for a non insured benefit must be paid in full to the Provider Such fees or materials are not covered This is a snapshot of your benefits The Certificate of Insurance is on file with your employer Benefits are available from the EyeMed Vision Care LLC provider network and are administered by First American Administrators Inc independent companies that offer benefits on behalf of Blue Cross and Blue Shield of Texas Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Dearborn Life Insurance Company is an independent licensee of Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 42 750190 1119

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Vision Care Mobilize Your Vision Plan Vision Benefit App Powered by EyeMed The EyeMed member app was the first of its kind But innovation like your life never stops Your vision benefit is powered by EyeMed which means you are able to download the EyeMed member app to access ahead of the game resources wherever you are before during and after your eye appointment Here s How to Access the EyeMed Member App REGISTER 1 DOWNLOAD Search EyeMed Members in your App store iTunes or Google Play 2 OPEN You can use some features right away others unlock once you register 3 REGISTER You ll need your member ID or the last four digits of your Social Security number 4 LOG IN It s that easy Find nearby network providers On the fly appointment scheduling Turn by turn directions and map Eye exam and contact lens reminders Electronic ID card for office visits Save vision prescriptions Benefit plan details Answers to common questions Direct line to member support Ready when you download Unlocked when you register Get a Clear View Download the EyeMed member app now and register to access your vision benefit information on the go For employee use Benefits are available from the EyeMed Vision Care LLC provider network and are administered by First American Administrators Inc independent companies that offer benefits on behalf of Blue Cross and Blue Shield of Texas Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue4C3ross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 750422 0919

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Group Benefit Program Summary for Bill Clark Pest Control VF026824 Term Life Accidental Death Dismemberment AD D The death of a family member can mean not only dealing with the loss of a loved one but the loss of financial security as well With Our Group Term Life plan an employee can achieve peace of mind by giving their family the financial security they can depend on Eligibility All eligible active full time employees Group Term Life AD D Benefit Employee 25 000 Guarantee Issue Amount Age Reduction Schedule Waiver of Premium Accelerated Death Benefit ADB Conversion Privilege Life Coverage Beneficiary Resource Services Travel Resource Services 25 000 Life and AD D benefits reduce by 35 at age 65 and further reduce by 50 of the original amount at age 70 Benefits terminate at retirement If an employee is unable to engage in any occupation as a result of injury or sickness for a minimum of nine months prior to age 60 premium will be waived for the employee s life insurance benefit until the employee is no longer disabled or reaches age 65 whichever occurs first Upon the employee s request this benefit pays a lump sum up to 75 of the employee s life insurance if diagnosed with a terminal illness and has a life expectancy of 12 months or less Minimum 7 500 Maximum 250 000 The amount of group term life insurance otherwise payable upon the employee s death will be reduced by the ADB Included Includes grief legal and financial counseling for beneficiaries funeral planning and online legal library including templates to create a legal will and other legal documents Helps travelers with the unexpected that may take place while traveling Services include emergency medical assistance financial legal and communication assistance and access to other critical services and resources available via the Internet For illustrative purposes only May not be available in all jurisdictions Coverage may be subject to limitations exclusions and other coverage conditions contained in issued policy Please consult the policy for the actual terms of coverage Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 51

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Group AD D is an additional death benefit that pays in the event a covered employee dies or is dismembered in a covered accident AD D benefit is 24 hour coverage AD D Schedule of Loss Loss of life Loss of both hands or both feet Loss of one hand and one foot Loss of speech and hearing Loss of sight of both eyes Loss of one hand and sight of one eye Principal Sum 100 100 100 100 100 100 AD D PRODUCT FEATURES INCLUDED Seatbelt and Airbag Benefits Repatriation Benefit Education Benefit EXCLUSIONS Unless specifically covered in the policy or required by state law we will not pay any AD D benefit for any loss that directly or indirectly results in any way from or is contributed to by Loss of one foot and sight of one eye 100 1 disease of the mind or body or any treatment thereof Quadriplegia Paraplegia Hemiplegia Loss of sight of one eye 100 75 50 50 2 infections except those from an accidental cut or wound 3 suicide or attempted suicide 4 intentionally self inflicted injury 5 war or act of war 6 travel or flight in any aircraft while a member of the crew Loss of one hand or one foot 50 7 commission of or participation in a felony Loss of speech or hearing 50 Loss of thumb and index finger of same hand 25 Uniplegia 25 Loss must occur within 365 days of accident 8 under the influence of certain drugs narcotics or hallucinogen unless properly used as prescribed by a physician or 9 intoxication as defined in the jurisdiction where the accident occurred 10 participation in a riot This piece is for illustrative purposes only and is not a contract It is intended to provide only a brief summary of the type of policy and insurance coverage advertised The policy provides the actual terms of coverage including any exclusions conditions and limitations and reduction of benefits and or terms under which the policy may be continued or discontinued The policy may be cancelled by the insurer at any time The insurer reserves the right to change premium rates but not more than once in a 12 month period Refer to your certificate for complete details and limitations of coverage 52

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Group Benefit Program Summary for Bill Clark Pest Control VF026824 Supplemental Term Life Accidental Death Dismemberment AD D The death of a family member can mean not only dealing with the loss of a loved one but the loss of financial security as well With Our Group Term Life plan an employee can achieve peace of mind by giving their family the financial security they can depend on Eligibility All eligible active full time employees Group Term Life AD D Benefit Employee 10 000 500 000 in increments of 10 000 Guarantee Issue Amount Employee Group Term Life AD D Benefit Spouse Includes Domestic Partners Under Age 70 100 000 Age 70 and Over 10 000 Guarantee issue amounts are based on a minimum participation requirement of 25 of all eligible employees If participation requirements are not achieved underwriting will be utilized on all employees and spouse applications 5 000 100 000 in increments of 5 000 not to exceed 50 of the employee benefit amount Guarantee Issue Amount Spouse Under Age 70 30 000 Age 70 and Over 10 000 Birth to 14 days 1000 Group Term Life AD D Benefit Child ren Age 15 days to 6 months 1000 Age 6 months to 26 years or 26 years if full time student 1 000 to 5 000 in increments of 1 000 Life and AD D benefits reduce by 35 at age 65 Age Reduction Schedule and further reduce by 50 of the original amount at age 70 Benefits terminate at retirement Employee Contribution 100 percent Waiver of Premium If an employee is unable to engage in any occupation as a result of injury or sickness for a minimum of nine months prior to age 60 premium will be waived for the employee s life insurance benefit until the employee is no longer disabled or reaches age 65 whichever occurs first Accelerated Death Benefit ADB Upon the employee s request this benefit pays a lump sum up to 75 of the employee s life insurance if diagnosed with a terminal illness and has a life expectancy of 12 months or less Minimum 7 500 Maximum 250 000 The amount of group term life insurance otherwise payable upon the employee s death will be reduced by the ADB Portability Feature Life Coverage Included employee Conversion Privilege Life Coverage Included Beneficiary Resource Services Includes grief legal and financial counseling for beneficiaries funeral planning and online legal library including templates to create a legal will and other legal documents Travel Resource Services Exclusions Helps travelers with the unexpected that may take place while traveling Services include emergency medical assistance financial legal and communication assistance and access to other critical services and resources available via the Internet One year suicide exclusion applies to Supplemental Group Term Life coverage AD D exclusions are the same as Basic AD D exclusions For illustrative purposes only May not be available in all jurisdictions Coverage may be subject to limitations exclusions and other coverage conditions contained in issued policy Please consult the policy for the actual terms of coverage Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 53

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Group AD D is an additional death benefit that pays in the event a covered employee dies or is dismembered in a covered accident AD D benefit is 24 hour coverage AD D Schedule of Loss Loss of life Loss of both hands or both feet Loss of one hand and one foot Loss of speech and hearing Loss of sight of both eyes Loss of one hand and sight of one eye Principal Sum 100 100 100 100 100 100 AD D PRODUCT FEATURES INCLUDED Seatbelt and Airbag Benefits Repatriation Benefit Education Benefit EXCLUSIONS Unless specifically covered in the policy or required by state law we will not pay any AD D benefit for any loss that directly or indirectly results in any way from or is contributed to by Loss of one foot and sight of one eye 100 1 disease of the mind or body or any treatment thereof Quadriplegia Paraplegia Hemiplegia Loss of sight of one eye Loss of one hand or one foot 100 75 50 50 50 2 infections except those from an accidental cut or wound 3 suicide or attempted suicide 4 intentionally self inflicted injury 5 war or act of war 6 travel or flight in any aircraft while a member of the crew 7 commission of or participation in a felony Loss of speech or hearing 50 Loss of thumb and index finger of same hand 25 Uniplegia 25 Loss must occur within 365 days of accident 8 under the influence of certain drugs narcotics or hallucinogen unless properly used as prescribed by a physician or 9 intoxication as defined in the jurisdiction where the accident occurred 10 participation in a riot This piece is for illustrative purposes only and is not a contract It is intended to provide only a brief summary of the type of policy and insurance coverage advertised The policy provides the actual terms of coverage including any exclusions conditions and limitations and reduction of benefits and or terms under which the policy may be continued or discontinued The policy may be cancelled by the insurer at any time The insurer reserves the right to change premium rates but not more than once in a 12 month period Refer to your certificate for complete details and limitations of coverage 54

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Supplemental Life and AD D PREMIUM RATE GRID Bill Clark Pest Control VF026824 Eligibility You are eligible to enroll if you work the minimum number of hours per week by your employer and you have satisfied any waiting period Supplemental Life and AD D Employee Benefit 10 000 to 500 000 in 10 000 increments Spouse Benefit 5 000 to 100 000 in 5 000 increments not to exceed 50 of the employee benefit Note Spouse may not have coverage unless the employee has coverage Guarantee Issue Employee Spouse NEW HIRES ONLY 100 000 30 000 Employee Spouse Supplemental Life Monthly rates per 1 000 Age Under 20 20 24 Rates 0 062 0 062 25 29 0 062 30 34 35 39 40 44 45 49 50 54 0 062 0 102 0 192 0 282 0 502 55 59 60 64 65 69 70 0 882 1 402 2 222 3 572 Child Coverage Birth to 14 days 15 days to 6 months 6 months to age 26 1 000 1 000 1 000 to 5 000 in increments of 1 000 Supplemental AD D Monthly rates per 1 000 Employee 0 028 Spouse 0 028 Life and AD D benefits reduce by 35 of the original amount at age 70 and further reduce by 50 of the original amount at age 75 Supplemental Life and AD D Premium Cost Based on 12 payroll deductions per year Benefit Amount EE AD D 10 000 0 28 20 000 0 56 30 000 0 84 40 000 1 12 50 000 1 40 60 000 1 68 70 000 1 96 80 000 2 24 90 000 2 52 100 000 2 80 150 000 4 20 200 000 5 60 250 000 7 00 300 000 8 40 350 000 9 80 400 000 11 20 450 000 12 60 500 000 14 00

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Group Benefit Program Summary for Bill Clark Pest Control VF026824 Voluntary Group Short term Disability Insurance STD Today most Americans would not be able to make payments on their homes or keep their family financially stable without their current salary STD reduces the burden during these unstable times It is a convenient economical way of securing an income while out of work from an unexpected injury or illness Voluntary Group STD is a guaranteed issue coverage which requires no health questionnaires to complete Eligibility All eligible active full time employees Group STD Benefit 60 of basic weekly earnings Weekly Maximum Benefit 750 Benefits Are Payable On 8th day for injury 8th day for sickness Maximum Benefit Period 26 Weeks or until LTD begins whichever is earlier Employee Contribution 100 percent Total Disability Total Disability means that due to Injury or Sickness the employee is unable to perform all of the material and substantial duties of the employee s regular occupation and the employee s disability earnings if any are less than the percentage 20 of the employee s pre disability weekly earnings Partial Disability Partial Disability means that during the elimination period the employee is able to perform some but not all of the material and substantial duties of the employee s regular occupation After the elimination period partial disability means that due to injury or sickness the employee is able to perform some but not all of the material and substantial duties of the employee s regular occupation and the employee s disability earnings if any are at least the minimum percentage 20 but less than the maximum percentage of the employee s pre disability weekly earnings 80 Pre Existing Conditions Limitation A pre existing condition is a sickness or injury for which you have received treatment within 12 months prior to your effective date Any disability contributed to or caused by a Pre Existing Condition within the first 12 months of your effective date will not be covered Exclusions We do not pay benefits for any loss or disability caused by resulting from arising out of or substantially contributed to directly by any one or more of the following 1 Loss of professional license occupational license or certification 2 Commission of participation in or an attempt to commit an assault or felony 3 Intentionally self inflicted injuries 4 Attempted suicide regardless of mental capacity 5 Cosmetic surgery except when required due to illness or injury 6 Occupational sickness or injury 7 Participation in a war declared or undeclared or any act of war Additional Features Survivor Benefit Work Incentive Benefit Worksite Modification Benefit For illustrative purposes only May not be available in all jurisdictions Coverage may be subject to limitations exclusions and other coverage conditions contained in issued policy Please consult the policy for the actual terms of coverage Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 56

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Voluntary Short Term Disability Insurance Bill Clark Pest Control VF026824 Benefit Schedule Benefit Percentage Elimination Period Injury Elimination Period Sickness Benefits Begin Injury Benefits Begin Sickness Maximum Period Payable Pre Existing Conditions Limitation Work Incentive Benefit Worksite Modification Benefit Recurrent Disability FMLA Coverage Extension Survivor Income Benefit 60 of Weekly Earnings to a maximum weekly benefit of 750 7 Days 7 Days 8th Day 8th Day 26 weeks or until LTD begins whichever is earlier 3 12 Included Monthly Rate per 10 of Weekly Benefit Age Rate Under 20 0 450 20 24 0 450 25 29 0 823 30 34 0 938 35 39 0 681 40 44 0 373 45 49 0 643 50 54 0 630 55 59 0 797 60 64 0 977 65 69 1 015 70 1 067 Weekly Earnings means your weekly rate of earnings from your employer in effect immediately prior to the date disability begins It includes total income before taxes including deduction made for pre tax contributions to a qualified deferred compensation plan Section 125 plan or flexible spending account It does not include bonuses overtime pay or any other extra compensation other than commissions Commissions will be averaged over the 12 month period prior to the date disability begins Sample Premium Calculation Sample assumes a 30 year old employee with 45 000 in annual earnings Annual Salary 52 Weekly Earnings x STD Benefit 10 max 250 x 45 000 52 865 x 0 60 51 90 x STD Rate from table above 0 938 Monthly Premium 48 68 x 12 26 x 12 26 Bi Weekly Premium 22 47 Your Premium Calculation Enter your salary and the rate for your current age from the table above Annual Salary 52 Weekly Earnings x STD Benefit 10 max 250 x STD Rate from table above 52 x 0 60 x Monthly Premium x 12 26 Bi Weekly Premium x 12 26 To determine Bi Weekly Premium multiply Monthly Premium by 12 and then divide by 26 To determine Semi Monthly Premium multiply Monthly Premium by 12 and then divide by 24 To determine Weekly Premium multiply Monthly Premium by 12 and then divide by 52 This information is only a product highlight This Premium Cost Chart is for illustrative purposes only your premium cost may be slightly higher or lower due to rounding NOTE For purposes of this illustration we have assumed a 40 hour work week The policy has exclusions limitations and reduction of benefits and or terms under which the policy may be continued or discontinued The policy may be cancelled by the insurer at any time The insurer reserves the right to change premium rates but not more than once in a 12 month period Product features and availability vary by state and company and are solely the responsibility of each affiliate Refer to your certificate for complete details and limitations of coverage Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent Blue Cross and Blue Shield licensee BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 57

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Group Benefit Program Summary for Bill Clark Pest Control VF026824 Voluntary Group Long term Disability Insurance LTD Without a steady income most people would not be able to make payments on their homes or keep their family financially stable LTD reduces the burden during these unstable times It is a convenient economical way of securing an income while out of work from an unexpected injury or illness Your employer has made LTD coverage available for you to enroll in Below are some of the major features of this program Eligibility All eligible active full time employees Group LTD Benefit Percentage 60 Maximum Monthly Benefit 5 000 Minimum Monthly Benefit 100 or 10 of gross monthly earnings whichever is greater Elimination Period 180 days Maximum Period Payable Social Security Normal Retirement Age SSNRA Social Security Offset Method Primary and Family Integration Own Occupation Period 24 months Partial Disability Earnings Test During Own Occ Period Earnings Test After Own Occ Period 80 60 Work Incentive Benefit Rehabilitation Incentive Income RII Proportionate 12 months Partially disabled employees are eligible for a Work Incentive Benefit The Work Incentive Benefit allows the partially disabled employee to receive their monthly benefit if their benefit plus their earnings do not exceed 100 of indexed predisability income If their benefit plus their earnings exceeds 100 of indexed pre disability income their benefit is reduced by the excess After 12 months the employee s Work Incentive Benefit is calculated by multiplying their monthly benefit by their loss of salary ratio Partially Disabled means that an employee is working in a partial or part time capacity after becoming disabled and meets the earnings test shown above Proportionate 12 months RII is offered to employees who agree to take part in a rehabilitation plan structured to return them to gainful employment in another occupation because they can not return to their regular occupation During the first 12 months RII is equal to the monthly benefit If disability earnings during this period exceed 100 of indexed pre disability earnings the monthly benefit is reduced by the excess After 12 months RII is equal to the monthly benefit reduced by multiplying the monthly benefit by the adjusted loss of salary ratio Survivor Benefit If the employee passes away after being disabled and receiving long term disability benefits for 6 consecutive months We will pay the employee s beneficiary a lump sum benefit equal to three months of disability benefits For illustrative purposes only May not be available in all jurisdictions Coverage may be subject to limitations exclusions and other coverage conditions contained in issued policy Please consult the policy for the actual terms of coverage Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 58

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Mental Disorder Limitation 24 months Substance Abuse Limitation 24 months Special Conditions Limitation 24 months Pre Existing Condition Limitation 3 12 A pre existing condition means a sickness or injury for which an employee received treatment within 3 months prior to the effective date Any disability contributed to or caused by a pre existing condition within the first 12 months of the effective date will not be covered Disability Resource Services In addition to the resource services available on line at GuidanceResources com Disability Resource Services provides a 24 hour telephonic support Additional Features for all LTD insureds for behavioral health issues A staff of master degree clinicians are available to provide each caller with assessment counseling and referral advice for face to face counseling Face to face counseling Up to three face to face counseling sessions per year to address appropriate behavioral health issues Available for groups with 10 or more employees This piece is for illustrative purposes only and is not a contract It is intended to provide only a brief summary of the type of policy and insurance coverage advertised The policy provides the actual terms of coverage including any exclusions conditions and limitations and reduction of benefits and or terms under which the policy may be continued or discontinued The policy may be cancelled by the insurer at any time The insurer reserves the right to change premium rates but not more than once in a 12 month period Refer to your certificate for complete details and limitations of coverage 59

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Voluntary Long Term Disability Percentage of Salary Program Premium Calculation Bill Clark Pest Control VF026824 Benefit Schedule Benefit Percentage Benefit Maximum Maximum Monthly covered earnings Benefit Duration Elimination Period Pre Existing Conditions Limitation 60 of Basic Monthly Earnings 5 000 8 333 Social Security Normal Retirement Age SSNRA 180 Days 3 12 Basic Monthly Earnings Insured Salary means the monthly compensation you earn from your normal occupation with your employer It includes total income before taxes including deductions made for pre tax contributions to a qualified deferred compensation plan Section 125 plan or flexible spending account It does not include earnings from bonuses overtime pay or any other extra compensation other than commissions Commissions will be averaged over the 12 month period prior to the date death or disability begins Monthly Rate per 100 of Covered Payroll Age Rate Under 20 0 135 20 24 0 135 25 29 0 278 30 34 0 270 35 39 0 438 40 44 0 472 45 49 0 860 50 54 0 961 55 59 1 188 60 64 0 834 65 69 0 784 70 0 380 Sample Premium Calculation Sample assumes a 30 year old employee with 2 500 in monthly earnings Monthly Earnings maximum 8333 x Rate from table above Amount 100 Monthly Premium 2 500 x 0 270 675 00 100 6 75 x 12 26 x 12 26 Bi weekly Premium 3 12 Your Premium Calculation Enter your salary and the rate for your current age from the table above Monthly Earnings maximum 8333 x Rate from table above x Amount 100 100 Monthly Premium x 12 26 x 12 26 Bi weekly Premium To determine Bi Weekly Premium multiply Monthly Premium by 12 and then divide by 26 To determine Semi Monthly Premium multiply Monthly Premium by 12 and then divide by 24 To determine Weekly Premium multiply Monthly Premium by 12 and then divide by 52 This information is only a product highlight This Premium Cost Chart is for illustrative purposes only your premium cost may be slightly higher or lower due to rounding NOTE For purposes of this illustration we have assumed a 40 hour work week The policy has exclusions limitations and reduction of benefits and or terms under which the policy may be continued or discontinued The policy may be cancelled by the insurer at any time The insurer reserves the right to change premium rates but not more than once in a 12 month period Product features and availability vary by state and company and are solely the responsibility of each affiliate Refer to your certificate for complete details and limitations of coverage Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 60

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WHY VOLUNTARY BENEFITS Covers out of pocket expenses not covered by health insurance Benefits pay directly to you Cover yourself and dependents even if not covered on company health insurance Portable at the same rate if you leave or retire File claims easily at www coloniallife com file a claim BENEFITS AVAILABLE Accident Accidents happen in places where you and your family spend the most time at work in the home or at play and they emergency room fees deductibles and co payments that can result from a covered accident 2 levels available Guarantee Issue Cancer Helps offset the out of pocket medical and indirect noncover including treatment medication reconstruction experimental treatment transportation and lodging Includes Initial Diagnosis Benefit available up to 10 000 Includes 75 Annual Health Screening benefit Critical Illness Compliments your major medical coverage by providing a lump sum benefit that you can use to pay the direct and indirect costs related to a covered critical illness which can often be lengthy and expensive These include heart attack stroke major organ transplant end renal failure coma blindness paralysis occupational HIV or Hep B C or D coronary bypass surgery 25 of face amount Guarantee Issue 50 Annual Wellness Benefit Medical Bridge Having health insurance today often means having larger deductibles and higher co payments which also means higher out ofof pocket expenses related to a covered accident or sickness 1000 and 2000 confinement benefit payable when admitted to the hospital for an accident or sickness including maternity Includes outpatient surgical benefit of 500 1000 depending on tier of surgery Speak to a Colonial Life representative to sign up or get more information 70

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Group Accident Accident Coverage Benefits Colonial Life pays these benefits once per covered person for each covered accident unless otherwise noted Accident Benefits Plan 2 Plan 3 Accident Emergency Treatment 4 visits per person per calendar year Doctor s office urgent care facility or emergency room Accident Follow Up Doctor Visit Doctor s office urgent care facility or emergency room Accidental Death Accidental Death Common Carrier Accidental Dismemberment Loss of Finger Toe Loss of Hand Foot Sight Ambulance Air Ambulance Ground Appliances such as wheelchair crutches Blood Plasma Platelets Burns based on size and degree Burns Skin Graft Catastrophic Accident For severe injuries that result in the total and irrevocable loss of one hand and one foot loss of both hands or both feet loss or loss of use of one arm and one leg loss or loss of use of both arms or both legs loss of sight of both eyes loss of hearing of both ears loss of the ability to speak 365 day elimination period Coma duration of at least 14 consecutive days Concussion Dislocation Based on joint and if repaired by open or closed reduction 125 per visit 50 visit 3 visits per covered accident 12 visits per calendar year 25 000 EE SP 5 000 CH 100 000 EE SP 20 000 CH 1 750 2 1 500 1 7 500 2 15 000 1 500 200 100 300 2nd Degree 36 of body 1 000 3rd Degree 9sq 18sq 2 000 18sq 35sq 4 000 Over 35 sq 12 000 50 of burn benefit 50 000 EE SP 25 000 CH 10 000 150 150 6 000 125 per visit 50 visit 4 visits per covered accident 16 visits per calendar year 50 000 EE SP 10 000 CH 200 000 EE SP 40 000 CH 1 1 500 2 3 000 1 15 000 2 30 000 2 000 400 200 500 2nd Degree 36 of body 1 500 3rd Degree 9sq 18sq 3 000 18sq 35sq 6 000 Over 35 sq 18 000 50 of burn benefit 75 000 EE SP 37 500 CH 20 000 200 200 8 000 Emergency Dental Work 300 crown implant or denture or 600 crown implant or denture or Applicable to TX PS01623 This information is only intended for proposal use with employers Colonial Life products are underwritten by Colonial Life Accident Insurance Company for which Colonial Life is the marketing brand 09 2019 Colonial Life Accident Insurance Company 1200 Colonial Life Boulevard Columbia South Carolina 29210

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Accident Benefits Plan 2 Plan 3 Eye Injury Fracture Based on bone and if repaired by open or closed reduction Hospital Admission1 Hospital Confinement2 Hospital ICU Admission1 100 extraction 300 150 7 500 1 000 200 day up to 365 days 1 500 200 extraction 400 200 10 000 1 500 300 day up to 365 days 2 500 Hospital ICU Confinement2 400 day up to 15 days 600 day up to 15 days Rehabilitation Unit Confinement3 Knee Cartilage Torn Laceration based on size and repair 100 day up to 15 days per covered accident and up to 30 days per calendar year 500 No Stitches 25 With stitches less than 2 75 2 6 300 greater than 6 600 150 day up to 15 days per covered accident and up to 30 days per calendar year 1 250 No Stitches 50 With stitches less than 2 150 2 6 600 greater than 6 1 200 Lodging Companion per day up to 30 days 150 200 Medical Imaging Study Limit one per covered person per 150 400 calendar year Pain Management Epidural Anesthesia 100 150 Prosthetic Device Artificial Limb 500 1 1 000 2 1 000 1 2 000 2 Ruptured Disc with Surgical Repair 500 1 200 Surgery Cranial Open Abdominal Thoracic 1 500 2 000 Surgery Hernia 200 250 Surgery Exploratory and Arthroscopic 150 250 Tendon Ligament Rotator Cuff 500 1 750 2 1 200 1 1 800 2 Therapy Occupational and Physical Therapy 25 40 per day up to 10 days Transportation per trip up to 3 trips per 500 600 accident X Ray Benefit 30 50 1We will not pay the hospital admission benefit and the hospital ICU admission benefit for the same covered accident simultaneously 2We will not pay the hospital confinement benefit and the hospital ICU confinement benefit simultaneously 3We will not pay the hospital confinement benefit and the rehabilitation unit confinement benefit simultaneously Applicable to TX PS01623 This information is only intended for proposal use with employers Colonial Life products are underwritten by Colonial Life Accident Insurance Company for which Colonial Life is the marketing brand 09 2019 Colonial Life Accident Insurance Company 1200 Colonial Life Boulevard Columbia South Carolina 29210

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Individual Cancer Individual Cancer Insurance Plan Benefits Benefits are payable for each covered person under the policy Benefits are payable only when charges are incurred Benefits Air Ambulance per trip Maximum trips per confinement Ambulance per trip Maximum trips per confinement Anesthesia General Anesthesia Local per procedure Anti Nausea Medication per day Maximum per month Blood Plasma Platelets Immunoglobulins per day Maximum per calendar year Bone Marrow or Peripheral Stem Cell Donation per donation Maximum one per lifetime Bone Marrow Stem Cell Transplant per transplant Peripheral Stem Cell Transplant per transplant Maximum transplants per lifetime Companion Transportation per mile Maximum per round trip Egg s Extraction or Harvesting or Sperm Collection one per lifetime Egg s or Sperm Storage one per lifetime Experimental Treatment per day Maximum per lifetime Family Care per day Maximum per calendar year Hair External Breast Voice Box Prosthesis per calendar year Home Health Care Services Per Day Maximum per calendar year Hospice Initial Hospice Daily Maximum combined Initial and Daily per lifetime Hospital Confinement 30 days or less per day Level 2 Level 3 2 000 2 000 2 2 250 250 2 2 25 of Surgical Procedures Benefit 30 40 40 50 160 200 150 175 10 000 10 000 500 750 4 000 4 000 2 0 50 1 000 7 000 7 000 2 0 50 1 200 700 1 000 200 250 12 500 40 2 000 350 300 15 000 50 2 500 200 350 75 1 000 50 15 000 150 100 1 000 50 15 000 250

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Hospital Confinement 31 days or more per day Lodging per day Maximum days per calendar year Medical Imaging Studies per study Maximum per calendar year Outpatient Surgical Center per day Maximum per calendar year Private Full time Nursing Services per day Prosthetic Device Artificial Limb per device or limb Maximum per lifetime Radiation Chemotherapy Injected chemotherapy by medical personnel one per week Radiation delivered by medical personnel one per week Self Injected Chemotherapy one per month Pump Chemotherapy one per month Topical Chemotherapy one per month Oral Hormonal Chemotherapy 1 24 months one per month Oral Hormonal Chemotherapy 25 months one per month Oral Non Hormonal Chemotherapy one per month 300 50 70 125 250 200 600 75 1 500 3 000 500 500 200 200 200 200 100 200 500 75 70 175 350 300 900 125 2 000 4 000 750 750 300 300 300 300 150 300 Reconstructive Surgery per surgical unit Maximum per procedure including 25 for general anesthesia Second Medical Opinion one per lifetime Skilled Nursing Care Facility Per day up to the number of days for hospital confinement Skin Cancer Initial Diagnosis one per lifetime Supportive Protective Care Drugs Colony Stimulating Factors per day Maximum per calendar year Surgical Procedures per unit Maximum per procedure Transportation per mile Maximum per round trip Additional Benefits Bone Marrow Donor Screening Maximum of one per lifetime Cancer Vaccine Benefit Maximum of one per lifetime Waiver of Premium Annual Wellness Benefit Cancer Wellness Additional Invasive Diagnostic Test or Surgical Procedure 40 2 500 200 100 300 100 800 50 3 000 0 50 1 000 Level 2 50 60 3 000 300 100 400 150 1 200 60 5 000 0 50 1 200 Level 3 50 50 50 Yes Yes 75 75 75 75 Optional Initial Diagnosis Benefit Available from 1 000 to 10 000 in incriments of 1 000 Pays upon diagnosis of an internal cancer

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FOR FASTEST RESULTS FILE ONLINE 1 Go to and click Register or Login in the upper right corner 2 3 Enjoy streamlined claims management and faster service online DIGITALLY FILE ALL TYPES OF CLAIMS Disability Insurance Leaves of absence disability FMLA maternity etc Life Insurance Accident Critical Illness Hospital Insurance Cancer Insurance Wellness screening tests Just answer a fe BEFORE YOU FILE Review the appropriate claims checklist at and have this information handy to make the process go smoothly Proper documentation must be AFTER YOU FILE Check your claim status and manage your claim by logging into your account at ColonialLife com If you need to talk to someone give us a call On the policyholder site you can your policy to see what s amounts Track your claim Follow your claim from receive alerts if we need additional information Sign up for direct deposit and receive payment faster ColonialLife com Colonial Life products are underwritten by Colonial Life Accident Insurance Company Columbia SC Colonial Life Accident Insurance Company is not licensed in New York In New York insurance products are underwritten by The Paul Revere Life Insurance Company Worcester MA and administered by Colonial Life Accident Insurance Company 2021 Colonial Life Accident Insurance Company All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life Accident Insurance Company 73

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Vision Care Vision Benefit Information and Resources Finding a provider and scheduling an appointment is AS EASY AS At Blue Cross and Blue Shield of Texas we ve made it easier than ever to access your vision benefit information and schedule your annual eye exam Everything you need is available through our member portal 1 Register and log in to the member portal at eyemedvisioncare com bcbstxvis 2 Review your vision benefit information 1 Our member portal gives you access to benefit details claims provider locations and more And since many providers offer extended evening and weekend hours you can get care when it works for you 3 Find a provider near you Log in to eyemedvisioncare com bcbstxvis and then select Click here to find a provider Enter your zip code to be connected with eye health experts near you Still have questions Feel free to contact our award winning2 Customer Care Center at 855 556 8796 You can also learn more by visiting eyemedvisioncare com bcbstxvis All in network providers can look up eligible members in the EyeMed system with a name and date of birth to verify benefits ID cards are not required for eligible members to use their vision benefits Blue Cross and Blue Shield of Texas Vision Care ID Cards You will receive a one time welcome packet containing two ID cards and a member brochure You do not need ID cards to receive services Mailed ID cards will only have the employee s name listed but any covered family member may use the card Additional ID cards can be downloaded or printed by registering at eyemedvisioncare com bcbstxvis or by using the EyeMed App 1Actual benefits and frequencies vary by plan 2Purdue University Benchmark Portal independent assessment of call centers nationwide For employee use only Benefits are available from the EyeMed Vision Care LLC provider network and are administered by First American Administrators Inc independent companies that offer benefits on behalf of Blue Cross and Blue Shield of Texas Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and 4Bl4ue Shield Association an association of independent Blue Cross and Blue Shield Plans 750120 0919

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Vision Care Give Your EYES a Front Row Seat Maximize Your Contacts Benefit Benefit overview With your vision benefit you re eligible for either contacts or spectacle lenses within the defined benefit frequency If you use your benefit for contacts you re still eligible to use your frame benefit too Sample vision plan 130 frame allowance 10 lens copay 130 contact allowance Sample member transaction You buy contacts apply 130 contacts allowance You buy a pair of glasses apply 130 frame allowance and 20 off any amount over plus receive 20 off spectacle lenses Additional discounts 40 off unlimited complete pairs of prescription eyewear once benefit has been used 20 off partial eyewear purchases and non covered items 15 off conventional contacts For illustrative purposes only May not be available in all jurisdictions Coverage may be subject to limitations exclusions and other coverage conditions contained in the issued policy Please consult the policy for the actual terms of coverage For employee use Benefits are available from the EyeMed Vision Care LLC provider network and are administered by First American Administrators Inc independent companies that offer benefits on behalf of Blue Cross and Blue Shield of Texas Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered servi4ce5marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 750297 0919

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Vision Care See More Save More Your eyes say a lot about you from your emotions to vision and your overall health And when you re proactive about protecting your eyes the impact is clear Your Blue Cross and Blue Shield of Texas BCBSTX vision insurance gives you access to a vast network of independent eye doctors and popular retailers Your vision benefit lets you score the hottest brands for less Locate an eye doctor Our network has thousands of independent eye doctors and popular retailers So you can see who you want to see when and where you want to see them Visit eyemedvisioncare com bcbstxvis to find an in network provider near you Schedule an appointment Schedule an appointment online call ahead or stop by one of the many eye doctors who offer walk ins Most offer evening and weekend hours to fit any schedule Use your benefit When you arrive present your ID card or simply let the eye doctor know you have a benefit through your BCBSTX vision insurance Lucky you Regular eye exams not only correct vision problems but can also reveal early warning signs of more serious health conditions such as hypertension cardiovascular disease and diabetes So schedule eye exams annually and you ll be set on a path to better health Member Patient Services eyemedvisioncare com bcbstxvis 855 556 8796 Select Network BCBSTX Vision Care Group 1023239 Member Patient Services eyemedvisioncare com bcbstxvis 855 556 8796 EyeMed Doctors Providers Only Visit eyemed com or call 844 323 8302 to receive plan information FOLD For employee use only Benefits are available from the EyeMed Vision Care LLC provider network and are administered by First American Administrators Inc independent companies that offer benefits on behalf of Blue Cross and Blue Shield of Texas Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shie4ld6Association an association of independent Blue Cross and Blue Shield Plans 751575 0919

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Vision Care The RIGHT OPTIONS are waiting for you Estimate Your Eye Care Costs In An Instant With the Know Before You Go out of pocket cost estimator you can get a feel for what you might pay for vision services and materials before you even step foot into a store or eye doctor s office The tool includes simple clear definitions of common vision products and add ons all while calculating a range of costs with each click So you can feel confident from check in to check out The Know Before You Go Out Of Pocket Cost Estimator is Easy to Access and Use 1 Log into your registered account at eyemedvisioncare com bcbstxvis and click the estimate costs tab 2 Pick the type of exam you ll need Just need glasses or contacts Skip to Step 3 3 Choose from a variety of lens types options and add ons Plus get detailed descriptions of each product so you feel confident in your choices 4 The best part You get a range of costs based on your choices and applied vision benefits We do the math so you stay in the know before you go QUESTIONS Call 1 855 556 8796 or visit eyemedvisioncare com bcbstxvis to learn more For employee use only For illustrative purposes only The out of pocket cost estimator is created established and maintained by EyeMed EyeMed is an independent organization and is solely responsible for the products and services it provides Vision Insurance offered by Dearborn Life Insurance Company located at 701 E 22nd Street Lombard IL 60148 Blue Cross and Blue Shield of Texas an Independent Licensee of the Blue Cross and Blue Shield Association EyeMed Vision Care LLC and First American Administrators Inc are independent companies that offer provider network and administration services on behalf of Dearborn Life Insur4a7nce Company 759021 0522

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Vision Care Got questions about your vision plan We Can Help Your Questions Answered Q My eyes are fine Do I really need to have them checked regularly A Yes regular eye exams are the way to go It s not just about correcting your vision it s about overall health Eye exams can spot health conditions like glaucoma diabetes cataracts and hypertension early The sooner these issues are spotted the sooner you can get treatment Q Will I save more money with this vision care benefit or with an eyewear coupon or other promotional offer A Great question There are lots of special offers and coupons out there When you compare them to your plan coverage you ll likely find that your vision plan saves you more money in almost every case A nice bonus is that you can use your vision benefit whenever you need to Say goodbye to coupon expiration dates and limited time offers Keep in mind that your benefit can t be combined with any other discounts or promotional offers Naturally you re responsible for copays any remaining outof pocket expenses and applicable sales tax Q Can I get new contacts and glasses in the same year A Every 12 months you can get either contacts or spectacle lenses Check your plan s benefits summary for additional frequencies such as updating your look with new frames every 24 months Q Do I need to have my ID card with me to use my benefits A Nope An in network provider only needs your name and date of birth Q How do I get another member ID card A If your member ID card gets lost no worries You don t even need one to receive service But if you want an additional card you can access one and print it through our website eyemedvisioncare com bcbstxvis Q What s included in a covered exam Is dilation an extra cost A No worries we ve got you covered Eye exams at participating providers include dilation and other important eye health tests There are no added outof pocket costs other than a copay if applicable Q How does the standard lens benefit work A It s simple We give you a standard plastic lens either single vision or lined multifocal as part of the covered benefit You re only responsible for a copay if applicable and taxes How do I get in touch with the Customer Care Center It s easy You can talk to a representative a real person by calling 855 556 8796 Also you ll find automated features online at eyemedvisioncare com bcbstxvis or through our automated voice response system Hours of live operation Monday Saturday 6 30 a m to 10 00 p m CST Sunday 10 00 a m to 7 00 p m CST 48 Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148

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Are additional discounts available Yes indeed You can enjoy these additional savings 40 off additional complete pairs of prescription glasses 20 off any remaining frame balance 20 off non covered items including non prescription sunglasses accessories and lens cleaner 15 off any remaining conventional contact lens balance 15 off the standard price or 5 off promotional price of LASIK or PRK services Q What about add ons to the standard lenses A Want UV and scratch protection Or any anti reflective coatings Good news Most of these common add ons are discounted at Blue Cross and Blue Shield of Texas BCBSTX vision care providers Check with your provider before ordering for details Q Can I receive no line bifocals as part of the lens benefit A Absolutely Set pricing on standard progressive no line lenses are available Also some plans offer set pricing on premium progressive lenses based on the lens brand Q Does my allowance amount only apply to certain frames A No you re free to apply your allowance toward the retail price of ANY frame at any in network location You also have a 20 discount on the difference between the retail price and your allowance amount Q How does the contact lens benefit work A Just like the frame allowance the contact allowance is applied to the retail price of any contact lens No fussy formularies to worry about Also you can apply a 15 discount to the difference between the retail price and the allowance amount for non disposable contacts Q What is a contact fitting A After buying contacts a provider may ask you to check back in just to make sure they re perfect for you They will assess your eyes and ensure that the new contacts are a great fit Q Can I carry over an unused allowance amount to another purchase A Sorry the contact allowance amount is a one time allowance It s best to use the full benefit on your initial purchase of contacts Q Do I need to pay the full retail price for non covered items A You have a 20 discount to buy items not covered by the plan at network providers This discount applies to everything except professional services and contact lenses Q Do I need to submit claims for services rendered at an in network provider A Not at all If you visit a BCBSTX participating provider you don t need to worry about filling out forms or vouchers to get your benefits After collecting the appropriate copays and other out of pocket expenses at the time of service the provider submits the claim on your behalf Q Do members have to go to a participating provider A No restrictions here You have the freedom to choose non participating providers But please keep in mind that you can make the most of your benefit and save money by choosing an in network provider We make it convenient and easy to find one which is why 98 of our members visit in network providers Use our Provider Locator on eyemedvisioncare com bcbstxvis to find providers near you At non participating providers you must pay full out of pocket pricing at the time of service Then you can submit a claim for reimbursement of covered services 49

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For overall wellness don t forget your annual eye exam Q Who qualifies for medically necessary contact lenses A Members who are diagnosed with any of the following Anisometropia of 3D in meridian powers High Ametropia exceeding 10D or 10D in meridian powers Keratoconus when the member s vision is not correctable to 20 25 in either or both eyes using standard spectacle lenses Vision improvement other than keratoconus for members whose vision can be corrected by two lines on the visual acuity chart when compared to the best corrected standardspectacle lenses Seem confusing Our award winning service center is always available to answer tough questions Q Does your provider network include both independent and optical retailers A Yes Members can choose from thousands of private practitioners and the nation s leading optical retailers LensCrafters Target Optical and most Pearle Vision locations And if your favorite provider isn t in our network yet you can nominate it Just complete a Provider Nomination Form available through our Customer Care Center The provider must accept and agree to the Terms and Conditions of our Professional Provider Agreement and complete the credentialing process to ensure they meet our quality standards Q Do you offer a discount on laser vision correction A You bet we do Members get 5 off any promotion or 15 off the retail price for treatments performed through the U S Laser Network which is owned and administered by LCA Vision Q How do I access the laser vision discount A Follow these simple steps to get the ball rolling 1 First pick which laser correction provider you d like to use Call the U S Laser Network at 877 5LASER6 for a complete list 2 Next set up a consultation with the provider When making the appointment be sure to tell them you re a Blue Cross and Blue Shield of Texas member 3 The consultation is next That s when you and your provider will decide whether or not you re a good candidate for the procedure Be sure to bring questions 4 Going ahead with laser correction Great Call the U S Laser Network to request an authorization for your discount At this time you ll also need to put down a refundable deposit The authorization will be sent to you and the laser provider 5 All that s left is scheduling your procedure After surgery be sure to follow all post operative instructions carefully Then treat your new eyes to a beautiful view For emloyee use For illustrative purposes only May not be available in all jurisdictions Coverage may be subject to limitations exclusions and other coverage conditions contained in the issued policy Please consult the policy for the actual terms of coverage Benefits are available from the EyeMed Vision Care LLC provider network and are administered by First American Administrators Inc independent companies that offer benefits on behalf of Blue Cross and Blue Shield of Texas Blue Cross and Blue Shield of Texas a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 50 750122 0919

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Life Insurance Services for Insureds Beneficiaries and Their Families Beneficiary Resource ServicesTM Benefits Beyond a Check When a loved one dies families often face complex issues ranging from estate planning legal questions funeral planning and coping with grief and financial uncertainties That s why we offer Beneficiary Resource Services a program that combines family wellness and security at the most difficult of times Services include grief and financial counseling funeral planning legal support and online will preparation Beneficiary Resource Services is provided by Morneau Shepell Services for Insureds and Their Families Beneficiary Resource ServicesTM Counseling 800 769 9187 BeneficiaryResource com Username beneficiary Online Will Preparation You and your family have access to a full legal library with many estate planning documents including an online will You can create your own will online in a safe and secure way right from your home The will can be saved and updated as family situations change Creating a will provides security and peace of mind for several reasons Appoints a guardian for children Controls where property and assets go Provides family security Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Online Funeral Planning You have access to an online funeral planning site that features a variety of helpful tools and information such as A downloadable funeral planning guide to document vital information your loved ones will need when making final arrangements Calculators to estimate and compare expenses for various types of funeral arrangements Information on funeral requirements and various religious customs Directories to locate funeral homes and cemeteries in your area 61

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Services for Beneficiaries and Their Families The following services are available after a life claim or for those who qualify for an accelerated death benefit Face to Face Working Sessions Five face to face working sessions are available to you or your beneficiaries All five sessions may be used with one grief counselor or legal advisor or they may be split among the two types of counselors or advisors in geographically accessible locations A one hour financial consultation on the phone is also available Unlimited Phone Contact Available for up to one year with a grief counselor legal advisor or financial planner Referrals and Support Services Morneau Shepell maintains a comprehensive directory of qualified and accessible grief counselors and legal and financial consultants Follow Up Counselors will initiate follow up calls when necessary for up to one full year from the date of initial contact Morneau Shepell s network of experienced professionals can offer counseling for those facing emotional financial or legal issues Morneau Shepell s counselors are available 24 hours a day 365 days a year All calls are completely confidential To access these valuable resources call or visit 800 769 9187 BeneficiaryResource com Username beneficiary May include face to face sessions over the phone sessions or time taken for research or document preparation For employee use Beneficiary Resource Services is provided by Morneau Shepell Morneau Shepell is an independent organization that does not provide Blue Cross and Blue Shield of Texas BCBSTX or Dearborn Life Insurance Company products or services Morneau Shepell is solely responsible for the products and services described in this flier Legal services will not be provided for court proceedings or for the preparation of briefs for legal appearances or actions or for any action against any party providing Beneficiary Resource Services Legal services provided under Beneficiary Resource Services are not intended for adversarial matters May include face to face sessions over the phone sessions or time taken for research or document preparation Neither Morneau Shepell BCBSTX nor Dearborn Life Insurance Company are responsible or liable for care or advice rendered by any referral resources Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans Beneficiary Resource ServicesTM Counseling 800 769 9187 BeneficiaryResource com Username beneficiary Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association 62 750109 0919

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Life Insurance Beneficiary Designation Guide Employer Sponsored Life Insurance Programs You have chosen to participate in the term life insurance program sponsored by your employer An important part of the benefit program is the designation of a beneficiary By designating a beneficiary you control the distribution of your life insurance benefits upon your death To be sure your intentions are clear fill out the beneficiary designation form which can be found under Forms on bcbstx com ancillary write clearly sign and date the form and submit it to your Human Resources department Once accepted by Human Resources the designation will be valid These same steps apply if you choose to change your beneficiary designation Your company may have an online capability tied to your enrollment platform to complete your beneficiary designation If that is available to you select your beneficiaries online Primary and Contingent Beneficiaries Please be sure to designate both primary and contingent beneficiaries Upon your death the primary beneficiary or beneficiaries if you choose more than one will receive any payable life benefits The contingent beneficiary or beneficiaries will receive life benefits ONLY if all primary beneficiaries have predeceased you You may choose to have your beneficiaries share the benefits equally or you may apply different percentages to each Allotted percentages should add up to 100 If no primary or contingent beneficiaries survive you or if you have not named a beneficiary life benefits are paid to Your spouse or certified domestic partner if living Your children if living in equal portions Your parents if living in equal portions Your brothers and or sisters if living in equal portions If none of the above applies to your estate you may designate any of the following as your primary or contingent beneficiary A person or persons An institution trust charity or corporation you may not name your employer or policyholder Your estate upon your death Letters Testamentary or Letters of Administration appointing a personal representative of your estate will be required If you name a living trust you should make sure that the trust is established and that it remains in effect through your death in order for the trust to receive the proceeds We cannot pay life insurance proceeds directly to a minor If you want to name a minor as a beneficiary you can use a trust to make a beneficiary designation If you are acting as a power of attorney on behalf of an employee making a beneficiary designation please refer to the FAQ Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Who are you protecting Life insurance is the tool most people use to financially protect their families from premature death Do you have a beneficiary When you designate a beneficiary YOU control who receives your life insurance benefits and whose financial future you protect Make your intentions clear and fill out the Beneficiary Designation Form You may obtain a copy of your beneficiary designation by contacting your Human Resources department 63

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Frequently Asked Questions About Designating Beneficiaries 1 How many times may I change my beneficiary designation You may change the beneficiary designation for group life insurance as often as you wish and at any time A change should be considered any time you experience a significant life event such as a birth marriage divorce or death This change is not valid until it is accepted by Human Resources 2 I am not comfortable giving my beneficiary s Social Security number Is it required The Social Security number is not required however the beneficiary will be required to provide it at time of the claim to expedite the processing of the benefits It will be used to help positively identify your beneficiary 3 Can my Power of Attorney complete my beneficiary form and can he or she name himself or herself as beneficiary Yes if the Power of Attorney documents specifically state that you have delegated this right If you wish the Power of Attorney to be able to name himself or herself as beneficiary the Power of Attorney document must also specifically state that you have delegated this right Most standard Power of Attorney documents do not include a designation of these rights Please carefully review your Power of Attorney documents You may wish to consult with your attorney for further advice 4 I am in the process of getting divorced How should I word my form Since each divorce case or dissolution of a civil union is different and can be complex we suggest discussing your beneficiary designation with your attorney at the time the divorce dissolution paperwork is filed and again after the final decree has been issued 5 I am considering setting up a trust may I name a trust as beneficiary You may choose to designate an established trust to receive your group life insurance benefit If you elect to do so you MUST provide the name and date of the trust and the name and address of the trustee to contact upon your death You do not need to provide a copy of the trust documents with your Designation of Beneficiary form but the trustee will have to present them at the time of the claim 6 Can group life insurance benefits get paid directly to funeral homes Benefits can be made payable directly to a funeral home so long as the designated beneficiary ies authorize the specific amount to be paid to the funeral home However required documentation is needed and must be provided in a timely manner before the claim payment is made Please note that proceeds designated to a minor cannot be assigned to a funeral home to cover burial expenses Beneficiary Designation Tips Use proper names Nicknames can be confusing When naming a married female as beneficiary be certain the proper name is given e g Angela J Harmon not Mrs John R Harmon Use specific names The phrase my children can be vague and ambiguous Does it mean my children living at the time I completed this form or my children living at the time of my death Secure your spouse s consent if you are not naming your spouse as a beneficiary and you reside in a community property state Community property states currently are Arizona California Guam Idaho Louisiana Nevada New Mexico Nevada Puerto Rico Texas Washington and Wisconsin Make a copy of your completed beneficiary designation form before submitting it to Human Resources and periodically review it to make sure all your beneficiary information is correct and current It is especially important to update this information after a life event such as a birth marriage divorce or death Complete this form with an ink pen Human Resources will not accept a form completed in pencil Don t use white out or cross out names to make changes in designation doing so could invalidate the form Human Resources asks that you read the beneficiary designation form document carefully to ensure that your wishes are properly and validly carried out 64

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Frequently Asked Questions About Designating Beneficiaries 7 Do I need a beneficiary designation for my group dependent life coverages For group dependent life coverages the employee is always the beneficiary and therefore you DO NOT have to designate a beneficiary However if you and the dependent should die at the same time and benefits are payable the proceeds would be paid to your estate 8 I would like to name a minor child as beneficiary What happens if I die and the child is still a minor at the time of my death If you name a minor as a beneficiary 1 The benefits can be held on behalf of the minor at a nominal interest rate until the minor becomes of legal age 2 Depending on the law in the minor s state of residence you may be able to put the funds in a Uniform Transfer to Minors Act UTMA account that you set up 3 A guardian of the minor s estate may submit appropriate documentation to direct distribution of the benefits State law varies widely on this matter and should be consulted before making any decision 9 I named my three grandchildren to be sole heirs in my will Will this ensure that any life proceeds are distributed to them A will is a separate document Life insurance benefits will be paid according to the most current beneficiary designation form on file with Human Resources 10 What is facility of payment A facility of payment order is used for cases where there is no named beneficiary or all primary and contingent beneficiaries listed have passed away before the insured The order is always spelled out in your life insurance certificate For employee use only For illustrative purposes onlyand is not intended to provide legal advice May not be available in all jurisdictions Always consult an attorney if you have questions or concerns about the subject matter in this document If there is a conflict between the terms and conditions of the insurance policy and certificate and the statements in this document the policy and certificate will control Coverage may be subject to limitations exclusions and other coverage conditions contained in the issued policy Please consult the policy for the actual terms of coverage Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 65 756138 0521

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Travel Resource Services Travel Resource ServicesTM Your Ticket to Safe and Worry Free Travel Our Travel Resource Services provider Assist America offers around the clock emergency and information services that can help you access emergency assistance when you are traveling 100 or more miles away from home Medical Emergency Assistance Medical referral Medical monitoring Emergency medical evacuation Foreign hospital admission assistance Medical repatriation Prescription assistance Travel Emergency Assistance Compassionate visit Care of minor children Evacuation transport for family members Return of mortal remains Other services include Return of vehicle Legal interpreter referrals Pre trip information Download the Mobile App Access a wide range of global emergency assistance services from your phone by downloading the FREE Assist America Mobile App Enter your Assist America Reference Number to set up the App 01 AA TRS 12201 Tap for Help One touch call to Assist America s 24 7 Operations Center Voice Over Internet Protocols VoIP Avoid international phone charges by calling Assist America using a Wi Fi connection Pre Trip Information Access detailed country specific information to prepare your trip Embassy U S Pharmacy Locator Locate the nearest embassy consulate of 23 countries and pharmacies near you U S pharmacies only Travel Alerts Receive alerts on urgent global situations that may impact travel Travel Status Indicator A GPS feature letting you know when you are eligible for services Mobile ID Card Your Assist America ID card is conveniently stored within the app Available in 7 languages The app is available in English Spanish Arabic Mandarin Thai Bahasa and French Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 How to Activate Services If you are traveling more than 100 miles away from home or in a foreign country and require assistance contact Assist America s 24 7 Operations Center Your Assist America Reference Number is 01 AA TRS 12201 TAP FOR HELP On the Mobile App 800 872 1414 Toll Free within the U S 1 609 986 1234 outside the U S medservices assistamerica com 66

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Medical Emergency Assistance Medical Referral Assist America s 24 7 Operations Center is staffed by trained multilingual assistance personnel who can make immediate recommendations for any emergency situation Medical Monitoring Assist America maintains regular communication with members their families and attending medical staff closely monitoring the quality and course of treatment Emergency Medical Evacuation If a member becomes ill or injured where an adequate medical facility is not available Assist America will arrange to transport the member under medical supervision if required to the nearest medical facility capable of providing the required care Foreign Hospital Admission Assistance Assist America fosters prompt hospital admission by validating the member s health insurance or advancing funds as needed to the hospital Medical Repatriation When the member has been stabilized to the satisfaction of Assist America s consulting physicians and the attending physician and is medically cleared for travel we will arrange and pay for transportation via commercial carrier back home or to a rehabilitation facility with medical supervision if required Prescription Assistance When a prescription is lost or left behind Assist America works with the prescribing physician and a local pharmacy to replace the member s medicine Travel Emergency Assistance Compassionate Visit Assist America will arrange and pay for a family member or a friend to join a member who is traveling alone and is expected to be hospitalized for more than seven days Care of Minor Children If an injured member has minor children left unattended Assist America will pay for them to return home to a family member or will arrange childcare locally or at home Evacuation Transport for Family Members If a member is evacuated Assist America will arrange and pay for either the return of the immediate family members spouse children parents home or the transportation to the location where the member is evacuated Return of Mortal Remains In the event that a member passes away Assist America will arrange and pay for the required documents preparation of the remains and transport to a funeral home near the member s place of residence Other services include Return of vehicle Legal interpreter referrals Emergency cash bail bond coordination Pre trip information For employee use Travel Resource Services is administered by Assist America Inc Assist America is an independent organization that does not provide Blue Cross and Blue Shield of Texas or Dearborn Life Insurance Company products or services Assist America is solely responsible for the products and services associated with Travel Resource Services Usage of the Assist America mobile app may be subject to additional terms and conditions Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans Conditions and Exclusions All travel transportation services must be arranged by Assist America Claims for reimbursement will not be accepted under the Assist America Global Emergency Assistance program Assist America is not medical insurance Medical bills are the responsibility of the member or the health insurance as applicable Upon verification of your eligibility Assist America will arrange and pay for the following services Emergency Medical Evacuation and Medical Repatriation 150 000 Combined Single Limit Repatriation of Mortal Remains Up to 15 000 Care of Minor Children Up to 5 000 Return of Vehicle Up to 2 500 Compassionate Visit Up to 5 000 Assist America will not provide services in the following instances Suicide or attempted suicide intentionally self inflicted injuries The transfer from one medical facility to another of similar capabilities which provides the same level of care Occurrence of mild lesions simple injuries such as sprains simple fractures or mild sickness which can be treated by local doctors that do not prevent the continuation of travel Participation in any war invasion acts of foreign enemies hostilities between nations whether declared or not or civil war rebellion revolution and insurrection military or usurped power Participation in any military maneuver or training exercise Traveling against the advice of a physician Traveling for the purpose of obtaining medical treatment Traveling in any country in which the U S State Department issued travel restrictions prior to such travel Piloting or learning to pilot or acting as a member of the crew of any aircraft Mental or emotional disorders unless hospitalized Being under the influence of drugs or intoxicants unless prescribed by a physician Commission or the attempt to commit a criminal act Participation as a professional in athletics or underwater activities Participating in bodily contact sports skydiving hang gliding parachuting mountaineering any race bungee cord jumping speed contests spelunking or caving heli skiing extreme skiing Dental treatment except as a result of accidental injury to sound natural teeth Any non emergency treatment or surgery routine physical examinations hearing aids eyeglasses or contact lenses Pregnancy and childbirth except for complications of pregnancy prior to the 28th week of the pregnancy Curtailment or delayed return for other than covered reasons Services not shown as covered trips exceeding 90 days in length from primary legal residence The services described above currently are available in every country of the world Due to political and other situations in certain areas of the world Assist America may not be able to respond in the usual manner Assist America also reserves the right to suspend curtail or limit its services in any area in the event of rebellion riot military uprising war terrorism labor disturbance strikes nuclear accidents Acts of God or refusal of authorities to permit Assist America to fully provide services Assist America is not responsible and cannot be held liable for any malpractice performed by a local physician or attorney who is not an employee of Assist America or for any loss or damage to your vehicle during the return of vehicle or for any loss or damage to any personal belongings 67 750178 0221

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Evidence of Insurability EOI Frequently Asked Questions for Employees 1 What is Evidence of Insurability EOI EOI is an application process where you provide information on the condition of your health or your dependent s health in order to be considered for certain types of insurance coverage The completed EOI application needs to be reviewed and approved before coverage becomes effective 6 What if I don t have Internet access Will you still accept an EOI application in paper form Yes printable EOI applications are available for your employer to download and print in the Forms section of our website You can work with your employer to fill out the paper EOI application which can be mailed or faxed to us 2 Why is EOI needed EOI is utilized to protect an employer s group insurance program from adverse risks and reduce the likelihood of disproportionate claims risks This helps your employer s utilization and controls the cost of their insurance program 3 When is EOI required and why must I answer health questions Most group life policies offer a certain amount of guaranteed coverage EOI may be required if 1 you apply for an amount of coverage higher than the guarantee issue amount 2 you are currently enrolled and want to increase your insurance amount or 3 you decline coverage during your initial eligibility period and then want coverage at a later date 4 What does the online EOI application consist of The online EOI application process allows you to securely input information on medical conditions and treatment into an electronic application That application then goes through an automated review that can speed up the decision making process resulting in a quick decision or highlighting that additional information is needed 5 What about privacy when using online EOI submission Privacy and security features have been built into our website to assure the protection of your personal information Your answers to all the questions are kept strictly confidential and are not shared with your employer For more information read our online privacy statement 7 What are the advantages of online EOI submission Online EOI submission eliminates or reduces the processing of paper applications for coverage requests increases accuracy and confidentiality and speeds up the overall application process Step by step instructions lead you through the application process which usually takes about 15 to 30 minutes The website includes many interactive features to help ensure submissions are accurate and completed correctly After your application is completed and submitted our system will provide confirmation that your application has been received Based on information you provided a decision may be made immediately or you will get notified of any additional information that is needed Once we receive all of the required information a decision will be made within 5 to 10 days and you will be notified An online EOI application can be submitted 24 hours a day 7 days a week 8 What information do I need to know before beginning the online application process You will need The EOI form link which will either be supplied by your Employer or emailed to you from us Your date of birth and Social Security number for security validation in the EOI form link Your current height and weight treatment history and medication s for any health condition s name and address of any physician hospital or other practitioner that provided medical care consultation or treatment 74 Insurance products issued by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148

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9 What is the underwriting process After we receive your EOI application we create a record for you and your application goes through an automated system resulting in a decision or it is turned over to an underwriter for further review Factors such as current physical condition medical history and height and weight are used to determine if you meet our acceptance standards for the type of insurance requested 10 What information is required to process my EOI application Your EOI application is usually processed using only the information you provide However in some cases a physical examination is needed The basic physical examination includes height weight pulse blood pressure and a medical history questionnaire The examination may include special testing such as a blood test urinalysis and an EKG If an examination by a qualified medical professional is required we will securely and electronically notify the exam center of any required testing and you will receive notification that will include a brochure to help you prepare for the examination The exam center will contact you to schedule an appointment Most exams can be done in the convenience of your own home and take less than 30 minutes There is no charge for the examination We may also call or send a letter to you to clarify information during the evaluation process A review of your past medical records may be necessary to evaluate your EOI application If so a medical records retrieval service is used to obtain the requested information from your doctor or other healthcare provider We will also notify you that your medical records have been requested Your medical records are considered confidential and information is not released to anyone else without your consent or a court order There is no charge for the medical records 11 If an exam is required or medical records are requested how long does it take to receive the requested information When you complete the physical examination a report of the examination is sent to our medical underwriting department We usually receive the reports in our office within a week to 10 days after the examination If blood tests or a urinalysis are needed they are handled by an independent laboratory We usually receive these results within a week of the examination If we need to write to your doctor for medical records it may take 2 to 4 weeks depending on the physician s office procedures Sometimes it helps if you call your doctor s office and ask for a prompt response 12 What is the time frame for processing my EOI application Your EOI application will be active in the review process for 60 days Once we receive all the information requested we will review it promptly Most of our decisions are made within 5 10 days of receipt of all requested information Occasionally additional information might be needed If further information is needed to evaluate your EOI application we will notify you by mail within a few days If we do not receive the requested application information medical records and or exam lab tests within 45 days from the date of the initial request your file will be closed and you must reapply for the coverage you want 13 Whom should I contact for underwriting questions or the status of my EOI application For underwriting questions or the status of your EOI application please contact us at 877 442 4207 Hours of operation are Monday Friday 8 00 a m to 4 30 p m CST 14 What is the appeal process if I am denied coverage through EOI If you are denied coverage through medical underwriting you will receive a letter with an explanation and a reason for the denial If you wish to contest the decision you must appeal it in writing You may also provide us with additional medical documentation for reevaluation and review For employee use only For illustrative purposes only May not be available in all jurisdictions Coverage may be subject to limitations exclusions and other coverage conditions contained in the issued policy Please consult the policy for the actual terms of coverage Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans 75 753303 0622

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Glossary of Health Coverage and Medical Terms This glossary has many commonly used terms but isn t a full list These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan Some of these terms also might not have exactly the same meaning when used in your policy or plan and in any such case the policy or plan governs See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document Bold blue text indicates a term defined in this Glossary See page 4 for an example showing how deductibles co insurance and out of pocket limits work together in a real life situation Allowed Amount Maximum amount on which payment is based for covered health care services This may be called eligible expense payment allowance or negotiated rate If your provider charges more than the allowed amount you may have to pay the difference See Balance Billing Appeal A request for your health insurer or plan to review a decision or a grievance again Balance Billing When a provider bills you for the difference between the provider s charge and the allowed amount For example if the provider s charge is 100 and the allowed amount is 70 the provider may bill you for the remaining 30 A preferred provider may not balance bill you for covered services Co insurance Your share of the costs of a covered health care service calculated as a percent for example 20 of the allowed amount for the service Jane pays Her plan pays You pay co insurance 20 80 plus any deductibles See page 4 for a detailed example you owe For example if the health insurance or plan s allowed amount for an office visit is 100 and you ve met your deductible your co insurance payment of 20 would be 20 The health insurance or plan pays the rest of the allowed amount Co payment A fixed amount for example 15 you pay for a covered health care service usually when you receive the service The amount can vary by the type of covered health care service Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay For example if your deductible is 1000 Jane pays 100 Her plan pays 0 your plan won t pay See page 4 for a detailed example anything until you ve met your 1000 deductible for covered health care services subject to the deductible The deductible may not apply to all services Durable Medical Equipment DME Equipment and supplies ordered by a health care provider for everyday or extended use Coverage for DME may include oxygen equipment wheelchairs crutches or blood testing strips for diabetics Emergency Medical Condition An illness injury symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm Emergency Medical Transportation Ambulance services for an emergency medical condition Complications of Pregnancy Conditions due to pregnancy labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus Morning sickness and a nonemergency caesarean section aren t complications of pregnancy Emergency Room Care Emergency services you get in an emergency room Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse OMB Control Numbers 1545 2229 1210 0147 and 0938 1146 76

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Excluded Services Health care services that your health insurance or plan doesn t pay for or cover Grievance A complaint that you communicate to your health insurer or plan Habilitation Services Health care services that help a person keep learn or improve skills and functioning for daily living Examples include therapy for a child who isn t walking or talking at the expected age These services may include physical and occupational therapy speech language pathology and other services for people with disabilities in a variety of inpatient and or outpatient settings Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium Home Health Care Health care services a person receives at home Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay An overnight stay for observation could be outpatient care Hospital Outpatient Care Care in a hospital that usually doesn t require an overnight stay In network Co insurance The percent for example 20 you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan In network co insurance usually costs you less than out of network co insurance In network Co payment A fixed amount for example 15 you pay for covered health care services to providers who contract with your health insurance or plan In network co payments usually are less than out of network co payments Medically Necessary Health care services or supplies needed to prevent diagnose or treat an illness injury condition disease or its symptoms and that meet accepted standards of medicine Network The facilities providers and suppliers your health insurer or plan has contracted with to provide health care services Non Preferred Provider A provider who doesn t have a contract with your health insurer or plan to provide services to you You ll pay more to see a non preferred provider Check your policy to see if you can go to all providers who have contracted with your health insurance or plan or if your health insurance or plan has a tiered network and you must pay extra to see some providers Out of network Co insurance The percent for example 40 you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan Outof network co insurance usually costs you more than innetwork co insurance Out of network Co payment A fixed amount for example 30 you pay for covered health care services from providers who do not contract with your health insurance or plan Out of network copayments usually are more than in network co payments Out of Pocket Limit The most you pay during a policy period usually a year before your health insurance or plan begins to pay 100 of the allowed amount This limit never Jane pays Her plan pays includes your premium 0 100 balance billed charges or health care your health See page 4 for a detailed example insurance or plan doesn t cover Some health insurance or plans don t count all of your co payments deductibles co insurance payments out of network payments or other expenses toward this limit Physician Services Health care services a licensed medical physician M D Medical Doctor or D O Doctor of Osteopathic Medicine provides or coordinates 77

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Plan A benefit your employer union or other group sponsor provides to you to pay for your health care services Preauthorization A decision by your health insurer or plan that a health care service treatment plan prescription drug or durable medical equipment is medically necessary Sometimes called prior authorization prior approval or precertification Your health insurance or plan may require preauthorization for certain services before you receive them except in an emergency Preauthorization isn t a promise your health insurance or plan will cover the cost Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount Check your policy to see if you can see all preferred providers or if your health insurance or plan has a tiered network and you must pay extra to see some providers Your health insurance or plan may have preferred providers who are also participating providers Participating providers also contract with your health insurer or plan but the discount may not be as great and you may have to pay more Premium The amount that must be paid for your health insurance or plan You and or your employer usually pay it monthly quarterly or yearly Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications Prescription Drugs Drugs and medications that by law require a prescription Primary Care Physician A physician M D Medical Doctor or D O Doctor of Osteopathic Medicine who directly provides or coordinates a range of health care services for a patient Primary Care Provider A physician M D Medical Doctor or D O Doctor of Osteopathic Medicine nurse practitioner clinical nurse specialist or physician assistant as allowed under state law who provides coordinates or helps a patient access a range of health care services Provider A physician M D Medical Doctor or D O Doctor of Osteopathic Medicine health care professional or health care facility licensed certified or accredited as required by state law Reconstructive Surgery Surgery and follow up treatment needed to correct or improve a part of the body because of birth defects accidents injuries or medical conditions Rehabilitation Services Health care services that help a person keep get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick hurt or disabled These services may include physical and occupational therapy speech language pathology and psychiatric rehabilitation services in a variety of inpatient and or outpatient settings Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home Skilled care services are from technicians and therapists in your own home or in a nursing home Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose manage prevent or treat certain types of symptoms and conditions A non physician specialist is a provider who has more training in a specific area of health care UCR Usual Customary and Reasonable The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service The UCR amount sometimes is used to determine the allowed amount Urgent Care Care for an illness injury or condition serious enough that a reasonable person would seek care right away but not so severe as to require emergency room care 78