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Important NoticesI. Initial Notice About Special Enrollment Rights in Your Group Health Plan A federal law called Health Insurance Portability and Accountability Act (HIPAA) requires that we notify you about very important provisions in the plan. You have the right to enroll in the plan under its “special enrollment provision” without being considered a late enrollee if you acquire a new dependent or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. Section I of this notice may not apply to certain self-insured, non-federal governmental plans. Contact your employer or plan administrator for more information. A. SPECIAL ENROLLMENT PROVISIONS Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program) If you are declining enrollment for yourself or your eligible dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if you move out of an HMO service area, or the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or move out of the prior plan’s HMO service area, or after the employer stops contributing toward the other coverage). Loss of Coverage For Medicaid or a State Children’s Health Insurance Program If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program. New Dependent by Marriage, Birth, Adoption, or Placement for Adoption If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. Eligibility for State Premium Assistance for Enrollees of Medicaid or a State Children’s Health Insurance Program If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance. To request special enrollment or obtain more information, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.

II. Additional Notices Other federal laws require we notify you of additional provisions of your plan. NOTICES OF RIGHT TO DESIGNATE A PRIMARY CARE PROVIDER FOR NONGRANDFATHERED HEALTH PLANS ONLY For plans that require or allow for the designation of primary care providers by participants or beneciaries: If the plan generally requires or allows the designation of a primary care provider, you have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card. For plans that require or allow for the designation of a primary care provider for a child: For children, you may designate a pediatrician as the primary care provider. For plans that provide coverage for obstetric or gynecological care and require the designation by a participant or beneciary of a primary care provider: You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in pediatrics, obstetrics or gynecology, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.53715.0415Blue 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

Women's Health and Cancer Rights Act of 1998 Notification In 1998, the U.S. Congress passed the Women’s Health and Cancer Rights Act of 1998 that provides coverage for reconstructive surgery and related services following a mastectomy in conjunction with a diagnosis of breast cancer. In the case of a covered person receiving benefits under their plan in connection with a mastectomy and who elects breast reconstruction, coverage will be provided in a manner determined in consultation with the attending physician and the patient for: • Coverage will be provided for the reconstructive surgery of the breast on which a mastectomy has been performed. • Coverage will be provided for surgery and reconstruction of the other breast to produce a symmetrical appearance. • Coverage will be provided for prostheses and physical complications through all stages of a mastectomy, including swelling associated with the removal of lymph nodes. Newborns’ and Mothers’ Health Protection Act of 1996 Group health plans and health insurance issuers generally, may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours if applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Genetic Information Nondiscrimination Act of 2008 (GINA) GINA prohibits employers and other entities covered by GINA from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request. “Genetic information” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Please do not include any family medical history or any information related to genetic testing, genetic services, genetic counseling or genetic diseases for which an individual may be at risk

Premium Assistance Under Medicaid and theChildren’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). You may be eligible for assistance paying your employer health plan premiums. In Texas, contact information regarding eligibility is listed below. Website: http://gethipptexas.com/ Phone: 1-800-440-0493 For information about premium assistance in other states, or for more information on special enrollment rights, contact either: U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)1-877-267-2323, Menu Option 4, Ext. 61565January 2021

NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. I. USE AND DISCLOSURE OF HEALTH INFORMATIONThe Texas Association of Counties Health and Employee Benefits Pool ("Pool") has created a health plan that provides health coverages for employees (and their dependents) of the counties and county- related entities that are members of the Pool ("the Plan"). The Plan is subject to the requirements of the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the Privacy Rule published by the United States Department of Health and Human Services at 45 CFR §§ 160 -164 ("Privacy Rule"). HIPAA and the Rule regulate the Plan's use of your protected health information. The Plan may use your protected health information for purposes of making or obtaining payment for your care and conducting health care operations. The Plan has established a policy to guard against unnecessary disclosure of your health information. The following is a summary of the circumstances under which and purposes for which your health information may be used and disclosed without getting an authorization from you or giving you a chance to agree or object to the disclosure: A.To Make or Obtain Payment.The Plan may use or disclose your health information to make payment to or collect payment from third parties, such asother health plans or providers, for the care you receive. For example, the Plan may provide information regarding yourcoverage or health care treatment to other health plans to coordinate payment of benefits.B.To Conduct Health Care Operations.The Plan may use or disclose health information for its own health care operations, to facilitate the administration of thePlan, and as necessary to provide coverage and services to all of the Plan's participants. If the Plan needs to use yourinformation, but does not need to disclose it to third parties, it will be used but will not be disclosed. Health care operationsincludes such activities as:Quality assessment and improvement activities.Activities designed to improve health or reduce health care costs.Clinical guideline and protocol development, case management and care coordination.Contacting health care providers and participants with information about treatment alternatives and other relatedfunctions.Health care professional competence or qualifications review and performance evaluation.Accreditation, certification, licensing or similar activities.Underwriting, premium rating or related functions to create, renew or replace health insurance or health benefits.However, while we may use and disclose your health information for underwriting purposes, we are prohibited fromusing or disclosing genetic information of an individual for such purposes.Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.Business planning and development, including cost management and planning related analyses and formularydevelopment.Business management and general administrative activities of the Plan, including customer service and resolutionof internal grievances.For example, the Plan may use your health information to conduct case management reviews, to review and assess the quality of the various components of the Plan and the utilized health care providers, or to engage in customer service and grievance resolution activities. C. For Treatment Alternatives.The Plan may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

D. For Distribution of Health-Related Benefits and Services.The Plan may use or disclose your health information to provide to you information on health-related benefits andservices that may be of interest to you.E. For Disclosure to the Plan Sponsor.The Plan may provide summary health information to the plan sponsor so that the plan sponsor may solicit premium bidsfrom health insurers or modify, amend or terminate the plan. The Plan also may disclose to the plan sponsor informationon whether you are participating in the health plan.In addition, the Plan may disclose your protected health information (PHI) to the plan sponsor as necessary for the plan sponsor to perform administration functions on behalf of the Plan. The Plan will not provide your name in connection with your health information and will otherwise de- identify the information to the extent it is practical to do so. PHI will be disclosed to the plan sponsor only upon receipt of a certification by the plan sponsor that the plan sponsor agrees to: Not use or further disclose the information other than as permitted or required by the plan documents or as required bylaw;Ensure that any agents to whom it provides PHI received from HEBP agree to the same restrictions that apply to theplan sponsor with respect to such information;Not use or disclose the information for employment related actions and decisions or in connection with any otherbenefit or employee benefit plan of the plan sponsor;Report to HEBP any use or disclosure of PHI that is inconsistent with the uses or disclosures provided for of which itbecomes aware;Make available PHI for amendment and incorporate any amendments to PHI agreed to or required by HEBP;Make PHI available to an individual who has a right to access it pursuant to the Privacy Rule;Make available the information required to provide an accounting of disclosures in accordance with the PrivacyRule;Make its internal practices, books, and records relating to the use and disclosure of PHI received form HEBP availableto the Secretary for purposes of determining compliance by HEBP with the Privacy Rule; andIf feasible, return or destroy all PHI received from HEBP that the sponsor still maintains in any form and retain nocopies of such information when no longer needed for the purpose for which the disclosure was made.Any PHI disclosed by the Plan will be disclosed to the Pool Coordinator designated by the Plan Sponsor. The Plan Sponsor will restrict access to and use of PHI to those individuals who need it to perform plan administration functions or to obtain bids for health coverage. The plan sponsor will provide an effective mechanism for resolving any issues if such persons use or disclose your PHI inappropriately. F. When Legally Required.The Plan will disclose your health information when it is required to do so by any federal, state or local law.G. To Conduct Health Oversight Activities.The Plan may disclose your health information to a health oversight agency for authorized activities including audits,civil, administrative, or criminal investigations, inspections, licensure or disciplinary action. The Plan, however, may notdisclose your health information if you are the subject of an investigation and the investigation does not arise out of or isnot directly related to your receipt of health care or public benefits.H. In Connection With Judicial and Administrative Proceedings.The Plan may disclose your health information in the course of any judicial or administrative proceeding in response toan order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena,discovery request or other lawful process, but only when the Plan makes reasonable efforts to either notify you aboutthe request or to obtain an order protecting your health information.I. For Law Enforcement Purposes.As permitted or required by state law, the Plan may disclose your protected health information to a law enforcementofficial for certain law enforcement purposes, including, but not limited to, if the Plan has a suspicion that your death wasthe result of criminal conduct or in an emergency to report a crime.J. In the Event of a Serious Threat to Health or Safety. The Plan may, consistent with applicable law and ethicalstandards of conduct, disclose your protected health information if the Plan, in good faith, believes that suchdisclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the healthand safety of the public.

K. For Specialized Government Functions.We may be required to disclose your information to federal authorities. Federal regulations require the Plan to use ordisclose your health information to facilitate specified government functions related to the military and veterans, nationalsecurity and intelligence activities, protective services for the president and others, and correctional institutions andinmates.L. For Worker's Compensation.The Plan may release your health information to the extent necessary to comply with laws related to workers'compensation or similar programs.M. Public Health Activities.The Plan may disclose your protected health information to a public health authority authorized by law to collect suchinformation to prevent or control disease, injury, or disability, and to report such information as birth or death, the conductof public health surveillance and public health investigations. The Plan also may disclose your information to anappropriate government authority authorized to receive reports about child abuse. The Plan also may disclose yourinformation to a person responsible for activities related to the quality, safety and effectiveness of products regulated by the federal Food and Drug Administration. The Plan may disclose your protected health information to a government authority if there is a reasonable belief that you are a victim of abuse, neglect, or domestic violence. II.AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATIONOther than as stated above, the Plan will not disclose your health information unless you give us your written authorization. Specifically, we must have your written authorization to use or disclose psychotherapy notes except as permitted or required by law and personal information for marketing purposes, in most instances. In addition, we do not sell your personal information. If you authorize the Plan to use or disclose your health information, you may revoke that authorization in writing at any time, unless the Plan has taken an action based on your authorization. III.YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATIONYou have the following rights regarding your health information that the Plan maintains: A.Right to Request Restrictions.You may request restrictions on certain uses and disclosures of your health information. You have the right to request alimit on the Plan's disclosure of your health information to someone involved in the payment of your care. The Plan is notrequired to agree to your request, but will certainly consider it. We must, however, agree to any request you may make torestrict disclosure of your personal information to a health plan if the disclosure is for the purpose of carrying out paymentor health care operations and is not otherwise required by law and the information pertains solely to a health care item orservice for which you or someone acting on your behalf paid the provider in full. If you wish to make a request forrestrictions, please contact TAC HEBP Program Manager at 800-456-5974.B.Right to Receive Confidential Communications. You have the right to request that the Plan communicate withyou in a certain way if you feel it is necessary to protect your interests. For example, you may ask that the Plan onlycommunicate with you at a certain telephone number or by e-mail. If you wish to receive confidential communications,please make your request in writing to TAC HEBP Program Manager, P.O. Box 2131, Austin, Texas 78768, Fax 512-481-8481. The Plan will honor your reasonable requests for confidential communications.C.Right to Inspect and Copy Your Health Information.You have the right to inspect and copy your health information. A request to inspect and copy records containing yourhealth information must be made in writing to TAC HEBP Program Manager, P.O. Box 2131, Austin, Texas 78768, Fax512-481-8481. Ifyou request a copy of your health information, the Plan may charge a reasonable fee for labor for copying, the costs ofsupplies for creating an electronic copy on portable media, the cost of preparing an explanation or summary of theinformation if you agree, and postage, if applicable, associated with your request.D.Right to Amend Your Health Information.If you believe that your health information records are inaccurate or incomplete, you may request that the Plan amendany records in its possession. A request for an amendment of records must be made in writing, must express a reasonthe records should be amended, and must be sent to TAC HEBP Program Manager, P.O. Box 2131, Austin, TX 78768,

Fax 512-481-8481. The Plan may deny the request if it does not include a reason to support the amendment. The request also may be denied if your health information records were not created by the Plan, if the information requested is not part of a designated record set, if the health information you are requesting to amend is not part of the Plan's records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy (including psychotherapy notes, and information compiled for or in anticipation of a civil, criminal or administrative proceeding), or if the Plan determines the records containing your health information are accurate and complete. E.Right to an Accounting.The Privacy Rule requires the Plan to keep a record of certain disclosures of health information, such as disclosures for public purposes authorized by law or disclosures that are not in accordance with the Plan's privacy policies and applicable law. You have the right to request a copy of this record. The request must be made in writing to TAC HEBP Program Manager, P.O. Box 2131, Austin, Texas 78768, Fax 512-481-8481. The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. Accounting requests may not be made for periods of time going back more than six (6) years. The Plan will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost- based fee. The Plan will inform you in advance of the fee, if applicable. F.Right to a Paper Copy of this Notice.You have a right to request and receive a paper copy of this Notice at any time, even if you have received this Noticepreviously or agreed to receive the Notice electronically. To obtain a paper copy, please contact TAC HEBP ProgramManager, P.O. Box 2131, Austin, Texas 78768, Fax 512-481- 8481. You also may view a copy of the current version ofthe Plan's Privacy Notice at the Web site, http://www.County.Org.IV.DUTIES OF TAC HEBP HEALTH PLANThe Plan is required by law to maintain the privacy of your health information as set forth in this Notice and to provide to you this Notice of its duties and privacy practices. The Plan is also required by law to notify any affected individuals following a breach of their unsecured protected health information. The Plan is required to abide by the terms of this Notice, which may be amended from time to time. The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If the Plan changes its policies and procedures, the Plan will revise the Notice and will provide a copy of the revised Notice to you within 60 days of the change. The Plan will also post the revised Notice on its website by the effective date of the Notice. You have the right to express complaints to the Plan and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to the Plan should be made in writing to TAC HEBP Privacy Official, Robert Ressmann, P.O. Box 2131, Austin, Texas 78768, Fax: 512-478-0519. The Plan encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. CONTACT PERSON The Plan has designated Robert Ressmann, Privacy Official as its contact person for all issues regarding patient privacy and your privacy rights. You may contact him at P.O. Box 2131, Austin, Texas 78768, 512-478-8753. EFFECTIVE DATE This Notice is effective November 8, 2013. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, please contact Robert Ressmann, TAC HEBP Privacy Official, P.O. Box 2131, Austin, Texas 78768, 512-478-8753. TAC HEBP Rev. 7/15

New Health Insurance Marketplace Coverage Options and Your Health Coverage PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and yo ur fa m ily, th is notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one- stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums in the Marketplace? Yo u m a y q ualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible fo r a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be e lig ib le fo r a t a x c re d it that lowers your monthly premium, or a reduction in certain cost- sharing if your employer does not offer coverage to you at all or does not offer coverage that meets c erta in s ta nd a rd s . If the co s t o f a pla n fro m yo ur employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" stand ard s et by the Affordable Care Act, you may be eligible for a tax credit.1 No te : If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer- offered coverage. Also, this employer contribution - as well as your employee contribution to employer- offered coverage- is o ften exclud ed from inc o m e fo r Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact . The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Ma rke tp la c e a n d its c o s t . P le a s e vis it HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. 1 An employer- sponsored he a lth pla n m eets the "minim um va lu e standard" if the pla n ' s s ha re of the total a llo we d benefit costs covered by the p la n is no less than 60 percent of such costs . Form Approved OMB No. 1210-0149 (expires 7-31-2023)

PART B: Information About Health Coverage Offered by Your Employer Th is s e c tio n c o n t a in s in fo rm a tio n a b out any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name 4. Employer Identification Number (EIN) \5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address Here is some basic information about health coverage offered by th is employer: • As your employer, we offer a health plan to: All e m p lo ye e s . Elig ib le e m p lo ye e s a re : Some employees. Elig ib le e m p lo ye e s are: • With resp ect to dependents: We do offer coverage. Elig ib le d e p e nd e nts are: We do not offer coverage. If checked, this coverage meets the minimum value standard, and the cos t of this coverage to you is intended to be affordable, based on employee wages. ** Eve n if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a pre m ium d is co unt. If, fo r exa m p le, yo ur wa ge s vary fro m week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid- year, or if yo u have other income losses, you may s till q ua lify fo r a premium dis count. If yo u decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the e m p lo ye r in fo rm a tio n yo u' ll e n te r wh e n yo u vis it HealthCare.gov to find out if yo u can get a tax credit to lower your monthly premiums.

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, b u t will h e lp e n s ure e m p lo ye e s un d erstand their coverage choices. 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee) 14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee. 16. What change will the employer make for the new plan year? Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly • An employer- sponsored he a lth p la n m eets the "minim um va lue standard" if the plan's s ha re of the tota l allowed benefit cos ts covered b y the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

EMERGENCY EVACUATION MEDICAL INFORMATION Please keep the following information where it can be referred to in the event of an emergency evacuation. Special arrangements have been made to assist our members of the Health and Employee Benefits Pool (TAC HEBP) in the event of an official evacuation. If your county has officially been declared by the Governor’s office to evacuate, we will notify Blue Cross Blue Shield of Texas (BCBSTX) and Navitus Health Solutions so they are ready to assist those that are faced with emergency medical situations. In the event you have to leave your home and need assistance with getting your prescription refilled or medical care in an unfamiliar community, we are here to assist you. KEEP YOUR TAC HEBP/BCBSTX HEALTH PLAN ID CARD WITH YOU: The information on this card is necessary to get you the care that you need with minimal disruption. BlueCross Blue Shield of Texas and Navitus are both nationwide networks and customer service can be reached at the number provided on the back of your ID card. FOR CUSTOMERS OF CHAIN PHARMACIES: If you have your prescriptions at a large CHAIN pharmacy (i.e.; Wal-Mart, Walgreens, Brookshire Brothers, HEB, CVS, etc.), you should be able to go to the local branch of that chain pharmacy and have your prescription transferred to your current location for filling. Once you return home, you will need to have it transferred back to your regular pharmacy. If there are no local branches accessible to you, please follow the instructions below. FOR CUSTOMERS OF LOCAL PHARMACIES: If you have your prescriptions at a local pharmacy that is closed or is not accessible to you due to the evacuation, you will need to have a doctor call in a new prescription to a pharmacy where you are located, or to the Costco mail order facility. If you want to use the Costco mail order pharmacy, please have an address ready where the medicine can be sent. If you cannot reach your local doctor to call in a prescription, you can see a doctor where you are located. BCBSTX has made your health care records electronically available to physicians across the state so that you can continue to receive excellent health care while you are away from home. FOR SPECIALTY PHARMACY CUSTOMERS: Cold Pack medicines are shipped via UPS. Please call Lumicera Health Services at 855-847-3553 . IMPORTANT NUMBERS: Navitus Customer Care: 866-333-2757Costco Mail Order Pharmacy: For doctor to fax in a prescription: 800-633-0334 For doctor to call in a prescription: 800-607-6871 BCBSTX Customer Service and MD Live Telemedicine Service: 855-357-5228 Texas Association of Counties Health and Employee Benefits: 800-456-5974 Rev 7/2023

TACHEBPSpouseEligibilityVerificationForm  Revised7/2023Spouse Eligibility Verification Form In order to enroll a spouse in your group health plan, this form must be filled out to verify other coverage. Please keep a copy of this document for your files & return original to your employer. I. Employee Information Name: Social Security No: Employer’s Name: II. Spouse Information If any employer-sponsored health plan is available to your spouse, they must be enrolled in that plan as their primary coverage in order to be eligible for coverage through your employer’s TAC HEBP group health plan. If your spouse enrolls in your employer group plan, the TAC coverage is secondary. If your spouse is self-employed, the employer is his/her company. If your spouse is unemployed or retired, you do not need to complete SECTION A of this form; proceed to the Acknowledgement section below; sign, date and return to your employer. Spouse’s Name: Social Security #: Is your spouse: Employed Self-employed Retired Unemployed but not retired Section A: Spouse Employment Information Spouse’s Employer or Business Name: Work Phone Number: Is spouse enrolled in the employer’s group health plan? Yes No If so, provide the benefit effective date: If the employer does not provide a group plan, is coverage for the employee provided through individual health insurance coverage? Yes No If insured, either through a group or an individual policy, provide the name and telephone number of the insurance company: Spouse Eligibility Verification Employee Acknowledgment I hereby certify that I have read this document and the answers are true and correct. I further understand that a false or fraudulent statement or representation, made in order to procure coverage under a health benefit plan, including a public plan such as Texas Association of Counties Health and Employee Benefits Pool, for a person who is ineligible for such plan, is a violation of the anti-fraud provisions of the Health Insurance Portability and Accountability Act, 18 USC § 1035, to which civil and criminal penalties, including imprisonment, can apply. Employee Signature: Title/Dept: Date: