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2024-2025EMPLOYEE BENEFIT GUIDEHealth. Wealth. Peace of Mind.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : MTBCP044 Blue Choice PPOSM 044 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $6,000 Individual/$15,800 FamilyOut-of-Network: $10,000 Individual/$20,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. Network office visits with a copayment, prescription drugs and preventive care services and services with a copayment are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $8,150 Individual/$16,300 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No C :doireP egarevo 0 4202/10/3 -0 5202/82/2C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : MTBCP044 Blue Choice PPOSM 044 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $6,000 Individual/$15,800 FamilyOut-of-Network: $10,000 Individual/$20,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. Network office visits with a copayment, prescription drugs and preventive care services and services with a copayment are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $8,150 Individual/$16,300 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No C :doireP egarevo 0 4202/10/3 -0 5202/82/2C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$40/visit; deductible does not apply50% coinsuranceVirtual visits are available. See your benefit booklet* for details.Specialist visit$80/visit; deductible does not apply50% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not apply50% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)No Charge; deductible does not apply50% coinsuranceIf you have a testImaging (CT/PET scans, MRIs)20% coinsurance50% coinsuranceInpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.Generic drugs (Preferred)Retail - Preferred - No ChargeNon-Preferred - $10/prescriptionMail - No Charge;deductible does not applyRetail - $10/prescription;deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsGeneric drugs (Non-Preferred)Retail - Preferred - $10/prescriptionNon-Preferred - $20/prescriptionMail - $30/prescription; deductible does not applyRetail - $20/prescription;deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$40/visit; deductible does not apply50% coinsuranceVirtual visits are available. See your benefit booklet* for details.Specialist visit$80/visit; deductible does not apply50% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not apply50% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)No Charge; deductible does not apply50% coinsuranceIf you have a testImaging (CT/PET scans, MRIs)20% coinsurance50% coinsuranceInpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.Generic drugs (Preferred)Retail - Preferred - No ChargeNon-Preferred - $10/prescriptionMail - No Charge;deductible does not applyRetail - $10/prescription;deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsGeneric drugs (Non-Preferred)Retail - Preferred - $10/prescriptionNon-Preferred - $20/prescriptionMail - $30/prescription; deductible does not applyRetail - $20/prescription;deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-

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

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

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$40/office visit; deductible does not apply or 20% coinsurance for other outpatient services50% coinsuranceCertain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services20% coinsurance50% coinsurancePreauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.Office visitsPrimary Care: $40/initial visitSpecialist: $80/initial visit; deductible does not apply50% coinsuranceChildbirth/delivery professional services20% coinsurance50% coinsuranceIf you are pregnantChildbirth/delivery facility services20% coinsurance50% coinsuranceCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to preventive services. Depending on the type of services, copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health care20% coinsurance50% coinsurance60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Rehabilitation services20% coinsurance50% coinsuranceHabilitation services20% coinsurance50% coinsuranceFor Outpatient, limited to combined 35 visits per year, including Chiropractic.Skilled nursing care20% coinsurance50% coinsurance25-day maximum per calendar year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. Durable medical equipment20% coinsurance50% coinsuranceNoneIf you need help recovering or have other special health needsHospice servicesNo Charge; deductible does not apply50% coinsuranceInpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.Outpatient: Preauthorization may be required

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$40/office visit; deductible does not apply or 20% coinsurance for other outpatient services50% coinsuranceCertain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services20% coinsurance50% coinsurancePreauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.Office visitsPrimary Care: $40/initial visitSpecialist: $80/initial visit; deductible does not apply50% coinsuranceChildbirth/delivery professional services20% coinsurance50% coinsuranceIf you are pregnantChildbirth/delivery facility services20% coinsurance50% coinsuranceCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to preventive services. Depending on the type of services, copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health care20% coinsurance50% coinsurance60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Rehabilitation services20% coinsurance50% coinsuranceHabilitation services20% coinsurance50% coinsuranceFor Outpatient, limited to combined 35 visits per year, including Chiropractic.Skilled nursing care20% coinsurance50% coinsurance25-day maximum per calendar year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. Durable medical equipment20% coinsurance50% coinsuranceNoneIf you need help recovering or have other special health needsHospice servicesNo Charge; deductible does not apply50% coinsuranceInpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.Outpatient: Preauthorization may be required

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

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

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

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

Page 7 of 8CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.

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

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

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : MTBCP023 Blue Choice PPOSM 023 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $2,500 Individual/$7,500 FamilyOut-of-Network: $5,000 Individual/$15,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. Network office visits with a copayment, prescription drugs and preventive care services and services with a copayment are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $5,500 Individual/$14,700 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No C :doireP egarevo 0 4202/10/3 -0 5202/82/2C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : MTBCP023 Blue Choice PPOSM 023 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $2,500 Individual/$7,500 FamilyOut-of-Network: $5,000 Individual/$15,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. Network office visits with a copayment, prescription drugs and preventive care services and services with a copayment are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $5,500 Individual/$14,700 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No C :doireP egarevo 0 4202/10/3 -0 5202/82/2C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$30/visit; deductible does not apply40% coinsuranceVirtual visits are available. See your benefit booklet* for details.Specialist visit$60/visit; deductible does not apply40% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not apply40% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)No Charge; deductible does not apply40% coinsuranceIf you have a testImaging (CT/PET scans, MRIs)20% coinsurance40% coinsuranceInpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.Generic drugs (Preferred)Retail - Preferred - No ChargeNon-Preferred - $10/prescriptionMail - No Charge;deductible does not applyRetail - $10/prescription;deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsGeneric drugs (Non-Preferred)Retail - Preferred - $10/prescriptionNon-Preferred - $20/prescriptionMail - $30/prescription; deductible does not applyRetail - $20/prescription;deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$30/visit; deductible does not apply40% coinsuranceVirtual visits are available. See your benefit booklet* for details.Specialist visit$60/visit; deductible does not apply40% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not apply40% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)No Charge; deductible does not apply40% coinsuranceIf you have a testImaging (CT/PET scans, MRIs)20% coinsurance40% coinsuranceInpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.Generic drugs (Preferred)Retail - Preferred - No ChargeNon-Preferred - $10/prescriptionMail - No Charge;deductible does not applyRetail - $10/prescription;deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsGeneric drugs (Non-Preferred)Retail - Preferred - $10/prescriptionNon-Preferred - $20/prescriptionMail - $30/prescription; deductible does not applyRetail - $20/prescription;deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 3 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Preferred)Retail - Preferred - $50/prescriptionNon-Preferred - $70/prescriptionMail - $150/prescription; deductible does not applyRetail - $70/prescription;deductible does not apply plus 50% additional chargeBrand drugs (Non-Preferred)Retail - Preferred - $100/prescriptionNon-Preferred - $120/prescriptionMail - $300/prescription; deductible does not applyRetail - $120/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Preferred)$150/prescription; deductible does not apply$150/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Non-Preferred)$250/prescription;deductible does not apply$250/prescription;deductible does not apply plus 50% additional chargeday supply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)20% coinsurance40% coinsuranceIf you have outpatient surgeryPhysician/surgeon fees20% coinsurance40% coinsuranceCertain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.Emergency room care$500/visit plus 20% coinsurance$500/visit plus 20% coinsuranceCopayment waived if admitted.Emergency medical transportation20% coinsurance20% coinsuranceIf you need immediate medical attentionUrgent care$75/visit; deductible does not apply40% coinsuranceNoneFacility fee (e.g., hospital room)20% coinsurance40% coinsuranceIf you have a hospital stayPhysician/surgeon fees20% coinsurance40% coinsurancePreauthorization required. Preauthorization penalty: $250 out-of-network. See your benefit booklet* for details.

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 3 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Preferred)Retail - Preferred - $50/prescriptionNon-Preferred - $70/prescriptionMail - $150/prescription; deductible does not applyRetail - $70/prescription;deductible does not apply plus 50% additional chargeBrand drugs (Non-Preferred)Retail - Preferred - $100/prescriptionNon-Preferred - $120/prescriptionMail - $300/prescription; deductible does not applyRetail - $120/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Preferred)$150/prescription; deductible does not apply$150/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Non-Preferred)$250/prescription;deductible does not apply$250/prescription;deductible does not apply plus 50% additional chargeday supply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)20% coinsurance40% coinsuranceIf you have outpatient surgeryPhysician/surgeon fees20% coinsurance40% coinsuranceCertain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.Emergency room care$500/visit plus 20% coinsurance$500/visit plus 20% coinsuranceCopayment waived if admitted.Emergency medical transportation20% coinsurance20% coinsuranceIf you need immediate medical attentionUrgent care$75/visit; deductible does not apply40% coinsuranceNoneFacility fee (e.g., hospital room)20% coinsurance40% coinsuranceIf you have a hospital stayPhysician/surgeon fees20% coinsurance40% coinsurancePreauthorization required. Preauthorization penalty: $250 out-of-network. See your benefit booklet* for details.

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$30/office visit; deductible does not apply or 20% coinsurance for other outpatient services40% coinsuranceCertain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services20% coinsurance40% coinsurancePreauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.Office visitsPrimary Care: $30/initial visitSpecialist: $60/initial visit; deductible does not apply40% coinsuranceChildbirth/delivery professional services20% coinsurance40% coinsuranceIf you are pregnantChildbirth/delivery facility services20% coinsurance40% coinsuranceCopayment 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).Home health care20% coinsurance40% coinsurance60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Rehabilitation services20% coinsurance40% coinsuranceHabilitation services20% coinsurance40% coinsuranceFor Outpatient, limited to combined 35 visits per year, including Chiropractic.Skilled nursing care20% coinsurance40% coinsurance25-day maximum per calendar year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. Durable medical equipment20% coinsurance40% coinsuranceNoneIf you need help recovering or have other special health needsHospice servicesNo Charge; deductible does not apply40% coinsuranceInpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.Outpatient: Preauthorization may be required

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$30/office visit; deductible does not apply or 20% coinsurance for other outpatient services40% coinsuranceCertain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services20% coinsurance40% coinsurancePreauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.Office visitsPrimary Care: $30/initial visitSpecialist: $60/initial visit; deductible does not apply40% coinsuranceChildbirth/delivery professional services20% coinsurance40% coinsuranceIf you are pregnantChildbirth/delivery facility services20% coinsurance40% coinsuranceCopayment 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).Home health care20% coinsurance40% coinsurance60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Rehabilitation services20% coinsurance40% coinsuranceHabilitation services20% coinsurance40% coinsuranceFor Outpatient, limited to combined 35 visits per year, including Chiropractic.Skilled nursing care20% coinsurance40% coinsurance25-day maximum per calendar year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. Durable medical equipment20% coinsurance40% coinsuranceNoneIf you need help recovering or have other special health needsHospice servicesNo Charge; deductible does not apply40% coinsuranceInpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.Outpatient: Preauthorization may be required

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

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

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

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

Page 7 of 8CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. The plan’s overall deductible $2,500 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost$12,700In this example, Peg would pay:Cost SharingDeductibles$2,500Copayments$30Coinsurance$1,800What isn’t coveredLimits or exclusions$60The total Peg would pay is$4,390 The plan’s overall deductible $2,500 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter)Total Example Cost$5,600In this example, Joe would pay:Cost SharingDeductibles$800Copayments$700Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,520 The plan’s overall deductible $2,500 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example Cost$2,800In this example, Mia would pay:Cost SharingDeductibles$2,100Copayments$500Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,600The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)Mia’s Simple Fracture(in-network emergency room visit and follow up care)

Page 8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. The plan’s overall deductible $2,500 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost$12,700In this example, Peg would pay:Cost SharingDeductibles$2,500Copayments$30Coinsurance$1,800What isn’t coveredLimits or exclusions$60The total Peg would pay is$4,390 The plan’s overall deductible $2,500 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter)Total Example Cost$5,600In this example, Joe would pay:Cost SharingDeductibles$800Copayments$700Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,520 The plan’s overall deductible $2,500 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example Cost$2,800In this example, Mia would pay:Cost SharingDeductibles$2,100Copayments$500Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,600The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)Mia’s Simple Fracture(in-network emergency room visit and follow up care)

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : MTBCP011 Blue Choice PPOSM 011 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $1,000 Individual/$3,000 FamilyOut-of-Network: $2,000 Individual/$6,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. Network office visits with a copayment, prescription drugs and preventive care services and services with a copayment are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $4,000 Individual/$12,000 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No C :doireP egarevo 0 4202/10/3 -0 5202/82/2C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : MTBCP011 Blue Choice PPOSM 011 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $1,000 Individual/$3,000 FamilyOut-of-Network: $2,000 Individual/$6,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. Network office visits with a copayment, prescription drugs and preventive care services and services with a copayment are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $4,000 Individual/$12,000 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No C :doireP egarevo 0 4202/10/3 -0 5202/82/2C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$30/visit; deductible does not apply40% coinsuranceVirtual visits are available. See your benefit booklet* for details.Specialist visit$60/visit; deductible does not apply40% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not apply40% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)No Charge; deductible does not apply40% coinsuranceIf you have a testImaging (CT/PET scans, MRIs)20% coinsurance40% coinsuranceInpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.Generic drugs (Preferred)Retail - Preferred - No ChargeNon-Preferred - $10/prescriptionMail - No Charge;deductible does not applyRetail - $10/prescription;deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsGeneric drugs (Non-Preferred)Retail - Preferred - $10/prescriptionNon-Preferred - $20/prescriptionMail - $30/prescription; deductible does not applyRetail - $20/prescription;deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$30/visit; deductible does not apply40% coinsuranceVirtual visits are available. See your benefit booklet* for details.Specialist visit$60/visit; deductible does not apply40% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not apply40% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)No Charge; deductible does not apply40% coinsuranceIf you have a testImaging (CT/PET scans, MRIs)20% coinsurance40% coinsuranceInpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.Generic drugs (Preferred)Retail - Preferred - No ChargeNon-Preferred - $10/prescriptionMail - No Charge;deductible does not applyRetail - $10/prescription;deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsGeneric drugs (Non-Preferred)Retail - Preferred - $10/prescriptionNon-Preferred - $20/prescriptionMail - $30/prescription; deductible does not applyRetail - $20/prescription;deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available.Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 3 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Preferred)Retail - Preferred - $50/prescriptionNon-Preferred - $70/prescriptionMail - $150/prescription; deductible does not applyRetail - $70/prescription;deductible does not apply plus 50% additional chargeBrand drugs (Non-Preferred)Retail - Preferred - $100/prescriptionNon-Preferred - $120/prescriptionMail - $300/prescription; deductible does not applyRetail - $120/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Preferred)$150/prescription; deductible does not apply$150/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Non-Preferred)$250/prescription;deductible does not apply$250/prescription;deductible does not apply plus 50% additional chargeday supply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)20% coinsurance40% coinsuranceIf you have outpatient surgeryPhysician/surgeon fees20% coinsurance40% coinsuranceCertain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.Emergency room care$500/visit plus 20% coinsurance$500/visit plus 20% coinsuranceCopayment waived if admitted.Emergency medical transportation20% coinsurance20% coinsuranceIf you need immediate medical attentionUrgent care$75/visit; deductible does not apply40% coinsuranceNoneFacility fee (e.g., hospital room)20% coinsurance40% coinsuranceIf you have a hospital stayPhysician/surgeon fees20% coinsurance40% coinsurancePreauthorization required. Preauthorization penalty: $250 out-of-network. See your benefit booklet* for details.

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 3 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Preferred)Retail - Preferred - $50/prescriptionNon-Preferred - $70/prescriptionMail - $150/prescription; deductible does not applyRetail - $70/prescription;deductible does not apply plus 50% additional chargeBrand drugs (Non-Preferred)Retail - Preferred - $100/prescriptionNon-Preferred - $120/prescriptionMail - $300/prescription; deductible does not applyRetail - $120/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Preferred)$150/prescription; deductible does not apply$150/prescription;deductible does not apply plus 50% additional chargeSpecialty drugs (Non-Preferred)$250/prescription;deductible does not apply$250/prescription;deductible does not apply plus 50% additional chargeday supply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)20% coinsurance40% coinsuranceIf you have outpatient surgeryPhysician/surgeon fees20% coinsurance40% coinsuranceCertain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.Emergency room care$500/visit plus 20% coinsurance$500/visit plus 20% coinsuranceCopayment waived if admitted.Emergency medical transportation20% coinsurance20% coinsuranceIf you need immediate medical attentionUrgent care$75/visit; deductible does not apply40% coinsuranceNoneFacility fee (e.g., hospital room)20% coinsurance40% coinsuranceIf you have a hospital stayPhysician/surgeon fees20% coinsurance40% coinsurancePreauthorization required. Preauthorization penalty: $250 out-of-network. See your benefit booklet* for details.

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$30/office visit; deductible does not apply or 20% coinsurance for other outpatient services40% coinsuranceCertain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services20% coinsurance40% coinsurancePreauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.Office visitsPrimary Care: $30/initial visitSpecialist: $60/initial visit; deductible does not apply40% coinsuranceChildbirth/delivery professional services20% coinsurance40% coinsuranceIf you are pregnantChildbirth/delivery facility services20% coinsurance40% coinsuranceCopayment 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).Home health care20% coinsurance40% coinsurance60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Rehabilitation services20% coinsurance40% coinsuranceHabilitation services20% coinsurance40% coinsuranceFor Outpatient, limited to combined 35 visits per year, including Chiropractic.Skilled nursing care20% coinsurance40% coinsurance25-day maximum per calendar year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. Durable medical equipment20% coinsurance40% coinsuranceNoneIf you need help recovering or have other special health needsHospice servicesNo Charge; deductible does not apply40% coinsuranceInpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.Outpatient: Preauthorization may be required

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024. Page 4 of 8 What You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$30/office visit; deductible does not apply or 20% coinsurance for other outpatient services40% coinsuranceCertain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services20% coinsurance40% coinsurancePreauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.Office visitsPrimary Care: $30/initial visitSpecialist: $60/initial visit; deductible does not apply40% coinsuranceChildbirth/delivery professional services20% coinsurance40% coinsuranceIf you are pregnantChildbirth/delivery facility services20% coinsurance40% coinsuranceCopayment 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).Home health care20% coinsurance40% coinsurance60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.Rehabilitation services20% coinsurance40% coinsuranceHabilitation services20% coinsurance40% coinsuranceFor Outpatient, limited to combined 35 visits per year, including Chiropractic.Skilled nursing care20% coinsurance40% coinsurance25-day maximum per calendar year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. Durable medical equipment20% coinsurance40% coinsuranceNoneIf you need help recovering or have other special health needsHospice servicesNo Charge; deductible does not apply40% coinsuranceInpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.Outpatient: Preauthorization may be required

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

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

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

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

Page 7 of 8CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. The plan’s overall deductible $1,000 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost$12,700In this example, Peg would pay:Cost SharingDeductibles$1,000Copayments$30Coinsurance$2,100What isn’t coveredLimits or exclusions$60The total Peg would pay is$3,190 The plan’s overall deductible $1,000 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter)Total Example Cost$5,600In this example, Joe would pay:Cost SharingDeductibles$800Copayments$700Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,520 The plan’s overall deductible $1,000 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example Cost$2,800In this example, Mia would pay:Cost SharingDeductibles$1,000Copayments$500Coinsurance$200What isn’t coveredLimits or exclusions$0The total Mia would pay is$1,700The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)Mia’s Simple Fracture(in-network emergency room visit and follow up care)

Page 8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. The plan’s overall deductible $1,000 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost$12,700In this example, Peg would pay:Cost SharingDeductibles$1,000Copayments$30Coinsurance$2,100What isn’t coveredLimits or exclusions$60The total Peg would pay is$3,190 The plan’s overall deductible $1,000 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter)Total Example Cost$5,600In this example, Joe would pay:Cost SharingDeductibles$800Copayments$700Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,520 The plan’s overall deductible $1,000 Specialist copayment $60 Hospital (facility) coinsurance 20% Other coinsurance 20%This EXAMPLE event includes services like:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example Cost$2,800In this example, Mia would pay:Cost SharingDeductibles$1,000Copayments$500Coinsurance$200What isn’t coveredLimits or exclusions$0The total Mia would pay is$1,700The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)Mia’s Simple Fracture(in-network emergency room visit and follow up care)

BlueCare DentalSM Plan ID: DTNLR36 This information only provides a summary of the benefits for this Dental Plan. Please refer to your Dental Benefit Booklet for additional benefit information. The Deductibles, Coinsurance and Benefit Period Maximum shown below are subject to change as permitted by applicable law. Benefit Period Maximum $1,000 Deductible $50 Individual/$150 Family $50 Individual/$150 Family No Annual Maximum No Annual Maximum Diagnostic Evaluations Periodic oral evaluations Problem focused oral evaluations Comprehensive oral evaluations 100% (Deductible does not apply) 100% (Deductible does not apply) Preventive Services Prophylaxis (cleanings) Topical fluoride applications 100% (Deductible does not apply) 100% (Deductible does not apply) Diagnostic Radiographs Full-mouth and panoramic films Bitewing films Periapical films 100% (Deductible does not apply) 100% (Deductible does not apply) Miscellaneous Preventive Services Sealants Space maintainers 80% 80% Basic Restorative Services Amalgams Resin-based composite restorations 80% 80% Non-Surgical Extractions Removal of retained coronal remnants Removal of erupted tooth or exposed root 80% 80% Non-Surgical Periodontal Services Periodontal scaling and root planing Full-mouth debridement Periodontal maintenance procedures 80% 80% Adjunctive Services Palliative treatment (emergency) Deep sedation / general anesthesia 80% 80% Endodontic Services Therapeutic pulpotomy and pulpal debridement Root canal therapy Apexification/recalcification 50% 50% Summary of Dental Benefits Program Basics Contracting Dentist Non-Contracting Dentist Covered Services

BlueCare DentalSM Plan ID: DTNLR36 This information only provides a summary of the benefits for this Dental Plan. Please refer to your Dental Benefit Booklet for additional benefit information. The Deductibles, Coinsurance and Benefit Period Maximum shown below are subject to change as permitted by applicable law. Benefit Period Maximum $1,000 Deductible $50 Individual/$150 Family $50 Individual/$150 Family No Annual Maximum No Annual Maximum Diagnostic Evaluations Periodic oral evaluations Problem focused oral evaluations Comprehensive oral evaluations 100% (Deductible does not apply) 100% (Deductible does not apply) Preventive Services Prophylaxis (cleanings) Topical fluoride applications 100% (Deductible does not apply) 100% (Deductible does not apply) Diagnostic Radiographs Full-mouth and panoramic films Bitewing films Periapical films 100% (Deductible does not apply) 100% (Deductible does not apply) Miscellaneous Preventive Services Sealants Space maintainers 80% 80% Basic Restorative Services Amalgams Resin-based composite restorations 80% 80% Non-Surgical Extractions Removal of retained coronal remnants Removal of erupted tooth or exposed root 80% 80% Non-Surgical Periodontal Services Periodontal scaling and root planing Full-mouth debridement Periodontal maintenance procedures 80% 80% Adjunctive Services Palliative treatment (emergency) Deep sedation / general anesthesia 80% 80% Endodontic Services Therapeutic pulpotomy and pulpal debridement Root canal therapy Apexification/recalcification 50% 50% Summary of Dental Benefits Program Basics Contracting Dentist Non-Contracting Dentist Covered Services

730320.0220 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 50% 50% 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 50% 50% Major Restorative Services Single crown restorations Inlay/onlay restorations Labial veneer restorations Crowns placed over implants 50% 50% Prosthodontic Services Complete and removable partial dentures Denture reline/rebase procedures Fixed bridgework Prosthetics placed over implants 50% 50% Miscellaneous Restorative and Prosthodontic Services Prefabricated crowns Recementations Post and core, pin retention and crown/bridge repairs Adjustments 50% 50% Orthodontic Services Orthodontic Diagnostic Procedures and Treatment Lifetime Maximum per Participant Not Covered Dental implants are not covered. 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 possible 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 Blue Shield Association Covered Services (continued) Contracting Dentist Non-Contracting Dentist Orthodontic Services

730320.0220 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 50% 50% 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 50% 50% Major Restorative Services Single crown restorations Inlay/onlay restorations Labial veneer restorations Crowns placed over implants 50% 50% Prosthodontic Services Complete and removable partial dentures Denture reline/rebase procedures Fixed bridgework Prosthetics placed over implants 50% 50% Miscellaneous Restorative and Prosthodontic Services Prefabricated crowns Recementations Post and core, pin retention and crown/bridge repairs Adjustments 50% 50% Orthodontic Services Orthodontic Diagnostic Procedures and Treatment Lifetime Maximum per Participant Not Covered Dental implants are not covered. 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 possible 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 Blue Shield Association Covered Services (continued) Contracting Dentist Non-Contracting Dentist Orthodontic Services

BlueCare DentalSM Plan ID: DTNHR32 This information only provides a summary of the benefits for this Dental Plan. Please refer to your Dental Benefit Booklet for additional benefit information. The Deductibles, Coinsurance and Benefit Period Maximum shown below are subject to change as permitted by applicable law. Benefit Period Maximum $2,000 Deductible $50 Individual/$150 Family $50 Individual/$150 Family No Annual Maximum No Annual Maximum Diagnostic Evaluations Periodic oral evaluations Problem focused oral evaluations Comprehensive oral evaluations 100% (Deductible does not apply) 100% (Deductible does not apply) Preventive Services Prophylaxis (cleanings) Topical fluoride applications 100% (Deductible does not apply) 100% (Deductible does not apply) Diagnostic Radiographs Full-mouth and panoramic films Bitewing films Periapical films 100% (Deductible does not apply) 100% (Deductible does not apply) Miscellaneous Preventive Services Sealants Space maintainers 100% (Deductible does not apply) 100% (Deductible does not apply) Basic Restorative Services Amalgams Resin-based composite restorations 80% 80% Non-Surgical Extractions Removal of retained coronal remnants Removal of erupted tooth or exposed root 80% 80% Non-Surgical Periodontal Services Periodontal scaling and root planing Full-mouth debridement Periodontal maintenance procedures 80% 80% Adjunctive Services Palliative treatment (emergency) Deep sedation / general anesthesia 80% 80% Endodontic Services Therapeutic pulpotomy and pulpal debridement Root canal therapy Apexification/recalcification 80% 80% Summary of Dental Benefits Covered Services Program Basics Contracting Dentist Non-Contracting Dentist

BlueCare DentalSM Plan ID: DTNHR32 This information only provides a summary of the benefits for this Dental Plan. Please refer to your Dental Benefit Booklet for additional benefit information. The Deductibles, Coinsurance and Benefit Period Maximum shown below are subject to change as permitted by applicable law. Benefit Period Maximum $2,000 Deductible $50 Individual/$150 Family $50 Individual/$150 Family No Annual Maximum No Annual Maximum Diagnostic Evaluations Periodic oral evaluations Problem focused oral evaluations Comprehensive oral evaluations 100% (Deductible does not apply) 100% (Deductible does not apply) Preventive Services Prophylaxis (cleanings) Topical fluoride applications 100% (Deductible does not apply) 100% (Deductible does not apply) Diagnostic Radiographs Full-mouth and panoramic films Bitewing films Periapical films 100% (Deductible does not apply) 100% (Deductible does not apply) Miscellaneous Preventive Services Sealants Space maintainers 100% (Deductible does not apply) 100% (Deductible does not apply) Basic Restorative Services Amalgams Resin-based composite restorations 80% 80% Non-Surgical Extractions Removal of retained coronal remnants Removal of erupted tooth or exposed root 80% 80% Non-Surgical Periodontal Services Periodontal scaling and root planing Full-mouth debridement Periodontal maintenance procedures 80% 80% Adjunctive Services Palliative treatment (emergency) Deep sedation / general anesthesia 80% 80% Endodontic Services Therapeutic pulpotomy and pulpal debridement Root canal therapy Apexification/recalcification 80% 80% Summary of Dental Benefits Covered Services Program Basics Contracting Dentist Non-Contracting Dentist

730312.0220 Oral Surgery Services Surgical tooth extractions Alveoloplasty and vestibuloplasty Excision of benign odontogenic tumor/cyst Excision of bone tissue Incision and drainage of an intraoral abscess 80% 80% Surgical Periodontal Services Gingivectomy or gingivoplasty and gingival flap procedures Clinical crown lengthening Osseous surgery Osseous grafts Soft tissue grafts/allografts Distal or proximal wedge procedure 80% 80% Major Restorative Services Single crown restorations Inlay/onlay restorations Labial veneer restorations Crowns placed over implants 50% 50% Prosthodontic Services Complete and removable partial dentures Denture reline/rebase procedures Fixed bridgework Prosthetics placed over implants 50% 50% Implants 50% 50% Miscellaneous Restorative and Prosthodontic Services Prefabricated crowns Recementations Post and core, pin retention and crown/bridge repairs Adjustments 50% 50% Orthodontic Services Orthodontic Diagnostic Procedures and Treatment Lifetime Maximum per Participant Adult coverage and dependent children to age 19 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 possible 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 Blue Shield Association Contracting Dentist Non-Contracting Dentist Covered Services (continued) Orthodontic Services

730312.0220 Oral Surgery Services Surgical tooth extractions Alveoloplasty and vestibuloplasty Excision of benign odontogenic tumor/cyst Excision of bone tissue Incision and drainage of an intraoral abscess 80% 80% Surgical Periodontal Services Gingivectomy or gingivoplasty and gingival flap procedures Clinical crown lengthening Osseous surgery Osseous grafts Soft tissue grafts/allografts Distal or proximal wedge procedure 80% 80% Major Restorative Services Single crown restorations Inlay/onlay restorations Labial veneer restorations Crowns placed over implants 50% 50% Prosthodontic Services Complete and removable partial dentures Denture reline/rebase procedures Fixed bridgework Prosthetics placed over implants 50% 50% Implants 50% 50% Miscellaneous Restorative and Prosthodontic Services Prefabricated crowns Recementations Post and core, pin retention and crown/bridge repairs Adjustments 50% 50% Orthodontic Services Orthodontic Diagnostic Procedures and Treatment Lifetime Maximum per Participant Adult coverage and dependent children to age 19 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 possible 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 Blue Shield Association Contracting Dentist Non-Contracting Dentist Covered Services (continued) Orthodontic Services

Summary of Vision BenetsAdditional discountsTake a sneak peek before enrolling20%20%40%OFFOFFOFFComplete pair of prescription eyeglassesNon-prescription sunglassesRemaining balance beyond plan coverageThese discounts are not insured benets and are for in-network providers only.• 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 CareInsurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. PLAN 8: 12/12/24/$130 MS 300 VFrequencyExamination Once every 12 monthsLenses or contact lenses Once every 12 monthsFrame Once every 24 monthsContact lens eval/tting N/AVision Care Services In-Network Member CostOut-of-Network Reimbursement*Exam with dilation as necessary $10 copay Up to $30Contact lens t and follow-up Up to $40 for standard; 10% o retail price for premium N/AFramesAny available frame at provider location $0 copay, $130 allowance, 20% o balance over $130 Up to $65Standard LensesSingle vision $25 copay Up to $25Bifocal $25 copay Up to $40Trifocal $25 copay Up to $55Lenticular $25 copay Up to $55Standard progressive lens $90 copay Up to $40Premium progressive lens See table on page 2. Up to $40Lens OptionsTint (solid and gradient) $15 N/AScratch resistant coating $0 Up to $5Polycarbonate lenses $0 kids; $40 adults Up to $5 kidsUltraviolet coating $15 N/AAnti-reective coating See table on page 2. N/AHigh index lenses 20% o retail N/APolarized lenses 20% o retail N/APhotochromic/transitions plastic $75 N/AContact Lenses (in lieu of spectacle lenses)Conventional $0 copay, $130 allowance, 15% o balance over $130 Up to $104Disposable $0 copay, $130 allowance, plus balance over $130 Up to $104Medically necessary $0 copay, paid-in-full Up to $210OtherLaser vision correction 15% retail price or 5% o promotional price N/AAdditional pairs benet40% o purchase of complete pair of eyeglasses and a 15% o conventional contact lenses once the funded benet has been usedN/AAmplifon hearing discount40% o hearing exams and low price guarantee on discounted hearing aidsN/AAdditional discounts 20% o non-covered items with limitations N/AMonthly RatesEmployee $7.60Employee + spouse $14.44Employee + child(ren) $15.20Employee + family $22.35Eligibility: All active full-time employees as dened by your employer.Dependent coverage is available to age 26.CAT5 Resources LLC

Summary of Vision BenetsAdditional discountsTake a sneak peek before enrolling20%20%40%OFFOFFOFFComplete pair of prescription eyeglassesNon-prescription sunglassesRemaining balance beyond plan coverageThese discounts are not insured benets and are for in-network providers only.• 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 CareInsurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. PLAN 8: 12/12/24/$130 MS 300 VFrequencyExamination Once every 12 monthsLenses or contact lenses Once every 12 monthsFrame Once every 24 monthsContact lens eval/tting N/AVision Care Services In-Network Member CostOut-of-Network Reimbursement*Exam with dilation as necessary $10 copay Up to $30Contact lens t and follow-up Up to $40 for standard; 10% o retail price for premium N/AFramesAny available frame at provider location $0 copay, $130 allowance, 20% o balance over $130 Up to $65Standard LensesSingle vision $25 copay Up to $25Bifocal $25 copay Up to $40Trifocal $25 copay Up to $55Lenticular $25 copay Up to $55Standard progressive lens $90 copay Up to $40Premium progressive lens See table on page 2. Up to $40Lens OptionsTint (solid and gradient) $15 N/AScratch resistant coating $0 Up to $5Polycarbonate lenses $0 kids; $40 adults Up to $5 kidsUltraviolet coating $15 N/AAnti-reective coating See table on page 2. N/AHigh index lenses 20% o retail N/APolarized lenses 20% o retail N/APhotochromic/transitions plastic $75 N/AContact Lenses (in lieu of spectacle lenses)Conventional $0 copay, $130 allowance, 15% o balance over $130 Up to $104Disposable $0 copay, $130 allowance, plus balance over $130 Up to $104Medically necessary $0 copay, paid-in-full Up to $210OtherLaser vision correction 15% retail price or 5% o promotional price N/AAdditional pairs benet40% o purchase of complete pair of eyeglasses and a 15% o conventional contact lenses once the funded benet has been usedN/AAmplifon hearing discount40% o hearing exams and low price guarantee on discounted hearing aidsN/AAdditional discounts 20% o non-covered items with limitations N/AMonthly RatesEmployee $7.60Employee + spouse $14.44Employee + child(ren) $15.20Employee + family $22.35Eligibility: All active full-time employees as dened by your employer.Dependent coverage is available to age 26.CAT5 Resources LLC

Summary of Benets ContinuedProgressive Price List2Member Cost In-NetworkStandard progressive $90 copayPremium Progressives3 as Follows:Tier 1 $110 copayTier 2 $120 copayTier 3 $135 copayTier 4$90 copay 80% of charge less $120 allowanceAnti-Reective Coating Price List2Member Cost In-NetworkStandard anti-reective coating $45Premium anti-reective3 coatings as follows:Tier 1 $57Tier 2 $68Tier 3 80% of chargeOther Add-ons Price List Member Cost In-NetworkPhotochromic $75Polarized 80% of chargePlan Exclusions1. Orthoptic or vision training, subnormal vision aids and anyassociated supplemental testing; aniseikonic lenses2. Medical and/or surgical treatment of the eye, eyes or supportingstructures3. Any eye or vision examination, or any corrective eyewear required bya Policyholder as a condition of employment; safety eyewear4. Services provided as a result of any Workers’ Compensation law,or similar legislation, or required by any governmental agency orprogram whether federal, state or subdivisions thereof5. Plano (non-prescription) lenses and/or contact lenses6. Non-prescription sunglasses7. Two pair of glasses in lieu of bifocals8. Services rendered after the date an insured person ceases to becovered under the policy, except when vision materials orderedbefore coverage ended are delivered, and the services rendered tothe insured person are within 31 days from the date of such order9. Services or materials provided by any other group benet planproviding vision care10. Lost or broken lenses, frames, glasses or contact lenses will not bereplaced except in the next benet frequency when vision materialswould next become available750940.11191Member 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 reective of brands at the listed product level. All providers are not required to carry all brands at all levels. 3Premium progressives and premium anti-reective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market conditions. Fixed pricing is reective 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, benets, 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 benets, employee contributions, the number of eligible employees, or the imposition of any new taxes, fees or assessments by Federal or State regulatory agencies. Benets may not be combined with any discount, promotional oering or other group benet plans. Benet allowance provides no remaining balance for future use with the same benets year. Fees charged for a non-insured benet must be paid in full to the Provider. Such fees or materials are not covered. This is a snapshot of your benets. The Certicate of Insurance is on le with your employer. Benets are available from the EyeMed Vision Care, LLC provider network and are administered by First American Administrators, Inc., independent companies that oer benets 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.

Summary of Benets ContinuedProgressive Price List2Member Cost In-NetworkStandard progressive $90 copayPremium Progressives3 as Follows:Tier 1 $110 copayTier 2 $120 copayTier 3 $135 copayTier 4$90 copay 80% of charge less $120 allowanceAnti-Reective Coating Price List2Member Cost In-NetworkStandard anti-reective coating $45Premium anti-reective3 coatings as follows:Tier 1 $57Tier 2 $68Tier 3 80% of chargeOther Add-ons Price List Member Cost In-NetworkPhotochromic $75Polarized 80% of chargePlan Exclusions1. Orthoptic or vision training, subnormal vision aids and anyassociated supplemental testing; aniseikonic lenses2. Medical and/or surgical treatment of the eye, eyes or supportingstructures3. Any eye or vision examination, or any corrective eyewear required bya Policyholder as a condition of employment; safety eyewear4. Services provided as a result of any Workers’ Compensation law,or similar legislation, or required by any governmental agency orprogram whether federal, state or subdivisions thereof5. Plano (non-prescription) lenses and/or contact lenses6. Non-prescription sunglasses7. Two pair of glasses in lieu of bifocals8. Services rendered after the date an insured person ceases to becovered under the policy, except when vision materials orderedbefore coverage ended are delivered, and the services rendered tothe insured person are within 31 days from the date of such order9. Services or materials provided by any other group benet planproviding vision care10. Lost or broken lenses, frames, glasses or contact lenses will not bereplaced except in the next benet frequency when vision materialswould next become available750940.11191Member 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 reective of brands at the listed product level. All providers are not required to carry all brands at all levels. 3Premium progressives and premium anti-reective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market conditions. Fixed pricing is reective 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, benets, 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 benets, employee contributions, the number of eligible employees, or the imposition of any new taxes, fees or assessments by Federal or State regulatory agencies. Benets may not be combined with any discount, promotional oering or other group benet plans. Benet allowance provides no remaining balance for future use with the same benets year. Fees charged for a non-insured benet must be paid in full to the Provider. Such fees or materials are not covered. This is a snapshot of your benets. The Certicate of Insurance is on le with your employer. Benets are available from the EyeMed Vision Care, LLC provider network and are administered by First American Administrators, Inc., independent companies that oer benets 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.

Quote ID: 167126 Generation Date: 01/13/2022Group Benefit Program Summary forCAT5 Resources, LLCGroup Term LifeThe 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. WithBlue Cross and Blue Shield of Texas' Group Term Life plan, an employee can achieve peace of mind by giving their family the financialsecurity they can depend on.Eligibility All Active Full-Time EmployeesGroup Term Life Benefit:Employee$25,000Guarantee Issue Amount - Employee $25,000Group Term Life Age Reduction ScheduleBenefits reduce by 35% of the original amount at age 65; and further reduce by: 50% ofthe original amount at age 70.Waiver of Premium Elimination Period: 9 Months; Duration: To age 65Accelerated Death Benefit (ADB) Benefit: Up to 75% of the employee's life insurance; Life expectancy: 24 months or lessPortability Feature (Life Coverage) Not IncludedConversion IncludedBeneficiary Resource ServiceIncludes grief, legal and financial counseling for beneficiaries, funeral planning; andonline legal library, including templates to create a legal will and other legal documents.Travel Resource ServicesHelps travelers with the unexpected that may take place while traveling. Services includeemergency medical assistance, financial, legal and communication assistance andaccess to other critical services and resources available via the Internet. This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are subjectto issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can providethe 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 Blue Cross and Blue Shield licensee. BLUE CROSS®, BLUE SHIELD® and theCross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross andBlue Shield Plans.

Quote ID: 167126 Generation Date: 01/13/2022Group Benefit Program Summary forCAT5 Resources, LLCGroup Term LifeThe 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. WithBlue Cross and Blue Shield of Texas' Group Term Life plan, an employee can achieve peace of mind by giving their family the financialsecurity they can depend on.Eligibility All Active Full-Time EmployeesGroup Term Life Benefit:Employee$25,000Guarantee Issue Amount - Employee $25,000Group Term Life Age Reduction ScheduleBenefits reduce by 35% of the original amount at age 65; and further reduce by: 50% ofthe original amount at age 70.Waiver of Premium Elimination Period: 9 Months; Duration: To age 65Accelerated Death Benefit (ADB) Benefit: Up to 75% of the employee's life insurance; Life expectancy: 24 months or lessPortability Feature (Life Coverage) Not IncludedConversion IncludedBeneficiary Resource ServiceIncludes grief, legal and financial counseling for beneficiaries, funeral planning; andonline legal library, including templates to create a legal will and other legal documents.Travel Resource ServicesHelps travelers with the unexpected that may take place while traveling. Services includeemergency medical assistance, financial, legal and communication assistance andaccess to other critical services and resources available via the Internet. This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are subjectto issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can providethe 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 Blue Cross and Blue Shield licensee. BLUE CROSS®, BLUE SHIELD® and theCross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross andBlue Shield Plans.

Quote ID: 167126 Generation Date: 01/13/2022Group Accidental Death & Dismemberment (AD&D)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 a 24-hour coverage.Group AD&D Benefit:EmployeeSame as Basic LifeAD&D Age Reduction Schedule Same as Basic LifeAD&D Schedule of Loss* Principal SumLoss of Life 100%Loss of both hands or both feet 100%Loss of one hand and one foot 100%Loss of speech and hearing 100%Loss of sight of both eyes 100%Loss of one hand and sight of one eye 100%Loss of one foot and sight of one eye 100%Quadriplegia 100%Paraplegia 75%Hemiplegia 50%Loss of sight of one eye 50%Loss of one hand or one foot 50%Loss of speech or hearing 50%Loss of thumb and index finger of the same hand 25%Uniplegia 25% AD&D PRODUCT FEATURES INCLUDED: ▲ Seatbelt Benefit▲ Airbag Benefit▲ Repatriation Benefit▲ Education Benefit*Loss must occur within 365 days of accident.This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are subjectto issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can providethe actual terms of coverage.

Quote ID: 167126 Generation Date: 01/13/2022Group Accidental Death & Dismemberment (AD&D)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 a 24-hour coverage.Group AD&D Benefit:EmployeeSame as Basic LifeAD&D Age Reduction Schedule Same as Basic LifeAD&D Schedule of Loss* Principal SumLoss of Life 100%Loss of both hands or both feet 100%Loss of one hand and one foot 100%Loss of speech and hearing 100%Loss of sight of both eyes 100%Loss of one hand and sight of one eye 100%Loss of one foot and sight of one eye 100%Quadriplegia 100%Paraplegia 75%Hemiplegia 50%Loss of sight of one eye 50%Loss of one hand or one foot 50%Loss of speech or hearing 50%Loss of thumb and index finger of the same hand 25%Uniplegia 25% AD&D PRODUCT FEATURES INCLUDED: ▲ Seatbelt Benefit▲ Airbag Benefit▲ Repatriation Benefit▲ Education Benefit*Loss must occur within 365 days of accident.This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are subjectto issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can providethe actual terms of coverage.

Base PlanMTBCP044 - BASE Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 908.85 650.00 258.85 119.47EMPLOYEE + SPOUSE 2,090.85 650.00 1,440.85 665.01EE + CHILD(REN) 1,635.91 650.00 985.91 455.04EE + FAMILY 2,817.42 650.00 2,167.42 1000.35Buy Up Plan #1MTBCP023 BUY-UP 1 Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 1,042.88 650.00 392.88 181.33EMPLOYEE + SPOUSE 2,398.61 650.00 1,748.61 807.05EE + CHILD(REN) 1,877.16 650.00 1,227.16 566.38EE + FAMILY 3,232.89 650.00 2,582.89 1192.10Buy Up Plan #2MTBCP011 BUY-UP 2 Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 1,118.31 650.00 468.31 216.14EMPLOYEE + SPOUSE 2,572.09 650.00 1,922.09 887.12EE + CHILD(REN) 2,012.94 650.00 1,362.94 629.05EE + FAMILY 3,466.71 650.00 2,816.71 1300.02BCBS DTNLR36Dental Base 1,000 Limit Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 23.35 - 23.35 10.78EMPLOYEE + SPOUSE 46.70 - 46.70 21.55EE + CHILD(REN) 58.51 - 58.51 27.00EE + FAMILY 89.58 - 89.58 41.34BCBS DTNHR32Dental Buy-Up 2,000 Limit Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 30.87 - 30.87 14.25EMPLOYEE + SPOUSE 61.75 - 61.75 28.50EE + CHILD(REN) 82.90 - 82.90 38.26EE + FAMILY 125.18 - 125.18 57.78BCBSVision - EyeMed Network Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 7.60 - 7.60 3.51EMPLOYEE + SPOUSE 14.44 - 14.44 6.66EE + CHILD(REN) 15.20 - 15.20 7.02EE + FAMILY 22.35 - 22.35 10.32Employer Paid Life AD&D25KCAT5 Resources 24-25 RATES

Base PlanMTBCP044 - BASE Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 908.85 650.00 258.85 119.47EMPLOYEE + SPOUSE 2,090.85 650.00 1,440.85 665.01EE + CHILD(REN) 1,635.91 650.00 985.91 455.04EE + FAMILY 2,817.42 650.00 2,167.42 1000.35Buy Up Plan #1MTBCP023 BUY-UP 1 Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 1,042.88 650.00 392.88 181.33EMPLOYEE + SPOUSE 2,398.61 650.00 1,748.61 807.05EE + CHILD(REN) 1,877.16 650.00 1,227.16 566.38EE + FAMILY 3,232.89 650.00 2,582.89 1192.10Buy Up Plan #2MTBCP011 BUY-UP 2 Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 1,118.31 650.00 468.31 216.14EMPLOYEE + SPOUSE 2,572.09 650.00 1,922.09 887.12EE + CHILD(REN) 2,012.94 650.00 1,362.94 629.05EE + FAMILY 3,466.71 650.00 2,816.71 1300.02BCBS DTNLR36Dental Base 1,000 Limit Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 23.35 - 23.35 10.78EMPLOYEE + SPOUSE 46.70 - 46.70 21.55EE + CHILD(REN) 58.51 - 58.51 27.00EE + FAMILY 89.58 - 89.58 41.34BCBS DTNHR32Dental Buy-Up 2,000 Limit Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 30.87 - 30.87 14.25EMPLOYEE + SPOUSE 61.75 - 61.75 28.50EE + CHILD(REN) 82.90 - 82.90 38.26EE + FAMILY 125.18 - 125.18 57.78BCBSVision - EyeMed Network Monthly Cost CAT5 Contribution Emp Montly Cost Employee per pay periodEMPLOYEE ONLY 7.60 - 7.60 3.51EMPLOYEE + SPOUSE 14.44 - 14.44 6.66EE + CHILD(REN) 15.20 - 15.20 7.02EE + FAMILY 22.35 - 22.35 10.32Employer Paid Life AD&D25KCAT5 Resources 24-25 RATES

For more information, talk with your benefits counselor.Accident InsurancePreferred PlanColonialLife.comIAC4000 – PREFERRED PLANAccident insurance can help with medical or other costs associated with a covered accident or injury that your health insurance may not cover. Coverage options are available for you, your spouse and eligible dependent children. Benefits are per covered person per covered accident unless stated otherwiseAccident emergency treatment ................................................................................................$125 One visit per covered person per covered accidentAccident follow-up treatment (including transportation/telemedicine) ...................................................$55Up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar yearAccidental death Accidental deathPer covered person Accidental death common carrier¾ Named insured .....................................................................$40,000 .................. $160,000¾ Spouse ...............................................................................$40,000 .................. $160,000¾ Dependent child(ren) .............................................................. $10,000 ....................$30,000Examples of common carriers are mass transit trains, buses and planesAccidental dismembermentLoss, loss of use or paralysis¾ One hand, arm, foot, leg or sight of an eye ........................................................................$10,000¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination ................................ $20,000Loss or loss of use¾ One finger or one toe ...................................................................................................... $900¾ Two or more fingers; two or more toes; or any combination ................................................... $1,800¾ Partial dismemberment of one finger or toe .........................................................................$450¾ Partial dismemberment of two or more fingers or toes; or any combination ...................................$900Accidental dismemberment due to a catastrophic accidentSubject to a 180-day elimination period; payable once per lifetime per covered person¾ Named insured ........................................................................................................ $25,000¾ Spouse .................................................................................................................. $25,000 ¾ Dependent child(ren) ................................................................................................. $25,000 Accidental injury due to an automobile accident ..........................................................................$250 Requires transportation to a hospital or medical facility by ambulance Payable once per calendar year for all covered persons combinedAir ambulance .................................................................................................................. $2,000 Transportation to or from a hospital or medical facilityAmbulance (ground or water)...................................................................................................$200 Transportation to or from a hospital or medical facilityBlood/plasma/platelets (transfusion) .........................................................................................$300 A transfusion required during treatment of a covered accidentBurn¾ 2nd-degree burns (covering at least 36% of the body’s surface) ..................................................$1,000 ¾ 3rd-degree burns (based on size) ......................................................................... $2,000 – $12,000

For more information, talk with your benefits counselor.Accident InsurancePreferred PlanColonialLife.comIAC4000 – PREFERRED PLANAccident insurance can help with medical or other costs associated with a covered accident or injury that your health insurance may not cover. Coverage options are available for you, your spouse and eligible dependent children. Benefits are per covered person per covered accident unless stated otherwiseAccident emergency treatment ................................................................................................$125 One visit per covered person per covered accidentAccident follow-up treatment (including transportation/telemedicine) ...................................................$55Up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar yearAccidental death Accidental deathPer covered person Accidental death common carrier¾ Named insured .....................................................................$40,000 .................. $160,000¾ Spouse ...............................................................................$40,000 .................. $160,000¾ Dependent child(ren) .............................................................. $10,000 ....................$30,000Examples of common carriers are mass transit trains, buses and planesAccidental dismembermentLoss, loss of use or paralysis¾ One hand, arm, foot, leg or sight of an eye ........................................................................$10,000¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination ................................ $20,000Loss or loss of use¾ One finger or one toe ...................................................................................................... $900¾ Two or more fingers; two or more toes; or any combination ................................................... $1,800¾ Partial dismemberment of one finger or toe .........................................................................$450¾ Partial dismemberment of two or more fingers or toes; or any combination ...................................$900Accidental dismemberment due to a catastrophic accidentSubject to a 180-day elimination period; payable once per lifetime per covered person¾ Named insured ........................................................................................................ $25,000¾ Spouse .................................................................................................................. $25,000 ¾ Dependent child(ren) ................................................................................................. $25,000 Accidental injury due to an automobile accident ..........................................................................$250 Requires transportation to a hospital or medical facility by ambulance Payable once per calendar year for all covered persons combinedAir ambulance .................................................................................................................. $2,000 Transportation to or from a hospital or medical facilityAmbulance (ground or water)...................................................................................................$200 Transportation to or from a hospital or medical facilityBlood/plasma/platelets (transfusion) .........................................................................................$300 A transfusion required during treatment of a covered accidentBurn¾ 2nd-degree burns (covering at least 36% of the body’s surface) ..................................................$1,000 ¾ 3rd-degree burns (based on size) ......................................................................... $2,000 – $12,000

Burn – skin gra .................................................................... 50% of applicable burn benefitAs a result of 2nd-degree or 3rd-degree burnsComa ...............................................................................................................$12,500Lasting for seven or more consecutive daysConcussion ............................................................................................................ $150Dislocation (separated joint) Non-surgical Surgical¾ Hip ........................................................................................$2,250 $4,500¾ Knee (except patella) ..................................................................$1,125 $2,250¾ Ankle, bone or bones of the foot (other than toes) ...............................$1,000 $2,000¾ Collarbone (sternoclavicular) ..........................................................$750 $1,500¾ Collarbone (acromioclavicular and separation) ....................................$500 $1,000¾ Lower jaw, shoulder, elbow, wrist, bone(s) of the hand ............................ $ 500 $1,000¾ Finger, toe ..................................................................................$100 $200¾ Incomplete dislocation or dislocation reduction.................................. 25% of the applicable without anesthesia non-surgical amountEmergency dental work ¾ Dental crown, denture or implant .........................................................................$300 ¾ Dental extraction .............................................................................................$100 Eye injury ..............................................................................................................$300 With surgical repair or removal of a foreign objectFracture (complete) Non-surgical Surgical¾ Skull, depressed fracture (except face/nose) ......................................$3,000 $6,000¾ Skull, simple non-depressed fracture ..............................................$1,200 $2,400¾ Hip, thigh (femur) ......................................................................$2,200 $4,400¾ Body of vertebrae (excluding vertebral processes), pelvis, leg .................$1,000 $2,000¾ Bones of the face or nose (except mandible or maxilla) ...........................$500 $1,000¾ Upper jaw, maxilla, upper arm between .............................................$450 $900 elbow and shoulder¾ Lower jaw, mandible ....................................................................$375 $750¾ Kneecap, ankle, foot or heel ............................................................$375 $750¾ Shoulder blade ...........................................................................$375 $750¾ Collarbone, vertebral processes ....................................................... $625 $1,250¾ Forearm, hand, wrist ....................................................................$375 $750¾ Rib ..........................................................................................$625 $1,250¾ Coccyx .....................................................................................$250 $500¾ Finger ......................................................................................$325 $650¾ Toe .......................................................................................... $325 $650¾ Chip fracture .................................................25% of the applicable non-surgical amountHearing-loss injuries ................................................................................................$120 Maximum of one benefit for each injured ear per covered person per lifetimeHospital admission ............................................................................................... $1,000 Per covered person per covered accidentHospital confinement .................................................................................... $250 per dayUp to 365 days per covered person per covered accidentHospital sub-acute intensive care unit confinement .............................................. $325 per dayUp to 30 days per covered person per covered accidentIntensive care unit admission .................................................................................. $2,000 Per covered person per covered accidentIntensive care unit confinement ....................................................................... $450 per dayUp to 15 days per covered person per covered accidentJohn was cleaning out the gutters when he fell. EMERGENCY ROOM VISITJohn was admitted to the hospital for surgery on his leg.Over the next several weeks, he had three follow-up appointments with his doctor.John had eight sessions of PT to help him regain the strength in his leg.The doctor ordered an X-ray and discovered John had fractured his leg.John was taken by ambulance to the nearest emergency room and received immediate care.DIAGNOSTIC PROCEDUREHOSPITAL CONFINEMENTDOCTORʼS OFFICE VISITPHYSICAL THERAPYFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.JOHN’S BENEFITS Ambulance $200Emergency room visit $125X-ray $30Hospital admission $1,000Hospital confinement $750Leg fracture (surgical) $2,000Physical therapy $280Medical equipment (crutches) $100Doctor’s oice visit $165$4,650JOHNʼS OUT-OF-POCKET EXPENSESWhen John totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, John had accident coverage to help with these expenses.

Burn – skin gra .................................................................... 50% of applicable burn benefitAs a result of 2nd-degree or 3rd-degree burnsComa ...............................................................................................................$12,500Lasting for seven or more consecutive daysConcussion ............................................................................................................ $150Dislocation (separated joint) Non-surgical Surgical¾ Hip ........................................................................................$2,250 $4,500¾ Knee (except patella) ..................................................................$1,125 $2,250¾ Ankle, bone or bones of the foot (other than toes) ...............................$1,000 $2,000¾ Collarbone (sternoclavicular) ..........................................................$750 $1,500¾ Collarbone (acromioclavicular and separation) ....................................$500 $1,000¾ Lower jaw, shoulder, elbow, wrist, bone(s) of the hand ............................ $ 500 $1,000¾ Finger, toe ..................................................................................$100 $200¾ Incomplete dislocation or dislocation reduction.................................. 25% of the applicable without anesthesia non-surgical amountEmergency dental work ¾ Dental crown, denture or implant .........................................................................$300 ¾ Dental extraction .............................................................................................$100 Eye injury ..............................................................................................................$300 With surgical repair or removal of a foreign objectFracture (complete) Non-surgical Surgical¾ Skull, depressed fracture (except face/nose) ......................................$3,000 $6,000¾ Skull, simple non-depressed fracture ..............................................$1,200 $2,400¾ Hip, thigh (femur) ......................................................................$2,200 $4,400¾ Body of vertebrae (excluding vertebral processes), pelvis, leg .................$1,000 $2,000¾ Bones of the face or nose (except mandible or maxilla) ...........................$500 $1,000¾ Upper jaw, maxilla, upper arm between .............................................$450 $900 elbow and shoulder¾ Lower jaw, mandible ....................................................................$375 $750¾ Kneecap, ankle, foot or heel ............................................................$375 $750¾ Shoulder blade ...........................................................................$375 $750¾ Collarbone, vertebral processes ....................................................... $625 $1,250¾ Forearm, hand, wrist ....................................................................$375 $750¾ Rib ..........................................................................................$625 $1,250¾ Coccyx .....................................................................................$250 $500¾ Finger ......................................................................................$325 $650¾ Toe .......................................................................................... $325 $650¾ Chip fracture .................................................25% of the applicable non-surgical amountHearing-loss injuries ................................................................................................$120 Maximum of one benefit for each injured ear per covered person per lifetimeHospital admission ............................................................................................... $1,000 Per covered person per covered accidentHospital confinement .................................................................................... $250 per dayUp to 365 days per covered person per covered accidentHospital sub-acute intensive care unit confinement .............................................. $325 per dayUp to 30 days per covered person per covered accidentIntensive care unit admission .................................................................................. $2,000 Per covered person per covered accidentIntensive care unit confinement ....................................................................... $450 per dayUp to 15 days per covered person per covered accidentJohn was cleaning out the gutters when he fell. EMERGENCY ROOM VISITJohn was admitted to the hospital for surgery on his leg.Over the next several weeks, he had three follow-up appointments with his doctor.John had eight sessions of PT to help him regain the strength in his leg.The doctor ordered an X-ray and discovered John had fractured his leg.John was taken by ambulance to the nearest emergency room and received immediate care.DIAGNOSTIC PROCEDUREHOSPITAL CONFINEMENTDOCTORʼS OFFICE VISITPHYSICAL THERAPYFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.JOHN’S BENEFITS Ambulance $200Emergency room visit $125X-ray $30Hospital admission $1,000Hospital confinement $750Leg fracture (surgical) $2,000Physical therapy $280Medical equipment (crutches) $100Doctor’s oice visit $165$4,650JOHNʼS OUT-OF-POCKET EXPENSESWhen John totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, John had accident coverage to help with these expenses.

For more information, talk with your benefits counselor.IAC4000 – PREFERRED PLANKnee cartilage (torn) .............................................................................................................$650 Laceration (no repair, without stitches) ..........................................................................................$30 Laceration (repaired by stitches)¾ Total of all lacerations is less than two inches long .....................................................................$75¾ Total of all lacerations is at least two but less than six inches long ................................................. $275¾ Total of all lacerations is six inches or longer ...........................................................................$600 Lodging (companion) ..................................................................................................$125 per dayUp to 30 days per covered person per covered accident Medical equipment¾ Tier 1 ..........................................................................................................................$30 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint¾ Tier 2 ........................................................................................................................ $100 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot¾ Tier 3 ........................................................................................................................ $200 Back brace, body jacket, Continuous Passive Movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair li chair, wheelchairMedical imaging study (CT, CAT scan, EEG, EMG, MR or MRI) ..............................................................$200 One benefit per covered person per covered accident per calendar yearObservation room ..................................................................................................... $150 per day Up to two days per covered person per calendar yearPain management for epidural anesthesia (non-surgical) ................................................................ $100 Post-Traumatic Stress Disorder (PTSD) .......................................................................................$200 Diagnosed from a covered accident with one benefit per covered person per calendar yearProsthetic device/artificial limb¾ One .......................................................................................................................... $750 ¾ More than one ........................................................................................................... $1,500 Repair or replacement¾ Repair .......................................................................................................................$375 ¾ Replacement ............................................................................................................... $750 One repair or replacement per prosthetic device/artificial limb per covered person per lifetimeRehabilitation unit confinement ....................................................................................$150 per day Immediately aer a period of hospital confinement due to a covered accident; up to 15 days per covered person per covered accident, not to exceed 30 days per covered person per calendar yearRuptured disc with surgical repair ............................................................................................$750 Surgery¾ Cranial, open abdominal and thoracic .............................................................................. $1,500 ¾ Hernia with surgical repair ...............................................................................................$200Surgery (exploratory and arthroscopic) ....................................................................................... $300 Tendon/ligament/rotator cu¾ One with surgical repair ..................................................................................................$650 ¾ Two or more with surgical repair ..................................................................................... $1,300 Therapy (occupational, physical or speech) ......................................................................... $35 per day Up to 10 days per covered person per covered accidentTransportation for hospital confinement (per round trip) ................................................................$600 Up to 3 round trips for more than 50 miles from home per covered person per covered accidentX-ray ...................................................................................................................................$30

For more information, talk with your benefits counselor.IAC4000 – PREFERRED PLANKnee cartilage (torn) .............................................................................................................$650 Laceration (no repair, without stitches) ..........................................................................................$30 Laceration (repaired by stitches)¾ Total of all lacerations is less than two inches long .....................................................................$75¾ Total of all lacerations is at least two but less than six inches long ................................................. $275¾ Total of all lacerations is six inches or longer ...........................................................................$600 Lodging (companion) ..................................................................................................$125 per dayUp to 30 days per covered person per covered accident Medical equipment¾ Tier 1 ..........................................................................................................................$30 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint¾ Tier 2 ........................................................................................................................ $100 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot¾ Tier 3 ........................................................................................................................ $200 Back brace, body jacket, Continuous Passive Movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair li chair, wheelchairMedical imaging study (CT, CAT scan, EEG, EMG, MR or MRI) ..............................................................$200 One benefit per covered person per covered accident per calendar yearObservation room ..................................................................................................... $150 per day Up to two days per covered person per calendar yearPain management for epidural anesthesia (non-surgical) ................................................................ $100 Post-Traumatic Stress Disorder (PTSD) .......................................................................................$200 Diagnosed from a covered accident with one benefit per covered person per calendar yearProsthetic device/artificial limb¾ One .......................................................................................................................... $750 ¾ More than one ........................................................................................................... $1,500 Repair or replacement¾ Repair .......................................................................................................................$375 ¾ Replacement ............................................................................................................... $750 One repair or replacement per prosthetic device/artificial limb per covered person per lifetimeRehabilitation unit confinement ....................................................................................$150 per day Immediately aer a period of hospital confinement due to a covered accident; up to 15 days per covered person per covered accident, not to exceed 30 days per covered person per calendar yearRuptured disc with surgical repair ............................................................................................$750 Surgery¾ Cranial, open abdominal and thoracic .............................................................................. $1,500 ¾ Hernia with surgical repair ...............................................................................................$200Surgery (exploratory and arthroscopic) ....................................................................................... $300 Tendon/ligament/rotator cu¾ One with surgical repair ..................................................................................................$650 ¾ Two or more with surgical repair ..................................................................................... $1,300 Therapy (occupational, physical or speech) ......................................................................... $35 per day Up to 10 days per covered person per covered accidentTransportation for hospital confinement (per round trip) ................................................................$600 Up to 3 round trips for more than 50 miles from home per covered person per covered accidentX-ray ...................................................................................................................................$30

ColonialLife.com2-17 | 101776HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be oered to employees who do not have HSAs.THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Accidental Dismemberment Due to Catastrophic Accident benefits for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form IAC4000 (plus state abbreviations where applicable, such as IAC4000-TX). Coverage may vary by state and may not be available in all states. Premium at the eective date will vary according to the family coverage type.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife.com2-17 | 101776HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be oered to employees who do not have HSAs.THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Accidental Dismemberment Due to Catastrophic Accident benefits for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form IAC4000 (plus state abbreviations where applicable, such as IAC4000-TX). Coverage may vary by state and may not be available in all states. Premium at the eective date will vary according to the family coverage type.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

For more information, talk with your benefits counselor.Hospital Confinement Indemnity InsurancePlan 2IMB7000 – PLAN 2The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.Tier 1 outpatient surgical procedures Breast– Axillary node dissection– Breast capsulotomy– Lumpectomy  Cardiac– Pacemaker insertion  Digestive– Colonoscopy– Fistulotomy– Hemorrhoidectomy– Lysis of adhesions  Skin– Laparoscopic hernia repair– Skin graing  Ear, nose, throat, mouth– Adenoidectomy– Removal of oral lesions– Myringotomy– Tonsillectomy– Tracheostomy– Tympanotomy  Gynecological– Dilation and curettage (D&C)– Endometrial ablation– Lysis of adhesions  Liver– Paracentesis  Musculoskeletal system– Carpal/cubital repair or release– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)– Removal of orthopedic hardware– Removal of tendon lesionOur Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement .........................................................................$_______________ Maximum of one benefit per covered person per calendar yearObservation room .................................................................................. $100 per visitMaximum of two visits per covered person per calendar yearRehabilitation unit confinement .................................................................$100 per dayMaximum of 15 days per confinement with a 30-day maximum per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered hospital confinement of the named insuredOutpatient surgical procedure  Tier 1.................................................................................................$_______________  Tier 2.................................................................................................$_______________Maximum of $________________ per covered person per calendar year for all covered outpatient surgical procedures combined

For more information, talk with your benefits counselor.Hospital Confinement Indemnity InsurancePlan 2IMB7000 – PLAN 2The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.Tier 1 outpatient surgical procedures Breast– Axillary node dissection– Breast capsulotomy– Lumpectomy  Cardiac– Pacemaker insertion  Digestive– Colonoscopy– Fistulotomy– Hemorrhoidectomy– Lysis of adhesions  Skin– Laparoscopic hernia repair– Skin graing  Ear, nose, throat, mouth– Adenoidectomy– Removal of oral lesions– Myringotomy– Tonsillectomy– Tracheostomy– Tympanotomy  Gynecological– Dilation and curettage (D&C)– Endometrial ablation– Lysis of adhesions  Liver– Paracentesis  Musculoskeletal system– Carpal/cubital repair or release– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)– Removal of orthopedic hardware– Removal of tendon lesionOur Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement .........................................................................$_______________ Maximum of one benefit per covered person per calendar yearObservation room .................................................................................. $100 per visitMaximum of two visits per covered person per calendar yearRehabilitation unit confinement .................................................................$100 per dayMaximum of 15 days per confinement with a 30-day maximum per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered hospital confinement of the named insuredOutpatient surgical procedure  Tier 1.................................................................................................$_______________  Tier 2.................................................................................................$_______________Maximum of $________________ per covered person per calendar year for all covered outpatient surgical procedures combined

EXCLUSIONS We will not pay benefits for losses which are caused by: dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, intoxicants or narcotics, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months aer the eective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months aer the eective date due to a pre-existing condition. A pre-exisiting condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the eective date of the policy.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-TX. This is not an insurance contract and only the actual policy provisions will control.ColonialLife.com©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 3-15 | 101578-TX  Breast– Breast reconstruction– Breast reduction  Cardiac– Angioplasty– Cardiac catheterization  Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy  Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– Tympanoplasty  Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy Tier 2 outpatient surgical procedures Gynecological– Hysterectomy– Myomectomy  Musculoskeletal system– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)– Arthroscopic shoulder surgery– Clavicle resection– Dislocations (open reduction with internal fixation)– Fracture (open reduction with internal fixation)– Removal or implantation of cartilage– Tendon/ligament repair  Thyroid– Excision of a mass  Urologic – Lithotripsy

EXCLUSIONS We will not pay benefits for losses which are caused by: dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, intoxicants or narcotics, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months aer the eective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months aer the eective date due to a pre-existing condition. A pre-exisiting condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the eective date of the policy.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-TX. This is not an insurance contract and only the actual policy provisions will control.ColonialLife.com©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 3-15 | 101578-TX  Breast– Breast reconstruction– Breast reduction  Cardiac– Angioplasty– Cardiac catheterization  Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy  Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– Tympanoplasty  Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy Tier 2 outpatient surgical procedures Gynecological– Hysterectomy– Myomectomy  Musculoskeletal system– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)– Arthroscopic shoulder surgery– Clavicle resection– Dislocations (open reduction with internal fixation)– Fracture (open reduction with internal fixation)– Removal or implantation of cartilage– Tendon/ligament repair  Thyroid– Excision of a mass  Urologic – Lithotripsy

For more information, talk with your benefits counselor.Hospital Confinement Indemnity InsuranceHealth ScreeningWaiting period means the first 30 days following any covered person’s policy coverage eective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.IMB7000 – HEALTH SCREENING BENEFIT | 5-18 | 101579-2ColonialLife.comHealth screening .............................................................................. $100.00Maximum of one health screening benefit per covered person per calendar year; subject to a 30-day waiting period  Blood test for triglycerides  Bone marrow testing  Breast ultrasound  CA 15-3 (blood test for breast cancer)  CA 125 (blood test for ovarian cancer)  CEA (blood test for colon cancer)  Carotid Doppler  Chest X-ray  Colonoscopy  Echocardiogram (ECHO)  Electrocardiogram (EKG, ECG)  Fasting blood glucose test  Flexible sigmoidoscopy  Hemoccult stool analysis  Mammography  Pap smear  PSA (blood test for prostate cancer)  Serum cholesterol test for HDL and LDL levels  Serum protein electrophoresis (blood test for myeloma)  Skin cancer biopsy  Stress test on a bicycle or treadmill  Thermography  ThinPrep pap test  Virtual colonoscopyIndividual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

For more information, talk with your benefits counselor.Hospital Confinement Indemnity InsuranceHealth ScreeningWaiting period means the first 30 days following any covered person’s policy coverage eective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.IMB7000 – HEALTH SCREENING BENEFIT | 5-18 | 101579-2ColonialLife.comHealth screening .............................................................................. $100.00Maximum of one health screening benefit per covered person per calendar year; subject to a 30-day waiting period  Blood test for triglycerides  Bone marrow testing  Breast ultrasound  CA 15-3 (blood test for breast cancer)  CA 125 (blood test for ovarian cancer)  CEA (blood test for colon cancer)  Carotid Doppler  Chest X-ray  Colonoscopy  Echocardiogram (ECHO)  Electrocardiogram (EKG, ECG)  Fasting blood glucose test  Flexible sigmoidoscopy  Hemoccult stool analysis  Mammography  Pap smear  PSA (blood test for prostate cancer)  Serum cholesterol test for HDL and LDL levels  Serum protein electrophoresis (blood test for myeloma)  Skin cancer biopsy  Stress test on a bicycle or treadmill  Thermography  ThinPrep pap test  Virtual colonoscopyIndividual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Air Ambulance .................................................................................$2,000 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]Ambulance ..................................................................................... $250 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]AnesthesiaAdministered during a surgical procedure for cancer treatment ■ General Anesthesia ......................................................................... 25% of Surgical Procedures Benefit■ Local Anesthesia............................................................................$40 per procedureAnti-nausea Medication .....................................................................$50 per day administered orDoctor-prescribed medication for radiation or chemotherapy [$200 monthly max.] per prescription filledBlood/Plasma/Platelets/Immunoglobulins ............................................$175 per dayA transfusion required during cancer treatment [$10,000 calendar year max.]Bone Marrow Donor Screening ............................................................$50Testing in connection with being a potential donor [once per lifetime]Bone Marrow or Peripheral Stem Cell Donation .......................................$750Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]Bone Marrow or Peripheral Stem Cell Transplant .....................................$7,000 per transplantTransplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]Cancer Vaccine ................................................................................$50An FDA-approved vaccine for the prevention of cancer [once per lifetime]Companion Transportation ................................................................$0.50 per mileCompanion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,200 per round trip]Egg(s) Extraction or Harvesting/Sperm Collection and StorageExtracted/harvested or collected before chemotherapy or radiation [once per lifetime]■ Egg(s) Extraction or Harvesting/Sperm Collection ........................................$1,000■ Egg(s) or Sperm Storage (Cryopreservation) ..............................................$350Experimental Treatment ...................................................................$300 per dayHospital, medical or surgical care for cancer [$15,000 lifetime max.]Family Care ....................................................................................$50 per dayInpatient or outpatient treatment for a covered dependent child [$2,500 calendar year max.]Hair/External Breast/Voice Box Prosthesis .............................................$350 per calendar yearProsthesis needed as a direct result of cancerHome Health Care Services ................................................................$100 per dayExamples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 30 days per calendar year or twice the number of days hospital confined, whichever is greater]Hospice (Initial or Daily Care) An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both]■ Initial hospice care [once per lifetime] .....................................................$1,000■ Daily hospice care ..........................................................................$50 per dayBENEFIT DESCRIPTION BENEFIT AMOUNTCancer InsuranceLevel 3 BenefitsOur cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.For more information, talk with your benefits counselor.CANCER ASSIST LEVEL 3

Air Ambulance .................................................................................$2,000 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]Ambulance ..................................................................................... $250 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]AnesthesiaAdministered during a surgical procedure for cancer treatment ■ General Anesthesia ......................................................................... 25% of Surgical Procedures Benefit■ Local Anesthesia............................................................................$40 per procedureAnti-nausea Medication .....................................................................$50 per day administered orDoctor-prescribed medication for radiation or chemotherapy [$200 monthly max.] per prescription filledBlood/Plasma/Platelets/Immunoglobulins ............................................$175 per dayA transfusion required during cancer treatment [$10,000 calendar year max.]Bone Marrow Donor Screening ............................................................$50Testing in connection with being a potential donor [once per lifetime]Bone Marrow or Peripheral Stem Cell Donation .......................................$750Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]Bone Marrow or Peripheral Stem Cell Transplant .....................................$7,000 per transplantTransplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]Cancer Vaccine ................................................................................$50An FDA-approved vaccine for the prevention of cancer [once per lifetime]Companion Transportation ................................................................$0.50 per mileCompanion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,200 per round trip]Egg(s) Extraction or Harvesting/Sperm Collection and StorageExtracted/harvested or collected before chemotherapy or radiation [once per lifetime]■ Egg(s) Extraction or Harvesting/Sperm Collection ........................................$1,000■ Egg(s) or Sperm Storage (Cryopreservation) ..............................................$350Experimental Treatment ...................................................................$300 per dayHospital, medical or surgical care for cancer [$15,000 lifetime max.]Family Care ....................................................................................$50 per dayInpatient or outpatient treatment for a covered dependent child [$2,500 calendar year max.]Hair/External Breast/Voice Box Prosthesis .............................................$350 per calendar yearProsthesis needed as a direct result of cancerHome Health Care Services ................................................................$100 per dayExamples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 30 days per calendar year or twice the number of days hospital confined, whichever is greater]Hospice (Initial or Daily Care) An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both]■ Initial hospice care [once per lifetime] .....................................................$1,000■ Daily hospice care ..........................................................................$50 per dayBENEFIT DESCRIPTION BENEFIT AMOUNTCancer InsuranceLevel 3 BenefitsOur cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.For more information, talk with your benefits counselor.CANCER ASSIST LEVEL 3

The policy has limitations and exclusions that may aect benefits payable. Most benefits require that a charge be incurred. Policy may not be available in all states and may vary by state. For cost and complete details, see your benefits counselor.This chart highlights the benefits of policy form CanAssist (including state abbreviations where used – for example: CanAssist-TX). This chart is not complete without form #101481. Hospital ConfinementHospital stay (including intensive care) required for cancer treatment■ 30 days or less ..........................................................................................$250 per day■ 31 days or more ........................................................................................$500 per dayLodging .....................................................................................................$75 per dayHotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]Medical Imaging Studies ................................................................................ $175 per studySpecific studies for cancer treatment [$350 calendar year max.]Outpatient Surgical Center ............................................................................$300 per daySurgery at an outpatient center for cancer treatment [$900 calendar year max.]Private Full-time Nursing Services ...................................................................$125 per dayServices while hospital confined other than those regularly furnished by the hospitalProsthetic Device/Artificial Limb ......................................................................$2,000 per device or limbA surgical implant needed because of cancer surgery [payable one per site, $4,000 lifetime max.]Radiation/ChemotherapyWeekly Benefit [max. once per week]■ Injected chemotherapy by medical personnel ........................................................$750■ Radiation delivered by medical personnel ............................................................$750Monthly Chemotherapy Benefit [max. once per month]■ Self-Injected ............................................................................................$300■ Pump ...................................................................................................$300■ Topical ..................................................................................................$300■ Oral Hormonal [1-24 months] ..........................................................................$300■ Oral Hormonal [25+ months]...........................................................................$150■ Oral Non-Hormonal ....................................................................................$300Reconstructive Surgery .................................................................................$60 per surgical unitA surgery to reconstruct anatomic defects that result from cancer treatment[up to $3,000 per procedure, including 25% for general anesthesia]Second Medical Opinion ................................................................................$300A second physician’s opinion on cancer surgery or treatment [once per lifetime]Skilled Nursing Care Facility ...........................................................................$100 per dayConfinement to a covered facility aer hospital release [up to the number of days paid for hospital confinement]Skin Cancer Initial Diagnosis ...........................................................................$400A skin cancer diagnosis while the policy is in force [once per lifetime]Supportive or Protective Care Drugs and Colony Stimulating Factors ......................$150 per dayDoctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,200 calendar year max.] Surgical Procedures .....................................................................................$60 per surgical unitInpatient or outpatient surgery for cancer treatment [$5,000 max. per procedure]Transportation ............................................................................................$0.50 per mileTravel expenses when being treated for cancer more than 50 miles from home [up to $1,200 per round trip]Waiver of Premium ......................................................................................Is availableNo premiums due if the named insured is disabled longer than 90 consecutive daysBENEFIT DESCRIPTION BENEFIT AMOUNT©2014 Colonial Life & Accident Insurance CompanyColonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.1-14ColonialLife.com101484

The policy has limitations and exclusions that may aect benefits payable. Most benefits require that a charge be incurred. Policy may not be available in all states and may vary by state. For cost and complete details, see your benefits counselor.This chart highlights the benefits of policy form CanAssist (including state abbreviations where used – for example: CanAssist-TX). This chart is not complete without form #101481. Hospital ConfinementHospital stay (including intensive care) required for cancer treatment■ 30 days or less ..........................................................................................$250 per day■ 31 days or more ........................................................................................$500 per dayLodging .....................................................................................................$75 per dayHotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]Medical Imaging Studies ................................................................................ $175 per studySpecific studies for cancer treatment [$350 calendar year max.]Outpatient Surgical Center ............................................................................$300 per daySurgery at an outpatient center for cancer treatment [$900 calendar year max.]Private Full-time Nursing Services ...................................................................$125 per dayServices while hospital confined other than those regularly furnished by the hospitalProsthetic Device/Artificial Limb ......................................................................$2,000 per device or limbA surgical implant needed because of cancer surgery [payable one per site, $4,000 lifetime max.]Radiation/ChemotherapyWeekly Benefit [max. once per week]■ Injected chemotherapy by medical personnel ........................................................$750■ Radiation delivered by medical personnel ............................................................$750Monthly Chemotherapy Benefit [max. once per month]■ Self-Injected ............................................................................................$300■ Pump ...................................................................................................$300■ Topical ..................................................................................................$300■ Oral Hormonal [1-24 months] ..........................................................................$300■ Oral Hormonal [25+ months]...........................................................................$150■ Oral Non-Hormonal ....................................................................................$300Reconstructive Surgery .................................................................................$60 per surgical unitA surgery to reconstruct anatomic defects that result from cancer treatment[up to $3,000 per procedure, including 25% for general anesthesia]Second Medical Opinion ................................................................................$300A second physician’s opinion on cancer surgery or treatment [once per lifetime]Skilled Nursing Care Facility ...........................................................................$100 per dayConfinement to a covered facility aer hospital release [up to the number of days paid for hospital confinement]Skin Cancer Initial Diagnosis ...........................................................................$400A skin cancer diagnosis while the policy is in force [once per lifetime]Supportive or Protective Care Drugs and Colony Stimulating Factors ......................$150 per dayDoctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,200 calendar year max.] Surgical Procedures .....................................................................................$60 per surgical unitInpatient or outpatient surgery for cancer treatment [$5,000 max. per procedure]Transportation ............................................................................................$0.50 per mileTravel expenses when being treated for cancer more than 50 miles from home [up to $1,200 per round trip]Waiver of Premium ......................................................................................Is availableNo premiums due if the named insured is disabled longer than 90 consecutive daysBENEFIT DESCRIPTION BENEFIT AMOUNT©2014 Colonial Life & Accident Insurance CompanyColonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.1-14ColonialLife.com101484

BENEFIT DESCRIPTION BENEFIT AMOUNTCancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.For more information, talk with your benefits counselor.CANCER ASSIST – LEVEL 4Air ambulance .................................................................................$2,000 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]Ambulance .....................................................................................$250 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]AnesthesiaAdministered during a surgical procedure for cancer treatment ■ General anesthesia .........................................................................25% of surgical procedures benefit■ Local anesthesia ............................................................................$50 per procedureAnti-nausea medication .....................................................................$60 per day administered orDoctor-prescribed medication for radiation or chemotherapy [$240 monthly max.] per prescription filledBlood/plasma/platelets/immunoglobulins ..............................................$250 per dayA transfusion required during cancer treatment [$10,000 calendar year max.]Bone marrow donor screening .............................................................$50Testing in connection with being a potential donor [once per lifetime]Bone marrow or peripheral stem cell donation .........................................$1,000Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]Bone marrow or peripheral stem cell transplant ........................................$10,000 per transplantTransplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]Cancer vaccine .................................................................................$50An FDA-approved vaccine for the prevention of cancer [once per lifetime]Companion transportation ..................................................................$0.50 per mileCompanion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,500 per round trip]Egg(s) extraction or harvesting/sperm collection and storageExtracted/harvested or collected before chemotherapy or radiation [once per lifetime]■ Egg(s) extraction or harvesting/sperm collection .........................................$1,500■ Egg(s) or sperm storage (cryopreservation) ...............................................$500Experimental treatment .....................................................................$300 per dayHospital, medical or surgical care for cancer [$15,000 lifetime max.]Family care .....................................................................................$60 per dayInpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]Hair/external breast/voice box prosthesis ................................................ $500 per calendar yearProsthesis needed as a direct result of cancerHome health care services ..................................................................$150 per dayExamples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 30 days per calendar year or twice the number of days hospital confined, whichever is greater]Hospice (initial or daily care)An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both]■ Initial hospice care [once per lifetime] .....................................................$1,000■ Daily hospice care ..........................................................................$50 per dayCancer InsuranceLevel 4 Benefits

BENEFIT DESCRIPTION BENEFIT AMOUNTCancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.For more information, talk with your benefits counselor.CANCER ASSIST – LEVEL 4Air ambulance .................................................................................$2,000 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]Ambulance .....................................................................................$250 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]AnesthesiaAdministered during a surgical procedure for cancer treatment ■ General anesthesia .........................................................................25% of surgical procedures benefit■ Local anesthesia ............................................................................$50 per procedureAnti-nausea medication .....................................................................$60 per day administered orDoctor-prescribed medication for radiation or chemotherapy [$240 monthly max.] per prescription filledBlood/plasma/platelets/immunoglobulins ..............................................$250 per dayA transfusion required during cancer treatment [$10,000 calendar year max.]Bone marrow donor screening .............................................................$50Testing in connection with being a potential donor [once per lifetime]Bone marrow or peripheral stem cell donation .........................................$1,000Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]Bone marrow or peripheral stem cell transplant ........................................$10,000 per transplantTransplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]Cancer vaccine .................................................................................$50An FDA-approved vaccine for the prevention of cancer [once per lifetime]Companion transportation ..................................................................$0.50 per mileCompanion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,500 per round trip]Egg(s) extraction or harvesting/sperm collection and storageExtracted/harvested or collected before chemotherapy or radiation [once per lifetime]■ Egg(s) extraction or harvesting/sperm collection .........................................$1,500■ Egg(s) or sperm storage (cryopreservation) ...............................................$500Experimental treatment .....................................................................$300 per dayHospital, medical or surgical care for cancer [$15,000 lifetime max.]Family care .....................................................................................$60 per dayInpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]Hair/external breast/voice box prosthesis ................................................ $500 per calendar yearProsthesis needed as a direct result of cancerHome health care services ..................................................................$150 per dayExamples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 30 days per calendar year or twice the number of days hospital confined, whichever is greater]Hospice (initial or daily care)An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both]■ Initial hospice care [once per lifetime] .....................................................$1,000■ Daily hospice care ..........................................................................$50 per dayCancer InsuranceLevel 4 Benefits

The policy has limitations and exclusions that may aect benefits payable. Most benefits require that a charge be incurred. Policy may not be available in all states and may vary by state. For cost and complete details, see your benefits counselor.This chart highlights the benefits of policy form CanAssist (including state abbreviations where used – for example: CanAssist-TX). This chart is not complete without form number 101481.Hospital confinementHospital stay (including intensive care) required for cancer treatment■ 30 days or less ..........................................................................................$350 per day■ 31 days or more ........................................................................................$700 per dayLodging .....................................................................................................$80 per dayHotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]Medical imaging studies .................................................................................$225 per studySpecific studies for cancer treatment [$450 calendar year max.]Outpatient surgical center ..............................................................................$400 per daySurgery at an outpatient center for cancer treatment [$1,200 calendar year max.]Private full-time nursing services ......................................................................$150 per dayServices while hospital confined other than those regularly furnished by the hospitalProsthetic device/artificial limb ........................................................................$3,000 per device or limbA surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]Radiation/chemotherapyWeekly benefit [max. once per week]■ Injected chemotherapy by medical personnel ........................................................$1,000■ Radiation delivered by medical personnel.............................................................$1,000Monthly chemotherapy benefit [max. once per month]■ Self-injected ............................................................................................$400■ Pump ...................................................................................................$400■ Topical ..................................................................................................$400■ Oral hormonal [1-24 months] ..........................................................................$400■ Oral hormonal [25+ months] ...........................................................................$200■ Oral non-hormonal .....................................................................................$400Reconstructive surgery ..................................................................................$60 per surgical unitA surgery to reconstruct anatomic defects that result from cancer treatment[up to $3,000 per procedure, including 25% for general anesthesia]Second medical opinion .................................................................................$300A second physician’s opinion on cancer surgery or treatment [once per lifetime]Skilled nursing care facility .............................................................................. $150 per dayConfinement to a covered facility aer hospital release [up to the number of days paid for hospital confinement]Skin cancer initial diagnosis ............................................................................$600A skin cancer diagnosis while the policy is in force [once per lifetime]Supportive or protective care drugs and colony stimulating factors ...........................$200 per dayDoctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.] Surgical procedures ......................................................................................$70 per surgical unitInpatient or outpatient surgery for cancer treatment [$6,000 max. per procedure]Transportation.............................................................................................$0.50 per mileTravel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]Waiver of premium .......................................................................................Is availableNo premiums due if the named insured is disabled longer than 90 consecutive daysBENEFIT DESCRIPTION BENEFIT AMOUNTColonialLife.com10-15 | 101485-1©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

The policy has limitations and exclusions that may aect benefits payable. Most benefits require that a charge be incurred. Policy may not be available in all states and may vary by state. For cost and complete details, see your benefits counselor.This chart highlights the benefits of policy form CanAssist (including state abbreviations where used – for example: CanAssist-TX). This chart is not complete without form number 101481.Hospital confinementHospital stay (including intensive care) required for cancer treatment■ 30 days or less ..........................................................................................$350 per day■ 31 days or more ........................................................................................$700 per dayLodging .....................................................................................................$80 per dayHotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]Medical imaging studies .................................................................................$225 per studySpecific studies for cancer treatment [$450 calendar year max.]Outpatient surgical center ..............................................................................$400 per daySurgery at an outpatient center for cancer treatment [$1,200 calendar year max.]Private full-time nursing services ......................................................................$150 per dayServices while hospital confined other than those regularly furnished by the hospitalProsthetic device/artificial limb ........................................................................$3,000 per device or limbA surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]Radiation/chemotherapyWeekly benefit [max. once per week]■ Injected chemotherapy by medical personnel ........................................................$1,000■ Radiation delivered by medical personnel.............................................................$1,000Monthly chemotherapy benefit [max. once per month]■ Self-injected ............................................................................................$400■ Pump ...................................................................................................$400■ Topical ..................................................................................................$400■ Oral hormonal [1-24 months] ..........................................................................$400■ Oral hormonal [25+ months] ...........................................................................$200■ Oral non-hormonal .....................................................................................$400Reconstructive surgery ..................................................................................$60 per surgical unitA surgery to reconstruct anatomic defects that result from cancer treatment[up to $3,000 per procedure, including 25% for general anesthesia]Second medical opinion .................................................................................$300A second physician’s opinion on cancer surgery or treatment [once per lifetime]Skilled nursing care facility .............................................................................. $150 per dayConfinement to a covered facility aer hospital release [up to the number of days paid for hospital confinement]Skin cancer initial diagnosis ............................................................................$600A skin cancer diagnosis while the policy is in force [once per lifetime]Supportive or protective care drugs and colony stimulating factors ...........................$200 per dayDoctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.] Surgical procedures ......................................................................................$70 per surgical unitInpatient or outpatient surgery for cancer treatment [$6,000 max. per procedure]Transportation.............................................................................................$0.50 per mileTravel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]Waiver of premium .......................................................................................Is availableNo premiums due if the named insured is disabled longer than 90 consecutive daysBENEFIT DESCRIPTION BENEFIT AMOUNTColonialLife.com10-15 | 101485-1©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

For more information, talk with your benefits counselor.To encourage early detection,our cancer insurance oers benefits for wellness and health screening tests. Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed aer the waiting period and while the policy is in force. Payable once per calendar year, per covered person.Cancer wellness tests■ Bone marrow testing■ Breast ultrasound■ CA 15-3 (blood test for breast cancer)■ CA 125 (blood test for ovarian cancer)■ CEA (blood test for colon cancer)■ Chest X-ray■ Colonoscopy■ Flexible sigmoidoscopy■ Hemoccult stool analysis■ Mammography■ Pap smear■ PSA (blood test for prostate cancer)■ Serum protein electrophoresis (blood test for myeloma)■ Skin biopsy■ Thermography■ ThinPrep pap test■ Virtual colonoscopyPart two: Cancer wellness — additional invasive diagnostic test or surgical procedureProvided when a doctor performs a diagnostic test or surgical procedure aer the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in part one. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.Health screening tests■ Blood test for triglycerides■ Carotid Doppler■ Echocardiogram (ECHO)■ Electrocardiogram (EKG, ECG)■ Fasting blood glucose test■ Serum cholesterol test for HDL and LDL levels■ Stress test on a bicycle or treadmillCancer InsuranceWellness BenefitsWaiting period means the first 30 days following the policy’s coverage eective date during which no benefits are payable.The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable, for example: CanAssist-TX).©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.CANCER ASSIST WELLNESS | 3-15 | 101486-1

For more information, talk with your benefits counselor.To encourage early detection,our cancer insurance oers benefits for wellness and health screening tests. Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed aer the waiting period and while the policy is in force. Payable once per calendar year, per covered person.Cancer wellness tests■ Bone marrow testing■ Breast ultrasound■ CA 15-3 (blood test for breast cancer)■ CA 125 (blood test for ovarian cancer)■ CEA (blood test for colon cancer)■ Chest X-ray■ Colonoscopy■ Flexible sigmoidoscopy■ Hemoccult stool analysis■ Mammography■ Pap smear■ PSA (blood test for prostate cancer)■ Serum protein electrophoresis (blood test for myeloma)■ Skin biopsy■ Thermography■ ThinPrep pap test■ Virtual colonoscopyPart two: Cancer wellness — additional invasive diagnostic test or surgical procedureProvided when a doctor performs a diagnostic test or surgical procedure aer the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in part one. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.Health screening tests■ Blood test for triglycerides■ Carotid Doppler■ Echocardiogram (ECHO)■ Electrocardiogram (EKG, ECG)■ Fasting blood glucose test■ Serum cholesterol test for HDL and LDL levels■ Stress test on a bicycle or treadmillCancer InsuranceWellness BenefitsWaiting period means the first 30 days following the policy’s coverage eective date during which no benefits are payable.The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable, for example: CanAssist-TX).©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.CANCER ASSIST WELLNESS | 3-15 | 101486-1

For more information, talk with your benefits counselor.ColonialLife.comSubsequent diagnosis of a dierent critical illness3If you receive a benefit for a specified critical illness, and later you are diagnosed with a dierent specified critical illness, the original percentage of the face amount is payable for that particular specified critical illness.Subsequent diagnosis of the same critical illness3If you receive a benefit for a specified critical illness, and later you are diagnosed with the same specified critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass gra surgery/disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.Specified Critical Illness InsuranceIf you’re diagnosed with a covered critical illness, specified critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.Face amount: $_______________ For the diagnosis of this covered critical illness condition:1This percentage of the face amount is payable:Heart attack (myocardial infarction) 100%Stroke 100%End-stage renal (kidney) failure 100%Major organ failure 100%Permanent paralysis due to a covered accident 100%Coma 100%Blindness 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Coronary artery bypass gra surgery/disease225%Critical illness benefitCRITICAL ILLNESS 1.0 WITH SUBSEQUENT DIAGNOSIS The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined. The policy will terminate when the maximum benefit amount for specified critical illness has been paid.

For more information, talk with your benefits counselor.ColonialLife.comSubsequent diagnosis of a dierent critical illness3If you receive a benefit for a specified critical illness, and later you are diagnosed with a dierent specified critical illness, the original percentage of the face amount is payable for that particular specified critical illness.Subsequent diagnosis of the same critical illness3If you receive a benefit for a specified critical illness, and later you are diagnosed with the same specified critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass gra surgery/disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.Specified Critical Illness InsuranceIf you’re diagnosed with a covered critical illness, specified critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.Face amount: $_______________ For the diagnosis of this covered critical illness condition:1This percentage of the face amount is payable:Heart attack (myocardial infarction) 100%Stroke 100%End-stage renal (kidney) failure 100%Major organ failure 100%Permanent paralysis due to a covered accident 100%Coma 100%Blindness 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Coronary artery bypass gra surgery/disease225%Critical illness benefitCRITICAL ILLNESS 1.0 WITH SUBSEQUENT DIAGNOSIS The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined. The policy will terminate when the maximum benefit amount for specified critical illness has been paid.

ColonialLife.com1 Please refer to the policy for complete definitions of covered conditions. 2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass gra surgery when health savings account (HSA) compliant plan is selected.3 Dates of diagnoses of a covered specified critical illness must be separated by at least 180 days.THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR SPECIFIED CRITICAL ILLNESSWe will not pay benefits for a specified critical illness that occurs as a result of a covered person’s: felonies or illegal occupations; intoxicants and narcotics; pre-existing condition; psychiatric or psychological condition; suicide or self-inflicted injuries; or war or armed conflict. This is not an insurance contract and only the actual policy provisions will control. Applicable to policy form CI-1.0-AK, CI-1.0-DE or CI-1.0-TX. Please see your Colonial Life benefits counselor for details.6-17 | 101824-AK-DE-TXUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife.com1 Please refer to the policy for complete definitions of covered conditions. 2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass gra surgery when health savings account (HSA) compliant plan is selected.3 Dates of diagnoses of a covered specified critical illness must be separated by at least 180 days.THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR SPECIFIED CRITICAL ILLNESSWe will not pay benefits for a specified critical illness that occurs as a result of a covered person’s: felonies or illegal occupations; intoxicants and narcotics; pre-existing condition; psychiatric or psychological condition; suicide or self-inflicted injuries; or war or armed conflict. This is not an insurance contract and only the actual policy provisions will control. Applicable to policy form CI-1.0-AK, CI-1.0-DE or CI-1.0-TX. Please see your Colonial Life benefits counselor for details.6-17 | 101824-AK-DE-TXUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

For more information, talk with your benefits counselor.Critical Illness InsuranceHealth Screening Benefit For cost and complete details, see your Colonial Life benefits counselor. Applicable to form CI-1.0-P and GCC1.0-P (including state abbreviations where used, for example: CI-1.0-P-TX and GCC1.0-P-TX). Coverage may vary by state and may not be available in all states. GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 10-16 | 100355-2ColonialLife.comHealth screening benefit ................................................................$ 50.00 Maximum of one screening test per covered person per calendar year.  Blood test for triglycerides  Bone marrow testing  Breast ultrasound  CA 15-3 (blood test for breast cancer)  CA 125 (blood test for ovarian cancer)  Carotid Doppler  CEA (blood test for colon cancer)  Chest X-ray  Colonoscopy  Echocardiogram (ECHO)  Electrocardiogram (EKG, ECG)  Fasting blood glucose test  Flexible sigmoidoscopy  Hemoccult stool analysis  Mammography  Pap smear  PSA (blood test for prostate cancer)  Serum cholesterol test for HDL and LDL levels  Serum protein electrophoresis(blood test for myeloma)  Skin cancer biopsy  Stress test on a bicycleor treadmill  Thermography  ThinPrep pap test  Virtual colonoscopyThe optional health screening benefit can help you reduce the risk of serious illness through early detection.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2016 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

For more information, talk with your benefits counselor.Critical Illness InsuranceHealth Screening Benefit For cost and complete details, see your Colonial Life benefits counselor. Applicable to form CI-1.0-P and GCC1.0-P (including state abbreviations where used, for example: CI-1.0-P-TX and GCC1.0-P-TX). Coverage may vary by state and may not be available in all states. GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 10-16 | 100355-2ColonialLife.comHealth screening benefit ................................................................$ 50.00 Maximum of one screening test per covered person per calendar year.  Blood test for triglycerides  Bone marrow testing  Breast ultrasound  CA 15-3 (blood test for breast cancer)  CA 125 (blood test for ovarian cancer)  Carotid Doppler  CEA (blood test for colon cancer)  Chest X-ray  Colonoscopy  Echocardiogram (ECHO)  Electrocardiogram (EKG, ECG)  Fasting blood glucose test  Flexible sigmoidoscopy  Hemoccult stool analysis  Mammography  Pap smear  PSA (blood test for prostate cancer)  Serum cholesterol test for HDL and LDL levels  Serum protein electrophoresis(blood test for myeloma)  Skin cancer biopsy  Stress test on a bicycleor treadmill  Thermography  ThinPrep pap test  Virtual colonoscopyThe optional health screening benefit can help you reduce the risk of serious illness through early detection.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2016 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Disability 1000-TXHow long could you aord to go without a paycheck?Help protect your paycheck with Colonial Life’s short-term disability insurance.You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness?Monthly Expenses: $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ Total $_________________My Coverage Worksheet (For use with your Colonial Life Benets Counselor)Short-TermDisability InsuranceHow much coverage do I need? On-Job Accident and On-Job Sickness $________ O-Job Accident and O-Job Sickness $________How long will I receive benets? Total Disability: ___________ months Partial Disability: 3 months* *Partial Disability is 50% of the Total Disability AmountWhen will my benets start? After an Accident: ___________ days After a Sickness: ___________ daysHow much will it cost? Your cost will vary based on the level of coverage you select. What additional features are included?l Waiver of Premiuml Worldwide Coverage

Disability 1000-TXHow long could you aord to go without a paycheck?Help protect your paycheck with Colonial Life’s short-term disability insurance.You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness?Monthly Expenses: $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ Total $_________________My Coverage Worksheet (For use with your Colonial Life Benets Counselor)Short-TermDisability InsuranceHow much coverage do I need? On-Job Accident and On-Job Sickness $________ O-Job Accident and O-Job Sickness $________How long will I receive benets? Total Disability: ___________ months Partial Disability: 3 months* *Partial Disability is 50% of the Total Disability AmountWhen will my benets start? After an Accident: ___________ days After a Sickness: ___________ daysHow much will it cost? Your cost will vary based on the level of coverage you select. What additional features are included?l Waiver of Premiuml Worldwide Coverage

Will my disability income payment be reduced if I have other insurance?You’re paid regardless of any other insurance you may have with other insurance companies. Benets are paid directly to you (unless you specify otherwise).When am I considered totally disabled?Totally disabled means you are:l Unable to perform the material and substantial duties of your regular occupation;l Not in fact, working at any occupation for wage or prot; andl Under the regular and appropriate care of a doctor, unless the doctor states that continued treatment in the future would be of no benet to you.What if I want to return to work part-time after I am totally disabled?You may be able to return to work part-time and still receive benets. We call this “Partial Disability.” Partially disabled means:l You are unable to perform the material and substantial duties of your regular occupation for 20 hours or more per week;l You are able to work at your regular occupation or any other occupation for less than 20 hours per week;l Your employer will allow you to work for less than 20 hours per week; andl You are under the regular and appropriate care of a doctor.What if I change employers?If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable to age 70 as long as you continue to pay your premiums when they are due. Here are some What is a pre-existing condition?Pre-existing condition is when you have a sickness or physical condition for which you were treated, received medical advice or had taken medication within 12 months before the eective date of the policy.If you become disabled because of a pre-existing condition, we will not pay for any disability period if it begins during the rst 12 months (6 months if you are age 65 or older on the eective date of the policy) the policy is in force. Can my premium change?You may choose the amount of coverage to meet your needs (subject to your income). You can elect more or less coverage which will change your premium. Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued. What is a covered accident or a covered sickness?A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury.A covered accident or covered sickness:l Occurs after the eective date of the policy;l Is of a type listed on the Policy Schedule;l Occurs while the policy is in force; andl Is not excluded by name or specic description in the policy. How do I le a claim?Visit coloniallife.com or call our Policyholder Service Center at 1.800.325.4368 for additional information.frequently asked questionsabout Colonial Life’s disability insurance:Colonial Life 1200 Colonial Life BoulevardColumbia, South Carolina 29210coloniallife.com5/11©2011 Colonial Life & Accident Insurance Company.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.Colonial Life and Making benets count are registered service marks of Colonial Life & Accident Insurance Company. EXCLUSIONSWe will not pay benets for losses that are caused by or are the result of: ying; giving birth within the rst nine months after the eective date of the policy; hazardous avocations; felonies and illegal occupation; intoxicants and narcotics; having a pre-existing condition as described and limited by the policy; racing; semi-professional or professional sports; suicide or self-inicted injuries; war or armed conict. For cost and complete details, see your Colonial Life benets counselor. Applicable to policy forms DIS1000-TX and DIS 1000-3M-TX. This is not an insurance contract and only the actual policy provisions will control.59212-10Disability 1000-TX

Will my disability income payment be reduced if I have other insurance?You’re paid regardless of any other insurance you may have with other insurance companies. Benets are paid directly to you (unless you specify otherwise).When am I considered totally disabled?Totally disabled means you are:l Unable to perform the material and substantial duties of your regular occupation;l Not in fact, working at any occupation for wage or prot; andl Under the regular and appropriate care of a doctor, unless the doctor states that continued treatment in the future would be of no benet to you.What if I want to return to work part-time after I am totally disabled?You may be able to return to work part-time and still receive benets. We call this “Partial Disability.” Partially disabled means:l You are unable to perform the material and substantial duties of your regular occupation for 20 hours or more per week;l You are able to work at your regular occupation or any other occupation for less than 20 hours per week;l Your employer will allow you to work for less than 20 hours per week; andl You are under the regular and appropriate care of a doctor.What if I change employers?If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable to age 70 as long as you continue to pay your premiums when they are due. Here are some What is a pre-existing condition?Pre-existing condition is when you have a sickness or physical condition for which you were treated, received medical advice or had taken medication within 12 months before the eective date of the policy.If you become disabled because of a pre-existing condition, we will not pay for any disability period if it begins during the rst 12 months (6 months if you are age 65 or older on the eective date of the policy) the policy is in force. Can my premium change?You may choose the amount of coverage to meet your needs (subject to your income). You can elect more or less coverage which will change your premium. Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued. What is a covered accident or a covered sickness?A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury.A covered accident or covered sickness:l Occurs after the eective date of the policy;l Is of a type listed on the Policy Schedule;l Occurs while the policy is in force; andl Is not excluded by name or specic description in the policy. How do I le a claim?Visit coloniallife.com or call our Policyholder Service Center at 1.800.325.4368 for additional information.frequently asked questionsabout Colonial Life’s disability insurance:Colonial Life 1200 Colonial Life BoulevardColumbia, South Carolina 29210coloniallife.com5/11©2011 Colonial Life & Accident Insurance Company.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.Colonial Life and Making benets count are registered service marks of Colonial Life & Accident Insurance Company. EXCLUSIONSWe will not pay benets for losses that are caused by or are the result of: ying; giving birth within the rst nine months after the eective date of the policy; hazardous avocations; felonies and illegal occupation; intoxicants and narcotics; having a pre-existing condition as described and limited by the policy; racing; semi-professional or professional sports; suicide or self-inicted injuries; war or armed conict. For cost and complete details, see your Colonial Life benets counselor. Applicable to policy forms DIS1000-TX and DIS 1000-3M-TX. This is not an insurance contract and only the actual policy provisions will control.59212-10Disability 1000-TX

Term Life InsuranceHelp protect the people who depend on youIf something happened to you, the last thing your family should have to worry about is financial burdens. Funeral expenses, medical bills and taxes could be just the beginning. How would they cover ongoing living expenses, such as a mortgage, utilities and health care?Plan for the future with term life insurance from Colonial Life & Accident Insurance Company.The advantages of term life insurance  Level death benefit.  Lower cost option compared with cash value insurance.  Coverage for specified periods of time, which can be during high-need years.  Benefit for the beneficiary that is typically free from income tax.Benefits and features  Guaranteed premiums do not increase during the term.  Coverage is guaranteed renewable to age 95 as long as premiums are paid when due.  You can convert it to cash value insurance.  Portability allows you to take it with you if you change jobs or retire.  An accelerated death benefit is included.Your cost will vary based on the level of coverage you select. Talk with your Colonial Life benefits counselor for information about what level of coverage would work best for you.TERM LIFE 1000

Term Life InsuranceHelp protect the people who depend on youIf something happened to you, the last thing your family should have to worry about is financial burdens. Funeral expenses, medical bills and taxes could be just the beginning. How would they cover ongoing living expenses, such as a mortgage, utilities and health care?Plan for the future with term life insurance from Colonial Life & Accident Insurance Company.The advantages of term life insurance  Level death benefit.  Lower cost option compared with cash value insurance.  Coverage for specified periods of time, which can be during high-need years.  Benefit for the beneficiary that is typically free from income tax.Benefits and features  Guaranteed premiums do not increase during the term.  Coverage is guaranteed renewable to age 95 as long as premiums are paid when due.  You can convert it to cash value insurance.  Portability allows you to take it with you if you change jobs or retire.  An accelerated death benefit is included.Your cost will vary based on the level of coverage you select. Talk with your Colonial Life benefits counselor for information about what level of coverage would work best for you.TERM LIFE 1000

Benefits worksheetFor use with your Colonial Life benefits counselor£ YOU $ __________________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year term£ SPOUSE $ ______________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year termSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Waiver of premium benefit rider£ Accidental death benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured commits suicide within two years (one year in CO and ND) from the coverage eective date, whether he is sane or insane (not applicable in AZ), we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. In MO, should death occur as a result of suicide, our company is responsible only for the return of premiums paid when application is made with intent to commit suicide.You will receive a policy summary or illustration (whichever is applicable to your state) when your policy is issued if this policy has exclusions, limitations or reductions of benefits. For costs and complete details, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms TERM1000, R-TERM1000-ADB, R-TERM1000-CTR, R-TERM1000-STR, R-TERM1000-WAIVER (and applicable state variations, for example: TERM1000-TX, R-TERM1000-ADB-TX-1, R-TERM1000-CTR-TX, R-TERM1000-STR-TX and R-TERM1000-WAIVER-TX-1). See your Colonial Life benefits counselor for additional information specific for your state. This coverage contains limitations and exclusions that may aect benefits payable. Product may vary by state.Cash value policy conversionYou can convert your policy to a Colonial Life cash value life insurance policy any time through age 75 (unless you have used the accelerated death benefit or waiver of premium benefit rider) with no evidence of insurability. Premiums will be based on your age at the time you convert your policy.Accelerated death benefitIf you are diagnosed with a terminal illness, you can request up to 75% of the policy’s death benefit, not to exceed $150,000. We deduct a fee only if you use the benefit, and your death benefit will then be reduced by the amount you receive. In addition, there may be tax consequences for receiving the accelerated benefit; ask your tax advisor for advice. Please refer to your policy for details.Spouse coverage optionsTwo options are available for spouse coverage at an additional cost:1. Spouse term life policy: Oers guaranteed premiums and level death benefits equivalent to those available to you – whether or not you buy a policy for yourself.2. Spouse term life rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).Dependent coverageYou may add a children’s term life rider to cover all of your eligible dependent children with up to $10,000 in coverage each for one premium. The children’s term life rider may be added to either the primary or spouse policy, not both.Waiver of premium benefit riderThis rider waives all premiums (for the policy and any riders) if you become totally and permanently disabled before the age of 65. To be considered permanent, your total disability must continue with no interruptions for at least six consecutive months. Premiums waived by this rider do not have to be repaid. This rider is available for the spouse policy as well, subject to home oice approval.Accidental death benefit riderThis rider provides an additional benefit to the beneficiary if the insured dies as a result of an accident before age 70. The benefit doubles if the injury resulting in death occurs while insured is a fare-paying passenger on a public conveyance, such as a commercial aircra or taxicab. An additional seatbelt benefit is also payable.©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 4-16 | 64815-10ColonialLife.com

Benefits worksheetFor use with your Colonial Life benefits counselor£ YOU $ __________________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year term£ SPOUSE $ ______________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year termSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Waiver of premium benefit rider£ Accidental death benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured commits suicide within two years (one year in CO and ND) from the coverage eective date, whether he is sane or insane (not applicable in AZ), we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. In MO, should death occur as a result of suicide, our company is responsible only for the return of premiums paid when application is made with intent to commit suicide.You will receive a policy summary or illustration (whichever is applicable to your state) when your policy is issued if this policy has exclusions, limitations or reductions of benefits. For costs and complete details, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms TERM1000, R-TERM1000-ADB, R-TERM1000-CTR, R-TERM1000-STR, R-TERM1000-WAIVER (and applicable state variations, for example: TERM1000-TX, R-TERM1000-ADB-TX-1, R-TERM1000-CTR-TX, R-TERM1000-STR-TX and R-TERM1000-WAIVER-TX-1). See your Colonial Life benefits counselor for additional information specific for your state. This coverage contains limitations and exclusions that may aect benefits payable. Product may vary by state.Cash value policy conversionYou can convert your policy to a Colonial Life cash value life insurance policy any time through age 75 (unless you have used the accelerated death benefit or waiver of premium benefit rider) with no evidence of insurability. Premiums will be based on your age at the time you convert your policy.Accelerated death benefitIf you are diagnosed with a terminal illness, you can request up to 75% of the policy’s death benefit, not to exceed $150,000. We deduct a fee only if you use the benefit, and your death benefit will then be reduced by the amount you receive. In addition, there may be tax consequences for receiving the accelerated benefit; ask your tax advisor for advice. Please refer to your policy for details.Spouse coverage optionsTwo options are available for spouse coverage at an additional cost:1. Spouse term life policy: Oers guaranteed premiums and level death benefits equivalent to those available to you – whether or not you buy a policy for yourself.2. Spouse term life rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).Dependent coverageYou may add a children’s term life rider to cover all of your eligible dependent children with up to $10,000 in coverage each for one premium. The children’s term life rider may be added to either the primary or spouse policy, not both.Waiver of premium benefit riderThis rider waives all premiums (for the policy and any riders) if you become totally and permanently disabled before the age of 65. To be considered permanent, your total disability must continue with no interruptions for at least six consecutive months. Premiums waived by this rider do not have to be repaid. This rider is available for the spouse policy as well, subject to home oice approval.Accidental death benefit riderThis rider provides an additional benefit to the beneficiary if the insured dies as a result of an accident before age 70. The benefit doubles if the injury resulting in death occurs while insured is a fare-paying passenger on a public conveyance, such as a commercial aircra or taxicab. An additional seatbelt benefit is also payable.©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 4-16 | 64815-10ColonialLife.com

Your cost will vary based on the level of coverage you select. Whole Life InsuranceYou can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.Advantages of whole life insurance  Permanent coverage that stays the same throughout the life of the policy  Guaranteed level premiums that do not increase because of changes in health or age  Access to the policy’s cash value through a policy loan for emergencies  Benefit for the beneficiary that is typically tax-freeBenefits and features  Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100  Stand-alone spouse policy available whether or not you buy a policy for yourself  Flexibility to keep the policy if you change jobs or retire  Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness  Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses  Pays cash surrender value at age 100 (when the policy endows)WHOLE LIFE (IWL5000)HealthAairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.Talk with your benefits counselor for information about what level of coverage would work best for you.In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person.$

Your cost will vary based on the level of coverage you select. Whole Life InsuranceYou can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.Advantages of whole life insurance  Permanent coverage that stays the same throughout the life of the policy  Guaranteed level premiums that do not increase because of changes in health or age  Access to the policy’s cash value through a policy loan for emergencies  Benefit for the beneficiary that is typically tax-freeBenefits and features  Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100  Stand-alone spouse policy available whether or not you buy a policy for yourself  Flexibility to keep the policy if you change jobs or retire  Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness  Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses  Pays cash surrender value at age 100 (when the policy endows)WHOLE LIFE (IWL5000)HealthAairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.Talk with your benefits counselor for information about what level of coverage would work best for you.In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person.$

£ YOU $ ___________________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100£ SPOUSE $ _______________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/R-IWL5000-GPO and applicable state variations.Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three dierent points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.Benefits worksheetFor use with your benefits counselorSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Guaranteed purchase option rider£ Waiver of premium benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your benefits counselor.ColonialLife.com6-19 | 101935£ DEPENDENT STUDENT $____________£ Paid-Up at Age 70 £ Paid-Up at Age 100 1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

£ YOU $ ___________________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100£ SPOUSE $ _______________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/R-IWL5000-GPO and applicable state variations.Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three dierent points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.Benefits worksheetFor use with your benefits counselorSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Guaranteed purchase option rider£ Waiver of premium benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your benefits counselor.ColonialLife.com6-19 | 101935£ DEPENDENT STUDENT $____________£ Paid-Up at Age 70 £ Paid-Up at Age 100 1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Getting startedThe easiest way to manage your business with us is through ColonialLife.com. To sign up for the website, click Register at the top right of the home page and follow the instructions. Consider your optionsAt Colonial Life, our goal is to give you an excellent customer experience that is simple, modern and personal. For your convenience, you can choose how you interact with us. For the quickest service, we recommend using our website, which lets you do the following:  Review, print or download a copy of your policy/certificate by clicking on the My Correspondence tab.  Update contact information or add family member profile information for use when filing online claims.  Access service forms to make changes to your policy, such as a beneficiary change.  Submit your claim using our eClaims system.  Check the status of your claim and view claims correspondence.  Access claim forms.Policyholder Service GuideeClaims are quick and easyWith the eClaims feature on ColonialLife.com, you can file most claims online by simply answering a few questions and uploading your supporting documentation. You’re able to spend less time on paperwork, and we’re able to process your claim faster.  From Colonial Life.com, file claims from any device. It’s fast, easy and available 24/7.  Select direct deposit to receive your benefit payment faster.  Easily submit additional documents.Paper claims  If you don’t want to file online, download the form you need by visiting the Claims Center page on ColonialLife.com and clicking on claim and service forms.  You may fax your claim to 1-800-880-9325.  Follow the instructions, tips and videos to complete and submit your claim.ColonialLife.comContact us Online ColonialLife.com Log in and click on Contact UsTelephone 1-800-325-4368Hearing-impaired customers 803-798-4040If you do not have a TDD, call Voiance Telephone Interpretation Services. 844-495-61058-17 | 43233-39Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Getting startedThe easiest way to manage your business with us is through ColonialLife.com. To sign up for the website, click Register at the top right of the home page and follow the instructions. Consider your optionsAt Colonial Life, our goal is to give you an excellent customer experience that is simple, modern and personal. For your convenience, you can choose how you interact with us. For the quickest service, we recommend using our website, which lets you do the following:  Review, print or download a copy of your policy/certificate by clicking on the My Correspondence tab.  Update contact information or add family member profile information for use when filing online claims.  Access service forms to make changes to your policy, such as a beneficiary change.  Submit your claim using our eClaims system.  Check the status of your claim and view claims correspondence.  Access claim forms.Policyholder Service GuideeClaims are quick and easyWith the eClaims feature on ColonialLife.com, you can file most claims online by simply answering a few questions and uploading your supporting documentation. You’re able to spend less time on paperwork, and we’re able to process your claim faster.  From Colonial Life.com, file claims from any device. It’s fast, easy and available 24/7.  Select direct deposit to receive your benefit payment faster.  Easily submit additional documents.Paper claims  If you don’t want to file online, download the form you need by visiting the Claims Center page on ColonialLife.com and clicking on claim and service forms.  You may fax your claim to 1-800-880-9325.  Follow the instructions, tips and videos to complete and submit your claim.ColonialLife.comContact us Online ColonialLife.com Log in and click on Contact UsTelephone 1-800-325-4368Hearing-impaired customers 803-798-4040If you do not have a TDD, call Voiance Telephone Interpretation Services. 844-495-61058-17 | 43233-39Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Deductions per year: 26Individual Accident (IAC4000) for TXApplicable to Policy Forms IAC4000lOn/Off-Job Accident CoverageBENEFIT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYPreferred 0-80 $8.75 $12.90 $15.78 $19.73Individual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$1000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500,$100 Health Screening Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $11.77 $21.81 $14.77 $24.8050-59 $15.50 $28.89 $18.51 $31.8960-64 $19.43 $36.35 $22.43 $39.3565-75 $24.09 $45.18 $27.09 $48.19Individual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$2000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500,$100 Health Screening Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $18.14 $33.85 $23.90 $39.6250-59 $24.23 $45.51 $30.00 $51.2760-64 $31.33 $58.96 $37.11 $64.7365-75 $39.97 $75.32 $45.74 $81.10Cancer Assist for TXApplicable to policy form CanAssistlwith $100 Health Screening BenefitCOVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYLevel 3 17-75 $12.30 $20.49 $12.51 $20.70Level 4 17-75 $16.43 $27.42 $16.71 $27.69CAT5 Resources InsuricaPage 1 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Deductions per year: 26Individual Accident (IAC4000) for TXApplicable to Policy Forms IAC4000lOn/Off-Job Accident CoverageBENEFIT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYPreferred 0-80 $8.75 $12.90 $15.78 $19.73Individual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$1000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500,$100 Health Screening Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $11.77 $21.81 $14.77 $24.8050-59 $15.50 $28.89 $18.51 $31.8960-64 $19.43 $36.35 $22.43 $39.3565-75 $24.09 $45.18 $27.09 $48.19Individual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$2000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500,$100 Health Screening Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $18.14 $33.85 $23.90 $39.6250-59 $24.23 $45.51 $30.00 $51.2760-64 $31.33 $58.96 $37.11 $64.7365-75 $39.97 $75.32 $45.74 $81.10Cancer Assist for TXApplicable to policy form CanAssistlwith $100 Health Screening BenefitCOVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYLevel 3 17-75 $12.30 $20.49 $12.51 $20.70Level 4 17-75 $16.43 $27.42 $16.71 $27.69CAT5 Resources InsuricaPage 1 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Critical Illness 1.0 for TXApplicable to policy form CI-1.0lwith Subsequent Diagnosis Coverage, Health Screening BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $2.10 $3.18 $2.10 $3.1825-29 $2.42 $3.74 $2.42 $3.7430-34 $2.79 $4.34 $2.79 $4.3435-39 $3.90 $6.00 $3.90 $6.0040-44 $4.64 $7.10 $4.64 $7.1045-49 $6.02 $9.23 $6.02 $9.2350-54 $7.68 $11.81 $7.68 $11.8155-59 $9.48 $14.54 $9.48 $14.5460-64 $11.74 $18.04 $11.74 $18.0465-70 $14.24 $21.87 $14.24 $21.87$20,000 17-24 $3.21 $4.84 $3.21 $4.8425-29 $3.85 $5.95 $3.85 $5.9530-34 $4.59 $7.15 $4.59 $7.1535-39 $6.81 $10.47 $6.81 $10.4740-44 $8.28 $12.69 $8.28 $12.6945-49 $11.05 $16.94 $11.05 $16.9450-54 $14.37 $22.10 $14.37 $22.1055-59 $17.97 $27.55 $17.97 $27.5560-64 $22.50 $34.57 $22.50 $34.5765-70 $27.48 $42.23 $27.48 $42.23$30,000 17-24 $4.31 $6.50 $4.31 $6.5025-29 $5.28 $8.17 $5.28 $8.1730-34 $6.39 $9.97 $6.39 $9.9735-39 $9.71 $14.95 $9.71 $14.9540-44 $11.93 $18.27 $11.93 $18.2745-49 $16.08 $24.64 $16.08 $24.6450-54 $21.07 $32.40 $21.07 $32.4055-59 $26.47 $40.57 $26.47 $40.5760-64 $33.25 $51.09 $33.25 $51.0965-70 $40.73 $62.58 $40.73 $62.58CAT5 Resources Insurica(Continued...)Page 2 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Critical Illness 1.0 for TXApplicable to policy form CI-1.0lwith Subsequent Diagnosis Coverage, Health Screening BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $2.10 $3.18 $2.10 $3.1825-29 $2.42 $3.74 $2.42 $3.7430-34 $2.79 $4.34 $2.79 $4.3435-39 $3.90 $6.00 $3.90 $6.0040-44 $4.64 $7.10 $4.64 $7.1045-49 $6.02 $9.23 $6.02 $9.2350-54 $7.68 $11.81 $7.68 $11.8155-59 $9.48 $14.54 $9.48 $14.5460-64 $11.74 $18.04 $11.74 $18.0465-70 $14.24 $21.87 $14.24 $21.87$20,000 17-24 $3.21 $4.84 $3.21 $4.8425-29 $3.85 $5.95 $3.85 $5.9530-34 $4.59 $7.15 $4.59 $7.1535-39 $6.81 $10.47 $6.81 $10.4740-44 $8.28 $12.69 $8.28 $12.6945-49 $11.05 $16.94 $11.05 $16.9450-54 $14.37 $22.10 $14.37 $22.1055-59 $17.97 $27.55 $17.97 $27.5560-64 $22.50 $34.57 $22.50 $34.5765-70 $27.48 $42.23 $27.48 $42.23$30,000 17-24 $4.31 $6.50 $4.31 $6.5025-29 $5.28 $8.17 $5.28 $8.1730-34 $6.39 $9.97 $6.39 $9.9735-39 $9.71 $14.95 $9.71 $14.9540-44 $11.93 $18.27 $11.93 $18.2745-49 $16.08 $24.64 $16.08 $24.6450-54 $21.07 $32.40 $21.07 $32.4055-59 $26.47 $40.57 $26.47 $40.5760-64 $33.25 $51.09 $33.25 $51.0965-70 $40.73 $62.58 $40.73 $62.58CAT5 Resources Insurica(Continued...)Page 2 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Critical Illness 1.0 for TXApplicable to policy form CI-1.0lwith Subsequent Diagnosis Coverage, Health Screening BenefitTobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $2.56 $3.92 $2.56 $3.9225-29 $3.16 $4.84 $3.16 $4.8430-34 $3.94 $6.09 $3.94 $6.0935-39 $5.47 $8.40 $5.47 $8.4040-44 $7.08 $10.89 $7.08 $10.8945-49 $9.11 $13.98 $9.11 $13.9850-54 $11.47 $17.58 $11.47 $17.5855-59 $14.56 $22.38 $14.56 $22.3860-64 $17.51 $26.90 $17.51 $26.9065-70 $21.44 $32.95 $21.44 $32.95$20,000 17-24 $4.13 $6.32 $4.13 $6.3225-29 $5.33 $8.17 $5.33 $8.1730-34 $6.90 $10.66 $6.90 $10.6635-39 $9.94 $15.27 $9.94 $15.2740-44 $13.17 $20.26 $13.17 $20.2645-49 $17.24 $26.44 $17.24 $26.4450-54 $21.94 $33.64 $21.94 $33.6455-59 $28.13 $43.24 $28.13 $43.2460-64 $34.04 $52.29 $34.04 $52.2965-70 $41.88 $64.38 $41.88 $64.38$30,000 17-24 $5.70 $8.72 $5.70 $8.7225-29 $7.50 $11.49 $7.50 $11.4930-34 $9.85 $15.23 $9.85 $15.2335-39 $14.42 $22.15 $14.42 $22.1540-44 $19.27 $29.63 $19.27 $29.6345-49 $25.36 $38.90 $25.36 $38.9050-54 $32.42 $49.70 $32.42 $49.7055-59 $41.70 $64.10 $41.70 $64.1060-64 $50.56 $77.67 $50.56 $77.6765-70 $62.33 $95.81 $62.33 $95.81Disability 1000 for TX AAA Risk ClassApplicable to policy form DIS1000lOn/Off-Job Accident and Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $12.92 $19.38 $25.85 $38.77 N/A50-69 $15.69 $23.54 $31.38 $47.08 N/ACAT5 Resources Insurica(Continued...)Page 3 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Critical Illness 1.0 for TXApplicable to policy form CI-1.0lwith Subsequent Diagnosis Coverage, Health Screening BenefitTobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $2.56 $3.92 $2.56 $3.9225-29 $3.16 $4.84 $3.16 $4.8430-34 $3.94 $6.09 $3.94 $6.0935-39 $5.47 $8.40 $5.47 $8.4040-44 $7.08 $10.89 $7.08 $10.8945-49 $9.11 $13.98 $9.11 $13.9850-54 $11.47 $17.58 $11.47 $17.5855-59 $14.56 $22.38 $14.56 $22.3860-64 $17.51 $26.90 $17.51 $26.9065-70 $21.44 $32.95 $21.44 $32.95$20,000 17-24 $4.13 $6.32 $4.13 $6.3225-29 $5.33 $8.17 $5.33 $8.1730-34 $6.90 $10.66 $6.90 $10.6635-39 $9.94 $15.27 $9.94 $15.2740-44 $13.17 $20.26 $13.17 $20.2645-49 $17.24 $26.44 $17.24 $26.4450-54 $21.94 $33.64 $21.94 $33.6455-59 $28.13 $43.24 $28.13 $43.2460-64 $34.04 $52.29 $34.04 $52.2965-70 $41.88 $64.38 $41.88 $64.38$30,000 17-24 $5.70 $8.72 $5.70 $8.7225-29 $7.50 $11.49 $7.50 $11.4930-34 $9.85 $15.23 $9.85 $15.2335-39 $14.42 $22.15 $14.42 $22.1540-44 $19.27 $29.63 $19.27 $29.6345-49 $25.36 $38.90 $25.36 $38.9050-54 $32.42 $49.70 $32.42 $49.7055-59 $41.70 $64.10 $41.70 $64.1060-64 $50.56 $77.67 $50.56 $77.6765-70 $62.33 $95.81 $62.33 $95.81Disability 1000 for TX AAA Risk ClassApplicable to policy form DIS1000lOn/Off-Job Accident and Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $12.92 $19.38 $25.85 $38.77 N/A50-69 $15.69 $23.54 $31.38 $47.08 N/ACAT5 Resources Insurica(Continued...)Page 3 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

6 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $16.38 $24.58 $32.77 $49.15 N/A50-69 $21.92 $32.88 $43.85 $65.77 N/A12 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $22.62 $33.92 $45.23 $67.85 N/A50-69 $28.15 $42.23 $56.31 $84.46 N/A24 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $31.38 $47.08 $62.77 $94.15 N/A50-69 $42.92 $64.38 $85.85 $128.77 N/ATerm Life (ITL5000) for TXApplicable to policy form ITL5000l10-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $3.07 $4.29 $4.7235 $3.50 $5.15 $5.2045 $4.24 $6.62 $8.6055 $7.47 $13.09 $16.7965 $16.10 $17.11 $40.0075 $42.19 $50.36 $123.11Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $4.80 $7.76 $8.2035 $5.32 $8.80 $9.1045 $6.91 $11.98 $18.8955 $14.87 $27.89 $45.2765 $30.31 $34.96 $84.6275 $63.37 $75.03 $184.80CAT5 Resources Insurica(Continued...)Page 4 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

6 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $16.38 $24.58 $32.77 $49.15 N/A50-69 $21.92 $32.88 $43.85 $65.77 N/A12 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $22.62 $33.92 $45.23 $67.85 N/A50-69 $28.15 $42.23 $56.31 $84.46 N/A24 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $31.38 $47.08 $62.77 $94.15 N/A50-69 $42.92 $64.38 $85.85 $128.77 N/ATerm Life (ITL5000) for TXApplicable to policy form ITL5000l10-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $3.07 $4.29 $4.7235 $3.50 $5.15 $5.2045 $4.24 $6.62 $8.6055 $7.47 $13.09 $16.7965 $16.10 $17.11 $40.0075 $42.19 $50.36 $123.11Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $4.80 $7.76 $8.2035 $5.32 $8.80 $9.1045 $6.91 $11.98 $18.8955 $14.87 $27.89 $45.2765 $30.31 $34.96 $84.6275 $63.37 $75.03 $184.80CAT5 Resources Insurica(Continued...)Page 4 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $15,000 $20,000 $25,00025 $4.25 $6.37 $8.49 $10.6235 $5.78 $8.66 $11.55 $14.4445 $9.18 $13.76 $18.36 $22.9455 $14.98 $22.46 $29.95 $37.4465 $26.65 $39.98 $53.31 $66.63Tobacco RatesISSUE AGE $10,000 $15,000 $20,000 $25,00025 $7.42 $11.12 $14.83 $18.5435 $9.02 $13.53 $18.05 $22.5645 $13.44 $20.15 $26.87 $33.5955 $22.64 $33.97 $45.29 $56.6165 $38.73 $58.09 $77.46 $96.82Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2024 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Houston Hamilton |CAT5 Resources Insurica(Continued...)Page 5 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $15,000 $20,000 $25,00025 $4.25 $6.37 $8.49 $10.6235 $5.78 $8.66 $11.55 $14.4445 $9.18 $13.76 $18.36 $22.9455 $14.98 $22.46 $29.95 $37.4465 $26.65 $39.98 $53.31 $66.63Tobacco RatesISSUE AGE $10,000 $15,000 $20,000 $25,00025 $7.42 $11.12 $14.83 $18.5435 $9.02 $13.53 $18.05 $22.5645 $13.44 $20.15 $26.87 $33.5955 $22.64 $33.97 $45.29 $56.6165 $38.73 $58.09 $77.46 $96.82Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2024 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Houston Hamilton |CAT5 Resources Insurica(Continued...)Page 5 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

GLOSSARYAllowed AmountMaximum amount on which payment is based for covered healthcare services. This may be called “eligible expense,” “paymentallowance” or “negotiated rate.” If your provider charges morethan the allowed amount, you may have to pay the difference.(See Balance Billing.)Balance BillingWhen a provider bills you for the difference between theprovider’s charge and the allowed amount. For example, if theprovider’s charge is $100 and the allowed amount is $70, theprovider may bill you for the remaining $30. An in-networkprovider may NOT balance bill you for covered services.CoinsuranceYour share of the costs of a covered health care service,calculated as a percent (for example 20%) of the allowed amountfor the service. You pay coinsurance plus any deductibles youowe. For example, if the health insurance or plan’s allowedamount for an office visit is $100 and you’ve met your deductible,your coinsurance payment of 20% would be $20. The healthinsurance or plan pays the rest of the allowed amount.CopaymentA fixed amount (for example, $25) you pay for a covered healthcare service, usually when you receive the service. The amountcan vary by the type of covered health care service.DeductibleThe amount you owe for health care services your healthinsurance or plan covers before your health insurance or planbegins to pay. For example, if your deductible is $1,000, yourplan won’t pay anything until you’ve met your $1,000 deductiblefor covered health care services subject to the deductible. Thedeductible may not apply to all services.Durable Medical EquipmentEquipment and supplies ordered by a health care provider foreveryday or extended use. Coverage for DME may include: oxygenequipment, wheelchairs, crutches or blood testing strips fordiabetics.Emergency Medical ConditionAn illness, injury, symptom or condition so serious that areasonable person would seek care right away to avoid severeharm.Emergency Medical TransportationAmbulance services for an emergency medical condition.Emergency Room CareAn evaluation of an emergency medical condition and thetreatment to prevent the condition from getting worse in anemergency room.Evidence of Insurability (EOI)(Also known as “Proof of Good Health”) an application process inwhich you provide information on the condition of your health oryour dependent's health in order to be considered for certaintypes of insurance coverage.Excluded ServicesHealth care services that your health insurance or plan doesn’tpay for or cover.Health InsuranceA contract that requires your health insurer to pay some or all ofyour health care costs in exchange for a premium.HospitalizationCare in a hospital that requires admission as an inpatient andusually requires an overnight stay. An overnight stay forobservation could be outpatient care.Hospital Outpatient CareCare in a hospital that usually doesn’t require an overnight stay.In-Network CoinsuranceThe percent (for example, 20%) you pay of the allowed amount forcovered health care services to providers who contract with yourhealth insurance or plan. In-network coinsurance usually costsyou less than out-of-network coinsurance.In-Network CopaymentA fixed amount (for example, $25) you pay for covered services toproviders who contract with your health insurance or plan. In-network copayments usually are less than out-of-networkcopayments.In-Network ProviderA provider who has a contract with your health insurer or plan toprovide services to you at a discount. Check your policy to see ifyou can see all preferred providers or if your health insurance orplan has a “tiered” network and you must pay extra to see someproviders. Your health insurance or plan may have preferredproviders who are also “participating” providers. Participatingproviders also contract with your health insurer or plan, but thediscount may not be as great, and you may have to pay more.Medically NecessaryHealth care services or supplies needed to prevent, diagnose ortreat an illness, injury, condition, disease or its symptoms andthat meet accepted standards of medicine.NetworkThe facilities, providers and suppliers your health insurer or planhas contracted with to provide health care services.Out-of-Network CoinsuranceThe percent (for example, 40%) you pay of the allowed amount forcovered health care services to providers who do not contractwith your health insurance or plan. Out-of-network coinsuranceusually costs you more than in-network coinsurance.Out-of-Network DeductibleSee Balance Billing.

GLOSSARYAllowed AmountMaximum amount on which payment is based for covered healthcare services. This may be called “eligible expense,” “paymentallowance” or “negotiated rate.” If your provider charges morethan the allowed amount, you may have to pay the difference.(See Balance Billing.)Balance BillingWhen a provider bills you for the difference between theprovider’s charge and the allowed amount. For example, if theprovider’s charge is $100 and the allowed amount is $70, theprovider may bill you for the remaining $30. An in-networkprovider may NOT balance bill you for covered services.CoinsuranceYour share of the costs of a covered health care service,calculated as a percent (for example 20%) of the allowed amountfor the service. You pay coinsurance plus any deductibles youowe. For example, if the health insurance or plan’s allowedamount for an office visit is $100 and you’ve met your deductible,your coinsurance payment of 20% would be $20. The healthinsurance or plan pays the rest of the allowed amount.CopaymentA fixed amount (for example, $25) you pay for a covered healthcare service, usually when you receive the service. The amountcan vary by the type of covered health care service.DeductibleThe amount you owe for health care services your healthinsurance or plan covers before your health insurance or planbegins to pay. For example, if your deductible is $1,000, yourplan won’t pay anything until you’ve met your $1,000 deductiblefor covered health care services subject to the deductible. Thedeductible may not apply to all services.Durable Medical EquipmentEquipment and supplies ordered by a health care provider foreveryday or extended use. Coverage for DME may include: oxygenequipment, wheelchairs, crutches or blood testing strips fordiabetics.Emergency Medical ConditionAn illness, injury, symptom or condition so serious that areasonable person would seek care right away to avoid severeharm.Emergency Medical TransportationAmbulance services for an emergency medical condition.Emergency Room CareAn evaluation of an emergency medical condition and thetreatment to prevent the condition from getting worse in anemergency room.Evidence of Insurability (EOI)(Also known as “Proof of Good Health”) an application process inwhich you provide information on the condition of your health oryour dependent's health in order to be considered for certaintypes of insurance coverage.Excluded ServicesHealth care services that your health insurance or plan doesn’tpay for or cover.Health InsuranceA contract that requires your health insurer to pay some or all ofyour health care costs in exchange for a premium.HospitalizationCare in a hospital that requires admission as an inpatient andusually requires an overnight stay. An overnight stay forobservation could be outpatient care.Hospital Outpatient CareCare in a hospital that usually doesn’t require an overnight stay.In-Network CoinsuranceThe percent (for example, 20%) you pay of the allowed amount forcovered health care services to providers who contract with yourhealth insurance or plan. In-network coinsurance usually costsyou less than out-of-network coinsurance.In-Network CopaymentA fixed amount (for example, $25) you pay for covered services toproviders who contract with your health insurance or plan. In-network copayments usually are less than out-of-networkcopayments.In-Network ProviderA provider who has a contract with your health insurer or plan toprovide services to you at a discount. Check your policy to see ifyou can see all preferred providers or if your health insurance orplan has a “tiered” network and you must pay extra to see someproviders. Your health insurance or plan may have preferredproviders who are also “participating” providers. Participatingproviders also contract with your health insurer or plan, but thediscount may not be as great, and you may have to pay more.Medically NecessaryHealth care services or supplies needed to prevent, diagnose ortreat an illness, injury, condition, disease or its symptoms andthat meet accepted standards of medicine.NetworkThe facilities, providers and suppliers your health insurer or planhas contracted with to provide health care services.Out-of-Network CoinsuranceThe percent (for example, 40%) you pay of the allowed amount forcovered health care services to providers who do not contractwith your health insurance or plan. Out-of-network coinsuranceusually costs you more than in-network coinsurance.Out-of-Network DeductibleSee Balance Billing.

GLOSSARYOut-of-Network CopaymentA fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your healthinsurance or plan. Out-of-network copayments are usually higherthan in-network copayments.Out-of-Network ProviderA provider who doesn’t have a contract with your health insurer orplan 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 allproviders who have contracted with your health insurance orplan, or if your health insurance or plan has a “tiered” networkand you must pay extra to see some providers.Out-of-Pocket LimitThe most you pay during a policy period (usually a year) beforeyour health insurance or plan begins to pay 100% of the allowedamount. This limit never includes your premium balance-billedcharges or health care your health insurance or plan doesn’tcover. Some health insurance or plans don’t count all of yourcopayments, deductibles, or coinsurance payments, out-or-network payments or other expenses toward this limit.Physician ServicesHealth care services a licensed medical physician (M.D. –Medical Doctor or D.O. – Doctor of Osteopathic Medicine)provides or coordinates.PreauthorizationA decision by your health insurer or plan that a health careservice, treatment plan, prescription drug or durable medicalequipment is medically necessary. Sometimes called priorauthorization, prior approval, or precertification. Your healthinsurance or plan may require preauthorization for certainservices before you receive them, except in an emergency.Preauthorization isn’t a promise your health insurance or plan willcover the cost.Predetermination of BenefitsA review by your insurer's medical staff to decide if they agreethat the treatment is right for your healthneeds. Predeterminations are done before you get care, so thatyou will know early if it is covered by your health insurance plan.PremiumThe amount that must be paid for your health insurance or plan.You and/or your employer usually pay it monthly, quarterly, oryearly.Prescription Drug CoverageHealth insurance or plan that helps pay for prescription drugs andmedications that by law require a prescription.Primary Care PhysicianA physician (M.D. – Medical Doctor or D.O. – Doctor ofOsteopathic Medicine) who directly provides or coordinates arange of health care services for a patient.Primary Care ProviderA physician (M.D. – Medical Doctor of D.O. – Doctor ofOsteopathic Medicine), nurse practitioner, clinical nursespecialist or physician assistant, as allowed under state law, whoprovides, coordinates or helps a patient access a range of healthcare services.ProviderA physician (M.D. – Medical Doctor of D.O. – Doctor ofOsteopathic Medicine), health care professional or health carefacility licensed, certified or accredited as required by state law.Reconstructive SurgerySurgery and follow-up treatment needed to correct or improve apart of the body because of birth defects, accidents, injuries ormedical conditions.Rehabilitation ServicesHealth care services that help a person keep, get back or improveskills and functioning for daily living that have been lost orimpaired because a person was sick, hurt or disabled. Theseservices may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in avariety of inpatient and/or outpatient settings.Skilled Nursing CareServices from licensed nurses in your own home or in a nursinghome. Skilled care services are from technicians and therapistsin your own home or in a nursing home.SpecialistA physician specialist focuses on a specific area of medicine or agroup of patients to diagnose, manage, prevent or treat certaintypes of symptoms and conditions. A non-physician specialist is aprovider 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 areabased on what providers in the area usually charge for the sameor similar medical service. The UCR amount sometimes is used todetermine the allowed amount.Urgent CareCare for an illness, injury or condition serious enough that areasonable person would seek care right away, but not so severeas to require emergency room care.

GLOSSARYOut-of-Network CopaymentA fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your healthinsurance or plan. Out-of-network copayments are usually higherthan in-network copayments.Out-of-Network ProviderA provider who doesn’t have a contract with your health insurer orplan 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 allproviders who have contracted with your health insurance orplan, or if your health insurance or plan has a “tiered” networkand you must pay extra to see some providers.Out-of-Pocket LimitThe most you pay during a policy period (usually a year) beforeyour health insurance or plan begins to pay 100% of the allowedamount. This limit never includes your premium balance-billedcharges or health care your health insurance or plan doesn’tcover. Some health insurance or plans don’t count all of yourcopayments, deductibles, or coinsurance payments, out-or-network payments or other expenses toward this limit.Physician ServicesHealth care services a licensed medical physician (M.D. –Medical Doctor or D.O. – Doctor of Osteopathic Medicine)provides or coordinates.PreauthorizationA decision by your health insurer or plan that a health careservice, treatment plan, prescription drug or durable medicalequipment is medically necessary. Sometimes called priorauthorization, prior approval, or precertification. Your healthinsurance or plan may require preauthorization for certainservices before you receive them, except in an emergency.Preauthorization isn’t a promise your health insurance or plan willcover the cost.Predetermination of BenefitsA review by your insurer's medical staff to decide if they agreethat the treatment is right for your healthneeds. Predeterminations are done before you get care, so thatyou will know early if it is covered by your health insurance plan.PremiumThe amount that must be paid for your health insurance or plan.You and/or your employer usually pay it monthly, quarterly, oryearly.Prescription Drug CoverageHealth insurance or plan that helps pay for prescription drugs andmedications that by law require a prescription.Primary Care PhysicianA physician (M.D. – Medical Doctor or D.O. – Doctor ofOsteopathic Medicine) who directly provides or coordinates arange of health care services for a patient.Primary Care ProviderA physician (M.D. – Medical Doctor of D.O. – Doctor ofOsteopathic Medicine), nurse practitioner, clinical nursespecialist or physician assistant, as allowed under state law, whoprovides, coordinates or helps a patient access a range of healthcare services.ProviderA physician (M.D. – Medical Doctor of D.O. – Doctor ofOsteopathic Medicine), health care professional or health carefacility licensed, certified or accredited as required by state law.Reconstructive SurgerySurgery and follow-up treatment needed to correct or improve apart of the body because of birth defects, accidents, injuries ormedical conditions.Rehabilitation ServicesHealth care services that help a person keep, get back or improveskills and functioning for daily living that have been lost orimpaired because a person was sick, hurt or disabled. Theseservices may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in avariety of inpatient and/or outpatient settings.Skilled Nursing CareServices from licensed nurses in your own home or in a nursinghome. Skilled care services are from technicians and therapistsin your own home or in a nursing home.SpecialistA physician specialist focuses on a specific area of medicine or agroup of patients to diagnose, manage, prevent or treat certaintypes of symptoms and conditions. A non-physician specialist is aprovider 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 areabased on what providers in the area usually charge for the sameor similar medical service. The UCR amount sometimes is used todetermine the allowed amount.Urgent CareCare for an illness, injury or condition serious enough that areasonable person would seek care right away, but not so severeas to require emergency room care.

IMPORTANT NOTICES (TABLE OF CONTENTS)Important NoticesThe Affordable Care Act (PPACA) and the Employee Retirement Income Security Act of 1974 (ERISA)requires SpectrumVoIP to provide a number of informational notices to ensure that individuals haveaccess to sufficient information to protect their rights and benefits. The following notices areincluded in this benefit guide: Notice Regarding Availability of Health Insurance Exchanges Women's Health and Cancer Rights Act (WHCRA) Notices Notice Regarding Newborns' and Mothers' Health Protection Act (NMHPA) Notice of HIPAA Privacy Practices Notice of HIPAA Special Enrollment Rights Medical Loss Ratio (MLR) Rule Notice Notice of Patient ProtectionsWhereas, these informational notices are also provided during open enrollment as separatedocuments. See Rene Garza for questions on where to find the following items. Summary of Benefits and Coverage (SBC) and Uniform Glossary Premium Assistance Under Medicaid and Children's Health Insurance Program (CHIP) Medicare Part D Creditable & Non-Creditable Coverage Notice

IMPORTANT NOTICES (TABLE OF CONTENTS)Important NoticesThe Affordable Care Act (PPACA) and the Employee Retirement Income Security Act of 1974 (ERISA)requires SpectrumVoIP to provide a number of informational notices to ensure that individuals haveaccess to sufficient information to protect their rights and benefits. The following notices areincluded in this benefit guide: Notice Regarding Availability of Health Insurance Exchanges Women's Health and Cancer Rights Act (WHCRA) Notices Notice Regarding Newborns' and Mothers' Health Protection Act (NMHPA) Notice of HIPAA Privacy Practices Notice of HIPAA Special Enrollment Rights Medical Loss Ratio (MLR) Rule Notice Notice of Patient ProtectionsWhereas, these informational notices are also provided during open enrollment as separatedocuments. See Rene Garza for questions on where to find the following items. Summary of Benefits and Coverage (SBC) and Uniform Glossary Premium Assistance Under Medicaid and Children's Health Insurance Program (CHIP) Medicare Part D Creditable & Non-Creditable Coverage Notice

IMPORTANT NOTICESNew Health Insurance Marketplace CoverageOptions and Your Health CoverageGeneral InformationNow that key parts of the health care law have taken effect, there is a new way to buy health insurance: The HealthInsurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basicinformation 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. TheMarketplace offers “one-stop shopping” to find and compare private health insurance options. You may also be eligiblefor a new kind of tax credit that lowers your monthly premium right away. For 2020, open enrollment for health insurancecoverage through theMarketplace begins November 1st for coverage starting January 1st .Can I Save Money on my Health Insurance Premiums in the Marketplace?You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, oroffers coverage that doesn’t meet certain standards. The savings on your premium that you’re eligible for depends onyour 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 for atax credit through the Marketplace and may wish to enroll in your employer’s health plan. However, you may be eligible fora tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offercoverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employerthat would cover you (and not any other members of your family) is more than 9.86% of your household income for 2019(9.78% for 2020), or if the coverage your employer provides does not meet the “minimum value” standard set by theAffordable Care Act, you may be eligible for a tax credit.[1]If you work full-time and are eligible for coverage under your employer’s health plan, the plan satisfies the minimum valuestandard, and the cost is intended to be affordable based on employee wages.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 often excluded from income for Federal andState 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 orcontact your Human Resource department.The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through theMarketplace and its costs. Please visitHealthcare.gov for more information, including an online application for healthinsurance coverage and contact information for a Health Insurance Marketplace in your area.Or if you would like a quote and benefit information for the Exchange visit the following web link:www.gohealth.com/benefitadvisorsnetwork when accessing the link, use the referral code BANARD. There is also anumber on the website in which an individual representative can personally assist you.[1] A health plan provides “minimum value” if the plan’s share of the total allowed benefit costs covered by the plan is atleast 60% of such costsForm ApprovedOMB No. 1210-0149(expires 5-31-2020)

IMPORTANT NOTICESNew Health Insurance Marketplace CoverageOptions and Your Health CoverageGeneral InformationNow that key parts of the health care law have taken effect, there is a new way to buy health insurance: The HealthInsurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basicinformation 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. TheMarketplace offers “one-stop shopping” to find and compare private health insurance options. You may also be eligiblefor a new kind of tax credit that lowers your monthly premium right away. For 2020, open enrollment for health insurancecoverage through theMarketplace begins November 1st for coverage starting January 1st .Can I Save Money on my Health Insurance Premiums in the Marketplace?You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, oroffers coverage that doesn’t meet certain standards. The savings on your premium that you’re eligible for depends onyour 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 for atax credit through the Marketplace and may wish to enroll in your employer’s health plan. However, you may be eligible fora tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offercoverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employerthat would cover you (and not any other members of your family) is more than 9.86% of your household income for 2019(9.78% for 2020), or if the coverage your employer provides does not meet the “minimum value” standard set by theAffordable Care Act, you may be eligible for a tax credit.[1]If you work full-time and are eligible for coverage under your employer’s health plan, the plan satisfies the minimum valuestandard, and the cost is intended to be affordable based on employee wages.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 often excluded from income for Federal andState 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 orcontact your Human Resource department.The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through theMarketplace and its costs. Please visitHealthcare.gov for more information, including an online application for healthinsurance coverage and contact information for a Health Insurance Marketplace in your area.Or if you would like a quote and benefit information for the Exchange visit the following web link:www.gohealth.com/benefitadvisorsnetwork when accessing the link, use the referral code BANARD. There is also anumber on the website in which an individual representative can personally assist you.[1] A health plan provides “minimum value” if the plan’s share of the total allowed benefit costs covered by the plan is atleast 60% of such costsForm ApprovedOMB No. 1210-0149(expires 5-31-2020)

IMPORTANT NOTICESWomen's Health and Cancer Rights Act (WHCRA)NoticeIf you have had or are going to have a mastectomy, youmay be entitled to certain benefits under the Women'sHealth and Cancer Rights Act of 1998 (WHCRA). Forindividuals receiving mastectomy related benefits,coverage will be provided in a manner determined inconsultation with the attending physician and the patient,for: All stages of reconstruction of the breast on which themastectomy was performed; Surgery and reconstruction of the other breast toproduce a symmetrical appearance; Prostheses; and Treatment of physical complication of themastectomy, including lymph edema.These benefits will be provided subject to the samedeductibles and coinsurance applicable to other medicaland surgical benefits provided under this plan. Therefore,the deductibles and coinsurance according to your planapply. If you would like more information on WHCRAbenefits, call BlueCross BlueShield of TX at 800-521-2227.Annual Notice: Do you know that your plan, as required bythe Women’s Health and Cancer Rights Act of 1998,provides benefits for mastectomy-related servicesincluding all stages of reconstruction and surgery toachieve symmetry between the breasts, prostheses, andcomplications resulting from a mastectomy, includinglymphedema? Call Rene Garza at 972-312-0388 for moreinformation.Newborns' and Mother's Health Protection Act(NMHPA)Group health plans and health insurance issuers generallymay not, under Federal law, restrict benefits for anyhospital length of stay in connection with childbirth for themother or newborn child to less than 48 hours following avaginal delivery, or less than 96 hours following a cesareansection. However, Federal law generally does not prohibitthe mother's or newborn's attending provider, afterconsulting with the mother, from discharging the mother orher newborn earlier than 48 hours (or 96 hours asapplicable). In any case, plans and issuers may not, underFederal law, require that a provider obtain authorizationfrom the plan or the insurance issuer for prescribing alength of stay not in excess of 48 hours (or 96 hours). Foradditional information regarding this coverage, refer to theSummary Plan Description (SPD).Medical Loss Ratio (MLR) Rule NoticeThe Affordable Care Act requires health insurers in theindividual and small group markets to spend at least 80percent of the premiums they receive on health careservices and activities to improve health care quality (in thelarge group market, this amount is 85 percent). This isreferred to as the Medical Loss Ratio (MLR) rule or the80/20 rule. If a health insurer does not spend at least 80percent of the premiums it receives on health care servicesand activities to improve health care quality, the insurermust rebate the difference.

IMPORTANT NOTICESWomen's Health and Cancer Rights Act (WHCRA)NoticeIf you have had or are going to have a mastectomy, youmay be entitled to certain benefits under the Women'sHealth and Cancer Rights Act of 1998 (WHCRA). Forindividuals receiving mastectomy related benefits,coverage will be provided in a manner determined inconsultation with the attending physician and the patient,for: All stages of reconstruction of the breast on which themastectomy was performed; Surgery and reconstruction of the other breast toproduce a symmetrical appearance; Prostheses; and Treatment of physical complication of themastectomy, including lymph edema.These benefits will be provided subject to the samedeductibles and coinsurance applicable to other medicaland surgical benefits provided under this plan. Therefore,the deductibles and coinsurance according to your planapply. If you would like more information on WHCRAbenefits, call BlueCross BlueShield of TX at 800-521-2227.Annual Notice: Do you know that your plan, as required bythe Women’s Health and Cancer Rights Act of 1998,provides benefits for mastectomy-related servicesincluding all stages of reconstruction and surgery toachieve symmetry between the breasts, prostheses, andcomplications resulting from a mastectomy, includinglymphedema? Call Rene Garza at 972-312-0388 for moreinformation.Newborns' and Mother's Health Protection Act(NMHPA)Group health plans and health insurance issuers generallymay not, under Federal law, restrict benefits for anyhospital length of stay in connection with childbirth for themother or newborn child to less than 48 hours following avaginal delivery, or less than 96 hours following a cesareansection. However, Federal law generally does not prohibitthe mother's or newborn's attending provider, afterconsulting with the mother, from discharging the mother orher newborn earlier than 48 hours (or 96 hours asapplicable). In any case, plans and issuers may not, underFederal law, require that a provider obtain authorizationfrom the plan or the insurance issuer for prescribing alength of stay not in excess of 48 hours (or 96 hours). Foradditional information regarding this coverage, refer to theSummary Plan Description (SPD).Medical Loss Ratio (MLR) Rule NoticeThe Affordable Care Act requires health insurers in theindividual and small group markets to spend at least 80percent of the premiums they receive on health careservices and activities to improve health care quality (in thelarge group market, this amount is 85 percent). This isreferred to as the Medical Loss Ratio (MLR) rule or the80/20 rule. If a health insurer does not spend at least 80percent of the premiums it receives on health care servicesand activities to improve health care quality, the insurermust rebate the difference.

IMPORTANT NOTICESNotice of HIPAA Privacy PracticesThis notice is intended to inform you of the privacypractices followed by the SpectrumVoIP Health Plan andthe Plan’s legal obligations regarding your protected healthinformation under the Health Insurance Portability andAccountability Act of 1996 (HIPAA). The notice alsoexplains the privacy rights you and your family membershave as participants of the Plan. It is effective on January1, 2020. The Plan often needs access to your protectedhealth information in order to provide payment for healthservices and perform plan administrative functions. Wewant to assure the plan participants covered under thePlan that we comply with federal privacy laws and respectyour right to privacy. SpectrumVoIP requires all members ofour workforce and third parties that are provided access toprotected health information to comply with the privacypractices outlined below.Protected Health InformationYour protected health information is protected by theHIPAA Privacy Rule. Generally, protected health informationis information that identifies an individual created orreceived by a health care provider, health plan or anemployer on behalf of a group health plan that relates tophysical or mental health conditions, provision of healthcare, or payment for health care, whether past, present orfuture.How We May Use Your Protected Health Information. Underthe HIPAA Privacy Rule, we may use or disclose yourprotected health information for certain purposes withoutyour permission. This section describes the ways we canuse and disclose your protected health information.Payment. We use or disclose your protected healthinformation without your written authorization in order todetermine eligibility for benefits, seek reimbursement froma third party, or coordinate benefits with another healthplan under which you are covered. For example, a healthcare provider that provided treatment to you will provide uswith your health information. We use that information inorder to determine whether those services are eligible forpayment under our group health plan.Health Care Operations. We use and disclose yourprotected health information in order to perform planadministration functions such as quality assuranceactivities, resolution of internal grievances, and evaluatingplan performance. For example, we review claimsexperience in order to understand participant utilizationand to make plan design changes that are intended tocontrol health care costs.Treatment. Although the law allows use and disclosure ofyour protected health information for purposes oftreatment, as a health plan we generally do not need todisclose your information for treatment purposes. Yourphysician or health care provider is required to provide youwith an explanation of how they use and share your healthinformation for purposes of treatment, payment, andhealth care operations.As permitted or required by law. We may also use ordisclose your protected health information without yourwritten authorization for other reasons as permitted by law.We are permitted by law to share information, subject tocertain requirements, in order to communicate informationon health-related benefits or services that may be ofinterest to you, respond to a court order, or provideinformation to further public health activities (e.g.,preventing the spread of disease) without your writtenauthorization.We are also permitted to share protected healthinformation during a corporate restructuring such as amerger, sale, or acquisition. We will also disclose healthinformation about you when required by law, for example,in order to prevent serious harm to you or others.Pursuant to Your Authorization. When required by law, wewill ask for your written authorization before using ordisclosing your protected health information. If you chooseto sign an authorization to disclose information, you canlater revoke that authorization to prevent any future usesor disclosures.To Business Associates. We may enter into contracts withentities known as Business Associates that provideservices to or perform functions on behalf of the Plan. Wemay disclose protected health information to BusinessAssociates once they have agreed in writing to safeguardthe protected health information. For example, we maydisclose your protected health information to a BusinessAssociate to administer claims. Business Associates arealso required by law to protect protected healthinformation.To the Plan Sponsor. We may disclose protected healthinformation to certain employees of SpectrumVoIP for thepurpose of administering the Plan. These employees willuse or disclose the protected health information only asnecessary to perform plan administration functions or asotherwise required by HIPAA, unless you have authorizedadditional disclosures. Your protected health informationcannot be used for employment purposes without yourspecific authorization.

IMPORTANT NOTICESNotice of HIPAA Privacy PracticesThis notice is intended to inform you of the privacypractices followed by the SpectrumVoIP Health Plan andthe Plan’s legal obligations regarding your protected healthinformation under the Health Insurance Portability andAccountability Act of 1996 (HIPAA). The notice alsoexplains the privacy rights you and your family membershave as participants of the Plan. It is effective on January1, 2020. The Plan often needs access to your protectedhealth information in order to provide payment for healthservices and perform plan administrative functions. Wewant to assure the plan participants covered under thePlan that we comply with federal privacy laws and respectyour right to privacy. SpectrumVoIP requires all members ofour workforce and third parties that are provided access toprotected health information to comply with the privacypractices outlined below.Protected Health InformationYour protected health information is protected by theHIPAA Privacy Rule. Generally, protected health informationis information that identifies an individual created orreceived by a health care provider, health plan or anemployer on behalf of a group health plan that relates tophysical or mental health conditions, provision of healthcare, or payment for health care, whether past, present orfuture.How We May Use Your Protected Health Information. Underthe HIPAA Privacy Rule, we may use or disclose yourprotected health information for certain purposes withoutyour permission. This section describes the ways we canuse and disclose your protected health information.Payment. We use or disclose your protected healthinformation without your written authorization in order todetermine eligibility for benefits, seek reimbursement froma third party, or coordinate benefits with another healthplan under which you are covered. For example, a healthcare provider that provided treatment to you will provide uswith your health information. We use that information inorder to determine whether those services are eligible forpayment under our group health plan.Health Care Operations. We use and disclose yourprotected health information in order to perform planadministration functions such as quality assuranceactivities, resolution of internal grievances, and evaluatingplan performance. For example, we review claimsexperience in order to understand participant utilizationand to make plan design changes that are intended tocontrol health care costs.Treatment. Although the law allows use and disclosure ofyour protected health information for purposes oftreatment, as a health plan we generally do not need todisclose your information for treatment purposes. Yourphysician or health care provider is required to provide youwith an explanation of how they use and share your healthinformation for purposes of treatment, payment, andhealth care operations.As permitted or required by law. We may also use ordisclose your protected health information without yourwritten authorization for other reasons as permitted by law.We are permitted by law to share information, subject tocertain requirements, in order to communicate informationon health-related benefits or services that may be ofinterest to you, respond to a court order, or provideinformation to further public health activities (e.g.,preventing the spread of disease) without your writtenauthorization.We are also permitted to share protected healthinformation during a corporate restructuring such as amerger, sale, or acquisition. We will also disclose healthinformation about you when required by law, for example,in order to prevent serious harm to you or others.Pursuant to Your Authorization. When required by law, wewill ask for your written authorization before using ordisclosing your protected health information. If you chooseto sign an authorization to disclose information, you canlater revoke that authorization to prevent any future usesor disclosures.To Business Associates. We may enter into contracts withentities known as Business Associates that provideservices to or perform functions on behalf of the Plan. Wemay disclose protected health information to BusinessAssociates once they have agreed in writing to safeguardthe protected health information. For example, we maydisclose your protected health information to a BusinessAssociate to administer claims. Business Associates arealso required by law to protect protected healthinformation.To the Plan Sponsor. We may disclose protected healthinformation to certain employees of SpectrumVoIP for thepurpose of administering the Plan. These employees willuse or disclose the protected health information only asnecessary to perform plan administration functions or asotherwise required by HIPAA, unless you have authorizedadditional disclosures. Your protected health informationcannot be used for employment purposes without yourspecific authorization.

IMPORTANT NOTICESYour RightsRights to Inspect and Copy. In most cases, you have the right to inspect and copy the protected health information we maintain about you. If you request copies, we will charge you a reasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format.Right to Amend. If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to amend your health information. If we deny your request, you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information.Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2) to you;(3) pursuant to your authorization; (4) to your friends orfamily in your presence or because of an emergency; (5) fornational security purposes; or (6) incidental to otherwisepermissible disclosures.Your request for an accounting must be submitted inwriting to the person listed below. You may request anaccounting of disclosures made within the last six years.You may request one accounting free of charge within a12-month period.Right to Request Restrictions. You have the right to request that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. You also have the right to request that we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or friend.Your request for restrictions must be submitted in writing to the person listed below. We will consider your request, but in most cases are not legally obligated to agree to those restrictions. However, we will comply with any restriction request if the disclosure is to a health plan for purposes of payment or health care operations (not for treatment) and the protected health information pertains solely to a health care item or service that has been paid for out-of-pocket and in full.Right to Request Confidential Communications. You have the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address.Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements.Right to Receive a Paper Copy of this Notice. If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the person listed below.Our Legal Responsibilities. We are required by law to protect the privacy of your protected health information, provide you with certain rights with respect to your protected health information, provide you with this notice about our privacy practices, and follow the information practices that are described in this notice. We may change our policies at any time. In the event that we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.Complaints: If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact HR. You also may send a written complaint to the U.S. Department of Health and Human Services — Office of Civil Rights. HR can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.

IMPORTANT NOTICESYour RightsRights to Inspect and Copy. In most cases, you have the right to inspect and copy the protected health information we maintain about you. If you request copies, we will charge you a reasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format.Right to Amend. If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to amend your health information. If we deny your request, you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information.Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2) to you;(3) pursuant to your authorization; (4) to your friends orfamily in your presence or because of an emergency; (5) fornational security purposes; or (6) incidental to otherwisepermissible disclosures.Your request for an accounting must be submitted inwriting to the person listed below. You may request anaccounting of disclosures made within the last six years.You may request one accounting free of charge within a12-month period.Right to Request Restrictions. You have the right to request that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. You also have the right to request that we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or friend.Your request for restrictions must be submitted in writing to the person listed below. We will consider your request, but in most cases are not legally obligated to agree to those restrictions. However, we will comply with any restriction request if the disclosure is to a health plan for purposes of payment or health care operations (not for treatment) and the protected health information pertains solely to a health care item or service that has been paid for out-of-pocket and in full.Right to Request Confidential Communications. You have the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address.Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements.Right to Receive a Paper Copy of this Notice. If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the person listed below.Our Legal Responsibilities. We are required by law to protect the privacy of your protected health information, provide you with certain rights with respect to your protected health information, provide you with this notice about our privacy practices, and follow the information practices that are described in this notice. We may change our policies at any time. In the event that we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.Complaints: If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact HR. You also may send a written complaint to the U.S. Department of Health and Human Services — Office of Civil Rights. HR can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.

IMPORTANT NOTICESNotice of HIPAA Special Enrollment RightsThis notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time.Loss of Other CoverageIf you are declining coverage for yourself or your 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 the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).In addition, 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. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.Medicaid or CHIPIf you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy. Notice of Patient ProtectionsBlueCross BlueShield of TX generally 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 children, you may designate a pediatrician as the primary care provider.You do not need prior authorization from BlueCross BlueShield of TX 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, includingobtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.

IMPORTANT NOTICESNotice of HIPAA Special Enrollment RightsThis notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time.Loss of Other CoverageIf you are declining coverage for yourself or your 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 the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).In addition, 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. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.Medicaid or CHIPIf you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy. Notice of Patient ProtectionsBlueCross BlueShield of TX generally 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 children, you may designate a pediatrician as the primary care provider.You do not need prior authorization from BlueCross BlueShield of TX 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, includingobtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.