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EMPLOYEE BENEFITS Effective 11/1/2023 through 10/31/2024 Medical MASA Colonial Life

Medical Benefits MASA Recuro– Telemedicine Colonial Life Products Medical SBCs GET READY! New Benefits Choices Are Coming Your Way The City of Newton is pleased to offer its employees an excellent benefits program. These benefits are designed to protect you and your family while you are an active employee. The benefit choices you make should be tailored to your personal needs. After the open enrollment period ends, you may not add, delete, or change the coverage you have selected for yourself or your dependents until the next open enrollment period. Make sure to review this guide to learn about your options. Outside of open enrollment, changes to insurance coverage can only be made within 30 days of a Qualifying Family Status Change, which are as follows: • Marriage • Birth or adoption of a dependent child • Change in custody of a dependent child • Death of a spouse or dependent child • Your spouse has a change of employment or status affecting benefits coverage • Your change of employment status • You experience an involuntary loss of other group benefits coverage • Or within 60 days if the Qualifying Event is relative to Medicaid or CHIP Eligibility • Employees or Dependents become eligible or lose eligibility with state Medicaid or CHIP subsidies (Special Enrollment Rights Offered) PRE- TAX ADVANTAGE One of the advantages of your Employee Benefit Program is that your premium contributions are deducted from your paycheck on a pre-tax basis. When you pay for your premiums with pre-tax dollars, you are actually reducing your taxable income. Instead of paying taxes on your total income, you now pay on your income minus pre-tax deductions. This booklet is intended for illustrative and information purposes only. Not all plan provisions, limitations, and exclusions are included in this publication. In the event of any conflict between the information contained in this publication and the plan provisions, the Plan Documents and insurance contracts will govern. TABLE OF CONTENTS

BLUE CHOICE PPO PLAN OPTIONS ATBCB203 Employee Cost per Pay Period Employee Only $ 88.84 Employee + Spouse $ 497.90 Employee + Child(ren) $ 435.21 Employee + Family $ 844.26 ATBCB211 Employee Cost per Pay Period Employee Only $ 38.22 Employee + Spouse $ 391.36 Employee + Child(ren) $ 337.24 Employee + Family $ 690.39

BLUE ADVANTAGE HMO PLAN OPTION This plans require a PCP selection. ATBCP203 Employee Cost per Pay Period Employee Only FREE Employee + Spouse $ 304.95 Employee + Child(ren) $ 257.78 Employee + Family $ 565.57

EMERGENT PLUS MEMBERSHIP BENEFITSContact Your Representative, to learn more:Emergency Air Ambulance Coverage1MASA MTS covers out-of-pocket expenses associated with emergency air transportation to a medical facility for serious medical emergencies deemed medically necessary for you or your dependent family member. Emergency Ground Ambulance Coverage1MASA MTS covers out-of-pocket expenses associated with emergency ground transportation to a medical facility for serious medical emergencies deemed medically necessary for you or your dependent family member. Hospital to Hospital Ambulance Coverage1MASA MTS covers out-of-pocket expenses that you or a dependent family member may incur for hospital transfers, due to a serious emergency, to the nearest and most appropriate medical facility when the current medical facility cannot provide the required level of specialized care by air ambulance to include medically equipped helicopter or fi xed-wing aircraft. Repatriation to Hospital Near Home Coverage1MASA MTS provides services and covers out-of-pocket expenses for the coordination of a Member’s non-emergency transportation by a medically equipped, air or ground ambulance in the event of hospitalization more than one hundred (100) miles from the Member’s home if the treating physician and MASA MTS’ Medical Director says it’s medically appropriate and possible to transfer the Member to a hospital nearer to home for continued care and recuperation. A MASA MTS Membership provides the ultimate peace of mind at an aff ordable rate for emergency ground andair transportation assistance expenses within the continental United States, Alaska, Hawaii, and while travelingin Canada, regardless of whether the provider is in or out of your group healthcare benefi ts network. After thegroup health plan pays its portion, MASA works with providers to make certain our Members have no out-of-pocketexpenses~ for emergency ambulance transportation assistance and other related services.MASAEP_CB_FLR_14_032422are sent to the emergency room through ground or air ambulance every year*.Insurance companies may not may not cover all air and ground ambulance expenses which can result in max in-network out-of-pocket** costs of:DID YOU KNOW?MILLIONPEOPLE25$8,700 Individual $17,400 FamilyGround ambulance out-of-network out-of-network transportation costs may be even transportation costs may be even higher than in-networkhigher than in-network since the No Surprises Act does not apply to ground ambulance at this time.$14/MONTHStephanietexasfinancialcenter.com409-224-2012

1250 S. Pine Island Rd., Suite 500,Plantation, FL 33324800-643-9023 I www.masamts.comThe information provided in this product information sheet is for informational purposes only. The benefi ts listed and the descriptions thereof do not represent the full terms and conditions applicable for usage and may only be off ered in some memberships. Premiums and benefi ts vary depending on the benefi ts selected. Commercial air and Worldwide coverage are not available in all territories. For a complete list of benefi ts, premiums, and full terms, conditions, and restrictions, please refer to the applicable member services agreement for your territory. MASA MTS products and services are not available in AK, NY, WA, ND, and NJ. MASA MTS utilizes third-party transportation service providers for all transportation services. MASA Global, MASA MTS and MASA TRS are registered service marks of MASA Holdings, Inc., a Delaware corporation. Void where prohibited by law.~If a member has a high deductible health plan that is compatible with a health savings account, benefi ts will become available under the MASA membership for expenses incurred for medical care (as defi ned under Internal Revenue Code (“IRC”) section 213 (d)) once a member satisfi es the applicable statutory minimum deductible under IRC section 223(c) for high-deductible health plan coverage that is compatible with a health savings account. COVERAGE TERRITORIES:1. All coverage provided by this membership is limited to the continental United States, Alaska, Hawaii, and Canada, and must originate and conclude therein.SOURCES:*ACEP NOW 2014** Patient Protection and Aff ordable Care Act; HHS Notice of Benefi t and Payment Parameters for 2022 and Pharmacy Benefi t Manager Standards. May 5, 2021.MASAEP_CB_FLR_14_032422

Getting StartedCare ServicesVirtual Urgent Care• Acne / Rash• Allergies• Cold / Flu• GI Issues• Ear Problems• Fever• Insect Bites• Nausea• Pink Eye• Respiratory• UTI's• And More...Example Conditions Treatedcustomerservice@recurohealth.com | 855.6RECURO | Scan QR Code to Download $0Copay010203ActivateAccess your Recuro Care benefit by:Mobile App: Android or ApplePhone: 1.855.673.2876Online: member.recurohealth.comCreate LoginCreate your login credentials by entering your email, name, and date of birth, then create your username and password.Request a ConsultYou’re now ready to request a consult with a Doctor.Or visit: “member.recurohealth.com"Scan here or search for “Recuro Care” in your app store.Activate Now

Voluntary Benefits Colomal Life. ■ ■ ■ ■ ■ ■ ■ To make su you get the covege you need, schedule your 1-to-1 benets counseling session today.

Deductions per year: 26 These rates were prepared on 10/10/2019 and are valid for 90 days.Individual Dental PPO(IDN8000) for TXApplicable to policy form Individual Dental PPO(IDN8000)lwith Vision RiderZip Codes: 755, 756, 757, 758, 759, 763, 767, 768, 769, 777, 779, 780, 781, 782, 783, 784, 785,788, 790, 791, 792, 793, 794, 795, 796, 797, 798, 799, 885COVERAGE LEVEL ISSUE AGE INDIVIDUAL INDIVIDUAL ANDSPOUSEINDIVIDUAL ANDCHILDRENINDIVIDUAL ANDFAMILYPlan 3 - 100/80/50,$1,500 MAC17-74 $16.52 $31.34 $38.33 $57.20Plan 5 - 100/80/50,$1,500 PPO17-74 $23.14 $44.44 $55.19 $82.44Optional Vision RiderISSUE AGE INDIVIDUAL INDIVIDUAL ANDSPOUSEINDIVIDUAL ANDCHILDRENINDIVIDUAL ANDFAMILYCOVERAGE LEVEL17-74$2.89$5.71 $6.01 $9.42Individual Accident (IAC4000) for TXApplicable to Policy Forms IAC4000lOn/Off-Job Accident CoverageBENEFIT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYBasic 0-80 $6.65 $9.86 $11.93 $15.00Preferred 0-80 $8.75 $12.90 $15.78 $19.73Individual Disability - ISTD3000 for TX AA Risk ClassApplicable to policy form Individual DisabilitylOff Job Accident & Off Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,200* $1,600* $2,000* $2,400**monthly benefit amount0 days Accident/7 days Sickness 17-49 $9.53 $16.34 $21.78 $27.23 $32.6850-64 $11.31 $19.38 $25.85 $32.31 $38.7765-74 $13.21 $22.65 $30.20 $37.75 $45.300 days Accident/14 days Sickness 17-49 $6.78 $11.63 $15.51 $19.38 $23.2650-64 $7.95 $13.62 $18.17 $22.71 $27.2565-74 $10.14 $17.39 $23.19 $28.98 $34.787 days Accident/7 days Sickness 17-49 $8.88 $15.23 $20.31 $25.38 $30.4650-64 $10.21 $17.50 $23.34 $29.17 $35.0065-74 $12.37 $21.21 $28.28 $35.35 $42.42Underwritten by Colonial Life & Accident Insurance Company14 days Accident/14 days Sickness 17-49 $5.78 $9.91 $13.22 $16.52 $19.8350-64 $7.01 $12.02 $16.02 $20.03 $24.0465-74 $8.72 $14.95 $19.94 $24.92 $29.91

Individual Disability - ISTD3000 for TX AA Risk ClassApplicable to policy form Individual Disability6 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,200* $1,600* $2,000* $2,400**monthly benefit amount0days Accident/7 days Sickness 17-49 $11.95 $20.49 $27.32 $34.15 $40.9850-64 $15.51 $26.58 $35.45 $44.31 $53.1765-74 $20.16 $34.56 $46.08 $57.60 $69.120 days Accident/14 days Sickness 17-49 $8.79 $15.06 $20.09 $25.11 $30.1350-64 $11.31 $19.38 $25.85 $32.31 $38.7765-74 $14.54 $24.92 $33.23 $41.54 $49.857 days Accident/7 days Sickness 17-49 $11.15 $19.11 $25.48 $31.85 $38.2250-64 $14.70 $25.20 $33.60 $42.00 $50.4065-74 $19.09 $32.73 $43.64 $54.55 $65.467 days Accident/14 days Sickness 17-49 $8.50 $14.57 $19.42 $24.28 $29.1350-64 $10.37 $17.78 $23.70 $29.63 $35.5665-74 $13.60 $23.32 $31.09 $38.86 $46.6314 days Accident/14 days Sickness 17-49 $7.82 $13.40 $17.87 $22.34 $26.8150-64 $9.98 $17.11 $22.82 $28.52 $34.2365-74 $13.18 $22.60 $30.13 $37.66 $45.19Critical Illness 1.0 for TXApplicable to policy form CI-1.0lwith Subsequent Diagnosis Coverage, Health Screening Benefit, Cancer BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $2.88 $4.38 $3.62 $5.1725-29 $3.81 $5.81 $4.54 $6.6030-34 $4.77 $7.29 $5.51 $8.0735-39 $6.21 $9.50 $6.94 $10.2940-44 $7.45 $11.40 $8.19 $12.1845-49 $9.71 $14.95 $10.50 $15.6950-54 $13.45 $20.67 $14.19 $21.4155-59 $16.54 $25.43 $17.33 $26.2160-64 $21.90 $33.64 $22.68 $34.4365-70 $26.01 $39.97 $26.84 $40.80(Continued...)Underwritten by Colonial Life & Accident Insurance CompanyTobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $3.67 $5.63 $4.45 $6.4125-29 $5.19 $7.98 $5.97 $8.7230-34 $7.08 $10.89 $7.87 $11.6735-39 $9.34 $14.35 $10.13 $15.1440-44 $11.70 $18.00 $12.48 $18.7845-49 $15.02 $23.12 $15.81 $23.8650-54 $20.42 $31.38 $21.21 $32.1755-59 $25.96 $39.87 $26.70 $40.6160-64 $33.11 $50.86 $33.90 $51.6465-70 $39.71 $61.01 $40.54 $61.84

Individual 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,$50 Health Screening Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $10.02 $18.81 $13.01 $21.8050-59 $13.75 $25.89 $16.76 $28.8960-64 $17.67 $33.35 $20.68 $36.35(Continued...)Underwritten by Colonial Life & Accident Insurance Company65-75 $22.34 $42.18 $25.34 $45.19Applicable to policy form Individual Medical Bridgel$2000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500,$50 Health Screening Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $16.38 $30.85 $22.15 $36.6250-59 $22.47 $42.51 $28.25 $48.2760-64 $29.58 $55.96 $35.36 $61.7365-75 $38.22 $72.32 $43.98 $78.10Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $25,000 $49,000 $50,000 $100,000 $150,00025 $4.97 $7.97 $4.87 $7.89 $10.9135 $6.11 $10.20 $5.35 $8.85 $12.3545 $8.41 $14.70 $10.06 $18.27 $26.4855 $18.07 $21.00 $21.39 $40.92 $60.4665 $28.41 $53.90 $54.96 $108.08 $161.19Tobacco RatesISSUE AGE $25,000 $49,000 $50,000 $100,000 $150,00025 $9.33 $16.51 $8.41 $14.97 $21.5235 $10.75 $19.30 $9.52 $17.20 $24.8745 $15.57 $28.74 $20.99 $40.12 $59.2555 $36.39 $48.00 $48.95 $96.04 $143.1365 $47.86 $92.03 $93.87 $185.88 $277.90Whole Life (IWL5000) for TXlAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $4.78 $8.18 $11.58 $14.98 $16.61

Whole Life (IWL5000) for TXApplicable to policy forms ICC19-IWL500-70/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-GPOlAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00035 $6.26 $11.14 $16.02 $20.90 $23.5245 $8.92 $16.46 $24.00 $31.55 $36.4055 $14.10 $26.81 $34.50 $45.53 $56.5765 $24.97 $39.15 $58.03 $76.92 $95.80Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $7.26 $13.15 $19.03 $24.92 $24.3835 $9.13 $16.89 $24.64 $32.40 $31.9645 $12.51 $23.64 $34.77 $45.90 $49.1355 $21.70 $42.02 $47.76 $63.22 $78.6865 $38.79 $52.59 $78.20 $103.80 $129.42Important 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.© 2014 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.Jamie Pope | jamie@colonialtx.com | (409) 782-1910(Continued...)Underwritten by Colonial Life & Accident Insurance Company

For more information, talk with your benefits counselor.Dental InsurancePlan 3 – MAC (In-network Only)Plan 5 - Passive PPO IDN8000 – PLAN 3Dental insurance from Colonial Life can help preserve your smile with easy-to-use coverage that promotes overall wellness. Benefits can help with a variety of dental costs, from routine cleanings to more advanced procedures. Coverage is available for you, your spouse and dependent children.Plan detailsThe benefit year maximum for this plan is $1,500 per person.Class A, B and C services apply toward the benefit year maximum.This plan has a deductible of $50 per person. Families only pay the deductible for a maximum of three people. Applies only to class B and C services.The co-insurance for this plan is:ColonialLife.comCLASS TYPE OF SERVICE INSURANCE PAYSClass A Preventive services 100%Class B Basic services 80%Class C Major services 50%See reverse for covered procedures and waiting periods.NetworkOur national dental network oers more than 323,000 access points.1 Members may choose any dentist but may receive additional savings by choosing an in-network dentist. Plus, services not covered by this plan may also still be eligible for in-network savings.2Out-of-network benefits are paid at the network negotiated rate.3To locate a participating dentist, access the provider search at ColonialLifeDental.com.

Covered procedures and waiting periodsColonialLife.comPreventive services (Class A): No waiting period  Routine exams and cleanings (twice every 12 months) – One additional cleaning per 12 months if memberis in second or third trimester of pregnancy4  X-rays – Bitewing X-rays (up to four films; once every 12 months)  Children’s services (up to age 14) – Fluoride treatment (once every 12 months) – Sealants (once every 36 months) – Space maintainers (up to age 14; once every 24 months)  Adjunctive pre-diagnostic oral cancer screening (for age 40 or older; once every 12 months)Basic services (Class B): No waiting period  Full mouth/panoramic X-rays (once every five years)  Simple restorative services (fillings)  Simple extractions  Emergency treatmentMajor services (Class C): 12-month waiting period  Oral surgery (extractions and impacted teeth)  Anesthesia (subject to review; covered with complex oral surgery)  Repair of crown, denture or bridge  Periodontics (gum treatments)  Endodontics (root canals)  Inlays and onlays  Crowns  Bridges  Dentures  Endosteal implants (in lieu of an approved three-unit bridge)4-18 | 101838-1©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. 1 Internal data (2017). Access points are sites where network dentists see patients. Some dentists may be available at more than one access point.2 Not an insured benefit. 3 If you visit an out-of-network dentist, you may be billed for remaining amounts over the benefit amount paid, up to the billed charge. 4 Member may have one additional periodontal maintenance in lieu of an additional cleaning. Periodontal maintenance is a major service and subject to a 12-month waiting period.The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may aect any benefits payable. See the actual policy or your Colonial Life benefits counselor for specific provisions and details of availability.

For more information, talk with your benefits counselor.Individual Dental PPO InsuranceVision RiderIDN8000 – VISION RIDERDental insurance oers an optional vision rider to help pay for eye exams and materials, such as glasses and contact lenses. This coverage can help you maintain healthy vision and overall wellness, as well as provide valuable financial protection for you, your spouse and dependent children.Vision benefitsIN-NETWORKOUT-OF-NETWORKALLOWANCECO-PAYSExam (once per 12 months) $10 Up to $35Materials $25 See belowSTANDARD PLASTIC LENSES (once per 12 months)Single vision Covered by co-pay Up to $25Bifocal Covered by co-pay Up to $40Trifocal Covered by co-pay Up to $50Lenticular $80 allowance Up to $50Progressive $70 allowance Up to $40Polycarbonate lenses (for children to age 19) Covered by co-pay N/AFRAMES1 (once per 12 months)Choose any frame available at provider locations $120 allowance Up to $50CONTACT LENSES2 (once per 12 months) (Includes fit, follow-up and materials) In lieu of eyeglass lenses and frames Elective Up to $120 allowance Up to $100 allowanceMedically necessary Up to $210 allowance Up to $210 allowanceFreedom of choiceYou’ll have access to a national vision network that includes independent optometrists, ophthalmologists and retail stores including Walmart, Sam’s Club Optical, Costco,3 Pearle Vision and Target. You can search for providers at ColonialLifeVision.com.Additional vision benefit advantages  Eye exams and materials (frames, lenses) can be purchased from dierent locations and providers. For example, you could have an eye exam with your favorite eye care professional and order contacts online.  Check the network for Value Added and Service Plus providers. They can provide special discounts for extra purchases of lenses and coatings, frames, contact lenses and other products.ColonialLife.com

ColonialLife.com4-18 | 101851-21 Eyeglass lenses and frames are paid in lieu of the contact lenses benefit.2 The contact lenses benefit is paid in lieu of eyeglass lenses and frames. Contact lenses consist of three components: materials, exams and fittings. Coverage is for materials and the exam, up to the contact lenses allowance. Fittings may be covered but only up to the amount of any unused contact lenses allowance – aer materials.3 Optometrists at Costco Optical outlets are independent of Costco and may not be in network. To verify that your vision exam will be fully covered aer co-pay, confirm that your doctor is an in-network provider. Special payment and reimbursement terms apply for material purchases at Costco. Additional discounts are not applicable.4 Not a covered benefit. These schedules are subject to change without notice. Added value discounts may not be available in all geographical areas and vary by network. Many providers are not able to oer discounts on “Prestige” frames. Special lens packages that combine numerous lens enhancements at value price points are not covered by these added value programs. Cannot be combined with any other promotions or discounts.5 Some retail chains sell sunglasses in departments outside of their optical shops where discounts do not apply.The policy or its provisions may vary or be unavailable in some states. The policy had exclusions and limitations, which may aect any benefits payable. See the actual policy or your Colonial Life benefits counselor for specific provisions and details of availability.Special discounts on material purchases4Providers identified as Value Added or Service Plus in our online provider directory oer the following additional values for our members on vision material purchases. We encourage you to contact your selected provider prior to visiting their location to confirm their continued participation. Not all providers, such as Walmart, Sam’s Club and Costco Optical,³ choose to participate in these special discounts.Value Added providersDISCOUNTS FOR FIRST PAIR OF GLASSESLens options (add-ons for insured purchases):PURCHASE A SECOND PAIR OF GLASSES AND RECEIVE PREFERRED PRICINGLenses:DISCOUNTS ON FRAMES, CONTACT LENSES AND OTHER PRODUCTSService Plus providersRECEIVE UP TO A 20% DISCOUNT FOR THE FOLLOWING ADD-ONS TO INSURED PURCHASES:  UV coating  Solid tinting/gradient tinting  Standard scratch resistance coating  UV coating…$15  Solid tinting/gradient tinting…$15  Standard scratch resistance coating…$15  Standard anti-reflective coating…$45  Premium anti-reflective coating…$70  Ultra anti-reflective coating…20% discount  Polarized…$75  Transition…$75  Progressive lenses: – Standard…$110 – Premium…$170 – Ultra…member receives a 20% discount  Standard polycarbonate …$40  High index (single vision) – 1.56-1.60…$60 – 1.66+…20% discount  High index (multi-focal) – 1.56-1.60…$75 – 1.66+…20% discount  Single vision plastic lenses…$40  Bifocal plastic lenses…$60  Trifocal lenses…$70  Progressive lenses (standard)…$110  Progressive lenses (premium and ultra)…20% discount  Frames – Up to 35% discount  Contact Lenses – 5-15% discount, depending on type  Other products – 20% discount on non-prescription sunglasses and other ancillary products/solutions  Standard anti-reflective coating  Premium anti-reflective coating  Transition  Standard polycarbonateUnderwritten 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.

Accident InsurancePreferred PlanIAC4000 – PREFERRED PLANOUR COVERAGE INCLUDES:All of this can help you get back on your feet. You never expect an accident to happen. But if it does, your focus should be on recovery – not medical bills. Colonial Life accident insurance can help cover medical costs. Whether the accident is as simple as a cut hand from a fall or as complex as a car accident, you can count on us to support you. DOCTORʼS OFFICE VISITOver the next several weeks, he had three follow-up appointments with his doctor.URGENT CARE CENTER VISITMilo went to an urgent care center and received immediate care.DIAGNOSTIC PROCEDUREThe doctor ordered an X-ray and discovered Milo had fractured his hand.LACERATIONThe doctor also found that Milo had a cut on his hand.MEDICAL EQUIPMENTMilo was discharged with a splint.MILOʼS BENEFITSWith Colonial Life accident benefits, Milo’s parents were able to pay the annual deductible and co-payments.Accident emergency treatment $125X-ray $30Laceration (no stitches) $30Fracture (hand) $375Medical equipment (splint) $30Accident follow-up treatment (3 visits)$165Total: $755For illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.Milo was running on the playground when he tripped and injured his hand.  Benefits payable directly to you  No medical questions to qualify for coverage  Coverage for simple and complex injuries  Benefits payable, regardless of other insurance  Worldwide coverage  Keep coverage no matter where you go  Works alongside your health savings account (HSA)

INITIAL CAREAccident emergency treatment ........................................................................ $125Hospital emergency room, urgent care facility or physician’s oiceAccidental injury due to an automobile accident .................................................. $250 Air ambulance1 .......................................................................................... $2,000 Ambulance – ground or water1 ......................................................................... $200 Observation room (up to two days per calendar year) .................................. $150 per day X-ray ........................................................................................................... $30 COMMON ACCIDENTAL INJURIESBurn (based on size and degree)......................................................... $1,000 – $12,000Burn – skin gra ......................................................... 50% of applicable burn benefitComa (lasting for seven or more consecutive days).............................................$12,500Concussion ................................................................................................. $150 Dislocation – separated joint¾ Non-surgical – repair .................................................................... $100 – $2,250Incomplete dislocation – or dislocation without anesthesia ....................25% of benefit Examples: elbow: $500 | ankle: $1,000 | knee: $1,125 | hip: $2,250 ¾ Surgical – repair .......................................................................... $200 – $4,500 Examples: elbow: $1,000 | ankle: $2,000 | knee: $2,250 | hip: $4,500Emergency dental work .........................................................................$100 – $300Dental extraction or dental crown, denture or implantEye injury – with surgical repair or removal of a foreign object ................................... $300 Fracture – complete¾ Non-surgical – repair .................................................................... $250 – $3,000Chip fracture ............................................................................. 25% of benefit Examples: hand: $375 | foot: $375 | collarbone: $625 | leg: $1,000¾ Surgical – repair .......................................................................... $500 – $6,000 Examples: hand: $750 | foot: $750 | collarbone: $1,250 | leg: $2,000Hearing-loss injuries2 .................................................................................... $120 Knee cartilage – torn (with surgical repair) ........................................................... $650 Laceration (based on repair and length) ....................................................... $30 – $600 Ruptured disc (with surgical repair) ................................................................... $750 Tendon/ligament/rotator cu (with surgical repair) ¾ One ......................................... $650 ¾ Two or more ........................ $1,300 HOSPITAL CAREHospital admission ..................................................................................... $1,000 Hospital confinement (up to 365 days) ..................................................... $250 per dayHospital sub-acute intensive care unit confinement (up to 30 days) ................. $325 per dayIntensive care unit admission ........................................................................ $2,000 Intensive care unit confinement (up to 15 days) .......................................... $450 per daySURGICAL CAREBlood/plasma/platelets – transfusion ................................................................ $300 Surgery (based on type of repair and surgery) ............................................ $200 – $1,500Benefits are per covered person per covered accident unless stated otherwise.Olivia was driving to the store when she got into a car accident.AMBULANCE AND EMERGENCY ROOM VISITOlivia was admitted to the hospital for surgery on her leg. She was confined for three days.Over the next several weeks, she had six follow-up appointments with her doctor.Olivia had eight sessions of physical therapy to help regain the strength in her leg.The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for brain injury.OLIVIA'S BENEFITSOlivia’s accident benefits helped cover her annual deductible and co-payments.Ambulance $200Accidental injury due to an automobile accident$250Accident emergency treatment $125X-ray $30Medical imaging study (CT) $200Hospital admission $1,000Hospital confinement (3 days) $750Thigh fracture - femur (surgical) $4,400Surgery (exploratory/arthroscopic) $300Medical equipment (crutches) $100Accident follow-up treatment (6 visits)$330Physical therapy (8 days) $280Total: $7,965Olivia arrived by ambulance to the nearest emergency room and received immediate care.DIAGNOSTIC PROCEDURESHOSPITAL ADMISSION, CONFINEMENT AND SURGERYDOCTORʼS OFFICE VISITSPHYSICAL THERAPYFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.

For more information, talk with your benefits counselor.IAC4000 – PREFERRED PLANTRANSPORTATION & LODGINGTransportation for hospital confinement ..................................................... $600 per round trip(up to three round trips, 50+ miles from home)Lodging – companion (up to 30 days) .................................................................. $125 per dayFOLLOW-UP CAREAccident follow-up treatment – including transportation/telemedicine ...................................$55 (up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar year)Medical equipment¾ Tier 1 ............................................................................................................... $30 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint ¾ Tier 2 ............................................................................................................. $100 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot ¾ 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 per calendar year)Pain management for epidural anesthesia – non-surgical ................................................... $100 Post-traumatic stress disorder (PTSD) .......................................................................... $200 Prosthetic device/artificial limb¾ One ............................................ $750 ¾ More than one .............................. $1,500¾ Repair/replacement3 ................................................................................... $375/$750Rehabilitation unit confinement ....................................................................... $150 per day(up to 15 days, not to exceed 30 days per calendar year)Therapy – occupational, physical or speech (up to ten days)........................................$35 per dayACCIDENTAL DISMEMBERMENTAccidental dismemberment .......................................................................... $4504 – $20,000¾ Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye¾ Loss, loss of use – finger, toe, partial dismemberment of finger or toeAccidental dismemberment due to a catastrophic accidentNamed insured, spouse or child ...........................................................................$25,0005¾ Total and irrecoverable loss, loss of use or paralysis – 180-day elimination period¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears, or loss of ability to speakACCIDENTAL DEATHAccidental death¾ Named insured, spouse .................................................................................. $40,000¾ Child ......................................................................................................... $10,000Accidental death common carrierExamples of common carriers are mass transit trains, buses and planes¾ Named insured, spouse ................................................................................. $160,000¾ Child ......................................................................................................... $30,000

Individual Short-Term Disability Insurance ISTD3000 BASEYou never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If a covered accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.Benefits worksheetHow much coverage do I need?Monthly benefit amount for o-job accident and o-job sickness: ______________Choose a monthly benefit amount between $400 and $6,500.*If your plan includes on-job accident/sickness benefits, the benefit is 50% of the o-job amount.What is the benefit period?Benefit period: _______ monthsThe partial disability benefit period is three months.When may my total disability benefits start?Aer an accident: _______ days Aer a sickness: _______ daysCan you aord to not protect your income? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.Aer calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.ColonialLife.comMONTHLY EXPENSESRound to the nearest hundred.1 Rent or mortgage $2 Transportation $3 Utilities (phone, internet, electricity/gas, water, etc.) $4 Food and necessities $5 Other expenses $ Total monthly expenses (add lines 1-5 together) $*Subject to income requirements

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, mental or nervous disorders, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months aer the coverage eective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which you were treated, had medical testing, received medical advice or had taken medication within 12 months before the policy coverage eective date shown on the policy schedule.Aer this policy has been in force for 12 months (six (6) months if you are age 65 or older on the policy coverage eective date) from the policy coverage eective date shown on the policy schedule, we will pay benefits for any pre-existing condition not excluded by name or specific description if the covered disability began at least 12 months (six (6) months if you are age 65 or older on the Policy Coverage Eective Date) aer the policy coverage eective date and the elimination period has been satisfied.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-TX and rider form ISTD3000-ADIB-TX. This is not an insurance contract and only the actual policy and rider provisions will control.12-17 | 101629-2-TXProduct information Total disability definitionTotally disabled or total disability means you are: unable to perform the material and substantial duties of your occupation, not, in fact, working at any occupation, and under the regular and appropriate care of a physician.How partial disability worksIf you are able to return to work part-time aer at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.Waiver of premiumWe will waive your premium payments aer 90 consecutive days of a covered disability.Geographical limitationsIf you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.Issue ageCoverage is available from ages 17 to 74.Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.For more information, talk with your benefits counselor.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.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: cancer, coronary artery bypass gra surgery/disease,2 carcinoma in situ, and occupational infectious HIV or occupational infectious hepatitis B, C or D.Specified Critical Illness InsuranceIf you’re diagnosed with a covered critical illness or cancer, 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:Cancer 100%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%Carcinoma in situ 25%Critical illness benefitCRITICAL ILLNESS 1.0 WITH CANCER AND 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 | 101825-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.Cancer vaccine benefit: ................................................................. $50 This benefit is payable if you or your covered family members incur a charge for any FDA-approved cancer vaccine while your policy is inforce.

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 ......................................................................... $1,500 per dayMaximum 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....................................................................................................... $ 500  Tier 2................................................................................................. ......$1000Maximum of $________________ per covered person per calendar year for all covered outpatient surgical procedures combined

THIS POLICY PROVIDES LIMITED BENEFITS.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-existing 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-AK and IMB7000-TX. This is not an insurance contract and only the actual policy provisions will control.ColonialLife.com©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. 6-16 | 101578-AK-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

Term Life InsurancePeace of mind for you and your loved onesYou want what’s best for your family, and that includes making sure they’re prepared for the future. With term life insurance from Colonial Life & Accident Insurance Company, you can provide financial security to help them cover their ongoing living expenses.Advantages of term life insurance  Lower cost when compared to cash value life insurance  Same benefit payout throughout the duration of the policy  Several term period options for flexibility during high-need years  Benefit for the beneficiary that is typically tax-freeBenefits and features  Stand-alone spouse policy available whether or not you buy a policy for yourself  Guaranteed premiums that do not increase during the selected term  Ability to convert all or a portion of the benefit amount into cash value life insurance  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  Premium savings for face amounts over $250,000 based on your healthTERM LIFE (ITL5000)LIMRA, 2017 Insurance Barometer Study.of Americans would have trouble paying living expenses immediately or within several months if the primary wage-earner died.54%married/partnered consumersLIMRA, 2018 Insurance Barometer Study.1-in-3wish their spouse or partner would purchase more life insurance.

How much coverage do you need?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS 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. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/R-ITL5000-STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/R-ITL5000-ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC and applicable state variations. Spouse term life riderYour spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available. Children’s term life riderYou can 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. 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.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. 6-19 | 101895-1ColonialLife.com1 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.2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring.3 You must resume premium payments once you are no longer disabled.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.Optional ridersAt an additional cost, you can purchase the following riders for even more financial protection.£ YOU $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-year£ SPOUSE $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-yearSelect 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£ Waiver of premium benefit rider

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.

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.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023-12/31/2023 : ATBCB203 Blue Choice PPO Basic A203 Coverage for: Individual/Family | Plan Type: PPO Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-800-521-2227. For definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Network: $1,500 Individual/$4,500 Family Out-of-Network: $3,000 Individual/$9,000 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Network office visits, prescription drugs and preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? Network: $4,500 Individual/$13,500 Family Out-of-Network: Unlimited Individual/Unlimited Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance billing charges, and health care this plan 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 ATBCB2032023E01012023 0000014 0851C :doireP egarevo 1 3202/10/1 -1 4202/13/0C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Page 2 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $35/visit; deductible does not apply 40% coinsurance Virtual visits are available. See your benefit booklet* for details. Specialist visit $70/visit; deductible does not apply 40% coinsurance None Preventive care/screening/ immunization No Charge; deductible does not apply 40% coinsurance You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Inpatient: Certain services may require Preauthorization for Out-of-Network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for Out-of-Network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details. Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-lists Preferred generic drugs Retail - Preferred - No Charge Non-Preferred - $10/prescription Mail - No Charge; deductible does not apply Retail - $10/prescription; deductible does not apply plus 50% additional charge Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional charge will not apply to any deductible or out-of-pocket amounts. Cost Sharing for insulin included in the drug list will Non-preferred generic drugs Retail - Preferred - $10/prescription Non-Preferred - $20/prescription Mail - $30/prescription; deductible does not apply Retail - $20/prescription; deductible does not apply plus 50% additional charge 0000014 0851

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023. Page 3 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Preferred brand drugs Retail - Preferred - $50/prescription Non-Preferred - $70/prescription Mail - $150/prescription; deductible does not apply Retail - $70/prescription; deductible does not apply plus 50% additional charge not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription. Non-preferred brand drugs Retail - Preferred - $100/prescription Non-Preferred - $120/prescription Mail - $300/prescription; deductible does not apply Retail - $120/prescription; deductible does not apply plus 50% additional charge Preferred specialty drugs $150/prescription; deductible does not apply $150/prescription; deductible does not apply plus 50% additional charge Non-preferred specialty drugs $250/prescription; deductible does not apply $250/prescription; deductible does not apply plus 50% additional charge If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Certain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details. Physician/surgeon fees 20% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care $500/visit plus 20% coinsurance $500/visit plus 20% coinsurance Copayment waived if admitted. Emergency medical transportation 20% coinsurance 20% coinsurance None Urgent care $75/visit; deductible does not apply 40% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Preauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit 0000014 0851

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023. Page 4 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Physician/surgeon fees 20% coinsurance 40% coinsurance booklet* for details. If you need mental health, behavioral health, or substance abuse services Outpatient services $35/office visit; deductible does not apply or 20% coinsurance for other outpatient services 40% coinsurance Certain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details. Inpatient services 20% coinsurance 40% coinsurance Preauthorization required Out-of-Network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits. If you are pregnant Office visits Primary Care: $35/initial visit Specialist: $70/initial visit; deductible does not apply 40% coinsurance Copayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 20% coinsurance 40% coinsurance Childbirth/delivery facility services 20% coinsurance 40% coinsurance If you need help recovering or have other special health needs Home health care 20% coinsurance 40% coinsurance 60 visits/year. Preauthorization may be required for Out-of-Network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details. Rehabilitation services 20% coinsurance 40% coinsurance For Outpatient, limited to combined 35 visits per year, including Chiropractic. Habilitation services 20% coinsurance 40% coinsurance Skilled nursing care 20% coinsurance 40% coinsurance 25-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 equipment 20% coinsurance 40% coinsurance None Hospice services No Charge after deductible 40% coinsurance Inpatient: Preauthorization may be required for Out-of-Network; failure to preauthorize may 0000014 0851

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023. Page 5 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) result in a $250 reduction in benefits. Outpatient: 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. If your child needs dental or eye care Children’s eye exam Not Covered Not Covered None Children’s glasses Not Covered Not Covered None Children’s dental check-up Not Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) • Acupuncture • Bariatric surgery • Cosmetic surgery • Dental care (Adult) • Long-term care • Most coverage provided out the United States. See www.bcbstx.com • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care (Outpatient – max. 35 visits/year) • Hearing aids (Limited to one hearing aid per ear every 36 months) • Infertility treatment (In vitro 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 0000014 0851

Page 6 of 7 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 on how 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: the Claim review section at Blue Cross and Blue Shield of Texas or visit www.bcbstx.com or the Texas Department of Insurance, or www.tdi.texas.gov. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. 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. 0000014 0851

Page 7 of 7 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.  The plan’s overall deductible $1,500  Specialist copayment $70  Hospital (facility) coinsurance 20%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $1,500 Copayments $40 Coinsurance $2,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,800  The plan’s overall deductible $1,500  Specialist copayment $70  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 $5,600 In this example, Joe would pay: Cost Sharing Deductibles $900 Copayments $700 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $1,620  The plan’s overall deductible $1,500  Specialist copayment $70  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 $2,800 In this example, Mia would pay: Cost Sharing Deductibles $1,500 Copayments $600 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,200 The plan would be responsible for the other costs of these EXAMPLE covered services. Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) 0000014 0851

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023-12/31/2023 : ATBCB211 Blue Choice PPO Basic A211 Coverage for: Individual/Family | Plan Type: PPO Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-800-521-2227. For definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Network: $3,000 Individual/$9,000 Family Out-of-Network: $10,000 Individual/$20,000 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Network office visits, prescription drugs and preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? 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 Family Out-of-Network: Unlimited Individual/Unlimited Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance billing charges, and health care this plan 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 ATBCB2112023E01012023 0000018 0851C :doireP egarevo 1 3202/10/1 -1 4202/13/0C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Page 2 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $35/visit; deductible does not apply 40% coinsurance Virtual visits are available. See your benefit booklet* for details. Specialist visit $70/visit; deductible does not apply 40% coinsurance None Preventive care/screening/ immunization No Charge; deductible does not apply 40% coinsurance You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Inpatient: Certain services may require Preauthorization for Out-of-Network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for Out-of-Network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details. Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-lists Preferred generic drugs Retail - Preferred - No Charge Non-Preferred - $10/prescription Mail - No Charge; deductible does not apply Retail - $10/prescription; deductible does not apply plus 50% additional charge Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional charge will not apply to any deductible or out-of-pocket amounts. Cost Sharing for insulin included in the drug list will Non-preferred generic drugs Retail - Preferred - $10/prescription Non-Preferred - $20/prescription Mail - $30/prescription; deductible does not apply Retail - $20/prescription; deductible does not apply plus 50% additional charge 0000018 0851

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023. Page 3 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Preferred brand drugs Retail - Preferred - $50/prescription Non-Preferred - $70/prescription Mail - $150/prescription; deductible does not apply Retail - $70/prescription; deductible does not apply plus 50% additional charge not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription. Non-preferred brand drugs Retail - Preferred - $100/prescription Non-Preferred - $120/prescription Mail - $300/prescription; deductible does not apply Retail - $120/prescription; deductible does not apply plus 50% additional charge Preferred specialty drugs $150/prescription; deductible does not apply $150/prescription; deductible does not apply plus 50% additional charge Non-preferred specialty drugs $250/prescription; deductible does not apply $250/prescription; deductible does not apply plus 50% additional charge If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Certain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details. Physician/surgeon fees 20% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care $500/visit plus 20% coinsurance $500/visit plus 20% coinsurance Copayment waived if admitted. Emergency medical transportation 20% coinsurance 20% coinsurance None Urgent care $75/visit; deductible does not apply 40% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Preauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit 0000018 0851

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023. Page 4 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Physician/surgeon fees 20% coinsurance 40% coinsurance booklet* for details. If you need mental health, behavioral health, or substance abuse services Outpatient services $35/office visit; deductible does not apply or 20% coinsurance for other outpatient services 40% coinsurance Certain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details. Inpatient services 20% coinsurance 40% coinsurance Preauthorization required Out-of-Network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits. If you are pregnant Office visits Primary Care: $35/initial visit Specialist: $70/initial visit; deductible does not apply 40% coinsurance Copayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 20% coinsurance 40% coinsurance Childbirth/delivery facility services 20% coinsurance 40% coinsurance If you need help recovering or have other special health needs Home health care 20% coinsurance 40% coinsurance 60 visits/year. Preauthorization may be required for Out-of-Network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details. Rehabilitation services 20% coinsurance 40% coinsurance For Outpatient, limited to combined 35 visits per year, including Chiropractic. Habilitation services 20% coinsurance 40% coinsurance Skilled nursing care 20% coinsurance 40% coinsurance 25-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 equipment 20% coinsurance 40% coinsurance None Hospice services No Charge after deductible 40% coinsurance Inpatient: Preauthorization may be required for Out-of-Network; failure to preauthorize may 0000018 0851

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023. Page 5 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) result in a $250 reduction in benefits. Outpatient: 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. If your child needs dental or eye care Children’s eye exam Not Covered Not Covered None Children’s glasses Not Covered Not Covered None Children’s dental check-up Not Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) • Acupuncture • Bariatric surgery • Cosmetic surgery • Dental care (Adult) • Long-term care • Most coverage provided out the United States. See www.bcbstx.com • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care (Outpatient – max. 35 visits/year) • Hearing aids (Limited to one hearing aid per ear every 36 months) • Infertility treatment (In vitro 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 0000018 0851

Page 6 of 7 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 on how 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: the Claim review section at Blue Cross and Blue Shield of Texas or visit www.bcbstx.com or the Texas Department of Insurance, or www.tdi.texas.gov. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. 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. 0000018 0851

Page 7 of 7 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.  The plan’s overall deductible $3,000  Specialist copayment $70  Hospital (facility) coinsurance 20%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $3,000 Copayments $40 Coinsurance $1,900 What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,000  The plan’s overall deductible $3,000  Specialist copayment $70  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 $5,600 In this example, Joe would pay: Cost Sharing Deductibles $900 Copayments $700 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $1,620  The plan’s overall deductible $3,000  Specialist copayment $70  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 $2,800 In this example, Mia would pay: Cost Sharing Deductibles $2,100 Copayments $600 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,700 The plan would be responsible for the other costs of these EXAMPLE covered services. Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) 0000018 0851

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023-12/31/2023 : ATBAP305 Blue Advantage HMO A305 Coverage for: Individual/Family | Plan Type: HMO Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-877-299-2377. For definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $2,500 Individual/$7,500 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Network office visits, prescription drugs and preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? Yes. ER $500. There are no other specific deductibles. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. What is the out-of-pocket limit for this plan? $5,500 Individual/$14,700 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance billing charges, and health care this plan 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/bahmo or call 1-877-299-2377 for a list of Participating 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? Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. SLMR ATBAP3052023E01012023 0000005 0851C :doireP egarevo 1 3202/10/1 -1 4202/13/0C :rof egarevo I ylimaF + laudividn | P :epyT nal H OM

Page 2 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $35/visit; deductible does not apply Not Covered Virtual visits are available. See your benefit booklet* for details. Specialist visit $70/visit; deductible does not apply Not Covered Referral required. Preventive care/screening/ immunization No Charge; deductible does not apply Not Covered You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No Charge; deductible does not apply Not Covered None Imaging (CT/PET scans, MRIs) 30% coinsurance Not Covered If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-lists Preferred generic drugs Retail - Preferred - No Charge Non-Preferred - $10/prescription Mail - No Charge; deductible does not apply Not Covered Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Cost Sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription. Non-preferred generic drugs Retail - Preferred - $10/prescription Non-Preferred - $20/prescription Mail - $30/prescription; deductible does not apply Not Covered Preferred brand drugs Retail - Preferred - $50/prescription Non-Preferred - $70/prescription Mail - $150/prescription; deductible does not apply Not Covered 0000005 0851

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023. Page 3 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Non-preferred brand drugs Retail - Preferred - $100/prescription Non-Preferred - $120/prescription Mail - $300/prescription; deductible does not apply Not Covered Preferred specialty drugs $150/prescription; deductible does not apply Not Covered Non-preferred specialty drugs $250/prescription; deductible does not apply Not Covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 30% coinsurance Not Covered For Outpatient Infusion Therapy, see your benefit booklet* for details. Physician/surgeon fees 30% coinsurance Not Covered If you need immediate medical attention Emergency room care $500/visit plus 30% coinsurance $500/visit plus 30% coinsurance Per Occurrence Deductible waived if admitted. Emergency medical transportation 30% coinsurance 30% coinsurance None Urgent care $75/visit; deductible does not apply Not Covered If you have a hospital stay Facility fee (e.g., hospital room) 30% coinsurance Not Covered None Physician/surgeon fees 30% coinsurance Not Covered If you need mental health, behavioral health, or substance abuse services Outpatient services $35/office visit; deductible does not apply or 30% coinsurance for other outpatient services Not Covered None Inpatient services 30% coinsurance Not Covered None If you are pregnant Office visits Primary Care: $35/initial visit Specialist: $70/initial visit; deductible does not apply Not Covered 0000005 0851

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023. Page 4 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Childbirth/delivery professional services 30% coinsurance Not Covered Copayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery facility services 30% coinsurance Not Covered If you need help recovering or have other special health needs Home health care 30% coinsurance Not Covered None Rehabilitation services 30% coinsurance Not Covered None Habilitation services 30% coinsurance Not Covered Skilled nursing care 30% coinsurance Not Covered 60-day maximum per calendar year. Durable medical equipment 30% coinsurance Not Covered None Hospice services No Charge after deductible Not Covered None If your child needs dental or eye care Children’s eye exam Not Covered Not Covered Eye screenings only. Does not include refractions. One visit per year for members ages 17 and younger. Children’s glasses Not Covered Not Covered None Children’s dental check-up Not Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) • Acupuncture • Bariatric surgery • Children's dental check-up • Children's glasses • Cosmetic surgery • Dental care (Adult) • Long-term care • Non-emergency care when traveling outside the U.S. • Weight loss programs 0000005 0851

Page 5 of 7 Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care (Preauthorization required) • Hearing aids (Limited to one hearing aid per ear every 36 months) • Infertility treatment (Invitro not covered) • Private-duty nursing (Only when ordered or authorized by the Primary Care Physician) • Routine eye care (Adult - One visit every two years for members ages 18 and older) • Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. 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 1-877-299-2377. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377. Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-299-2377. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377. 0000005 0851

Page 6 of 7 To see examples of how this plan might cover costs for a sample medical situation, see the next section. 0000005 0851

Page 7 of 7 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.  The plan’s overall deductible $2,500  Specialist copayment $70  Hospital (facility) coinsurance 30%  Other coinsurance 30% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $2,500 Copayments $40 Coinsurance $2,700 What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,300  The plan’s overall deductible $2,500  Specialist copayment $70  Hospital (facility) coinsurance 30%  Other coinsurance 30% 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 $5,600 In this example, Joe would pay: Cost Sharing Deductibles $800 Copayments $700 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $1,520  The plan’s overall deductible $2,500  Specialist copayment $70  Hospital (facility) coinsurance 30%  Other coinsurance 30% 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 $2,800 In this example, Mia would pay: Cost Sharing Deductibles $2,100 Copayments $600 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,700 The plan would be responsible for the other costs of these EXAMPLE covered services. Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) 0000005 0851

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This brochure highlights the main features of the City of Newton’s employee benets program. It does not include all plan rules, details, limitaons, and exclusions. The terms of your benet plans are governed by legal documents, including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents, the plan documents are nal authority. The City of Newton reserves the right to change or disconnue the employee benets plans at any me. Prepared by Texas Financial Center 150 W. Gibson Street Jasper, Texas 75951