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Message 2025 Benefits Enrollment GuideSTAR URGENT CARE PLLC, DBA DAVAM URGENT CAREPresented by:

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Page 3WELCOME TO OPEN ENROLLMENT FOR YOUR 2025BENEFITS“WORKING TOGETHER FOR A HEALTHY WELL-BEING AND FINANCIAL SECURITY”Star Urgent Care PLLC, DBA Davam Urgent Care is pleased to provide you with a benefitprogram designed to safeguard your financial and health care needs. This booklet is a guideto help you make benefit choices that are best for you and your family. It is not a completedescription of the plan provisions. Copies of the Policy Documents and/or Summary ofBenefits and Coverage are available by contacting Human Resources.2025 BENEFITS• Medical benefits with BC/BS of Texas• Basic Life benefits with Standard Insurance• Voluntary Life benefits with Standard Insurance

Page 4TABLE OF CONTENTSWelcome to Open Enrollment for Your 2025 Benefits ............................................................. 3Introduction ............................................................................................................................... 5Important Information & Contacts ............................................................................................ 6Medical Benefits – BC/BS of Texas .......................................................................................... 7Medical Benefits – BC/BS of Texas .......................................................................................... 8Medical Benefits – BC/BS of Texas .......................................................................................... 9Medical Benefits – BC/BS of Texas ........................................................................................ 10Medical Benefits – BC/BS of Texas ........................................................................................ 11Medical Benefits – BC/BS of Texas ........................................................................................ 12Provider Finder ........................................................................................................................ 13BCBS App ................................................................................................................................ 14Virtual Visits............................................................................................................................. 15Well On Target ......................................................................................................................... 17Basic Life and AD&D Benefits – Standard Insurance............................................................. 19BASIC LIFE SUMMARY ............................................................................................................. 20Voluntary Life and AD&D Benefits – Standard Insurance ...................................................... 22VOLUNTARY LIFE SUMMARY ................................................................................................... 23Notes ....................................................................................................................................... 30

Page 5INTRODUCTIONWHO IS ELIGIBLE?Eligible employees are full-time, working 30 hours or more per week.WHEN IS MY COVERAGE EFFECTIVE?Coverage is effective on the 1st of the month following 60 days for new hires and 1/1/2025for open enrollment.WHO ARE MY ELIGIBLE DEPENDENTS?Eligible dependents include:• Legal spouse• Biological, adopted or stepchildren less than age 26• Physically or mentally handicapped children (regardless of age)HOW DO I ENROLL?To enroll, you must complete and submit the following documents:• Enrollment FormHOW DO I DECLINE COVERAGE?To decline, you must complete and submit the following documents:• Enrollment Form (check waiver boxes)• Beneficiary Designation Form (if applicable)CAN I CHANGE MY COVERAGE DURING THE YEAR?The benefits you elect during open enrollment will remain in effect through the end of theplan year. Outside of open enrollment, you can only make a change to your coverage whenyou have a qualifying event.QUALIFYING CHANGES INCLUDE:• Change to your legal marital status• Birth, legal adoption or legal placement for adoption of a child• Dependent child ceases to be an eligible dependent• Death of spouse or dependent child• Termination of Employment / Reduction of work hours• Spouse or dependent child’s loss of other coveragePlease note, you must notify Human Resources within 30 days of the qualifying event.

Page 6IMPORTANT INFORMATION & CONTACTSFor the issues listed below, the answers to your questions, can be easily found on thecarrier’s website or by calling the carrier directly:• Finding In-Network Doctors• Replacing/Ordering ID Cards• When is my effective date?• Benefit coverage information• Is my prescription covered?• How much will my prescription cost?• Who is covered under my plan?• Claims inquires• What is my deductible?• How much of mydeductible has been met?• Is this procedure covered?CARRIER INFORMATIONContact Group Number Phone WebsiteMedicalBC/BS of Texas176643(800) 521-2227www.bcbstx.comLife and AD&DStandard Insurance168988(888) 937-4783www.standard.comVoluntary Life and AD&DStandard Insurance168988(888) 937-4783www.standard.comBENEFITS SPECIALISTS TEAMNameTitlePhoneEmailCynthia FaldynAccount Manager(713) 388-1253Cynthia.Faldyn@frostinsurance.comCharles KelleyProducer(713) 388-1563Charles.Kelley@frostinsurance.comEligibilityHoustonEligibility@frostinsurance.com

Page 7MEDICAL BENEFITS – BC/BS OF TEXASStar Urgent Care PLLC, DBA Davam Urgent Care offers eligible employees and their dependentsmedical insurance through BC/BS of Texas. The following chart summarizes the services offered thisplan year. A more detailed description of the plan can be found in the Summary of Benefits andCoverage.Network: Blue AdvantageYou can locate In-Network providers through the BC/BS of Texas website at www.bcbstx.com.B660ADT HMOIn-NetworkCalendar Year Deductible (Individual / Family) $7,500 / $15,000Coinsurance (Carrier / Member) 100% / 0%Out of Pocket Maximum (Individual / Family) $7,500 / $15,000Physician Office Visit 0% after deductibleSpecialist Office Visit 0% after deductibleDiagnostic Test (Lab and X-ray) 0% after deductibleAdvanced Imaging (CT, MRI, Pet Scan) 0% after deductibleInpatient Hospitalization 0% after deductibleOutpatient Surgery 0% after deductibleEmergency Room $750 copay after deductibleUrgent Care 0% after deductiblePreventive Services 100% CoveredPrescription Drug Deductible (Individual / Family) 0% after deductiblePrescription Drug Copay - Mail Order 0% after deductibleTelemedicine MDLIVEOut-of-NetworkCalendar Year Deductible (Individual / Family) No CoverageCoinsurance (Carrier / Member) No CoverageOut of Pocket Maximum (Individual / Family) No CoverageAGE RATED

Page 8MEDICAL BENEFITS – BC/BS OF TEXASStar Urgent Care PLLC, DBA Davam Urgent Care offers eligible employees and their dependentsmedical insurance through BC/BS of Texas. The following chart summarizes the services offered thisplan year. A more detailed description of the plan can be found in the Summary of Benefits andCoverage.Network: Blue AdvantageYou can locate In-Network providers through the BC/BS of Texas website at www.bcbstx.com.S644ADT HMOIn-NetworkCalendar Year Deductible (Individual / Family) $8,200 / $16,400Coinsurance (Carrier / Member) 100% / 0%Out of Pocket Maximum (Individual / Family) $8,200 / $16,400Physician Office Visit $55 copaySpecialist Office Visit $110 copayDiagnostic Test (Lab and X-ray)Lab: 0% after deductibleX-Ray: $200/test after deductibleAdvanced Imaging (CT, MRI, Pet Scan) $300/testInpatient Hospitalization $350 copay + 0% after deductibleOutpatient Surgery $300 copay + 0% after deductibleEmergency Room $500 copay + 0% after deductibleUrgent Care $75Preventive Services 100% coveredPrescription Drug Deductible (Individual / Family) $0/$10$/$50/$100 / $150/$250Prescription Drug Copay - Mail Order 3x copayTelemedicine MDLIVEOut-of-NetworkCalendar Year Deductible (Individual / Family) No CoverageCoinsurance (Carrier / Member) No CoverageOut of Pocket Maximum (Individual / Family) No CoverageAGE RATES

Page 9MEDICAL BENEFITS – BC/BS OF TEXASStar Urgent Care PLLC, DBA Davam Urgent Care offers eligible employees and their dependentsmedical insurance through BC/BS of Texas. The following chart summarizes the services offered thisplan year. A more detailed description of the plan can be found in the Summary of Benefits andCoverage.Network: Blue AdvantageYou can locate In-Network providers through the BC/BS of Texas website at www.bcbstx.com.G663ADT HMOIn-NetworkCalendar Year Deductible (Individual / Family) $1,600 / $4,800Coinsurance (Carrier / Member) 80% / 20%Out of Pocket Maximum (Individual / Family) $5,350 / $10,705Physician Office Visit $50 copaySpecialist Office Visit $100 copayDiagnostic Test (Lab and X-ray) 20% after deductibleAdvanced Imaging (CT, MRI, Pet Scan) $300/testInpatient Hospitalization 20% after deductibleOutpatient Surgery 20% after deductibleEmergency Room $500/visit + 20% after deductibleUrgent Care $100/visitPreventive Services 100% coveredPrescription Drug Deductible (Individual / Family) $5/$15/$50/$100/$150 / $250Prescription Drug Copay - Mail Order 3x copayTelemedicine MDLIVEOut-of-NetworkCalendar Year Deductible (Individual / Family) No CoverageCoinsurance (Carrier / Member) No CoverageOut of Pocket Maximum (Individual / Family) No CoverageAGE RATES

Page 10MEDICAL BENEFITS – BC/BS OF TEXASStar Urgent Care PLLC, DBA Davam Urgent Care offers eligible employees and their dependentsmedical insurance through BC/BS of Texas. The following chart summarizes the services offered thisplan year. A more detailed description of the plan can be found in the Summary of Benefits andCoverage.Network: Blue ChoiceYou can locate In-Network providers through the BC/BS of Texas website at www.bcbstx.com.B662CHC PPOIn-NetworkCalendar Year Deductible (Individual / Family) $8,650 / $17,300Coinsurance (Carrier / Member) 100% / 0%Out of Pocket Maximum (Individual / Family) $8,650 / $17,300Physician Office Visit 0% after deductibleSpecialist Office Visit 0% after deductibleDiagnostic Test (Lab and X-ray) 0% after deductibleAdvanced Imaging (CT, MRI, Pet Scan) 0% after deductibleInpatient Hospitalization 0% after deductibleOutpatient Surgery 0% after deductibleEmergency Room 0% after deductibleUrgent Care 0% after deductiblePreventive Services 100% coveredPrescription Drug Deductible (Individual / Family) 0% after deductiblePrescription Drug Copay - Mail Order 0% after deductibleTelemedicine MDLIFEOut-of-NetworkCalendar Year Deductible (Individual / Family) $17,300 / $34,600Coinsurance (Carrier / Member) 100% / 0%Out of Pocket Maximum (Individual / Family) $17,300 / $34,600AGE RATES

Page 11MEDICAL BENEFITS – BC/BS OF TEXASStar Urgent Care PLLC, DBA Davam Urgent Care offers eligible employees and their dependentsmedical insurance through BC/BS of Texas. The following chart summarizes the services offered thisplan year. A more detailed description of the plan can be found in the Summary of Benefits andCoverage.Network: Blue ChoiceYou can locate In-Network providers through the BC/BS of Texas website at www.bcbstx.com.G656CHC PPOIn-NetworkCalendar Year Deductible (Individual / Family) $4,100 / $12,300Coinsurance (Carrier / Member) 100% / 0%Out of Pocket Maximum (Individual / Family) $4,100 / $12,300Physician Office Visit 0% after deductibleSpecialist Office Visit 0% after deductibleDiagnostic Test (Lab and X-ray) 0% after deductibleAdvanced Imaging (CT, MRI, Pet Scan) 0% after deductibleInpatient Hospitalization 0% after deductibleOutpatient Surgery 0% after deductibleEmergency Room 0% after deductibleUrgent Care 0% after deductiblePreventive Services 100% COVEREDPrescription Drug Deductible (Individual / Family) 0% after deductiblePrescription Drug Copay - Mail Order 0% after deductibleTelemedicine MDLIVEOut-of-NetworkCalendar Year Deductible (Individual / Family) $8,200 / $24,600Coinsurance (Carrier / Member) 100% / 0%Out of Pocket Maximum (Individual / Family) $8,200 / $24,600AGE RATES

Page 12MEDICAL BENEFITS – BC/BS OF TEXASStar Urgent Care PLLC, DBA Davam Urgent Care offers eligible employees and their dependentsmedical insurance through BC/BS of Texas. The following chart summarizes the services offered thisplan year. A more detailed description of the plan can be found in the Summary of Benefits andCoverage.Network: Blue ChoiceYou can locate In-Network providers through the BC/BS of Texas website at www.bcbstx.com.P620CHC PPOIn-NetworkCalendar Year Deductible (Individual / Family) $350 / $1,050Coinsurance (Carrier / Member) 80% / 20%Out of Pocket Maximum (Individual / Family) $1,600 / $4,800Physician Office Visit $35 copaySpecialist Office Visit $70 copayDiagnostic Test (Lab and X-ray) 20% after deductibleAdvanced Imaging (CT, MRI, Pet Scan) $250/testInpatient Hospitalization $150 copay + 20% after deductibleOutpatient Surgery $100 copay +20% after deductibleEmergency Room $300 copay + 20% after deductibleUrgent Care $35 copayPreventive Services 100% coveredPrescription Drug Deductible (Individual / Family) $0/$10/$35/$75/$150/$250Prescription Drug Copay - Mail Order 3x copayTelemedicine MDLIVEOut-of-NetworkCalendar Year Deductible (Individual / Family) $700 / $2,100Coinsurance (Carrier / Member) 60% / 40%Out of Pocket Maximum (Individual / Family) Unlimited / UnlimitedAGE RATES

Page 19BASIC LIFE AND AD&D BENEFITS – STANDARD INSURANCEStar Urgent Care PLLC, DBA Davam Urgent Care offers eligible actively at work employees aBasic Life and Accidental Death & Dismemberment (AD&D) benefit through StandardInsurance. This benefit is at no cost to you.In addition to your Basic Life benefit, Basic Accidental Death & Dismemberment benefits arepayable to your beneficiary, if you are deceased within 365 days after a covered accidentand the cause of death can be attributed to the covered accident. Your AD&D benefit isequal to your Basic Life benefit amount. The loss must have occurred within 365 days of thecovered accident. A more detailed description of the plan can be found in the Summary ofBenefits and Coverage.Basic Life BenefitBenefit Amount $50,000Age Reduction Schedule65% @ age 65 50% @ age 70 35% @ age75

Page 22VOLUNTARY LIFE AND AD&D BENEFITS – STANDARDINSURANCEStar Urgent Care PLLC, DBA Davam Urgent Care offers eligible actively at work employeesand their dependents the option to purchase Voluntary Life and Accidental Death &Dismemberment (AD&D) benefit through Standard Insurance.In addition to your Voluntary Life benefit, Voluntary Accidental Death & Dismembermentbenefits are payable to your beneficiary, if you are deceased within 365 days after a coveredaccident and the cause of death can be attributed to the covered accident. The loss musthave occurred within 365 days of the covered accident. A more detailed description of theplan can be found in the Summary of Benefits and Coverage.Employee Life BenefitEmployee Life Increments or Salary$10,000 IncrementsEmployee Guarantee Issue$150,000Employee Maximum Amount$300,000Spouse Life BenefitSpouse Life Increments$5,000 IncrementsSpouse Guarantee Issue$10,000Spouse MaximumAmount$150,000Child(ren) Life BenefitChild(ren) Life Increments$2,000 IncrementsChild(ren) Guarantee Issue$10,000OtherAge-Based ReductionPortableEmployees and dependents have the ability to elect coverage up to the guaranteed issueamount without having to provide Evidence of Insurability, if coverage is elected within 30days of your date of eligibility. Evidence of Insurability is required if you enroll for coverageover the guaranteed issue amount, if you increase your current election, or if you do notenroll within 30 days from your date of eligibility.

Page 30NOTES________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Page 31This Benefits Enrollment Guide (this “Guide”) is presented by Frost Insurance Agency, Inc. (“FIA”) on behalf ofStar Urgent Care PLLC, DBA Davam Urgent Care (“Plan Sponsor”) for illustrative and informational purposesonly. This Guide does not include all of the details contained in the applicable insurance contracts and plandocuments. If there is any discrepancy between this information and the insurance contracts and plandocuments, the insurance contracts and plan documents will control. If there are any errors or omissions in thisGuide, the Plan Sponsor and FIA reserve the right to correct such errors or omissions. In addition, Plan Sponsorreserves the right to unilaterally amend, change, or terminate the health benefit plans, any underlying contractsor any other programs, at any time and without notice, at its sole discretion, according to the terms of theapplicable plans or programs.

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