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Medical Comparison Benefit Summary UMR TPA High Deductible Health Plan UMR TPA Standard Plan In Network Benefits Out of Network Benefits In Network Benefits Out of Network Benefits Annual Deductible Individual 1 500 2 500 1 000 2 000 Family 3 000 5 000 2 000 4 000 Coinsurance 90 70 90 70 Maximum Out of Pocket Individual 3 000 5 000 3 100 6 200 Family 6 000 10 000 6 200 12 400 Physician Office Visit Primary Care 90 after deductible 70 after deductible 25 copay per visit 70 after deductible Specialty Care 90 after deductible 70 after deductible 40 copay per visit 70 after deductible Preventive Care Adult Periodic Exams 100 70 after deductible 100 70 after deductible Well Child Care 100 70 after deductible 100 70 after deductible Diagnostic Services X ray and Lab Tests 90 after deductible 70 after deductible 90 after deductible 70 after deductible Complex Radiology 90 after deductible 70 after deductible 90 after deductible 70 after deductible Urgent Care Facility 90 after deductible 70 after deductible 50 copay 70 after deductible Emergency Room Facility Charges 90 after deductible 100 copay then 90 after deductible Inpatient Facility Charges 90 after deductible 70 after deductible 90 after deductible 70 after deductible Outpatient Facility and Surgical Charges 90 after deductible 70 after deductible 90 after deductible 70 after deductible Mental Health Inpatient 90 after deductible 70 after deductible 90 after deductible 70 after deductible Outpatient 90 after deductible 70 after deductible 90 after deductible 70 after deductible Substance Abuse Inpatient 90 after deductible 70 after deductible 90 after deductible 70 after deductible Outpatient 90 after deductible 70 after deductible 90 after deductible 70 after deductible Other Services Chiropractic 90 after deductible 70 after deductible 90 after deductible 70 after deductible Retail Pharmacy 30 Day Supply at Participating Pharmacies Generic Tier 1 10 copay after deductible 10 copay Preferred Tier 2 25 copay after deductible 25 copay Non Preferred Tier 3 50 copay after deductible 50 copay Mail Order Pharmacy 90 Day Supply Filled at Caremark CVS Mail Order Generic Tier 1 30 copay after deductible 30 copay Preferred Tier 2 75 copay after deductible 75 copay Non Preferred Tier 3 150 copay after deductible 150 copay Important HSA Plan Notice for those enrolled in Family Coverage No individual members deductible or out of pocket is considered satisfied until the FULL FAMILY deductible and out of pocket has been met for the plan year

13 Dental City of Appleton will continue to offer a dental program through Delta Dental It is recommended when a course of treatment is expected to cost 300 or more and is of a non emergency nature your dentist should submit a treatment plan before treatment begins This enables you to see your expected out of pocket expenses to budget accordingly There is also a possibility that suggested procedures may be denied and alternative procedures approved based upon X rays and supporting documentation Please refer to the summary plan description for complete plan details Dental Monthly Rate Employee Family Monthly Rate 10 00 per month 20 00 per month Full Premium 51 33 130 53 Dental Comparison Annual Deductible Individual Family Waived for Preventive Care Annual Maximum Per Individual Preventive Basic Major Oral Surgery Annual Maximum per person per year Surgical procedures Orthodontia Benefit Percentage Adults and Covered Full Time Students if Eligible Dependent Child ren Lifetime Maximum Benefit Waiting Periods Delta Dental of Wisconsin Inc PPO Premier 91812 In Network Benefits 50 150 Yes 1 500 100 80 50 2 000 50 50 Covered Covered 2 500 N A

14 Vision The City s Vision Plan is a voluntary benefit and is provided through DeltaVision To access the summary plan document please visit the Human Resources benefits webpage https www appleton org government humanresources employee benefits DeltaVision Network Frame Contact Allowance Copay exams standard plastic lenses Frequency exams lenses or contact frames Based on calendar year Dependent Age Limit Full Plan Insight 150 150 10 10 12 months 12 months 24 months Materials Only Plan Insight 150 150 10 12 months 24 months To age 26 Benefit Details In Network Comprehensive Glasses Exam Standard Contact Lens Fit and Follow Up Premium Contact Lens Fit and Follow Up Frames any available frame at provider location Laser Vision Correction Lasik or PRK Standard Plastic Lenses Single Vision Bifocal Trifocal Standard Progressive Member pays 10 plan pays balance Member pays up to 40 10 discount off retail 150 allowance then 20 off balance 15 off retail price or 5 off promotional price Member pays 10 plan pays balance Member pays 10 plan pays balance Member pays 10 plan pays balance Member pays 75 Premium Progressive Lens Tier 1 95 copay Tier 2 Tier 3 105 copay 120 copay Tier 4 75 copay 80 of charge less 120 allowance Out of Network Reimbursement 35 In Network N A None N A None N A 75 None 150 allowance then 20 off balance 15 off retail price or 5 off promotional price 25 Member pays 10 plan pays balance 40 Member pays 10 plan pays balance 55 Member pays 10 plan pays balance 40 Member pays 75 60 95 copay 60 105 copay 60 120 copay 75 copay 80 of charge 60 less 120 allowance Out of Network Reimbursement N A N A N A 75 None 25 40 55 40 60 60 60 60

15 Lens Options UV Coating Tint solid and gradient Standard Scratch Resistance Standard Polycarbonate Member pays 15 Member pays 15 Member pays 15 Member pays 40 None None None None Member pays 15 Member pays 15 Member pays 15 Member pays 40 Standard Anti Reflective Coating Member pays 45 Premium Anti Reflective Coating Tier 1 57 None None Member pays 45 57 Tier 2 68 None 68 Tier 3 80 of charge None 80 of charge Other Add Ons and Services 20 off retail None 20 off retail Contact Lenses In lieu of glasses Contact lens allowance covers materials only Conventional Disposable 150 allowance then 15 off balance 150 allowance 120 120 150 allowance then 15 off balance 150 allowance Medically Necessary Paid in full 200 Paid in full None None None None None None None None None 120 120 200 Lenses that are spherical power only soft lens materials including planned replacement and conventional lenses Lenses are to be used in a daily wear removed prior to sleep mode only Includes all lens powers and designs other than spherical powers i e toric multifocal etc modes of wear that are extended or overnight schedules and rigid or gas permeable materials Medically necessary contacts require authorization from a vision doctor when some conditions are present Please contact the plan for more information Vision Monthly Rate Full Plan Employee 5 73 per month Family 14 27 per month Materials Only Plan 4 01 per month 9 99 per month

16 Flexible Spending Account The Flexible Spending Account FSA plan allows you to set aside pre tax dollars to cover qualified expenses employees would normally pay out of pocket with post tax dollars The plan is comprised of a dependent care account only The money placed in an FSA is not subject to federal or state taxes How an FSA works Choose a specific amount of money to contribute each pay period pre tax to your account This amount is automatically deducted from your pay each pay period As you incur eligible expenses you may submit the appropriate paperwork to be reimbursed by the plan Important rules to keep in mind The IRS has a strict use it or lose it rule for Dependent Care FSA If you do not use the full amount in your FSA by the end of the calendar year you will lose any remaining funds Once you enroll in the FSA you cannot change your contribution amount during the year unless you experience a qualifying life event You cannot transfer funds from one FSA to another Please plan your FSA contributions carefully as any funds not used by the end of the year will be forfeited Reenrollment is required each year Maximum Annual Election Dependent Care FSA 5 000 DIVERSIFIED BENEFIT SERVICES PO Box 260 Hartland WI 53029 262 367 3300 800 234 1229 www dbsbenefits com

17 Life Insurance Basic Life Insurance provided as an Employer Paid Benefit Non Union Employees All employees who work 20 hours are covered with a term life policy that is 1X your salary rounded to the next even thousand The policy is capped at 50 000 Teamster Employees All full time employees have a 20 000 term life policy APPA Union Employees All full time employees have a 50 000 term life policy Voluntary Life and AD D Insurance All employees working 20 or more hours week have the option to purchase additional life insurance through New York Life at time of hire If you already have this coverage it will appear as a deduction on your payroll statement If you are interested in purchasing or requesting to increase decrease cancel your coverage please contact Blia Vang for appropriate paperwork If this benefit was waived during your initial eligibility you will need to submit an Evidence of Insurability to Underwriting to be approved for this benefit Available Coverage Benefit Amount Employee Units of 10 000 Spouse Units of 10 000 Child ren 10 000 Maximum Lesser of 7 times salary or 500 000 250 000 10 000 Guaranteed Issue 150 000 50 000 All amounts Age 0 19 20 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75 79 Employee Cost Per 1 000 0 080 0 080 0 080 0 090 0 130 0 210 0 340 0 510 0 770 1 260 2 280 3 230 6 970 Spouse Cost Per 1 000 0 080 0 080 0 080 0 090 0 130 0 210 0 340 0 510 0 770 1 260 2 280 N A N A How to Calculate Your Monthly Cost Step 1 Use the rate chart to find your Monthly rate based on your age as of your effective date Step 2 Multiply this rate by your desired coverage amount in units of 1 000 Step 3 The result is the Monthly cost Child Cost Per 1 000 0 200 Example Bob is 27 years old with 100 000 coverage amount 0 08 x 100 000 1 000 8 00 per month Actual per pay period premiums may differ slightly due to rounding The rates above reflect the total cost All spouse rates are based on spouse age Rates vary by age and may be subject to change in the future Benefits will reduce based on age see Benefits Reduction Schedule for details found on the Human Resources benefit webpage

18 Long Term Disability Insurance NON UNION EMPLOYEES City of Appleton provides long term income protection through New York Life in the event you become unable to work due to a non workrelated illness or injury This benefit covers 60 of your monthly base salary up to 5 000 Benefit payments begin after 90 days of disability See Certificate of Coverage for benefit duration Please see the summary plan description for complete plan details FIRE POLICE AND TEAMSTER UNION EMPLOYEES City of Appleton offers long term income protection through New York Life in the event you become unable to work due to a non work related illness or injury on a voluntary basis Plan Option 1 This benefit covers 60 of your monthly base salary up to 5 000 Benefit payments begin after 90 days of disability See Certificate of Coverage for benefit duration Please see the summary plan description for complete plan details on the Human Resources benefits webpage This plan pays out until the employee is able to return to work or for a maximum of 5 years Plan Option 2 City of Appleton offers long term income protection through New York Life in the event you become unable to work due to a non work related illness or injury This benefit covers 60 of your monthly base salary up to 5 000 Benefit payments begin after 180 days of disability See Certificate of Coverage for benefit duration Please see the summary plan description for complete plan details on the Human Resources benefits webpage This plan pays out until employee is able to return to work or until age 65 Short Term Disability Offering All employees are eligible to purchase shortterm disability on a voluntary basis Plan Option 1 City of Appleton offers a short term disability option through New York Life This benefit covers 60 of your weekly base salary up to 750 week The benefit begins after 14 days of injury or illness and lasts up to 11 weeks Please see the summary plan description for complete plan details on the Human Resources benefits webpage Plan Option 2 City of Appleton offers a short term disability option through New York Life This benefit covers 60 of your weekly base salary up to 750 week The benefit begins after 30 days of injury or illness and lasts up to 26 weeks Please see the summary plan description for complete plan details on the Human Resources benefits webpage IF YOU DID NOT ELECT THIS VOLUNTARY COVERAGE AT ELIGIBILITY YOU NEED TO CONTACT BLIA VANG TO REQUEST PAPERWORK FOR UNDERWRITING APPROVAL AS A LATE APPLICANT COVERAGE APPEARS AS DEDUCTION ON YOUR PAYROLL STATEMENT

19 Post Employment Health Plan HRA The City s PEHP HRA vendor is MidAmerica All fulltime employees have an active account while employed with the City The City contributes 10 per month for all full time benefited employees into this account Log into www myMidAmericaJourney com to view your account balance at any time and manage the mutual fund s The default fund is set to a fixed rate mutual or you can move it to another available fund option Once you separate from the City the funds in this account will be available to be used to pay for any qualified medical expenses Accident Insurance Accident insurance is affordable voluntary insurance that can help you pay for out of pocket costs you may experience after an accident It pays you benefits for specific injuries and events resulting from a covered accident The amount paid depends on the type of injury and care received Monthly Rates Policy Type Employee only Employee Spouse Employee Children Family Per Check Deduction 6 21 10 29 11 72 15 80 Wellness benefit included in this policy when you complete a wellness test i e City s health screening in fall mammogram colonoscopy pap test etc you are guaranteed the annual 100 employee and 100 spouse payment Children under age 18 that have a well child check are eligible for 50 per child to a maximum of 200 per family Open enrollment is the election period for this benefit every year If you wish to add or cancel this benefit please make your online election during the enrollment process for 2023

21 Retirement Wisconsin Retirement System WRS All employees working more than 1200 hours per year are automatically enrolled in the state pension Both the employee and employer contribute each payroll to this benefit Visit www etf wi gov to learn more and to calculate an unofficial projection of your WRS benefits Contributor ALL EMPLOYEES EMPLOYER General EMPLOYER Protective with Social Security EMPLOYER Protective without Social Security 2023 per payroll 6 8 6 8 13 2 18 1 Deferred Compensation 457 Plan The City s retirement savings plan through Voya Financial helps you to set a little aside regularly for the kind of retirement you can look forward to The earlier you begin to set aside funding the better it grows You can enroll in the plan view plan information review investment options and performance access retirement articles seminars newsletters and schedule meetings with Julie Rodriguez our Voya rep Website Appleton beready2retire com