ROC Benefits Guide : simplebooklet.com

Employee Benefits Guide April 2024– March 2025EligibilityAll full-time employees are eligible to enroll in the employee benefits outlined in this guide. If you are a newly hired employee, you become eligible for benefits on 1st for the month following 60th day of hire. Employees may also enroll their spouse and any dependent children up to the age of 26 in the benefits they elect. If a dependent child turns 26 during the plan year, he or she will automatically be removed from the benefits at the end of their birth month as they are no longer eligible. For questions on dependent children Eligibility, please visit https://www.healthcare.gov/young-adults/children-under-26/. Open EnrollmentWe are renewing with Aetna for medical and moving Dental and Vision to Aetna for the 2024-2025 plan year. Life and Disability coverage will remain the same. Open Enrollment is from March 25th– March 28th. To get enrolled this year, all eligible employees will need to speak to a Benefits Counselor. Benefit Counselors will meet with each employee individually and review all benefit options. There will be a Benefit Counselor onsite March 25th and 26th. If you are unable to meet with a Benefits Counselor in person, please schedule a call with a Benefits Counselor at the following link or scanning the QR code:https://calendly.com/roc-of-houston-2024-2025-open-enrollment/roc-of-houston-2024-2025-open-enrollmentElections must be made no later than Friday, March 28th. This is an active enrollment which means all employees must speak to a Benefits Counselor and either elect or decline all coverages as we will also be offering NEW voluntary supplemental coverage. You must speak to a counselor and elect/decline coverage even if you are not making any changes. You cannot make a mid-year change to your benefits unless you have a qualifying life event, so now is the time to evaluate the needs of your family.New HiresTo schedule a call with a Benefits Counselor, please follow the link below or scan the QR code:https://calendly.com/roc-of-houston-new-hire-enrollment/roc-of-houston-new-hire-enrollmentQualifying Life EventIf you have a qualifying life event during the plan year, you have 30 days from the date of the event to notify HR of any changes that need to be made to your benefit coverages. Examples of a qualifying life event include marriage, divorce, birth, or adoption of a child, change in child’s dependent status, or death.Contents:Page 2 – Benefit ConciergePage 3 – Medical Benefits (Aetna)Page 5 - Money Saving TipsPage 6 – Dental & Vision,(Aetna)Page 8 – Life & Disability (Dearborn)Page 10 – Health Savings Account Info (HSA)Page 13- Voluntary Supplemental Products (Colonial)

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Deductions per year: 26 These rates were prepared on 3/22/2024 and are valid for 90 days.Group Accident (GAC4100) for TXApplicable to policy forms GAC4100-P,GAC4100-ClAdditional Benefits:On/Off-Job Accident CoverageBENEFIT LEVEL AD&D BENEFIT LEVEL ISSUE AGE EMPLOYEE EMPLOYEE ANDSPOUSEEMPLOYEE ANDDEPENDENTCHILD(REN)EMPLOYEE, SPOUSEAND DEPENDENTCHILD(REN)Premier Not Included 17-99 $5.96 $9.12 $14.40 $17.63Premier Preferred 17-99 $6.97 $10.83 $15.78 $19.73Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWithout Wellbeing AssistanceHOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 2: $100017-49 $4.38 $7.89 $6.25 $9.7650-59 $5.68 $11.26 $7.55 $13.1360-64 $7.94 $16.52 $9.81 $18.3965-99 $11.12 $23.12 $12.99 $24.99HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $8.72 $15.69 $12.44 $19.4150-59 $11.31 $22.43 $15.02 $26.1560-64 $15.83 $32.95 $19.55 $36.6765-99 $22.20 $46.15 $25.92 $49.87Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $50 BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $4.11 $6.03 $4.11 $6.0325-29 $5.29 $7.83 $5.29 $7.8330-34 $6.53 $9.63 $6.53 $9.6335-39 $9.30 $13.85 $9.30 $13.8540-44 $12.07 $18.00 $12.07 $18.0045-49 $16.64 $25.06 $16.64 $25.0650-54 $21.14 $32.13 $21.14 $32.1355-59 $27.37 $41.61 $27.37 $41.6160-64 $36.86 $56.01 $36.86 $56.0165-69 $44.89 $68.33 $44.89 $68.3370-74 $44.89 $68.33 $44.89 $68.33Page 1 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice

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Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $50 BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$30,000 17-24 $6.88 $9.97 $6.88 $9.9725-29 $9.23 $13.57 $9.23 $13.5730-34 $11.72 $17.17 $11.72 $17.1735-39 $17.26 $25.62 $17.26 $25.6240-44 $22.80 $33.93 $22.80 $33.9345-49 $31.94 $48.05 $31.94 $48.0550-54 $40.94 $62.17 $40.94 $62.1755-59 $53.40 $81.14 $53.40 $81.1460-64 $72.37 $109.94 $72.37 $109.9465-69 $88.43 $134.59 $88.43 $134.5970-74 $88.43 $134.59 $88.43 $134.59Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $5.77 $8.38 $5.77 $8.3825-29 $7.71 $11.29 $7.71 $11.2930-34 $9.65 $14.20 $9.65 $14.2035-39 $14.08 $20.84 $14.08 $20.8440-44 $18.51 $27.56 $18.51 $27.5645-49 $25.78 $38.84 $25.78 $38.8450-54 $32.98 $50.13 $32.98 $50.1355-59 $42.95 $65.36 $42.95 $65.3660-64 $58.11 $88.41 $58.11 $88.4165-69 $70.99 $108.00 $70.99 $108.0070-74 $70.99 $108.00 $71.06 $108.07$30,000 17-24 $10.20 $14.68 $10.20 $14.6825-29 $14.08 $20.50 $14.08 $20.5030-34 $17.96 $26.31 $17.96 $26.3135-39 $26.82 $39.60 $26.82 $39.6040-44 $35.68 $53.03 $35.68 $53.0345-49 $50.22 $75.60 $50.22 $75.6050-54 $64.62 $98.17 $64.62 $98.1755-59 $84.56 $128.63 $84.56 $128.6360-64 $114.88 $174.74 $114.88 $174.7465-69 $140.63 $213.93 $140.63 $213.9370-74 $140.63 $213.93 $140.77 $214.06Important 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.(Continued...)Page 2 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice

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Group Accident InsurancePremier PlanIf you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benets directly to you to use however you like — from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benets can offer nancial support when you need it.Our coverage includes:• Benets payable directly to you• No medical questions to qualify for coverage• Coverage for simple and complex injuries• Benets payable regardless of other insurance• Worldwide coverage• Works alongside your Health Savings Account (HSA)BENEFITS STORY Milo was working in his yard when he tripped and injured his hand.With Colonial Life accident benets, Milo was able to pay the annual deductible and co-payments for his health insurance plan without using his savings or taking on debt.MILO’S ACCIDENT BENEFITSMilo went to an urgent care facility and received immediate care.Treatment in a physician’s office or urgent care facility$150The doctor ordered an X-ray and discovered Milo had fractured his hand.• X-ray• Fracture (hand)$60$1,200The doctor also found that Milo had a cut on his hand but did not require stitches. Laceration (no repair) $75Milo was discharged with a splint. Durable medical equipment $65Over the next several weeks, Milo had two follow-up appointments with his doctor. Physician follow-up visits (2 visits)$50 x 2 = $100Total $1,650For illustrative purposes only. Benet amounts may vary and may not cover all expenses. GROUP ACCIDENT (GAC4100) — PREMIER PLAN

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Give your benets a boostWe know that more complicated or severe accidents result in more expensive medical bills and more disruption in your life. Group Accident includes a Benet Booster* to provide additional nancial support for serious accidents. If you have more than $5,000 in payable benets for a covered accident, we will give you a $500 boost to your benets to help you with whatever expenses you have. *Payable once per Insured per covered accidentBENEFITS STORY Olivia was driving to the store when she got into a car accident.Olivia’s benets helped her cover her medical expenses when she was injured in a car accident, helping her to focus on her recovery.OLIVIA’S ACCIDENT BENEFITSOlivia arrived by ambulance at the nearest emergency room and received immediate care.• Ambulance• Emergency department visit• Injury due to auto accident$400$250 $250The 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.• X-ray• Medical imaging• Fracture (thigh)$60$400 $4,200Olivia required surgery for her leg.• Surgical repair (thigh fracture)• General anesthesia$4,200 $300Olivia boarded her pet for two nights after her surgery. Pet boarding (2 days) $20 x 2 = $40Olivia had eight sessions of physical therapy to help regain the strength in her leg and two follow-up appointments with her doctor.• Therapy services (8 sessions)• Physician follow-up visits (2 visits)$55 x 8 = $440$50 x 2 = $100Olivia’s benefits for this accident totaled more than $5,000.Benefit Booster $500Total $11,140For illustrative purposes only. Benet amounts may vary and may not cover all expenses. Benets are per covered person per covered accident unless stated otherwiseInjury benets • Burns (based on size and degree) ............. $750–$21,000• Concussion ........................................ $500• Connective tissue damage ......................$100–$200• Eye injury .......................................... $400 • Hearing loss injuries ..................................$120(Maximum once per lifetime per ear per insured)• Injury due to auto accident ........................... $250 • Internal injuries ..................................... $200 • Knee cartilage (meniscus) injury ...................... $200 • Lacerations ...................................$75–$1,200• Loss of a digit — partial .........................$400–$800• Loss of a digit ..............................$1,000–$3,000• Ruptured or herniated disc ......................$200–$400

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Fracture benets• Injury .......................................$200–$5,000 Examples: nger: $200 | wrist: $1,200 | hip: $4,200• Surgical repair of fracture ............................100%(Payable as an additional % of the applicable fractures benet)• Chip fracture ........................................25% (Payable as a % of the applicable fractures benet)Dislocation benets• Injury .......................................$260–$4,000 Examples: elbow: $600 | ankle: $1,600 | hip: $4,000• Surgical repair of dislocation ..........................100%(Payable as an additional % of the applicable dislocations benet)• Incomplete dislocation ................................25%(Payable as a % of the applicable dislocations benet)Treatment benets• Air ambulance .....................................$2,000 • Ambulance (ground or water) ......................... $400 • Durable medical equipment ......................$65–$250• Emergency dental repair ........................$200–$600• Emergency department .............................. $250(Maximum 4 per year) • Family care ................................... $50 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of children)• Injections to prevent or limit infection ...................$50 • Lodging ..................................... $250 per day (Maximum 30 days)• Medical imaging ..................................... $400 • Pain management injections ..........................$150 • Pet boarding .................................. $20 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of pets that are boarded)• Prosthetic device or articial limb ............$1,750–$3,500• Skin grafts (due to burns) .............................50%(Payable as a % of the applicable burn benet)• Skin grafts (not due to burns) ....................$375–$750• Transfusions ........................................ $500 • Transportation ............................... $200 per trip (Maximum 6 one-way trips)• Treatment in a physician’s oce or urgent care facility ...$150(Maximum 4 per year) • X-ray or ultrasound ....................................$60Surgery benets• Anesthesia ....................................$150–$300• Connective tissue surgery ..................... $150–$2,200• Eye surgery .........................................$400• General surgery –Abdominal, thoracic, or cranial ................... $2,000 –Exploratory surgery ...............................$275 • Hernia surgery ......................................$400 • Knee cartilage (meniscus) surgery ..............$150–$1,050• Outpatient surgical facility ............................$400 • Ruptured or herniated disc surgery ............ $150–$2,000Recovery care benets• At-home care ................................ $125 per day(Maximum 5 days) • Benet Booster .....................................$500• Physician follow-up visits ............................. $50 (Maximum 6 days per covered accident and 24 days per calendar year)• Rehabilitation or sub-acute rehabilitation unit connement .............................$200 per day (Maximum 15 days per covered accident and 30 days per calendar year)• Therapy services (speech, physical therapy, occupational therapy) ..........................$55 per day(Maximum 15 days)Options checked below have been chosen by your employer to enhance your Group Accident Coverage.  Recovery Plus package• Behavioral health therapy ...................$55 per day (Maximum 15 days)• Post-traumatic stress disorder (PTSD) ............ $200 • Prescription drug .................................$25 • Additional therapy services (chiropractic, acupuncture, alternative therapy) ......$55 (Existing therapy services benet maximum applies to additional therapy services, maximum 15 days)• Injury due to felonious act of violence or sexual assault ................................ $250(Maximum once per insured per calendar year, with an accompanying police report) Gunshot wound benetThis benet can help pay your medical expenses if you receive a non-fatal gunshot wound. It offers you a lump sum for a covered injury regardless of any other insurance you may have and includes on/off-job coverage.• Gunshot wound .............................$_________This benet covers a non-fatal gunshot wound from a conventional rearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you are shot more than once in a 24-hour period, we can pay benets only for the rst wound.

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For more information, talk with your benefits counselor.ColonialLife.comGroup Hospital Indemnity InsurancePlan 1 (HSA-Compliant)PA: “Hospital Confinement Admission” benefit replaces the “Hospital Confinement” benefitTHIS INSURANCE PROVIDES LIMITED BENEFITS.Insureds in California must be covered by comprehensive health insurance before applying for Hospital Confinement Indemnity Insurance.EXCLUSIONSWe will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occur as a result of the following exclusions and limitations. (a) alcoholism or drug addiction; (b) dental procedures; (c) elective procedures and cosmetic surgery; (d) felonies or illegal occupations; (e) mental or nervous disorders; (f) pregnancy of a dependent child; (g) suicide or injuries which any covered person intentionally does to himself or herself; or (h) war. We will not pay benefits for hospital confinement (i) due to giving birth within the first nine months aer the eective date of the policy or (j) for a newborn who is neither injured nor sick. (k) The policy may have additional exclusions and limitations which may aect any benefits payable.PRE-EXISTING CONDITION LIMITATIONS(l) We will not pay benefits for loss during the first 12 months aer the certificate eective date due to a pre-existing condition. (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the certificate eective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Inpatient Mental and Nervous, Rehabilitation Unit Confinement and Specified Critical Illness.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy formGMB7000-P and certificate form GMB7000-C (including state abbreviations where applicable, such as policy forms GMB7000-P-AU-TX and GMB7000-P-EE-TX, and certificate forms GMB7000-C-AU-TX and GMB7000-C-EE-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without form #101733.GMB7000 – PLAN 1 | 6-21 | 101917-2Group Medical BridgeTM insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement ............................................................... $_______________ per dayMaximum of one day per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered confinement of the named insured£ Daily hospital confinement .................................................................... $100 per dayMaximum of 365 days per covered person per confinement. Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.Health savings account (HSA) compatibleThis plan is compatible with HSA guidelines and any other HSA plan that a covered family member may participate in. It may also be oered to employees who do not have HSAs.Colonial Life & Accident Insurance Company’s Group Medical Bridge oers an HSA-compatible plan in most states.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.1,000 or 2,000

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Group Critical Illness InsurancePlan 2GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCERWhen life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.Coverage amount: ____________________________COVERED CRITICAL ILLNESS CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTBenign brain tumor100%Coma100%End stage renal (kidney) failure100%Heart attack (myocardial infarction)100%Loss of hearing100%Loss of sight100%Loss of speech100%Major organ failure requiring transplant100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Stroke100%Sudden cardiac arrest 100%Coronary artery disease25%COVERED CANCER CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTInvasive cancer (including all breast cancer)100%Non-invasive cancer25%Skin cancer initial diagnosis ............................................................ $400 per lifetimeCritical illness and cancer benefitsSpecial needs daycareA hospital stay and treatment for corrective heart surgeryPhysical therapy to build muscle strengthFor illustrative purposes only.Preparing for a lifelong journeyRebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPEDThe lump-sum amount from the family coverage benefit helped pay for:5,000 - 50,000

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ColonialLife.com6-20 | 387100-TX1. Refer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B, C or D.THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: doctor or physician relationship; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.EXCLUSIONS AND LIMITATIONS FOR CANCER We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period aer the coverage eective date. Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage eective date.This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy forms GCI6000-P-EE-TX and GCI6000-P-AU-TX and certificate forms GCI6000-C-EE-TX and GCI6000-C-AU-TX. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.COVERED CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTCerebral palsy 100%Cle lip or palate 100%Cystic fibrosis 100%Down syndrome 100%Spina bifida 100%KEY BENEFITSAdditional covered conditions for dependent childrenSubsequent diagnosis of a dierent critical illnessIf you receive a benefit for a critical illness and are later diagnosed with a dierent critical illness, 100% of the coverage amount may be payable for that particular critical illness.Subsequent diagnosis of the same critical illnessIf you receive a benefit for a critical illness and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.Reoccurrence of invasive cancer (including all breast cancer)If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.For more information, talk with your benefits counselor.Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.  Available coverage for spouse and eligible dependent children at 50% of your coverage amount  Cover your eligible dependent children at no additional cost  Receive coverage regardless of medical history, within specified limits  Works alongside your health savings account (HSA)  Benefits payable regardless of other insurance

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Group Critical Illness InsuranceWellbeing Assistance BeneﬁtThe wellbeing assistance benefit can help reduce the risk of serious illness through early detection of disease or risk factors.Wellbeing assistance benefit ............................................................. $_____________ Maximum of one test per covered person per calendar year; subject to a 30-day waiting period before the benefit is payable. The test must be performed aer the waiting period.  Blood test for triglycerides  Bone marrow testing  BRCA1 or BRCA2 testing (genetic test for breast cancer)  Breast ultrasound  CA 15-3 (blood test for ovarian cancer)  CA 125 (blood test for breast cancer)  Carotid Doppler  CEA (blood test for colon cancer)  Chest x-ray  Colonoscopy  Echocardiogram (ECHO)  Electrocardiogram (EKG, ECG)  Fasting blood glucose test  Flexible sigmoidoscopy  Hemoccult stool analysis  Mammography  Pap smear  PSA (blood test for prostate cancer)  Serum cholesterol test for HDL and LDL levels  Serum protein electrophoresis (blood test for myeloma)  Skin cancer biopsy  Stress test on a bicycle or treadmill  Thermography  ThinPrep pap test  Virtual colonoscopyFor more information, talk with your benefits counselor.ColonialLife.comGCI6000 – WELLBEING ASSISTANCE BENEFIT | 5-20 | 387307Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.THIS INSURANCE PROVIDES LIMITED BENEFITS.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.50

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Employee Benefit GuideApril 2024– March 2025The benefit descriptions shown below are partial summaries. Consult the certificate of coverage and oficial summary for further details..Web: www.Aetna.com Group Number: 0191554Phone Number: 888-802-3862 Medical PlansPlease note: - Mandatory Generic / Step Therapy / Maintenance drugs- after two retail fills, you are required to fill a 90-day supply at CVS Caremark® Mail Service Pharmacy or CVS Pharmacy.- Plans 1, 2 and 3 are in the Aetna OAAS network which has no benefit for Non-Network Providers unless it is a life-threatening event. Also, no coverage in Alaska or Hawaii for these plans.- Plan 1 is compatible with a Health Savings Account (HSA) and allows for pre-tax/tax deductible contributions into an HSA Bank Account.Basic Benefit OverviewPlan 1: Aetna OAAS 6500 HSA 70% E CY V23 (HSA Qualified)Plan 2: Aetna OAAS 7350 80% CY V23Plan 3: Aetna OAAS 2750 50% CY V23Plan 4:Aetna CPOSII 2500 100/50 CY V23Network OAAS EPO OAAS EPO OAAS EPO CPOSII PPOAnnual Deductible (Single/Family) $6,500 / $13,000 $7,300 / $14,700 $2,750 / $5,000$2,500 / $5,000Annual Out-of-Pocket Limit (Single/Family) $7,500 / $15,000 $8,750 / $17,500 $7,250 / $14,500$6,000 / $12,000Coinsurance 70% 80% 50%100%Routine Preventive Care Visit No Cost No Cost No CostNo CostPrimary Care Office Visit Deductible then $40 $45 $45$25Specialist Office Visit Deductible then $80 $90 $90$75Outpatient Surgery and Facility Charge 70% after Ded 80% after Ded 50% after Ded100% after DedMajor Diagnostic Testing 70% after Ded 80% after Ded 50% after Ded100% after DedInpatient Hospitalization (Facility/Physician) 70% after Ded 80% after Ded 50% after Ded100% after DedEmergency ServicesEmergency Room 70% after Ded$300 Copay + Ded then 80%$300 Copay + Ded then 80%$300 Copay + Ded then 100%Urgent Care 70% after Ded $100 $100 $75Telehealth 70% after Ded $0 $0 $0Prescription Drugs (2x Copay for Mail Order 90-day Supply)Low-Cost Generic / Preferred Generic Ded then $3 / Ded then $10 $3 / $10 $3 / $10 $3 / $10Preferred Brand / Non-Preferred Brand Ded then $10 / Ded then $50 $50 / $100 $50 / $100 $45 / $75Specialty Ded then 20% to $250 20% to $250 20% to $250 20% to $250Non-Preferred Specialty Ded then 40% to $500 40% to $500 40% to $500 40% to $500Cost per Paycheck*Employee Only $87.34 $104.91 $123.94 $166.44Employee + Spouse $334.04 $380.90 $431.68 $545.03Employee + Child(ren) $251.04 $288.05 $328.15 $417.67Employee + Family $487.36 $552.42 $622.93 $780.32

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*.Contact lenses are in lieu of lenses and frameCost Per Pay-CheckEmployee Only$17.40Employee + Spouse$33.28Employee + Child(ren)$43.48Employee + Family$59.31Basic Benefit Overview VisionExams every 12 months $10 CopayLenses every 12 months $25 CopayFrames every 12 months$130 Allowance (20% off additional balance)Contacts every 12 months* $130 AllowanceVoluntary Dental Plan 1 (Base DHMO) Vol 1.2A DMO Copay 76I.Web: www.Aetna.comGroup Number: 0191554Phone Number: 888-802-3862Basic Benefit OverviewMust Designate Primary Care DentistAnnual Deductible/Individual$0Annual Deductible/Family$0Annual Plan Maximum (per person)N/AType IPreventive Services 100%Type IIBasic Services (Fillings, Simple Extractions)Subject to Fee ScheduleType IIIMajor Services (Bridges, Dentures)Subject to Fee ScheduleType IVOrthodontia (Child Only) NACost Per Pay-CheckEmployee Only $6.28Employee + Spouse $12.32Employee + Child(ren) $16.57Employee + Family $22.62Employee Benefits GuideApril 2024– March 2025Web: www.Aetna.comGroup Number: 0191554Phone Number: 888-802-3862Voluntary Vision Plan (Aetna)Basic Benefit Overview DPPOAnnual Deductible/Individual $50Annual Deductible/Family $150Annual Plan Maximum (per person) $2000Type IPreventive Services 100%Type IIBasic Services (Fillings, Simple Extractions) 80% after DeductibleType IIIMajor Services (Bridges, Dentures) 50% after DeductibleType IVOrthodontia (Child Only) $1000Voluntary Dental Plan 2 (Buy Up PPO) Vol 4.1A PDN Max 2000 OrthoWeb: www.Aetna.comGroup Number: 0191554Phone Number: 888-802-3862Cost Per Pay-CheckEmployee Only$3.18Employee + Spouse$6.06Employee + Child(ren)$6.38Employee + Family$9.37

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Plan InformationLong-Term DisabilityMonthly Benefit60% of your before-tax monthly earningsMaximum Monthly Benefit$7,500Accident Benefits BeginDay 91Sickness Benefits BeginDay 91Voluntary Life / AD&DEmployee Benefits GuideApril 2024– March 2025Web: My Benefits (bcbstx.com)Group Number: GFY35026100% VoluntaryThere is a 6/12 pre-existing condition limitation on this benefit.Voluntary Long-Term DisabilityBasic Benefit OverviewVoluntary Life/AD&DEmployee Benefit$10,000 - $500,000Spouse Benefit$5,000 - $500,000Child Benefit (Age 15 days to 25 years)$2,000 - $10,000Web: My Benefits (bcbstx.com)Group Number: GFY35026100% VoluntaryRates for this coverage is dependent on coverage level, age band, and tobacco use. Voluntary Short-Term DisabilityWeb: My Benefits (bcbstx.com)Group Number: GFY35026100% VoluntaryPlan Information Short-Term DisabilityMonthly Benefit 60% of your before-tax weekly earningsMaximum Weekly Benefit $1,500Accident Benefits Begin Day 15Sickness Benefits Begin Day 15

ROC Benefits Guide

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