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Terrabella Environmental Services Benefit Program Guide

Benefit Program February 1, 2024 – January 31, 2025The benefit descriptions shown below are partial summaries. Consultthe certificate of coverage and official summary for further details.Medical PlansWeb:Member Services:Monthly Payroll DeductionsCoverage Tier B661ADT B662CHC G9L1CHC S9J9ADT S9L7CHC S666CHCEmployee Only $69.35 $289.41 $485.32 $147.38 $390.66 $381.46Employee & Spouse $488.70 $928.82 $1320.64 $644.76 $1131.32 $1112.92Employee & Child(ren) $488.70 $928.82 $1320.64 $644.76 $1131.32 $1112.92Employee & Family $908.05 $1568.23 $2155.96 $1142.14 $1871.98 $1844.38Benefits (In Network)B661ADT (HMO)B662CHC (PPO)G9L1CHC (PPO)S9J9ADT (HMO)S9L7CHC (PPO)S666CHC (PPO)NetworkBlue Advantage Blue Choice Blue Choice Blue Advantage Blue Choice Blue ChoiceDeductible (calendar year)$8550 / $17,100 $8550 / $17,100 $2000 / $6000 $3500 / $10,500 $8100 / $16,200 $4250 / $12,750Coinsurance0% 0% 20% 40% 0% 30%Out-of-Pocket Max1$8550 / $17,100 $8550 / $17,100 $6000 / $17,100 $9000 / $18,000 $8100 / $16,200 $9000 / $18,000Preventative Care2No charge No charge No charge No charge No charge No chargePrimary CareNo charge after deductible No charge after deductible $30 copay $50 copay $50 copay $50 copaySpecialist CareNo charge after deductible No charge after deductible $60 copay $90 copay $100 copay $90 copayUrgent Care VisitsNo charge after deductibleNo charge after deductible$75 copay $100 copay $75 copay $100 copayEmergency RoomNo charge after deductible No charge after deductible $300 copay + Ded + 20%**$500 copay + Ded + 40%**Ded + $500 copay**$650 copay + Ded + 30%**Lab / X-rayNo charge after deductibleNo charge after deductibleDed + 20% Ded + 40%Lab: Ded ; X-ray: Ded + $200 copayDed + 30%Advanced Imaging (CAT, PET, MRI)No charge after deductible No charge after deductible $250 copay per test Ded + 40% $300 copay per test $300 copay per testOutpatient Care (e.g.: surgery)No charge after deductible No charge after deductible Ded + 20% Ded + 40% Ded + $300 copayDed + $300 copay + 30%Inpatient CareNo charge after deductible No charge after deductible Ded + 20% Ded + 40% Ded + $350 copayDed + $300 copay + 30%Prescription Drugs No charge after deductible No charge after deductible $10/$20/$70* $10/$20/$70* $10/$20/$70* $15/$25/$70*1 The deductible & out-of-pocket maximum apply to each calendar year. The out-of-pocket max includes deductible, coinsurance and copays2 See full BCBS summary for more details on Preventive Care and other services*Rx Copay savings when Utilizing a Preferred Pharmacy vs a Participating Pharmacy – see plan SBC for details. Mail order Prescriptions available for 3xs Pref Pharmacy copay.** ER Copayment Waived if admitted.

Dental PlanCoverage TierMonthly Payroll DeductionHigh LowEmployee Only$31.23 $22.89Employee & Spouse$63.68 $47.05Employee & Child(ren)$81.96 $55.10Employee & Family$120.51 $83.14Benefits (In Network) High Plan Low PlanNetworkPrincipal Plan Dental Deductible (calendar year)$50 / $150 $50 / $150Annual Benefit Max$2000 $1000Preventive Services 100% 100%Basic Services 80% 80%Major Services 50% 50%Orthodontic Services Lifetime Max (Children under 19)50% up to $1000 50% up to $1000Out of Network Fee Basis90th of usual and customary90th of usual and customaryAdditional Benefits – see benefit summary for listing of all additional benefitsMax Accumulation Benefit Max Accumulation Benefit Vision PlanBenefits (In Network) Benefit ScheduleNetworkVSP Vision Care Exam Copay$10Materials Copay$10Frames Annual Maximum$200Contacts Annual Maximum $200Contact Fitting and EvaluationUp to $60Exam FrequencyEvery 12 monthsLenses FrequencyEvery 12 months Frames FrequencyEvery 12 monthsContacts Frequency Every 12 monthsNonstandard lenses and upgrades are an additional upcharge. In network providers offer 20% discount on additional charges. Contact lenses are in lieu of spectacle lenses. See plan summary for more details. . Coverage TierMonthly Payroll DeductionEmployee Only $8.61Employee & Spouse $19.17Employee & Child(ren) $19.79Employee & Family $32.56Endodontic and Periodontal services fall under basic services on the high plan but major services on the low plan. See plan summary for more details.

Employer Paid Term Life and AD&D PlanBenefits Benefit ScheduleBasic Life Benefit & Guaranteed Issue$15,000AD&D BenefitMatches life benefitBenefit Reduction35% reduction at age 65 and 50% at age 70Additional Benefits Accelerated death benefit, coverage during disability, conversion, seat belt/air bag benefit, repatriation See plan summary for full details of coverage.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : B661ADT Blue Advantage Bronze HMOSM 833 Coverage for: Individual/Family | Plan Type: HMOBlue 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 7The 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/bb/grp/bb_bhsg10bavstxo_tx_2024.pdf or by calling 1-877-299-2377. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?$8,550 Individual/$17,100 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. In-Network Preventive Health 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?$8,550 Individual/$17,100 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/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 Pharmacy No 0000005 1027C :doireP egarevo 0 4202/10/2 -0 5202/13/1C :rof egarevo I ylimaF + laudividn | P :epyT nal H OM

Page 2 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_bhsg10bavstxo_tx_2024.pdf.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illnessNo Charge after deductibleNot CoveredVirtual Visits are available. See your benefit booklet* (Your PCP) for details.Specialist visitNo Charge after deductibleNot CoveredReferral required.If you visit a health care provider’s office or clinicPreventive care/screening/ immunizationNo Charge; deductible does not applyNot CoveredYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)No Charge after deductibleNot CoveredReferral may be required. Preauthorization may also be required; see your benefit booklet* (Outpatient Lab and X-Ray services) for details.If you have a testImaging (CT/PET scans, MRIs) No Charge after deductibleNot CoveredReferral may be required. Preauthorization may also be required; see your benefit booklet* (Outpatient Lab and X-Ray services) for details.Generic drugs (Preferred)No Charge after deductibleNot CoveredGeneric drugs (Non-preferred)No Charge after deductibleNot CoveredBrand drugs (Preferred)No Charge after deductibleNot CoveredBrand drugs (Non-preferred)No Charge after deductibleNot CoveredSpecialty drugs (Preferred)No Charge after deductibleNot CoveredIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx24/6TSpecialty drugs (Non-preferred)No Charge after deductibleNot CoveredLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Certain drugs require approval before they will be covered. 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.0000005 1027

Page 3 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_bhsg10bavstxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationFacility fee (e.g., ambulatory surgery center)No Charge after deductibleNot CoveredIf you have outpatient surgery Physician/surgeon feesNo Charge after deductibleNot CoveredReferral required. Preauthorization may also be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room careNo Charge after deductibleNo Charge after deductibleNoneEmergency medical transportationNo Charge after deductibleNo Charge after deductiblePreauthorization may be required for non-emergency transportation; see your benefit booklet* (Ambulance Services) for details.If you need immediate medical attentionUrgent careNo Charge after deductibleNot CoveredNoneFacility fee (e.g., hospital room)No Charge after deductibleNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon feesNo Charge after deductibleNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Professional Services) for details.Outpatient servicesNo Charge after deductible Not CoveredPreauthorization may be required; see your benefit booklet* (Behavioral Health Services) for details.If you need mental health, behavioral health, or substance abuse servicesInpatient servicesNo Charge after deductibleNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Behavioral Health Services) for details.Office visitsNo Charge after deductible Not CoveredChildbirth/delivery professional servicesNo Charge after deductibleNot CoveredIf you are pregnantChildbirth/delivery facility servicesNo Charge after deductibleNot CoveredCost sharing does not apply for preventive services. Depending on the type of services, deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).If you need help recovering or have other special health needsHome health careNo Charge after deductibleNot Covered60 visits/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.0000005 1027

Page 4 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_bhsg10bavstxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationRehabilitation servicesNo Charge after deductible Not CoveredHabilitation servicesNo Charge after deductible Not CoveredSeparate 35-visit maximum per benefit period for Habilitation and Rehabilitation services, including chiropractic care. Referral required. Preauthorization may also be required; see your benefit booklet* (Rehabilitation Services and Habilitation Services) for details.Skilled nursing careNo Charge after deductibleNot Covered25 days/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipmentNo Charge after deductibleNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Durable Medical Equipment) for details.Hospice servicesNo Charge after deductibleNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Children’s eye examNo Charge; deductible does not applyUp to a $30 reimbursement is available; deductible does not applyOne visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.Children’s glassesNo Charge; deductible does not applyUp to a $75 reimbursement is available; deductible does not applyOne pair of glasses every 12 months. Reimbursement for frames, lenses, and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.If your child needs dental or eye careChildren’s dental check-upNo Charge after deductibleNo Charge after deductibleOral exams are limited to two every benefit period. Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months. See your benefit booklet* (Pediatric Dental Benefits Rider) for details.0000005 1027

Page 5 of 7Excluded 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 (Except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases when medically necessary) Dental care (Adult)  Infertility treatment (Diagnosis and treatment covered; in vitro not covered)  Long-term care  Non-emergency care when traveling outside the U.S. Private-duty nursing (Unless medically necessary)  Routine eye care (Adult)  Routine foot care (Except when medically necessary) 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 (35 visits/year combined with habilitation and rehabilitation services) Hearing aids (Limited to 1 hearing aid per ear every 36 months)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: the plan at Blue Cross and Blue Shield of Texas at 1-888-697-0683 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 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.0000005 1027

Page 6 of 7Language 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.To see examples of how this plan might cover costs for a sample medical situation, see the next section.0000005 1027

Page 7 of 7The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)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)  The plan’s overall deductible $8,550 Specialist copayment $0 Hospital (facility) copayment $0 Other copayment $0This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost$12,700 In this example, Peg would pay:Cost sharingDeductibles$8,550Copayments$0Coinsurance$0What isn’t coveredLimits or exclusions$60The total Peg would pay is$8,610 The plan’s overall deductible $8,550 Specialist copayment $0 Hospital (facility) copayment $0 Other copayment $0This 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 sharingDeductibles$2,300Copayments$300Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$2,620 The plan’s overall deductible $8,550 Specialist copayment $0 Hospital (facility) copayment $0 Other copayment $0This 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 sharingDeductibles$2,800Copayments$0Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,800About 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. 0000005 1027

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : B662CHC Blue Choice Bronze PPOSM 833 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/bb/grp/bb_bpsg10bcastxo_tx_2024.pdf or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $8,550 Individual/$17,100 FamilyOut-of-Network: $17,100 Individual/$34,200 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. In-Network Preventive Health 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: $8,550 Individual/$17,100 FamilyOut-of-Network: $17,100 Individual/$34,200 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-521-2227 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No 0000004 1026C :doireP egarevo 0 4202/10/2 -0 5202/13/1C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Page 2 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_bpsg10bcastxo_tx_2024.pdf.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illnessNo Charge after deductibleNo Charge after deductible Virtual Visits are available. See your benefit booklet* (Your PCP) for details.Specialist visitNo Charge after deductibleNo Charge after deductibleNoneIf you visit a health care provider’s office or clinicPreventive care/screening/ immunizationNo Charge; deductible does not applyNo Charge after deductibleYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)No Charge after deductibleNo Charge after deductible Preauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.If you have a testImaging (CT/PET scans, MRIs) No Charge after deductibleNo Charge after deductiblePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.Generic drugs (Preferred)No Charge after deductibleRetail - No Charge after deductible plus 50% additional charge Generic drugs (Non-preferred)No Charge after deductibleRetail - No Charge after deductible plus 50% additional charge Brand drugs (Preferred)No Charge after deductibleRetail - No Charge after deductible plus 50% additional charge Brand drugs (Non-preferred)No Charge after deductibleRetail - No Charge after deductible plus 50% additional charge If you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx24/6TSpecialty drugs (Preferred)No Charge after deductibleNo Charge after deductible plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional Out-of-Network charge will not apply to any deductible or out-of-pocket amounts. Certain drugs require approval before they will be covered. 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.0000004 1026

Page 3 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_bpsg10bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationSpecialty drugs (Non-preferred)No Charge after deductibleNo Charge after deductible plus 50% additional chargeFacility fee (e.g., ambulatory surgery center)No Charge after deductibleNo Charge after deductible If you have outpatient surgery Physician/surgeon feesNo Charge after deductibleNo Charge after deductible Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room careNo Charge after deductibleNo Charge after deductibleNoneEmergency medical transportationNo Charge after deductibleNo Charge after deductiblePreauthorization may be required for non-emergency transportation; see your benefit booklet* (Ambulance Services) for details.If you need immediate medical attentionUrgent careNo Charge after deductibleNo Charge after deductibleNoneFacility fee (e.g., hospital room)No Charge after deductibleNo Charge after deductiblePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon feesNo Charge after deductibleNo Charge after deductiblePreauthorization required. See your benefit booklet* (Inpatient Professional Services) for details.Outpatient servicesNo Charge after deductible No Charge after deductible Preauthorization may be required; see your benefit booklet* (Behavioral Health Services) for details.If you need mental health, behavioral health, or substance abuse servicesInpatient servicesNo Charge after deductibleNo Charge after deductiblePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Behavioral Health Services) for details.If you are pregnantOffice visitsNo Charge after deductible No Charge after deductibleCost sharing does not apply for preventive services. Depending on the type of services, 0000004 1026

Page 4 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_bpsg10bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationChildbirth/delivery professional servicesNo Charge after deductibleNo Charge after deductible Childbirth/delivery facility servicesNo Charge after deductibleNo Charge after deductibledeductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health careNo Charge after deductibleNo Charge after deductible60 visits/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation servicesNo Charge after deductible No Charge after deductibleHabilitation servicesNo Charge after deductible No Charge after deductibleSeparate 35-visit maximum per benefit period for Habilitation and Rehabilitation services, including chiropractic care. Preauthorization may be required; see your benefit booklet* (Rehabilitation Services and Habilitation Services) for details.Skilled nursing careNo Charge after deductibleNo Charge after deductible25 days/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipmentNo Charge after deductibleNo Charge after deductiblePreauthorization may be required. See your benefit booklet* (Durable Medical Equipment) for details.If you need help recovering or have other special health needsHospice servicesNo Charge after deductibleNo Charge after deductiblePreauthorization may be required. See your benefit booklet* (Extended Care Services) for details.Children’s eye examNo Charge; deductible does not applyUp to a $30 reimbursement is available; deductible does not applyOne visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.If your child needs dental or eye careChildren’s glassesNo Charge; deductible does not applyUp to a $75 reimbursement is available; deductible does not applyOne pair of glasses every 12 months. Reimbursement for frames, lenses, and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.0000004 1026

Page 5 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_bpsg10bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationChildren’s dental check-upNo Charge after deductibleNo Charge after deductibleOral exams are limited to two every benefit period. Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months. See your benefit booklet* (Pediatric Dental Benefits Rider) for details.0000004 1026

Page 6 of 8Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture  Bariatric surgery  Cosmetic surgery (Except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases when medically necessary) Dental care (Adult)  Infertility treatment (Diagnosis and treatment covered; in vitro not covered)  Long-term care  Non-emergency care when traveling outside the U.S. Private-duty nursing (Except for extended care)  Routine eye care (Adult)  Routine foot care (Except when medically necessary) 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 (35 visits/year combined with habilitation and rehabilitation services) Hearing aids (Limited to 1 hearing aid per ear every 36 months)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: the plan at Blue Cross and Blue Shield of Texas at 1-888-697-0683 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 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.Does this plan provide Minimum Essential Coverage? Yes.Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, 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.0000004 1026

Page 7 of 8Language 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.0000004 1026

Page 8 of 8The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)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)  The plan’s overall deductible $8,550 Specialist copayment $0 Hospital (facility) copayment $0 Other copayment $0This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost$12,700 In this example, Peg would pay:Cost sharingDeductibles$8,550Copayments$0Coinsurance$0What isn’t coveredLimits or exclusions$60The total Peg would pay is$8,610 The plan’s overall deductible $8,550 Specialist copayment $0 Hospital (facility) copayment $0 Other copayment $0This 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 sharingDeductibles$2,300Copayments$300Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$2,620 The plan’s overall deductible $8,550 Specialist copayment $0 Hospital (facility) copayment $0 Other copayment $0This 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 sharingDeductibles$2,800Copayments$0Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,800About 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. 0000004 1026

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : G9L1CHC Blue Choice Gold PPOSM 117 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/bb/grp/bb_gpsj64bcastxo_tx_2024.pdf or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $2,000 Individual/$6,000 FamilyOut-of-Network: $4,000 Individual/$8,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. In-Network Preventive Health Care services, certain services with a copayment, and prescription drugs 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: $6,000 Individual/$17,100 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-521-2227 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No 0000047 1027C :doireP egarevo 0 4202/10/2 -0 5202/13/1C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Page 2 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_gpsj64bcastxo_tx_2024.pdf.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$30/visit; deductible does not apply 30% coinsuranceVirtual Visits are available. See your benefit booklet* (Your PCP) for details.Specialist visit$60/visit; deductible does not apply 30% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/ immunizationNo Charge; deductible does not apply30% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)20% coinsurance30% coinsurancePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.If you have a testImaging (CT/PET scans, MRIs) $250/test; deductible does not apply 30% coinsurancePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.Generic drugs (Preferred)Retail - Preferred Participating - No ChargeParticipating - $10/prescriptionMail - No Charge; deductible does not applyRetail - $10/prescription; deductible does not apply plus 50% additional chargeGeneric drugs (Non-preferred)Retail - Preferred Participating - $10/prescription Participating - $20/prescription Mail - $30/prescription; deductible does not apply Retail - $20/prescription; deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx24/6TBrand drugs (Preferred)Retail - Preferred Participating - $50/prescription Participating - $70/prescription Mail - $150/prescription; deductible does not apply Retail - $70/prescription; deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional Out-of-Network charge will not apply to any deductible or out-of-pocket amounts. Certain drugs require approval before they will be covered. Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day 0000047 1027

Page 3 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_gpsj64bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Non-preferred)Retail - Preferred Participating - $100/prescription Participating - $120/prescription Mail - $300/prescription; deductible does not apply Retail - $120/prescription; deductible does not apply plus 50% additional chargeSpecialty drugs (Preferred)$150/prescription; deductible does not apply $150/prescription; deductible does not apply plus 50% additional chargeSpecialty drugs (Non-preferred)$250/prescription; deductible does not apply$250/prescription; deductible does not apply plus 50% additional chargesupply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)$100/visit plus 20% coinsurance$200/visit plus 30% coinsuranceIf you have outpatient surgery Physician/surgeon fees20% coinsurance30% coinsurancePreauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$300/visit plus 20% coinsurance$300/visit plus 20% coinsuranceCopayment waived if admitted. Out-of-Network cost share is subject to Network deductible.Emergency medical transportation20% coinsurance20% coinsurancePreauthorization may be required for non-emergency transportation; see your benefit booklet* (Ambulance Services) for details.If you need immediate medical attentionUrgent care$75/visit; deductible does not apply30% coinsuranceNoneFacility fee (e.g., hospital room)$150/visit plus 20% coinsurance$250/visit plus 30% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon fees20% coinsurance30% coinsurancePreauthorization required. See your benefit booklet* (Inpatient Professional Services) for details.0000047 1027

Page 4 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_gpsj64bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$30/office visit; deductible does not apply;20% coinsurance for other outpatient services30% coinsurancePreauthorization may be required; see your benefit booklet* (Behavioral Health Services) for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services$150/visit plus 20% coinsurance$250/visit plus 30% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Behavioral Health Services) for details.Office visitsPrimary Care: $30/initial visit; deductible does not applySpecialist: $60/initial visit; deductible does not apply 30% coinsuranceChildbirth/delivery professional services20% coinsurance30% coinsuranceIf you are pregnantChildbirth/delivery facility services$150/visit plus 20% coinsurance$250/visit plus 30% coinsuranceCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health care20% coinsurance30% coinsurance60 visits/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation services20% coinsurance30% coinsuranceHabilitation services20% coinsurance30% coinsuranceSeparate 35-visit maximum per benefit period for Habilitation and Rehabilitation services, including chiropractic care. Preauthorization may be required; see your benefit booklet* (Rehabilitation Services and Habilitation Services) for details.Skilled nursing care20% coinsurance30% coinsurance25 days/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipment20% coinsurance30% coinsurancePreauthorization may be required. See your benefit booklet* (Durable Medical Equipment) for details.If you need help recovering or have other special health needsHospice services20% coinsurance30% coinsurancePreauthorization may be required. See your benefit booklet* (Extended Care Services) for details.0000047 1027

Page 5 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_gpsj64bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationChildren’s eye examNo Charge; deductible does not applyUp to a $30 reimbursement is available; deductible does not applyOne visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.Children’s glassesNo Charge; deductible does not applyUp to a $75 reimbursement is available; deductible does not applyOne pair of glasses every 12 months. Reimbursement for frames, lenses, and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.If your child needs dental or eye careChildren’s dental check-up30% coinsurance30% coinsuranceOral exams are limited to two every benefit period. Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months. See your benefit booklet* (Pediatric Dental Benefits Rider) for details.0000047 1027

Page 6 of 8Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture  Bariatric surgery  Cosmetic surgery (Except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases when medically necessary) Dental care (Adult)  Infertility treatment (Diagnosis and treatment covered; in vitro not covered)  Long-term care  Non-emergency care when traveling outside the U.S. Private-duty nursing (Except for extended care)  Routine eye care (Adult)  Routine foot care (Except when medically necessary) 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 (35 visits/year combined with habilitation and rehabilitation services) Hearing aids (Limited to 1 hearing aid per ear every 36 months)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: the plan at Blue Cross and Blue Shield of Texas at 1-888-697-0683 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 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.Does this plan provide Minimum Essential Coverage? Yes.Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, 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.0000047 1027

Page 7 of 8Language 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.0000047 1027

Page 8 of 8The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)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)  The plan’s overall deductible $2,000 Specialist copayment $60 Hospital (facility) copayment/coinsurance$150+20% Other coinsurance 20%This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost$12,700 In this example, Peg would pay:Cost sharingDeductibles$2,000Copayments$500Coinsurance$2,000What isn’t coveredLimits or exclusions$60The total Peg would pay is$4,560 The plan’s overall deductible $2,000 Specialist copayment $60 Hospital (facility) copayment/coinsurance$150+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 sharingDeductibles$900Copayments$700Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,620 The plan’s overall deductible $2,000 Specialist copayment $60 Hospital (facility) copayment/coinsurance$150+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 sharingDeductibles$2,000Copayments$600Coinsurance$10What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,610About 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. 0000047 1027

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : S9J9ADT Blue Advantage Silver HMOSM 134 Coverage for: Individual/Family | Plan Type: HMOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/bb/grp/bb_shsj54bavstxo_tx_2024.pdf or by calling 1-877-299-2377. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?$3,500 Individual/$10,500 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. In-Network Preventive Health Care services, certain services with a copayment, and prescription drugs 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?$9,000 Individual/$18,000 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/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 Pharmacy No 0000085 1027C :doireP egarevo 0 4202/10/2 -0 5202/13/1C :rof egarevo I ylimaF + laudividn | P :epyT nal H OM

Page 2 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_shsj54bavstxo_tx_2024.pdf.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$50/visit; deductible does not apply Not CoveredVirtual Visits are available. See your benefit booklet* (Your PCP) for details.Specialist visit$90/visit; deductible does not apply Not CoveredReferral required.If you visit a health care provider’s office or clinicPreventive care/screening/ immunizationNo Charge; deductible does not applyNot CoveredYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)40% coinsuranceNot CoveredReferral may be required. Preauthorization may also be required; see your benefit booklet* (Outpatient Lab and X-Ray services) for details.If you have a testImaging (CT/PET scans, MRIs) 40% coinsuranceNot CoveredReferral may be required. Preauthorization may also be required; see your benefit booklet* (Outpatient Lab and X-Ray services) for details.Generic drugs (Preferred)Retail - Preferred Participating - No ChargeParticipating - $10/prescriptionMail - No Charge; deductible does not applyNot CoveredGeneric drugs (Non-preferred)Retail - Preferred Participating - $10/prescription Participating - $20/prescription Mail - $30/prescription; deductible does not apply Not CoveredIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx24/6TBrand drugs (Preferred)Retail - Preferred Participating - $50/prescription Participating - $70/prescription Mail - $150/prescription; deductible does not apply Not CoveredLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Certain drugs require approval before they will be covered. Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day 0000085 1027

Page 3 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_shsj54bavstxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Non-preferred)Retail - Preferred Participating - $100/prescription Participating - $120/prescription Mail - $300/prescription; deductible does not apply Not CoveredSpecialty drugs (Preferred)$150/prescription; deductible does not apply Not CoveredSpecialty drugs (Non-preferred)$250/prescription; deductible does not applyNot Coveredsupply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)$200/visit plus 40% coinsuranceNot CoveredIf you have outpatient surgery Physician/surgeon fees40% coinsuranceNot CoveredReferral required. Preauthorization may also be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$500/visit plus 40% coinsurance$500/visit plus 40% coinsuranceCopayment waived if admitted.Emergency medical transportation40% coinsurance40% coinsurancePreauthorization may be required for non-emergency transportation; see your benefit booklet* (Ambulance Services) for details.If you need immediate medical attentionUrgent care$100/visit; deductible does not applyNot CoveredNoneFacility fee (e.g., hospital room)$250/visit plus 40% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon fees40% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Professional Services) for details.Outpatient services$50/office visit; deductible does not apply;40% coinsurance for other outpatient servicesNot CoveredPreauthorization may be required; see your benefit booklet* (Behavioral Health Services) for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services$250/visit plus 40% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Behavioral Health Services) for details.0000085 1027

Page 4 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_shsj54bavstxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationOffice visitsPrimary Care: $50/initial visit; deductible does not applySpecialist: $90/initial visit; deductible does not apply Not CoveredChildbirth/delivery professional services40% coinsuranceNot CoveredIf you are pregnantChildbirth/delivery facility services$250/visit plus 40% coinsuranceNot CoveredCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health care40% coinsuranceNot Covered60 visits/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation services40% coinsuranceNot CoveredHabilitation services40% coinsuranceNot CoveredSeparate 35-visit maximum per benefit period for Habilitation and Rehabilitation services, including chiropractic care. Referral required. Preauthorization may also be required; see your benefit booklet* (Rehabilitation Services and Habilitation Services) for details.Skilled nursing care40% coinsuranceNot Covered25 days/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipment40% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Durable Medical Equipment) for details.If you need help recovering or have other special health needsHospice services40% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.If your child needs dental or eye careChildren’s eye examNo Charge; deductible does not applyUp to a $30 reimbursement is available; deductible does not applyOne visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.0000085 1027

Page 5 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_shsj54bavstxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationChildren’s glassesNo Charge; deductible does not applyUp to a $75 reimbursement is available; deductible does not applyOne pair of glasses every 12 months. Reimbursement for frames, lenses, and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.Children’s dental check-up30% coinsurance30% coinsuranceOral exams are limited to two every benefit period. Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months. See your benefit booklet* (Pediatric Dental Benefits Rider) for details.0000085 1027

Page 6 of 8Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture  Bariatric surgery  Cosmetic surgery (Except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases when medically necessary) Dental care (Adult)  Infertility treatment (Diagnosis and treatment covered; in vitro not covered)  Long-term care  Non-emergency care when traveling outside the U.S. Private-duty nursing (Unless medically necessary)  Routine eye care (Adult)  Routine foot care (Except when medically necessary) 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 (35 visits/year combined with habilitation and rehabilitation services) Hearing aids (Limited to 1 hearing aid per ear every 36 months)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: the plan at Blue Cross and Blue Shield of Texas at 1-888-697-0683 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 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.0000085 1027

Page 7 of 8Language 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.To see examples of how this plan might cover costs for a sample medical situation, see the next section.0000085 1027

Page 8 of 8The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)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)  The plan’s overall deductible $3,500 Specialist copayment $90 Hospital (facility) copayment/coinsurance$250+40% Other coinsurance 40%This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost$12,700 In this example, Peg would pay:Cost sharingDeductibles$3,500Copayments$300Coinsurance$3,500What isn’t coveredLimits or exclusions$60The total Peg would pay is$7,360 The plan’s overall deductible $3,500 Specialist copayment $90 Hospital (facility) copayment/coinsurance$250+40% Other coinsurance 40%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 sharingDeductibles$900Copayments$900Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,820 The plan’s overall deductible $3,500 Specialist copayment $90 Hospital (facility) copayment/coinsurance$250+40% Other coinsurance 40%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 sharingDeductibles$2,100Copayments$600Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,700About 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. 0000085 1027

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : S9L7CHC Blue Choice Silver PPOSM 146 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/bb/grp/bb_spsj70bcastxo_tx_2024.pdf or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $8,100 Individual/$16,200 FamilyOut-of-Network: $16,200 Individual/$32,400 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. In-Network Preventive Health Care services, certain services with a copayment, and prescription drugs 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: $8,100 Individual/$16,200 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-521-2227 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No 0000098 1027C :doireP egarevo 0 4202/10/2 -0 5202/13/1C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Page 2 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_spsj70bcastxo_tx_2024.pdf.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$50/visit; deductible does not apply 20% coinsuranceVirtual Visits are available. See your benefit booklet* (Your PCP) for details.Specialist visit$100/visit; deductible does not apply 20% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/ immunizationNo Charge; deductible does not apply20% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)Lab: No Charge after deductibleX-Rays: $200/test plus plan deductible 20% coinsurancePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.If you have a testImaging (CT/PET scans, MRIs) $300/test; deductible does not apply 20% coinsurancePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.Generic drugs (Preferred)Retail - Preferred Participating - No ChargeParticipating - $10/prescriptionMail - No Charge; deductible does not applyRetail - $10/prescription; deductible does not apply plus 50% additional chargeGeneric drugs (Non-preferred)Retail - Preferred Participating - $10/prescription Participating - $20/prescription Mail - $30/prescription; deductible does not apply Retail - $20/prescription; deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx24/6TBrand drugs (Preferred)Retail - Preferred Participating - $50/prescription Participating - $70/prescription Mail - $150/prescription; deductible does not apply Retail - $70/prescription; deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional Out-of-Network charge will not apply to any deductible or out-of-pocket amounts. Certain drugs require approval before they will be covered. Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day 0000098 1027

Page 3 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_spsj70bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Non-preferred)Retail - Preferred Participating - $100/prescription Participating - $120/prescription Mail - $300/prescription; deductible does not apply Retail - $120/prescription; deductible does not apply plus 50% additional chargeSpecialty drugs (Preferred)$150/prescription; deductible does not apply $150/prescription; deductible does not apply plus 50% additional chargeSpecialty drugs (Non-preferred)$250/prescription; deductible does not apply$250/prescription; deductible does not apply plus 50% additional chargesupply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)$300/visit plus plan deductible$300/visit plus 20% coinsuranceIf you have outpatient surgery Physician/surgeon feesNo Charge after deductible20% coinsurancePreauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$500/visit plus plan deductible$500/visit plus plan deductibleCopayment waived if admitted. Out-of-Network cost share is subject to Network deductible.Emergency medical transportationNo Charge after deductibleNo Charge after deductiblePreauthorization may be required for non-emergency transportation; see your benefit booklet* (Ambulance Services) for details.If you need immediate medical attentionUrgent care$75/visit; deductible does not apply20% coinsuranceNoneFacility fee (e.g., hospital room)$350/visit plus plan deductible$350/visit plus 20% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon feesNo Charge after deductible20% coinsurancePreauthorization required. See your benefit booklet* (Inpatient Professional Services) for details.0000098 1027

Page 4 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_spsj70bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$50/office visit; deductible does not apply;No Charge for other outpatient services20% coinsurancePreauthorization may be required; see your benefit booklet* (Behavioral Health Services) for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services$350/visit plus plan deductible$350/visit plus 20% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Behavioral Health Services) for details.Office visitsPrimary Care: $50/initial visit; deductible does not applySpecialist: $100/initial visit; deductible does not apply 20% coinsuranceChildbirth/delivery professional servicesNo Charge after deductible20% coinsuranceIf you are pregnantChildbirth/delivery facility services$350/visit plus plan deductible$350/visit plus 20% coinsuranceCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, copayment or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health careNo Charge after deductible20% coinsurance60 visits/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation servicesNo Charge after deductible 20% coinsuranceHabilitation servicesNo Charge after deductible 20% coinsuranceSeparate 35-visit maximum per benefit period for Habilitation and Rehabilitation services, including chiropractic care. Preauthorization may be required; see your benefit booklet* (Rehabilitation Services and Habilitation Services) for details.Skilled nursing careNo Charge after deductible20% coinsurance25 days/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipmentNo Charge after deductible20% coinsurancePreauthorization may be required. See your benefit booklet* (Durable Medical Equipment) for details.If you need help recovering or have other special health needsHospice servicesNo Charge after deductible20% coinsurancePreauthorization may be required. See your benefit booklet* (Extended Care Services) for details.0000098 1027

Page 5 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_spsj70bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationChildren’s eye examNo Charge; deductible does not applyUp to a $30 reimbursement is available; deductible does not applyOne visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.Children’s glassesNo Charge; deductible does not applyUp to a $75 reimbursement is available; deductible does not applyOne pair of glasses every 12 months. Reimbursement for frames, lenses, and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.If your child needs dental or eye careChildren’s dental check-upNo Charge after deductibleNo Charge after deductibleOral exams are limited to two every benefit period. Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months. See your benefit booklet* (Pediatric Dental Benefits Rider) for details.0000098 1027

Page 6 of 8Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture  Bariatric surgery  Cosmetic surgery (Except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases when medically necessary) Dental care (Adult)  Infertility treatment (Diagnosis and treatment covered; in vitro not covered)  Long-term care  Non-emergency care when traveling outside the U.S. Private-duty nursing (Except for extended care)  Routine eye care (Adult)  Routine foot care (Except when medically necessary) 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 (35 visits/year combined with habilitation and rehabilitation services) Hearing aids (Limited to 1 hearing aid per ear every 36 months)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: the plan at Blue Cross and Blue Shield of Texas at 1-888-697-0683 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 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.Does this plan provide Minimum Essential Coverage? Yes.Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, 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.0000098 1027

Page 7 of 8Language 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.0000098 1027

Page 8 of 8The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)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)  The plan’s overall deductible $8,100 Specialist copayment $100 Hospital (facility) copayment $350 Other copayment $0This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost$12,700 In this example, Peg would pay:Cost sharingDeductibles$7,800Copayments$300Coinsurance$0What isn’t coveredLimits or exclusions$60The total Peg would pay is$8,160 The plan’s overall deductible $8,100 Specialist copayment $100 Hospital (facility) copayment $350 Other copayment $0This 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 sharingDeductibles$900Copayments$900Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,820 The plan’s overall deductible $8,100 Specialist copayment $100 Hospital (facility) copayment $350 Other copayment $0This 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 sharingDeductibles$2,300Copayments$400Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,700About 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. 0000098 1027

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : S666CHC Blue Choice Silver PPOSM 844 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/bb/grp/bb_spsg15bcastxo_tx_2024.pdf or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $4,250 Individual/$12,750 FamilyOut-of-Network: $8,500 Individual/$25,500 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. In-Network Preventive Health Care services, certain services with a copayment, and prescription drugs 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: $9,000 Individual/$18,000 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-521-2227 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR Pharmacy No 0000036 1026C :doireP egarevo 0 4202/10/2 -0 5202/13/1C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP

Page 2 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_spsg15bcastxo_tx_2024.pdf.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$50/visit; deductible does not apply 50% coinsuranceVirtual Visits are available. See your benefit booklet* (Your PCP) for details.Specialist visit$90/visit; deductible does not apply 50% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/ immunizationNo Charge; deductible does not apply50% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)30% coinsurance50% coinsurancePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.If you have a testImaging (CT/PET scans, MRIs) $300/test; deductible does not apply 50% coinsurancePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.Generic drugs (Preferred)Retail - Preferred Participating - $5/prescription Participating - $15/prescription Mail - $15/prescription; deductible does not apply Retail - $15/prescription; deductible does not apply plus 50% additional chargeGeneric drugs (Non-preferred)Retail - Preferred Participating - $15/prescription Participating - $25/prescription Mail - $45/prescription; deductible does not apply Retail - $25/prescription; deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx24/6TBrand drugs (Preferred)Retail - Preferred Participating - $50/prescription Participating - $70/prescription Mail - $150/prescription; deductible does not apply Retail - $70/prescription; deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional Out-of-Network charge will not apply to any deductible or out-of-pocket amounts. Certain drugs require approval before they will be covered. Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day 0000036 1026

Page 3 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_spsg15bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationBrand drugs (Non-preferred)Retail - Preferred Participating - $100/prescription Participating - $120/prescription Mail - $300/prescription; deductible does not apply Retail - $120/prescription; deductible does not apply plus 50% additional chargeSpecialty drugs (Preferred)$250/prescription; deductible does not apply $250/prescription; deductible does not apply plus 50% additional chargeSpecialty drugs (Non-preferred)$350/prescription; deductible does not apply$350/prescription; deductible does not apply plus 50% additional chargesupply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)$250/visit plus 30% coinsurance$300/visit plus 50% coinsuranceIf you have outpatient surgery Physician/surgeon fees30% coinsurance50% coinsurancePreauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$650/visit plus 30% coinsurance$650/visit plus 30% coinsuranceCopayment waived if admitted. Out-of-Network cost share is subject to Network deductible.Emergency medical transportation30% coinsurance30% coinsurancePreauthorization may be required for non-emergency transportation; see your benefit booklet* (Ambulance Services) for details.If you need immediate medical attentionUrgent care$100/visit; deductible does not apply50% coinsuranceNoneFacility fee (e.g., hospital room)$300/visit plus 30% coinsurance$350/visit plus 50% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon fees30% coinsurance50% coinsurancePreauthorization required. See your benefit booklet* (Inpatient Professional Services) for details.0000036 1026

Page 4 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_spsg15bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$50/office visit; deductible does not apply;30% coinsurance for other outpatient services50% coinsurancePreauthorization may be required; see your benefit booklet* (Behavioral Health Services) for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services$300/visit plus 30% coinsurance$350/visit plus 50% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Behavioral Health Services) for details.Office visitsPrimary Care: $50/initial visit; deductible does not applySpecialist: $90/initial visit; deductible does not apply 50% coinsuranceChildbirth/delivery professional services30% coinsurance50% coinsuranceIf you are pregnantChildbirth/delivery facility services$300/visit plus 30% coinsurance$350/visit plus 50% coinsuranceCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health care30% coinsurance50% coinsurance60 visits/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation services30% coinsurance50% coinsuranceHabilitation services30% coinsurance50% coinsuranceSeparate 35-visit maximum per benefit period for Habilitation and Rehabilitation services, including chiropractic care. Preauthorization may be required; see your benefit booklet* (Rehabilitation Services and Habilitation Services) for details.Skilled nursing care30% coinsurance50% coinsurance25 days/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipment30% coinsurance50% coinsurancePreauthorization may be required. See your benefit booklet* (Durable Medical Equipment) for details.If you need help recovering or have other special health needsHospice services30% coinsurance50% coinsurancePreauthorization may be required. See your benefit booklet* (Extended Care Services) for details.0000036 1026

Page 5 of 8*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb_spsg15bcastxo_tx_2024.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationChildren’s eye examNo Charge; deductible does not applyUp to a $30 reimbursement is available; deductible does not applyOne visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.Children’s glassesNo Charge; deductible does not applyUp to a $75 reimbursement is available; deductible does not applyOne pair of glasses every 12 months. Reimbursement for frames, lenses, and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.If your child needs dental or eye careChildren’s dental check-up30% coinsurance30% coinsuranceOral exams are limited to two every benefit period. Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months. See your benefit booklet* (Pediatric Dental Benefits Rider) for details.0000036 1026

Page 6 of 8Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture  Bariatric surgery  Cosmetic surgery (Except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases when medically necessary) Dental care (Adult)  Infertility treatment (Diagnosis and treatment covered; in vitro not covered)  Long-term care  Non-emergency care when traveling outside the U.S. Private-duty nursing (Except for extended care)  Routine eye care (Adult)  Routine foot care (Except when medically necessary) 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 (35 visits/year combined with habilitation and rehabilitation services) Hearing aids (Limited to 1 hearing aid per ear every 36 months)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: the plan at Blue Cross and Blue Shield of Texas at 1-888-697-0683 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 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.Does this plan provide Minimum Essential Coverage? Yes.Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, 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.0000036 1026

Page 7 of 8Language 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.0000036 1026

Page 8 of 8The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)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)  The plan’s overall deductible $4,250 Specialist copayment $90 Hospital (facility) copayment/coinsurance$300+30% Other coinsurance 30%This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost$12,700 In this example, Peg would pay:Cost sharingDeductibles$4,250Copayments$700Coinsurance$2,300What isn’t coveredLimits or exclusions$60The total Peg would pay is$7,310 The plan’s overall deductible $4,250 Specialist copayment $90 Hospital (facility) copayment/coinsurance$300+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 sharingDeductibles$900Copayments$1,000Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,920 The plan’s overall deductible $4,250 Specialist copayment $90 Hospital (facility) copayment/coinsurance$300+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 sharingDeductibles$2,000Copayments$700Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,700About 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. 0000036 1026

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Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-15 11172310368 - 7 Page 1 of 7 10/2023Policyholder: Terrabella EnvironmentalServicesGroup dental insuranceBenefit summaryEffective date: 02/01/2024What's available to me?Dental insurance helps pay for all, or a portion, of the costs associated with dental care, from routinecleanings to root canals.EligibilityEligible employeesAll active, full-time employeesCalendar-year deductible Coinsurance your policy paysOption 1 (members electing high dental plan)In-network Out-of-network In-network Out-of-networkPreventive$0 $0 100% 100%Basic$50 $50 80% 80%Major$50 $50 50% 50%Orthodontia $0 $050% 50%Additional provisionsFamily deductible3 times the per person deductible amountCombined deductibleYour deductibles that are in and out-of-network for basic and major services arecombined.Combined maximumMaximums for preventive, basic, and major procedures are combined. In-networkcalendar year maximums are $2,000 per person or non-network calendar yearmaximums are $2,000 per person.Orthodontia lifetimemaximum$1,000 PPO in-network maximum / $1,000 PPO out-of-network maximumMaximumaccumulationIncludedPlan typeUnscheduledCalendar-year deductible Coinsurance your policy paysOption 2 (members electing low dental plan)In-network Out-of-network In-network Out-of-networkPreventive$0 $0 100% 100%

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-15 11172310368 - 7 Page 2 of 7 10/2023Basic$50 $50 80% 80%Major$50 $50 50% 50%Orthodontia $0 $050% 50%Additional provisionsFamily deductible3 times the per person deductible amountCombined deductibleYour deductibles that are in and out-of-network for services are combined.Combined maximumMaximums for preventive, basic, and major procedures are combined. In-networkcalendar year maximums are $1,000 per person or non-network calendar yearmaximums are $1,000 per person.Orthodontia lifetimemaximum$1,000 PPO in-network maximum / $1,000 PPO out-of-network maximumMaximumaccumulationIncludedPlan typeUnscheduledWho can buy coverage?• You may buy coverage if you're an active, full-time employee. Seasonal, temporary, or contractemployees aren't eligible.o If you’re on regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal timeoff, you’re still considered actively at work, as long as you’re fulfilling your regular duties and wereworking the day immediately prior to your time off.o You must enroll within 31 days of being eligible. If you don’t, you’ll have to wait until the next openenrollment period, or qualifying event.Additional eligibility requirements may apply.Which procedures are covered, and how often?Option 1PreventiveRoutine examsTwice per calendar yearRoutine cleaningsTwice per calendar yearBitewing X-raysOnce per calendar yearFull mouth X-raysOnce every 60 monthsFluorideOnce per calendar year (covered only for dependent children under age 14)BasicSealantsCovered only for dependent children under age 14; once per tooth each 36months

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-15 11172310368 - 7 Page 3 of 7 10/2023Emergency examsSubject to routine exam frequency limitPeriodontal maintenanceIf three months have passed since active surgical periodontal treatment;subject to routine cleaning frequency limitFillings Replacement fillings every 24 monthsComposite (tooth colored) Covered on posterior teethOral surgerySimpleSimple endodontics Root canal therapy for anterior teethComplex endodontics Root canal therapy for molar teethNon-surgical periodontics,including scaling and rootplaningOnce per quadrant per 24 monthsPeriodontal surgicalproceduresOnce per quadrant per 36 monthsHarmful habit applianceCovered only for dependent children under age 14MajorOral surgeryComplexGeneral anesthesia / IVsedation (covered only forspecific procedures)Covered only for specific proceduresCrownsEach 120 months per tooth if tooth cannot be restored by a fillingCore buildupEach 120 months per toothBridges120 months old (initial placement / replacement)Dentures 60 months old (initial placement / replacement)Repairs Partial denture, bridge, crown, relines, rebasing, tissue conditioning andadjustment to bridge/denture, within policy limitationsOrthodontiaCoverageFor your dependent children. Bands that are placed on a dependent child'steeth before age 19 may be covered.Additional benefitsPrevailing charge When you receive care from an out-of-network-provider, benefits will be basedon the 90thpercentile of the usual and customary charges.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-15 11172310368 - 7 Page 4 of 7 10/2023Maximum accumulationSome of your unused annual benefit maximum can be carried over to the nextyear. To qualify, you must have had a dental service performed within thecalendar year and used less than the maximum threshold. The threshold isequal to the lesser of 50% of the out-of-network maximum benefit or $1,000. Ifthe qualification is met, 50% of the threshold is carried over to next year'smaximum benefit. Individuals with fourth quarter effective dates will startqualifying for rollover at the beginning of the next calendar year. You canaccumulate no more than four times the carry over amount. The entireaccumulation amount will be forfeited if no dental service is submitted within acalendar yearPeriodontal program If you’re pregnant or have diabetes or heart disease, you may receive scalingand root planing covered at 100% (if dentally necessary), or one additionalcleaning (routine or periodontal) subject to deductible and coinsurance.Second opinion program You may be eligible for second opinions from dental providers at 100%. Thisprogram makes sure you get the best advice to make an informed decisionabout your care.Cancer treatment oralhealth programIf you have cancer and are undergoing chemotherapy or head/neck radiationtherapy, you may receive up to three fluoride treatments every 12 monthscovered at 100% plus one additional routine cleaning.General anesthesiaprogramIf you have autism, Down syndrome, cerebral palsy, muscular dystrophy, orspina bifida you may receive general anesthesia or intravenous sedationcoverage. Services must be administered in a dental office. All othercontractual limitations apply.Option 2PreventiveRoutine examsTwice per calendar yearRoutine cleaningsTwice per calendar yearBitewing X-raysOnce per calendar yearFull mouth X-raysOnce every 60 monthsFluorideOnce per calendar year (covered only for dependent children under age 14)BasicSealantsCovered only for dependent children under age 14; once per tooth each 36monthsEmergency examsSubject to routine exam frequency limitPeriodontal maintenanceIf three months have passed since active surgical periodontal treatment;subject to Routine cleaning frequency limitFillings Replacement fillings every 24 months

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-15 11172310368 - 7 Page 5 of 7 10/2023Composite (tooth colored)filingsCovered on posterior teethHarmful habit applianceCovered only for dependent children under age 14MajorOral surgerySimple and complexGeneral anesthesia / IVsedationCovered only for specific proceduresSimple endodontics Root canal therapy for anterior teethComplex endodontics Root canal therapy for molar teethNon-surgical periodontics Once per quadrant per 24 months (including scaling and root planing)Periodontal surgicalproceduresOnce per quadrant per 36 monthsCrownsEach 120 months per tooth if tooth cannot be replaced by a fillingCore buildupEach 120 monthsBridges120 months old (initial placement / replacement)Dentures 60 months old (initial placement / replacement)Repairs Partial denture, bridge, crown, relines, rebasing, tissue conditioning andadjustment to bridge/denture, within policy limitationsOrthodontiaCoverageFor your dependent children. Bands that are placed on a dependent child'steeth before age 19 may be covered.Additional benefitsPrevailing charge When you receive care from an out-of-network-provider, benefits will be basedon the 90thpercentile of the usual and customary charges.Maximum accumulationSome of your unused annual benefit maximum can be carried over to the nextyear. To qualify, you must have had a dental service performed within thecalendar year and used less than the maximum threshold. The threshold isequal to the lesser of 50% of the out-of-network maximum benefit or $1,000. Ifthe qualification is met, 50% of the threshold is carried over to next year'smaximum benefit. Individuals with fourth quarter effective dates will startqualifying for rollover at the beginning of the next calendar year. You canaccumulate no more than four times the carry over amount. The entireaccumulation amount will be forfeited if no dental service is submitted within acalendar yearPeriodontal program If you’re pregnant or have diabetes or heart disease, you may receive scalingand root planing covered at 100% (if dentally necessary), or one additionalcleaning (routine or periodontal) subject to deductible and coinsurance.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-15 11172310368 - 7 Page 6 of 7 10/2023Second opinion program You may be eligible for second opinions from dental providers at 100%. Thisprogram makes sure you get the best advice to make an informed decisionabout your care.Cancer treatment oralhealth programIf you have cancer and are undergoing chemotherapy or head/neck radiationtherapy, you may receive up to three fluoride treatments every 12 monthscovered at 100% plus one additional routine cleaning.General anesthesiaprogramIf you have autism, Down syndrome, cerebral palsy, muscular dystrophy, orspina bifida you may receive general anesthesia or intravenous sedationcoverage. Services must be administered in a dental office. All othercontractual limitations apply.How do I find a network dentist?When you receive services from a dentist in our network, your cost may be lower. Network dentists agree tolower their fees for dental services and not charge you the difference. You’ll have access to the Principal PlanDental network, with more than 117,000 dentists nationwide. Visit principal.com/dentist to find a dentist orcall 800-247-4695.What if my dentist isn't in the network?You can refer your dentist to our network. Please submit the dentist’s name and information by calling800-247-4695, or submitting a form at principal.com/refer-dental-provider.What are the limitations and exclusions of my coverage?• Missing tooth provision –This means the initial placement of bridges, partials, dentures, and implantservices to replace teeth missing before this coverage starts may not be covered. If the policy youremployer purchased replaces coverage with another carrier, continuous coverage under the prior planmay be applied and you may be eligible for coverage to replace teeth missing before this coverage started.Your effective date with your current employer, along with the employer's effective date with Principal areused to determine coverage. MIssing tooth provision doesn’t apply to pediatric essential benefits.• Frequency limitations for services are calculated to the month and exact date from the last date of serviceor placement date.There are additional limitations to your coverage. Please review your booklet for more information. Westrongly recommend submitting a predetermination to determine benefits.

principal.comThis is a summary of dental coverage insured by or with administrative services provided by Principal LifeInsurance Company. This outline is a brief description of your coverage. It is not an insurance contract or acomplete statement of the rights, benefits, limitations and exclusions of the coverage. If there is a discrepancybetween the policy and this document, the actual policy provision prevails. For complete coverage details,refer to the booklet.© 2023 Principal Financial Services, Inc., Principal, Principal and symbol design and Principal Financial Group are trademarks and servicemarks of Principal Financial Services, Inc., a member of the Principal Financial Group.Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-15 11172310368 - 7 Page 7 of 7 10/2023What are the restrictions of my coverage?OrthodontiaIf there is orthodontia (ortho) treatment in progress on the coverage effective date andyou are covered under any prior group coverage for ortho, there will be immediatecoverage for treatment if proof is submitted that shows:1) The lifetime maximum under any prior group coverage has not been exceeded,2) Ortho treatment was started and bands or appliances were inserted while insuredunder any prior group coverage, and3) Ortho treatment has been continued while insured under this policy.Principal Life will credit payments made by the prior carrier toward the Principal Lifelifetime ortho payment limit.You will not be covered if ortho treatment is in progress prior to the effective date withPrincipal Life and you are not covered under any prior group coverage for ortho.There are additional limitations to your coverage. A complete list is included in your booklet.U 1 P 1YesU 1 P 2YesU 2 P 1YesU 2 P 2YesU 3 P 1YesU 3 P 2Yes

Policyholder: Terrabella EnvironmentalServicesGroup visionBenefit summary for all membersEffective date: 02/01/2024Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62454-7 11172310368 - 7 Page 1 of 4 05/2023What's available to me?Vision insurance is offered through Principal®and VSP®Vision Care. It provides choice, flexibility and savingsthrough a VSP doctor.If you buy this coverage, an established network of VSP doctors will provide quality care for you and yourdependents.VSP choice networkExamsEvery 12 months, one exam is covered in full after $10 copayPrescription glassesLenses - 1 pair covered every12 monthsFrames - covered up to $200every 12 months; 20% offamount over allowance1$10 copay• Single lenses• Lined bifocal lenses• Lined trifocal lenses• Lenticular lenses• Polycarbonate lenses for dependent children under age 18Lens enhancements Standard progressive lenses covered once every 12 months with a $0 copay¹Most other popular lens enhancements are covered after a copay, saving ourmembers an average of 30%¹Elective contactsCovered up to $200 every 12 months. Contact lenses can be chosen insteadof glasses.Contact fitting andevaluationUp to $60 copayNecessary contactsCovered in full after $10 copay every 12 monthsContact lenses can be chosen instead of glasses.1This can vary based on state laws and provider location Savings may not apply at participating retail chains.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62454-7 11172310368 - 7 Page 2 of 4 05/2023Who can buy coverage?• You may buy coverage if you’re an active, full-time employee. Seasonal, temporary, or contract employeescan’t purchase.o If you’re on regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal timeoff, you’re still considered actively at work, as long as you’re fulfilling your regular duties and wereworking the day immediately prior to your time off.o You must enroll within 31 days of being eligible. If you don’t, you’ll have to wait until the next openenrollment period.• If you’re covered, you may buy coverage for your dependents.Additional eligibility requirements may apply.What's the difference between elective and necessary contacts?• Elective - when vision can be corrected by glasses, but contacts are worn.• Necessary - when vision can't be corrected with glasses due to extreme vision problems.Why am I charged an additional copay for contact fitting and evaluation?• Contact lens wearers require an additional evaluation of the eyes’ measurements, and possible follow-upappointments, for fitting and training on proper use of contact lenses.• For these additional services, you won’t pay more than $60 at in-network providers.Are benefits the same for all VSP doctors?• Yes, with the exception of Costco®, Walmart®, and Sam’s Club®. The frame allowance at these locations is$110 which is equivalent to a $200 allowance at other VSP doctor locations. Not all providers atparticipating retail chains are in-network for exam services.• Benefits may also vary by location due to state law.How do I find a VSP doctor?• Visit vsp.com to locate VSP doctors close to you -- or to see if your current eye care professional is in theVSP network.o You’ll need to choose the “Choice” doctor network to view the VSP doctors for your coverage.• Call 800-877-7195.Will I get an ID card?• Yes, your card will have a unique member ID that your doctor will use to verify benefits.Will my doctor submit my claim?• If you’re seeing a VSP doctor, they’ll submit the claim for you.• If you’re seeing someone outside the VSP network, you’re responsible for submitting your own claim. Youcan get that form from vsp.com after logging in as a member using your member ID. Or call 800-877-7195.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62454-7 11172310368 - 7 Page 3 of 4 05/2023Are there any additional savings with VSP?• Glasses and sunglasses - you can save an average of 20-25% off glasses or sunglasses from any VSP doctorwithin 12 months of your last covered vision exam.• Laser vision correction - you pay an average of 15% off the regular price and 5% off the promotional price.You’ll only receive these discounts from contracted clinics. Go to VSP.com and register using your memberID to see the laser vision promotions and find a contracted clinic.These savings can vary based on state laws and provider location.What benefits do I receive if my doctor is outside VSP's network?Covered charges Benefit FrequencyExams Up to $45Once every 12 monthsSingle lenses Up to $30 One pair every 12 monthsLined bifocal lenses Up to $50 One pair every 12 monthsLined trifocal lenses Up to $65 One pair every 12 monthsLenticular lenses Up to $100 One pair every 12 monthsFrames Up to $70One set every 12 monthsElective contacts Up to $105 Contacts are instead of frames and lensesNecessary contactsUp to $210Contacts are instead of frames and lensesWhat are the limitations of my benefits?• Visual analysis or vision aids that aren't medically necessary aren't covered.• No benefits will be paid for:o Non-prescription glasseso Medical or surgical treatment of the eyeso Claims submitted by a doctor who is part of your familyOnce enrolled, you'll receive a booklet with more details regarding your plan limitations and exclusions.

principal.comThis is a summary of vision coverage insured by or with administrative services provided by Principal LifeInsurance Company. This outline is a brief description of your coverage. It is not an insurance contract or acomplete statement of the rights, benefits, limitations and exclusions of the coverage. If there is a discrepancybetween the policy and this document, the actual policy provision prevails. For complete coverage details,refer to the booklet.© 2023 Principal Financial Services, Inc., Principal, Principal and symbol design and Principal Financial Group are trademarks and servicemarks of Principal Financial Services, Inc., a member of the Principal Financial Group.Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62454-7 11172310368 - 7 Page 4 of 4 05/2023Texas Department of Insurance NoticePreferred Provider Benefit PlanYou have the right to an adequate network of preferred providers (also known as "network providers"). If youbelieve that the VSP network is inadequate, you may file a complaint with the Texas Department of Insurance.You have the right, in most cases, to obtain estimates in advance:• from out-of-network providers of what they will charge for their services; and• from VSP of what it will pay for the services.You may obtain a current directory of VSP preferred providers at the following website: https://www.vsp.com/or by calling 1-800- 877-7195 for assistance in finding available preferred providers.If you are treated by a provider that is not a preferred provider, you may be billed for anything not paid byVSP.If the VSP directory information is materially inaccurate and you rely on it, you may be entitled to have anout-of-network claim paid at the in-network level of reimbursement and your out-of-network expensescounted toward your in-network copayment and maximum payment limit.GH 198 TX (VSP)

Policyholder: Terrabella Environmental ServicesGroup term life insuranceBenefit summary for all membersEffective date: 02/01/2024Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62508-6 11172310368 - 7 Page 1 of 2 07/2023THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS'COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHERYOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM.What's available to me?Protect what means the most to you – the people you love. If something were to happen to you, your lifeinsurance proceeds would go to the people you've designated as your beneficiaries.BenefitGuaranteedissue1Benefitreduction2You$15,000 If you're under70: $15,000If you're 70 orolder: The lesserof $15,000 orthe amount withthe prior carrier35% reductionat age 65, withan additional15% reductionat age 701Amount of coverage you may buy within 31 days of initial eligibility for coverage without providing healthinformation.2As you get older, your life insurance benefit amount decreases. Age reductions apply to the benefit amountafter providing health information.Who receives coverage?• You'll receive coverage if you’re an active, full-time employee. Seasonal, temporary, or contract employeesaren't eligible.o If you’re on a regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal timeoff, you’re still considered actively at work, as long as you’re fulfilling your regular duties and wereworking the day immediately prior to your time off.Additional eligibility requirements may apply.Do I need to provide health information?Benefit amounts up to the guaranteed issue shown in the table above won't require health information.What benefits does Accidental Death and Dismemberment (AD&D) provide?If you're accidentally injured on or off the job, you may receive a benefit equal to your life benefit.Loss AD&D BenefitLoss of life, loss of both hands or both feet or one hand andone foot, or loss of sight of both eyes100%

principal.comThis is a summary of group term life coverage insured by or with administrative services provided by PrincipalLife Insurance Company. This outline is a brief description of your coverage. It is not an insurance contract or acomplete statement of the rights, benefits, limitations and exclusions of the coverage. If there is a discrepancybetween the policy and this document, the actual policy provision prevails. For complete coverage details,refer to the booklet.© 2023 Principal Financial Services, Inc., Principal, Principal and symbol design and Principal Financial Group are trademarks and servicemarks of Principal Financial Services, Inc., a member of the Principal Financial Group.Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62508-6 11172310368 - 7 Page 2 of 2 07/2023Loss of one hand, or one foot, or sight of one eye 50%Loss of thumb and index finger on the same hand 25%Seatbelt / airbag - If you die in a car accident while wearinga seat belt or protected by an airbag$10,000Repatriation - If you die at least 100 miles from your home Up to $2,000Loss of use or paralysis - total loss of movement for 12 consecutive months or permanent paralysisQuadriplegia 100%Paraplegia, hemiplegia, or loss of use of both hands or bothfeet or one hand and one foot.50%Loss of use of one arm, one leg, one hand or one foot 25%Loss of speech and/or hearing - total loss for 12 consecutive monthsLoss of speech and hearing in both ears 100%Loss of speech or hearing in both ears 50%Loss of hearing in one ear 25%Additional benefits:Accelerated death benefit If you're terminally ill, you may be able to receive a portion of your life benefit.Coverage during disabilityIf you're disabled, you may be able to continue your coverage and not paypremium.Conversion of terminatedcoverageIf you terminate employment, you may be able to convert coverage to anindividual policy.The benefit summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet.

Group life insuranceHelp protect your family, your finances —and your futureCreate and store your important documents using your Will & Legal Document CenterIf you’re like most of us, you want to be in the driver’s seat when it comes to your wishes for the future, like who will inherit your assets or make medical decisions for you if you’re not able to. Especially since life can be so unpredictable. That’s why it’s important to be proactive and make a plan to help protect your family and finances. With your group term or voluntary term life insurance through Principal, you can do just that with access to resources from the Will & Legal Document Center provided by ARAG.Resources for help with legal documentsHaving the proper documents in place can help ensure you’re still in control in case something happens to you. With ARAG’s online resources, you and/or your spouse can prepare these documents: Standard Will. Specify what happens to your property and assets after you die, and appoint the person who will carry out your wishes. You can also name a guardian for your minor children. Health care power of attorney. Grant someone permission to make medical decisions on your behalf in case you’re no longer able to make them yourself. Durable power of attorney. Grant someone permission to make financial decisions in case you’re no longer able to make them yourself. Living will. Let your family and health care providers know your wishes for medical treatment if you’re unable to speak for yourself. Authorization for a Minor’s Medical Treatment. Grant consent for medical personnel to treat your child(ren) if you’re away and can’t be reached.HIPAA authorization. Designate person/s to access your protected medical records and health information.Plus, you can also access: Personal Information Organizer. Record your personal and financial information—as well as funeral arrangements—in one convenient spot. Estate planning education, tools, and resources. Get access to a variety of articles and legal resources.

Protect your identityIt’s not just inconvenient to have your identity stolen. It can have a direct impact on your credit rating and your financial security. The good news is you can help protect your identity with online resources from ARAG, including:An Identity Theft Victim Action Kit.to help speed your recovery if you experience identity theft. Guidebooks and articles that outline how you can prevent identity theft- and what steps to take if it happens. Guidebooks and articles.that outline how you can prevent identity theft- and what steps to take if it happens.It’s easy to get startedFollow these simple steps to start using these resources today:1 | Visit aragwills.com/principal.2 | Register by completing the required fields.3 | You’re in! Complete the forms or download the materials you need.Let’s connectNeed help with registration? Call ARAG Customer Care at 800.546.3718. Or, if you have questions about the services, call Principal at 866.539.1728.Insurance products and plan administrative services provided through Principal Life Insurance Company®, a member of the Principal Financial Group®, Des Moines, IA 50392..The value-added resources provided through ARAG Services, LLC (ARAG®) are not a part of any insurance products and plan administrative services provided through Principal Life Insurance Company® or affiliated with any company of the Principal Financial Group®. All resources may be changed or canceled at any time. Not available to group policies issued in New York.The use of resources provided by ARAG should not be considered a substitute for consultation with an attorney or advisor. Principal® is not responsible for any loss, injury, claim, liability, or damages related to the use of the ARAG Will & Legal Document Center resources.Please remember that the ARAG legal documents are accurate and useful in many situations. Due to possible changes by a state, it is a good idea to periodically review a template used to be sure it is the most current template. Whether or not the document is right for you and your situation depends on your circumstances. If you want specific advice regarding your situation, consult an attorney.This information is intended to be educational in nature and is not intended to be taken as a recommendation. Principal®, Principal Financial Group®, and Principal and the logomark design are registered trademarks of Principal Financial Services, Inc., a Principal Financial Group company, in the United States and are trademarks and service marks of Principal Financial Services, Inc., in various countries around the world.GP54930-12 (SP1348-06) | 03/2023 | 2843700-042023 | © 2023 Principal Financial Services, Inc.

Model General Notice of COBRA Continuation Coverage Rights** Continuation Coverage Rights Under COBRA**IntroductionYou’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.What is COBRA continuation coverage?COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:• Your hours of employment are reduced, or• Your employment ends for any reason other than your gross misconduct.If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:• Your spouse dies;• Your spouse’s hours of employment are reduced;• Your spouse’s employment ends for any reason other than his or her gross misconduct;• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or• You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:• The parent-employee dies;• The parent-employee’s hours of employment are reduced;• The parent-employee’s employment ends for any reason other than his or her gross misconduct;• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);• The parents become divorced or legally separated; or• The child stops being eligible for coverage under the Plan as a “dependent child.”When is COBRA continuation coverage available?The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:• The end of employment or reduction of hours of employment;• Death of the employee;• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to:Joan Wiederhold, Office Manager, jwiederhold@terrabellaes.com, 830-569-8959How is COBRA continuation coverage provided?Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.There are also ways in which this 18-month period of COBRA continuation coverage can be extended:Disability extension of 18-month period of COBRA continuation coverageIf you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to dicare benefits (under Part A, Part B, or both); gets

divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.Are there other coverage options besides COBRA Continuation Coverage?Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of• The month after your employment ends; or• The month after group health plan coverage based on current employment ends.If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.For more information visit https://www.medicare.gov/medicare-and-you.If you have questionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.Keep your Plan informed of address changesTo protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.Plan contact informationJoan Wiederhold, Office Manager, jwiederhold@terrabellaes.com, 830-569-8959

OMB 0938-0990CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 1 Important Notice from Terrabella Environmental Services About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Terrabella Environmental Services and about your options under Medicare’s prescriptiondrug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone withMedicare. You can get this coverage if you join a Medicare Prescription Drug Planor join a Medicare Advantage Plan (like an HMO or PPO) that offers prescriptiondrug coverage. All Medicare drug plans provide at least a standard level ofcoverage set by Medicare. Some plans may also offer more coverage for a highermonthly premium.2. Terrabella Environmental Services has determined that the prescription drugcoverage offered by the BCBS Health plans are, on average for all plan participants,expected to pay out as much as standard Medicare prescription drug coveragepays and is therefore considered Creditable Coverage. Because your existingcoverage is Creditable Coverage, you can keep this coverage and not pay a higherpremium (a penalty) if you later decide to join a Medicare drug plan.__________________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

OMB 0938-0990 Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 2 What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Terrabella Enironmenta Services coverage will not be affected. You can keep this coverage if you elect part D and this plan will coordinate with Part D coverage; for those individuals who elect Part D coverage. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.If you do decide to join a Medicare drug plan and drop your current Terrabella Environmental Services coverage, be aware that you and your dependents will be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Terrabella Environmental Services and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information contact Joan Wiederhold at 830-569-8959 jwiederhold@terrabellaes.com NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Terrabella Environmental Services changes. You also may request a copy of this notice at any time. CMS Form 10182-CC

OMB 0938-0990 Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 3 For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). CMS Form 10182-CC

OMB 0938-0990CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 4 Contact--Position/Office: Email Address: Phone Number: Joan Wiederhold, Office Managerjwiederhold@terrabellaes.com830-569-8959

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2024. Contact your State for more information on eligibility – ALABAMA – Medicaid ALASKA – Medicaid Website: http://myalhipp.com/Phone: 1-855-692-5447 The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.comMedicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspxARKANSAS – Medicaid CALIFORNIA – Medicaid Website: http://myarhipp.com/Phone: 1-855-MyARHIPP (855-692-7447) Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hippPhone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.govCOLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) FLORIDA – Medicaid Health First Colorado Website: https://www.healthfirstcolorado.com/Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plusCHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/HIBI Customer Service: 1-855-692-6442 Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.htmlPhone: 1-877-357-3268

GEORGIA – Medicaid INDIANA – Medicaid GA HIPP Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hippPhone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party-liability/childrens-health-insurance-program-reauthorization-act-2009-chipraPhone: 678-564-1162, Press 2 Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/Phone: 1-800-457-4584 IOWA – Medicaid and CHIP (Hawki) KANSAS – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/membersMedicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hippHIPP Phone: 1-888-346-9562 Website: https://www.kancare.ks.gov/Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660 KENTUCKY – Medicaid LOUISIANA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspxPhone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.govKCHIP Website: https://kynect.ky.govPhone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dmsWebsite: www.medicaid.la.gov or www.ldh.la.gov/lahippPhone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP) MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP Enrollment Website: https://www.mymaineconnection.gov/benefits/s/?language=en_USPhone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-formsPhone: 1-800-977-6740 TTY: Maine relay 711 Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.comMINNESOTA – Medicaid MISSOURI – Medicaid Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/other-insurance.jspPhone: 1-800-657-3739 Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005 MONTANA – Medicaid NEBRASKA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1-800-694-3084 Email: HHSHIPPProgram@mt.govWebsite: http://www.ACCESSNebraska.ne.govPhone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

NEVADA – Medicaid NEW HAMPSHIRE – Medicaid Medicaid Website: http://dhcfp.nv.govMedicaid Phone: 1-800-992-0900 Website: https://www.dhhs.nh.gov/programs-services/medicaid/health-insurance-premium-programPhone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 5218 NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710 Website: https://www.health.ny.gov/health_care/medicaid/Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid Website: https://medicaid.ncdhhs.gov/Phone: 919-855-4100 Website: https://www.hhs.nd.gov/healthcarePhone: 1-844-854-4825 OKLAHOMA – Medicaid and CHIP OREGON – Medicaid and CHIP Website: http://www.insureoklahoma.orgPhone: 1-888-365-3742 Website: http://healthcare.oregon.gov/Pages/index.aspxPhone: 1-800-699-9075 PENNSYLVANIA – Medicaid and CHIP RHODE ISLAND – Medicaid and CHIP Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP-Program.aspxPhone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov)CHIP Phone: 1-800-986-KIDS (5437) Website: http://www.eohhs.ri.gov/Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) SOUTH CAROLINA – Medicaid SOUTH DAKOTA - Medicaid Website: https://www.scdhhs.govPhone: 1-888-549-0820 Website: http://dss.sd.govPhone: 1-888-828-0059 TEXAS – Medicaid UTAH – Medicaid and CHIP Website: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human ServicesPhone: 1-800-440-0493 Medicaid Website: https://medicaid.utah.gov/CHIP Website: http://health.utah.gov/chipPhone: 1-877-543-7669 VERMONT– MedicaidVIRGINIA – Medicaid and CHIPWebsite: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health AccessPhone: 1-800-250-8427 Website: https://coverva.dmas.virginia.gov/learn/premium-assistance/famis-selecthttps://coverva.dmas.virginia.gov/learn/premium-assistance/health-insurance-premium-payment-hipp-programsMedicaid/CHIP Phone: 1-800-432-5924 WASHINGTON – MedicaidWEST VIRGINIA – Medicaid and CHIPWebsite: https://www.hca.wa.gov/Phone: 1-800-562-3022 Website: https://dhhr.wv.gov/bms/http://mywvhipp.com/Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

WISCONSIN – Medicaid and CHIP WYOMING – Medicaid Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htmPhone: 1-800-362-3002 Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/Phone: 1-800-251-1269 To see if any other states have added a premium assistance program since January 31, 2024, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov1-877-267-2323, Menu Option 4, Ext. 61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137 (expires 1/31/2026)

Group Disability InsuranceGROUP DISABILITY 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.Can 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) $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 $7,500.*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: _______ days*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: alcoholism or drug addiction, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, 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 certificate. We will not pay for loss when the disability is a pre-existing condition as described in the certificate.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 coverage eective date.We will not pay for loss when the disability is a pre-existing condition as defined in this certificate, unless you have satisfied the pre-existing condition limitation period (typically 12 months) shown on the Certificate Schedule on the date you suer a loss due to a covered accident or covered sickness.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form GDIS-P-EE-TX and certificate form GDIS-C-EE-TX. This is not an insurance contract and only the actual policy and certificate provisions will control.Product information and features Total disabilityTotally disabled or total disability means you are: unable to perform the material and substantial duties of your regular occupation, not working at any occupation, and under the regular and appropriate care of a doctor.Partial disabilityIf 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, Mexico or Canada, you may receive benefits for up to 60 days before you have to return to the U.S. Issue ageCoverage is available from ages 17 to 74.PortabilityYou may be able to keep your coverage even if you change jobs.For more information, talk with your benefits counselor.10-19 | 101296-3Underwritten 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.

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

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

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.

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

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

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

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

Term Life InsurancePeace of mind for you and your loved ones You 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 nancial security to help them cover their ongoing living expenses.Advantages of term life insurance Lower cost when compared to cash value life insurance Same benet payout throughout the duration of the policy Several term period options for exibility during high-need years Benet for the beneciary that is typically tax freeBenets 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 benet amount into cash value life insurance• Flexibility to keep the policy if you change jobs or retire• Built-in terminal illness accelerated death benet that provides up to 75% of the policy’s death benet (up to $150,000) if you’re diagnosed with a terminal illness1• Premium savings for face amounts over $250,000 based on your health44% of Americans say their household would face nancial hardship within six months should a wage earner die unexpectedly.LIMRA, 2022 Life Insurance Barometer Study.GAP54% of Americans have life insurance coverage, with an average coverage gap of $200,000.LIMRA, 2021 “Industry Associations Unite to Help Address the Life Insurance Coverage Gap in the United States.”TERM LIFE (ITL5000)

Optional ridersAt an additional cost, you can purchase the following riders for even more nancial protection.Spouse term life riderYour spouse can have up to $50,000 of coverage for a 10-year or 20-year term period.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 benet riderThe beneciary may receive an additional benet if the covered person dies as a result of an accident before age 70. The benet 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 benet riderIf a licensed health care practitioner certies that you have a chronic illness, you may receive an advance on all or a portion of the death benet, available in a one-time lump sum or monthly payments.1 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.² Premiums are waived during the benet period. Critical illness accelerated death benet riderIf you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benet is payable.1 A subsequent diagnosis benet is included.Waiver of premium benet 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.3How much coverage do you need? 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 benet rider Chronic care accelerated death benet rider Critical illness accelerated death benet rider Waiver of premium benet riderTo learn more, talk with your Colonial Life benets counselor.1. Any payout would reduce the death benet. Benets may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benets. 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.EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benet. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benets payable. 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 (plus state abbreviations where applicable, for example ITL5000-TX). For cost and complete details of the coverage, call or write your Colonial Life benets counselor or the company.Insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2022 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 6-22 | 101895-3ColonialLife.com

Whole Life Plus InsuranceOur individual whole life plan offers dependable lifetime coverage and guaranteed cash value to help employees during challenging times.Whether employees want the nancial security of a predictable death benet or access to the plan’s cash value through a policy loan for emergency situations, Whole Life Plus insurance has the exibility to provide both.1Product guarantees(as long as premiums are paid and no loans are taken)Competitive features• Death benet stays the same2• Choice of two plan designs based on length of time premiums are paid (Paid-Up at Age 70 and Paid-Up • Accumulates cash value based on a nonforfeiture at Age 100)interest rate of 3.75%1 • Coverage for broad issue age ranges, up to 79 on • Premiums remain the samePaid-Up at Age 100 plan• Tobacco-distinct, unisex ratesAttractive underwriting• Accelerated death benet due to terminal illness2• Face amounts up to $500,000• $3,000 advance claim payment from the death benet2• Guaranteed issue available• Policy loans available ($250 minimum)1• Nonmedical underwriting (no blood proles or examinations) available for certain age bands and face amounts• Spouse signature not required for spouse term rider or spouse whole life plus policy with face • Policy pays cash surrender value at age 100 (when the policy endows)• Portability that enables employees to take coverage with them if they change jobs or retireamounts up to $50,000, except in states that require applicant to signOptional riders• Accidental death benet riderFamily coverage options• Chronic care accelerated death benet rider• Stand-alone spouse and juvenile policies available with no employee policy required• Spouse term rider (10- and 20-year) available on • Critical illness accelerated death benet rider• Guaranteed purchase option rider• Waiver of premium benet rideremployee policy • Children’s term rider available on employee or spouse policyWHOLE LIFE PLUS (IWL5000)

Why choose Colonial Life?Life is full of unexpected moments. Colonial Life offers an unexpected approach to benets. Service at every step: We make account setup, enrollment, billing and claims easy. And we have a team ready to help when you need it.Personalized benets counseling: Our benets counselors can meet with employees individually to create a personalized benets solution that ts their needs now and in the future. A trusted partnership: As business and employees’ needs change, we ensure that the support we provide changes and adapts, too. One in four employers indicated life insurance is now more important and they are considering changes to their plans, such as adding supplemental life.3Contact your Colonial Life representative to learn more about Whole Life Plus.ColonialLife.com1. Accessing the accumulated cash value reduces the death benet by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy.2. Any accelerated benet payout would reduce the death benet. Benets may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benets.3. LIMRA, 2021 Insurance Barometer Study. https://www.limra.com/en/research/research-abstracts-public/2021/2021-insurance-barometer-study. Accessed July 2021.EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benet. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benets payable. 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. For cost and complete details of the coverage, call or write your Colonial Life benets counselor or the company.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. FOR BROKERS AND EMPLOYERS 7-21 | 642200

Life insurance: Term or Whole?LIFE INSURANCEIf you’re wondering which life insurance to offer your employees — term or whole life? The answer is: They need both options. Term and Whole Life work hand in hand Term and Whole Life insurance work together to provide nancial protection for your employees and their loved ones at all phases of life — whether they’re just starting out, raising a family or planning for retirement. Term Life offers nancial protection and peace of mind for employees and their families during their working years.Whole Life provides coverage employees can keep into retirement — at competitive rates when they buy it early. Life insurance for all phases of your employees’ livesWhole life Term life Childhood Young professional Mid-career RetirementBy offering these benets at work with premiums paid by payroll deduction, you provide valuable coverage options for employees without added costs to your bottom line. Coverage for spouse and children also provides critical protection for your employees’ family.When employees purchase both types of life insurance, they have valuable nancial protection that can last a lifetime.

This information is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benets payable. Applicable to policy forms GTL1.0-P and certicate number GTL1.0-C, ICC18-ITL5000/ITL5000, ICC19- IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, and ICC19-IWL5000J/IWL5000J and applicable state variations. For cost and complete details of the coverage, call or write your Colonial Life benets counselor or the company.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. FOR BROKERS AND EMPLOYERS 7-21 | 6911501. Any payout would reduce the death benet. Benets may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benets.2. Accessing the accumulated cash value reduces the death benet by the amount accessed. Cash value will be reduced by any outstanding loans against the policy.Term LifeWHAT IS TERM LIFE?• Offers nancial protection for loved ones during an employee’s working years • Offers highest amount of life insurance coverage for the lowest premiums KEY BENEFITS• Income replacement if the insured passes away• Can help pay ongoing expenses for the family, such as: ‐ Mortgage or rent ‐ Education ‐ Saving for retirementHOW IT WORKS Group Term Life • Employer-owned • Limited portability options• Flexible coverage that normally ends at retirement• Benet typically decreases after age 70• Guaranteed issue — coverage with no health questions or examsIndividual Term Life • Employee can continue their coverage if they change jobs or retire• The insured chooses a term period of 10, 15, 20, or 30 years• Guaranteed level premiums that do not increase during the selected term period • After the term period, the insured can end or renew coverage, or convert to a whole life policyWhole Life WHAT IS WHOLE LIFE? • Provides nancial protection for loved ones through their retirementKEY BENEFITS • Can help with nal expenses• Can provide a living benet to help pay for expenses associated with a terminal illness, chronic illness or critical illness1• Accumulates cash value at a guaranteed interest rate; employees can borrow against this value during times of need2HOW IT WORKS • Guaranteed issue — coverage with no health questions or exams• Permanent coverage for life with level premiums that can be paid-up at age 70 or 100• Death benet stays the same, as long as the employee makes payments How they work togetherTerm Life and Whole Life provide comprehensive life insurance with nancial protection during working years and benets that carry into retirement. Together, Term Life and Whole Life can help your employees and their loved ones give each other stronger nancial security and, perhaps, some peace of mind after they’re gone. ColonialLife.comTo learn more, talk with your Colonial Life benets representative.

Deductions per year: 12 These rates were prepared on 2/21/2024 and are valid for 90 days.Group Disability for TX A Risk ClassApplicable to policy forms GDIS-P & GDIS-ClOff-Job Accident and Off-Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $12.08 $30.20 $60.40 $90.60 N/A50-64 $14.08 $35.20 $70.40 $105.60 N/A65-74 $17.04 $42.60 $85.20 $127.80 N/A14 days Accident/14 days Sickness 17-49 $8.36 $20.90 $41.80 $62.70 $83.6050-64 $9.92 $24.80 $49.60 $74.40 $99.2065-74 $12.64 $31.60 $63.20 $94.80 $126.406 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $15.24 $38.10 $76.20 $114.30 N/A50-64 $20.20 $50.50 $101.00 $151.50 N/A65-74 $26.28 $65.70 $131.40 $197.10 N/A14 days Accident/14 days Sickness 17-49 $11.40 $28.50 $57.00 $85.50 $114.0050-64 $14.40 $36.00 $72.00 $108.00 $144.0065-74 $19.20 $48.00 $96.00 $144.00 $192.00Group 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 $12.91 $19.77 $31.19 $38.20Premier Preferred 17-99 $15.10 $23.46 $34.20 $42.75Group 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 $9.50 $17.10 $13.55 $21.1550-59 $12.30 $24.40 $16.35 $28.4560-64 $17.20 $35.80 $21.25 $39.8565-99 $24.10 $50.10 $28.15 $54.15HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $18.90 $34.00 $26.95 $42.0550-59 $24.50 $48.60 $32.55 $56.65Page 1 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Group 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 FAMILY60-64 $34.30 $71.40 $42.35 $79.4565-99 $48.10 $100.00 $56.15 $108.05Group 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 $8.90 $13.05 $8.90 $13.0525-29 $11.45 $16.95 $11.45 $16.9530-34 $14.15 $20.85 $14.15 $20.8535-39 $20.15 $30.00 $20.15 $30.0040-44 $26.15 $39.00 $26.15 $39.0045-49 $36.05 $54.30 $36.05 $54.3050-54 $45.80 $69.60 $45.80 $69.6055-59 $59.30 $90.15 $59.30 $90.1560-64 $79.85 $121.35 $79.85 $121.3565-69 $97.25 $148.05 $97.25 $148.0570-74 $97.25 $148.05 $97.25 $148.05$30,000 17-24 $14.90 $21.60 $14.90 $21.6025-29 $20.00 $29.40 $20.00 $29.4030-34 $25.40 $37.20 $25.40 $37.2035-39 $37.40 $55.50 $37.40 $55.5040-44 $49.40 $73.50 $49.40 $73.5045-49 $69.20 $104.10 $69.20 $104.1050-54 $88.70 $134.70 $88.70 $134.7055-59 $115.70 $175.80 $115.70 $175.8060-64 $156.80 $238.20 $156.80 $238.2065-69 $191.60 $291.60 $191.60 $291.6070-74 $191.60 $291.60 $191.60 $291.60(Continued...)Page 2 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

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 BenefitTobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $12.50 $18.15 $12.50 $18.1525-29 $16.70 $24.45 $16.70 $24.4530-34 $20.90 $30.75 $20.90 $30.7535-39 $30.50 $45.15 $30.50 $45.1540-44 $40.10 $59.70 $40.10 $59.7045-49 $55.85 $84.15 $55.85 $84.1550-54 $71.45 $108.60 $71.45 $108.6055-59 $93.05 $141.60 $93.05 $141.6060-64 $125.90 $191.55 $125.90 $191.5565-69 $153.80 $234.00 $153.80 $234.0070-74 $153.80 $234.00 $153.95 $234.15$30,000 17-24 $22.10 $31.80 $22.10 $31.8025-29 $30.50 $44.40 $30.50 $44.4030-34 $38.90 $57.00 $38.90 $57.0035-39 $58.10 $85.80 $58.10 $85.8040-44 $77.30 $114.90 $77.30 $114.9045-49 $108.80 $163.80 $108.80 $163.8050-54 $140.00 $212.70 $140.00 $212.7055-59 $183.20 $278.70 $183.20 $278.7060-64 $248.90 $378.60 $248.90 $378.6065-69 $304.70 $463.50 $304.70 $463.5070-74 $304.70 $463.50 $305.00 $463.80Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $6.71 $10.77 $10.54 $13.81 $17.0835 $7.69 $13.23 $11.58 $15.37 $19.1745 $9.68 $18.21 $21.79 $30.69 $39.5855 $18.06 $39.14 $46.33 $67.50 $88.6665 $41.00 $61.54 $119.08 $176.62 $234.16Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $10.48 $20.21 $18.21 $25.31 $32.4235 $11.72 $23.29 $20.62 $28.94 $37.2545 $15.89 $33.73 $45.46 $66.19 $86.9155 $33.93 $78.83 $106.04 $157.06 $208.0865 $70.14 $103.68 $203.37 $303.05 $402.73(Continued...)Page 3 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base Plan20-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $2.36 $4.72 $7.07 $9.43 $11.7935 $2.81 $5.62 $8.42 $11.23 $14.0445 $6.56 $13.12 $19.67 $26.23 $32.79Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $5.00 $10.00Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $9.20 $23.00 $46.00 $69.00 $92.0035 $12.52 $31.29 $62.58 $93.87 $125.1645 $19.88 $49.71 $99.41 $149.12 $198.8355 $32.45 $81.12 $162.24 $243.37 $324.4965 $57.75 $144.37 $288.74 $433.11 $577.48Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $16.07 $40.17 $80.33 $120.50 $160.6635 $19.55 $48.87 $97.75 $146.62 $195.4945 $29.11 $72.77 $145.54 $218.30 $291.0755 $49.06 $122.66 $245.32 $367.99 $490.6565 $83.91 $209.78 $419.57 $629.35 $839.1320-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $3.32 $6.63 $9.95 $13.27 $16.5835 $4.21 $8.42 $12.62 $16.83 $21.0445 $7.57 $15.13 $22.70 $30.27 $37.83(Continued...)Page 4 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice

Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $5.00 $10.00Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2024 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.(Continued...)Page 5 of 5Underwritten by Colonial Life & Accident Insurance CompanySee page 5 for Important Notice