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EMPLOYEE BENEFITS Effective January 1, 2024 through December 31, 2024Medical Dental Vision Colonial Life WEAVER MOTORS INC. OF KIRBYVILLEWEAVER BROTHERS MOTOR COMANY INC.

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

ELIGIBILITY Eligibility: You are eligible for benefits if you are classified as an active, full-time employee working 30 hours a week or more. Your coverage is effective the first of the month following 60 days. Dependent Eligibility: If you wish, your dependents may also be covered under the medical, dental, vision and supplemental plans. Newborns must be enrolled within 30 days from the date of birth. Eligible Dependents include: * Legal spouse, as defined by the Federal Law* Dependent childrenMEDICAL - Your children up to the end of the month in which they turn age 26, regardless of marital status, financial dependency, residency with the Eligible Employee, student status, employment status, or eligibility for other coverage. DENTAL – Dependent children are eligible until the end of the month in which they turn 26, regardless of whether or not they are dependent on the employee or whether they are a full-time or part-time student. VISION – Dependent children are eligible until the end of the month in which they turn 26, regardless of whether or not they are dependent on the employee or whether they are a full-time or part-time student. CLARIFICATION ON ELIGIBILITY FOR DEPENDENT COVERAGE Plans that offer dependent coverage must offer coverage to enrollees’ adult children until age 26, even if the young adult no longer lives with his or her parents, is not a dependent on a parent’s tax return, is no longer a student, or is married. This booklet is intended for illustrative and information purposes only. Not all plan provisions, limitations, and exclusions are included in this publication. In the event of any conflict between the information contained in this publication and the plan provisions, the Plan Documents and insurance cont racts will govern.

Medical: BlueCross Blue Shield of TexasPPO: HMO: Blue Choice PPO Network Blue Advantage HMO NetworkEmployee Weekly (52)Employee Weekly (52)G9L1CHC G9E5ADTEO 114.27$ EO 33.50$ ES 324.31$ ES 162.78$ EC 324.31$ EC 162.78$ EF 534.35$ EF 292.05$ S663CHC S9J7ADTEO 91.10$ EO 18.57$ ES 277.97$ ES 132.90$ EC 277.97$ EC 132.90$ EF 464.84$ EF 247.24$ Dental:Aetna Dental Administrators NetworkNipponEmployee Weekly (52)EO: 7.83$ ES: 19.30$ EC: 22.18$ EF: 32.67$ Vision:Eyemed Insight NetworkNipponEmployee Weekly (52)EO: 1.69$ ES: 3.72$ EC: 3.55$ EF: 6.59$ Pricing for plan year 1/1/2024-12/31/2024Weaver Motors

BLUE CHOICE PPO PLAN OPTIONS

BLUE ADVANTAGE HMO PLAN OPTIONS These plans require a PCP selection.

DeductibleDeductible CombinedDeductible Waived for PreventiveAnnual MaximumReimbursementRolloverTimely Entrant Waiting PeriodChild Orthodontic BenefitChild Orthodontic Lifetime MaximumAdult Orthodontic BenefitAdult Orthodontic Lifetime MaximumNot IncludedNot Included50%50%OrthodontiaIn NetworkOut of NetworkCrowns - other than stainless steel (once per 84 months), Dentures/Bridges/Repairs (Fixed-once per 84 months, Removable-once per 60 months), Inlays/Onlay (Fixed-once per 84 months, Removable-once per 60 months), Relining or rebasing of dentures (once in 36 months) , ImplantsNot IncludedNot IncludedN/ANot IncludedN/AN/A80%80%Type 3 Major ServicesIn NetworkOut of NetworkNoneType 2 Basic ServicesIn NetworkOut of NetworkNoneType 1 Preventive ServicesIn NetworkOut of Network100%100%Preventive Exams (once per 6 months), Teeth Cleaning (once per 6 months), Fluoride Treatment (every 12 months under age 16), Bitewing X-rays (every 12 months), Panoramic/Full Mouth X-rays (one set per 60 months), Oral Cancer Screenings (once per 24 months), Sealants (Dependent children under age 16 once per 36 months)Crowns (Stainless Steel) (only if tooth cannot be restored by filling - once per 84 months), Minor Oral Surgery (No Limit), Problem Focused Exams, Occlusal/Periapical X-rays, Space Maintainers, (Dependent children under age 16), Restorations/Fillings (once per 24 months), Simple Extractions, Extraoral X-rays (once per 6 months), Periodontal Prophylaxis (twice in 12 months), Endodontic Services/Root Canal Therapy, Periodontal Surgical Services (once per 36 months), Complex Oral Surgery, General AnesthesiaDental Benefit SummaryWEAVER MOTORS, INC OF KIRBYVILLE Effective: January 01, 2024$50YesYes$1,500Fee ScheduleYesYes$1,50090th PercentileOut of NetworkIn Network(waived for preventive)ALL MEMBERS PassiveADA ALL MEMBERS$50Not IncludedN/AThe above highlights are intended as an overview. In any discrepancy between the highlights and the master contract, the master contract will govern. These highlights do not guarantee benefits or eligibility. All terms, provisions, conditions, limitations and exclusions shown in the booklet-certificate and master policy will apply.WEAVER MOTORS, INC OF KIRBYVILLE LF0200 January 2024 Renewal

ExaminationLenses or Contact LensesFramesAdditional benefits are described in your Group Plan bookletPlease NotePremium Progressive Lenses (price varies by tier)FramesConventionalDisposableFrames/Contact LensesMembers also receive a 40% discount off complete pair of eyeglass purchases and a 15% discount off conventional contact lenses once the provided benefit has been used.FrequencyOnce in 24 MonthsOnce in 12 MonthsAdditional Pairs Benefit (In-Network Only)N/A15% Off RetailIn NetworkOut of Network$65 Reimbursement$130 AllowancePremiumRetinal Imaging Benefit Laser Vision Correction***$0 Copay, 10% Medically Necessary$104 Reimbursement$104 ReimbursementVision Benefit SummaryWEAVER MOTORS, INC OF KIRBYVILLE Effective: January 01, 2024ExamIn NetworkOut of NetworkExam with Dilation as NecessaryEyeglass LensesIn NetworkOut of Network$10 Copay$30 ReimbursementSingle VisionBifocalTrifocal$25 Copay$15 Reimbursement$25 Copay$5 ReimbursementLenticularStandard Progressive Lenses$40 Reimbursement$0 Copay, Paid in FullUp to $3915% Off RetailOnce in 12 Months*Out of Network is a reimbursement amount. Member reimbursement for services completed out of network will be the lesser of the listed amount or the member's actual cost from the out of network provider. In certain states, members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see EyeMed's online provider locator to determine which participating providers have agreed to the discounted rate.EyeMed Insight Network$210 Reimbursement$0 Copay$40 ReimbursementStandardContact Lens Fitting/Follow Up**In NetworkOut of Network$130 Allowance$15 Reimbursement$33 Reimbursement$33 Reimbursement$15 Reimbursement$110 to $135 Copay$25 Copay$25 Copay$90 Copay$130 Allowance

**Contact Lens fitting and 2 follow up visits are available once a comprehensive eye exam has been completed.***When Lasik or PRK from U.S. Laser Network is used.The above highlights are intended as an overview. In any discrepancy between the highlights and the master contract, the master contract will govern. These highlights do not guarantee benefits or eligibility. All terms, provisions, conditions, limitations and exclusions shown in the booklet-certificate and master policy will apply.*Out of Network is a reimbursement amount. Member reimbursement for services completed out of network will be the lesser of the listed amount or the member's actual cost from the out of network provider. In certain states, members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see EyeMed's online provider locator to determine which participating providers have agreed to the discounted rate.

*Guarantee Issue is only applicable for initial eligibilityThe above highlights are intended as an overview. In any discrepancy between the highlights and the master contract, the master contract will govern. These highlights do not guarantee benefits or eligibility. All terms, provisions, conditions, limitations and exclusions shown in the booklet-certificate and master policy will apply.Flat $15,000Basic Life / AD&D Benefit SummaryWEAVER MOTORS, INC OF KIRBYVILLE Effective: January 01, 2024ALL MEMBERSLife BenefitWaiver of Premium Accelerated Death Benefit AD&D Benefit Amount100% of Life benefit will be paid if the employee dies as the result of an accidentWaiver if disabled prior to 60, terms at normal retirement ageIncluded Except for Life Benefit of less than $10,000.

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

Deductions per year: 52Individual Accident (IAC4000) for TXApplicable to Policy Forms IAC4000lOn/Off-Job Accident CoverageBENEFIT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYPreferred 0-80 $4.37 $6.45 $7.89 $9.87Cancer Assist for TXApplicable to policy form CanAssistlwith $75 Health Screening Benefit$5,000 Initial Diagnosis BenefitCOVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYLevel 2 17-75 $6.29 $10.01 $6.48 $10.20Level 3 17-75 $7.44 $12.45 $7.67 $12.67Individual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$2000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $7.52 $14.27 $10.41 $17.1650-59 $10.57 $20.10 $13.45 $22.9960-64 $14.13 $26.83 $17.01 $29.7165-75 $18.43 $35.01 $21.33 $37.89Critical Illness 1.0 for TXApplicable to policy form CI-1.0lwith Subsequent Diagnosis Coverage, Health Screening BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $1.05 $1.59 $1.05 $1.5925-29 $1.22 $1.87 $1.22 $1.8730-34 $1.40 $2.17 $1.40 $2.1735-39 $1.95 $3.00 $1.95 $3.0040-44 $2.32 $3.55 $2.32 $3.5545-49 $3.02 $4.61 $3.02 $4.6150-54 $3.85 $5.91 $3.85 $5.9155-59 $4.75 $7.27 $4.75 $7.2760-64 $5.88 $9.02 $5.88 $9.0265-70 $7.12 $10.94 $7.12 $10.94Page 1 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Critical Illness 1.0 for TXApplicable to policy form CI-1.0lwith Subsequent Diagnosis Coverage, Health Screening BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$20,000 17-24 $1.61 $2.42 $1.61 $2.4225-29 $1.93 $2.98 $1.93 $2.9830-34 $2.30 $3.58 $2.30 $3.5835-39 $3.41 $5.24 $3.41 $5.2440-44 $4.15 $6.34 $4.15 $6.3445-49 $5.53 $8.47 $5.53 $8.4750-54 $7.19 $11.05 $7.19 $11.0555-59 $8.99 $13.78 $8.99 $13.7860-64 $11.25 $17.28 $11.25 $17.2865-70 $13.75 $21.11 $13.75 $21.11Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $1.28 $1.96 $1.28 $1.9625-29 $1.58 $2.42 $1.58 $2.4230-34 $1.98 $3.04 $1.98 $3.0435-39 $2.74 $4.20 $2.74 $4.2040-44 $3.55 $5.44 $3.55 $5.4445-49 $4.56 $6.99 $4.56 $6.9950-54 $5.74 $8.79 $5.74 $8.7955-59 $7.28 $11.19 $7.28 $11.1960-64 $8.76 $13.45 $8.76 $13.4565-70 $10.72 $16.48 $10.72 $16.48$20,000 17-24 $2.07 $3.16 $2.07 $3.1625-29 $2.67 $4.08 $2.67 $4.0830-34 $3.45 $5.33 $3.45 $5.3335-39 $4.98 $7.64 $4.98 $7.6440-44 $6.59 $10.13 $6.59 $10.1345-49 $8.62 $13.22 $8.62 $13.2250-54 $10.98 $16.82 $10.98 $16.8255-59 $14.07 $21.62 $14.07 $21.6260-64 $17.02 $26.14 $17.02 $26.1465-70 $20.95 $32.19 $20.95 $32.19Disability 1000 for TX A Risk ClassApplicable to policy form DIS1000lOff-Job Accident, Off-Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,400* $2,400* $4,000* $6,500**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $4.93 $9.85 $16.89 N/A N/A50-69 $5.98 $11.95 $20.49 N/A N/A(Continued...)Page 2 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Disability 1000 for TX A Risk ClassApplicable to policy form DIS1000lOff-Job Accident, Off-Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,400* $2,400* $4,000* $6,500**monthly benefit amount14 days Accident / 14 days Sickness 17-49 $3.55 $7.11 $12.18 $20.31 $33.0050-69 $4.44 $8.88 $15.23 $25.38 $41.256 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,400* $2,400* $4,000* $6,500**monthly benefit amount7 days Accident / 7 days Sickness 17-49 $6.22 $12.44 $21.32 N/A N/A50-69 $8.16 $16.32 $27.97 N/A N/A14 days Accident / 14 days Sickness 17-49 $4.85 $9.69 $16.62 $27.69 $45.0050-69 $6.46 $12.92 $22.15 $36.92 $60.00Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $25,000 $49,000 $50,000 $100,000 $150,00025 $2.48 $3.98 $2.43 $3.94 $5.4535 $3.05 $5.09 $2.67 $4.42 $6.1745 $4.20 $7.35 $5.03 $9.13 $13.2455 $9.03 $10.49 $10.69 $20.46 $30.2365 $14.20 $26.95 $27.48 $54.03 $80.59Tobacco RatesISSUE AGE $25,000 $49,000 $50,000 $100,000 $150,00025 $4.66 $8.25 $4.20 $7.48 $10.7635 $5.37 $9.65 $4.76 $8.59 $12.4345 $7.78 $14.37 $10.49 $20.05 $29.6255 $18.19 $24.00 $24.47 $48.02 $71.5665 $23.92 $46.01 $46.93 $92.93 $138.94Whole Life (IWL5000) for TXApplicable to policy forms ICC19-IWL500-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPOlAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $2.39 $4.09 $5.79 $7.49 $8.3135 $3.13 $5.57 $8.01 $10.45 $11.7645 $4.46 $8.23 $12.00 $15.77 $18.20(Continued...)Page 3 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Whole Life (IWL5000) for TXApplicable to policy forms ICC19-IWL500-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPOlAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00055 $7.05 $13.41 $17.25 $22.77 $28.2965 $12.48 $19.57 $29.02 $38.46 $47.90Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $3.63 $6.57 $9.52 $12.46 $12.1935 $4.57 $8.44 $12.32 $16.20 $15.9845 $6.26 $11.82 $17.39 $22.95 $24.5655 $10.85 $21.01 $23.88 $31.61 $39.3465 $19.40 $26.30 $39.10 $51.90 $64.71Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2014 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Jamie Pope | jamie@colonialtx.com | (409) 782-1910(Continued...)Page 4 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

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

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

For more information, talk with your benefits counselor.IAC4000 – PREFERRED PLANTRANSPORTATION & LODGINGTransportation for hospital confinement ..................................................... $600 per round trip(up to three round trips, 50+ miles from home)Lodging – companion (up to 30 days) .................................................................. $125 per dayFOLLOW-UP CAREAccident follow-up treatment – including transportation/telemedicine ...................................$55 (up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar year)Medical equipment¾ Tier 1 ............................................................................................................... $30 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint ¾ Tier 2 ............................................................................................................. $100 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot ¾ Tier 3 ............................................................................................................. $200 Back brace, body jacket, continuous passive movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair li chair, wheelchairMedical imaging study – CT, CAT scan, EEG, EMG, MR or MRI................................................. $200 (one per calendar year)Pain management for epidural anesthesia – non-surgical ................................................... $100 Post-traumatic stress disorder (PTSD) .......................................................................... $200 Prosthetic device/artificial limb¾ One ............................................ $750 ¾ More than one ..............................$1,500¾ Repair/replacement3 ................................................................................... $375/$750Rehabilitation unit confinement ....................................................................... $150 per day(up to 15 days, not to exceed 30 days per calendar year)Therapy – occupational, physical or speech (up to ten days)........................................$35 per dayACCIDENTAL DISMEMBERMENTAccidental dismemberment .......................................................................... $4504 – $20,000¾ Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye¾ Loss, loss of use – finger, toe, partial dismemberment of finger or toeAccidental dismemberment due to a catastrophic accidentNamed insured, spouse or child ...........................................................................$25,0005¾ Total and irrecoverable loss, loss of use or paralysis – 180-day elimination period¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears, or loss of ability to speakACCIDENTAL DEATHAccidental death¾ Named insured, spouse .................................................................................. $40,000¾ Child ......................................................................................................... $10,000Accidental death common carrierExamples of common carriers are mass transit trains, buses and planes¾ Named insured, spouse ................................................................................. $160,000¾ Child ......................................................................................................... $30,000

For more information, talk with your benefits counselor.Hospital Confinement Indemnity InsurancePlan 2IMB7000 – PLAN 2The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.Tier 1 outpatient surgical procedures  Breast– Axillary node dissection– Breast capsulotomy– Lumpectomy  Cardiac– Pacemaker insertion  Digestive– Colonoscopy– Fistulotomy– Hemorrhoidectomy– Lysis of adhesions  Skin– Laparoscopic hernia repair– Skin graing  Ear, nose, throat, mouth– Adenoidectomy– Removal of oral lesions– Myringotomy– Tonsillectomy– Tracheostomy– Tympanotomy  Gynecological– Dilation and curettage (D&C)– Endometrial ablation– Lysis of adhesions  Liver– Paracentesis  Musculoskeletal system– Carpal/cubital repair or release– Foot surgery (bunionectomy, exostectomy,arthroplasty, hammertoe repair)– Removal of orthopedic hardware– Removal of tendon lesionOur Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement .........................................................................$_______________ Maximum of one benefit per covered person per calendar yearObservation room .................................................................................. $100 per visitMaximum of two visits per covered person per calendar yearRehabilitation unit confinement .................................................................$100 per dayMaximum of 15 days per confinement with a 30-day maximum per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered hospital confinement of the named insuredOutpatient surgical procedure  Tier 1.................................................................................................$_______________  Tier 2.................................................................................................$_______________Maximum of $________________ per covered person per calendar year for all covered outpatient surgical procedures combined2,0005001,000

THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS We will not pay benefits for losses which are caused by: dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, intoxicants or narcotics, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months aer the eective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months aer the eective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the eective date of the policy.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-AK and IMB7000-TX. This is not an insurance contract and only the actual policy provisions will control.ColonialLife.com©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 6-16 | 101578-AK-TX  Breast– Breast reconstruction– Breast reduction  Cardiac– Angioplasty– Cardiac catheterization  Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy  Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– Tympanoplasty  Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy Tier 2 outpatient surgical procedures  Gynecological– Hysterectomy– Myomectomy  Musculoskeletal system– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)– Arthroscopic shoulder surgery– Clavicle resection– Dislocations (open reduction with internal fixation)– Fracture (open reduction with internal fixation)– Removal or implantation of cartilage– Tendon/ligament repair  Thyroid– Excision of a mass  Urologic – Lithotripsy

For more information, talk with your benefits counselor.ColonialLife.comSubsequent diagnosis of a dierent critical illness3If you receive a benefit for a specified critical illness, and later you are diagnosed with a dierent specified critical illness, the original percentage of the face amount is payable for that particular specified critical illness.Subsequent diagnosis of the same critical illness3If you receive a benefit for a specified critical illness, and later you are diagnosed with the same specified critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass gra surgery/disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.Specified Critical Illness InsuranceIf you’re diagnosed with a covered critical illness, specified critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.Face amount: $_______________ For the diagnosis of this covered critical illness condition:1This percentage of the face amount is payable:Heart attack (myocardial infarction) 100%Stroke 100%End-stage renal (kidney) failure 100%Major organ failure 100%Permanent paralysis due to a covered accident 100%Coma 100%Blindness 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Coronary artery bypass gra surgery/disease225%Critical illness benefitCRITICAL ILLNESS 1.0 WITH SUBSEQUENT DIAGNOSIS The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined. The policy will terminate when the maximum benefit amount for specified critical illness has been paid.

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

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, mental or nervous disorders, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months aer the coverage eective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which you were treated, had medical testing, received medical advice or had taken medication within 12 months before the policy coverage eective date shown on the policy schedule.Aer this policy has been in force for 12 months (six (6) months if you are age 65 or older on the policy coverage eective date) from the policy coverage eective date shown on the policy schedule, we will pay benefits for any pre-existing condition not excluded by name or specific description if the covered disability began at least 12 months (six (6) months if you are age 65 or older on the Policy Coverage Eective Date) aer the policy coverage eective date and the elimination period has been satisfied.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-TX and rider form ISTD3000-ADIB-TX. This is not an insurance contract and only the actual policy and rider provisions will control.12-17 | 101629-2-TXProduct information Total disability definitionTotally disabled or total disability means you are: unable to perform the material and substantial duties of your occupation, not, in fact, working at any occupation, and under the regular and appropriate care of a physician.How partial disability worksIf you are able to return to work part-time aer at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.Waiver of premiumWe will waive your premium payments aer 90 consecutive days of a covered disability.Geographical limitationsIf you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.Issue ageCoverage is available from ages 17 to 74.Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.For more information, talk with your benefits counselor.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Term Life InsurancePeace of mind for you and your loved onesYou want what’s best for your family, and that includes making sure they’re prepared for the future. With term life insurance from Colonial Life & Accident Insurance Company, you can provide financial security to help them cover their ongoing living expenses.Advantages of term life insurance  Lower cost when compared to cash value life insurance  Same benefit payout throughout the duration of the policy  Several term period options for flexibility during high-need years  Benefit for the beneficiary that is typically tax-freeBenefits and features  Stand-alone spouse policy available whether or not you buy a policy for yourself  Guaranteed premiums that do not increase during the selected term  Ability to convert all or a portion of the benefit amount into cash value life insurance  Flexibility to keep the policy if you change jobs or retire  Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness  Premium savings for face amounts over $250,000 based on your healthTERM LIFE (ITL5000)LIMRA, 2017 Insurance Barometer Study.of Americans would have trouble paying living expenses immediately or within several months if the primary wage-earner died.54%married/partnered consumersLIMRA, 2018 Insurance Barometer Study.1-in-3wish their spouse or partner would purchase more life insurance.

How much coverage do you need?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/R-ITL5000-STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/R-ITL5000-ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC and applicable state variations. Spouse term life riderYour spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available. Children’s term life riderYou can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living. Premiums are waived during the benefit period. Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. 6-19 | 101895-1ColonialLife.com1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring.3 You must resume premium payments once you are no longer disabled.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.Optional ridersAt an additional cost, you can purchase the following riders for even more financial protection.£ YOU $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-year£ SPOUSE $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-yearSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Waiver of premium benefit rider

Your cost will vary based on the level of coverage you select. Whole Life InsuranceYou can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.Advantages of whole life insurance  Permanent coverage that stays the same throughout the life of the policy  Guaranteed level premiums that do not increase because of changes in health or age  Access to the policy’s cash value through a policy loan for emergencies  Benefit for the beneficiary that is typically tax-freeBenefits and features  Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100  Stand-alone spouse policy available whether or not you buy a policy for yourself  Flexibility to keep the policy if you change jobs or retire  Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness  Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses  Pays cash surrender value at age 100 (when the policy endows)WHOLE LIFE (IWL5000)HealthAairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.Talk with your benefits counselor for information about what level of coverage would work best for you.In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person.$

£ YOU $ ___________________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100£ SPOUSE $ _______________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/R-IWL5000-GPO and applicable state variations.Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three dierent points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.Benefits worksheetFor use with your benefits counselorSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Guaranteed purchase option rider£ Waiver of premium benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your benefits counselor.ColonialLife.com6-19 | 101935£ DEPENDENT STUDENT $____________£ Paid-Up at Age 70 £ Paid-Up at Age 100 1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Search online via Provider Finder® to nd a reward-eligible location for your procedure or service.Receive a cash reward by check, which will be mailed directly to your home, after your claim is paid and the location is veried as reward-eligible.How it worksShop online with Provider Finder by visiting bcbstx.com, register or log in to Blue Access for MembersSM and select “Find Care.” If you need help, call the Customer Service number on the back of your member ID card.Step 1 Step 3Get the procedure or service at your chosen reward-eligible location.Step 2Healthy You, Healthy Wallet!Member Rewards helps you compare costs, save money and earn cash rewards.Costs for the same medical care can vary.With Member Rewards, you can shop and earn cash rewards for procedures and services, which can vary based on location. It is quick and easy to shop in-network for scans, colonoscopies, surgeries and more. The Member Rewards program is part of your health plan benets and administered by Sapphire Digital – part of Zelis.759558.0922Sapphire Digital is an independent company that has contracted with Blue Cross and Blue Shield of Texas (BCBSTX) to administer the Member Rewards program for members with coverage through BCBSTX. Reward-eligible options and reward amounts are subject to change. Eligibility for rewards is subject to terms and conditions of the Member Rewards program. Amounts received through Member Rewards may be taxable. BCBSTX does not provide tax advice. Members that have primary coverage with Medicaid or Medicare are not eligible to receive incentive rewards under the Member Rewards program.BCBSTX makes no endorsement, representations or warranties regarding third-party vendors and the products and services offered by them.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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 4202/10/1 -1 4202/13/2C :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 : S663CHC Blue Choice Silver PPOSM 827 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_spsg13bcastxo_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: $3,000 Individual/$9,000 FamilyOut-of-Network: $6,000 Individual/$18,000 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: $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 0000097 1027C :doireP egarevo 0 4202/10/1 -1 4202/13/2C :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_spsg13bcastxo_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$45/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) $250/test plus 30% coinsurance50% 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 0000097 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_spsg13bcastxo_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 30% coinsurance$350/visit plus 50% coinsuranceIf you have outpatient surgery Physician/surgeon fees$100/visit plus 30% coinsurance50% coinsurancePreauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$600/visit plus 30% coinsurance$600/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)$350/visit plus 30% coinsurance$400/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.0000097 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_spsg13bcastxo_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$45/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$350/visit plus 30% coinsurance$400/visit plus 50% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Behavioral Health Services) for details.Office visitsPrimary Care: $45/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$350/visit plus 30% coinsurance$400/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.0000097 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_spsg13bcastxo_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.0000097 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.0000097 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.0000097 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 $3,000 Specialist copayment $90 Hospital (facility) copayment/coinsurance$350+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$3,000Copayments$700Coinsurance$2,600What isn’t coveredLimits or exclusions$60The total Peg would pay is$6,360 The plan’s overall deductible $3,000 Specialist copayment $90 Hospital (facility) copayment/coinsurance$350+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$800Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,720 The plan’s overall deductible $3,000 Specialist copayment $90 Hospital (facility) copayment/coinsurance$350+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. 0000097 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 : G9E5ADT Blue Advantage Gold HMOSM 923 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_ghsa03bavstxo_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?$1,250 Individual/$3,750 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?$5,250 Individual/$10,500 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 0000025 1027C :doireP egarevo 0 4202/10/1 -1 4202/13/2C :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_ghsa03bavstxo_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$45/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)Lab: 20% coinsuranceX-Rays: $150/test plus 20% 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) $250/test plus 20% 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 0000025 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_ghsa03bavstxo_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)$250/visit plus 20% coinsuranceNot CoveredIf you have outpatient surgery Physician/surgeon fees20% coinsuranceNot CoveredReferral required. Preauthorization may also be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$600/visit plus 20% coinsurance$600/visit plus 20% coinsuranceCopayment waived if admitted.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 applyNot CoveredNoneFacility fee (e.g., hospital room)$300/visit plus 20% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon fees20% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Professional Services) for details.Outpatient services$45/office visit; deductible does not apply;20% 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$300/visit plus 20% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Behavioral Health Services) for details.0000025 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_ghsa03bavstxo_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: $45/initial visit; deductible does not applySpecialist: $90/initial visit; deductible does not apply Not CoveredChildbirth/delivery professional services20% coinsuranceNot CoveredIf you are pregnantChildbirth/delivery facility services$300/visit plus 20% 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 care20% coinsuranceNot Covered60 visits/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation services20% coinsuranceNot CoveredHabilitation services20% 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 care20% coinsuranceNot Covered25 days/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipment20% 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 services20% 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.0000025 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_ghsa03bavstxo_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.0000025 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.0000025 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.0000025 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 $1,250 Specialist copayment $90 Hospital (facility) copayment/coinsurance$300+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$1,250Copayments$700Coinsurance$2,100What isn’t coveredLimits or exclusions$60The total Peg would pay is$4,110 The plan’s overall deductible $1,250 Specialist copayment $90 Hospital (facility) copayment/coinsurance$300+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$800Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,720 The plan’s overall deductible $1,250 Specialist copayment $90 Hospital (facility) copayment/coinsurance$300+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$1,250Copayments$700Coinsurance$100What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,050About 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. 0000025 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 : S9J7ADT Blue Advantage Silver HMOSM 127 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_shsj52bavstxo_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?$3,000 Individual/$9,000 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?$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 0000084 1027C :doireP egarevo 0 4202/10/1 -1 4202/13/2C :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_shsj52bavstxo_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$45/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)30% 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) $250/test plus 30% 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 0000084 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_shsj52bavstxo_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)$300/visit plus 30% coinsuranceNot CoveredIf you have outpatient surgery Physician/surgeon fees$100/visit plus 30% coinsuranceNot CoveredReferral required. Preauthorization may also be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$600/visit plus 30% coinsurance$600/visit plus 30% coinsuranceCopayment waived if admitted.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 applyNot CoveredNoneFacility fee (e.g., hospital room)$350/visit plus 30% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon fees30% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Professional Services) for details.Outpatient services$45/office visit; deductible does not apply;30% 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$350/visit plus 30% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Behavioral Health Services) for details.0000084 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_shsj52bavstxo_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: $45/initial visit; deductible does not applySpecialist: $90/initial visit; deductible does not apply Not CoveredChildbirth/delivery professional services30% coinsuranceNot CoveredIf you are pregnantChildbirth/delivery facility services$350/visit plus 30% 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 care30% coinsuranceNot Covered60 visits/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation services30% coinsuranceNot CoveredHabilitation services30% 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 care30% coinsuranceNot Covered25 days/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipment30% 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 services30% 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.0000084 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_shsj52bavstxo_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.0000084 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.0000084 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.0000084 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 $3,000 Specialist copayment $90 Hospital (facility) copayment/coinsurance$350+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$3,000Copayments$700Coinsurance$2,600What isn’t coveredLimits or exclusions$60The total Peg would pay is$6,360 The plan’s overall deductible $3,000 Specialist copayment $90 Hospital (facility) copayment/coinsurance$350+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$800Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,720 The plan’s overall deductible $3,000 Specialist copayment $90 Hospital (facility) copayment/coinsurance$350+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. 0000084 1027

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This brochure highlights the main features of Weaver Motors Inc. of Kirbyville and Weaver Brothers Motor Company, Inc. employee benets program. It does not include all plan rules, details, limitations, and exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents, the plan documents are final authority. Weaver Motors Inc. of Kirbyville and Weaver Brothers Motor Company, Inc. reserve the right to change or discontinue the employee benefits plans at any time. Prepared by Texas Financial Center 150 W. Gibson Street Jasper, Texas 75951 Phone: 409.384.4441 Fax: 409.384.7800 stephanie@texasfinancialcenter.com