EXPLORE

YOUR
BENEFITS
2025 Benefit Guide
What’s Inside?
3 Eligibility and Enrollment 11 Life and Disability Coverage
4 Medical Benefits 12 Financial Coaching by ProsperWise℠
5 Health Savings Account (HSA) 13 Retirement 401(k)
6 Flexible Spending Accounts (FSA) 14 Peloton
7 Medical Plan Tools 15 Tickets at Work

8 Medical Plan: Know Where to Go 16 Life Mart

9 Dental and Vision Benefits 17 Important Benefit Contacts

10 Health Care Rates 18 Required Notices

19

2
Enrollment and Eligibility
ELIGIBILITY ENROLLING IN COVERAGE
All employees actively working over 25 hours a week and their eligible dependents (spouse and It is so important to carefully review your options and make sure they meet the needs of you and your family.
dependent children) are allowed to enroll in PRIME AE’s medical benefits. You must be actively Your Open Enrollment benefit elections will run through the December 31, 2025.
working over 30 hours a week to enroll in PRIME AE’s dental, vision, life/disability, and accident
Benefits elections throughout the year are ineligible to be changed once Open Enrollment is closed, unless
benefits. Coverage is effective on your date of hire.
you expereince a qualifying life event.

Eligible dependents include:

*Qualifying Life Events include:
Spouses
Marriage
Dependent children who have not attained age 26
Divorce
Dependent children of any age if they became physically or mentally incapable of self-support
Legal separation or annulment
before age 19 and remain incapacitated and enrolled in the plan
Birth or adoption of a child (or placement of a child for adoption)
Death of a dependent
ENROLLMENT CHECKLIST
A change in you/your spouse's employement, if it results in a loss/gain of eligibility for coverage

Learn If you have a qualifying change in status during the year, you must notify HR within 30 days of the status
Review this brochure to understand your PRIME AE 2025 benefit options. change to request a change to your benefit elections. Otherwise, you will have to wait until the next calendar
year.

Decide
Think about you and your family’s benefit needs for the coming year and decide which
options are best for you and your family.

Have questions about your eligibility or enrollment?

Elect Please feel free to email:
Visit ADP to make your benefit elections. Jay Secrist at [email protected]

3 Make your benefit elections via ADP

Medical Plan Options
BUY UP PLAN BASE PLAN: HSA ELIGIBLE BUY DOWN PLAN: HSA ELIGIBLE

In Network Out of Network In Network Out of Network In Network Out of Network

Deductible (Employee / Family) $1,250 / $2,500 $4,000 / $8,000 $1,650 / $3,300 $4,000 / $8,000 $3,300 / $6,600 $5,000 / $10,000

Out of Pocket Max. $3,250 / $6,500 $8,000 / $16,000 $3,500 / $7,000 $8,000 / $16,000 $5,000 / $10,000 $10,000 / $20,000

Office Visits $30 copay 40% after deductible 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Specialist Visits $45 copay 40% after deductible 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Preventive Services* Covered in Full Covered in Full Covered in Full Covered in Full Covered in Full Covered in Full

Emergency Room Visit (waived

$200 copay $200 copay 20% after deductible 20% after deductible 20% after deductible 20% after deductible
if admitted to hospital)

Lab 20% after deductible 40% after deductible 20% after deductible 40% after deductible 20% after deductible 40% after deductible

X-Ray $45 copay 40% after deductible 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Outpatient Surgery Facility 20% after deductible 40% after deductible 20% after deductible 40% after deductible 20% after deductible 40% after deductible

In-Patient Hospitalization 20% after deductible 40% after deductible 20% after deductible 40% after deductible 20% after deductible 40% after deductible

$10 / $35 / $60 / 50% co- $10 / $35 / $60 / 50% co-
Prescription Drug Coverage $10 / $35 / $60 / 50% co-
Not Covered insurance up to $250 after Not Covered insurance up to $250 after Not Covered
(Retail 30-Day Supply) insurance up to $250
deductible deductible

Prescription Drug Coverage $25 / $87.50 / $150 $25 / $87.50 / $150

$25 / $87.50 / $150 Not Covered Not Covered Not Covered
(Mail Order 90-Day Supply) after deductible after deductible

*Preventive Care: Services available to you, such as screenings, vaccinations, and counseling, that can help you avoid illness and improve your health, at no cost to you.

4 Make your benefit elections via ADP.

Health Savings Account
When you select the Base or Buy-Down plans, you can choose an employee-funded Health Savings
Account. This allows you to pay for out-of-pocket medical, dental, and vision expenses with pre-
2025 HSA Contribution Limits
tax dollars.

Employee: $4,350
HEALTH SAVINGS ACCOUNT (HSA) Family: $8,550
If you choose the Base or Buy-Down Medical Plan, you can make contributions to an HSA on a
pre-tax basis. These contributions grow tax free and because the HSA is composed of your own Catch-up Contributions: $1,000 for HSA-eligible participants age 55+
contributions, they are yours to keep. Each year, you may contribute up to the annual IRS
maximum: $4,350 for an individual plan and $8,550 for a family plan. If you are age 55 years or
older, you may contribute an additional $1,000 per year to the HSA. Unused HSA dollars can roll
over and continue to accumulate or be rolled into another HSA if you change jobs or health plans.
With an HSA, you can also contribute to a Limited Purpose FSA , which allows you to put money
aside to pay for eligible dental and vision expenses.

HSA FACTS
Who contributes? Employee

Who owns the account? Employee

Employees are able to invest their contributions within the HSA

What happens to the account if I leave PRIME? Money stays with the employee

Can I enroll in an FSA? Limited Purpose FSA (dental and vision) only

Other uses: premiums for COBRA, Long Term Care, or Medicare

5 Make your benefit elections via ADP.

Flexible Spending Account Options
PRIME offers three types of Flexible Spending Accounts (FSAs) that help you pay for your medical
expenses while lowering your taxable income. With an FSA, you can set aside pre-tax money to
pay for out-of-pocket expenses such as co-payments, deductibles, day care providers, eyeglasses,
and other expenses not fully covered by the health plan.

You should only contribute the amount of money you expect to pay during the plan year for out-of-
pocket expenses as you will forfeit any unused amounts.

YOUR CHOICES

Health Care FSA: Used to pay for eligible out-of-pocket medical, dental, and vision care expenses
for you and your eligible dependent(s). Eligible expenses include but are not limited to: copays,
deductibles, coinsurance, eye exams, contact lenses and eyeglasses, hearing services, dental 2025 FSA Limits
services and orthodontia, chiropractic services, and prescriptions.

Health Care: $3,200

Dependent Care FSA: Used to pay for eligible expenses for the care of a dependent child under Dependent Care: $5,000 per family
age 13 or a dependent adult. Some eligible expenses include eligible preschool, before- and after- ($2,500 if married and filing separately)
school programs, and child or elder day care. Dependent health care expenses are not eligible for
reimbursement with this account; those expenses may be covered with a Health Care FSA.
Remember, unused funds left in your FSA at the end of the year are forfeited —
so be sure to carefully estimate the amount you would like to put aside. You are
Limited Purpose FSA: Used to pay for eligible dental and vision expenses only. PLEASE NOTE: If permitted to roll over $640 of your Health Care FSA to the following year. You
you are enrolled in the PPO plan with HSA and would like to enroll in the HSA, you must enroll in may file a claim incurred in 2025 through 3/31/2025.
the limited purpose FSA.

6 Make your benefit elections via ADP.

Medical Plan Tools
When you enroll in a Anthem Blue Cross Blue Shield medical plan, you have access to several handy TERMS TO KNOW
planning tools and resources that can help you make the most of your medical coverage.
Coinsurance: The percentage of a covered expense you must pay after you meet your
deductible, but before you reach the annual out-of-pocket maximum. The remaining
YOUR TOOLS percentage is paid by the health plan.

Sydney Mobile App: Find doctors, dentists, hospitals, and other health care providers Compare provider Copayment: The per-service fixed fee you pay for certain covered medical expenses.
cost and quality before you choose services. Download the Sydney mobile app from the App Store or Google
Play to access your ID card, find a plan doctor and much more. Deductible: The amount you must pay each year for medical expenses before the medical
plan begins to pay benefits.
LiveHealthOnline: Talk with and get treatment from a doctor on your computer, smartphone or tablet using
the free app. It is secure, private, easy to use and affordable. Visit LiveHealthOnline.com to learn more! Explanation of Benefits (EOB): Statement sent by the medical carrier to explain the
medical services that were covered on your behalf.
Care24 Nurse Line: Talk to a professionally trained, registered nurse 24/7. Call 800-700-9184.
Health Savings Account (HSA): A tax-free account you can use to pay for current and
future medical expenses.
SPECIALTY PHARMACY COST RELIEF PROGRAM
Out of Pocket Maximum: The limit the medical plan puts on the amount of money you
Cost Relief is a program that offers you select specialty medicines at no cost to you. That means $0 copay
have to pay each year out of your pocket for eligible medical expenses. Once you reach
when you fill a prescription through the Specialty Pharmacy. Call a Cost Relief Representative at 877-638-
the limit, the plan will pay 100% of your eligible expenses for the rest of the year.
4008 to find out if your medicine is eligible and to complete your enrollment in Cost Relief.
Preventive Care: Services available to you, such as screenings, vaccinations, and
You are not required to participate in the Cost Relief program. However, if you would like to pay less for
counseling, that can help you avoid illness and improve your health, at no cost to you.
your specialty medications, we strongly encourage you to complete your enrollment. If you choose not to
complete your enrollment in Cost Relief, you may have to pay up to 45% of the cost of your medicines if it
is included in the Cost Relief program.

Members enrolled in the Anthem Health Savings Account plan are required to meet their deductible prior to
receiving a $0 cost share.

7 Make your benefit elections via ADP

Medical Plan: Know Where to Go
TYPE APPROPRIATE FOR EXAMPLES ACCESS Cost
Where you get medical care can
Identifying symptoms
have a significant impact on the Quick answers from a trained
cost. Here’s a quick guide to help
Nurseline Decide if immediate care is needed 24/7 $0
nurse
Home treatement optiions and advice
you know where to go, based on
your condition, budget, and time.
Cold, flu, allergies
Headache, migraine
Many non-emergency health
Online Visit Skin conditions, rashes 24/7 $
conditions
Minor injuries
Mental health concerns

Preventive care
Routine medical care and
Office Visit Illnesses, injuries Office Hours $$
overall health management
Managing exisiting conditions

Stitches
Urgent Care / Non-life threatening conditions Sprains Office Hours,
$$$
Walk-in Clinic requiring prompt attention Animal bites or up to 24/7
Ear-nose-throat infections

Suspected heart attack or stroke

Life threatening conditions Major bone breaks
Emergency
requiring immediate medical Excessive bleeding 24/7 $$$$$
Room expertise Sever pain
Difficulty breathing

8 Make your benefit elections via ADP

Dental and Vision Plan
DENTAL VISION
As a PRIME AE employee, you can elect dental coverage, which is administered by Delta Dental. You may purchase vision care services for yourself and your dependents through VSP.

DENTAL PLAN VISION PLAN

In Network Out of Network

Frequency Benefit

Deductible (waived for preventive

$50 / $150 Eye Exam 12 months $10 copay
services)

Annual Maximum per Individual $1,500 Contact Lens — Fit and Follow-Up 12 months Up to $60

Preventive Services: oral exams, x-rays Prescription Glasses — Lenses: Single,

and diagnostics, teeth cleanings, 100% 100% of usual and customary charges* 12 months $25 copay
Bifocal, Trifocal, Standard Progressives
fluoride treatment

$0 copay, $200 allowance,

Basic Restorative Services: fillings, Prescription Glasses — Frames
20% off retail price over $200
space maintainers, oral surgery, 90% 80% of usual and customary charges*
periodontics, endodontics
Up to $60 copay, $200 allowance,
Contact Lens — Conventional
Major Restorative Services: porcelain 15% off retail price over $200
crowns, bridgework, full & partial 60% 50% of usual and customary charges*
dentures
Up to $60 copay, $200 allowance,
Contact Lens — Disposable
plus balance over $200
Orthodontia Benefit
60%
(Dependent children under age 19)
15% of retail,
Laser Vision Correction
Orthodontia Lifetime Maximum $1,000 5% off promotional rate

*Usual and customary charges are the amount paid for a medical
service in a geographic area based on what providers in the area
usually charge for the same or similar medical service.

9 Make your benefit elections via ADP

Health Care Plan Premiums
BUY-UP PLAN BASE PLAN - HSA BUY DOWN PLAN - HSA

Bi-Weekly Bi-Weekly Bi-Weekly

Employee Only $118.08 $87.67 $48.69

Employee + Spouse $312.91 $256.77 $101.87

Employee + Child(ren) $203.24 $150.89 $83.81

Family $422.30 $346.97 $137.66

DENTAL PLAN VISION PLAN

Bi-Weekly Bi-Weekly

Employee Only $6.80 Employee Only $3.46

Employee + Spouse $14.52 Employee + Spouse $5.83

Employee + Child(ren) $18.90 Employee + Child(ren) $5.94

Family $27.31 Family $9.41

10 Make your benefit elections via ADP

Life, Disability, and AD&D Coverage
SHORT TERM DISABILITY (STD): Income Protection Benefit You are also eligible to enroll in the following optional benefits, at your own cost.

Employees have the ability to purchase voluntary short term disability coverage. Benefit
begins 8 days following a non-occupation injury or illness. The benefit is 66.67% of your SUPPLEMENTAL LIFE AND AD&D FOR YOU
weekly salary, limited to $2,000 per week. Benefits received are not taxed. You may purchase coverage in $10,000 increments, over and above the basic life and AD&D Insurance coverage
provided by PRIME. The maximum amount you can purchase for yourself is the lesser of 5x your annual earnings or
LONG TERM DISABILITY (LTD): Income Protection Benefit $250,000. Evidence of Insurability (EOI) may be required for elections over $150,000.

Employees have the ability to purchase voluntary long term disability coverage. Benefit
begins 180 days following a non-occupation injury or illness. The benefit is 60% of your SUPPLEMENTAL LIFE AND AD&D FOR YOUR SPOUSE
monthly salary, limited to $10,000 per month. Benefits received are not taxed.
You may purchase coverage in $5,000 or $10,000 increments up to the maximum amount of $100,000. You must
purchased additional life coverage for yourself in order to purchase coverage for your spouse. EOI may be required
BASIC LIFE for election amounts over $50,000.

PRIME AE offers $50,000 in life insurance for each full-time employee at no additional
cost. SUPPLEMENTAL LIFE AND AD&D FOR CHILD(REN)
You may purchase $10,000 in coverage for each of your dependent child(ren) ages 6 months to age 19 (age 26 if a
BASIC ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) full-time student) if you purchase additional coverage for yourself.

PRIME AE offers $50,000 in life insurance for each full-time employee at no additional
cost. ACCIDENTAL INJURY INSURANCE
You can elect Prudential Accident Coverage for you and your family members should an accident occur. A covered
MATERNITY LEAVE accident is a sudden, unforeseeable, external event that results in a covered injury or covered loss. Examples of
PRIME AE offers 100% paid maternity leave for up to 3 weeks. covered accidents include (but are not limited to) broken bones, burns, joint dislocations, and concussions.

11 Make your benefit elections via ADP

Financial Coaching by ProsperWise℠
WHAT IS MMA PROSPER WISE℠? HOW SOON CAN I SPEAK WITH A FINANCIAL COACH?
MMA Prosper Wise℠ is a holistic approach to wellness combining a website with articles, videos, You can book an online appointment as soon as 24 hours in advance.
tools, assessments and resources that you can use any time with live coaching sessions that will
provide the answers to your questions and help you make your financial goals a reality.
WHAT CAN I EXPECT TO LEARN FROM THESE SESSIONS?
ARE YOUR COACHES’ FIDUCIARIES? WHAT DOES IT MEAN TO BE A We educate on entire financial life cycle topics in order to help you reach a timely retirement.
FIDUCIARY?)
Yes! As fiduciaries, we provide our clients a high standard of care. We have highly experienced WHAT IF I NEED TO RESCHEDULE?
coaches trained to meet your needs.
We understand life happens. You can reschedule using the link on the confirmation e-mail to
cancel or re-book your appointment.
WILL THERE BE ANY SALES PITCHES IN MY COACHING SESSIONS?
Absolutely not. This platform and the coaching sessions have been paid for through an arrangement
with your company. All information provided is with your best interest in mind and at no additional CAN MY SIGNIFICANT OTHER JOIN THE SESSION?
cost. Absolutely! This service is for you and your family. Anyone in your household can join or use these
financial coaching sessions and use the MMA Prosper Wise℠ website.
CAN YOU GIVE FINANCIAL ADVICE?
Yes, as fiduciaries, we can speak to your plan assets and can help you understand your options
within the plan. We can also provide financial education. Our advice focuses on financial decisions
and does not cover tax or legal advice.
SCHEDULE
A SESSION
WHAT HAPPENS IF I LEAVE THE COMPANY?
This resource is paid for and connected to your company. You can ask if your potential future
employer offers MMA Prosper Wise℠ to continue to use this service.

12 Make your benefit elections via ADP

401(k) Retirement / Student Debt Assistance
YOUR CONTRIBUTIONS SAVE FOR TOMORROW BY PAYING DOWN STUDENT DEBT TODAY
You can contribute between 1% and 100% of your eligible earnings up to the estimated
IRS limit of $24,000 for 2025. You can contribute up to an additional $7,500 if you To find out more, scan this code or visit
will be age 50 or over by the end of the year and contribute the maximum allowed by StudentDebtRetirement.Fidelity.com.
your plan.

VESTING
You are always 100% vested in the salary deferral portion of your account.

EMPLOYER CONTRIBUTIONS
PRIME contributes 100% of the first 3% in eligible compensation deferred and 50% of
the next 2% in eligible compensation deferred.

MATCHING
Matching begins after 6 months of employment and is immediately vested.

13 Make your benefit elections via ADP

Peloton
Peloton, a flexible, all-in-one wellness platform that offers a motivating total body workout
PELOTON APP ONE PELOTON APP+ ALL ACCESS
experience - no matter what your fitness level, mood, or goal is. Peloton Corporate Wellness is
about more than physical fitness. It’s about creating a culture, a community, and a sense of
Cost to You $0 $10.00 / month $31.00 / month
belonging in the workplace—taking connection and engagement to a new level.

With your PRIME AE benefit, you can get a free Peloton App One Membership and preferred Full access to
Strength, Cardio,
pricing on the Peloton Bike, Bike+, Tread, Guide, and/or Row. You can use the Peloton App to strength, yoga, and
Pilates, Yoga,
stream thousands of live and on-demand classes, no equipment needed. From yoga and guided more, plus limited Full Access Full Access
Outdoor Running,
meditation to outdoor walking, strength training, and much more, there is something for everyone. access to cardio
and more Classes.
equipment classes.

With your company benefit, you can get a:

Cardio Equipment
Peloton app membership for $0 per month Full access including
Classes: Cycling,
3 classes / month Full Access Lanebreak and
Peloton app+ for $10 per Month Treadmill, and
Scenic classes
All-access membership for $31 per month Rowing
Equipment discounts (preferred pricing on Peloton equipment purchases & rentals)
User Profiles 1 1 Entire Household

Equipment discounts include:

$10 off monthly Peloton v1 Bike Rental membership ($79 per month) Peloton app memberships are free for
$20 off monthly Peloton Bike + Rental membership ($99 per month) employees:
$100 discount off the current retail price of New Peloton BIke, Bike +, Row, and Tread 1. Verify your eligibility
SCAN HERE
$25 discount off the current retail price of New Peloton Guide 2. Activate your account
Refurbished Peloton Bike $995 purchase price 3. Download the Peloton App
Refurbished Peloton Bike + $1,595 purchase price 4. Find your next class

14 Make your benefit elections via ADP

Tickets at Work
WHAT IS TICKETS AT WORK
Having fun, getting away, and saving money are important for your well-being. This cost-free benefit provides you access to thousands of exclusive travel and entertainment discounts,
so you can make the most of your time away from work.

HOW DO I BECOME A MEMBER

Visit ticketsatwork.com and click Become a Member.
Use your company code or work email to create an account.

THERE’S SOMETHING FOR EVERYONE WITH SAVINGS ON:

Hotels Sporting Events
Theme Parks Movie Tickets
Concerts Rental Cars
Gift Cards Broadway Shows SCAN
Vegas Shows Retail HERE
Restaurants Spas
Sightseeing Tours Activities

15 Make your benefit elections via ADP

Life Mart
Save on Everyday Living with ADP® Discounts powered by LifeMart.

ADP Discounts powered by LifeMart helps you save time and money on the things you
want most, from every day needs to one-of-a-kind purchases. You’ll find a huge selection
of discounts on products and services from brands you know and love. Plus, great
savings on Hotels, Car Rentals, Electronics, Restaurants, Movie Tickets, Groceries, Child
Care, Senior Care and much more!

ADP discounts powered by LifeMart helps you:

Save time with one-stop shopping.
Make everyday life a little more affordable.
Shop at home or from any mobile device.

Plus, you can access LifeMart discounts anywhere, anytime, with the LifeMart mobile
app. Simply download the app and you can browse major savings on the go. Visit
lm.lifemart.com/group/lifemart/home or contact us at [email protected]
for more information.

16 Make your benefit elections via ADP

Benefit Contacts
BENEFIT VENDOR CONTACT INFORMATION

Bi-Weekly Bi-Weekly

Medical Anthem Blue Cross Blue Shield 1-866-870-1780 or anthem.com/login

Dental Delta Dental 1-800-872-0500 or deltadental.com

Vision VSP 1-800-877-7195 or vsp.com

1-800-532-3327 or https://www.flores-
Flexible Spending Accounts (FSA) Flores
associates.com/resource-open-enrollment.html

Life: 1-800-524-0542
Life, AD&D, STD, and LTD Prudential
Disability: 1-800-824-1718

Health Savings Account (HSA) Fidelity NetBenefits.com

Retirement 401(k) Fidelity 401k.com

Financial Coaching MMA Prosper Wise MMAWellness.as.me/schedule.php

17 Make your benefit elections via ADP

Required Annual Notices
HIPAA COBRA
If you do not enroll yourself and your dependents in a group health plan after you become eligible or during annual enrollment, you may be able to enroll The Consolidated Omnibus Budget Reconciliation Act (COBRA) requires group health plans to offer continuation coverage to covered employees, former
under the special enrollment rules under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) that apply when an individual declines employees, spouses, former spouses, and dependent children when group health coverage would otherwise be lost due to certain specific events. Those
coverage and later wishes to elect it. Generally, special enrollment is available if (i) you declined coverage because you had other health care coverage that events include the death of a covered employee, termination or reduction in the hours of a covered employee’s employment for reasons other than gross
you have now lost through no fault of your own (or employer contributions to your other health care coverage terminate); or (ii) you have acquired a new misconduct, a covered employee’s becoming entitled to Medicare, divorce or legal separation of a covered employee and spouse, and a child’s loss of
dependent (through marriage or the birth or adoption of a child) and wish to cover that person. When you have previously declined coverage, you must have dependent status (and therefore coverage) under the plan. COBRA sets rules for how and when continuation coverage must be offered and provided, how
given (in writing) the alternative coverage as your reason for waiving coverage under the group health plan when you declined to participate. In either case, employees and their families may elect continuation coverage, and what circumstances justify terminating continuation coverage.
as long as you meet the necessary requirements, you can enroll both yourself and all eligible dependents in the group health plan if you provide notice to the
Plan Administrator within 30 days after you lose your alternative coverage (or employer contributions to your alternative coverage cease) or the date of your
marriage or the birth, adoption, or placement for adoption of your child. See the Plan Administrator for details about special enrollment.
The Genetic Information Non-Discrimination Act (“GINA”)
GINA prohibits the Plan from discriminating against individuals on the basis of genetic information in providing any benefits under the Plan. Genetic
information includes the results of genetic tests to determine whether someone is at increased risk of acquiring a condition in the future, as well as an
Notice Regarding Lifetime & Annual Dollar Limits individual’s family medical history.
In accordance with applicable law, none of the lifetime dollar limits and annual dollar limits set forth in the Plan shall apply to “essential health benefits,” as
such term is defined under Section 1302(b) of the Affordable Care Act. The law defines “essential health benefits” to include, at minimum, items and services
covered within certain categories including emergency services, hospitalization, prescription drugs, rehabilitative and habilitative services and devices, and
Affordable Care Act Consumer Protections
laboratory services, but currently provides little further information. Accordingly, a determination as to whether a benefit constitutes an “essential health
benefit” will be based on a good faith interpretation by the Plan Administrator of the guidance available as of the date on which the determination is made. (a.) Coverage for Children Up to Age of 26. The Affordable Care Act of 2010 requires that the Plan must make dependent coverage available to adult children
until they turn 26 regardless if they are married, a dependent, or a student.

(b.) Prohibition of Lifetime Dollar Value of Benefits. The Affordable Care Act of 2010 prohibits the Plan from imposing a lifetime limit on the dollar value of
Special Rule for Women's Health Coverage benefits.
The Women’s Health and Cancer Rights Act of 1998 (“WHCRA”) requires group health plans, insurance issuers, and HMOs who already provide medical and
surgical benefits for mastectomy procedures to provide insurance coverage for reconstructive surgery following mastectomies. This expanded coverage (c.) Your Health Insurance Cannot Be Rescinded. The Affordable Care Act of 2010 prohibits the Plan, or any insurer, from rescinding your health insurance
includes (i) reconstruction of the breast on which the mastectomy has been performed; (ii) surgery and reconstruction of the other breast to produce a coverage under the Plan for misrepresentation.
symmetrical appearance; and (iii) prostheses and physical complications at all stages of mastectomy, including lymphedemas.
(d.) Prohibition of Pre-existing Conditions. Effective January 1, 2014, the Affordable Care Act of 2010 prohibits the Plan, or any insurer, from denying any health
insurance claim for any person because of a pre-existing condition.
Grandfathered Status
(e.) Prohibition of Restrictions on Annual Limits on Essential Benefits. The Affordable Care Act of 2010 prohibits the Plan, or any insurer, effective January 1,
The Plan believes that none of the group health plans available under the Plan are “grandfathered health plans” under the Patient Protection and Affordable
2014, from placing annual limits on the value of essential health benefits.
Care Act (the “Affordable Care Act”).

(f.) Notice of Marketplace/Exchange. If this health insurance is unaffordable (your cost of the premium exceeds 9.02% of your income) as defined under the
Affordable Care Act , you may have the right to subsidized health insurance purchased through an exchange/marketplace created pursuant to the Affordable
Special Rule for Maternity & Infant Coverage Care Act.
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with
childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However,
federal law generally does not prohibit the attending provider or physician, after consulting with the mother, from discharging the mother or her newborn
Patient Protection Disclosure
earlier than 48 hours (or 96 hours, as applicable).
You have the right to designate any participating primary care provider who is available to accept you or your family members (for children, you may designate
a pediatrician as the primary care provider). For information on how to select a primary care provider and for a list of participating primary care providers,
contact the Plan Administrator. You do not need prior authorization from the Plan or from any other person, including your primary care provider, in order to
Mental Health Parity & Addiction Equity obtain access to obstetrical or gynecological care from a health care professional; however, you may be required to comply with certain procedures, including
The Medical Plan provides the same coverage for any mental health service as are provided for medical coverage. This means that stated medical obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health
deductibles, copays, coinsurance and out-of-pocket limits will also apply to mental health services. care professionals who specialize in obstetrics or gynecology, contact the Plan Administrator.

Wellness
If your Plan includes a Wellness program that provides rewards or surcharges based on your ability to complete an activity or satisfy an initial health
standard, you have the right to request a reasonable alternative should it be determined that it is not medically advisable for you to either complete the
activity or satisfy the initial health standard.

18 Make your benefit elections via ADP

Required Annual Notices
GEORGIA - MEDICAID

GA HIPP: medicaid.georgia.gov/health-insurance-premium-payment-program-hipp or 678-564-1162, Press 1

GA CHIPRA: medicaid.georgia.gov/programs/third-party-liability/childrens-health-insurance-program-reauthorization-act-2009-chipra or 678-564-1162, Press 2

Premium Assistance Under Medicaid & The Children's Health Insurance Program (CHIP) INDIANA - MEDICAID

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium
assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid Healthy Indiana Plan for low-income adults 19-64:
or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health in.gov/fssa/dfr/ or 1-877-438-4479
Insurance Marketplace. For more information, visit healthcare.gov. All other Medicaid: in.gov/medicaid or1-800-457-4584

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find IOWA - MEDICAID AND CHIP (HAWKI)
out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of Medicaid: hhs.iowa.gov/programs/welcome-iowa-medicaid or 1-800-338-8366
these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or insurekidsnow.gov to find out how to apply. If you qualify, ask Hawki: hhs.iowa.gov/programs/welcome-iowa-medicaid/iowa-health-link/hawki or 1-800-257-8563
HIPP: hhs.iowa.gov/programs/welcome-iowa-medicaid/fee-service/hipp or 1-888-346-9562
your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must KANSAS - MEDICAID
allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage
within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department
kancare.ks.gov or 1-800-792-4884
of Labor at askebsa.dol.gov or call 1-866-444-EBSA(3272). HIPP Phone: 1-800-967-4660
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of
July 31, 2024. Contact your State for more information on eligibility – KENTUCKY - MEDICAID

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP): chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx

or 1-855-459-6328 or [email protected]
ALABAMA - MEDICAID KCHIP: kynect.ky.gov or 1-877-524-4718
Kentucky Medicaid: chfs.ky.gov/agencies/dms
myalhipp.com or 1-855-692-5447
LOUISIANA - MEDICAID
ALASKA - MEDICAID
medicaid.la.gov or ldh.la.gov/lahipp
The AK Health Insurance Premium Payment Program: myakhipp.com or 1-866-251-4861 or email [email protected] Medicaid: 1-888-342-6207 LaHIPP: 1-855-618-5488
Medicaid Eligibility: health.alaska.gov/dpa/Pages/default.aspx
MAINE - MEDICAL
ARKANSAS - MEDICAID
Enrollment: mymaineconnection.gov/benefits/s/?language=en_US or 1-800-442-6003 / TTY: Maine relay 711
myarhipp.com or 1-855-MyARHIPP (855-692-7447) Private Health Insurance Premium: maine.gov/dhhs/ofi/applications-forms or 1-800-977-6740
TTY: Maine relay 711
CALIFORNIA - MEDICAID
MASSACHUSETTS - MEDICAID AND CHIP
Health Insurance Premium Payment (HIPP) Program: dhcs.ca.gov/hipp or 916-445-8322 or [email protected] or Fax 916-440-5676
mass.gov/masshealth/pa or 1-800-862-4840 / TTY: 711
Email: [email protected]
COLORADO - HEALTH FIRST COLORADO (COLORADO’S MEDICAID PROGRAM) & CHILD HEALTH PLAN PLUS (CHP+)

MINNESOTA - MEDICAID
Health First Colorado: healthfirstcolorado.com
Health First Colorado Member Contact Center:
1-800-221-3943 / State Relay 711 mn.gov/dhs/health-care-coverage/ or 1-800-657-3739
CHP+: https://hcpf.colorado.gov/child-health-plan-plus
CHP+ Customer Service: 1-800-359-1991 / State Relay 711 MISSOURI - MEDICAID
Health Insurance Buy-In Program (HIBI): mycohibi.com
HIBI Customer Service: 1-855-692-6442 dss.mo.gov/mhd/participants/pages/hipp.htm or 573-751-2005

FLORIDA - MEDICAID MONTANA - MEDICAID

flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html or 1-877-357-3268 dphhs.mt.gov/MontanaHealthcarePrograms/HIPP or 1-800-694-3084 or [email protected]

19 Make your benefit elections via ADP

Required Annual Notices
TEXAS - MEDICAID

Health Insurance Premium Payment (HIPP) Program | Texas Health and Human Services or 1-800-440-0493

UTAH - MEDICAID AND CHIP

Medicaid: medicaid.utah.gov/ or [email protected] or 888-222-2542 or medicaid.utah.gov/expansion/ or medicaid.utah.gov/buyout-program/

NEBRASKA - MEDICAID CHIP: health.utah.gov/chip or 1-877-543-7669

ACCESSNebraska.ne.gov or 1-855-632-7633 VERMONT - MEDICAID

Lincoln: 402-473-7000 Omaha: 402-595-1178
Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access or 1-800-250-8427
NEVADA - MEDICAID
VIRGINIA - MEDICAID AND CHIP
dhcfp.nv.gov or 1-800-992-0900
coverva.dmas.virginia.gov/learn/premium-assistance/famis-select or coverva.dmas.virginia.gov/learn/premium-assistance/health-insurance-premium-payment-hipp-programs or
Medicaid/CHIP: 1-800-432-5924
NEW HAMPSHIRE - MEDICAID
WASHINGTON - MEDICAID
dhhs.nh.gov/programs-services/medicaid/health-insurance-premium-program or 603-271-5218
Toll free number for HIPP: 1-800-852-3345, ext. 15218
hca.wa.gov or 1-800-562-3022
Email: [email protected]

WEST VIRGINIA - MEDICAID AND CHIP

NEW JERSEY - MEDICAID AND CHIP

dhhr.wv.gov/bms or mywvhipp.com
Medicaid: state.nj.us/humanservices/
Medicaid: 304-558-1700
dmahs/clients/medicaid or 800-356-1561
CHIP Toll-free: 1-855-MyWVHIPP (1-855-699-8447)
CHIP: njfamilycare.org/index.html or609-631-2392 (Chip Premium Assistance) or 1-800-701-0710 (Chip Phone)

WISCONSIN - MEDICAID AND CHIP

NEW YORK - MEDICAID

health.ny.gov/health_care/medicaid or 1-800-541-2831 dhs.wisconsin.gov/badgercareplus/p-10095.htm or 1-800-362-3002

NORTH CAROLINA - MEDICAID WYOMING - MEDICAID

medicaid.ncdhhs.gov or 919-855-4100 health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility or 1-800-251-1269

NORTH DAKOTA - MEDICAID

To see if any other states have added a premium assistance program since July 31, 2024, or for more information on special enrollment rights, contact either:
hhs.nd.gov/healthcare or 1-844-854-4825
U.S. Department of Labor
OKLAHOMA - MEDICAID AND CHIP Employee Benefits Security Administration
dol.gov/agencies/ebsa; 1-866-444-EBSA (3272)
insureoklahoma.org or 1-888-365-3742
U.S. Department of Health & Human Services
OREGON - MEDICAID Centers for Medicare and Medicaid Services
cms.hhs.gov; 1-877-267-2323 (Menu Option 4, Ext. 61565)
healthcare.oregon.gov/Pages/index.aspx or 1-800-699-9075

PENNSYLVANIA - MEDICAID AND CHIP Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection
Medicaid: pa.gov/en/services/dhs/apply-for-medicaid-health-insurance-premium-payment-program-hipp.html or 800-692-7462 displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of
CHIP: dhs.pa.gov/CHIP/Pages/CHIP.aspx information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a
or 1-800-986-KIDS (5437) collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB
RHODE ISLAND - MEDICAID AND CHIP control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are
eohhs.ri.gov or 1-855-697-4347 encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this
Direct RIte Share Line: 401-462-0311 burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200
Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

20 Make your benefit elections via ADP

Notice of Privacy Practices
Health manage the health We can use your health information and share it with professionals who are treating you. Example: We use health information about
care treatment you receive. you to develop better services for you.

We can use and disclose your information to run our organization and contact you when necessary. We are not allowed to use
Run our organization. genetic information to decide whether we will give you coverage and the price of that coverage. That does not apply to long term
care plans. Example: We use health information about you to develop better services for you.
Your Information. Your Rights. Our Responsibility
This notice describes how health information about you, including your payment for health insurance, may be used and disclosed by our health plan under We can use and disclose your health information as we pay for your health services. Example: We share information about you with
Pay for your health services.
the Health Insurance Portability and Accountability Act (HIPAA) and how you can get access to this information. Please review it carefully. your dental plan to coordinate payment for your dental work.

We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts
Administer Your Plan
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
YOUR RIGHTS
help you.
We can share health information about you for certain situations such as:
Preventing disease
Get a copy of your health and You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. We will
Health with public health and Helping with product recalls
claims records provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
safety issues Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Ask us to correct health and You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. We may say "no" to your Preventing or reducing a serious threat to anyone's health or safety
claims records request, but we'll tell you why in writing within 60 days.
Do Research We can use or share your information for health research.
Request confidential You can ask us to contact you in a specific way (for example: home or office phone) or to send mail to a different address. We will consider all
communications reasonable requests, and you must say "yes" if you tell us you would be in danger if we do not. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services
Comply with the law
if it wants to see that we're complying with federal privacy law.

Ask us to limit what we use or You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your
Respond to organ and tissue
share request, and we may say "no" if it would affect your care.
donation requests and work We can share health information about you with organ procurement organizations.
with a medical examiner or We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, funeral director.
Get a list of those with whom and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures
we've shared information (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another We can use or share health information about you:
one within 12 months. Address workers'
For workers' compensation claims
compensation, law
For law enforcement purposes or with a law enforcement official
enforcement, and other
With health oversight agencies for activities authorized by law
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper government requests.
Get a copy of this privacy notice For special government functions such as military, national security, and presidential protective service
copy promptly.

Respond to lawsuits and legal

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Choose someone to act for you actions.
about your health information. We will make sure the person has this authority and can act for you before we take any action,

How else can we use or share your health information?

You can complain if you feel we have violated your rights by contacting us using the information on the back page. You can file a complaint with the
File a complaint if you feel your We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research.
U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201,
rights are violated
calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your
YOUR CHOICES Our Responsibilities
information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
Share information with your family, close friends, or others involved in payment for your care. Share information in a disaster relief situation. If you We must follow the duties and privacy practices described in this notice and give you a copy of it.
In these cases, you have both
are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your
the right and choice to tell us to:
best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
mind at any time. Let us know in writing if you change your mind.

For more information see:

In these cases we never share
Marketing Purposes hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/consumers/consumer_rights.pdf
your information unless you give
Sale of your information
us written permission:
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.
How do we typically use or share We generally do not use your health information for purposes other than administering the company's health plan. HIPAA does allow us, however, if The Effective Date of this Notice is January 1, 2024
your health information? we were to choose to do so, to use or share your health information in our possession the following ways. This Notice will serve as Notice for the following benefit enrolled employees:
PRIME AE

21 Make your benefit elections via ADP

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