CODAC 2024 Benefit Summaries and Carrier Materials

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2024 Benefit Summaries and Carrier Materials.

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CODAC HEALTH, RECOVERY & WELLNESS, INC. Policy #: 010-34425 -LOW PLAN

FUSION combines dental and eye care benefits into one easy-to-administer plan. This plan combines the annual maximum between the dental and vision plans. For the maximum:

· The member can use up to $1,000 Non PPO - $1,500 PPO toward any covered dental expense.

· The member can use up to $100 toward any covered eye care expense. · Total benefits paid between the two coverages will not exceed $1,500.

Dental Plan Benefits subject to FUSION plan design listed above Networks: Classic In-Network

Out-of-Network

Type 1 Preventive No Waiting Period

100%

Routine Exam (1 per 6 months)

Bitewing X-rays (1 per 12 months)

Cleaning (1 per 6 months)

Type 2 Basic No Waiting Period

100%

50%

Restorative Amalgams

Restorative Composites

Simple Extractions

Type 3 Major No Waiting Period

60%

25%

Surgical Extractions

Endodontics (nonsurgical)

Periodontics (nonsurgical)

Crowns (1 in 10 years per tooth)

Endodontics (surgical)

Periodontics (surgical)

Implants

Prosthodontics (Bridges, Dentures) (1 in 10 years)

Deductible* Type 1

$100 per person, per calendar year $100 per person, per calendar year When 3 family members satisfy their Deductible Amounts for this Calendar Year, no additional Deductibles will apply to any family members for the rest of this Calendar Year.

$50 per person, per calendar year When 3 family members satisfy their Deductible Amounts for this Calendar Year, no additional Deductibles will apply to any family members for the rest of this Calendar Year.

Family Maximum

Benefit Year Maximum Type 1, 2, and 3 (per person, per calendar year)

$1,500

$1,000

Orthodontia Benefits (children under age 19) No waiting period Plan Benefit

50%

Lifetime Deductible

Lifetime Maximum (per person)

$1,500

Claims Allowance Type 1, 2 and 3

Discounted Fee

Maximum Allowable Benefit

1 of 3

Class 1

Created 7/24/2023

CODAC HEALTH, RECOVERY & WELLNESS, INC. Policy #: 010-34425 -LOW PLAN

Vision Plan Benefits subject to FUSION plan design listed above Allowances Exam Subject to Maximum Lenses (per pair) Single Subject to Maximum Bifocal Subject to Maximum Trifocal Subject to Maximum Lenticular Subject to Maximum Progressive Subject to Maximum Contacts Elective/Medically Necessary Subject to Maximum Frames Subject to Maximum Exam Lenses Frames

Frequencies Based on date of service**

None None None

Maximum

$100

Deductibles (Lifetime deductible)

*Deductible applies to the first service received **Please submit claims within 90 days of the date of service so that the plan can consider benefits (subject to State requirements).

Member Cost for Vision Discounts (may vary by prescription, option chosen and retail location)

Exam

$5 off routine exam $10 off contact lens exam

With dilation as necessary

The following lenses, frame and lens options discounts and fees apply only if a complete pair of glasses is purchased. Standard Plastic Lenses Single Vision

$50 $70 $105

Bifocal Trifocal

Frame

35% of retail price

Lens Options

Standard Progressive Premium Progressive Standard Polycarbonate Tint (solid or gradient) Scratch-Resistant Coating Anti-Reflective Coating Ultraviolet coating Other Add-ons

$65 plus standard plastic lens cost 20% discount

$40 $15 $15 $45 $15 20% discount

Contact Lenses

Conventional

15% off retail price (does not apply to fitting) After initial purchase, replacement contacts by mail are offered at substantial savings online through eyemedvisioncare.com. Average discount of 15% off retail price or 5% off promotional price at US Laser Network participating providers.

Lasik or PRK

Items Not included

See limitations and exclusions

Limitations and Exclusions Discounts are not available for the following procedures material or services. · Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing. · Medical and/or surgical treatment of the eye, eyes, or supporting structures. · Corrective eye wear required by your employer as a condition of employment, includes safety eye wear unless specifically covered under your plan. · Worker's Compensation injury claims (or similar injury laws.) · Plano non-Prescription lenses and non-prescription sunglasses, but you receive 20% off retail for items purchased separately. · EyeMed provider professional services, or disposable contect lenses. · Two pairs of glasses in lieu of bifocals.

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CODAC HEALTH, RECOVERY & WELLNESS, INC. Policy #: 010-34425 -LOW PLAN

Open Enrollment If you do not elect to participate when initially eligible, you may elect to participate at the policyholder’s next enrollment period, which normally coincides with the policy anniversary date. Dental Rewards Your dental plan includes Dental Rewards as a way to grow your annual maximum benefit. Simply by visiting a dental provider each year and submitting a claim, you can increase your annual maximum benefit over time. After your initial benefit is used, accumulated rewards are there to help pay for more expensive procedures, such as root canals or crowns. Here's how it works. For each year, you submit at least one dental claim and your total dental benefits paid for the year are at or under $500 you qualify to carry over $250 in rewards to the following year. When your dental visit is to an Ameritas network provider, you earn an extra $100 PPO Bonus. You may accumulate rewards up to the maximum amount of $1000. Please note, if you do not submit a dental claim during the year, no rewards are earned and accumulated rewards are reset to zero. However, you can start qualifying for rewards again the very next year. Provider Flexibility and Network Savings Members aren't limited to one particular dentist, or a small group of providers, who may or may not be taking new patients. Each plan member is free to visit any provider they choose, including your current dentist, regardless if they are in- or out-of-network. And family members do not have to see the same dentist. When yo visit an in-network dentist there are no claim forms to complete. For a list of network dentists in your area, go to Find A Provider at Ameritas.com.

Late Entrant We strongly encourage you and/or your dependents to sign up for coverage when you are initially eligible. If you choose to enroll after initially declined, you and/or your eligible dependents will be considered a Late Entrant. Covered expenses will not include and benefits will not be payable in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations, prophylaxis (cleanings), and fluoride application. After 12 months, you will have access to all of the plan's benefits. Customer Service Customer Connections 800-487-5553 www.Ameritas.com Monday - Thursday 7am-12am CST, Friday 7am-6:30pm CST This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

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CODAC HEALTH, RECOVERY & WELLNESS, INC. Policy #: 010-34425 -HIGH PLAN

FUSION combines dental and eye care benefits into one easy-to-administer plan. This plan combines the annual maximum between the dental and vision plans. For the maximum:

· The member can use up to $2,000 Non PPO - $2,500 PPO toward any covered dental expense.

· The member can use up to $100 toward any covered eye care expense. · Total benefits paid between the two coverages will not exceed $2,500.

Dental Plan Benefits subject to FUSION plan design listed above Networks: Classic In-Network

Out-of-Network

Type 1 Preventive No Waiting Period

100%

Routine Exam (1 per 6 months)

Bitewing X-rays (1 per 12 months)

Cleaning (1 per 6 months)

Type 2 Basic No Waiting Period

100%

50%

Restorative Amalgams

Restorative Composites

Endodontics (nonsurgical)

Periodontics (nonsurgical)

Endodontics (surgical)

Periodontics (surgical)

Simple Extractions

Type 3 Major No Waiting Period

60%

25%

Surgical Extractions

Crowns (1 in 10 years per tooth)

Implants

Prosthodontics (Bridges, Dentures) (1 in 10 years)

Deductible* Type 1

Family Maximum

Benefit Year Maximum Type 1, 2, and 3 (per person, per calendar year)

$2,500

$2,000

Orthodontia Benefits (children under age 19) No waiting period Plan Benefit

50%

Lifetime Deductible

Lifetime Maximum (per person)

$2,500

Claims Allowance Type 1, 2 and 3

Discounted Fee

80th U&C

1 of 3

Class 2

Created 7/24/2023

CODAC HEALTH, RECOVERY & WELLNESS, INC. Policy #: 010-34425 -HIGH PLAN

Frequencies Based on date of service**

None None None

Maximum

$100

Deductibles (Lifetime deductible)

*Deductible applies to the first service received **Please submit claims within 90 days of the date of service so that the plan can consider benefits (subject to State requirements).

Member Cost for Vision Discounts (may vary by prescription, option chosen and retail location)

Exam

$5 off routine exam $10 off contact lens exam

With dilation as necessary

The following lenses, frame and lens options discounts and fees apply only if a complete pair of glasses is purchased. Standard Plastic Lenses Single Vision

$50 $70 $105

Bifocal Trifocal

Frame

35% of retail price

Lens Options

Standard Progressive Premium Progressive Standard Polycarbonate Tint (solid or gradient) Scratch-Resistant Coating Anti-Reflective Coating Ultraviolet coating Other Add-ons

$65 plus standard plastic lens cost 20% discount

$40 $15 $15 $45 $15 20% discount

Contact Lenses

Conventional

Lasik or PRK

Items Not included

See limitations and exclusions

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CODAC HEALTH, RECOVERY & WELLNESS, INC. Policy #: 010-34425 -HIGH PLAN

Open Enrollment If you do not elect to participate when initially eligible, you may elect to participate at the policyholder’s next enrollment period, which normally coincides with the policy anniversary date. Dental Rewards Your dental plan includes Dental Rewards as a way to grow your annual maximum benefit. Simply by visiting a dental provider each year and submitting a claim, you can increase your annual maximum benefit over time. After your initial benefit is used, accumulated rewards are there to help pay for more expensive procedures, such as root canals or crowns. Here's how it works. For each year, you submit at least one dental claim and your total dental benefits paid for the year are at or under $750 you qualify to carry over $400 in rewards to the following year. When your dental visit is to an Ameritas network provider, you earn an extra $200 PPO Bonus. You may accumulate rewards up to the maximum amount of $1200. Please note, if you do not submit a dental claim during the year, no rewards are earned and accumulated rewards are reset to zero. However, you can start qualifying for rewards again the very next year. Provider Flexibility and Network Savings Members aren't limited to one particular dentist, or a small group of providers, who may or may not be taking new patients. Each plan member is free to visit any provider they choose, including your current dentist, regardless if they are in- or out-of-network. And family members do not have to see the same dentist. When yo visit an in-network dentist there are no claim forms to complete. For a list of network dentists in your area, go to Find A Provider at Ameritas.com.

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CODAC HEALTH, RECOVERY & WELLNESS, INC. FUSION Highlight Sheet Policy # 34425

VISION BENEFITS CLAIM FORM PLEASE BE AS THOROUGH & ACCURATE AS POSSIBLE WHEN COMPLETING THIS FORM. ERRORS OR OMMISSIONS MAY DELAY CLAIM PAYMENTS. CLAIMS MUST BE SUBMITTED WITHIN 90 DAYS FROM SERVICE DATE.

TO BE COMPLETED BY THE CARDHOLDER

1. PATIENT’S NAME ( Last, First, Middle )

2. CARDHOLDER’S GROUP # 34425

3. CARDHOLDER’S ID#

4. PATIENT’S BIRTH DATE 5. PATIENT’S SEX  MALE  FEMALE

6. RELATIONSHIP TO CARDHOLDER  SELF

7. CARDHOLDER’S NAME ( Last, First, Middle)

 CHILD  OTHER

 SPOUSE

8. CARDHOLDER’S ADDRESS ( No., Street, City, State and Zip Code)

9. HOME NUMBER

WORK NUMBER

(

)

(

)

10. NAME OF INSURANCE CARRIER

11. NAME OF EMPLOYER CODAC Health, Recovery & Wellness, Inc.

12. CARDHOLDER’S STATUS  ACTIVE

13. CARDHOL DER’S BIRTH DATE

 RETIRED  SALARIED

Ameritas

 HOURLY

14. PATIENT IS COVERED FOR VISION CARE

15. NAME AND ADDRESS OF THE OTHER CARRIER

 YES

IF YES, PLEASE COMPLETE BOXES 15 THROUGH 16

BY ANOTHER PLAN

 NO

16. POLICY HOLDER’S N AME 17. RELATIONSHIP TO CARDHOLDER  SELF  CHILD  SPOUSE  OTHER

18. POLICY HOLDERS’ DATE OF BIRTH 19. 19. POLICYHOLDER’S S.S. #/GROUP #

SIGNATURE OF CARDHOLDER _________________________________________________________ DATE SIGNED _______________________

PLEASE CHECK ALL ITEMS BELOW THAT APPLY TO THE SERVICES RENDERED BY YOUR EYE CARE PROVIDER

DATE OF SERVICE ________________________________

EXAM



CONTACT LENS FITTING/EXAM



CONTACT LENSES



EYE GLASS LENSES



SINGLE VISION



BIFOCAL



TRIFOCAL



PROGRESSIVE (NO LINE BIFOCAL)



 OTHER _______________________________

 FRAME

PLEASE SUBMIT THIS FORM WITH YOUR ITEMIZED RECEIPT (S) TO THE FOLLOWING

$100 Flat Max

Send claims to: Ameritas Group Claim Office

P.O. Box 82520 Lincoln, NE 68501

 Check to send payment directly to provider.

Toll Free (800) 487-5553 www.ameritas.com

Member Signature _______________________

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: 01/01/2024 – 12/31/2024

Value Based Payments Plan Coverage for: Individual + Family | Plan Type: VBP

CODAC HEALTH, RECOVERY & WELLNESS, INC.: 7670-00-415125

The 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.codac.AHRICbenefits.com or by calling 1-866-952-0357. 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.codac.AHRICbenefits.com or call 1-866-952-0357 to request a copy. Important Questions Answers Why this Matters:

Generally, you must pay all 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. 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 https://www.healthcare.gov/coverage/preventive-care-benefits/ The 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. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. 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. You don’t have to meet deductibles for specific services.

Tier 1 - $2,500 person / $5,000 family Facility + PHCS Professional & Ancillary Tier 2 - $5,000 person / $10,000 family

What is the overall deductible?

Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out–of–pocket limit for this plan? What is not included in the out–of–pocket limit?

Yes. Preventive care services are covered before you meet your deductible.

No.

Tier 1 - $5,000 person / $10,000 family Facility + PHCS Professional & Ancillary Tier 2 - $10,000 person / $20,000 family Penalties, premiums, balance billing charges, and health care this plan doesn’t cover.

Yes. See www.codac.AHRICbenefits.com or call 1-866-952-0357 for a list of network providers.

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

No.

You can see the specialist you choose without a referral.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 1 Facility+ PHCS Professional & Ancillary

Tier 2 All Other Providers

Primary care visit to treat an injury or illness

$25 Copay per visit; Deductible Waived

50% Coinsurance

None

If you visit a health care provider’s office or clinic

$50 Copay per visit; Deductible Waived

Specialist visit

50% Coinsurance

None

You 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.

Preventive care/screening/ immunization

No charge; Deductible Waived

50% Coinsurance

Labs - office or outpatient setting no charge; Deductible Waived X-ray - office no charge; Deductible Waived $75 copay outpatient setting; Deductible Waived

Diagnostic test (x-ray, blood work)

50% Coinsurance

None

If you have a test

Preauthorization is required for MRI/MRA/PET scans. If you don’t get preauthorization, a penalty of $250 may be applied.

Imaging (CT/PET scans, MRIs)

30% Coinsurance

50% Coinsurance

Page 2 of 8

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 1 Facility+ PHCS Professional & Ancillary

Tier 2 All Other Providers

Retail: Up to a 31 day supply Mail-Order: Up to a 90 day supply 90 day supply at CVS retail pharmacy subject to Mail-Order copay. Specialty drugs 31 day supply regardless of retail or mail order. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by CVS/Caremark. For eligible specialty medications, $0 copay if filled through the PrudentRx program. If you opt out you will pay 30% of the cost. Certain drugs may have a prior authorization requirement. Not all drugs are covered. If you use a non-network pharmacy, you are responsible for any amount over the allowed amount. Certain preventive medications are covered at No Charge. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Retail: $15 copay Mail-Order: $37.50 copay

Retail: $15 copay + amount over allowed amount

Generic drugs (Tier 1)

If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.caremark. com & www.prudentrx. com.

Retail: $45 copay Mail-Order: $112.50 copay

Retail: $45 copay + amount over allowed amount

Preferred brand drugs (Tier 2)

Retail: $85 copay Mail-Order: $212.50 copay

Retail: $85 copay + amount over allowed amount

Non-preferred brand drugs (Tier 3)

Specialty drugs (Tier 4)

Retail: $170 copay Mail-Order: $170 copay

Retail: $170 copay + amount over allowed amount

Facility fee (e.g., ambulatory surgery center)

If you have outpatient surgery If you need immediate medical attention

30% Coinsurance

50% Coinsurance

Physician/surgeon fees

30% Coinsurance

50% Coinsurance

$350 Copay per visit; Deductible Waived

Emergency room care

Copay may be waived if admitted

Page 3 of 8

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 1 Facility+ PHCS Professional & Ancillary

Tier 2 All Other Providers

Tier 1 deductible applies to Tier 2 benefits; Preauthorization is required for Non-emergent transports. If you don’t get preauthorization, a penalty of $250 may be applied.

Emergency medical transportation

30% Coinsurance

$75 Copay per visit; Deductible Waived

Urgent care

50% Coinsurance

None

Facility fee (e.g., hospital room)

30% Coinsurance

50% Coinsurance

Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. Preauthorization is required for Partial hospitalization & Intensive treatment. If you don’t get preauthorization, a penalty of $250 may be applied. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. Cost sharing does not apply for preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

If you have a hospital stay

Physician/surgeon fees

30% Coinsurance

50% Coinsurance

$25 Copay per visit; Deductible Waived Office visits; 30% Coinsurance other outpatient services

If you have mental health, behavioral

Outpatient services

50% Coinsurance

health, or substance abuse services

Inpatient services

30% Coinsurance

50% Coinsurance

No charge; Deductible Waived

Office visits

50% Coinsurance

If you are pregnant

Childbirth/delivery professional services

30% Coinsurance

50% Coinsurance

Childbirth/delivery facility services

30% Coinsurance

50% Coinsurance

Page 4 of 8

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 1 Facility+ PHCS Professional & Ancillary

Tier 2 All Other Providers

60 Maximum visits per calendar year; Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Home health care

30% Coinsurance

50% Coinsurance

50% Coinsurance office therapy; Not covered outpatient hospital

20 Maximum visits per calendar year OT; 20 Maximum visits per calendar year PT; 20 Maximum visits per calendar year ST;

$25 Copay per visit; Deductible Waived

Rehabilitation services

50% Coinsurance office therapy; Not covered outpatient hospital

20 Maximum visits per calendar year Habilitation services for Learning Disabilities are not covered. 60 Maximum days per calendar year; Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. Preauthorization is required for DME in excess of $1,500 for purchases & all rentals. If you don’t get preauthorization, a penalty of $250 may be applied. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

If you need help recovering or have other special health needs

$25 Copay per visit; Deductible Waived

Habilitation services

Skilled nursing care

30% Coinsurance

50% Coinsurance

Durable medical equipment

30% Coinsurance

50% Coinsurance

Hospice service

30% Coinsurance

50% Coinsurance

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What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 1 Facility+ PHCS Professional & Ancillary

Tier 2 All Other Providers

$25 Copay per visit; Deductible Waived

Children’s eye exam

50% Coinsurance

1 Maximum exam every 2 calendar years

If your child needs dental or eye care

Children’s glasses

Not covered

None

Children’s dental check-up

Not covered

None

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Bariatric surgery • Infertility treatment • Private-duty nursing • Cosmetic surgery • Long-term care • Routine foot care • Dental care (Adult) • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture • Hearing aids • Routine eye care (Adult) • Chiropractic care 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: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. 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 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: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.HealthCare.gov and http://cciio.cms.gov/programs/consumer/capgrants/index.html.

Page 6 of 8

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 Standard? 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.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8

About 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.

Mia’s Simple Fracture (in-network emergency room visit and follow up care)

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well controlled condition)

 The plan's overall deductible  Specialist copayment  Hospital (facility) coinsurance

$2,500

 The plan's overall deductible  Specialist copayment  Hospital (facility) coinsurance

$2,500

 The plan's overall deductible  Specialist copayment  Hospital (facility) coinsurance

$2,500

$50 30%

 Other coinsurance 30% This EXAMPLE event includes services like: Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700

 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 Sharing Deductibles* $200 Copayments $200 Coinsurance $0 What isn’t covered Limits or exclusions $4,300 The total Joe would pay is $4,700

 Other coinsurance 30% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost

$2,800

In this example, Peg would pay: Cost Sharing Deductibles

In this example, Mia would pay: Cost Sharing Deductibles*

$2,500

$1,200

Copayments Coinsurance

$500

$2,200

What isn’t covered

Limits or exclusions

$70

Limits or exclusions

$10

The total Peg would pay is

$4,770

The total Mia would pay is

$1,710

*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”" row above.

The plan would be responsible for the other costs of these EXAMPLE covered services.

Page 8 of 8

You. Your family. Your job.

Confidential, free help for personal, family and work problems. Our Employee Assistance Program has one purpose – to work closely with you to correct situations before they interfere with your home or work life. We do this with high quality clinical and personal care. is described on this page; on the reverse side.

What types of problems are covered by JBG Clinical Care?

Confidential assessment and brief counseling for:

Marital Relationship Parent/Child Conflicts

Depression

    

Substance Abuse Workplace Issues

Grief and Loss

Anxiety Stress

Gambling

Other Concerns

Call Jorgensen Brooks Group at 520-575-8623 [toll free, 888-520-5400 ]. Local, in-person clinical appointments can be made Monday through Friday, 8:00am through 4:30pm. Virtual / Video, t elephone and Internet Chat clinical appointments with licensed therapists are also offered . Crisis services are available 24 hours/7 days. How do I contact JBG Clinical Care and what should I expect?

How many counseling sessions are available ?

You and your family members can have up-to- six [ 6 ] free sessions per problem, per person, per year. Counseling for a specific problem [regardless of the number of sessions provided] requires a one-year break before sessions can again be provided for that problem. Sessions for marital / relationship and family / child situations are authorized for the group involved; separate sessions may be authorized for individuals upon clinical review. Adult children living in the household may receive services until the age of 26.

What if I need services beyond JBG Clinical Care?

JBG Clinical Care can guide you to available options, including self-help groups; behavioral health professionals; treatment programs; or other resource based on your condition, financial needs and / or insurance coverage. Always, JBG Clinical Care will first refer you to network providers in your medical plan. Once referred, you will be responsible for the cost of these services.

Call – 24 hours/7 days Tucson: 520-575-8623 Toll Free: 888-520-5400

JBG Personal Care Your employer is not told who uses JBG Clinical Care or .

You and your family have free, unlimited use of JBG Personal Care ; the services are available 24 hours/7 days by telephone, internet chat, or website . Call - 24 hours / 7 days Tucson: 520 - 575 - 8623 Toll Free: 888 - 520 - 5400  www.jorgensenbrooks.com  Home page; Click JBG Personal Care  Find and click on "Click here to access your JBG Personal Care" ; in the new window, type your Company Login: " CODAC "  Follow instructions to JBG Personal Care  Home page, upper left  Click on LIVE CONNECT  Complete brief inquiry form to connect to Chat Now.  Download from Google Play [android] or App Store [IOS]  Register on the app  Enter Employer number " CODAC " and standard password "JBG" [not case sensitive] Mobile App - EAP / Assist JBG Personal Care Website L ive Chat

 Legal: Will preparation, landlord disputes, separation and divorce, estate issues; services can include 30 minute free consultation, in person or by telephone with a local attorney, and a 25% discount on attorney fees. Employee disputes with employers are not covered.  Financial: Budgeting, managing credit card debt, other matters. Financial planning is a regulated service and not included.  ID theft recovery: Assistance with prompt notification of creditors and other financial providers; guidance on managing a return to control of your identity.  Child and Elder care: Appropriate providers are nearby specialty resources for infants, children and older citizens  Education: Resources for all types - primary and private, non - profit and profit, trade and higher education.  Housing: Resources for all types – temporary and permanent, self - paying or subsidized.  Savings Center: Discounts on thousands of personal, home and business goods without a membership fee.  Medical advice: Website information provided through the Mayo Clinic is another important benefit of your Employee Assistance Program. With this free, confidential service, professional consultants help you solve non - clinical problems for which you may not have experience or resources. Without the support of , life ’ s pressures can become over-whelming Examples of key [not all] JBG Personal Care services are:

Term Life Insurance

We’ve Got You Covered As an active employee of CODAC Health, Recovery & Wellness, Inc, you have access to a life insurance policy from United of Omaha Life Insurance Company. It replaces the income you would have provided, and helps pay funeral costs, manage debt and cover ongoing expenses. How much insurance is enough? When determining how much life insurance you need, think about the expenses you may encounter now and through every stage of your life. Coverage guidelines and benefits are outlined in the chart below.

ELIGIBILITY - ALL ELIGIBLE EMPLOYEES Eligibility Requirement

You must be actively working a minimum of 30 hours per week to be eligible for coverage. The premiums for this insurance are paid in full by the policyholder. There is no cost to you for this insurance.

Premium Payment

45103

G000539J

BENEFITS Life Insurance Benefit Amount

For You: An amount equal to 1 times your annual salary, but in no event less than $0 or more than $300,000 In the event of death, the benefit paid will be equal to the benefit amount after any age reductions less any living care/accelerated death benefits previously paid under this plan. For You: The Principal Sum amount is equal to the amount of your life insurance benefit.

Accidental Death &

Dismemberment (AD&D) Benefit Amount FEATURES Living Care/ Accelerated Death Benefit

50% of the amount of the life insurance benefit is available to you if terminally ill, not to exceed $100,000. If it is determined that you are totally disabled, your life insurance benefit will continue without payment of premium, subject to certain conditions. In addition to basic AD&D benefits, you are protected by the following benefits: - Seat Belt - Airbag If your employment ends, you may apply for an individual life insurance policy from Mutual of Omaha without having to provide evidence of insurability (information about your health). You will be responsible for the premium for the coverage. The Travel Assistance program is an added benefit that provides assistance for your travels over 100 miles away from home or outside the country. The Hearing Discount Program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more. We work with Epoq, Inc. to offer employees online will prep tools. In just a few clicks you can complete a basic will or other documents to protect your family and property. To get started visit www.willprepservices.com.

Waiver of Premium

Additional AD&D Benefits

Conversion

SERVICES Travel Assistance

Hearing Discount Program Will Prep Services

AGE REDUCTIONS AND EXCLUSIONS Insurance benefits and guarantee issue amounts are subject to age reductions:

- At age 70, amounts reduce to 65% - At age 75, amounts reduce to 45% - At age 80, amounts reduce to 30% - At age 85, amounts reduce to 20% - At age 90, amounts reduce to 15% Information about the AD&D exclusions for this plan will be included in the summary of coverage, which you will receive after enrolling. Please contact your employer if you have questions prior to enrolling.

Who is eligible for this insurance? You must be actively working (performing all normal duties of your job) at least 30 hours per week. What is Guarantee Issue? The amount of insurance applied for without answering any health questions (or which does not require evidence of insurability). Coverage amounts over the Guarantee Issue Amount will require evidence of insurability. What is Evidence of Insurability? Evidence of Insurability or proof of good health – may be required if you are a late entrant and/or you request any additional coverage above your guarantee issue amount. Can I take this insurance with me if I change jobs/am no longer a member of this group? In the event this insurance ends due to a change in your employment/membership status with the group, or for certain other reasons, you may have the right to continue this insurance under the Conversion provision, subject to certain conditions. Are there any limitations, reductions or exclusions? The benefits payable are based on the following: · Insurance benefits and guarantee issue amounts are subject to age reductions: - At age 70, amounts reduce to 65% - At age 75, amounts reduce to 45% - At age 80, amounts reduce to 30% - At age 85, amounts reduce to 20% - At age 90, amounts reduce to 15% · Information about the AD&D exclusions for this plan will be included in the summary of coverage, which you will receive after enrolling. All exclusions may not be applicable, or may be adjusted, as required by state regulations.

This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificate booklet for a full explanation of the plan's benefits, exclusions, limitations and reductions. Should there be any discrepancy between the certificate booklet and this outline, the certificate booklet will prevail. Life insurance and accidental death & dismemberment insurance are underwritten by United of Omaha Life Insurance Company, 3300 Mutual of Omaha Plaza, Omaha, NE 68175. Policy form number 7000GM-U-EZ 2010 or state equivalent (in NC: 7000GM-U-EZ 2010 NC). United of Omaha Life Insurance Company is licensed nationwide, except New York.

TERM LIFE INSURANCE

Employee Assistance Program

Available Services When You Need Help the Most

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Life isn’t always easy. Sometimes a personal or professional issue can affect your work, health and general well-being. During these tough times, it’s important to have someone to talk with to let you know you’re not alone.

We are here for you

With Mutual of Omaha’s Employee Assistance Program, you can get the help you need so you spend less time worrying about the challenges in your life and can get back to being the productive worker your employer counts on to get the job done. Learn more about the Employee Assistance Program services available to you. Enhanced EAP Services

Visit the Employee Assistance Program website to view timely articles and resources

on a variety of financial, well-being, behavioral and mental health topics. mutualofomaha.com/eap

Features

Value to Company and Employees

Employee Family Clinical Services

• An in-house team of Master’s level EAP professionals who are available 24/7/365 to provide individual assessments • Outstanding customer service from a team dedicated to ongoing training and education in employee assistance matters • Access to subject matter experts in the field of EAP service delivery Three sessions per year (per household) conducted by either face-to-face* counseling or video

Counseling Options •

Exclusive Provider Network

• National network of more than 10,000 licensed clinical providers • Network continually expanding to meet customer needs • Flexibility to meet individual client/member needs

*California Residents: Knox-Keene Statute limits no more than three face-to-face sessions in a six-month period per person.

Continued on back.

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Enhanced EAP Services (continued)

Features

Value to Company and Employees

Access

• 1-800 hotline with direct access to a Master’s level EAP professional • 24/7/365 services available

• Telephone support available in more than 120 languages • Online submission form available for EAP service requests • EAP professionals will help members develop a plan and identify resources to meet their individual needs • Valuable resources – legal libraries, tools and forms – available on EAP website • A counseling session may be substituted for one legal consultation (up to 30 minutes) with an attorney • 25% discount for ongoing legal services for same issue • Inclusive financial platform powered by Enrich that includes financial assessment tools, personalized courses, articles and resources, and ongoing progress reports to help members monitor their financial health • A counseling session may be substituted for one financial consultation (up to 30 minutes) with an attorney • 25% discount for ongoing financial services for same issue

Employee Family Legal Services

Employee Family Financial Services

Employee Family Work/Life Services

• Child care resources and referrals • Elder care resources and referrals

Online Services

• An inclusive website with resources and links for additional assistance, including: • Current events and resources • Family and relationships • Emotional well-being • Financial wellness • Substance abuse and addiction • Legal assistance • Physical well-being • Work and career • Bilingual article library

Employee Communication

• All materials available in English and Spanish

Eligibility

• Full-time employees and their immediate family members; including the employee, spouse and dependent children (unmarried and under 26) who reside with the employee • EAP professionals will coordinate services with treatment resources/providers within the employee’s health insurance network to provide counseling services covered by health insurance benefits, whenever possible

Coordination with Health Plan(s)

Insurance products and services are offered by Mutual of Omaha Insurance Company or one of its affiliates. Mutual of Omaha Insurance Company is licensed nationwide. United of Omaha Life Insurance Company is licensed nationwide, except in New York. Companion Life Insurance Company is licensed in New York. Each underwriting company is solely responsible for its own contractual and financial obligations. Some exclusions or limitations may apply.

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