Sterling Estates - 2024 Benefits Guide

BENEFITS GUIDE 2024 PLAN YEAR

Sterling Estates is proud to offer you a comprehensive benefits package for the 2024 plan year. Keep in mind that new enrollment and changes will become effective January 1 st , 2024. Sterling Estates will continue to offer health insurance with Anthem Blue Cross Blue Shield of Georgia which has the largest network in Georgia. You can access your providers by visiting anthem.com Select - Find Care Select - Basic Search as Guest Select – Medical Plan or Network Select – Georgia Select – Medical (Employer Sponsored) Select – Blue Open Access POS Each employee will be enrolled with Anthem for the same level of coverage that they currently have. If you want to make any changes to your current coverage, please let HR know by December 31 st , 2024.

About Deductions

In preparation of your enrollment, please have the following information readily available for you and your dependent(s): • Date(s) of birth: Mandatory • Social Security Number(s): Mandatory • Full name, relationship, and Social Security Number(s) for Life Beneficiary(ies). (Beneficiaries must be at least 18 years old or you will be required to name a guardian for him/her.) Information Needed for Enrollment Premiums for medical, dental and vision plans are all deducted on a pre-tax basis because they are covered under Section 125 of the Internal Revenue Code. Once you elect benefits you will not be approved to make changes to your election or drop coverage until the next Open Enrollment period, unless you have a qualifying event. Voluntary life and short-term disability insurance premiums are deducted on a post-tax basis and may be changed outside of the Open Enrollment period.

Eligibility Information

Qualifying Life Events

As an employee of Sterling Estates you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the benefits package upon the 90th day from date of hire.

Qualifying events are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation of coverage.

You may enroll your eligible dependents for coverage once you are eligible. Your eligible

Qualifying events include:

dependents include: • Your legal spouse • Your children up to age 26 (as identified in the plan document)

• Marriage • Divorce or legal separation • Birth or adoption of a child • Death of spouse or dependent child • Change in employment status • Loss of other coverage • Entitlement to Medicare or Medicaid • Child turning 26 years old

*Once your elections are effective, they will remain in effect through the plan year.

You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.

STERLING ESTATES 2024 BENEFITS GUIDE

Medical and Pharmacy Coverage

Sterling Estates offers the following Medical plans through Anthem BlueCross BlueShield and offers “In and Out-of-Network” benefits. Insurance Carrier: Anthem BlueCross BlueShield Medical Insurance Medical Plan: $1,500 / 20% Coinsurance Plan In-Network: Office Visit Copay - Primary Care $30 Office Visit Copay - Specialist Care $60 Urgent Care Copay $75 Emergency Room Care $350; then 20% Coinsurance Preventative Visit Copay $0 Diagnostic Testing & Blood Work (Office) $60 Imaging Deductible; then 20% Coinsurance Coinsurance 80% Employee Deductible $1,500 Family Deductible $4,500 Employee Out-of-Pocket Max $4,500 Family Out-of-Pocket Max $9,000 Inpatient Hospital Deductible; then 20% Coinsurance Outpatient Hospital or Facility Deductible; then 20% Coinsurance Out-of-Network: Coinsurance 50% Employee Deductible $4,500 Family Deductible $13,500 Employee Out-of-Pocket Max $13,500 Family Out-of-Pocket Max $27,000 Prescription Drugs: ( 30 Day Supply) Tier 1 - Typically Generic $15 Tier 2 - Typically Preferred Brand $35 Tier 3 - Typically Non-Preferred Brand $60 Tier 4 - Typically Specialty 25% Coinsurance up to $350 Employee Semi-Monthly Deduction Employee Only $88.75 Employee + Spouse $267.50 Employee + Child(ren) $198.75 Family $267.50

STERLING ESTATES 2024 BENEFITS GUIDE

Basic Life and AD&D Insurance Coverage

Sterling Estates provides all Full Time employees with Basic Life AD&D (Accidental Death & Dismemberment) at no cost when electing medical coverage.

Insurance Carrier: Basic Life AD&D Eligibility Requirement Life Insurance Benefit

Anthem Basic Life AD&D Insurance

Full Time Employees (electing medical coverage)

$15,000

Guarantee Issue

Yes

Accidental Death & Dismemberment Benefit (AD&D)

$15,000

STERLING ESTATES 2024 BENEFITS GUIDE

Dental Coverage

Good dental care is critical to your overall well-being. With Sun Life Dental Insurance, you can get the attention your teeth need - at a cost you can afford. To get the most from your benefits and reduce out-of-pocket costs, choose an In-Network provider by utilizing our large national network. These providers have agreed to file your claims and uphold the highest quality standards. You can find In-Network providers at member.sunlifeconnect.com

Insurance Carrier:

Sun Life Dental Insurance

Plan Type:

Basic Plan

Enhanced Plan

Calendar Year Deductible Calendar Year Maximum

$50 Individual / $150 Family

$750

$1,000

Preventive Services

100%

Basic Services Major Services

80% 10%

80% 50%

Employee Semi-Monthly Deduction Employee Only

$8.88

$19.47 $37.82 $50.12 $68.46

Employee + Spouse Employee + Child(ren)

$17.04 $26.56 $34.72

Family

STERLING ESTATES 2024 BENEFITS GUIDE

Vision Coverage

You can help protect your eyesight by visiting an eye doctor regularly. Vision insurance includes an annual comprehensive eye exam with an eye care doctor. Taking care of your eyes today can lead to a better quality of life later. Your vision plan is through Sun Life and offers “In and Out-of-Network” benefits. You can find vision providers at vsp.com/eye-doctor

Insurance Carrier:

Sun Life Vision Insurance

In-Network $10 Copay $25 Copay $25 Copay $25 Copay

Exam Copay

Lenses - Single lined Lenses - Bifocal lined

Lenses - Trifocal

Frames

$ 130 Allowance

Elective Contact Lenses (in place of lenses & frame)

$130 Allowance

Frequency for Exam / Lenses / Frames Employee Semi-Monthly Deduction Employee Only

12 months / 12 months / 24 months

$4.91 $9.82

Employee + Spouse Employee + Child(ren)

$10.81 $15.72

Family

STERLING ESTATES 2024 BENEFITS GUIDE

Voluntary Term Life & Disability Coverage

As a supplemental benefit, Sterling Estates allows eligible employees to purchase additional life insurance coverage for yourself and your dependents. Employee must be enrolled to purchase coverage for your family. This coverage is paid for by you and is offered through Sun Life. Rates for the voluntary term life insurance are based on age, and volume, and benefits are subject to applicable age reductions.

Insurance Carrier: Voluntary Life AD&D Eligibility Requirement Employee Benefit Amounts Employee

Sun Life Voluntary Life AD&D Insurance

All Eligible Employees

Minimum of $20k up to $250k in increments of $10k

Spouse

Minimum of $5k up to $125k in increments of $5k

Child(ren)

Flat $10k

Disability Coverage The goal of Sterling Estates Disability Insurance Plan is to provide you with income replacement should you be unable to work due to a non-work-related illness or injury. The company provides all eligible employees with the option to purchase voluntary “Short-Term Disability” income benefits. Short-Term Disability coverage is offered through Sun Life. Insurance Carrier: Sun Life Short-Term Disability Insurance Plan Type: Voluntary Eligibility Requirement All Eligible Employees Benefit Percentage 60% Waiting Period - Accident 8 Days Waiting Period - Sickness 8 Days Maximum Weekly Benefit $1,000 Benefit Duration Executive Directors - 12 Weeks All Other Eligible Employees - 52 Weeks Pre-Existing Condition 3 / 12

STERLING ESTATES 2024 BENEFITS GUIDE

Accident Insurance

HELPS YOUR FINANCES AFTER A MISHAP. When you, your spouse or child has a covered accident, like a fall from a bicycle that requires medical attention, you can receive cash benefits to help cover the unexpected costs. HELPS COVER RELATED EXPENSES. While health plans may cover direct costs associated with an accident, you can use accident benefits to help cover related expenses like lost income, child care, deductibles and co-pays. PAYS CASH BENEFITS DIRECTLY TO YOU. Accident Insurance can be used however you want, and it pays in addition to any other coverage you may already have. Benefits are payable directly to you. And get this – there are no health questions or pre-existing conditions limitations. What’s more, all family members on your plan are eligible for a wellness-screening benefit, also paid directly to you once each year per covered person.

You can purchase this coverage for you and your family. Child coverage is available to age 26.

ACCIDENT FAST FACTS

Falls are the leading cause of injuries treated in emergency rooms every year, for people of all ages. 1

This coverage pays benefits for accidents that occur off the job.

Sun Life Assurance Company of Canada

1761669 ACC2 CL1 12/23/2021 11:52:23

800-247-6875 • sunlife.com/us

Accident Insurance

STERLING ESTATES 2024 BENEFITS GUIDE

Accident Insurance

What’s covered

Once your coverage goes into effect, you can file a claim for covered accidents that occur after your insurance plan’s effective date. Unless otherwise specified, benefits are payable only once for each covered accident, as applicable. The full list of benefits is listed here. DISLOCATIONS OPEN (SURGERY) CLOSED (NO SURGERY) Hip $4,000 $1,000 Knee or Shoulder $1,000 $400 Ankle or bones of the foot $1,000 $300 Elbow or wrist $800 $400 Collarbone or bones of the hand $1,600 $300 Finger(s) or toe(s) $200 $100 Lower jaw $1,000 $500 FRACTURES OPEN (SURGERY) CLOSED (NO SURGERY) Hip or thigh $3,000 $1,500 Skull-depressed $5,000 $2,500 Skull-simple $2,500 $1,250 Vertebral processes or Rib $1,200 $300 Bones of the face, Upper jaw or upper arm $750 $375 Nose, Heel or Finger $700 $175 Leg, Vertebrae, Sternum or Pelvis $1,600 $800 Lower jaw, Collarbone, Shoulder, Forearm, Hand, Wrist, Foot, Ankle, Kneecap or Elbow $650 $325 Toe $250 $125 Coccyx $400 $200 ADDITIONAL INJURIES Eye Injury - surgical repair $300 Eye Injury - object remove $65 Paralysis—paraplegia $25,000 Paralysis—quadriplegia $50,000 Coma $20,000 Concussion $100 BURNS 2ND DEGREE 3RD DEGREE 20-40 square centimeters $400 $1,000 41-65 square centimeters $800 $2,000 66-160 square centimeters $1,200 $6,000 161-225 square centimeters $1,600 $14,000 More than 225 square centimeters $2,000 $20,000 Skin graft 50% of the applicable Burn Benefit LACERATIONS No sutures and treated by doctor $35 Single laceration under 5 cm with sutures $65 5-15 cm with sutures (total of all lacerations) $250 Greater than 15 cm with sutures (total of all lacerations) $500

10 STERLING ESTATES 2024 BENEFITS GUIDE

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Accident Insurance

What’s covered MEDICAL SERVICES Diagnostic Exam - Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI (1 time per benefit year) Accident Emergency Treatment, non-emergency room (once per covered accident) Physician's Follow-up Treatment office visit (per visit, up to 6 times per covered accident)

$200

$75 $25 $25

Physical Therapy (per visit up to 10 visits per covered accident)

Medical Devices Prosthesis (one)

$125 $500 $200

Blood, Plasma, or Platelet Transfusion HOSPITAL Hospital Admission (once per benefit year)

$1,000

Hospital Confinement (per day up to 365 days per covered accident)

$250

Intensive Care Unit Admission (once per Benefit Year; payable instead of Hospital Admission benefit if Confined immediately to ICU) Intensive Care Unit Confinement (per day up to 30 days, payable in addition to any Hospital Confinement benefit)

$1,500

$500

Ambulance (Ground)

$200

Ambulance (Air)

$1,500

Emergency Room Admission

$150 $100 $600 $150

Family Lodging (per day up to 30 days per benefit year)

Transportation (100 or more miles up to 3 times per covered accident) Rehabilitation Unit (per day up to 365 days per covered accident)

SURGERY Miscellaneous Surgery requiring general anesthesia (not covered by any other benefit)

$300

Open Surgery

$1,250

Exploratory Surgery or Debridement

$300 $300 $625 $625 $625

Laparoscopic Surgery

Tendon/Ligament/Rotator Cuff Tear

Torn Knee Cartilage

Ruptured/Herniated Disc EMERGENCY DENTAL Emergency Dental extraction Emergency Dental crown WELLNESS Wellness Screening Benefit (once per benefit year)

$65

$200

$50

LIFE AND DISMEMBERMENT LOSSES* Accidental Death

$25,000 $100,000

Accidental Death Common Carrier (pays an additional benefit if accidental death occurs while traveling as a fare-paying passenger on a public conveyance) Catastrophic Loss: Both arms or both hands, both legs or both feet, one hand and one foot or one arm and one leg, or irrecoverable loss of sight of both eyes

$15,000

Loss of one hand, foot, leg, or arm

$7,500 $7,500 $1,500

Loss of sight of one eye or loss of one eye

Two or more fingers or toes

One finger or one toe $1,500 *Benefits displayed for life and dismemberment are for the employee only. Spouse benefits are 100% of the employee benefit amount for death and 50% of the employee benefit amount for dismemberment. Dependent children benefits are 20% of the employee benefit amount for death and 50% of the employee benefit amount for dismemberment.

STERLING ESTATES 2024 BENEFITS GUIDE

Accident Insurance

Frequently asked questions

How do I file an accident claim? If you have an accident after the effective date of coverage, you can file a claim with us by downloading forms from our website. We’ll ask that you and your doctor provide information about the accident and the treatment provided. What happens once my claim is approved? The benefit amount you receive will depend on your injury and/or the treatment provided. Remember, benefits are payable only once for each covered accident, unless noted otherwise in the benefit schedule. Is there a time period that I need to follow? Injuries and other related benefits due to a covered accident must be diagnosed or treated within a defined period of time from the date of your accident. This could be as few as three days for certain benefits. Please refer to your Certificate for details. How do I get the Wellness Screening Benefit? You may be paid the benefit when you or a covered family member submit proof of a covered screening each year, like specific blood tests and cancer screenings, cardiac stress tests, immunizations, school sports exams and more (may vary by state). Our wellness screening benefit claim form can also be downloaded from our website. Can I take my insurance with me if I leave my employer? Depending upon state variations and your employer’s plan, you may have an option to continue group coverage when your employment terminates. Your employer can advise you about your options. Is my benefit taxable? If you or your employer pay for all or part of the cost of coverage on a pre-tax basis, some or all of your benefit amount will be tax reported on a Form 1099 as taxable income. Please reach out to a tax advisor or your employer if you have any questions.

Accident Plan Monthly Rates

Accident insurance is a limited benefit policy. The Certificate has exclusions that may affect any benefits payable. Benefits payable are subject to all terms and conditions of your Certificate.

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Read the Important information section for more details including limitations and exclusions. 1. “Health, United States, 2016,” US Department of Health and Human Services, Table 75.

Cancer Insurance

Cancer insurance Azalea Estates Assisted Living & Retirement Communities | All Eligible Employees | 925592 Protect your savings against the costs of cancer A cancer diagnosis may have crossed your mind over the years. Or you may have a family history. Recovering from cancer would be your main focus. Cancer also has a financial impact that can be hard to recover from. Cancer insurance pays you cash benefits for a variety of the ways your cancer is treated. How it works. Your employer is offering you and your coworkers this coverage as a group, at a group rate. You are responsible for paying a portion or all of the cost. The benefit schedule on the following pages lists what the plan pays for covered cancer treatments.

What did cancer insurance mean for Beth?

Beth was diagnosed with breast cancer in her mid-50s. She was concerned about her health, and about her finances. Beth filed claims with Sun Life as she received treatments. We reviewed her medical information and details from her physician. We approved her claims. She received cash benefits for hospital stays, radiation and chemotherapy treatments. These benefits helped her pay her medical deductible and copays, and travel expenses for medical appointments Did you know? A recent study shows that cancer patients spend 11% of their household income on expenses related to their cancer treatments.* This may prompt you to consider cancer insurance.

Benefits

Coverage is provided for

A covered person who is diagnosed with cancer after the effective date of insurance. Coverage is available for you and your family. An eligible child is defined as your child from birth to age  . Benefits are payable directly to you, the employee This plan pays benefits in addition to any other coverage you may have.

Additional plan features

Sun Life Assurance Company of Canada sunlife.com 1-800-SUN-LIFE (247-6875)

13 STERLING ESTATES 2024 BENEFITS GUIDE

Cancer Insurance

Benefit schedule Once your coverage goes into effect, you can file a claim for covered cancer treatments for cancer diagnoses that occur after your insurance’s effective date. Unless otherwise specified, benefits are payable only once. The full list of benefits is listed here. Choose the plan (Level 1 or Level 2) that best meet your needs and your budget.

Covered service

Level 1

Level 2

Second Surgical Opinion

$200

Surgery and General Anesthesia Benefits vary based on the procedure performed. Combined maximum for any one surgery is $2,000 for Level 1 and $7,500 for Level 2. Surgery for skin cancer and reconstruction is not covered under this benefit.

Anesthesia $50 to $1,815

Surgical $150 to $5,500

Hospital Confinement (limited to 90 days per period of confinement)

$200 Daily

$400 Daily

In-hospital and Outpatient Blood and Plasma

$50 Daily

Ambulance (limited to 2 one-way trips per period of confinement per person)

$250

$250 Ground $2,000 Air

Cancer Screening Includes colonoscopy, CA 125 test, chest x-ray, flexible sigmoidoscopy, mammogram, pap smear, biopsy, PSA, CT scans or MRI scans, BRCA testing, or Hemocult stool specimen. This benefit is limited to once per benefit year.

$50

$75

In-hospital Doctor Visits Limited to a maximum of 75 visits.

$25 Daily

Prosthesis Lifetime maximum for surgically implanted prosthesis is $4,000 for Level 1 and $6,000 for Level 2. Lifetime maximum for other devices is $400 for Level 1 and $600 for Level 2.

Surgically implanted $2,000

Surgically implanted $3,000

Other $300

Other $200

Skin Cancer Biopsy Only

$100 $250 $375 $600

Reconstructive surgery following previous excision of skin cancer

Excision of skin cancer without flap or graft Excision of skin cancer with flap or graft

Radiation and Chemotherapy Injected Cytotoxic Medications

$300 Weekly $1,000 Weekly

Pump Dispensed Cytotoxic Medications

$300 First Prescription and Per Refill $150 Per Prescription

$1,000 First Prescription and Per Refill $500 Per Prescription

Oral Cytotoxic Medications

Cytotoxic Medications Administration by Any Other Method

$300 Weekly $1,000 Weekly

External Radiation Therapy

$400 Weekly $450 Weekly $400 Weekly

$600 Weekly $750 Weekly $600 Weekly

Insertion of Interstitial or Intracavity Administration of Radioisotopes or Radium

Oral or IV Radiation This benefit is not payable for the same day the Experimental Treatment benefit is payable. These benefits are not payable for treatment planning, therapeutic devices, immunotherapy, laboratory tests, diagnostic x-rays, dosimetry or simulation associated with these procedures.

sunlife.com 1-800-SUN-LIFE (247-6875)

14 STERLING ESTATES 2024 BENEFITS GUIDE

Cancer Insurance

Covered service

Level 1

Level 2

Maximums apply: Oral Cytotoxic Medications are subject to a monthly maximum of $450 for Level 1 and $1,500 for Level 2, other listed treatments are subject to a yearly maximum of $4,000 for Level 1 and $12,000 for Level 2. Extended-care Facility This benefit is payable if the extended care confinement occurs within 30 days of a period of hospital confinement due to internal cancer and you have received a Hospital Confinement benefit. Limited to a maximum of 90 days per benefit year per covered person. This benefit is not payable for any day the Hospital Confinement benefit is payable. Hospice Limited to a maximum of 100 days during the covered person’s lifetime. This benefit is not payable for any day the Extended-Care Facility benefit, the Home Health Care benefit or the Hospital Confinement benefit is payable.

$200 Daily

$100 Daily

Additional benefits available if you enroll in Level 2 Covered service

Benefit amount

First Occurrence Payable if diagnosed with Internal Cancer for the first time. This benefit is only payable once per lifetime. National Cancer Institute Evaluation/Consultation This benefit is not payable for the same day the Second Surgical Opinion benefit is payable. This benefit is limited and only payable once per lifetime. Medical Imaging When a follow-up evaluation is performed using any imaging test as directed by a doctor after an initial diagnosis of internal cancer, (except breast mammography and breast ultrasound) this benefit is payable. You may receive this benefit twice per benefit year provided you or your covered dependent are charged for these procedures and they are performed on an outpatient basis. Home Health Care The service must begin within 7 days of the date you or your covered dependent are released from hospital confinement. This benefit is not payable for any day the Hospice benefit is payable. Caregivers must be licensed or certified. Limited to a maximum of 10 visits per period of hospital confinement; up to 30 visits per benefit year. Outpatient Hospital Surgical This benefit is not payable for surgery performed in a doctor’s office or if you or your covered dependent are hospital confined on the same day. Limited to a maximum of 3 days per procedure. Transportation The hospital or clinic must be more than 100 miles away from your or your covered dependent’s residence. Limited to 3 round trips per benefit year, per covered person. Lodging The hospital or clinic must be more than 100 miles away from your or your covered dependent’s residence. Limited to 1 benefit per day up to 90 days per benefit year, per covered person.

$5,000

$500

$100

$50 Per Visit

$250 Daily

$500

$100 Daily

Bone Marrow or Stem Cell Transplant A benefit is paid for either a bone marrow transplant or a stem cell transplant, not both. Payable once per lifetime, per covered person.

Bone Marrow $10,000 Donor ($1,500) Stem Cell $2,500

Nursing Services Care must be provided by a licensed registered graduate nurse or vocational nurse, but not by a family member. Limited to 30 days per benefit year per covered person.

$125 Daily

15 STERLING ESTATES 2024 BENEFITS GUIDE sunlife.com 1-800-SUN-LIFE (247-6875)

Cancer Insurance

Covered service

Benefit amount

Immunotherapy We will not pay benefits under this provision for the same treatment under either the Radiation and Chemotherapy Benefit or the Experimental Treatment Benefit. Lifetime maximum of $3,500 applies, per covered person. Reconstructive Surgery In addition, 30% of the surgery amounts listed is paid for general anesthesia used during these procedures. Breast Symmetry (modification of the non-cancerous breast performed within 5 years of reconstructing the cancerous breast)

$450 Monthly

$350

Breast Reconstruction Facial Reconstruction

$700 $700

Breast Transverse Rectus Abdominis Myocutaneous (TRAM) Flap

$2,500

Alternative Care Pays the amount shown per visit to an accredited practitioner for you or your covered dependent upon the diagnosis of internal cancer for Palliative care (acupuncture, massage therapy, bio- feedback and hypnosis), and Lifestyle training (smoking cessation, Yoga, meditation, relaxation techniques, Tai Chi and nutritional counseling). Limited to 20 visits per benefit year under either category, per covered person and lifetime maximum of 2 benefit years. There is also a one- time benefit ($150) for Integrative Assessment and Education when performed by an accredited practitioner following the diagnosis of internal cancer. Experimental Treatment Treatment must be administered by medical personnel in a doctor’s office, clinic, or hospital; maximum monthly benefit is $1,050. We will not pay benefits under this provision for laboratory tests, immunotherapy, diagnostic x-rays and therapeutic device or other procedures related to these treatments. This benefit is not payable for any day the Radiation or Chemotherapy benefit is payable.

$50 Per Visit

$150 Daily

Anti-nausea drugs

$100 Monthly

Post-hospital Doctor Visits This benefit is payable per doctor visit once every 6 months. Benefits payable up to 5 years after the diagnosis of internal cancer for the purpose of ongoing cancer evaluation.

$50 Per Visit

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sunlife.com

Cancer Insurance

Cancer insurance FAQs How do I file a claim?

premium, some or all of your benefit amount will be tax reported on a Form 1099 as taxable income. Please consult with a tax advisor or your employer if you have any questions. What if I have a pre-existing condition? If you submit a claim within 1 months of your insurance taking effect, or 1 months following any increase in your amount of insurance, we will not pay any benefit for any pre-existing condition. A pre-existing condition includes anything you have sought or received treatment for in the 6 months prior to your insurance becoming effective. Treatment can include consultation, advice, care, services or a prescription for drugs or medicine. Can I take my insurance with me if I leave my employer? Depending upon state variations and your employer’s plan, you may have an option to continue group coverage when your employment terminates. Your employer can advise you about your options.

We will ask for information from you and your doctor about your medical condition. You can download forms from our website. Please complete and sign all forms. Missing information or signatures can delay your claim. Can I receive benefits for more than one cancer diagnosis? Regardless of types of Cancer or number of diagnoses, you may receive benefits for covered Cancer treatments from your inforce policy. If you have Level 2 coverage, the First Occurrence Benefit provides a one-time payment for your initial Cancer diagnosis in addition to your covered treatment benefits. Is my benefit taxable? If you pay for your coverage all post-tax, your benefit will not be taxable income or tax reported by us to the IRS. If you pay for your coverage all pre-tax, if you pay for part of your coverage post-tax and your employer pays for the rest, or if your employer pays the entire

“Cancer insurance” is a limited benefit policy. The certificate has exclusions and limitations that may affect any benefits payable. Benefits payable are subject to all terms and conditions of the certificate .

Read the important plan provisions section for more information including limitations and exclusions. Cancer Indemnity Insurance Monthly Rates Level 1 * Even Insured Patients Are Overwhelmed By The Cost Of Cancer Care,” Duke University study, www.forbes.com, August 2017

Level 2

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sunlife.com 1-800-SUN-LIFE (247-6875)

Frequently Asked Questions

What is included in the Medical Out-of-Pocket maximum? What is included in the Pharmacy Out- of-Pocket maximum? The Medical Out-of-Pocket maximum is the maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible and any coinsurance member responsibility. The Pharmacy OOP includes only pharmacy co-pays. The Medical OOP does NOT include monthly premiums, or billing from out-of-network providers. What is an in-network vs out-of-network provider? Anthem Blue Cross Blue Shield contracts with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies. These are the providers that are considered “in your network”. Specifically, each of these providers has agreed to accept Anthem Blue Cross Blue Shield’s contracted rate for your medical care and services rendered. The contracted rate includes both Anthem Blue Cross Blue Shield’s share of the cost, and the member’s. Your share may be in the form of a co-payment, deductible, or co-insurance. For example, Anthem Blue Cross Blue Shield’s contracted rate for a primary care visit might be $125. The Plan has a $25 co-payment for the visit; the member will pay $25 of the cost and your insurance plan will pay the remaining $100. An “out-of-network” provider is a medical doctor or facility that is not in contract with Anthem Blue Cross Blue Shield. This means that the provider may charge members higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of-network provider may charge $200 for a primary care visit. Anthem Blue Cross Blue Shield may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit. When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child. You can contact ADP anytime to update your beneficiary.

Term

Definition

Network Office Visit (PCP) The “per visit” co-pay cost for a primary care or standard network doctor.

The “per visit” co-pay cost for a specialized doctor (cardiologist, OB/GYN, orthopedic, gastrointestinal, etc.) The amount of money a member owes for any In-network health care services before co-insurance coverage begins. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) Deductibles run on a calendar year basis. After any applicable deductible is met, the remaining cost of any in-network health care service is divided between the insurance carrier and the member. A 70% / 30% network co-insurance would divide the cost of a service with 70% paid by the insurance carrier and 30% paid by the member. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) The maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible, any co-insurance member responsibility, primary care and specialist office visit co-pays, ER or Urgent Care co-pays, and prescription co-pays / costs. The OOP does NOT include monthly premiums, billing from out-of-network providers, or spending for non-essential health benefits. The cost of a one month supply of a prescription drug. All covered drugs are designated into tiered levels based on drug usage, cost, and clinical effectiveness. Tier 1 usually includes generics, while Tier 2 generally includes preferred brand name medications. Tier 3 typically includes non-preferred brand name medications, Tier 4 usually includes higher cost drugs and Specialty Drugs are covered under a separate tier.

Specialist Office Visit

Network Deductible

Co-Insurance

Network Out-of-Pocket Maximum (OOP)

Prescription Drug Tiers and Monthly Co-Pays

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Anthem Enrollment Application

Employee Enrollment Application For 51+ Employee Groups Georgia

You, the employee, must complete this application. You are solely responsible for its accuracy and completeness. To avoid the possibility of delay, answer all questions and be sure to sign and date your application.

Please complete electronically or in blue or black ink only. Employer name S t e r l ing Estates

Group no.

Subsection

L 0 7 5 5 8

Section A: Employee information Last name

First name

M.I.

Social Security no.* (required)

Birthdate (MMDDYYYY)

Home address

City

County

State ZIP code

Marital status Single

Primary phone no.

Sex

Male

Female

Married

Domestic Partner

Employee email address

Hire date (MMDDYYYY)

No. of hours worked per week

Employment status Full time

Part time

Disabled

Retired

Primary Care Physician (PCP) name

PCP ID no.

Existing patient? Yes No

Section B: Application type Select one

New enrollment Open enrollment

COBRA — (not applicable to life and disability) Select qualifying event

Qualifying event date

Left employment

Reduction in hours

Death

Loss of dependent child status

Divorce or legal separation

Medicare (not applicable to life and disability) Covered employee’s Medicare entitlement (not applicable to life and disability)

Additional qualifying events for Life and Disability: Marriage/Domestic Partnership/Civil Union Birth, adoption of child, legal guardianship of child

Divorce/terminate Domestic Partnership/Civil Union

Death of spouse

Death of child

Spouse left employment and lost group life insurance — applicable only for Life Change in class from full–time to part–time/part–time to full–time Qualifying event date: (MMDDYY) * Anthem Blue Cross and Blue Shield (Anthem) is required by the Internal Revenue Service to collect this information.

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19 STERLING ESTATES 2024 BENEFITS GUIDE

Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Life and Disability products are underwritten by Greater Georgia Life Insurance Company using the trade name Anthem Life. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

F0301.EE – 01012023

46697GAMENMUB Rev. 7/22 1 of 9

5837861 46697GAMENMUB LG 2023 Employee Prt FR 07 22

Anthem Enrollment Application

Social Security no.* (required)

Section C: Type of coverage 1. Medical coverage

OAP5/72LF

HMO

PPO

POS

EPO

Enter product name: __________________________________________________

Select network:

✔

Add HRA Wrap (Administered by Anthem) Member medical coverage — select one:

Employee only

Employee + Spouse/Domestic Partner

Employee + child(ren)

Family

2. Flexible Spending Account (FSA) coverage — Multiple plans can be selected. Healthcare FSA (excluded if you have an HSA plan) Limited-Purpose FSA (for dental and vision services) Dependent Care FSA

Commuter Parking Commuter Transit No FSA coverage at this time

3. Dental coverage

Enter product selected: ________________________________________________________ Member dental coverage — select one: Employee only Employee + Spouse/Domestic Partner 4. Vision coverage Enter product selected: ________________________________________________________ Member vision coverage — select one: Employee only Employee + Spouse/Domestic Partner

Employee + child(ren)

Family

Employee + child(ren)

Family

5. Life and disability coverage If you select life and/or disability coverage over the guarantee issue amount or are a late entrant an Evidence of Insurability form may be sent to you to complete. These coverages will become effective on the date established by the provisions of the group contract and certificates issued thereunder. Your employer will advise you of your plan options. These coverages may be subject to medical evidence underwriting and would only become effective upon approval.

Basic Life and AD&D Basic Dependent Life Supplemental/Voluntary Life and AD&D ($15,000)

Short Term Disability Long Term Disability

✔

$_____________ (employee amount) Supplemental/Voluntary Dependent Life Spouse $_____________ (spouse amount) Supplemental/Voluntary Dependent Life Child $_____________ (child amount)

Voluntary Short Term Disability Voluntary Long Term Disability Voluntary AD&D

Current annual income $_____________

Life and disability class no.

If choosing medical please select beneficiary for included $15,000 life insurance policy

Beneficiary designation — Attach a separate sheet if necessary. Beneficiary type Primary Contingent Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Total percentages should add up to 100%. If the total percentages add up to less than 100%, the remaining percentage will be paid in equal shares to all named beneficiaries to total 100%. If the total percentages add up to more than 100%, each named beneficiary’s share will be reduced equally to total 100%. If no percentages are indicated, the proceeds will be divided equally. If no primary beneficiary survives, the proceeds will be paid to the contingent beneficiary(ies) listed above. Beneficiaries may be changed by the insured’s written notice to his or her employer.

20 STERLING ESTATES 2024 BENEFITS GUIDE

* Anthem is required by the Internal Revenue Service to collect this information.

2 of 9

Anthem Enrollment Application

Social Security no.* (required)

If you live in AZ, CA, ID, LA, NM, NV, TX, WA, WI and your spouse is not 50% or more beneficiary, your spouse needs to sign below. In CA, NV, and WA, Spouse also includes your registered Domestic Partner. Spousal consent for community property states only (Note: The insurance company is not responsible for the validity of a spouse’s consent for designation.) If you live in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, and WI), your state may require you to obtain the signature of your spouse if your spouse will not be named as a primary beneficiary for 50% or more of your benefit amount. Please have your spouse read and sign the following. I am aware that my spouse, the Employee/Retiree named above, has designated someone other than me to be the beneficiary of group life insurance under the above policy. Spouse authorization, if applicable I hereby consent to such designation and waive any rights I may have to the proceeds of such insurance under applicable community property laws. I understand that this consent and waiver supersedes any prior spousal consent or waiver under this plan.

Spouse/Domestic Partner name

Date (MMDDYYYY)

Spouse/Domestic Partner signature X

Spouse sign here to waive community property rights

6. Group Supplemental Health plans — Refer to the summary of benefits for coverage options offered. Select all that apply. Accident Member accident coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Complete the following if there is more than one Voluntary Accident plan design offered: Contract code for plan elected: ________________ Critical Illness Member critical illness coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Contract code for plan elected: ________________ Employee coverage amount: ________________ Will all eligible individuals applying for Critical Illness coverage, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or group health insurance policy or an HMO or employer plan providing for essential health benefits? Yes No Complete the following if you or your spouse smoked or used tobacco products in the last 12 months: (tobacco product explanation) Employee smoker — select one: Yes No If yes, type of tobacco product: __________________________________ Spouse smoker — select one: Yes No If yes, type of tobacco product: __________________________________ Hospital Indemnity Member hospital indemnity coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Will all eligible individuals applying for Hospital Indemnity coverage, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or group health insurance policy or an HMO or employer plan providing for essential health benefits? Yes No Complete the following if there is more than one Voluntary Hospital Indemnity plan design offered: Contract code for plan elected: ________________ Group Accident, Critical Illness, and Hospital Indemnity Insurance beneficiary designation — Attach a separate sheet if necessary. Beneficiary type Primary Contingent Name of beneficiary Percentage % Social Security no.* Relationship to applicant Date of birth Street address City State ZIP code Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

21 STERLING ESTATES 2024 BENEFITS GUIDE

* Anthem is required by the Internal Revenue Service to collect this information.

3 of 9

Anthem Enrollment Application

Social Security no.* (required)

Section D: Coverage information — All fields required. Attach a separate sheet if necessary. Dependent information must be completed for all additional dependents (if any) to be covered under this coverage. An eligible dependent may be your spouse or domestic partner, your children, or your spouse’s or domestic partner’s children (to the end of the calendar month in which they turn age 26 unless they qualify as a disabled person). List all dependents beginning with the eldest. Spouse/Domestic Partner last name First name M.I. Social Security no.* (required)

Disabled Yes

Birthdate (MMDDYYYY)

Relationship to applicant Spouse

Sex

Male

Female

Domestic Partner

PCP name

PCP ID no.

Existing patient? Yes No

Dependent last name

First name

M.I.

Social Security no.* (required)

Sex

Disabled Yes

Birthdate (MMDDYYYY)

Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________

Male

Female

PCP name

PCP ID no.

Existing patient? Yes No

Does this dependent have a different address? No If yes, please enter: ____________________________________________________________________________________________ Dependent last name First name M.I. Social Security no.* (required) Yes

Disabled Yes

Birthdate (MMDDYYYY)

Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________

Sex

Male

Female

PCP name

PCP ID no.

Existing patient? Yes No

Disabled Yes

Birthdate (MMDDYYYY)

Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________

Sex

Male

Female

PCP name

PCP ID no.

Existing patient? Yes No

Does this dependent have a different address? No If yes, please enter: ____________________________________________________________________________________________ Yes

22 STERLING ESTATES 2024 BENEFITS GUIDE

Anthem Enrollment Application

Social Security no.* (required)

Section E: Medical information 1. Has anyone listed on this application ever had medical advice, treatment or do you know, or have reasons to know, of health problems in regard to the following? Check Yes or No. a. Cancer, tumor, or neoplasm † Yes No b. Organ transplantation Yes No c. Disorders of the heart or circulatory system Yes No d. Hepatitis Yes No 2. Is anyone listed on this application pregnant? Yes No If yes, when is the expected due date? 3. Has any applicant been advised to undergo a surgical operation or procedure within the last six months? Yes No 4. Is any applicant currently taking prescription drugs? Yes No If yes, please list on a separate sheet and attach. 5. Has anyone applying for coverage been treated for a serious illness (For example: cancer, diabetes, heart disease, cardiovascular disease, AIDS or AIDS– related disease, pregnancy, mental/nervous disorder, substance abuse, or any illnesses related to a major body organ) been hospitalized, had surgery, OR incurred healthcare claims in excess of $7,500 in the last 12 months? Yes No This section MUST be completed if you answered “Yes” to any questions 1–5 above. Person treated Name of illness or disorder Type of treatment received Treatment dates From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

23 STERLING ESTATES 2024 BENEFITS GUIDE

Anthem Enrollment Application

Social Security no.* (required)

Section F: Prior and other group coverage Are you or anyone applying for coverage currently eligible for Medicare?

Yes No If yes, give name: _____________________________________________________________________________________________ Medicare ID no. Part A effective date Part B effective date Medicare eligibility reason (check all that apply) Age Disability ESRD: Onset date: Medicare Part D ID no. Medicare Part D carrier Part D effective date

Are you or a family member previously or currently covered by a Medicare, health, and/or dental plan? Yes No If yes, please provide the following:

Coverage (check all that apply)

Name of person covered (Last name, first, M.I.)

Type (check one)

Policyholder name

Dates (if applicable)

Carrier name Carrier phone no.

Policy ID no.

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

24 STERLING ESTATES 2024 BENEFITS GUIDE

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