Tacodeli - 2025 Benefit Guide (English)

2025 Employee Benefit Guide AN OVERVIEW OF THE WIDE ARRAY OF BENEFITS PROVIDED BY TACODELI, TO HELP YOU ENJOY INCREASED WELL-BEING AND FINANCIAL SECURITY

PREPARED BY BRIO BENEFITS FOR TACODELI

Tacodeli

Table of Contents

Overview of Benefits Programs

Medical Benefits

Health Savings Account (HSA)

Critical Illness

Accident Insurance

Hospital Care

Dental Benefits

Vision Benefits

Voluntary Life Insurance

Voluntary Disability Insurance

Employee Assistance Program (EAP)

Pet Insurance

Online Enrollment

Legal Notices

Contact Page

This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.

2025 Employee Benefit Guide

Tacodeli

Overview of Benefits Benefits for 2025

Tacodeli provides an array of benefits that can help you enjoy increased well- being, deal with an unexpected illness or accident, build and protect your financial security, balance your personal and professional life and meet everyday needs. These benefits are affordable, comprehensive and competitive.

The table below summarizes the benefits available to eligible staff and their dependents. These benefits are described in greater detail in this booklet.

BENEFITS AT-A-GLANCE

COVERAGE

CARRIER

Medical

Cigna

Health Savings Account (HSA)

WEX

Dental

Cigna

Vision

MetLife

Voluntary Life/AD&D

Lincoln Financial Group

Short Term Disability

Lincoln Financial Group

Long Term Disability

Lincoln Financial Group

Employee Assistance Program

Lincoln Financial Group

Pet Insurance

Pet Benefit Solutions

Supplemental Health

Cigna

2025 Employee Benefit Guide

Tacodeli

Benefits for 2025

Overview of Benefits

Changes and Qualifying Events

When Coverage Begins and Ends

• Your coverage under the benefits plans will end if you no longer meet the eligibility requirements, your contributions are discontinued, or the Group Insurance Policy is terminated.

Qualifying Events

• Eligible employees may enroll or make changes to their benefits elections during the annual open enrollment period. As with most benefits, once you elect an option you are bound to that choice for the entire plan year unless you experience a “Qualifying Event”. These may include, but are not limited to:

▪ Changes in employment status ▪ Changes in legal marital status

▪ Changes in number of dependents ▪ Taking an unpaid leave of absence ▪ Dependent satisfies or ceases to satisfy eligibility requirement ▪ Family Medical Leave Act (FMLA) leave. ▪ A COBRA-qualifying event ▪ Entitlement to Medicare or Medicaid ▪ A change in the place of residence of the employee, resulting in the current carrier not being available

2025 Employee Benefit Guide

Tacodeli

Medical Benefits for 2025

Summary of Coverage

$5,000 Deductible HDHP Plan*

$2,000 Deductible Copay Plan (PPOHI)

$4,000 Deductible Copay Plan (PPOLO)

Network

In-Network

Annual Deductible Individual | Family Out-of-Pocket Max Individual | Family

$2,000 | $6,000

$4,000 | $8,000

$5,000 | $10,000

$5,000 | $14,700

$5,600 | $10,200

$5,000 | $10,000

Primary Care Specialty Care

$30 copay $60 copay

$40 copay $40 copay

0% after deductible

Preventive Care

No Charge

Diagnostic Lab and X-ray

No Charge

0% after deductible

Complex Radiology

20% after deductible

30% after deductible

0% after deductible

$65 copay plus 30% after deductible

Urgent Care

$75 copay

0% after deductible

20% after $500 copay

$100 copay

Emergency Room

0% after deductible

Hospital Inpatient & Outpatient

20% after deductible

30% after deductible

0% after deductible

Retail (30 day) / Mail Order (90 day)

Prescriptions

$10 / $30 Copay

$20 / $60 Copay

Generic Drug

$50 / $150 Copay

$40 / $120 Copay

Preferred Brand

0% after deductible

$100 / $300 Copay

$60 / $180 Copay

Non-Preferred

$150 Copay / NA

$80 Copay / NA

Specialty Drug**

*Enrollment in the HDHP Plan makes you eligible to open a Health Savings Account (HSA). **Specialty Drugs are available for 30-day supply ONLY

Go to hcpdirectory.cigna.com to find in-network providers in your area.

2025 Employee Benefit Guide

Tacodeli

Health Savings Account (HSA) Benefits for 2025

For 2025 Tacodeli is offering a Health Savings Account (HSA). This is how an HSA works:

By enrolling in the HDHP medical plan, you could be eligible to save money on a pre-tax basis by contributing to a Health Savings account through Wex to pay for future medical expenses.

2025 IRS Maximum Contribution Limits for HSA

Employee Only Enrollment

$4,300

Family Enrollment

$8,550

Employees age 55 and up

$1,000 additional contribution

Why is it a good idea to have an HSA? HSAs benefit everyone who is eligible to have this account – single individuals, families, and soon-to-be retirees. You save money on taxes in three ways: • Tax-free deposits – The money you contribute to your HSA isn’t taxed (up to the IRS annual limit). • Tax-free earnings – Your interest and any investment earnings grow tax-free. • Tax-free withdrawals – The money used toward eligible health care expenses isn’t taxed – now or in the future. • Setting aside pre-tax dollars into your HSA means you pay fewer taxes and increase your take-home pay by your tax savings. You save money on eligible expenses that you are paying for out of your pocket. The amount you save depends on your tax bracket. For example, if you are in the 30 percent tax bracket, you can save $30 on every $100 spent on eligible health care expenses. HSA funds roll over from year to year and accumulate in your account. There is no “use -it-or-lose- it” rule with HSAs, and you decide how and when to use your HSA funds, which can be used for eligible expenses you have now, in the future, or during retirement. And when you have a certain balance in your HSA, investment opportunities are available.

Refer to your HSA documentation for more information.

2025 Employee Benefit Guide

Tacodeli

Key Terms to Remember

Plan Types

c ollege oF b usiness Managemen

Out-of-Pocket Maximum This is the total amount you can pay out of pocket each calendar year

POS – Combines aspects of a PPO and HMO to manage cost

t Account Marketing Banking Finance HMO – A network that requires you to select a Primary Care Physician (PCP) who coordinates your health care EPO/PPO – A network of doctors, hospitals and other health care providers

before the plan pays 100 percent of covered expenses for the rest of the

calendar year. Most expenses that meet provider network requirements

HDHP – A plan that has higher cost sharing (e.g. deductible), but

count toward the annual out-of-pocket maximum, including expenses

paid to the annual deductible*, copays and coinsurance.

typically also lower monthly premiums.

*Except for Grandfathered medical plans

Copays and Coinsurance These expenses are your share of cost paid for covered health care

c ollege oF a rts & s cience Humanities Annual Deductible The amount you have to pay each year before the plan starts paying a portion of medical expenses. All family members’ expenses that

services. Copays are a fixed dollar amount, and are usually due at the

Science Biology Social Science History

time you receive care. Coinsurance is your share of the allowed amount

count toward a health plan deductible accumulate together in the

charged for a service, and is generally billed to you after the health

aggregate; however, each person also has a limit on their own

insurance company reconciles the bill with the provider.

individual accumulated expenses (the amount varies by plan).

The Value of Preventive Care Wellness and Health Management

Understanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and immunizations. Through the plans offered by Tacodeli , all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived. Which Preventive Care Services Are Covered? The US Preventive Services Task Force maintains a regular list of recommended services that all Affordable Care Act (i.e. Health Care Reform) compliant insurance plans should cover at 100% for in-network providers. Below is a list of common services that are included in the plans offered this year:

▪

Routine Physical Exam

Routine Colorectal Cancer Screening

▪

Well Baby and Child Care

▪

Routine Prostate Test

▪

Well Woman Visits

▪

Routine Lab Procedures

▪

Immunizations

▪

Routine Mammograms

▪

Routine Bone Density Test

▪

Routine Pap Smear

▪

Routine Breast Exam

▪ Smoking Cessation Programs

▪

Routine Gynecological Exam Screening for Gestational Diabetes Obesity Screening and Counseling Routine Digital Rectal Exam

▪ Health Education/Counseling Services ▪ Health Counseling for STDs and HIV

▪

Testing for HPV and HIV

▪

▪ Screening and Counseling for Domestic Violence

▪

Routine Colonoscopy

2025 Employee Benefit Guide

Tacodeli

Supplemental Health Benefits Tacodeli offers optional supplemental health benefits through Cigna. These plans are not medical insurance and do not replace your medical coverage, but rather pay cash directly to you in addition to any benefits you receive from your health plan. The plans are designed to help

offset expenses associated with unexpected injuries, illnesses, and hospital stays, such as deductibles, copays, and lost income. Insurance policies available for purchase (through after-tax payroll deductions) include Accident Insurance, Hospital Care Insurance and Critical Illness Insurance. KNOW ABOUT YOUR CRITICAL ILLNESS INSURANCE This insurance pays a lump-sum cash benefit directly to you following the diagnosis of a covered critical illness or event, such as a heart attack, stroke or cancer. The benefit is yours to use however you want, including paying for healthcare expenses, mortgage, rent, or other bills. COVERAGE OPTIONS: You can choose from three cash benefit levels for yourself and a spouse: $10,000 $20,000 $30,000 Coverage is also available for children, not to exceed 50% of the employee’s benefit. Portability included – allowing you to take the policy with you if you end employment. WELLNESS BENEFIT Critical Illness Insurance includes an annual benefit of $50 for any covered person when they take a qualified health screening test. Over 40 different screenings qualify, including: • Cholesterol screening • Mammogram • Immunizations, e.g., Covid-19

Covered Illnesses or Events*

100% Benefit Invasive Cancer Heart Attack, Heart Failure, Stroke Major Organ Transplant End-stage Renal Failure ALS, Alzheimer’s Parkinson’s, MS Paralysis Child Conditions: Cerebral Palsy, Cystic Fibrosis, Muscular Dystrophy

25% Benefit: Coronary Artery Disease, Non-invasive Cancer, Aortic & Cerebral Aneurysm, COPD, Advanced Obesity, Crohn’s Disease, Severe Sepsis

$250 Benefit: Skin Cancer

*This is an abbreviated list. Please refer to the benefit plan summaries for details and rates on all policies.

Rates for critical illness are based on your age and the benefit level selected. See your enrollment platform for more information.

Tacodeli

Supplemental Health Benefits

KNOW ABOUT YOUR ACCIDENT INSURANCE This insurance pays benefits directly to you to help offset the out-of-pocket expenses associated with an unexpected injury requiring medical treatment, such as deductibles or copays. Benefit payments are based on a schedule of injuries and treatments. The benefit is yours to use however you want, including paying for healthcare expenses, mortgage, rent, or other bills. *OVER 80 INJURIES AND SERVICES COVERED Below is a short list of injuries and services that may qualify for a benefit payment: Ambulance services Burns & Lacerations (cuts) Concussions Emergency room and urgent care Fractures/dislocations Hospital admissions and stays Medical appliances (e.g., crutches, wheelchairs) Physical Therapy

EXAMPLE CLAIM: Jim crashed his bicycle and was taken to the emergency room for treatment. He was diagnosed with a torn ligament. He required surgery to repair his torn ligament, and he missed several days of work. Fortunately, Jim’s Gold Accident plan paid him $4,781.25 to help keep him afloat financially while he made a full recovery.

Injuries & Treatment

Silver Plan Benefits

Gold Plan Benefits

COVERAGE OPTIONS: Coverage is available to employees, spouses and dependent children.

Ambulance

$300

$400

Emergency Room

$150

$200

ORGANIZED & PERSONAL SPORTS BENEFIT The plan will pay benefits when you or covered family member are injured while participating in an organized sport or personal sporting activity for physical fitness. Enhances benefit payout by 25% WELLNESS BENEFIT Critical Illness Insurance includes an annual benefit of $50 for any covered person when they take a qualified health screening test. Over 40 different screenings qualify, including: • Cholesterol screening • Mammogram • Immunizations, e.g., Covid-19

Diagnostic MRI

$200

$300

Fractured Wrist

$400

$800

Surgical repair of ACL

$750

$1,000

Crutches

$100

$150

3 Follow Up Visits

$150

$225

Physical Therapy

$500

$750

Sports Injury Benefit

$637.50

$956.25

Total Benefit

$3,187.50 $4,781.25

*Please refer to the benefit plan summaries for a full schedule of benefits

Tacodeli

Supplemental Health Benefits

HOSPITAL CARE INSURANCE This insurance pays benefits directly to you to help offset the out-of-pocket expenses associated with an unexpected hospital stay, such as deductibles, copays or lost income. Benefits are paid based on inpatient hospital admissions and confinement. The benefit is yours to use however you want, including paying for healthcare expenses, mortgage, rent, or other bills.

COVERED EVENTS Benefits are included for: • Hospital Admissions • Hospital Stays • Intensive Care Unit Admissions

EXAMPLE CLAIM: Laura is admitted the hospital to give birth to her new baby. Her normal delivery kept her in the hospital for a total of three days. Fortunately, Laura’s Hospital Care plan paid her cash benefits to help cover her medical costs – benefits that allowed her to focus on her new baby rather than the financial impact of the hospitalization

• Intensive Care Unit Stays • Newborn Nursery Care

ADDITIONAL BENEFITS: No pre-existing condition exclusion Portability included – allowing you to take the policy with you if you end employment

COVERAGE OPTIONS: Coverage is available to employees, spouses and dependent children

Laura’s Hospital Stay

Silver Plan Benefits

Gold Plan Benefits

Hospital Admission

$1,000

$1,500

WELLNESS BENEFIT Critical Illness Insurance includes an annual benefit of $50 for any covered person when they take a qualified health screening test. Over 40 different screenings qualify, including: • Cholesterol screening • Mammogram • Immunizations, e.g., Covid-19

2 Additional Days of Confinement Newborn Nursery Care (3 days)

$300

$400

$300

Total Benefit

$1,600

$2,200

*Please refer to the benefit plan summaries for details on all policies.

Tacodeli

Supplemental Health Benefits

CIGNA CLAIMS ASSISTANCE If you’re enrolled in a Cigna medical plan, and also enroll in Accident Insurance, Critical Illness Insurance or Hospital Care Insurance, you will have access to Cigna’s claims assistance program. This service, included at no additional cost, is designed to help make sure you get the benefits for which you’re eligible – and get them easier. Here’s how Cigna’s claims assistance does the heavy lifting for you:

Example of how Cigna Claims Assistance works

Matt injured his wrist and knee playing softball, which required a trip to the ER, starting a medical claim

REVIEW: Cigna will review your eligible medical claims

Cigna identified the medical claim as a potential accident claim, and saw that Matt may be eligible for an Accident benefit claim

NOTIFY: If any of your medical claims appear to qualify for a benefit payment from your supplemental health plan, you will receive a letter notifying you of the potential claim and including filing instructions ASSIST: Cigna will provide support to answer questions and help the member through the claim process AUTO-PAY WELLNESS: Cigna will automatically send benefit payment to covered members who complete wellness exams covered under any Accident or Critical Illness plan

Cigna conducted outreach to Matt to notify him of the potential claim and provide instructions on how to submit the claim

Cigna assisted Matt through the claims process, helping ensure he received benefits to offset his medical expenses

Tacodeli

Dental Coverage Benefits for 2025

Summary of Coverage

Key Features

Low Plan

High Plan

Annual Deductible Individual | Family

$25 | $75

$50 | $150

Calendar Year Max

$750 per person

$1,000 per person

Preventive Care Benefits

No Charge

20% after deductible

Basic Services

20% after deductible

Major Services

Not Covered

50% after deductible

50% (adults and children up to age 19) $1,000 per member (adults and children up to age 19)

Orthodontia

Not Covered

Orthodontia Lifetime Max

Not Covered

Go to hcpdirectory.cigna.com to find in-network providers in your area. Both plans use the “Cigna Total Network”

2025 Employee Benefit Guide

Tacodeli

Vision Coverage Benefits for 2025

Summary of Coverage

Your vision plan is administered by MetLife utilizing the MetLife Vision PPO network . To find an in-network provider, visit www.metlife.com.

Vision Benefit

In-Network

Frequency

Once every 12 months Once every 12 months

Examination

$10 copay

Lenses

$10 copay

$115 allowance & 20% off balance

Once every 24 months

Frames

Contact Lens Exam

$60 Copay

Once every 12 months

Elective

$115 allowance

Medically Necessary

$10 Copay

2025 Employee Benefit Guide

Tacodeli

Benefits for 2025 Voluntary Life Insurance

Summary of Coverage

Plan Features

Lincoln Voluntary Life

Employee Minimum Benefit Amount

$25,000

Employee Maximum Benefit Amount

5x Base Annual Earnings, up to $500,000

Employee Guarantee Issue Amount

$150,000

75% of elected benefit amount Minimum: $10,000 Maximum: $250,000

Accelerated Death Benefit (for terminal illness)

50% of Employee’s Amount, up to $250,000

Spouse Life and AD&D

Spouse Guarantee Issue Amount

$30,000

The following shows how much benefits are reduced at certain ages: Age Band Benefit Reduction 65 35% 70 50%

2025 Employee Benefit Guide

Tacodeli

Benefits for 2025

Voluntary Disability Insurance

Summary of Coverage

Voluntary Short-Term Disability

Plan Features

Lincoln Voluntary

Employee Benefit Amount

60% of Weekly Earnings

Maximum Benefit Amount

$1,500 Weekly

Elimination Period (Injury and Sickness)

7 Days

Benefit Duration

Up to 11 Weeks

Voluntary Long-Term Disability

Plan Features

Lincoln Benefits

Employee Benefit Amount

60% of Monthly Earnings

Maximum Benefit Amount

$12,000 Monthly

Elimination Period (Injury and Sickness)

90 Days

Benefit Duration

SS Retirement Age

2025 Employee Benefit Guide

Tacodeli

Employee Assistance Program (EAP) Benefits for 2025

Unlimited 24/7 Assistance

Online Resources

In-Person Guidance

Some matters are best resolved by meeting with a professional in person. With EmployeeConnect , you and your family get:

EmployeeConnect offers a wide range of information and resources you can access on your own. Expert advice and support tools are just a click away when you visit GuidanceResources.com or download the GuidanceNowSM mobile app. You’ll find: • Articles and tutorials • Videos

You and your family can access the following services anytime: online, on the mobile app, or with a toll-free call: • Information and referrals on family matters, such as child and

In-person help for short-term issues (up to five sessions with a counselor per person, per issue, per year)

•

elder care, pet care, vacation planning, moving, car buying, college planning and more EmployeeConnect

EmployeeConnect SM To find out more: Visit GuidanceResources.com (username: LFGSupport , password: LFGSupport1) Download the GuidanceNow SM mobile app Call 888-628-4824

2025 Employee Benefit Guide

Tacodeli

Pet Insurance Benefits for 2025

Your pets are part of your family, and you’ll do anything to keep them happy and healthy. But with the cost of pet care on the rise, it isn’t always easy. That’s why we’re offering the Total Pet Plan, which makes pet care more affordable. Enroll in Total Pet and get the same high-quality products and services your pets are used to, just at a lower price!

$11.75/month for one pet

$18.50/month for a family plan

For more details and how to enroll, visit https://www.petbenefits.com/land/tacodeli

2025 Employee Benefit Guide

Tacodeli

Online Enrollment Overview Benefits for 2025

Eligibility

New hires are eligible for benefits on the first of the month following 60 days of full-time employment. To be eligible for Health & Welfare Benefits you must be a full-time employee working at least 30 hours per week. When eligible, you may enroll yourself and your eligible dependents prior to your effective date. All elections are in effect for the entire plan year until the next Open Enrollment or if you have a family status change.

How to Enroll

To enroll, go to your UKG employee page at: nw12.ultipro.com

If this your fist time logging into UKG?

Your username will be your PERSONAL EMAIL you entered during onboarding. Your default password is your birthdate in MMDDYYYY format until you log in and adjust it.

Once you log into your UKG account, go to Menu > Myself > Benefits > Open Enrollment.

2025 Employee Benefit Guide

Legal Notices Benefits for 2025

Tacodeli

Health Insurance Portability and Accountability Act of 1996 (HIPAA) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that addresses the privacy and security of certain individually identifiable health information, called protected health information (or PHI). You have certain rights with respect to your PHI, including a right to see or get a copy of your health and claims records and other health information maintained by a health plan or carrier. For a copy of the Notice of Privacy Practices, describing how your PHI may be used and disclosed and how you get access to the information, contact Human Resources. Women’s Health and Cancer Rights Act Enrollment Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Woman’s Health and Cance r Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: 1. All stages of reconstruction of the breast on which mastectomy was performed. 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses. 3. Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply.. If you would like more information on WHCRA benefits, call your plan administrator at . Newborns’ and Mothers’ Health Protection Act Disclosure 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 mother’s or newborn’s attending provider, after consul ting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Patient Protection Notice Your carrier generally may require the designation of a primary care provider. You have the right to designate any primary care provider who participates in your network and who is available to accept you or your family members. Until you make this designation, your carrier may designate one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the plan administrator. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from your carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in your network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the administrator.

2025 Employee Benefit Guide

Legal Notices Benefits for 2025

Tacodeli

HIPAA Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request en rollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or b ecome eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy. To request special enrollment or to obtain more information about the plan's special enrollment provisions, contact the plan administrator.

2025 Employee Benefit Guide

Legal Notices Benefits for 2025

Tacodeli

Premium Assistance Under Medicaid and t he Children’s Health Insurance Program (CH IP) 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 chi ldren aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individ ual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” o pportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272 ).

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

If you 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, 2022. Contact your State for more information on eligibility —

ALABAMA-Medicaid

CALIFORNIA-Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov

ALASKA-Medicaid

COLORADO-Health First Colorado (Colorado’s Medicaid Program)& Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center : 1-800-221-3943/State Relay711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health- plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-InProgram (HIBI): https://www.colorado.gov/pacific/hcpf/health- insurance-buy-program HIBI Customer Service: 1-855-692-6442

The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

ARKANSAS-Medicaid

FLORIDA-Medicaid

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplre covery.com/hipp/index.html Phone: 1-877-357-3268

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

2025 Employee Benefit Guide

Legal Notices Benefits for 2025

Tacodeli

GEORGIA-Medicaid

MAINE-Medicaid

GA HIPP Website: https://medicaid.georgia.gov/health- insurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party- liability/childrens-health-insurance-program-reauthorization- act- 2009-chipra Phone: (678) 564-1162, Press 2

Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711

Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms

Phone: -800-977-6740. TTY: Maine relay 711

INDIANA-Medicaid

MASSACHUSETTS-Medicaid and CHIP

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: (617) 886-8102

IOWA-Medicaid and CHIP (Hawki)

MINNESOTA-Medicaid

Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website:

Website: https://mn.gov/dhs/people-we-serve/children-and- families/health-care/health-care-programs/programs-and- services/other-insurance.jsp Phone: 1-800-657-3739

http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a- to-z/hipp HIPP Phone: 1-888-346-9562

KANSAS-Medicaid

MISSOURI-Medicaid

Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

KENTUCKY-Medicaid

MONTANA-Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov

KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718

Kentucky Medicaid Website: https://chfs.ky.gov

LOUISIANA-Medicaid

NEBRASKA-Medicaid

Website: dhh.louisiana.gov/index.cfm/subhome/1/n/331 or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618- 5488 (LaHIPP)

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

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NEVADA-Medicaid

SOUTH CAROLINA-Medicaid

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

NEW HAMPSHIRE-Medicaid

SOUTH DAKOTA-Medicaid

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345,ext 5218

Website: http://dss.sd.gov Phone: 1-888-828-0059

NEW JERSEY-Medicaid and CHIP

TEXAS-Medicaid

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

NEW YORK-Medicaid

UTAH-Medicaid and CHIP

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

NORTH CAROLINA-Medicaid

VERMONT-Medicaid

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

NORTH DAKOTA-Medicaid

VIRGINIA-Medicaid and CHIP

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

Website: https://www.coverva.org/en/famis-select https://www.coverva.org/en/hipp Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-800-432-5924

OKLAHOMA-Medicaid and CHIP

WASHINGTON-Medicaid

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

OREGON-Medicaid

WEST VIRGINIA-Medicaid and CHIP

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

PENNSYLVANIA-Medicaid

WISCONSIN-Medicaid and CHIP

Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP- Program.aspx Phone: 1-800-692-7462

Website: https://www.dhs.wisconsin.gov/badgercareplus/p- 10095.htm Phone: 1-800-362-3002

RHODE ISLAND-Medicaid and CHIP

WYOMING-Medicaid

Website: https://health.wyo.gov/healthcarefin/medicaid/programs- and-eligibility/ Phone: 1-800-251-1269

Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

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To see if any other states have added a premium assistance program since July 31, 2022, or for more information on special enrollment rights, contact either:

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

The public reporting burden for this collection of information is estimated to average approximately four minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210- 0123.g any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately four minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210- 0137.

OMB Control Number 1210-0137 (expires 1/31/2025)

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Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic Information Nondiscrimination Act of 2008

The Genetic Information Nondiscrimination Act of 2008 (“GINA”) protects employees against discrimination based on their genetic information. Unless otherwise permitted, your Employer may not request or require any genetic information from you or your family members. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

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USERRA Notice Your Rights Under USERRA A. The Uniformed Services Employment and Reemployment Rights Act

USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. B. Reemployment Rights You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and: • You ensure that your employer receives advance written or verbal notice of your service; • You have five years or less of cumulative service in the uniformed services while with that particular employer; • You return to work or apply for reemployment in a timely manner after conclusion of service; and • You have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been absent due to military service or, in some cases, a comparable job. C. Right to Be Free from Discrimination and Retaliation If you: • Are a past or present member of the uniformed service; • Have applied for membership in the uniformed service; or • Are obligated to serve in the uniformed service; then an employer may not deny you o Initial employment; o Reemployment; o Retention in employment; o Promotion; or o Any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection. If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. • Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer's health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre-existing condition exclusions) except for service-connected illnesses or injuries. D. Health Insurance Protection •

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E. Enforcement •

The U.S. Department of Labor, Veterans' Employment and Training Service (VETS) is authorized to investigate and resolve complaints of USERRA violations. For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-DOL or visit its Web site at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm. • If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for representation. • You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA. The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the Internet at this address: http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and Training Service, 1-866-487-2365.

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Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans)

** Continuation Coverage Rights Under COBRA**

Introduction

You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has

important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under

the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and

what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for

other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation

Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family

when group health coverage would otherwise end. For more information about your rights and obligations under the Plan

and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to

buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you

may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-

day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if tha t

plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This

is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA

continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your

dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the

following qualifying events:

• Your hours of employment are reduced, or

• Your employment ends for any reason other than your gross misconduct.

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