Zoe Pediatrics - 2024 Benefits Guide

E MPLOYEE BENEFITS GUIDE 2024 - 2025 PLAN YEAR

WELCOME TO YOUR BENEFIT ENROLLMENT GUIDE 2024 PLAN YEAR

Please note: This benefit guide contains the basic information about your benefits program. It does not cover every detail; but it does provide a general description of each benefit plan. Every effort has been made to ensure that the information is accurate. However, this guide is not an insurance policy. If there is any question as to coverage, benefit eligibility, or interpretation, the insurance contract and the Certificate of Coverage you receive from the insurance carrier will govern the administration of your benefits. If you would like additional or specific information, please contact the Human Resources Department. Zoe Pediatrics is proud to offer you a comprehensive benefits package for the upcoming plan year. This enrollment guide will assist you in determining the coverage levels that will provide you and your family with the protection that gives you peace of mind. This guide explains each type of coverage, and provides examples to help you determine your benefit and payroll deduction amounts. We encourage you to take the time to review the enrollment guide prior to enrollment. Keep in mind that you have until Monday, July 22 nd , to select your benefits. The benefits you select during this enrollment will be effective August 1 st , 2024 and will continue through July 31 st 2025.

ADDITIONAL INFORMATION

ELIGIBILITY: As a Zoe Pediatrics employee, you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the benefits package following 90 days of employment.

WHO IS AN ELIGIBLE DEPENDENT? You can enroll the following dependents in our group benefit plans: • Your legal spouse • Your natural, adopted, or stepchildren living with you, or any other children whom you have legal guardianship, up to age 26 • Unmarried children of any age if disabled and claimed as a dependent on your federal income taxes

WHEN YOU CAN ENROLL IN BENEFITS:

• During your initial new hire eligibility period • During the annual Open Enrollment period for a August 1st effective date

If you fail to enroll within the time frame given for the new hire eligibility or annual enrollment window, you will not be able to elect benefits again until the next Open Enrollment period, and you will not have coverage, unless you experience a qualified life event. Please make your elections on time, or you may experience a delay in using your benefits.

QUALIFYING LIFE 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. Qualifying Life events include: • Marriage, divorce, or legal separation • Death of spouse or other dependent • Birth or adoption of a child • You or your spouse experience a work event that effects your benefits • A dependent’s eligibility status changes due to age, student status, marital status, or employment • Relocation into or outside of your plan’s service area 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.

HOW TO ENROLL

Step 1: Creating your Employee Navigator Account

Welcome Email:

• You will receive a Welcome email from Employee Navigator • Click on the “Registration Link” in the email • Create an account with username and password of your choice

• Go to https://www.employeenavigator.com/benefits/Account/Register • Enter [First Name], then [Last Name] • Enter your Company Identifier [Zoes] • PIN: Last four of your SSN • Enter your birthdate: MM/DD/YYY • Click “Next” to continue • When prompted, your username will be as follows: [First Name].[Last Name] Option 2:

Step 2: Complete HR Tasks

• Once your account is set up, you will be taken to your employee homepage.

• On the homepage, click the “Complete HR Tasks” to begin your new hire tasks first.

• The first few tasks require you to put in demographic information and e-sign for online acknowledgment.

T I P If you hit “Dismiss, complete later” you’ll be taken to your Home Page. You’ll still be able to start enrollments again by clicking “Start Enrollments”

Step 3: Benefit Elections

• To enroll dependents in a benefit, click the checkbox next to the dependent’s name under “Who am I enrolling?” If you do not click on their name(s), they will not get the insurance. • Below your dependents you can view your available plans and the cost per pay period. To elect a benefit, click Select Plan underneath the plan cost.

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Step 4: Forms

• If you have elected benefits that require a beneficiary designation, Primary Care Physician or completion of an Evidence of Insurability form, you will be prompted or required to complete.

Step 5: Review & Confirm Elections

• Review the benefits you selected on the enrollment summary page to make sure they are correct then click “Sign & Agree” to complete your enrollment. Print a summary of your elections for your records.

T I P If you miss a step you’ll see Enrollment Not Complete in the progress bar with the incomplete steps highlighted. Click on any incomplete steps in the drop down bar to complete them. ALL STEPS MUST BE COMPLETED! Step 6: HR Tasks (if applicable) • To complete any required HR tasks, click “Start Tasks”. If your HR department has not assigned any tasks, you’re finished!

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MEDICAL COVERAGE

Zoe Pediatrics offers the following medical plans.

Insurance Carrier:

Imagine360 Medical Insurance

Plan Type:

Base Plan

Buy-Up Plan

Primary Care Visits

100%

Specialist Care Visits

$60 Copay

Urgent Care

100% after $75 Copay

Emergency Room Care

80%; Deductible applies

90%; Deductible applies

Preventative Visit Copay

100%; Deductible waived

Diagnostic Testing (X-Ray / Blood Work)

80%; Deductible applies

90%; Deductible applies

Advanced Imaging

80%; Deductible applies

90%; Deductible applies

Plan Coinsurance

80%

90%

Employee Deductible

$3,000

$1,500

Family Deductible

$9,000

$4,500

Employee Out-of-Pocket Max

$7,900 (includes deductible & copays)

$4,500 (includes deductible & copays)

Family Out-of-Pocket Max

$15,800 (includes deductible & copays)

$9,000 (includes deductible & copays)

Inpatient Hospital

80%; Deductible applies

90%; Deductible applies

Outpatient Hospital or Facility

80%; Deductible applies

90%; Deductible applies

Prescription Drugs 30-day supply

VeracityRx Select Pharmacies

VeracityRx Non-Select Pharmacies

Tier 1 - Generic

$15 Copay

$30 Copay

Tier 2 - Preferred

$35 Copay

$50 Copay

Tier 3 - Non-Preferred

$60 Copay

$75 Copay

Tier 4 - Specialty

Excluded; Refer to VeracityRx Program for Specialty Access

Employee Bi-Weekly Deduction Employee Only

$0.00

$25.89

Employee + Spouse

$254.50

$310.17

Employee + Child(ren)

$172.62

$218.71

Family

$427.12

$502.99

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3 Your Pharmacy Plan

Heads up! We’re making some changes to our pharmacy benefits. As of August 1, 2024 , important changes will be made to your prescription benefit plan. This includes changes to your plan’s pharmacy network, as well as new choices for how and where you can fill your prescriptions. NEW Pharmacy Benefits Partner VeracityRx will oversee and manage your pharmacy benefits. As your new benefits partner, VeracityRx will handle all claims and customer service functions including Specialty and Personal Importation pharmacy fulfillment. Where You Can Fill Prescriptions Your plan uses a select/non-select pharmacy network, so most pharmacies can fill your prescription(s).* If you choose to go to a Non-Select pharmacy, you will have a higher copay. Non-select pharmacies are CVS, Target, Walgreens, and Rite- Aid. How to Connect • You can reach VeracityRx 24 hours a day, 7 days a week – they’re always available to take your call, even on holidays. • Locate a network pharmacy

• Understand your pharmacy benefit • Get prior authorization information

• Call 888-388-8228 Member Portal Access and Benefits Management • Register for your member portal access on or after August 1, 2024, and after you receive your ID card. o Register at: https://veracity.procarerx.com  Note: To access the secured portal listed above, the full web address must include https://

• Use your online account to:

o Access and/or restrict profile viewing by other family members o Review your prescription claims history or individual prescriptions o Look up a drug to identify formulary status and preferred alternatives o Locate pharmacies within a zip code, state, city, or county

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3 Prescription Coverage Overview

VeracityRx ____________________ ___________________________________________________________________ Here’s a few ways our Pharmacy program strives to save members money. Go Generic and Save • When you choose the generic prescription versus the brand name Rx, you can save on your member cost/copay. For example, if your physician prescribes the name brand “Norvasc” to manage your blood pressure, choose the generic form amlodipine and save yourself and the plan money. Avoid High-Cost Pharmacies • Effective August 1, 2024, the following pharmacies are considered Non-Select : CVS, Target, Walgreens, and Rite- Aid. Please note that Non-Select pharmacies have a higher copay. o Select Pharmacies: All independent pharmacies and grocery stores are considered select.

Get your 90-day prescription filled right at your favorite select pharmacy • You can elect to get a 90-day fill using your local select pharmacy. Please note that a 90-day fill is not available at non-select pharmacies.

Specialty Pharmacy Services • Specialty Medications

o For more information on specialty drugs, please go to www.veracity-rx.com and complete the “Enrollment Form” . Once completed, a VeracityRx Specialty team member will be in touch. See page 3 for additional details and a list of commonly prescribed Specialty Medications. • Personal Importation Medications o Medications that can be obtained internationally (from Canada) can also be acquired through VeracityRx Pharmacy Services. When the medications are obtained this way, the cost to you is $0 Copay . If you choose not to participate, you will be responsible for 50% of the cost of the medication at your local pharmacy. See page 4 for additional details and a list of commonly prescribed Personal Importation Medications.

Note: Some drugs require a pre-authorization. Even if you have obtained a pre-authorization with the current plan, you may have to obtain an updated one for the new plan.

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3 Specialty Medications

Specialty Medications________________________________________________________________________________

Specialty Medications are EXCLUDED from the plan. A Pharmacy Specialist, who is a registered pharmacist, will work with you as your advocate. Their team works closely with you (and/or covered family members who are taking a specialty medication) and with the specialty medication manufacturer and the prescriber to ensure continuity of care. A member of the pharmacy specialty team will assist in the process to help you obtain your medication(s). As your pharmacy specialist and patient advocate, they are here to assist on your behalf. If you or your covered dependent are currently taking a medication affected by these changes, please enroll at www.veracity-rx.com. Following your enrollment, a member of the team will contact you.

For more information, log onto the website below to complete the “Enrollment Form”.

VeracityRx Pharmacy Contact Information: Enroll at: www.veracity-rx.com

*List is only a sample of the top specialty drugs and is subject to change without notice. Additional specialty drugs can be pursued beyond this list.

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3 Personal Importation Medications

Personal Importation Medications______________________________________________________________________ Note: The personal importation medications process differs slightly from the specialty

Enrollment Process:

Step 1:

Please check the list below of commonly prescribed medications that can be sourced internationally (from Canada).

Step 2:

If you or a covered member of your household are on any of the drugs listed, please start by going to www.veracity-rx.com and completing the “Enrollment Form”.

Step 3:

Be on the lookout for an email from a VeracityRx Personal Importation Team member with next steps.

Step 4:

Contact your healthcare provider to have a new prescription sent into our pharmacy partner. *Instructions will be included in email on how to send in new prescription.

Commonly Prescribed Personal Importation Medications

Drug

Anoro Ellipta

Isentress Janumet

Skyrizi

Apidra

Spiriva Respimat

Apidra Solostar Arnuity Ellipta

Janumet XR

Tagrisso Tivicay

Januvia

Atripla

Jardiance

Toujeo Solostar

Basaglar Kwikpen

Juluca

Tradjenta

Biktarvy

Omnaris Orencia Ozempic Prezcobix Pulmozyne

Trelegy Ellipta

Breo Ellipta

Trintellix Trulicity Victoza Xarelto Xeljanz

Cimzia

Combivent Respimat

Dulera Eliquis

Qvar

Entresto Farxiga

Rexulti Rinvoq Silenor

Fiasp

Invokamet

*List is only a sample of the top personal importation drugs and is subject to change without notice. Additional personal importation drugs can be pursued beyond this list.

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3 Member Quick Reference Guide

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Save Money on Prescriptions

YOUR TRUSTED RESOURCE FOR IMPORTANT PRESCRIPTION ANSWERS

VeracityRx is excited to provide The VeracityRx App , your virtual pharmacist. The VeracityRx App helps you save money on prescriptions and make life easier!

Download The VeracityRx App to: • View medications and real-time pricing anytime • Switch medications and pharmacies with one-click • Receive saving alerts • And more!

To Get Started: • Download VeracityRx • Have your ID card handy • Check your phone to activate your account

Need help using the app? Call 866-330-9414 or email veracityrx@levrx.com

Disclaimer: The VeracityRx App is Powered by Levrx Technology, Inc. This is not a statement or a guarantee of savings. Outcomes are dependent several factors.

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DENTAL BENEFITS

Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower.

Keeping your teeth and gums clean and healthy will prevent most tooth decay and periodontal disease, and is an important part of maintaining your medical health.

Your dental plan is through MetLife and offers “in and out-of-network” benefits.

Insurance Carrier:

MetLife Dental Insurance

Plan Type:

Basic Plan

Buy - Up Plan

Calendar Year Deductible

$50 Individual / $150 Family

Calendar Year Maximum

$1,250

$2,250

Preventive Services

100%

Basic Services

80%

90%

Major Services

50%

60%

Orthodontic (dependent children only)

Up to 50%

Out-of-Network Reimbursement

$1,000

$2,000

Employee Bi-Weekly Deduction

Employee Only

$13.77

$18.20

Employee + Spouse

$25.74

$34.44

Employee + Child(ren)

$31.36

$40.20

Family

$46.59

$60.54

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VISION BENEFITS

You can help protect your eyesight by visiting an eye doctor regularly. Taking care of your eyes today can lead to a better quality of life later.

The vision plan covers routine eye exams and also pays for all or a portion of the cost of glasses or contact lenses if you need them.

Your vision plan is through MetLife and offers “in and out-of-network” benefits.

Insurance Carrier:

MetLife Vision Insurance

In-Network You pay:

Out-of-Network You are reimbursed:

Eye Exam every 12 months

$10 Copay

Up to $45

Lenses every 12 months • Single Vision

$25 Copay $25 Copay $25 Copay $25 Copay

Up to $30 Up to $50 Up to $65 Up to $100

• Bifocal • Trifocal • Lenticular

Frames every 24 months

$150 Allowance

$70 Allowance

$150 Allowance Medically Necessary: Covered

$105 Allowance Medically Necessary: Up to $210

Contacts every 12 months

Employee Bi-Weekly Deduction

Employee Only

$3.06 $6.11 $7.19

Employee + Spouse Employee + Child(ren)

Family

$11.02

*Contacts benefit is in lieu of eyeglass frames and lens benefit.

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VOLUNTARY TERM LIFE INSURANCE COVERAGE

As a supplemental benefit, Zoe Pediatrics allows eligible employees to purchase additional life insurance coverage for yourself and your dependents. This coverage is paid for by you and is offered through MetLife. Rates for the voluntary term life insurance are based on age, and volume, and benefits are subject to applicable age reductions.

Insurance Carrier:

MetLife Voluntary Life Insurance

Schedule of Benefits Eligibility Requirement

All Full Time Eligible Employees

Accidental Death & Dismemberment Benefit (AD&D)

Same as Voluntary Life Amount

Employee

5x Annual Earnings up to $500k in increments of $10k

Spouse

50% of Employee Election up to $100k in increments of $5k

Child(ren)

50% of Employee Election up to $10k in increments of $2k

Guarantee Issue Amounts Employee

$100k

Spouse

$25k

Child(ren)

$10k

Portable

Yes

Waiver of Premium

Included

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DISABILITY INSURANCE

The goal of Zoe Pediatrics’s 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 employees with the option to purchase voluntary “Short-Term and Long-Term Disability” income benefits. Both the Short-Term and Long-Term Disability coverages are offered through MetLife. Rates will be automatically calculated and shown in Employee Navigator during the enrollment process.

Insurance Carrier:

MetLife Short-Term Disability Insurance

Plan Type:

Voluntary

Eligibility Requirement

All Full Time Employees

Benefit Percentage

60%

Maximum Weekly Benefit Elimination Period - Accident Elimination Period - Sickness

$1,500 7 Days 7 Days

Pre-Existing Condition

3/12

Benefit Duration

12 Weeks

Insurance Carrier:

MetLife Long-Term Disability Insurance

Plan Type:

Voluntary

Eligibility Requirement Benefit Percentage Maximum Monthly Benefit

All Full Time Employees

60%

$5,000 90 Days 2 Years

Elimination Period

Own Occupation Definition Partial Disability Benefit

Better of 50% offset and proportionate loss formulas

Mental Disorders Drug & Alcohol Benefit Duration

24 Months per occurrence 24 Months per occurrence

RBD W/SSNRA

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AFLAC PRODUCTS

Aflac pays cash benefits directly to you in the event of a claim to help with out-of-pocket expenses. The following policies are currently available through payroll deduction.

Aflac pays cash benefits directly to you in the event of a claim to help with out-of-pocket expenses. The following policies are currently available through payroll deduction. Accident: • 24-hour coverage on and off-the-job for Accidental Injury • Emergency Treatment benefits • Hospital Confinement • Accidental-Death and Dismemberment coverage • Wellness Benefit

Cancer: • Pays benefits for the diagnosis/treatment of cancer • Initial Diagnosis Benefit • Radiation/Chemotherapy • Hospital Confinement • Travel/Transportation and Lodging

Hospital Indemnity: •

Hospital Confinement Emergency Room benefits

• •

Hospital Short-Stay

• Optional riders for additional benefits such as physician’s visits and surgery

Critical Care Protection: • Covers specified Health Events such as Heart Attack, Stroke, Coma, Cardiac Arrest • First-Occurrence benefits • Intensive Care • Hospital Confinement

For more information regarding these benefits, please contact your Aflac representative: Lisa McDaniel 706-332-8319 lisa_mcdaniel@us.aflac.com

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M ember C laims A dvocate

Employee Benefit Assistants You Can Count on

Zoe Pediatrics provides you and your family members a complimentary member claims service to help with claims, billing, missing ID cards and more.

give member claims advocate a call if :

• You received a provider bill or EOB and feel the claim was processed incorrectly • You are at the doctor or pharmacy and having trouble with your coverage • You need to confirm if a provider is In-Network • You are missing your ID card

Y ou can reach the M ember C laims A dvocate team by phone or email :

Monday through Friday, 8:30 AM EST - 5:00 PM EST

Charlie McDaniel - cmcdaniel@yatesins.com Resa Carter - rcarter@yatesins.com (706) 323-1600

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 phar- macy 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? Imagine360 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 Imagine360’s contracted rate for your medical care and services rendered. The contracted rate includes both Imagine360’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, Imagine360’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 Imagine360. 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. Imagine360 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.

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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LEGAL NOTICES

Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www. healthcare.gov. 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 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” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). 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 January 31, 2022. Contact your State for more information on eligibility –

ALABAMA - Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA - Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: Customer Service@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default. aspx ARKANSAS - Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) COLORADO - Medicaid Website: http://www.colorado.gov/hcpf Customer Contact Center: 1-800-221-3943 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY - Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUSIANA - Medicaid Website: http://dhh.louisiana.gov/index.cfm/ subhome/l/n/331 Phone: 1-888-695-2447

FLORIDA - Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA - Medicaid Website: http://dch.georgia.gov/medicaid - click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA - Medicaid Healthy Indiana Plan for Low-Income Adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 IOWA - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 MAINE - Medicaid Website: http://maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 1-800-442-6003 TTY: Maine relay 711

MASSACHUSETTS - Medicaid and CHIP Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120 MINNESOTA - Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739

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LEGAL NOTICES

MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 1-800-692-7462 RHODE ISLAND - Medicaid Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300 SOUTH CAROLINA - Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid

Phone: 573-751-2005 MONTANA - Medicaid Website: http://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084 NEBRASKA - Medicaid

Website: http://www.dhhs.ne.gov/Children_Family_ Services/AccessNebraska/Pages/accessnebraska_ index.aspx Phone: 1-855-632-7633 NEVADA - Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 NEW HAMPSHIRE - Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY - Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/cli- ents/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK - Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA - Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA - Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 OKLAHOMA - Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON - Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA - Medicaid Website: http://www.dhs.pa.gov/hipp

Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 UTAH - Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid CHIP Website: http://health.utah.gov/chip

Phone: 1-877-543-7669 VERMONT - Medicaid Website: http://www.greenmountaincare.org Phone: 1-800-250-8427 VIRGINIA - Medicaid and CHIP Medicaid & CHIP Website: http://www.coverva.org/programs_premi- um_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 WASHINGTON - Medicaid Website: http://www.hca.wa.gov/free-or-low-costhealth-care/pro- gram-administration/premiumpayment- program Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA - Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/ default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN - Medicaid and CHIP Website: http://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

Phone: 1-800-362-3002 WYOMING - Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

To see if any more States have added a premium assistance program since January 31, 2022, or for more information on special enrollment rights, you can contact either:

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/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

21 Zoe Pediatrics 2024 Benefits Guide |

LEGAL NOTICES

Important Notices about Medical Coverage HIPPA Special Enrollment Rights 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 or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment 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 result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 30 days after the marriage, birth, adoption, or placement for adoption. Effective April 1, 2009 special enrollment rights also exist in the following circumstances: • If you or your dependents experience a loss of eligibility for Medicaid or your State Children’s Health Insurance Program (SCHIP) coverage; or • If you or your dependents become eligible for premium assistance under an optional state of Medicaid or SCHIP program that would pay the employee’s portion of the health insurance premium. NOTE: In the two above listed circumstances only, you or your dependents will have sixty (60) days to request special enrollment in the group health plan coverage. An individual must request this special enrollment within sixty (60) days of the loss of coverage described at bullet one, and within sixty (60) days of when eligibility is determined as described in bullet two. Women’s Health and Cancer Rights Act of 1998 Annual Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer 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 all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of

physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under this plan. Our plan complies with these requirements. Benefits for these items generally are compatible to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information on WHCRA benefits, call Yates LLC at (706) 323-1600. Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, not withstanding 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 seven 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, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

22 | Zoe Pediatrics 2024 Benefits Guide

MEDICARE PART D

Medicare Part D Notice of Creditable Coverage Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Zoe Pediatrics and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your currant coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Zoe Pediatrics has determined that the prescription drug coverage offered by Imagine360 plans are on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Zoe Pediatrics coverage may or may not be affected. See pages 7-9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance (available at https://www.cms.hhs.gov/Creditable Coverage/ ), which outlines the prescription drug plan provisions / options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Zoe Pediatrics coverage, be aware that you and your dependents may or may not be able to get this coverage back.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Zoe Pediatrics and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without a creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For further information, call Yates LLC at (706) 323-1600. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Zoe Pediatrics changes. You may also request a copy of this notice at any time. More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Medicare Part D Notice of Creditable Coverage, cont. Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity. gov , or call them at 1-800-772- 1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium.

23 Zoe Pediatrics 2024 Benefits Guide |

COBRA

What is COBRA continuation health coverage? The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions amend the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act to require group health plans to provide a temporary continuation of group health coverage that otherwise might be terminated. What does COBRA do? COBRA requires continuation coverage to be offered to covered employees, their spouses, former spouses, and dependent children when group health coverage would otherwise be lost due to certain specific events. COBRA continuation coverage is often more expensive than the amount that active employees are required to pay for group health coverage, since the employer usually pays part of the cost of employees’ coverage and all of that cost can be charged to individuals receiving continuation coverage. What group health plans are subject to COBRA? The law generally applies to all group health plans maintained by private-sector employers with 20 or more employees, or by state or local governments. The law does not apply to plans sponsored by the Federal Government or by churches and certain church-related organizations. In addition, many states have laws similar to COBRA, including those that apply to health insurers of employers with less than 20 employees (sometimes called mini-COBRA). Check with your state insurance commissioner’s office to see if such coverage is available to you. Who is entitled to continuation coverage under COBRA? In order to be entitled to elect COBRA continuation coverage, your group health plan must be covered by COBRA; a qualifying event must occur; and you must be a qualified beneficiary for that event. Plan Coverage COBRA covers group health plans sponsored by an employer (private-sector or state/local government) that employed at least 20 employees on more than 50 percent of its typical business days in the previous calendar year. Both full-and part-time employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of a full-time employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full time. Qualified Beneficiaries A qualified beneficiary is an individual covered by a group health plan on the day before a qualifying event occurred that caused him or her to lose coverage. Only certain individuals can become qualified beneficiaries due to a qualifying event, and the type of qualifying event determines who can become a qualified beneficiary when it happens. A qualified beneficiary

must be a covered employee, the employee’s spouse or former spouse, or the employee’s dependent child. In certain cases involving the bankruptcy of the employer sponsoring the plan, a retired employee, the retired employee’s spouse or former spouse, and the retired employee’s dependent children may be qualified beneficiaries. In addition, any child born to or placed for adoption with a covered employee during a period of continuation coverage is automatically considered a qualified beneficiary. An employer’s agents, independent contractors, and directors who participate in the group health plan may also be qualified beneficiaries. Are there alternatives for health coverage other than COBRA? If you become entitled to elect COBRA continuation coverage when you otherwise would lose group health coverage under a group health plan, you should consider all options you may have to get other health coverage before you make your decision. There may be more affordable or more generous coverage options for you and your family through other group health plan coverage (such as a spouse’s plan), the Health Insurance Marketplace, or Medicaid. If you become entitled to elect COBRA continuation coverage when you otherwise would lose group health coverage under a group health plan, you should consider all options you may have to get other health coverage before you make your decision. There may be more affordable or more generous coverage options for you and your family through other group health plan coverage (such as a spouse’s plan), the Health Insurance Marketplace, or Medicaid. Under the Health Insurance Portability and Accountability Act (HIPAA), if you or your dependents are losing eligibility for group health coverage, including eligibility for continuation coverage, you may have a right to special enroll (enroll without waiting until the next open season for enrollment) in other group health coverage. For example, an employee losing eligibility for group health coverage may be able to special enroll in a spouse’s plan. A dependent losing eligibility for group health coverage may be able to enroll in a different parent’s group health plan. To have a special enrollment opportunity, you or your dependent must have had other health coverage when you previously declined coverage in the plan in which you now want to enroll. You must request special enrollment within 30 days from the loss of your job-based coverage. Losing your job-based coverage is also a special enrollment event in the Health Insurance Marketplace (Marketplace). The Marketplace offers “one-stop shopping” to find and compare private health insurance options. In the Marketplace, you could be eligible for a tax credit that lowers your monthly premiums and cost-sharing reductions (amounts that lower your out-of- pocket costs for deductibles, coinsurance and co-payments), and you can see what your premium, deductibles, and out-of- pocket costs will be before you make a decision to enroll.

24 | Zoe Pediatrics 2024 Benefits Guide

EXCHANGE NOTICES

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No. 1210-0149 (expires 6-30-2023)

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact . The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by

the plan is no less than 60 percent of such costs.

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