Group Indemnity Medical Insurance Supplements existing medical coverage with cash benefits to help you pay for out-of-pocket expenses.Group Indemnity Medical coverage from Allstate Benefits provides cash benefits for hospitalization or intensive care confinement, surgery or emergency treatment and can help cover them as they happen.

ABJ28944X Page 1 of 12

Benefit coverage for

Manna Development Group, LLC

These plans do not meet minimum creditable coverage.

What if you or a family

member were hospitalized tomorrow...

could you pay for out-of-pocket expenses associated with a hospital stay, plus cover daily living expenses?

GROCERIES BILLSCAR PRESCRIPTIONS

Page 2 of 12 ABJ28944X

meeting your needsIndemnity medical coverage • Coverage is guaranteed issue; there are no medical exams or tests to take

• Affordable premiums

• Benefits paid directly to you, unless you assign them to someone else

• Benefits include hospitalization due to Pregnancy

• Portability. If you leave your job, you can take the coverage with you as long as you make payments to Allstate Benefits

Indemnity medical+ coverage • PPO Network***

• Base benefits increase by 5% after the first coverage year and each coverage year thereafter, for the next 5 years

***The Preferred Provider Organization (PPO) Network, MultiPlan, provides unsurpassed value, combining nationwide access, deep discounts on covered services, and exceptional service. The network includes over 535,000 individual practitioners and over 87,000 facility locations, including more than 4,800 acute care hospitals.

Visit www.multiplan.com/allstate for more information.

indemnity medical benefit coverage* First Day Hospital Confinement* - Pays a benefit for the first day of a hospital stay. Payable once for each continuous confinement, up to once per year. Not paid for a newborn child’s initial confinement after birth.

†This coverage is not available to residents of the state of Massachusetts.*You must enroll in the GIM plan to be eligible for the benefit.

‡Group Indemnity Medical is the GIM2 plan. Group Indemnity Medical+ is the GIM plan.Please see page 8 for your plan details. See page 9 for limits and conditions and state variations.

group indemnity medical* and indemnity medical +†‡

Expenses associated with a hospital stay can be financially difficult if money is tight and you are not prepared. But having the right coverage in place to help when a sickness or injury occurs can help eliminate your financial concerns and provide support at a time when it is needed most. Group Indemnity Medical can help, by offering coverage for First Day Hosptial Confinements.

Below is an example of how benefits are paid in the event you or a covered family member are hospitalized.**

**The example shown may vary from the plan your employer is offering. Your individual experience may also vary.

Jane’s coverage provided the following benefits:

Jane chooses indemnity medical coverage under her Employer Approved Plan

Three years later, Jane’s on a summer cycling vacation when she falls and suffers bruising and swelling of her head.

Jane is taken by ambulance to the nearest hospital emergency room where she is admitted for trauma to her head.

Total Benefits: $1,000

Bike Path

Hospital

1 Normal pregnancy or complications from pregnancy, newborn child’s hospitalization after birth, and transfers to another hospital for additional care before being discharged are not covered.2 Routine nursing or well-baby care of newborn children are not covered.

indemnity medical + benefit coverage†‡

HOSPITALIZATION BENEFITS Initial Hospitalization Confinement1 - Pays a benefit for the first hospital confinement during the year, when a benefit is paid under Daily Hospital Confinement. Payable once each year per person.

Daily Hospital Confinement2 - Pays a daily benefit for a hospital stay. Max. of 180 days each continuous confinement.

Hospital Intensive Care - Pays a daily benefit for an intensive-care unit stay and in addition to the Daily Hospital Confinement. Max. of 60 days each continuous confinement.

SURGERY AND RELATED BENEFITSSurgery - Pays a benefit for covered surgery. Amount paid depends on surgery.

Anesthesia - Pays 25% of surgical benefit for anesthesia received during a covered surgery.

Inpatient Physician’s Treatment - Pays a daily benefit for physician services if hospital confined.

ABJ28944X Page 3 of 12

In Hospital John is in an automobile accident and is rushed to the emergency room by ambulance. John is admitted and undergoes surgery with anesthesia, plus a doctor visits him during a 2-day hospital stay.

Out of Hospital Two weeks later John schedules an appointment with his doctor for a follow-up exam. John’s doctor suggests he obtain treatment during his recovery that is not available locally.

John chooses the Group Indemnity Medical+

coverage offered by his

Employer*

**The example shown may vary from the plan your employer is offering. Your individual experience may also vary.

Our Group Indemnity Medical+ insurance policy provided you with the following benefits:Outpatient Emergency Accident $ 1,000Initial Hospital Confinement $ 1,000Daily Hospital Confinement $ 400Surgery $ 1,000Anesthesia $ 250Inpatient Physician Treatment $ 100Outpatient Physician Treatment $ 100Non-Local Transportation $ 600

TOTAL $4,450

OUTPATIENT, NURSING AND TRANSPORTATION BENEFITS Outpatient Emergency Accident - Pays a benefit for treatment in an emergency treatment center if injured. Payable 2 times each year per person.

Outpatient Physician’s Treatment - Pays a benefit for physician treatment outside a hospital. Max. of 5 visits each year for Employee, 10 visits for Employee and Spouse or Employee and Children, and 15 visits for Family coverage.

At Home Nursing - Pays a daily benefit for care, within 60 days after hospital confinement. One visit each day, up to 30 visits in 60 days.

Ambulance Services - Pays a benefit for transport to an emergency treatment center or hospital by licensed ambulance. Max. of 3 trips each year per person.

Non-Local Transportation - Pays a benefit for transportation when you have treatment not available locally. Max. of 3 trips each year per person.

WELLNESS AND DIAGNOSTIC BENEFITSOutpatient Diagnostic X-ray and Laboratory - Pays a benefit for diagnostic lab tests. Maximum of 1 test a day; up to 3 tests each year per person. Not paid if benefit paid under Wellness and Preventive Test benefit.

Wellness and Preventive Test - Pays a benefit for a routine exam or preventive test outside a hospital. Maximum of 1 exam or test each year per person.

Eligible tests and exams include: Bone Marrow Testing; CA15-3, CA125, PSA (blood tests for breast, ovarian and prostate cancer); Mammography, including Breast Ultrasound; Pap Smear, including ThinPrep Pap Test.

See your certificate for a complete listing. Not paid if benefit paid under Outpatient Diagnostic X-ray and Laboratory benefit.

ADDITIONAL DISCOUNT PROGRAMScriptSave® Prescription Drug - The ScriptSave® program provides: savings on brand name and generic medications for you and your family; continued savings when insurance limits are reached. For more information, contact ScriptSave® at: 1-800-700-3957.

(ScriptSave® Prescription Drug is a discount program only provided by a third party service provider. It does not provide insurance coverage.)

We have included the Group Indemnity Medical+ insurance coverage to help provide cash benefits if you are injured or ill and must visit the doctor, go to the emergency room, or stay in the hospital. Plus, the coverage includes benefits for transportation, ambulance, diagnostic X-ray, and Wellness and Preventive tests. Our coverage helps offer peace of mind when a hospitalization occurs.

Below is an example of how benefits are paid in the event you or a covered family member are hospitalized.**

Don’t wait for a sign...Emergency situations come up at any timeA sickness or injury that leads to hospitalization or intensive- care confinement, surgery or emergency treatment can be costly, especially if you are not financially prepared. Your current medical coverage may help pay for the associated expense, but might not cover all of the out- of-pocket expenses you could face. Don’t wait until you are rushed by ambulance to the emergency room to realize you need more protection.

Budget friendlySometimes, receiving hospital or outpatient treatment can be difficult if money is tight. We can help by providing you with supplemental coverage that can fit your needs and work within your budget.

Let our supplemental insurance help you and your family cover expenses for sickness or injury treatments, if and when one occurs. It’s the financially smart thing to do!

It’s never too early to prepare for the future.

Page 4 of 12 ABJ28944X

ANTI-INFECTIVE AGENTS (ORAL)ANTIBIOTICSCephalosporinsCefaclor (Ceclor*)Cefadroxil (Duricef*)Cefdinir (Omnicef*)Cefpodoxime (Vantin*)Cefprozil (Cefzil*)Cephalexin (Keflex*)Erythromycins & Other MacrolidesAzithromycin (Zithromax/Z-PAK*)Clarithromycin (Biaxin, Biaxin XL*)Erythromycin Ethylsuccinate (E.E.S., EryPed*)Erythromycin and Sulfisoxazole (Pediazole*)PenicillinsAmoxicillin (Amoxil*)Amoxicillin/Pot. Clav. (Augmentin*)Ampicillin (Principen*)Dicloxacillin*Penicillin VK (Pen-Vee K*)QuinolonesCiprofloxacin (Cipro*)Ofloxacin (Floxin*)SulfonamidesSulfisoxazole*Trimethoprim*TMP-SMX (Septra/ Septra DS)TetracyclinesDoxycycline (Vibramycin*)Minocycline (Minocin*)Tetracycline (Achromycin V*)

ANTIFUNGAL AGENTSClotrimazole (Mycelex*)Clotrimazole/Betamethasone(Lotrisone*)Econazole (Spectazole*)Fluconazole (Diflucan*)Griseofulvin (Gris-PEG/Grifulvin*)Ketoconazole (Nizoral*)Metronidazole (Flagyl*)Nystatin Oral (Mycostatin*)

ANTIFUNGALS (TOPICAL)Ciclopirox (Loprox*)Nystatin/Triamcinolone (Mycolog*)

ANTIFUNGALS (VAGINAL)Fluconazole (Diflucan*)Metronidazole Gel (MetroGel*)

ANTIHELMINICSMebendazole (Vermox*)

ANTI-INFECTIVE AGENTS- SPECIALIZED INDICATIONSChloroquine Phosphate (Aralen*)Ethambutol HCL (Myambutol*)Hydroxychloroquine (Plaquenil*)Mebendazole (Vermox*)Pyrazinamide*

ANTINEOPLASTIC/ IMMUNOSUPPRESANTSAzathioprine (Imuran*)Cyclophosphamide (Cytoxan*)Hydroxyurea (Hydrea*)Leucovorin (Wellcovorin*)Megestrol (Megace*)Methotrexate*Tamoxifen (Nolvadex*)

ANTIVIRAL AGENTSAcyclovir (Zovirax*)Amantadine (Symmetrel*)Famciclovir (Famvir*)

OTHER ANTI-INFECTIVESClindamycin HCL (Cleocin*)Isoniazid (Nydrazid*)Methenamine (Urex, Hiprex*)Methenamine/methylene blue/ hyoscamine/phenyl salicylate/sodium phosphate (Urimax, Utira-C*)Nitrofurantoin (Macrodantin/Macrobid*)Rifampin (Rifadin*)Sulfadiazine*Trimethoprim (Trimpex*)

TOPICAL ANTIBACTERIAL DRUGSSilver Sulfadiazine (Silvadene*)

AUTONOMIC AND CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS, ANTIMIGRAINEPentazocine/Naloxone (Talacen/Talwin NX*)Tramadol (Ultram*)

ANALGESICS, NARCOTICAPAP/Codeine (Tylenol w/Codeine)APAP/Hydrocodone (Vicodin/Norco*)ASA/Codeine (Empirin w/Codeine*)Butalbital/Acetaminophen (Phrenlin, Sedapap*)Butabital/Acetaminophen/ Caffeine (Fioricet*)Butorphanol (Stadol NS*)Hydrocodone/Ibuprofen (Vicoprofen*)Morphine Sulfate (MSIR, MSContin*)Oxycodone/APAP 5/325 (Percocet*)Propoxyphene Napsylate/APAP (Darvocet N-100/Wygesic*)

ANALGESICS, NON-STEROIDAL ANTI-INFLAMMATORYDiclofenac Potassium (Cataflam*)Diclofenac Sodium (Voltraren/XR*)Diflunisal (Dolobid*)Etodolac (Lodine*)Flurbiprofen (Ansaid*)Ibuprofen (Motrin*)Indomethacin (Indocin*)Ketoprofen (Orudis, Oruvail*)Ketorolac (Toradol*)Meclofenamate*Meloxicam (Mobic*)Nabumetone (Relafen*)Naproxen (Naprosyn*)Oxaprozin (Daypro*)Piroxicam (Feldene*)Sulindac (Clinoril*)Tolmetin (Tolectin/DS*)

ANTICONVULSANTSCarbamazepine (Tegretol*)Clonazepam (Klonipin*)Divalproex Na (Depakote Sprinkle/Depakote ER)Ethosuximide (Zarontin*)Gabapentin (Neurontin*)Lamotrigine (Lamictal*)Levetiracetum (Keppra*)Oxcarbazepine (Trileptal*)Phenobarbital*Phenytoin/Phenytoin Extended (Dilantin*)Primidone (Mysoline*)Topiramate (Topamax*)Valproic Acid/Valproate Sodium(Depakene/ Depakote*)Zonisamide (Zonegran*)

ANTIPARKINSON AGENTSAmantadine (Symmetrel*)Benzatropine Mesylate (Cogentin*)Bromocriptine (Parlodel*)Carbidopa/Levodopa (Sinemet/ Sinemet CR*)Ropinirole (Requip*)Trihexyphenidyl (Artane*)

ANTIPSYCHOTICSChlorpromazine (Thorazine*)Clozapine (Clozaril*)Haloperidol (Haldol*)Lithium Carbonate*Perphenazine*Risperidone (Risperdal*)Thioridazine (Mellaril*)Thiothixene (Navane*)Trifluoperazine (Stelazine*)

ANTIVERTIGO/ANTIEMETICSGranisetron (Kytril*)Hydroxyzine (Atarax*)Meclizine HCL (Antivert*)Ondasetron (Zofran*)Prochlorperazine (Compazine*)Promethazine HCL (Phenergan*)Trimethobenzamide (Tigan*)

Below is an alphabetical list of generic medications available to members for a fixed copayment amount up to the annual maximum benefit specific to the plan. Generic and brand products not listed are not eligible for the generic copayment benefit, but remain eligible for a pharmacy discount. If you are currently taking a brand-name medication, ask your doctor if an appropriate generic alternative is available.

*Generic Drug

catamaran RX generic formulary prescription drug listCatamaran Rx Outpatient Prescription Drug pays for covered prescription drug charges over the copay amount shown in the list on this page. Use your ID card to access benefits. Prescriptions can be filled at participating pharmacies by presenting the card, prescription, and paying the copay. No waiting periods for pre-existing conditions.

Schedule: Copayment - The dollar amount paid by you. Generic Formulary Drugs: Retail - $10 copay for each 30-day supply (maximum of $1,500/individual annually), and Oral Contraceptives (birth control pills) - $15 copay Brand Name Formulary Drugs: Discounted price at time of purchase. Unlimited discount savings (up to 40%) are based on your prescription, your pharmacy and where you live. Accepted at more than 60,000 pharmacies nationwide; mail order not available. No waiting periods for pre-existing conditions.

The formulary process is ongoing and changes can occur at any time. Contact Catamaran Rx for current drug coverage and/or benefits.

Refer to the formulary for a list of eligible medications. Retail dispensing limits on 30-day supply or specified unit doses.

ABJ28944X Page 5 of 12

ANXIOLYTICS, SEDATIVESAND HYPNOTICSAlprazolam (Xanax*)Buspirone (Buspar*)Chlordiazepoxide HCL (Librium*)Clonazepam (Klonopin*)Clorazepate (Tranxene*)Diazepam (Valium*)Estazolam (Prosom*)Flurazepam (Dalmane*)Lorazepam (Ativan*)Oxazepam (Serax*)Temazepam (brand Restoril*)Triazolam (Halcion*)Zolpidem Tartrate (Ambien*)

CNS STIMULANTS/ DRUGS TO TREATATTENTION DEFICIT DISORDERMethylphenidate (Ritalin/Methylin*)

DRUGS TO PREVENT AND TREAT GOUTAllupurinol (Zyloprim*)Colchicine*Probenecid*

MUSCLE RELAXANTS/ ANTISPASMODICSBaclofen (Lioresal*)Carisoprodol (Soma*)Carisoprodol and Aspirin (Soma Compound*)Chlorzoxazone (Parafon Forte DSC*)Cyclobenzaprine HCL (Flexeril*)Metaxalone (Skelaxin*)Methocarbamol (Robaxin*)Orphenadrine (Norflex, Banflex*)Orphenadrine/Aspirin/Caffeine (Norgesic*)Tizanidine (Zanaflex*)

PSYCHOTHERAPEUTIC AGENTSANTIDEPRESSANTSAmitriptyline (Elavil*)Amitriptyline/Chlordiazepoxide (Limbitrol*)Amoxapine (Asendin*)Bupropion (Wellbutrin & WellbutrinSR, Wellbutrin XL*)Citalopram (Celexa*)Clomipramine (Anafril*)Desipramine (Norpramin*)Doxepin (Sinequan*)Fluoxetine (Prozac*)Fluvoxamine (Luvox*)Imipramine (Tofranil*)Mirtazapine (Remeron*)Nortiptyline (Pamelor*)Paroxetine (Paxil*)Sertraline (Zoloft*)Tranylcypromine (Parnate*)Trazadone (Desyrel*)

CARDIOVASCULAR MEDICATIONSACE INHIBITORSBenazepril (Lotensin*)Captopril (Capoten*)Enalapril (Vasotec*)Fosinopril (Monopril*)Lisinopril (Zestril*)Moexipril (Univasc*)Perindopril (Aceon*)Quinapril (Accupril*)Ramipril (Altace*)

ALPHA BLOCKERSDoxazosin (Cardura*)Prazosin (Minipress*)Terazosin (Hytrin*)

ANGIOTENSIN RECEPTOR BLOCKERSLosartan (Cozaar*)Losartan/HCTZ (Hyzaar*)

ANTIARRHYTHMICSAmiodarone (Cordarone*)Flecainide (Tambicor*)Mexiletine (Mexitil*)Nitroglycerin*Propafenone (Rythmol*)Quinidine*Sotalol (Betapace*)

BETA-ADRENERGIC ANTAGONISTSAcebutolol (Sectral*)Atenolol (Tenormin*)Bisoprolol (Zebeta*)Carvedilol (Coreg*)Labetolol (Normodyne*)Metoprolol (Lopressor*)Metoprolol Succinate (Toprol XL*)Nadolol (Corgard*)Pindolol (Visken*)Propranolol (Inderal*)

CALCIUM CHANNEL BLOCKERSAmlodipine (Norvasc)Diltiazem (Cardizem/SR/Dilacor XR)Felodipine (Plendil*)Nifedipine (Procardia XL*)Verapamil (Calan SR/Isoptin SR*)

CARDIAC GLYCOSIDESDigoxin (Lanoxin*)

CHOLESTEROL-LOWERING AGENTSCholestyramine (Questran/Light*)Fenofibrate (Lofibra*)Gemfibrozil (Lopid*)Lovastatin (Mevacor*)Niacin*Pravastatin (Pravachol*)Simvastatin (Zocor*)

DIURETICSAmiloride/ HCTZ (Moduretic*)Bumetanide (Bumex*)Chlorthalidone (Hygroton*)Furosemide (Lasix*)Hydrochlorothiazide*Indapamide (Lozol*)Metolazone (Zaroxolyn*)

Spironolactone (Aldactone*)Torsemide (Demadex*)

DIURETIC COMBINATIONSAtenolol/Chlorthalidone (Tenoretic*)Hydrochlorothiazide -

Benazepril (Lotensin HCT*)Bisoprolol (Ziac*)Captopril (Capozide*)Enalapril (Vasoretic*)Fosinopril (Monopril HCT*)Lisinopril (Zestoretic*)Methyldopa (Aldoril)Metoprolol (Lopressor HCT*)Propranolol (Inderide*)Quinapril (Accuretic*)Spironolactone (Aldactazide*)Triamterene (Dyazide*)

OTHER ANTIHYPERTENSIVESAmilodopine Besylate/Benazepril HCLClonidine (Catapres*)Guanfacine (Tenex*)Hydralazine (Apresoline*)Methyldopa (Aldomet*)Midodrine (ProAmatine*)Minoxidil (Loniten*)

OTHER CARDIOVASCULAR DRUGSPentoxifylline (Trental*)

VASODILATING DRUGSIsosorbide Dinitrate (Isordil*)Isosorbide Mononitrate (Imdur*)Nitroglycerin SL (Nitrostat, Nitroquick*)

DERMATOLOGICALSANTI-ACNEBenzoyl Peroxide (Triaz*)Clindamycin (Cleocin-T/ClindetsPledgets*)Sulfacetamide/Sulfur, sublimed (Novacet/Sulfacet-R*)

OTHER DERMATOLOGICAL DRUGSAluminum Chloride (Drysol*)Permethrin (Elimite*)

TOPICAL CORTICOSTEROIDSAclometasone (Aclovate*)Augmented Betamethasone Dipropionate (Diprosone, Maxivate*)Betamethasone Valerate (Valisone*)Clobetasol Propionate (Temovate/E*)Desonide (DesOwen*)Desoximetasone (Topicort*)Diflorasone (Psorcon/E*)Fluocinonide (Lidex-E*)Fluocinolone acetonide (Synalar/Derma SmootheFS*)Fluticasone (Cutivate*)Halobetasol (Ultravate*)Hydrocortisone Acetate*Hydrocortisone Valerate*Mometasone Furoate (Elocon*)Triamcinolone (Aristocort*)

EAR, NOSE AND THROAT MEDICATIONSDRUGS AFFECTING THE EARAcetic Acid/Aluminum Acetate (Domeboro Otic*)Antipyrine/Benzocaine (Auralgan/AB Otic Solution*)Hydrocortisone/Acetic Acid (Acetasol HC*)Neomycin/Polymyxin/hc (Cortisporin*)Ofloxacin (Floxin Otic*)

DRUGS AFFECTING THE THROAT AND MOUTHChlorhexidine (Peridex*)Lidocaine HCL viscous solution (Xylocaine Viscous Gel*)

ENDOCRINE MEDICATIONSADRENAL CORTICOSTEROID DRUGSDexamethasone (Hexadrol*)Fludricortisone (Florinef*)Hydrocortisone (Cortef*)Methylprednisolone (Medrol/ Medrol Pak*)Prednisone (Deltasone*)

ANTIDIABETIC AGENTSChloropropamide (Diabinese*)Glimepiride (Amaryl*)Glipizide (Glucotrol*)Glyburide (Diabeta/Glynase*)Glyburide/Metformin (Glucovance*)Metformin (Glucophage*)HUMALOG VIALHUMULIN VIALLANTUS VIALLEVEMIR VIALNOVOLIN VIALNOVOLOG VIAL

DRUGS TO TREAT OSTEOPOROSISAlendronate (Fosamax)

THYROID AND ANTI-THYROID DRUGSLevothyroxine (Synthroid/Levoxyl*)Methimazole*Propylthiouracil*

GASTROINTESTINAL MEDICATIONSANTISPASMODICSBelladonna alkaloids phenobarbital (Donnatal*)Clidinium/Chlordiazepoxide (Librax*)Dicyclomine (Bentyl*)Diphenoxylate/Altropine (Lomotil*)Hyoscyamine (Levsin*)Metoclopramide (Reglan*)

OTHER GASTROINTESTINAL DRUGSElectrolyte solution/PEG’s (Golytely, Nulytely*)Hydrocortisone suppositories (Anusol HC*)Misoprostol (Cytotec*)PEG 3350/Electrolytes solution (Colyte*)Pramoxine/Hydrocortisone (Analpram-HC*)Pramoxine/Hydrocortisone/Chloroxylenol(Cortane B*)Sulfasalazine (Azulfidine*)

*Generic Drug

Page 6 of 12 ABJ28944X

NUTRITION, BLOOD MODIFIERS, ELECTROLYTES DRUGS AND VITAMINS AFFECTING COAGULATIONDipyridamole (Persantine*)Ticlodipine (Ticlid*)Warfarin (Coumadin*)

FLUORIDE PRODUCTSSodium Fluoride (Karidium/Luride/SF*)

POTASSIUM SUPPLEMENTSPotassium Chloride (K-DUR/Micro-K*)

VITAMINS/MINERALSCalcitriol (Rocaltrol*)Ergocalciferol (Calciferol*)Folic Acid (Folate*)

OPHTHALMIC AGENTSGLAUCOMA AGENTSAcetazolamide (Diamox*)Brimonidine Tartrate (Alphagan*)Dipivefrin (Propine*)Dorzolamide/Timolol (Cosopt*)Levobunolol (Betagan*)Pilocarpine (Pilocar*)Timolol (Timoptic/XE*)

OPHTHALMIC TOPICAL ANTI-BACTERIAL DRUGSBacitracin/Polymixin b*)Ciprofloxacin (Ciloxan*)Ciprofloxacin Ointment (Ciloxan Ointment*)Erythromycin*Gentamicin (Garamycin*)Neomycin/Bacitracin/ Polymixin b (Neomycin*)Ofloxacin (Ocuflox*)Polymyxin B/Trimethoprim (Polytrim*)Tobramycin (Tobrex*)

OPHTHALMIC ANTI-INFECTIVES/ CORTICOSTEROID DRUGSNeomycin/Dexamethasone/Polymyxin(Dexacidin/Maxitrol*)Sulfacetamide/Prednisolone (Blephamide*)Sulfacetamide/Prednisone (Vasocidin*)Tobramycin/Dexamethasone (Tobradex*)

OPHTHALMIC CORTICOSTEROID DRUGSDexamethasone (Decadron*)Fluoromethalone (FML Liquifilm*)Prednisolone (Econopred Plus/Pred Forte*)Prednisolone (Inflamase Forte*)

OPHTHALMIC TOPICAL ANTI-VIRAL DRUGSTrifluridine (Viroptic*)

OTHER OPHTHALMIC DRUGSCyclopentolate (Cyclogyl*)Phenylepinephrine (Neo-Synephrine*)Tetracaine*

OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS ANDROGENSDanazol (Danocrine*)

CONTRACEPTIVESEthinyl Estradiol and Desogestrel (Ortho-Cept/Desogen*)Ethinyl Estradiol and Ethynodiol Diacetate (Zovia*)Ethinyl Estradiol and Levonorgestrel (Triphasil/Levlen*)Norethindrone (NorQD/Ortho Micronor*)Norethindrone/Estradiol/fe fumarate(Loestrin fe*)Norethindrone/Ethinyl Estradiol (Mircette/Modicon/Tri-Norinyl*)Norethindrone/Mestranol (Ortho Novum*)Norgestimate/Ethinyl Estradiol (Ortho Cyclen*)Norgestimate/Ethinyl Estradiol (Ortho Tri-Cyclen*)

ESTROGEN PATCHESEstradiol (Climara*)

ORAL ESTROGEN DRUGSEstradiol (Estrace*) Estropipate (Ortho-Est/Ogen*)

PRENATAL VITAMINSAll vitamins are preferred on formulary

PROGESTIN DRUGSMedroxyprogesterone (Provera*)Norethindrone (Aygestin*)

RESPIRATORY, ALLERGY, COUGH & COLDANTIHISTAMINES/ANTI-ALLERGENICSCyproheptadine (Periactin*)Dexchlorpheniramine Tablet, SA (Polaramine Repetab*)Hydroxyzine Pamoate (Vistaril*)

ANTI-TUSSIVE COMBINATIONSGuaifenesin/Codeine (Robistussin A-C*)Guaifenesin/PSE/Hyrodrocodone (Deconamine CX*)Guaifenesin/Hydrocodone (Codiclear*)Hydrocodone/Homatropine (Hydromet*)Hydrocodone/Potassium Guaiaco (CoTuss*)Phenylephrine/Clorpheniramine/ Dextromethorphan (PE/GG LA*)Phenylephrine/Hydrocodone/ GG (Levall 5.0*)Phenylephrine/Pyrilamine/ DM (PolyHist DM*)Phenylephrine/Pyrilamine/ Hydrodocone (Codimal DH*)Promethazine/Codeine*Promethazine/DM*Pseudoephedrine/Brompheniramine/ Dextromethorphan (Bromdec DM*)Pseudoephedrine/Brompheniramine/ Hydrocodone (Brovex HC*)Pseudoephedrine/Cardinoxamine/ Dextromethorphen (Cardec DM*)Pseudoephedrine/Carbinoxamine/Hydrocodone (Histex HC*)

Pseudoephedrine/Codeine (Nucofed*)Pseudoephedrine w/Codeine/ GG (Codafed*)Pseudoephedrine-Chlor/ Codeine (Phenylhist*)Pseudoephedrine- CPM/ Hydrocodone (Genecof-HC*)Pseudoephedrine/Hydrocodone (Pancof*)Pseudoephedrine/Hydrocodone/ GG (Hydrotussin*)

BETA AGONIST INHALERSTerbutaline (Brethine*)

BETA AGONIST ORALAlbuterol (Proventil*)Albuterol Extended Release (Vospire ER*)

DECONGESTANTS/ANTIHISTAMINESBenzonatate (Tessalon Perle*)Pseudoephedrine/Chlorpheniramine TabSyrup/Cap, SA (DeconamineSR/Deconamine*)

EXPECTORANT COMBINATIONSGuiafenesin/Dextromethorphan (Guaibid*)Guaifenesin/PSE (Guaifed*, Deconsal/ Deconsal*, Entex PSE*)

INTRANASAL STEROIDSFlunisolide (Nasalide*)Fluticasone (Flonase*)

MISCELLANEOUS PULMONARY AGENTSCromolyn Sodium Ampul (Intal*)Ipratropium (Atrovent Inhaler/ Nasal Spray*)

PULMONARY AGENTSXanthinesTheophylline (Theo-Dur/ Slo-Phyllin/Theolair-SR)

UROLOGICAL MEDICATIONS ANTICHOLINERGICS/ANTISPASMODICSFlavoxate (Urispas*)

BENIGN PROSTATIC HYPERTROPHY DRUGSFinasteride (Proscar*)Tamsulosin (Flomax*)

MISCELLANEOUS UROLOGICALSOxybutynin (Ditropan*)Phenazopyridine (Pyridium*)

*Generic Drug

ABJ28944X Page 7 of 12

GROUP INDEMNITY MEDICAL†*‡

HOSPITALIZATION BENEFITS PLANFirst Day Hospitalization Confinement (once per confinement per year) $1,000

GROUP INDEMNITY MEDICAL+†‡

HOSPITALIZATION BENEFITS Initial Hospitalization Confinement (1 yearly, excludes pregnancy and birth) $1,000

Daily Hospital Confinement3 (up to 180 days4) $400

Hospital Intensive Care3 (up to 60 days4) $400

SURGERY AND RELATED BENEFITS Surgery (varies by surgery) $80-$2,000

Anesthesia (% of surgical benefit) 25%

Inpatient Physician’s Treatment (daily) $100

OUTPATIENT, NURSING AND TRANSPORTATION BENEFITS Outpatient Emergency Accident (2 yearly4) $1,000

Outpatient Physician’s Treatment5 $100

At Home Nursing6 (daily, total of 30 days) $200

Ambulance Services (3 trips yearly4) (pays 2 times amt stated for air ambulance) $600

Non-Local Transportation (3 trips yearly4) $600

WELLNESS AND DIAGNOSTIC BENEFITS Outpatient Diagnostic X-ray and Laboratory (1 daily and 3 yearly4) $75

Wellness and Preventive Test (1 yearly4) $150

ADDITIONAL DISCOUNT PROGRAM ScripSave® Prescription Drug Included

CATAMARAN Rx GENERIC PRESCRIPTION DRUG PLAN7 Annual Maximum per Individual $1,500

Generic Formulary Drugs (30 day supply) $10 copay

Oral Contraceptives (birth control pills) $15 copay

Brand Name Discount Only

Listed to the left are benefit amounts associated with the benefits described in the brochure.† This coverage is not available to residents of the state of Massachusetts.* You must enroll in the GIM plan to be eligible for the benefit.‡ Group Indemnity Medical is the GIM2 plan. Group Indemnity Medical+ is the GIM plan.3 Continuous confinement.4 Paid per person.5 Limited to 5 visits employee, 10 visits employee and spouse or employee and child(ren), 15 visits family.6 Within 60 days of a hospital confinement.7 Underwritten by Fidelity Security Life Insurance Co.

plan details

premiums

EE = Employee; EE + SP = Employee + Spouse; EE + CH = Employee + Children; F = Family. Issue Ages: 18 and over if Actively at Work

$52.44 $102.78 $87.86 $136.66

MODE EE EE + SP EE + CH F

Bi-Weekly

Page 8 of 12 ABJ28944X

CERTIFICATE SPECIFICATIONS

GROUP INDEMNITY MEDICAL‡

Conditions and Limits - We pay benefits as stated for service and treatment received by the covered person while coverage is in force, for sickness or injury. Hospital room and board charges must be incurred for benefits to be payable. Treatment must be received in the United States or its territories.

Your Eligibility - Your employer decides who is eligible for your group (such as length of service and hours worked each week). Issue ages are 18 and over.

Dependent Eligibility/Termination - (a) Coverage may include you, your spouse or domestic partner, and your children, and domestic partner’s children. (b) Coverage for children ends upon your death or when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. (c) Spouse coverage ends upon valid decree of divorce or your death. (d) Domestic partner coverage ends upon termination of domestic partnership or your death.

When Coverage Ends - Coverage under the policy ends on the earliest of: (a) the date the policy is canceled; (b) the last day of the period for which you made any required contributions; (c) the last day of the month you are in active employment, except as provided under the “Temporary Layoff, Leave of Absence, or Family and Medical Leave of Absence” provision; (d) the date you are no longer in an eligible class; (e) the date your class is no longer eligible; (f) upon discovery of fraud or material misrepresentation when filing for a claim.

Portability Privilege - Coverage may be continued under the Portability Provision when coverage under the policy ends.

Exclusions - Benefits are not paid for: (a) any act of war, participation in a riot, insurrection or rebellion; (b) suicide or attempt at suicide; (c) engaging in an illegal occupation or committing or attempting an assault or felony; (d) cosmetic dentistry or plastic surgery, except to treat an injury or correct a disorder of normal body function; (e) intentionally self-inflicted injuries; (f) confinement that begins before the effective date of coverage; (g) the reversal of a tubal ligation or vasectomy; (h) artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications or physician services, unless required by law; (i) participation in aeronautics (including parachuting and hang gliding) unless a fare-paying passenger on a licensed common-carrier aircraft operating between established airports; (j) a newborn child’s routine nursing or well-baby care during the initial confinement in the hospital; (k) driving in any race or speed test or testing any motorized vehicle on any racetrack or speedway; (l) mental or nervous disorders; (m) alcoholism, drug addiction or dependence upon any controlled substance.

GROUP INDEMNITY MEDICAL+‡

Limitations and Exclusions - Benefits not paid for: (a) injury or sickness incurred prior to the effective date; (b) acts of war, participation in riot, insurrection or rebellion; (c) suicide; (d) injury while under the influence of alcohol or any narcotic unless taken on the advice of a physician; (e) participation in aeronautics unless a fare-paying passenger on a licensed common-carrier aircraft; (f) engaging in an illegal occupation; (g) committing or attempting an assault or felony; (h) dental or plastic surgery for cosmetic purposes, unless to treat an injury or correct a disorder of normal bodily function; (i) alcoholism or dependence upon a controlled substance; (j) mental or nervous disorders; (k) intentionally self-inflicted injuries; (l) a newborn child’s routine nursing or well-baby care during initial hospital confinement; (m) childbirth within the first 10 months of the covered person’s effective date; (n) hospitalization starting before the effective date; (o) reversal of tubal ligation or vasectomy; artificial insemination, in vitro or test tube fertilization, related testing, medications, physician services, unless required by law; (p) routine eye exams or fittings; hearing aids or fittings; (q) dental exams and care unless from a result of an accident; or (r) driving in organized or scheduled race or speed test or testing any vehicle on any racetrack or speedway.

Initial Hospitalization Confinement Exclusion - Benefit is not paid for normal pregnancy or complications of pregnancy, or for a newborn child’s initial hospitalization after birth. A newborn child’s initial hospitalization includes any transfers to another hospital before the child is discharged home.

Hospital Intensive Care Exclusion - Benefits are not paid under the Hospital Intensive Care benefit for confinement in any care unit that does not qualify as a hospital intensive-care unit. Progressive care, sub-acute intensive care, intermediate care or step-down units, private rooms with monitoring or any other lesser care treatment units do not qualify.

ELIGIBILITY AND TERMINATION OF COVERAGE(a) Coverage may include you, your spouse and children. (b) Coverage under the policy ends the date the policy is canceled; the last day you made required contributions; the last day of active employment, except as provided under the “Temporary Layoff, Leave of Absence or Family Medical Leave of Absence” provision; the date you are no longer in an eligible class; or the date your class is no longer eligible. Spouse coverage terminates upon divorce; or your death. Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent.

‡Group Indemnity Medical is the GIM2 plan. Group Indemnity Medical+ is the GIM plan.

ABJ28944X Page 9 of 12

Catamaran Rx Outpatient Prescription Drug Benefits Exclusions - Benefits are not payable for the following list of drugs. However, they can be purchased at a discounted price. 1) Over-the-counter products and medications unless shown under the definition of Prescription Drug. This includes, but is not limited to, electrolyte replacement, infant formulas, miscellaneous nutritional supplements and all other over-the-counter products and medications. 2) Blood glucose meters, insulin-injecting devices; 3) Depo-Provera, levonorgestrel, condoms, contraceptive sponges, and spermicides, sexual dysfunction drugs; 4) biologicals (including allergy tests), blood products, growth hormones, hemophiliac factors, MS injectables, immunizations, all other injectables unless shown under the definition of Prescription Drug; 5) Aerochamber, Aerochamber with Mask, Peak Flow Meter, all other medical supplies and durable medical equipment unless shown under the definition of Prescription Drug; 6) liquid nutritional supplements - unless for treatment of PKU, pediatric legend drug vitamins, prenatal legend drug vitamins, prescribed versions of Vitamins A, D, K, B12, Folic Acid and Niacin - used in treatment versus as a dietary supplement, all other legend drug vitamins and nutritional supplements; 7) anorexiants, any cosmetic drugs including, but not limited to, Renova, skin pigmentation preps, any drugs or products used for the treatment of baldness, topical dental fluorides; 8) refills in excess of that specified by the prescribing physician, or refills dispensed after one year from the original date of the prescription; 9) all newly marketed pharmaceuticals or currently marketed pharmaceuticals with a new FDA-approved indication for a period of one year from such FDA approval for its intended indication; 10) any drug labeled “Caution - limited by Federal Law for Investigational Use” or experimental drugs; 11) any drug which the FDA has determined to be contraindicated for the specific treatment; 12) drugs needed due to conditions caused by taking part in a riot or other civil disorder, or taking part in the commission of a felony; 13) drugs due to conditions caused by declared or undeclared war or an act of war, or drugs dispensed to an insured person while on active duty in any armed force; 14) any expenses related to the administration of any drug; 15) needles or syringes unless shown under the definition of Prescription Drug; 16) drugs or medicines taken while in or administered by a hospital or any other health care facility or office; 17) drugs covered under Workers’ Compensation, Medicare, Medicaid or other governmental program; 18) drugs, medicines or products which are not medically necessary; 19) brand name prescription drugs; 20) diaphragms, erectile dysfunction legend drugs, infertility legend drugs; 21) EpiPen, EpiPen Jr., Ana Kit, Ana-Guard, Glucagon auto injection, Imitrex auto injection; or 22) smoking deterrents, legend or over-the-counter.

STATE VARIATIONSGROUP INDEMNITY MEDICAL‡

Michigan (changes affect pages 3, and 9) - In the Exclusions paragraph, item (c) is replaced with: suicide or attempt at suicide, while sane.

GROUP INDEMNITY MEDICAL+‡

Michigan (changes affect pages 3, and 9) - In the Exclusions paragraph, item (c) is replaced with: suicide or attempt at suicide, while sane.

‡Group Indemnity Medical is the GIM2 plan. Group Indemnity Medical+ is the GIM plan.

Page 10 of 12 ABJ28944X

Don’t wait for a sign...Emergency situations come up at any timeA sickness or injury that leads to hospitalization, surgery or emergency treatment can be costly, especially if you are not financially prepared. Your current medical coverage will help pay for the associated expense, but won’t cover all of the out-of-pocket expenses you may face. Don’t wait until you are rushed by ambulance to the emergency room to realize you need more protection.

Budget friendlySometimes, receiving in- or out-of-the-hospital treatment can be difficult if money is tight. We can help by providing you with supplemental coverage that can fit your needs and work within your budget.

Let our supplemental insurance help you and your family cover expenses for sickness or injury treatments, if and when one occurs. It’s the financially smart thing to do!

It’s never too early to prepare for the future.

ABJ28944X Page 11 of 12

Page 12 of 12 ABJ28944X

Allstate Benefits is the marketing name used by American Heritage Life Insurance Company a subsidiary of The Allstate Corporation. ©2014 Allstate Insurance Company. www.allstate.com or allstatebenefits.com

This material is valid as long as information remains current, but in no event later than October 30, 2017. Group Indemnity Medical benefits provided by policy form GVSP2, or state variations thereof. Group Indemnity Medical+ benefits provided by policy form GVSP1, or state variations thereof.

Coverage is provided by Limited Benefit Supplemental Health Insurance.

This is not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer’s Guide available from American Heritage Life Insurance Company.

Underwritten by American Heritage Life Insurance Company (Home Office, Jacksonville, FL). This is a brief overview of the benefits available under the Group Policy issued by American Heritage Life Insurance Company. However, the insurance will be governed solely by the terms and conditions of the Group Policy, which alone will make up the agreement by which the insurance will be provided.

Fidelity Security Life Insurance Company

Catamaran Rx Generic Outpatient Prescription Drug Insurance Plan The Catamaran Rx Generic Outpatient Prescription Drug Insurance Plan is underwritten by Fidelity Security Life Insurance Company, Kansas City, MO, Policy #PD-292/PD-293, Form #M-9031, M-9022. Some provisions, benefits, exclusions or limitations listed may vary by state. Not available in all states. Discounts are not insured benefits and are only applicable at a Participating Pharmacy. www.catamaranrx.com

This coverage does not constitute comprehensive health insurance coverage (often referred to as “major medical coverage”) and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

This brochure is for use in the Manna Development Group, LLC enrollment sitused in: MI