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SPD WRAP DOCUMENT – IMPORTANT INFORMATION -- PLEASE READ Dear Employer: The Employee Retirement Income and Security Act of 1974 (ERISA) requires that the sponsors of group plans comply with certain disclosure requirements including the requirement to supply employees with a Summary Plan Description (SPD). To be legally compliant with ERISA, an SPD must have certain statutorily-defined specific information about the underlying plan that is specific to the employer and is not contained in most Certificates of Coverage provided by insurance carriers. So, your SPD must include one or more documents you prepare and adopt in addition to the documents provided by an insurance carrier. This wrap document is being provided to help clients obtain a legally sufficient Summary Plan Description (SPD) under the Employee Retirement Income and Security Act of 1974 (ERISA). It is to be used in conjunction with an Insurance Summary or Insurance carrier’s explanation of benefits to create a Summary Plan Description. If self-insured benefits are offered, the HIPAA Notice of Privacy Practices attached to the SPD is only one component of compliance with the privacy and security provisions, and you should discuss your company’s HIPAA compliance with your counsel, claims administrator, or outside consultant. Moreover, under ERISA the responsibility for issuing an SPD rests with you, the Employer/Plan Administrator, and not with PrimePay. PrimePay is not the ERISA Plan Administrator and is not responsible for your compliance with ERISA outside of the terms of the ERISA Compliance Services Agreement (e.g., distributing your Summary Plan Description). Thank you, PrimePay ERISA Compliance Services [THIS PAGE IS INSTRUCTIONAL AND DOES NOT NEED TO BE PROVIDED TO PARTICIPANTS]

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Who must receive an SPD? SPDs must be provided to the following parties:

• Covered participants - Department of Labor regulations specifically exclude plan beneficiaries (i.e. spouses and dependents) from the distribution requirement;

• A child added to the plan through a Qualified Medical Child Support Order and his or her parent-guardian

• Spouse and/or dependent(s) of a deceased retiree (if your plan provides retiree coverage) • COBRA Qualified Beneficiaries (including the guardian of an incapacitated COBRA

Qualified Beneficiary) What methods can you use to distribute SPDs? SPDs must be furnished in a way “reasonably calculated to ensure actual receipt of the material.” The Department of Labor has issued regulations approving the following methods:

• First-Class Mail - Delivery by first-class mail is specifically approved so long as the mailing list is comprehensive and up to date.

• Second and Third-Class Mail - Second and third-class mail delivery is specifically approved so long as the mailing list is comprehensive and up to date, and return/forwarding postage is guaranteed and address correction is requested.

• Insert in Company Publication - SPDs can be delivered as a special insert in a union or company publication so long as the mailing list is comprehensive and up to date, there is a notice prominently displayed on the cover stating that an SPD is contained in that issue, and steps are taken to insure delivery to participants who may not be on the mailing list.

• By Hand - Delivery of SPDs by hand at a worksite has been approved; however, you cannot merely place copies of the SPD in a location frequented by participants.

• By Electronic Means - Delivery of SPDs by electronic means is acceptable; however a number of Department of Labor requirements must be met. Please ask your legal counsel if you are able to meet these requirements. See also, Department of Labor, Employee Benefits Security Administration Technical Release No. 2011-03, Interim Policy on Electronic Disclosure Under 29 CFR 2550.404a-5, located at: http://www.dol.gov/ebsa/newsroom/tr11-03.html

How often must you distribute SPDs? When your plan is established, a summary plan description must be provided to plan participants (covered employees) within 120 days of the plan’s effective date. Because these documents may be created mid-year, best practice would include immediate distribution and every open enrollment thereafter. Thereafter, new participants must receive an SPD within 90 days of joining the plan. If you make a material change to the employer- specific information contained in the SPD Wrap, you will need to distribute a Summary of Material Modifications describing the change within 210 days after the end of the plan year in which the modification is adopted. If the modification is a material reduction in services or benefits, covered participants must be notified within 60 days of the date the modification is adopted. In general, if there have been any plan amendments, the plan administrator must furnish an updated SPD every five years. Otherwise, an updated SPD must be furnished every 10 years even if no plan amendments have been made. [THIS PAGE IS INSTRUCTIONAL AND DOES NOT NEED TO BE PROVIDED TO PARTICIPANTS]

Providence Healthcare Management Employee Benefits Plan

Group Medical Group Dental Group Vision

Summary Plan Description for

Non-Management

Amended and Restated As Of:

October 1, 2017

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I. INTRODUCTION This document contains a summary in English of your plan rights and benefits under your employer’s employee benefit plan(s). If you have difficulty understanding any part of this booklet, contact the Plan Administrator identified below. This document is to be used in conjunction with the plan documents and insurance materials that are provided to you. These materials replace and supersede all other prior agreements between the Parties as well as any other prior written or oral understandings, negotiations, discussions or arrangements between the Parties related to matters covered under the plan documents or the documents incorporated herein. If any provision of this document is deemed to be invalid or illegal, that provision shall be fully severable and the remaining provisions of this document shall continue in full force and effect. The Plan Administrator has discretionary authority to interpret and administer, in its sole discretion, the terms of the plan and to make factual determinations. Under the Employee Retirement Income Security Act (ERISA), each participant and beneficiary of an employer welfare benefit plan must be provided with a Summary Plan Description (SPD) which explains the terms, rights and benefits available to the plan, in a summary form. The coverage available under the plan is explained in more detail in the individual group contracts, certificates, and plan documents, however those documents on their own may not contain all the information that ERISA requires for summary plan descriptions (SPDs) or are not concise enough to be easily understood. This SPD “wrap document” is designed to meet the ERISA requirements and is to be used in conjunction with the plan summary booklets that are provided to you. NOTE: The information contained herein is current as of December 2017. Providence Healthcare Management, Inc. (“Employer”) maintains the Providence Healthcare Management Employee Benefits Plan (“Plan”) for the exclusive benefit of its eligible employees and their eligible dependents. Benefits under the Plan are currently provided under group insurance contracts (“Group Insurance Contracts”) and/or service agreements (“Service Agreements”) entered into between the Employer and the carriers and/or administrators listed in the chart in Section III below. They are known collectively throughout this document as “Insurance Carriers” and individually as “Insurance Carrier.” The policies, contracts or booklets for each underlying Plan feature govern the benefits to be provided and include more details on how the Plan features operate. If there is any conflict between this plan document and such policies, contracts or booklets, then such other documents will control. Participants and beneficiaries should not rely on any oral description of the Plan because the written terms of the Plan will always govern. Plan benefits, including information about eligibility, are summarized in the documents issued by Insurance Carriers, copies of which are available from your Human Resources Department, free of charge. These documents together with this document constitute the Summary Plan Description required by ERISA. Capitalized terms not otherwise defined in this document are defined in the Certificate of Coverage.

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II. SPECIFIC PLAN INFORMATION

Plan Name: Providence Healthcare Management Employee Benefits Plan

Type of Plan: Group Medical Group Dental Group Vision

Plan Year: October 1 - September 30

Plan Number: 501

Employer / Plan Sponsor: Providence Healthcare Management, Inc. 29225 Chagrin Blvd., Suite 230 Pepper Pike, OH 44122

Plan Sponsor’s Employer Identification Number:

01-0919235

Plan Administrator: Human Resources Providence Healthcare Management, Inc. 29225 Chagrin Blvd., Suite 230 Pepper Pike, OH 44122 866-374-7362

Named Fiduciary: Providence Healthcare Management, Inc. 29225 Chagrin Blvd., Suite 230 Pepper Pike, OH 44122 866-374-7362

Agent for Service of Process: Providence Healthcare Management, Inc. 29225 Chagrin Blvd., Suite 230 Pepper Pike, OH 44122 866-374-7362 Service of process may also be made on the Plan Administrator.

Important Disclaimer: Plan benefits are provided under Group Insurance Contracts between the Employer and Insurance Carriers and/or Service Agreements with a Third-Party Administrator. If the terms of this summary document conflict with the terms of the Group Insurance Contracts or Service Agreement, the terms of the Group Insurance Contracts or Service Agreement will control, unless superseded by applicable law.

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III. ELIGIBILITY Subject to any additional eligibility requirements for a component benefit program that are set forth in the plan documents identified in the Attachments, employee eligibility requirements are as follows:

Benefit Plan Carrier/Administrator

Address Controlling Document (e.g., insurance contract)

Plan Funding

Premium Arrangement

FT/PT Eligibility and Hours

Waiting Period

Spouse/Dependent/ Domestic Partner Coverage

Group Medical HealthSCOPE Benefits, Inc. 27 Corporate Hill Drive Little Rock, AR 72205 (501) 225-1551

PPO Plans 1, 2 and 3 Employee Benefit Plan Document and Summary Plan Description

Self-insured

Both (mandatory ER contibutions and employee payroll deductions)

Full-time working 30 hours per week

You will become eligible 90 days following your date of employment.

Spouse: Yes Dependents: Yes Domestic Partners: No

Group Dental Humana Insurance Company P.O. Box 14313 Lexington, KY 40512-4313 (866) 537-0229

PPO Certificates of Insurance

Fully-insured

Entirely by Employee payroll deductions

Full-time working 30 hours per week

You will become eligible 90 days following your date of employment.

Spouse: Yes Dependents: Yes Domestic Partners: Yes registered and non-registered

Group Vision Humana Insurance Company P.O. Box 14313 Lexington, KY 40512-4313 (866) 537-0229

OH Humana Vision 130 Certificate of Insurance

Fully-insured

Entirely by Employee payroll deductions

Full-time working 30 hours per week

You will become eligible 90 days following your date of employment.

Spouse: Yes Dependents: Yes Domestic Partners: Yes registered and non-registered

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During the waiting period, you must work the specified minimum required hours except for paid time off and hours you do not work due to a medical condition, the receipt of healthcare, your health status or disability. To determine whether your spouse and dependent children are eligible to participate in the Plan, please read the eligibility information contained in the documents issued by Insurance Carriers. Providence Healthcare Management (the “Employer”) maintains the Providence Healthcare Management Employee Benefits Plan (“the Plan”) for the exclusive benefit of its eligible employees and their eligible dependents. Its purpose is to reward them by providing benefits for those eligible employees and their dependents and beneficiaries. The concept of this Plan is to allow employees to choose among different types of benefits based on their own particular goals, desires and needs. Plan benefits, including information about eligibility, are summarized in the documents issued by the Insurance Carrier[s] and/or Third Party Administrator as appropriate. These documents, together with this document, constitute the Summary Plan Description required by the federal law known as the Employee Retirement Income and Security Act (“ERISA”). Capitalized terms not otherwise defined in this document are defined in the Certificates of Coverage. Health premium contributions for married spouses (including same-sex couples) and their families are always permitted to be paid on a pre-tax basis under federal law. So, if an employee or retiree is legally married, regardless of sexual orientation, the entire premium for coverage of the employee and their spouse may be withheld from income whether the premium is paid for by the employee or the employer. By comparison, the cost of health coverage for domestic partners and any children of a domestic partner is typically a taxable benefit. Because the federal government does not recognize domestic partnership for tax purposes, employers that provide health insurance to beneficiaries other than a tax dependent as defined by the IRS, such as a non-dependent domestic partner, must calculate the estimated ‘fair market value’ of those health benefits and charge that amount to the employee as "imputed income" on the employee's Form W-2. Further, if you participate in a health FSA or HRA then claims of your domestic partner or domestic partner’s children are not eligible for reimbursement unless they qualify as your legal dependent under federal law. For employees who work an intermittent or otherwise irregular schedule it is the intention of the employer to comply with determination of hours counting rules as provided in Code §4980H and described as follows: Identifying full-time employee status for people working irregular schedules is made by calculating employees’ hours during a specified period of months (‘measurement period’) and then locking in that status (full-time or not) for a separate specified period (‘stability period’). This measurement method will be used for determining an employee’s status as full-time and eligibility for group health benefits. If you complete your initial measurement period and are eligible for coverage then your coverage will start no later than 13 months from the employee’s start date, plus if your start date is not the first day of a calendar month, the time remaining until the first day of the next calendar month. The look-back measurement method uses the following defined terms:

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• A “measurement period” is the look-back period over which hours are calculated to determine whether an employee has averaged at least 30 hours per week. There are two types of measurement periods: standard measurement periods and initial measurement periods.

• The “standard measurement period” is used for ongoing employees, the standard measurement period for this plan is 12 months.

• The “initial measurement period” is used for new employees, the initial measurement period for this plan is 12 months.

• The “stability period” is the period that follows, and is associated with, a particular measurement period. An employee’s full-time or part-time status (determined based on hours credited during the measurement period) generally is locked in for the full stability period, regardless of the employee’s actual hours during the stability period (provided that the employee continues to be an employee during the stability period). The stability period begins at the end of the measurement period and any administrative period and is 12 months for this plan.

• The “administrative period” is a period after the end of a measurement period—and before the beginning of the stability period associated with the measurement period—during which the employer can perform administrative tasks, such as calculating the hours for the measurement period, determining eligibility for coverage, providing enrollment materials to eligible employees, and conducting open enrollment. The administrative period for this plan for new employees is 1 month, and for ongoing employees is 90 days.

• An “ongoing employee” is an employee who has been employed for at least one complete standard measurement period.

• A “new employee” is an employee who has not been employed for at least one complete standard measurement period.

The Plan will extend benefits to dependent children placed with you for adoption under the same terms and conditions as apply in the case of dependent children who are your biological children. Also eligible is any child covered under a Qualified Medical Child Support Order (QMCSO) as defined by applicable law and determined by your Employer under its QMCSO procedures, a copy of which is available from your Human Resources Department, free of charge. If eligible, you must complete an application form to enroll in the Plan or otherwise comply with your Employer’s enrollment procedures. Coverage will terminate if you no longer meet the eligibility requirements. Coverage may also terminate if you fail to pay your share of the premium, if your hours drop below the required eligibility threshold, if you submit false claims, etc. (See the Certificate(s) of Coverage or Service Agreement for more information.) Coverage for your spouse and dependents stops when your coverage stops. Their coverage will also stop for other reasons specified in the Certificate of Coverage. NOTE: The Plan Administrator reserves the right to terminate your health care coverage prospectively without notice for cause (as determined by the Plan Administrator), or if you or a dependent are otherwise determined to be ineligible for coverage under the Plan. In addition, if you or your dependent commits fraud or intentional misrepresentation of a material fact (including, for example, in an application for health coverage under the Plan, in connection with a benefit claim or

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appeal, or in response to any request for information by the Plan Sponsor or its delegees (including the Plan Administrator or a claims administrator), the Plan Administrator may terminate your coverage retroactively upon 30 days’ notice. Failure to inform any such persons that you or your dependent is covered under another group health plan (if required by the Plan) or knowingly providing false information in order to obtain coverage for an ineligible dependent are examples of actions that constitute fraud under the Plan. Coverage may also be terminated retroactively and without notice (unless required by law) if the Plan Administrator or its delegee determines that a spouse or dependent is ineligible for coverage under the Plan and such retroactive termination would not be considered a rescission under the Affordable Care Act. If coverage is terminated retroactively, you must reimburse the Plan and/or its delegee for the costs associated with providing coverage to any ineligible persons (including benefit claims, processing fees, administrative charges and all other costs), plus interest and any attorneys’ fees incurred by them in order to collect such amounts. Additionally, you may be subject to further disciplinary action from the Plan Sponsor, including, but not limited to, termination of employment. IV. SPECIAL SITUATIONS & EXTENSION OF COVERAGE

A. Mid-year Benefit Changes Generally, the benefits that you elect at open enrollment remain in effect through the entire Plan Year. However, you may be able to make certain mid-year changes to your post-tax benefits. In addition, you may be able to make certain mid-year changes to your pre-tax benefits, provided the change meets standards set forth by the Internal Revenue Service. These changes, described below, are called status changes, and you must notify the Plan Administrator within 30 days of experiencing a status change event (or within 30 days or 60 days, as applicable, for a HIPAA special enrollment event, as described below).

B. Status Changes You may be able to make changes to your Medical, Dental and Vision if you experience a mid-year status change and can provide sufficient documentation of the event to the satisfaction of the Plan Administrator. The following events are considered status changes:

• Change in legal marital status (such as marriage, divorce, death of spouse, legal separation and annulment);

• Change in number of dependents (such as birth, adoption, placement for adoption and death. See also, HIPAA Special Enrollment, below.);

• Change in employment status (such as termination or commencement of employment, strike or lockout, commencement of or return from an unpaid leave of absence, or a change in worksite that affects benefits eligibility);

• Beginning or returning from FMLA leave; • Dependent satisfies or ceases to satisfy dependent eligibility requirements (such as due

to age); • Residence change (if the change affects benefits eligibility); and • Commencement or termination of adoption proceedings.

Any status change must also satisfy Internal Revenue Service “consistency” rules, which generally

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require the status change to be on an account of and correspond with an event that affects benefits eligibility. This also means that the change you make to your coverage has to be consistent with the status change. Please contact the Plan Administrator for more information.

C. Other Changes If any of the following events takes place mid-year, you may also be able to make a mid-year change to certain pre-tax benefits:

• Cost changes (such as significant increase or decrease of coverage costs); • Significant coverage changes (such as significant restrictions or detrimental coverage

changes, significant addition or significant improvement of a coverage option); • Changes under another employer’s plan (such as different open enrollment periods); or • Loss of other group health plan coverage (such as loss of governmental or educational

institution’s coverage, state children’s health insurance program (CHIP), or foreign government group health plan).

D. HIPAA Special Enrollments If you experience one of the following HIPAA special enrollment events and notify the Plan Administrator within the timeframes indicated below, you may make medical plan elections mid-year, which would include enrolling a Dependent or Spouse:

• Acquisition of a new dependent (such as marriage, birth, adoption and placement for adoption, if notice is provided to the Plan Administrator within 30 days of the event);

• Loss of coverage under a group health plan (such as under a spouse’s plan, including termination of employer contributions); or

• Gain or loss of eligibility under Medicaid or state children’s health insurance program (CHIP) (if notice is provided no later than 60 days after the date of the event).

All HIPAA special enrollment events must meet the requirements under HIPAA regulations.

E. Family Medical Leave Act If the Family Medical Leave Act (FMLA) applies to your Employer and you qualify for an approved family or medical leave of absence (as defined in the FMLA), eligibility may continue for the duration of the leave if required contributions are paid toward the cost of the coverage. Your Employer has the responsibility to provide you with prior written notice of the terms and conditions under which payment must be made. Failure to make payment within 30 days of the due date established by your Employer will result in the termination of coverage. Subject to certain exceptions, if you fail to return to work after the leave of absence, your Employer has the right to recover from you any contributions toward the cost of coverage made on your behalf during the leave, as outlined in the FMLA. If coverage is terminated for failure to make payments while you are on an approved family or medical leave of absence, coverage for you and your eligible dependents will be automatically reinstated on the date you return to employment if you and your dependents are otherwise eligible under the plan. Any waiting period for pre-existing conditions or other waiting periods will not

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apply. However, all accumulated annual and lifetime maximums will apply. If you do not return to work at the end of an FMLA leave, you may be entitled to elect COBRA Continuation Coverage, even if you were not covered under the Plan during the leave. Coverage continued under this provision is in addition to coverage described below under the section entitled “Continuation Coverage (COBRA).” The Plan intends to comply with all existing FMLA regulations. If for some reason the information presented differs from actual FMLA regulations, the Plan reserves the right to administer the FMLA in accordance with such actual regulations.

F. Military Leave Coverage The Uniformed Services Employment and Reemployment Rights Act (USERRA) establishes requirements that employers must meet for certain employees who are involved in the uniformed services. As used in this provision, “Uniformed Services” means:

• The Armed Forces; • The Army National Guard and the Air National Guard when engaged in active duty for

training, inactive duty training, or full-time National Guard duty (pursuant to orders issued under federal law);

• The commissioned corps of the Public Health Service; and • Any other category of persons designated by the President in time of war or national

emergency. As used in this provision, “Service in the Uniformed Services” or “Service” means the performance of a duty on a voluntary or involuntary basis in a Uniformed Service under competent authority and includes:

• Active duty; • Active duty for training; • Initial active duty training; • Inactive duty training; • Full-time National Guard duty; • A period for which you are absent from your job for purpose of an examination to

determine your fitness to perform any such duties; • A period for which you are absent from your job for the purpose of performing certain

funereal honors duty; and • Certain service by intermittent disaster response appointees of the National Disaster

Medical System (NDMS).

If you were covered under this Plan immediately prior to taking a leave for Service in the Uniformed Services, you may elect to continue your coverage under USERRA for up to 24 months from the date your leave for uniformed service began, if you pay any required contributions toward the cost of the coverage during the leave. This USERRA continuation coverage will end earlier if one of the following events takes place:

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• You fail to make a premium payment within the required time; • You fail to report to work or to apply for reemployment within the time period required

by USERRA following the completion of your service; or • You lose your rights under USERRA, for example, as a result of a dishonorable

discharge.

If the leave is 30 days or less, your contribution amount will be the same as for active employees. If the leave is longer than 30 days, the required contribution will not exceed 102% of the cost of coverage. Coverage continued under this provision runs concurrently with coverage described below under the section entitled “COBRA Continuation Coverage.” If your coverage under the Plan terminated because of your Service in the Uniformed Services, your coverage will be reinstated on the first day you return to employment if you are released under honorable conditions and you return to employment within the time period(s) required by USERRA. When coverage under this Plan is reinstated, all of the Plan’s provisions and limitations will apply to the extent that they would have applied if you had not taken military leave and your coverage had been continuous. This waiver of limitations does not provide coverage for any illness or injury caused or aggravated by your military service, as determined by the VA. (For complete information regarding your rights under USERRA, contact your Employer.) The Plan intends to comply with all existing regulations of USERRA. If for some reason the information presented in the Plan differs from the actual regulations of USERRA, the Plan reserves the right to administer the plan in accordance with such actual regulations. V. COBRA CONTINUATION COVERAGE The following benefits are subject to COBRA continuation coverage: Medical, Dental and Vision plans. COBRA Continuation Coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed below. 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 a group health plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. Federal law does not recognize your domestic partner as your spouse and a domestic partner is not recognized as a COBRA qualified beneficiary. Therefore, COBRA rights and protections do not apply to any extension of domestic partner coverage. However, the Plan may extend COBRA-like coverage to your domestic partner and his or her covered children. Please refer to the applicable underlying documents to determine any potential extension of coverage.

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If you are an employee, you will become a qualified beneficiary if you will lose your coverage under a group health plan because either one of the following qualifying events happens:

• Your hours of employment are reduced; or

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

If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under a group health plan because any of the following qualifying events happens:

• Your spouse dies;

• Your spouse’s hours of employment are reduced;

• Your spouse’s employment ends for any reason other than his or her gross misconduct;

• Your spouse becomes entitled to Medicare (Part A, Part B, or both); or

• You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they will lose coverage under a group health plan because any of the following qualifying events happens:

• The parent-employee dies;

• The parent-employee’s hours of employment are reduced;

• The parent-employee’s employment ends for any reason other than his or her gross misconduct;

• The parent-employee becomes entitled to Medicare (Part A, Part B, or both);

• The parents become divorced or legally separated; or

• The child stops being eligible for coverage under the plan as a “dependent child.”

If this plan offers coverage to retirees and you are a retiree, you will become a qualified beneficiary if you will lose your coverage under a group health plan because of your employer’s bankruptcy. If this plan does not offer retiree coverage, this qualifying event does not apply. The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the Eligible Employee, or the Eligible Employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), the Company must notify the Plan Administrator of the qualifying event.

You Must Give Notice of Some Qualifying Events. For all other qualifying events (divorce or legal separation of you and your spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You should send this notice, in writing, describing the qualifying event, to the Plan Administrator. If you do not provide timely notice, you may not be eligible for COBRA coverage.

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Note: To choose this continuation coverage, an individual must be covered under the Plan on the day before the qualifying event. In addition, your newborn child or child placed for adoption with you during a period of continuation coverage will remain eligible for continuation coverage for the remaining period of coverage even if you and/or your spouse terminate continuation coverage following the child’s birth or placement for adoption. Notification Requirements Subject to the Plan Administrator being informed in a timely manner of the qualifying events described in the above paragraphs, the Plan will promptly notify you and other qualifying individual(s) of their continuation coverage rights. You and any applicable dependents must elect continuation coverage within 60 days after Plan coverage would otherwise end, or, if later, within 60 days of the notice of continuation coverage rights. Failure to elect continuation coverage within this 60-day period will result in loss of continuation coverage rights. Trade Act of 2002 If you qualify for Trade Adjustment Assistance (TAA) as defined by the Trade Act of 2002, then you will be provided with an additional 60-day enrollment period, with continuation coverage beginning on the date of such TAA approval. Notice of Unavailability of Continuation Coverage If the Plan Administrator receives a notice of a qualifying event from you or your dependent and determines that the individual (you or your dependent) is not entitled to continuation coverage, the Plan Administrator will provide to the individual an explanation as to why the individual is not entitled to continuation coverage. This notice will be provided within the same time frame that the Plan Administrator would have provided the notice of right to elect continuation coverage. Maximum Period of Continuation Coverage The maximum period of continuation coverage is 36 months from the date of the qualifying event, unless the qualifying event is your termination of employment or reduction in hours. In that case, the maximum period of continuation coverage is generally 18 months from the date of the qualifying event. However, if a qualifying individual is disabled (as determined under the Social Security Act) at the time of your termination or reduction in hours or becomes disabled at any time during the first 60 days of continuation coverage, continuation coverage for the qualifying individual and any non- disabled eligible dependents who are also entitled to continuation coverage may be extended to 29 months provided the qualifying individual or dependent, if applicable, notifies the Plan Administrator in writing within the 18-month continuation coverage period and within 60 days after receiving notification of determination of disability. If a second qualifying event occurs (for example, your death or divorce) during the 18- or 29-month coverage period resulting from your termination of employment or reduction in hours, the maximum

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period of coverage will be computed from the date of the first qualifying event, but will be extended to the full 36 months if required by the subsequent qualifying event. A special rule applies if the qualifying individual is your spouse or dependent child whose qualifying event was the termination or reduction in hours of your employment and you became entitled to Medicare within 18 months before such qualifying event. In that case, the qualifying individual’s maximum period of continuation coverage is the longer of 36 months from the date of your Medicare entitlement or their otherwise applicable maximum period of coverage. Cost of Continuation Coverage The cost of continuation coverage is determined by the Employer and paid by the qualifying individual. If the qualifying individual is not disabled, the applicable premium cannot exceed 102 percent of the Plan’s cost of providing coverage. The cost of coverage during a period of extended continuation coverage due to a disability cannot exceed 150 percent of the Plan’s cost of coverage. Premium payments for continuation coverage for you or your eligible dependent’s “initial premium month(s)” are due by the 45th day after electing continuation coverage. The “initial premium month(s)” are any month that ends on or before the 45th day after you or the qualifying individual elect continuation coverage. All other premiums are due on the first of the month for which coverage is sought, subject to a 30-day grace period. Premium rates are established by your Employer and may change when necessary due to Plan modifications. The cost of continuation coverage is computed from the date coverage would normally end due to the qualifying event. Failure to make the first payment within 45 days or any subsequent payment within 30 days of the established due date will result in the permanent cancellation of continuation coverage. When Continuation Coverage Ends Continuation of coverage ends on the earliest of:

• The date the maximum continuation coverage period expires;

• The date your Employer no longer offers a group plan to any of its employees;

• The first day for which timely payment is not made to the Plan;

• The date the qualifying individual becomes covered by another group plan. However, if the new plan contains an exclusion or limitation for a pre-existing condition of the qualifying individual, continuation coverage will end as of the date the exclusion or limitation no longer applies;

• The date the qualifying individual becomes entitled to coverage under Medicare; and

• The first day of the month that begins more than 30 days after the qualifying individual who was entitled to a 29-month maximum continuation period is subject to a final determination under the Social Security Act that he or she is no longer disabled.

Note: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that all health insurance carriers that offer coverage in the individual market accept any eligible individuals

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who apply for coverage without imposing a pre-existing condition exclusion. In order to be eligible to apply for such coverage from a carrier after ceasing participation in the Plan, you or your eligible dependents must elect continuation coverage under the Plan, continue through the maximum continuation coverage period (18, 29, or 36 months, as applicable), and then apply for coverage with the individual insurance carrier before a 63 day lapse in coverage. For more information about your right to such individual insurance coverage, contact an independent insurance agent or your state insurance commissioner. You also may have other options available to you when you lose group 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 plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. Notice of Termination Before Maximum Period of COBRA Coverage Expires If continuation coverage for a qualifying individual terminates before the expiration of the maximum period of continuation coverage, the Plan Administrator will provide notice to the individual of the reason that the continuation coverage terminated, and the date of termination. The notice will be provided as soon as practicable following the Plan Administrator’s determination regarding termination of the continuation coverage. The Plan intends to comply with all applicable law regarding continuation (COBRA) coverage. If for some reason the information presented in this Plan differs from actual COBRA requirements, the Plan reserves the right to administer COBRA in accordance with such actual COBRA requirements. VI. SUMMARY OF PLAN BENEFITS The Plan provides eligible employees and their eligible dependents with health insurance. These benefits are provided under the Group Insurance Contracts with the Insurance Carriers. A summary of the benefits provided under the Plan is in the documents issued by the Insurance Carriers. The Plan, through the Group Insurance Contracts, provides benefits in accordance with the applicable requirements of federal laws, such as Employee Retirement Income Security Act (ERISA), Consolidated Omnibus Budget Reconciliation Act (COBRA), Health Insurance Portability Accountability Act (HIPAA), Newborns’ and Mothers’ Health Protection Act (NMHPA), Mental Health Parity Act (MHPA), and the Women’s Health and Cancer Rights Act (WHCRA). VII. PLAN ADMINISTRATION The administration of the Plan is under the supervision of the Plan Administrator. The principal duty of the Plan Administrator is to see that the Plan is carried out, in accordance with its terms, for the exclusive benefit of persons entitled to participate in the Plan without discriminating among them.

A. Administration Any fully-insured benefit as described in Section III above is provided under a Group Insurance

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Contract entered into between the Employer and the Insurance Carrier. Claims for benefits are sent to the Insurance Carrier, and the Insurance Carrier, not the Employer, is responsible for paying them. The Insurance Carrier is also responsible for determining the amount of any benefits payable under the Plan and prescribing claims procedures and forms to be followed to receive Plan benefits. The Insurance Carrier also has the discretionary authority to require participants to furnish it with such information as it determines is necessary for the proper administration of claims for Plan benefits. Any self-insured benefit as described in Section III above is provided under a Benefits Administration Contract entered into between the Employer and a Third-Party Administrator. Claims for benefits are sent to the Claims Administrator, and the Employer, not the Claims Administrator, is responsible for paying them. The Employer is responsible for determining eligibility for and the amount of any benefits payable under the Plan and prescribing claims procedures and forms to be followed to receive Plan benefits. The Claims Administrator also has the discretionary authority to require participants to furnish it with such information as it determines is necessary for the proper administration of claims for Plan benefits.

B. Amendment or Termination of the Plan As Plan Sponsor, the Employer has the right to amend or terminate the Plan at any time. You have no vested or permanent rights or benefits under the Plan. Plan benefits will typically change from year-to-year and you should examine the SPD provided to you each year to determine the benefits of the Plan.

C. No Contract of Employment The Plan is not intended to, and does not, either directly or indirectly constitute any form of employment contract or other employment arrangement between you and Employer.

D. Other Materials

The Certificates of Coverage (including the Member Payment Summary, and the Provider & Facility Directory) issued by the insurance carriers are part of the Summary Plan Description. Please refer to these materials for other important provisions regarding your participation in the Plan.

E. Claims and Appeals Claims for benefits under each Plan feature will be reviewed in accordance with procedures contained in the policies, contracts, summary plan descriptions or other written materials for such Plan component. However, all issues or disputes solely regarding eligibility for coverage or participation and all other general inquiries or requests should be directed to the Plan Administrator. If a non-insurance related claim under the Plan is denied in whole or in part, you or your beneficiary will receive written notification. The notification will include the reasons for the denial, with reference to the specific provisions of the Plan on which the denial was based, a description of any additional information needed to process the claim and an explanation of the claims review procedure.

The Plan Administrator has the exclusive right to interpret the provisions of the Plan. Decisions of the Plan Administrator are final, conclusive and binding. The Plan Administrator has final claims

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adjudication authority under the Plan. However, the Plan Administrator may delegate duties and authority to others to accomplish those duties. For instance, the applicable administrator listed in the table above is the claims administrator for the respective component plan; each has sole and complete discretionary authority to determine claims and appeals in accordance with the terms of the documents or instruments governing the plan in which you are enrolled. The insurance carrier or claims administrator of each ERISA plan sponsored by the Employer has sole and complete discretionary authority to administer and interpret the provisions of the plan it insures or administers. Fully Insured Benefits The insurance carrier that provides insured Benefits is responsible for paying claims and making benefits decisions for the fully insured Benefits under the plan. The claims procedures applicable to the insured Benefits are described in the applicable Benefit document. Self-Insured Benefits To the extent not otherwise covered in the underlying component benefit plan documents (such as those provided by a third-party administrator), self-insured Benefits are subject to the claims procedures below. If you make a claim under the Plan, the following procedures will be followed if your claim is denied, in whole or in part.

1. If your claim is denied, you will receive written notification within 90 days after the claim was submitted. The notification will include the reasons for the denial, with reference to the specific provisions of the Plan on which the denial was based, a description of any additional information needed to process the claim and an explanation of the claims review procedure. If you do not receive a response within 90 days, the claim is treated as not denied.

2. Within 60 days after notification of a claim denial, you may appeal the denial by submitting a written request for reconsideration of the claim to the Plan Administrator. Documents or records in support of the appeal should accompany any such request. The Plan Administrator will review the claim and provide, within 60 days, a written response to the appeal. This 60-day period may be extended an additional 60 days under special circumstances, as determined by the Plan Administrator. The Plan Administrator’s response will explain the reason for the decision with specific reference to the provisions of the Plan on which the decision is based. The Plan Administrator has the exclusive and discretionary right to interpret the appropriate plan provisions. Decisions of the Plan Administrator are conclusive and binding.

For additional information on the claims process and procedures, please see Exhibit A. VIII. HIPAA PRIVACY AND SECURITY The Notice of Privacy Practices (“Notice”) describes the legal obligations of the Plan and your legal rights regarding your protected health information held by the Plan under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act). The Insurance Carriers hold the primary obligation of providing you with this Notice for their respective benefits.

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IX. ADDITIONAL RIGHTS Your Rights Under The Employee Retirement Income Security Act (ERISA) As a participant in the Plan (which is a type of employee welfare plan called a “group plan”) you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all group plan participants shall be entitled to: Receive Information About Your Plan and Benefits

Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including, where applicable, insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a Qualifying Event. You or your dependents may have to pay for such coverage. Review this Summary Plan Description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. Reduction or elimination of exclusionary periods of coverage for preexisting conditions under the Plan, if you have creditable coverage from another group plan. You should be provided a certificate of creditable coverage, free of charge, from a group plan or a health insurance issuer when you lose coverage under a group plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the Plan. The people who operate the Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA.

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Enforce Your Rights

If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your Questions

If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration at 1.866.444.EBSA. You may also visit its website at www.dol.gov/ebsa.

Newborn’s and Mother’s Health Protection Act

Group 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 consulting 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). Women’s Health and Cancer Rights Act of 1998 (WHCRA) As required by the WHCRA, group plans are required to provide benefits for mastectomy- related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses,

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and complications resulting from a mastectomy (including lymphedema). An employee may obtain, without charge, additional information from the Plan Administrator. Genetic Information Nondiscrimination Act of 2008 Group plans are subject to the provision of GINA, which expands the genetic information nondiscrimination protections included in Title I of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Under GINA, premiums for a plan or a group of similarly situated individuals cannot be based on genetic information. GINA “generally prohibits plans and issuers from requesting or requiring an individual to undergo genetic tests, and prohibits a plan from collecting genetic information (including family medical history) prior to or in connection with enrollment, or for underwriting purposes.” Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) 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 on the notice in the link 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). For more information on which states offer this coverage and how to contact them, please go to: www.dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/chipra/model-notice.pdf

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Exhibit A

Claims and Appeals The following claims procedure will apply specifically to claims made under any group health plan covered under the Plan. To the extent that this procedure is inconsistent with the claims procedures contained in the policies, contracts, summary plan descriptions or other written materials for a group health plan covered under the Plan, the claims procedures in such other policies, contracts, summary plan descriptions, or other written materials will supersede this procedure as long as such other claims procedures comply with DOL Regulation §2560.503-1 and the Affordable Care Act. Benefit Determinations Post-Service Claims Post-Service Claims are those claims that are filed for payment of benefits after health care has been received. If your Post-Service Claim is denied, you will receive a written notice from the Plan Administrator within 30 days of receipt of the claim, as long as all needed information was provided with the claim. The Plan Administrator will notify you within this 30- day period if additional information is needed to process the claim, and may request a one-time extension not longer than 15 days and hold your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame and the claim is denied, the Plan Administrator will notify you of the denial within 15 days after the information is received. If you don’t provide the needed information within the 45-day period, your claim will be denied. Pre-Service Claims Pre-Service Claims are those claims that require notification or approval prior to receiving health care. If your claim is a Pre-Service Claim, and it is submitted improperly, the Plan Administrator will notify you of the improper filing and how to correct it within 5 days. If your Pre-Service Claim is submitted properly with all needed information, you will receive written notice of the claim decision from the Plan Administrator within 15 days of receipt of the claim. The Plan Administrator will notify you within this 15-day period if additional information is needed to process the claim, and may request a one-time extension not longer than 15 days and hold your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame, the Plan Administrator will notify you of the determination within 15 days after the information is received. If you don’t provide the needed information within the 45-day period, your claim will be denied. Urgent Claims Urgent Care Claims are those claims that require notification or approval prior to receiving medical care, where a delay in treatment could seriously jeopardize your life or health or the ability to regain maximum function or, in the opinion of a doctor with knowledge of your health condition, could

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cause severe pain. In these situations: • You will receive notice of the benefit determination in writing or electronically

within 72 hours after the Plan Administrator receives all necessary information, taking into account the seriousness of your condition.

• Notice of denial may be oral with a written or electronic confirmation to follow within 3 days.

If you file an Urgent Care Claim improperly, the Plan Administrator will notify you of the improper filing and how to correct it within 24 hours after the Urgent Care Claim is received. If additional information is needed to process the claim, the Plan Administrator will notify you of the information needed within 24 hours after the claim was received. You then have 48 hours to provide the requested information. You will be notified of a determination no later than 48 hours after:

• The Plan Administrator’s receipt of the requested information; or • The end of the 48-hour period within which you were to provide the additional

information. Concurrent Care Claims If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an Urgent Care Claim as defined above, your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the end of the approved treatment. The claims administrator will make a determination on your request for the extended treatment within 24 hours from receipt of your request. If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will be treated as an Urgent Care Claim and decided according to the timeframes described above. If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new claim and decided according to post-service or pre-service timeframes, whichever applies. Benefits Determination Notice A denial notice for a group health plan will include:

• the specific reason(s) for your adverse benefit determination; • reference to the specific Plan provision on which the determination is based; • a description of any additional material or information necessary for you to fix

your claim and an explanation of why such material or information is necessary; • a description of the review procedures, including a statement of your right to bring

a lawsuit following an adverse benefit determination on review; • either the specific rule or guideline used in making your benefits determination

or a statement that such a rule or guideline was relied upon in making the determination and that a copy of such rule or guideline will be provided free of

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charge upon request; • if the adverse benefit determination is based on a medical judgment, either an

explanation of such judgment, or a statement that such explanation will be provided to you free of charge upon request; and

• in the case of an Urgent Care Claim, a description of the expedited review process to which you may be entitled.

In addition to the notice standards described above, to the extent required by the Affordable Care Act, all adverse benefit determination notices will include the following: (a) information identifying the claim involved, including the date of service, the health care provider, the claim amount, the diagnosis code, the treatment code, and the corresponding meaning of those codes; (b) the reason or reasons for the adverse benefit determination that includes the denial code and its corresponding meaning and a description of the Plan’s standard, if any, that was used to deny the claim (for notices of final internal adverse benefit determinations, the description will include a discussion of the decision); (c) a description of available internal appeals and external review processes, including how to initiate an appeal; and (d) contact information for any applicable office of health insurance consumer assistance or ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes. How to Appeal a Claim Decision If you disagree with a claim determination, you can contact the Plan Administrator in writing to formally request an appeal. If the appeal relates to a claim for payment, your request should include:

• The patient’s name and the identification number from the ID card. • The date(s) of health care service(s). • The provider’s name. • The reason you believe the claim should be paid. • Any documentation or other written information to support your request for claim

payment. Your first appeal request must be submitted to the Plan Administrator within 180 days after you receive the claim denial. Appeal Process A qualified individual who was not involved in the decision being appealed will be appointed to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with appropriate expertise in the field who was not involved in the prior determination. The Plan Administrator may consult with, or seek the participation of, medical experts as part of the appeal resolution process. You consent to this referral and the sharing of pertinent health claim information. Upon request and free of charge you have the right to reasonable access to and copies of, all documents, records, and other information relevant to your claim for benefits. Appeals Determinations Pre-Service and Post-Service Claim Appeals

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You will be provided with written or electronic notification of the decision on your appeal as follows: For appeals of Pre-Service Claims, the first level appeal will be conducted and you will be notified by the Plan Administrator of the decision within 15 days from receipt of a request for appeal of a denied claim. The second level appeal will be conducted and you will be notified by the Plan Administrator of the decision within 15 days from receipt of a request for review of the first level appeal decision. For appeals of Post-Service Claims, the first level appeal will be conducted and you will be notified by the Plan Administrator of the decision within 30 days from receipt of a request for appeal of a denied claim. The second level appeal will be conducted and you will be notified by the Plan Administrator of the decision within 30 days from receipt of a request for review of the first level appeal decision. For procedures associated with Urgent Claims, see “Urgent Claim Appeals” below. If you are not satisfied with the first level appeal decision of the Plan Administrator, you have the right to request a second level appeal from the Plan Administrator. Your second level appeal request must be submitted to the Plan Administrator within 60 days from receipt of first level appeal decision. Please note that the Plan Administrator’s decision is based only on whether or not benefits are available under the group health plan for the proposed treatment or procedure. The determination as to whether the pending health service is necessary or appropriate is between you and your doctor. Urgent Claim Appeals Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health or the ability to regain maximum function or cause severe pain. In these urgent situations, the appeal does not need to be submitted in writing. You or your doctor should call the Plan Administrator as soon as possible, and provide the Plan Administrator with the information identified above under “How to Appeal a Claim Decision.” The Plan Administrator will provide you with a written or electronic determination within 72 hours following receipt of your request for review of the determination taking into account the seriousness of your condition. Appeal Determination Notice Your review decision on appeal will include:

• the specific reason(s) for the adverse determination; • reference to the specific Plan provision on which the benefit determination is based; • a statement that you are entitled to receive, without charge, reasonable access to any

document (i) relied on in making the determination, (ii) submitted, considered or generated in the course of making the benefit determination, (iii) that demonstrates compliance with the administrative processes and safeguards required in making the determination, or (iv) that constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment without regard to whether the statement was relied on;

• either the specific rule or guideline used in making your benefits determination or a statement that such a rule or guideline was relied upon in making the determination and

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that a copy of such rule or guideline will be provided free of charge upon request; • if the adverse determination is based on medical necessity or experimental treatment or a

similar exclusion or limit, either an explanation of the scientific or clinical judgment applying the terms of the Plan to your medical condition, or a statement that such explanation will be provided without charge on request;

• a statement describing the Plan’s optional appeals procedures, and your right to receive information about such procedures, as well as your right to bring a lawsuit; and

• the following statement: “You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.”

If you file an internal appeal for medical benefits, you will continue to be covered pending the outcome of the internal appeal. This means that the Plan shall not terminate or reduce any ongoing course of treatment without providing advance notice and the opportunity for review. Voluntary External Review If the Group Medical Feature in which you are enrolled is not subject to a State external review process and is not a “grandfathered” plan for purposes of the Affordable Care Act, and your internal appeal of a claim for benefits (not related to employee classifications or non-covered benefits) under such plan is denied, you will have the right to request an external (i.e., independent) review if you do so within four months after receiving notice of an adverse benefit determination or final internal adverse benefit determination. Within five business days after receiving your request, a preliminary review will be completed to determine whether: (i) you are/were covered under the Plan; (ii) the denial was based on your ineligibility under the terms of the Plan; (iii) you have exhausted the Plan’s internal process, if required; and (iv) you provided all information necessary to process the external review. Within one business day after completing the preliminary review, you will be notified in writing if your appeal is not eligible for an external review or if it is incomplete. If your appeal is complete but not eligible, the notice will include the reason(s) for ineligibility. If your appeal is not complete, the notice will describe any information needed to complete the appeal. You will have the remainder of the four-month filing period or 48 hours after receiving the notice, whichever is greater, to cure any defect. If eligible for an external review, your appeal will be assigned to an independent review organization (IRO). If the IRO reverses the Plan’s denial, the IRO will provide you written notice of its determination. In addition, you will have the right to an expedited external review in the following situations:

• Following an adverse benefit determination involving a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal appeal.

• Following a final internal adverse benefit determination involving (i) a medical condition for which the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function or (ii) an admission, availability of care, continued stay, or health care item or service for which you received emergency services but have not been discharged from a facility.

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The IRO will provide notice of its final external review decision as expeditiously as your medical condition or circumstances require, but not more than 72 hours after the IRO receives the request. The Plan Administrator has the exclusive right to interpret the provisions of the Plan. Decisions of the Plan Administrator are final, conclusive and binding. The Plan Administrator has final claims adjudication authority under the Plan. However, the Plan Administrator may delegate duties and authority to others to accomplish those duties. For instance, the applicable insurance carrier or administrator listed in the table in the Eligibility section is the claims administrator for the respective component plan; each has sole and complete discretionary authority to determine claims and appeals in accordance with the terms of the documents or instruments governing the plan in which you are enrolled. The insurance carrier or claims administrator of each ERISA component benefit sponsored by the Employer has sole and complete discretionary authority to administer and interpret the provisions of the plan it insures.

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Exhibit B

HIPAA Notice of Privacy Practices

How Your Protected Health Information May Be Used and Disclosed Under the law, the Plan Sponsor may use or disclose your protected health information under certain circumstances without your permission. The following categories describe the different ways that the Plan Sponsor may use and disclose your protected health information. For each category of uses or disclosures the Plan Sponsor will explain what it means and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways the Plan Sponsor is permitted to use and disclose information will fall within one of the categories. For Treatment. (Where a health plan is involved in rendering medical services) The Plan Sponsor may use or disclose your protected health information to facilitate medical treatment or services by providers. The Plan Sponsor may disclose medical information about you to providers, including doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you. For example, the Plan Sponsor might disclose information about your prior prescriptions to a pharmacist to determine if prior prescriptions contraindicate a pending prescription. For Payment. The Plan Sponsor may use or disclose your protected health information to determine your eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, the Plan Sponsor may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational, or medically necessary, or to determine whether the Plan will cover the treatment. The Plan Sponsor may also share your protected health information with a utilization review or precertification service provider. Likewise, the Plan Sponsor may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments. For Health Care Operations. The Plan Sponsor may use and disclose your protected health information for other Plan operations. These uses and disclosures are necessary to run the Plan. For example, the Plan Sponsor may use medical information in connection with conducting quality assessment and improvement activities; underwriting, premium rating, and other activities relating to Plan coverage; submitting claims for stop-loss (or excess-loss) coverage; conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs; business planning and development such as cost management; and business management and general Plan administrative activities. However, the Plan Sponsor will not use your genetic information for underwriting purposes. Treatment Alternatives or Health-Related Benefits and Services. The Plan Sponsor may use and disclose your protected health information to send you information about treatment alternatives or other health-related benefits and services that might be of interest to you. To Business Associates. The Plan Sponsor may contract with individuals or entities known as Business Associates to perform various functions on its behalf or to provide certain types of services. In order to perform these functions or to provide these services, Business Associates will receive,

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create, maintain, transmit, use, and/or disclose your protected health information, but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information. For example, the Plan Sponsor may disclose your protected health information to a Business Associate to process your claims for Plan benefits or to provide support services, such as utilization management, pharmacy benefit management, or subrogation, but only after the Business Associate enters into a Business Associate contract with us. As Required by Law. The Plan Sponsor will disclose your protected health information when required to do so by federal, state, or local law. For example, the Plan Sponsor may disclose your protected health information when required by national security laws or public health disclosure laws. To Avert a Serious Threat to Health or Safety. The Plan Sponsor may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, the Plan Sponsor may disclose your protected health information in a proceeding regarding the licensure of a physician. To Plan Sponsors. For the purpose of administering the plan, the Plan Sponsor may disclose to certain employees of the Employer protected health information. However, those employees will only use or disclose that information as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized further disclosures. Your protected health information cannot be used for employment purposes without your specific authorization. Special Situations In addition to the above, the following categories describe other possible ways that the Plan Sponsor may use and disclose your protected health information without your specific authorization. For each category of uses or disclosures, the Plan Sponsor will explain what it means and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways the Plan Sponsor is permitted to use and disclose information will fall within one of the categories. Organ and Tissue Donation. If you are an organ donor, the Plan Sponsor may release your protected health information after your death to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Military. If you are a member of the armed forces, the Plan Sponsor may release your protected health information as required by military command authorities. The Plan Sponsor may also release protected health information about foreign military personnel to the appropriate foreign military authority. Workers' Compensation. The Plan Sponsor may release your protected health information for workers' compensation or similar programs, but only as authorized by, and to the extent necessary to comply with, laws relating to workers' compensation and similar programs that provide benefits for work-related injuries or illness.

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Public Health Risks. The Plan Sponsor may disclose your protected health information for public health activities. These activities generally include the following:

• to prevent or control disease, injury, or disability; • to report births and deaths; • to report child abuse or neglect; • to report reactions to medications or problems with products; • to notify people of recalls of products they may be using; • to notify a person who may have been exposed to a disease or may be at risk for contracting

or spreading a disease or condition; and/or, • to notify the appropriate government authority if the Plan Sponsor believes that a patient has

been the victim of abuse, neglect, or domestic violence. The Plan Sponsor will only make this disclosure if you agree, or when required or authorized by law.

Health Oversight Activities. The Plan Sponsor may disclose your protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, the Plan Sponsor may disclose your protected health information in response to a court or administrative order. The Plan Sponsor may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process by someone involved in a legal dispute, but only if efforts have been made to tell you about the request or to obtain a court or administrative order protecting the information requested. Law Enforcement. The Plan Sponsor may disclose your protected health information if asked to do so by a law-enforcement official:

• in response to a court order, subpoena, warrant, summons, or similar process; • to identify or locate a suspect, fugitive, material witness, or missing person; • about the victim of a crime if, under certain limited circumstances, the Plan Sponsor is unable

to obtain the victim's agreement; • about a death that the Plan Sponsor believe may be the result of criminal conduct; and • about criminal conduct.

Coroners, Medical Examiners, and Funeral Directors. The Plan Sponsor may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. The Plan Sponsor may also release medical information about patients to funeral directors, as necessary to carry out their duties. National Security and Intelligence Activities. The Plan Sponsor may release your protected health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Inmates. If you are an inmate of a correctional institution or are in the custody of a law-enforcement official, the Plan Sponsor may disclose your protected health information to the correctional

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institution or law-enforcement official if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Research. The Plan Sponsor may disclose your protected health information to researchers when:

• the individual identifiers have been removed; or • when an institutional review board or privacy board has reviewed the research proposal and

established protocols to ensure the privacy of the requested information, and approves the research.

Required Disclosures The following is a description of disclosures of your protected health information the Plan Sponsor is required to make. Government Audits. The Plan Sponsor is required to disclose your protected health information to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining its compliance with the HIPAA privacy rule. Disclosures to You. When you request, the Plan Sponsor is required to disclose to you the portion of your protected health information that contains medical records, billing records, and any other records used to make decisions regarding your health care benefits. The Plan Sponsor is also required, when requested, to provide you with an accounting of most disclosures of your protected health information if the disclosure was for reasons other than for payment, treatment, or health care operations, and if the protected health information was not disclosed pursuant to your individual authorization.

Other Privacy Disclosures Personal Representatives. The Plan Sponsor will disclose your protected health information to individuals authorized by you, or to an individual designated as your personal representative, attorney-in-fact, etc., so long as you provide us with a written notice/authorization and any supporting documents (i.e., power of attorney). Note: Under the HIPAA privacy rule, the Plan Sponsor does not have to disclose information to a personal representative if it has a reasonable belief that:

• you have been, or may be, subjected to domestic violence, abuse, or neglect by such person; or

• treating such person as your personal representative could endanger you; and • in the exercise of professional judgment, it is not in your best interest to treat the person as

your personal representative.

Spouses and Other Family Members. With only limited exceptions, the Plan Sponsor will send all mail to the employee. This includes mail relating to the employee's spouse and other family members who are covered under the Plan, and includes mail with information on the use of Plan benefits by the employee's spouse and other family members and information on the denial of any Plan benefits to the employee's spouse and other family members. If a person covered under the Plan has requested

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Restrictions or Confidential Communications (see below under “Your Rights”), and if the Plan Sponsor has agreed to the request, it will send mail as provided by the request for Restrictions or Confidential Communications. Authorizations. Other uses or disclosures of your protected health information not described above will only be made with your written authorization. For example, in general and subject to specific conditions, the Plan Sponsor will not use or disclose your psychiatric notes; the Plan Sponsor will not use or disclose your protected health information for marketing; and the Plan Sponsor will not sell your protected health information, unless you give us a written authorization. You may revoke written authorizations at any time, so long as the revocation is in writing. Once the Plan Sponsor receives your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation. Your Privacy Rights You have the following rights with respect to your protected health information: Right to Inspect and Copy. You have the right to inspect and copy certain protected health information that may be used to make decisions about your Plan benefits. If the information you request is maintained electronically, and you request an electronic copy, the Plan Sponsor will provide a copy in the electronic form and format you request, if the information can be readily produced in that form and format; if the information cannot be readily produced in that form and format, the Plan Sponsor will work with you to come to an agreement on form and format. If the Plan Sponsor cannot agree on an electronic form and format, it will provide you with a paper copy. To inspect and copy your protected health information, you must submit your request in writing to the Plan Administrator. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed by submitting a written request to the Plan Administrator. Right to Amend. If you feel that the protected health information the Plan Sponsor has about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan. To request an amendment, your request must be made in writing and submitted to the Plan Administrator. In addition, you must provide a reason that supports your request. The Plan Sponsor may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, the Plan Sponsor may deny your request if you ask us to amend information that:

• is not part of the medical information kept by or for the Plan; • was not created by us, unless the person or entity that created the information is no longer

available to make the amendment; • is not part of the information that you would be permitted to inspect and copy; or

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• is already accurate and complete. If the Plan Sponsor denies your request, you have the right to file a statement of disagreement with us and any future disclosures of the disputed information will include your statement. Right to an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your protected health information. The accounting will not include (1) disclosures for purposes of treatment, payment, or health care operations; (2) disclosures made to you; (3) disclosures made pursuant to your authorization; (4) disclosures made to friends or family in your presence or because of an emergency; (5) disclosures for national security purposes; and (6) disclosures incidental to otherwise permissible disclosures. To request this list or accounting of disclosures, you must submit your request in writing to the Plan Administrator. Your request must state the time period you want the accounting to cover, which may not be longer than six years before the date of the request. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be provided free of charge. For additional lists, the Plan Sponsor may charge you for the costs of providing the list. The Plan Sponsor will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on your protected health information that the Plan Sponsor uses or discloses for treatment, payment, or health care operations. You also have the right to request a limit on your protected health information that the Plan Sponsor discloses to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that the Plan Sponsor not use or disclose information about a surgery that you had. Except as provided in the next paragraph, the Plan Sponsor is not required to agree to your request. However, if the Plan Sponsor does agree to the request, it will honor the restriction until you revoke it or it notifies you. The Plan Sponsor will comply with any restriction request if (1) except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and (2) the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid in full by you or another person. To request restrictions, you must make your request in writing to the Plan Administrator. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit the Plan Sponsor’s use, disclosure, or both; and (3) to whom you want the limits to apply—for example, disclosures to your spouse. Right to Request Confidential Communications. You have the right to request that the Plan Sponsor communicates with you about medical matters in a certain way or at a certain location. For example, you can ask that the Plan Sponsor only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Plan Administrator. The Plan Sponsor will not ask you the reason for your request. Your request must

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specify how or where you wish to be contacted. The Plan Sponsor will accommodate all reasonable requests. Right to Be Notified of a Breach. You have the right to be notified in the event that the Plan Sponsor (or a Business Associate) discovers a breach of unsecured protected health information. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. Complaints If you believe that your privacy rights have been violated, you may file a complaint with the Plan or with the Office for Civil Rights of the United States Department of Health and Human Services. To file a complaint with the Plan, contact the Plan Administrator. All complaints must be submitted in writing. You will not be penalized, or in any other way retaliated against, for filing a complaint with the Office for Civil Rights or with us.