Common use of Benefit Plan Selections Clause in Contracts

Benefit Plan Selections. Medical/Rx Plan Selection: Employer may offer any combination of plans, check all that apply. All plans selection must be made available to all Eligible Persons. Plan Structure PPO EPO Select PPO PPO EPO Select PPO HMO Select HMO HSA Plans HSA Plans HSA Plans Copay Plans Copay Plans Copay Plans Plans Plans Network access PPO PPO Select PPO PPO PPO Select PPO HMO Select HMO Pharmacy Network ESI ESI ESI ESI ESI ESI Xxxxxxx Xxxxxxx In‐network Benefits Yes Yes Yes Yes Yes Yes Yes Yes Out‐of‐network Benefits non‐emergency Yes No Yes Yes No Yes No No Direct access to care: No Gate Keeper (PCP) or referrals Yes Yes Yes Yes Yes Yes No No PPO Plans PPO HSA PRx 1600 PPO HSA PRx 1800 PPO HSA PRx 2000 PPO HSA PRx 3000 PPO HSA PRx 3900 PPO HSA PRx 5000 PPO HSA PRx 6350 PPO 10/0 PPO 45/1850 PPO 50/6250/OV3 EPO HSA PRx 3000 PPO 30/650 PPO 45/2250 PPO 75/7250 EPO 25/750 PPO 25/750 PPO 50/2500 EPO Plans EPO 50/2500 PPO 30/1000 PPO 45/2850 PPO 30/1250 PPO 65/4250 Select PPO Plans S.PPO HSA PRx 1600 S.PPO HSA PRx 1800 S.PPO HSA PRx 2000 S.PPO HSA PRx 3000 S.PPO HSA PRx 3900 S.PPO HSA PRx 5000 S.PPO HSA PRx 6350 S.PPO 10/0 S.PPO 45/1850 S.PPO 65/4250 S.PPO 30/650 S.PPO 45/2250 S.PPO 50/6250/OV3 S.PPO 25/750 S.PPO 50/2500 S.PPO 30/1000 S.PPO 45/2850 S.PPO 30/1250 S.PPO 45/2850 HMO Plans HMO 10/0 HMO 35/0 HMO 25/1000 HMO 30/3000 Select HMO Plans Select HMO 10/0 Select HMO 35/0 Select HMO 25/1000 Select HMO 30/3000 Dental Plan Selection: Not available as a stand‐alone product, must also select at least one medical plan. Dental requires 100% participation of all Eligible Persons without a valid waiver form. Stand‐alone Ancillary Administration Fee of $1.65/PEPM applies if medical is canceled. Dental PPO Vision Plan Selection: Choose one plan, not available as a stand‐alone product, must also select at least one medical plan. Vision plans require 100% participation of Eligible Persons without a valid waiver form. Stand‐alone Ancillary Administration Fee of $1.65/PEPM applies if medical is canceled. Choice Standard Plan Signature Standard Plan Choice Enhanced Signature Enhanced Plan Choice Premier Plan Group Term Life: Choose one option to offered to all Eligible Persons, not available as a stand‐alone product. Life plans require 100% participation of all active, regular, full‐time (working at least 30 hours per week) employees. Option 1: one times annual earnings up to $50,000 Option 2: one times annual earnings up to $100,000 Group Long Term Disability: Choose one option to offered to all Eligible Persons, not available as a stand‐alone product. LTD plans require 100% participation of all active, regular, full‐time (working at least 30 hours per week) employees. Stand‐alone Ancillary Administration Fee applies should medical get canceled. Option 1: 60% of the monthly rate of basic earnings less other benefits up to $6,000 per month Option 2: 60% of the monthly rate of basic earnings less other benefits up to $10,000 per month General Provisions

Benefit Plan Selections. Medical/Rx Plan Selection: Employer may offer any combination of plans, check all that apply. All plans selection must be made available to all Eligible Personseligible employees. Plan Structure PPO EPO Select PPO PPO EPO Select PPO HMO Select HMO HSA Plans HSA Plans HSA Plans Copay Plans Copay Plans Copay Plans Plans Plans Network access PPO PPO Select PPO PPO PPO Select PPO HMO Select HMO Pharmacy Network ESI ESI ESI ESI ESI ESI Xxxxxxx Xxxxxxx In‐network Benefits Yes Yes Yes Yes Yes Yes Yes Yes Out‐of‐network Benefits non‐emergency Yes No Yes Yes No Yes No No Direct access to care: No Gate Keeper (PCP) or referrals Yes Yes Yes Yes Yes Yes No No PPO Plans PPO HSA PRx 1600 1400 PPO HSA PRx 1800 1850 PPO HSA PRx 2000 2800 PPO HSA PRx 3000 3600 PPO HSA PRx 3900 4800 PPO HSA PRx 5000 PPO HSA PRx 6350 5800 PPO 10/0 PPO 45/1850 20/500 PPO 50/6250/OV3 EPO HSA PRx 3000 20/1000 PPO 30/650 30/550 PPO 45/2250 30/550 RxV PPO 75/7250 EPO 25/750 35/1200 PPO 25/750 40/2000 PPO 50/2500 EPO Plans EPO 50/2500 40/2000 RxV PPO 30/1000 45/1500 PPO 45/2850 45/2500 PPO 30/1250 65/3750 PPO 65/4250 Select PPO Plans S.PPO HSA PRx 1600 S.PPO HSA PRx 1800 S.PPO HSA PRx 2000 S.PPO HSA PRx 3000 S.PPO HSA PRx 3900 S.PPO HSA PRx 5000 S.PPO HSA PRx 6350 S.PPO 10/0 S.PPO 45/1850 S.PPO 65/4250 S.PPO 30/650 S.PPO 45/2250 S.PPO 50/6250/OV3 S.PPO 25/750 S.PPO 50/2500 S.PPO 30/1000 S.PPO 45/2850 S.PPO 30/1250 S.PPO 45/2850 HMO Plans 45/6000 Saver HMO 10/0 HMO 35/0 HMO 25/1000 25/1500 HMO 30/3000 Select HMO Plans PPO HSA 1400 Select PPO HSA 1850 Select PPO HSA 2800 Select PPO HSA 3600 Select PPO HSA 4800 Select PPO HSA 5800 Select PPO 10/0 Select PPO 20/500 Select PPO 20/1000 Select PPO 30/550 Select PPO 30/550 RxV Select PPO 35/1200 Select PPO 40/2000 Select PPO 40/2000 RxV Select PPO 45/1500 Select PPO 45/2500 Select PPO 65/3750 Select PPO 45/6000 Saver Select HMO 10/0 Select HMO 35/0 Select HMO 25/1000 25/1500 Select HMO 30/3000 Dental Plan Selection: Not Choose one plan, not available as a stand‐alone product, must also select at least one medical planplan to be offered to all eligible employees. Note: Dental requires plans require 100% participation of all Eligible Persons eligible employees without a valid waiver form. Stand‐alone Ancillary Administration Fee of $1.65/PEPM applies if medical is canceled. Dental PPO Dental HMO Vision Plan Selection: Choose one plan, not available as a stand‐alone product, must also select at least one medical planplan to be offered to all eligible employees. Note: Vision plans require 100% participation of Eligible Persons eligible employees without a valid waiver form. Stand‐alone Ancillary Administration Fee of $1.65/PEPM applies if medical is canceled. Choice Standard Plan Select one provider network: Select one plan option: Signature Network Standard Plan Choice Enhanced Signature Network Enhanced Plan Choice Premier Plan – Available with Choice Network only Group Long Term LifeDisability: Choose one option to be offered to all Eligible Persons, not available as a stand‐alone producteligible employees. Life plans require Note: requires 100% participation of all active, regular, full‐time (working at least 30 hours per week) employees. Option 1: one times annual earnings up to $50,000 Option 2: one times annual earnings up to $100,000 Group Long Term Disability: Choose one option to offered to all Eligible Persons, not available as a stand‐alone product. LTD plans require 100% participation of all active, regular, full‐time (working at least 30 hours per week) employees. Stand‐alone Ancillary Administration Fee applies should medical get canceledEmployees. Option 1: 60% of the monthly rate of basic earnings less other benefits up to $6,000 per month Option 2: 60% of the monthly rate of basic earnings less other benefits up to $10,000 per month General ProvisionsGroup Term Life: Choose one option to be offered to all eligible employees. Note: requires 100% participation of all active, regular, full‐time (working at least 30 hours per week) Employees.

Benefit Plan Selections. Medical/Rx Plan Selection: Employer may offer any combination of plans, check all that apply. All plans selection must be made available to all Eligible Persons. Plan Structure PPO EPO Select PPO PPO EPO Select PPO HMO Select HMO HSA Plans HSA Plans HSA Plans Copay Plans Copay Plans Copay Plans Plans Plans Network access PPO PPO Select PPO PPO PPO Select PPO HMO Select HMO Pharmacy Network ESI ESI ESI ESI ESI ESI Xxxxxxx Xxxxxxx In‐network Benefits Yes Yes Yes Yes Yes Yes Yes Yes Out‐of‐network Benefits non‐emergency Yes No Yes Yes No Yes No No Direct access to care: No Gate Keeper (PCP) or referrals Yes Yes Yes Yes Yes Yes No No PPO Plans PPO HSA PRx 1600 1500 PPO HSA PRx 1800 PPO HSA PRx 2000 PPO HSA PRx 3000 PPO HSA PRx 3900 3850 PPO HSA PRx 5000 PPO HSA PRx 6350 PPO 10/0 PPO 30/650 PPO 25/750 PPO 30/1000 PPO 35/1250 PPO 45/1850 PPO 45/2250 PPO 50/2500 PPO 45/2850 PPO 65/4250 PPO 50/6250/OV3 EPO HSA PRx 3000 PPO 30/650 PPO 45/2250 PPO 75/7250 EPO Network EPO HSA 3000 EPO 25/750 EPO 50/2500 Select PPO Network Select PPO HSA 1500 Select PPO HSA 2000 Select PPO HSA 3000 Select PPO HSA 3850 Select PPO HSA 5000 Select PPO HSA 6350 Select PPO 10/0 Select PPO 30/650 Select PPO 25/750 PPO 50/2500 EPO Plans EPO 50/2500 Select PPO 30/1000 Select PPO 45/2850 PPO 30/1250 35/1250 Select PPO 65/4250 Select PPO Plans S.PPO HSA PRx 1600 S.PPO HSA PRx 1800 S.PPO HSA PRx 2000 S.PPO HSA PRx 3000 S.PPO HSA PRx 3900 S.PPO HSA PRx 5000 S.PPO HSA PRx 6350 S.PPO 10/0 S.PPO 45/1850 S.PPO 65/4250 S.PPO 30/650 S.PPO Select PPO 45/2250 S.PPO Select PPO 50/2500 Select PPO 45/2850 Select PPO 50/6250/OV3 S.PPO 25/750 S.PPO 50/2500 S.PPO 30/1000 S.PPO 45/2850 S.PPO 30/1250 S.PPO 45/2850 Select PPO 75/7250 HMO Plans Network HMO 10/0 HMO 35/0 HMO 25/1000 25/1500 HMO 30/3000 Select HMO Plans Network Select HMO 10/0 Select HMO 35/0 Select HMO 25/1000 25/1500 Select HMO 30/3000 Dental Plan Selection: Not available as a stand‐alone product, must also select at least one medical plan. Dental requires 100% participation of all Eligible Persons without a valid waiver form. Stand‐alone Ancillary Administration Fee of $1.65/PEPM applies if should medical is get canceled. Dental PPO Vision Plan Selection: Choose one plan, not available as a stand‐alone product, must also select at least one medical plan. Vision plans require 100% participation of Eligible Persons without a valid waiver form. Stand‐alone Ancillary Administration Fee of $1.65/PEPM applies if should medical is get canceled. Choice Standard Plan Select one provider network: Select one plan option: Signature Network Standard Plan Choice Enhanced Signature Network Enhanced Plan Choice Premier Plan – Available with Choice Network only Group Term Life: Choose one option to offered to all Eligible Persons, not available as a stand‐alone product. Life plans require 100% participation of all active, regular, full‐time (working at least 30 hours per week) employees. Stand‐alone Ancillary Administration Fee applies should medical get canceled. Option 1: one times annual earnings up to $50,000 Option 2: one times annual earnings up to $100,000 Group Long Term Disability: Choose one option to offered to all Eligible Persons, not available as a stand‐alone product. LTD plans require 100% participation of all active, regular, full‐time (working at least 30 hours per week) employees. Stand‐alone Ancillary Administration Fee applies should medical get canceled. Option 1: 60% of the monthly rate of basic earnings less other benefits up to $6,000 per month Option 2: 60% of the monthly rate of basic earnings less other benefits up to $10,000 per month General Provisions

Benefit Plan Selections. Medical/Rx Plan Selection: Employer may offer any combination of plans, check all that apply. All plans selection must be made available to all Eligible Persons. Plan Structure PPO EPO Select PPO PPO EPO Select PPO HMO Select HMO HSA Plans HSA Plans HSA Plans Copay Plans Copay Plans Copay Plans Plans Plans Network access PPO PPO Select PPO PPO PPO Select PPO HMO Select HMO Pharmacy Network ESI ESI ESI ESI ESI ESI Xxxxxxx Xxxxxxx In‐network Benefits Yes Yes Yes Yes Yes Yes Yes Yes Out‐of‐network Benefits non‐emergency Yes No Yes Yes No Yes No No Direct access to care: No Gate Keeper (PCP) or referrals Yes Yes Yes Yes Yes Yes No No PPO Plans PPO HSA PRx 1600 PPO HSA PRx 1800 PPO HSA PRx 2000 PPO HSA PRx 3000 PPO HSA PRx 3900 PPO HSA PRx 5000 PPO HSA PRx 6350 PPO 10/0 PPO 45/1850 PPO 50/6250/OV3 EPO HSA PRx 3000 PPO 30/650 PPO 45/2250 PPO 75/7250 EPO 25/750 PPO 25/750 PPO 50/2500 EPO Plans EPO 50/2500 PPO 30/1000 PPO 45/2850 PPO 30/1250 PPO 65/4250 Select PPO Plans S.PPO HSA PRx 1600 S.PPO HSA PRx 1800 S.PPO HSA PRx 2000 S.PPO HSA PRx 3000 S.PPO HSA PRx 3900 S.PPO HSA PRx 5000 S.PPO HSA PRx 6350 S.PPO 10/0 S.PPO 45/1850 S.PPO 65/4250 S.PPO 30/650 S.PPO 45/2250 S.PPO 50/6250/OV3 S.PPO 25/750 S.PPO 50/2500 S.PPO 30/1000 S.PPO 45/2850 S.PPO 30/1250 S.PPO 45/2850 HMO Plans HMO 10/0 HMO 35/0 HMO 25/1000 25/1500 HMO 30/3000 Select HMO Plans Select HMO 10/0 Select HMO 35/0 Select HMO 25/1000 25/1500 Select HMO 30/3000 Dental Plan Selection: Not available as a stand‐alone product, must also select at least one medical plan. Dental requires 100% participation of all Eligible Persons without a valid waiver form. Stand‐alone Ancillary Administration Fee of $1.65/PEPM applies if medical is canceled. Dental PPO Vision Plan Selection: Choose one plan, not available as a stand‐alone product, must also select at least one medical plan. Vision plans require 100% participation of Eligible Persons without a valid waiver form. Stand‐alone Ancillary Administration Fee of $1.65/PEPM applies if medical is canceled. Choice Standard Plan Signature Standard Plan Choice Enhanced Signature Enhanced Plan Choice Premier Plan Group Term Life: Choose one option to offered to all Eligible Persons, not available as a stand‐alone product. Life plans require 100% participation of all active, regular, full‐time (working at least 30 hours per week) employees. Stand‐alone Ancillary Administration Fee applies should medical get canceled. Option 1: one times annual earnings up to $50,000 Option 2: one times annual earnings up to $100,000 Group Long Term Disability: Choose one option to offered to all Eligible Persons, not available as a stand‐alone product. LTD plans require 100% participation of all active, regular, full‐time (working at least 30 hours per week) employees. Stand‐alone Ancillary Administration Fee applies should medical get canceled. Option 1: 60% of the monthly rate of basic earnings less other benefits up to $6,000 per month Option 2: 60% of the monthly rate of basic earnings less other benefits up to $10,000 per month General Provisions