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E— ARCHIVE

Employee Benefits Package

November 1, 2016- December 31, 2017

Brian Stuart
Senior Vice President

bstuart@andreini.com

Debra Propst
Account Executive

dpropst@andreini.com

ARCHIVE

-U

Waiver/Declination of Coverage Form

I have read and understand all of the following:

I have been offered group health and dental insurance by my employer
I voluntarily choose not to enroll myself and my dependents in the company sponsored group benefits
The next opportunity to enroll myself and my dependents will be at the next open enrollment period.

I understand that this election is irrevocable once submitted and I can only re-enroll myself and
my dependents if I experience one of two specific situations:

1) I have lost other health insurance and must provide A Letter of Credible Coverage from the
insurance company within 30 days of the termination date

2) during the annual Open Enrollment period.

Employee Initial

Reason for waiving coverage (check one):

| | l am covered by an individual health

Name of Carrier:

| | l am covered by an individual dental
Name of Carrier:

| | l am covered by another employer's health plan through my spouse / domestic partner /parent.
In addition, I also understand that I must provide written proof of other employer-sponsored
group health insurance as well as this completed form to Employee Benefits.

Name of Carrier:

B l am covered by Medicare, Medi-Cal, or Tricare or VA

I am declining coverage. I do not have other coverage. I do not want coverage
I have read and understand the above conditions and procedures for opting out of the

Internet Archive Health Insurance Plan.

Employee Name ( please print)

Date

Employee Name ( please sign)

Last 4 of SS number

Your summary of benefits

Anthem^i

BlueCross WM®

Anthem Blue Cross

Your Plan: Premier HMO 30/500A/250 OP (Essential formulary RX $10/$25/$45/30%)

Your Network: Select HMO

This summary of benefits is a brief outline of coverage , designed to help you with the selection process. This summary does not reflect each and
every benefit , exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence
of Coverage (EOC), will prevail.

Anthem Blue Cross HMO benefits are covered only when services are provided or coordinated by the primary care physician and authorised
by the participating medical group or independent practice association (TP A); except OB/ GYN services received within the member's
medical group / IP A, and services for mental and nervous disorders and substance abuse. Benefits are subject to all terms, conditions,
limitations, and exclusions of the EOC.

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Overall Deductible

See notes section to understand how your deductible works. Your plan may also have
a separate Prescription Drug Deductible. See Prescription Drug Coverage section.

Out-of-Pocket Limit

When you meet your out-of-pocket limit, you will no longer have to pay cost-shares
during the remainder of your benefit period. See notes section for additional
information regardingyour out of pocket maximum.

$1,500 single /
$3,000 family

Doctor Home and Office Services

Preventive care/ screening/immunization

In-network preventive care is not subject to deductible, if your plan has a
deductible.

No charge

Not covered

Primary care visit to treat an injury or illness

$30 copay per visit

Not covered

Specialist care visit

$30 copay per visit

Not covered

Prenatal and Post-natal Care

In network preventive pre natal and post natal services covered at 1 00%.

$30 copay per visit

Not covered

Other practitioner visits:

Retail health clinic

Not covered

Page 1 of 7

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

On-line Visit

Not covered

Chiropractor services

Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined.
Chiropractor visits count towards your physical and occupational therapy
limit.

$30 copay per visit

Not covered

Acupuncture

$30 copay per visit

Not covered

Other services in an office:

Allergy testing

$30 copay per visit

Not covered

Chemo/ radiation therapy

$30 copay per visit

Not covered

Hemodialysis

$30 copay per visit

Not covered

Prescription drugs

Tor the drugs itself dispensed in the ojfce thru infusion / injection

20% coinsurance up
to $150 per visit

Not covered

Diagnostic Services

Lab:

Office

No charge

Not covered

Freestanding Lab

No charge

Not covered

Outpatient Hospital

No charge

Not covered

X-ray:

Office

No charge

Not covered

Freestanding Radiology Center

No charge

Not covered

Outpatient Hospital

No charge

Not covered

Advanced diagnostic imaging (for example, MRI/PET/CAT
scans):

Office

Costs may vary by site of service.

$100 copay per test

Not covered

Freestanding Radiology Center
Costs may vary by site of service.

$100 copay per test

Not covered

Outpatient Hospital

Costs may vary by site of service.

$100 copay per test

Not covered

Page 2 of 7

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Emergency and Urgent Care

Emergency room facility services

This is for the hospital / facility charge only. The ER physician charge may be
separate. Copay waived if admitted.

$100 copay per visit

Covered as In-
Network

Emergency room doctor and other services

No charge

Covered as In-
Network

Ambulance (air and ground)

$100 copay per trip
for ground and air

Covered as In-
Network

Urgent Care (office setting)

Copay waived if admitted. Costs may vary by site of service.

$30 copay per visit

Covered as In-
Network

Outpatient Mental/ Behavioral Health and Substance Abuse

Doctor office visit

$30 copay per visit

Not covered

Facility visit:

Facility fees

No charge

Not covered

Outpatient Surgery

Facility fees:

Hospital

$250 copay per
admission

Not covered

Freestanding Surgical Center

$250 copay per
admission

Not covered

Doctor and other services

No charge

Not covered

Hospital Stay (all inpatient stays including maternity, mental /
behavioral health, and substance abuse)

Facility fees (for example, room & board)

$500 copay per
admission

Not covered

Doctor and other services

No charge

Not covered

Recovery & Rehabilitation

Home health care

Coverage for In-Network Provider is limited to 1 00 visit limit per benefit

$30 copay per visit

Not covered

Page 3 of 7

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

period.

Rehabilitation services (for example,
physical/ speech/ occupational therapy):

Office

Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined. Costs may
vary by site of service. Chiropractor visits count towards your physical and
occupational therapy limit.

$30 copay per visit

Not covered

Outpatient hospital

Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined. Costs may
vary by site of service.

$30 copay per visit

Not covered

Habilitation services

Habilitation visits count towards your rehabilitation limit.

$30 copay per visit

Not covered

Cardiac rehabilitation

Office

Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined.

$30 copay per visit

Not covered

Outpatient hospital

Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined. Costs may
vary by site of service.

$30 copay per visit

Not covered

Skilled nursing care (in a facility)

Coverage for In-Network Provider is limited to 100 day limit per benefit period.

No charge

Not covered

Hospice

No charge

Not covered

Durable Medical Equipment

20% coinsurance

Not covered

Prosthetic Devices

No charge

Page 4 of 7

Your summary of benefits

Covered Prescription Drug Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Pharmacy Deductible

Pharmacy Out of Pocket

Prescription Drug Coverage

Preventive Pharmacy

Preventive Immunization

$0 copay (retail
only)

50% coinsurance
(retail only)

Female oral contraceptive
Generic and Single Source brand

$0 copay (retail
only)

50% coinsurance
(retail only)

Tierl - Typically Generic

Member pays the retail pharmacy copay plus 50% for out of network. Covers up
to a 30 day supply ( retail pharmacy) Covers up to a 90 day supply ( home
delivery program)

$10 copay per
prescription (retail
only) and $25 copay
per prescription
(home delivery only)

50% coinsurance
(retail only)

Tier2 - Typically Preferred / Brand

Member pays the retail pharmacy copay plus 50 % for out of network. Covers up
to a 30 day supply ( retail pharmacy) Covers up to a 90 day supply (home
delivery program) No coverage for nonformulary drugs.

$25 copay per
prescription (retail
only) and $75 copay
per prescription
(home delivery only)

50% coinsurance
(retail only)

Tier3 - Typically Non-Preferred / Specialty Drugs

Member pays the retail pharmacy copay plus 50 % for out of network. Covers up
to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home
delivery program) No coverage for nonformulary drugs.

$45 copay per
prescription (retail
only) and $135
copay per
prescription (home
delivery only)

50% coinsurance
(retail only)

Tier4 - Typically Specialty Drugs

Classified specialty drugs must be obtained through our Specialty Pharmacy
Program and are subject to the terms of the program. Member pays the retail
pharmacy copay plus 50% for out of network. Covers up to a 30 day supply
(retail pharmacy and home delivery program) No coverage for non-formulary
drugs.

30% coinsurance up
to $250 per
prescription (retail
and home delivery)

50% coinsurance
(retail only)

Page 5 of 7

Notes:

• This Summary of Benefits has been updated to comply with federal and state requirements, including
applicable provisions of the recendy enacted federal health care reform laws. As we receive additional guidance
and clarification on the new health care reform laws from the U.S. Department of Health and Human Services,
Department of Labor and Internal Revenue Service, we may be required to make additional changes to this
Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California
Department of Insurance and the California Department of Managed Health Care (as applicable).

• In addition to the benefits described in this summary, coverage may include additional benefits, depending
upon the member’s home state. The benefits provided in this summary are subject to federal and California
laws. There are some states that require more generous benefits be provided to their residents, even if the
master policy was not issued in their state. If the member's state has such requirements, we will adjust the
benefits to meet the requirements.

• Your plan requires a selection of a Primary Care Physician. Your plan requires a referral from your Primary
Care Physician for select covered services.

• Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV,
diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services,
HIV testing) and additional preventive care for women provided for in the guidance supported by Health
Resources and Service Administration.

• For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital,
reimbursement is based on the reasonable and customary value. Members may be responsible for any amount
in excess of the reasonable and customary value.

• If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your
emergency room facility copay is waived.

• Certain services are subject to the utilization review program. Before scheduling services, the member must
make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not
paid, according to the plan.

• Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to
receiving the additional services.

• Skilled Nursing Facility day limit does not apply to mental health and substance abuse.

• Respite Care limited to 5 visits per lifetime.

• Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility.

• Infertility services are not included in the out of pocket amount.

• Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health
or dental coverage so that the services received from all group coverage do not exceed 100% of the covered
expense

• When using non-network pharmacy; members are responsible for in-network pharmacy copay plus 50% of the
remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum
allowed amount. Members will pay upfront and submit a claim form.

• Supply limits for certain drugs may be different, go to Anthem website or call customer service.

• Certain drugs require pre-authorization approval to obtain coverage.

• For additional information on limitations and exclusions and other disclosure items that apply to this plan, go
to https:/ /le.anthem.com/pdf?x=CA LG HMO

Page 6 of 7

For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage.

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem
Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Questions: (855) 333-5730 or visit us at www.anthem.com/ ca

CA/L/F/HMO/LH2175SH/LR2079/01-16

Page 7 of 7

Your summary of benefits

Anthem^i

BlueCross WM®

Anthem Blue Cross

Your Plan: Classic PPO 750/30/20 (RX $15/$30/$50/30%)

Your Network: Prudent Buyer PPO

This summary of benefits is a brief outline of coverage , designed to help you with the selection process. This summary does not reflect each and
every benefit , exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
the formal Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of
Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail.

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Overall Deductible

See notes section to understand how your deductible works. Your plan may also have
a separate Prescription Drug Deductible. See Prescription Drug Coverage section.

$750 single / $2,250
family

$1,500 single /
$4,500 family

Out-of-Pocket Limit

When you meet your out-of pocket limit, you will no longer have to pay cost-shares
during the remainder of your benefit period. See notes section for additional
information regardingyour out of pocket maximum.

$5,000 single /
$10,000 family

$10,000 single /
$20,000 family

Doctor Home and Office Services

Preventive care/screening/immunization

In-network preventive care is not subject to deductible, if your plan has a
deductible.

No charge

40% coinsurance

Primary care visit to treat an injury or illness

Deductible does not apply to In-Network providers.

$30 copay per visit

40% coinsurance

Specialist care visit

Deductible does not apply to In-Network providers.

$30 copay per visit

40% coinsurance

Prenatal and Post-natal Care

Deductible does not apply to In-Network providers. In network preventive pre
natal and post natal services covered at 1 00%.

$30 copay per visit

40% coinsurance

Other practitioner visits:

Retail health clinic

Deductible does not apply to In-Network providers.

$30 copay per visit

40% coinsurance

On-line Visit

Deductible does not apply to In-Network providers.

$30 copay per visit

40% coinsurance

Page 1 of 8

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Chiropractor services

Coverage for In-Network Provider and Non-Network Provider combined is
limited to 30 visit limit per benefit period. Deductible does not apply to In-
Network providers.

$30 copay per visit

40% coinsurance

Acupuncture

Coverage for In-Network Provider and Non-Network Provider combined is
limited to 20 visit limit per benefit period. Deductible does not apply to In-
Network providers.

$30 copay per visit

40% coinsurance

Other services in an office:

Allergy testing

20% coinsurance

40% coinsurance

Chemo/ radiation therapy

20% coinsurance

40% coinsurance

Hemodialysis

20% coinsurance

40% coinsurance

Prescription drugs

For the drugs itself dispensed in the office thru infusion 1 injection

20% coinsurance

40% coinsurance

Diagnostic Services

Lab:

Office

20% coinsurance

40% coinsurance

Freestanding Lab

20% coinsurance

40% coinsurance

Outpatient Hospital

Coverage for Out-of -Network Provider is limited to $350 maximum per
visit.

20% coinsurance

40% coinsurance

X-ray:

Office

20% coinsurance

40% coinsurance

Freestanding Radiology Center

20% coinsurance

40% coinsurance

Outpatient Hospital

Coverage for Out-of-Network Provider is limited to $350 maximum per
visit.

20% coinsurance

40% coinsurance

Advanced diagnostic imaging (for example, MRI/PET/CAT
scans):

Office

Coverage for Out-of-Network Provider is limited to $800 maximum per
test.

20% coinsurance

40% coinsurance

Page 2 of 8

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Freestanding Radiology Center

Coverage for Out-of -Network Provider is limited to $ 800 maximum per
test.

20% coinsurance

40% coinsurance

Outpatient Hospital

Coverage for Out-of Network Provider is limited to $ 800 maximum per
test.

20% coinsurance

40% coinsurance

Emergency and Urgent Care

Emergency room facility services

Copay waived if admitted. This is for the hospital / facility charge only. The ER
physician charge may be separate.

$150 copay per
admission and then
20% coinsurance

Covered as In-
Network

Emergency room doctor and other services

20% coinsurance

Covered as In-
Network

Ambulance (air and ground)

20% coinsurance

Covered as In-
Network

Urgent Care (office setting)

Costs may vary by site of service. Deductible does not apply to In-Network
providers.

$30 copay per visit

40% coinsurance

Outpatient Mental/ Behavioral Health and Substance Abuse

Doctor office visit

Deductible does not apply to In-Network providers.

Facility visit:

$30 copay per visit

40% coinsurance

Facility fees

20% coinsurance

40% coinsurance

Outpatient Surgery

Facility fees:

Hospital

Coverage for Out-of-Network Provider is limited to $ 350 maximum per
visit.

20% coinsurance

40% coinsurance

Freestanding Surgical Center

Coverage for Out-of-Network Provider is limited to $ 350 maximum per
visit.

20% coinsurance

40% coinsurance

Doctor and other services

20% coinsurance

40% coinsurance

Page 3 of 8

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Hospital Stay (all inpatient stays including maternity, mental /
behavioral health, and substance abuse)

Facility fees (for example, room & board)

Co-pay $ 500 if you do not receive preauthori^ation. Coverage is limited to
$1 ,000 maximum per day. Apply to Out-of -Network Provider. Apply to non-
emergency admission.

20% coinsurance

40% coinsurance

Doctor and other services

20% coinsurance

40% coinsurance

Recovery & Rehabilitation

Home health care

Coverage for In-Network Provider and Non-Network Provider combined is
limited to 1 00 visit limit per benefit period.

20% coinsurance

40% coinsurance

Rehabilitation services (for example,
physical/ speech/ occupational therapy):

Office

Costs may vary by site of service.

20% coinsurance

40% coinsurance

Outpatient hospital

Coverage for Out-of-Network Provider is limited to $ 350 maximum per
visit.

20% coinsurance

40% coinsurance

Habilitation services

20% coinsurance

40% coinsurance

Cardiac rehabilitation

Office

20% coinsurance

40% coinsurance

Outpatient hospital

Coverage for Out-of-Network Provider is limited to $ 350 maximum per
visit.

20% coinsurance

40% coinsurance

Skilled nursing care (in a facility)

Coverage for In-Network Provider and Non-Network Provider combined is limited
to 100 day limit per benefit period.

20% coinsurance

40% coinsurance

Hospice

No charge

40% coinsurance

Durable Medical Equipment

20% coinsurance

40% coinsurance

Page 4 of 8

Your summary of benefits

Cost if you use an

Cost if you use a

Covered Medical Benefits

In-Network

Non-Network

Provider

Prosthetic Devices

20% coinsurance

40% coinsurance

Page 5 of 8

Your summary of benefits

Covered Prescription Drug Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Pharmacy Deductible

Pharmacy Out of Pocket

Prescription Drug Coverage

Preventive Pharmacy

Preventive Immunization

$0 copay (retail
only)

50% coinsurance
(retail only)

Female oral contraceptive
Generic and Single Source brand

$0 copay (retail
only)

50% coinsurance
(retail only)

Tierl - Typically Generic

Member pays the retail pharmacy copay plus 50% for out of network. Covers up
to a 30 day supply ( retail pharmacy) Covers up to a 90 day supply ( home
delivery program)

$15 copay per
prescription (retail
only) and $37.50
copay per
prescription (home
delivery only)

50% coinsurance
(retail only)

Tier2 - Typically Preferred / Brand

Member pays the retail pharmacy copay plus 50 % for out of network. Covers up
to a 30 day supply ( retail pharmacy) Covers up to a 90 day supply (home
delivery program)

$30 copay per
prescription (retail
only) and $90 copay
per prescription
(home delivery only)

50% coinsurance
(retail only)

Tier3 - Typically Non-Preferred / Specialty Drugs

Member pays the retail pharmacy copay plus 50% for out of network. Covers up
to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home
delivery program)

$50 copay per
prescription (retail
only) and $150
copay per
prescription (home
delivery only)

50% coinsurance
(retail only)

Tier4 - Typically Specialty Drugs

30% coinsurance up
to $250 per
prescription (retail
and home delivery)

50% coinsurance
(retail only)

Page 6 of 8

Notes:

• The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family
member will be applied to the individual deductible and individual out-of-pocket maximum; in addition,
amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one
member will pay more than the individual deductible and individual out-of-pocket maximum.

• All medical services subject to a coinsurance are also subject to the annual medical deductible.

• Annual Out-of-Pocket Maximums includes deductible, copays, coinsurance and prescription drug.

• In network and out of network deductible and out of pocket maximum are exclusive of each other.

• For plans with an office visit copay, the copay applies to the actual office visit and additional cost shares may
apply for any other service performed in the office (i.e., X-ray, lab, surgery), after any applicable deductible.

• If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your
emergency room facility copay is waived.

• If your plan includes out of network benefit and you use a non-network provider, you are responsible for any
difference between the covered expense and the actual non-participating providers charge.

• Non-emergency, out-of-network air ambulance services are limited to Anthem maximum payment of $50,000
per trip.

• Certain types of physicians may not be represented in the PPO network in the state where the member
receives services. If such physician is not available in the service area, the member's copay is the same as for
PPO (with and without pre-notification, if applicable). Member is responsible for applicable copays,
deductibles and charges which exceed covered expense.

Page 7 of 8

• Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to
receiving the additional services.

• If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in
and out of network.

• Transplants covered only when performed at Centers of Medical Excellence or Blue Distinction Centers.

• Bariatric Surgery covered only when performed at Blue Distinction Center for Specialty Care for Bariatric
Surgery.

• Skilled Nursing Facility day limit does not apply to mental health and substance abuse.

• Respite Care limited to 5 visits per lifetime.

• Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility.

• Preferred Generic Program: If a member requests a brand name drug when a generic drug version exists, the
member pays the generic drug copay plus the difference in cost between the prescription drug maximum
allowed amount for the generic drug and the brand name drug dispensed, but not more than 50% of our
average cost of that type of prescription drug. The Preferred Generic Program does not apply when the
physician has specified ’’dispense as written” (DAW) or when it has been determined that the brand name drug
is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply.

• Supply limits for certain drugs may be different, go to Anthem website or call customer service.

• Certain drugs require pre-authorization approval to obtain coverage.

• For additional information on limitations and exclusions and other disclosure items that apply to this plan, go
to https: //le.anthem.com/pdf?x=CA LG PPO

• For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of
the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue
Cross Association.

Questions: (855) 333-5730 or visit us at www.anthem.com/ ca
CA/L/F/PPO/LP2075/LR2055/01-16

Page 8 of 8

Your summary of benefits

Anthem[^i

BlueCross BB®

Anthem Blue Cross

Your Plan: Lumenos HSA 2500/3500 20/40 (LHSA499)

Your Network: Prudent Buyer PPO

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and
every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
the formal Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of
Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail.

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Overall Deductible

See notes section to understand how your deductible works. Your plan may also have
a separate Prescription Drug Deductible. See Prescription Drug Coverage section.

$2,500 single /
$5,000 family

$3,500 single /
$7,000 family

Out-of-Pocket Limit

$3,000 single /
$6,000 family

$7,000 single /
$14,000 family

Doctor Home and Office Services

Preventive care/screening/immunization

In-network preventive care is not subject to deductible, if your plan has a

deductible.

No charge

40% coinsurance

Primary care visit to treat an injury or illness

20% coinsurance

40% coinsurance

Specialist care visit

20% coinsurance

40% coinsurance

Prenatal and Post-natal Care

In network preventive pre natal and post natal services covered at 100%.

20% coinsurance

40% coinsurance

Other practitioner visits:

Retail health clinic

20% coinsurance

40% coinsurance

On-line Visit

20% coinsurance

40% coinsurance

Chiropractor services

Coverage for In-Network Provider and Non-Network Provider combined is
limited to 30 visit limit per benefit period.

20% coinsurance

40% coinsurance

Page 1 of 7

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Acupuncture

Coverage for In-Network Provider and Non-Network Provider combined is
limited to 20 visit limit per benefit period.

20% coinsurance

40% coinsurance

Other services in an office:

Allergy testing

20% coinsurance

40% coinsurance

Chemo/radiation therapy

20% coinsurance

40% coinsurance

Hemodialysis

20% coinsurance

40% coinsurance

Prescription drugs

For the drugs itself dispensed in the office thru infusion/injection

20% coinsurance

40% coinsurance

Diagnostic Services

Lab:

Office

20% coinsurance

40% coinsurance

Freestanding Lab

20% coinsurance

40% coinsurance

Outpatient Hospital

Coverage for Out-of-Network Provider is limited to $350 maximum per

admission.

20% coinsurance

40% coinsurance

X-ray:

Office

20% coinsurance

40% coinsurance

Freestanding Radiology Center

20% coinsurance

40% coinsurance

Outpatient Hospital

Coverage for Out-of-Network Provider is limited to $350 maximum per

admission.

20% coinsurance

40% coinsurance

Advanced diagnostic imaging (for example, MRI/PET/CAT
scans):

Office

Coverage for Out-of-Network Provider is limited to $800 maximum per

test.

20% coinsurance

40% coinsurance

Freestanding Radiology Center

Coverage for Out-of-Network Provider is limited to $800 maximum per

test.

20% coinsurance

40% coinsurance

Outpatient Hospital

20% coinsurance

40% coinsurance

Page 2 of 7

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Coverage for Out-of-Network Provider is limited to $800 maximum per

test.

Emergency and Urgent Care

Emergency room facility services

20% coinsurance

Covered as In-
Network

Emergency room doctor and other services

20% coinsurance

Covered as In-
Network

Ambulance (air and ground)

20% coinsurance

Covered as In-
Network

Urgent Care (office setting)

20% coinsurance

40% coinsurance

Outpatient Mental/Behavioral Health and Substance Abuse

Doctor office visit

20% coinsurance

40% coinsurance

Facility visit:

Facility fees

20% coinsurance

40% coinsurance

Outpatient Surgery

Facility fees:

Hospital

Coverage for Out-of-Network Provider is limited to $350 maximum per

admission.

20% coinsurance

40% coinsurance

Freestanding Surgical Center

Coverage for Out -of -Network Provider is limited to $350 maximum per

admission.

20% coinsurance

40% coinsurance

Doctor and other services

20% coinsurance

40% coinsurance

Hospital Stay (all inpatient stays including maternity, mental /
behavioral health, and substance abuse)

Facility fees (for example, room & board)

Coverage for Out-of-Network Provider is limited to $1,000 maximum per day.
Apply to non-emergency admission.

20% coinsurance

40% coinsurance

Page 3 of 7

Your summary of benefits

Covered Medical Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Doctor and other services

20% coinsurance

40% coinsurance

Recovery & Rehabilitation

Home health care

Coverage for In-Network Provider and Non-Network Provider combined is
limited to 100 visit limit per benefit period.

20% coinsurance

40% coinsurance

Rehabilitation services (for example,
physical/speech/occupational therapy) :

Office

20% coinsurance

40% coinsurance

Outpatient hospital

Coverage for Out-of -Network Provider is limited to $350 maximum per

admission.

20% coinsurance

40% coinsurance

Habilitation services

20% coinsurance

40% coinsurance

Cardiac rehabilitation

Office

20% coinsurance

40% coinsurance

Outpatient hospital

Coverage for Out-of-Network Provider is limited to $350 maximum per

admission.

20% coinsurance

40% coinsurance

Skilled nursing care (in a facility)

Coverage for In-Network Provider and Non-Network Provider combined is limited
to 100 day limit per benefit period.

20% coinsurance

40% coinsurance

Hospice

20% coinsurance

40% coinsurance

Durable Medical Equipment

50% coinsurance

Prosthetic Devices

20% coinsurance

40% coinsurance

Page 4 of 7

Your summary of benefits

Covered Prescription Drug Benefits

Cost if you use an

In-Network

Provider

Cost if you use a

Non-Network

Provider

Pharmacy Deductible

Pharmacy Out of Pocket

Prescription Drug Coverage

Preventive Pharmacy

Preventive Immunization

Deductible does not apply.

$0 copay (retail
only)

40% coinsurance
(retail only)

Female oral contraceptive

Generic and Single Source brand Deductible does not apply.

$0 copay (retail
only)

40% coinsurance
(retail only)

Tierl - Typically Generic

Covers up to a 30 day supply ( retail pharmacy) Covers up to a 90 day supply
(home delivery program)

$10 copay per
prescription (retail
only) and $25 copay
per prescription
(home delivery only)

40% coinsurance
(retail only)

Tier2 - Typically Preferred / Brand

Covers up to a 30 day supply ( retail pharmacy) Covers up to a 90 day supply
(home delivery program)

$40 copay per
prescription (retail
only) and $120
copay per
prescription (home
delivery only)

40% coinsurance
(retail only)

Tier3 - Typically Non-Preferred / Specialty Drugs

Covers up to a 30 day supply ( retail pharmacy) Covers up to a 90 day supply
(home delivery program)

$60 copay per
prescription (retail
only) and $180
copay per
prescription (home
delivery only)

40% coinsurance
(retail only)

Tier4 - Typically Specialty Drugs

Classified specialty drugs must be obtained through our Specialty Pharmacy
Program and are subject to the terms of the program. Covers up to a 30 day
supply ( retail pharmacy and home delivery program)

30% coinsurance up
to $250 per
prescription (retail
and home delivery)

40% coinsurance
(retail only)

Page 5 of 7

Your summary of benefits

Notes:

• This Summary of Benefits has been updated to comply with federal and state requirements, including
applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance
and clarification on the new health care reform laws from the U.S. Department of Health and Human Services,
Department of Labor and Internal Revenue Service, we may be required to make additional changes to this
Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California
Department of Insurance and the California Department of Managed Health Care (as applicable).

• In addition to the benefits described in this summary, coverage may include additional benefits, depending
upon the member's home state. The benefits provided in this summary are subject to federal and California
laws. There are some states that require more generous benefits be provided to their residents, even if the
master policy was not issued in their state. If the member's state has such requirements, we will adjust the
benefits to meet the requirements.

• The family deductible and out-of-pocket maximum are non-embedded meaning the cost shares of all family
members apply to one shared family deductible and one shared family out-of-pocket maximum. The individual
deductible and individual out-of-pocket maximum only apply to individuals enrolled under single coverage.

• Pharmacy deductible and pharmacy out of pocket is combined with medical deductible and out-of-pocket.

• This Lumenos plan is an innovative type of coverage that allows a member to use a Health Savings Account to
pay for medical care. The member can spend the money in the HSA account the way the member wants on
medical care, prescription drugs and other qualified medical expenses. There are no copays or deductibles to
satisfy first. Unused dollars can be saved from year to year to reduce the amount the member may have to pay
in the future. If covered expenses exceed the member's available HSA dollars, the traditional health coverage is
available after a limited out-of-pocket amount is paid by the member.

• All medical services subject to a coinsurance are also subject to the annual medical deductible.

• Annual Out-of-Pocket Maximums includes deductible, copays, coinsurance and prescription drug.

• In network and out of network deductible and out of pocket maximum are exclusive of each other.

• Non-emergency, out-of-network air ambulance services are limited to Anthem maximum payment of $50,000
per trip.

• Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to
receiving the additional services.

Page 6 of 7

Your summary of benefits

• If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in
and out of network.

• Transplants covered only when performed at Centers of Medical Excellence or Blue Distinction Centers.

• Bariatric Surgery covered only when performed at Blue Distinction Center for Specialty Care for Bariatric
Surgery.

• Skilled Nursing Facility day limit does not apply to mental health and substance abuse.

• Respite Care limited to 5 visits per lifetime.

• Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility.

• Preferred Generic Program: If a member requests a brand name drug when a generic drug version exists, the
member pays the generic drug copay plus the difference in cost between the prescription drug maximum
allowed amount for the generic drug and the brand name drug dispensed, but not more than 50% of our
average cost of that type of prescription drug. The Preferred Generic Program does not apply when the
physician has specified "dispense as written" (DAW) or when it has been determined that the brand name drug
is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply.

• Supply limits for certain drugs may be different, go to Anthem website or call customer service.

• Certain drugs require pre-authorization approval to obtain coverage.

• For additional information on limitations and exclusions and other disclosure items that apply to this plan, go
to https://le.anthem.com/pdf?x=CA LG CDHP

• For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage.

Questions: (855) 333-5730 or visit us at www.anthem.com/ca
C A/L/F/CDHP/LL2077/NA/0 1-16

Page 7 of 7

mmamBcm

You’re on the go

and so are we

Find a doctor

Search for a doctor, specialist, urgent care or hospital close by.

Get your ID card

Share, fax, or email your ID card right from your smartphone.

With the Anthem Anywhere app, you can manage
your benefits anytime and anywhere you go. Just
search for Anthem Anywhere and download
the app.

— V

Check your claims

Find out what your doctor billed, how much was paid and if you
owe anything.

Estimate your costs

See what nearby doctors and facilities charge for a procedure.
You can compare providers on cost and quality.

View your medical benefits

See your copays, deductibles, your percentage of the costs,
and other important plan benefit information.

Manage prescription benefits

Check the cost of drugs, get refills or switch to our home
delivery program.

No! signed up? Regater now.
Username
Password

D«eme«p>er my username

Forgot username or password?

Download the Anthem Anywhere app today.

Access your mobile Health Record

View your Health Record and share with your doctors whenever Together we can make healthy happen,

you go.

Download on the ■ androidappon

• AppStore I Google play

Anthem.

BlueCross

Only available on Apple and Android devices

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
59674CAMENABC_WGS VPOD 04/16

LiveHealth

Online

Quick and easy access
to a doctor 24/7

Have you ever been at work and didn’t feel well? Maybe you
had a fever or a sore throat but you didn’t have time to leave
and see your doctor or go to urgent care. Now, with LiveHealth
Online, you can see a board-certified doctor in minutes.

Just use your smartphone, tablet or computer with a webcam.
It’s so convenient, almost 90% of people who’ve used it feel
they saved two hours or more and would use it again in the
future. 1 Plus, online visits using LiveHealth Online are already
part of your Anthem Blue Cross benefits. To start using
LiveHealth Online, all you need to do is sign up at
livehealthonline.com or download the app.

1. 24/7 access to doctors. They can assess your condition,
provide treatment options and even send a prescription to
the pharmacy of your choice, if needed. 2 It’s a great way to
get care when your doctor isn’t available.

2. Medical care when you need it. For things like the flu, a
cold, sinus infection, pink eye, rashes, fever and more.

3. Convenience. Since there are no appointments or long
waits. In fact, most people are connected to a doctor in
about 10 minutes or less.

Doctors using LiveHealth Online typically charge $49 or less
per visit, depending on your health plan.

LiveHealth Online Psychology

An easy, convenient way to see a therapist or psychologist

injustafew days

If you’re feeling stressed, worried, or having a tough time, you can
talk to a licensed psychologist or therapist through video using
LiveHealth Online Psychology. It’s easy to use, private and, in most
cases, you can see a therapist within four days or less. 3 All you
have to do is sign up at livehealthonline.com or download the app
to get started. The cost is similar to what you’d pay for an office
therapy visit.

Make your first appointment - when it’s easy for you

o Use the app or go to livehealthonline.com and log in. Select
LiveHealth Online Psychology and choose the therapist
you’d like to see.

o Or, call LiveHealth Online at 1-844-784-8409 from 7 a.m.
to 11 p.m.

o You’ll get an email confirming your appointment.

Anthem

BlueCross

LiveHealth

ONLINE

57980CAMENABC VPOD 12/15

LiveHealth Online: what you need to know

What kind of doctors can you see on LiveHealth Online?

Doctors on LiveHealth Online are:

o Board certified with an average of 15 years of
practicing medicine

o Mainly primary care physicians
o Specially trained for online visits

When can you use LiveHealth Online?

LiveHealth Online is a great option for care when your own
doctor isn’t available and more convenient than a trip to the
urgent care. With LiveHealth Online, you can receive medical
care for things like:

o Cold and flu symptoms, such as a cough, fever
and headaches

o Allergies

o Sinus infections and more

How do I pay for an online visit using LiveHealth Online?

LiveHealth Online accepts Visa, MasterCard and Discover cards
as payment for an online doctor visit. Keep in mind that
charges for prescriptions aren’t included in the cost of your
doctor visit.

LiveHealth Online Psychology

What conditions can be treated when you have a visit with
a psychologist or therapist?

You can get help for these types of conditions:
o Stress
o Anxiety
o Depression

o Family or relationship issues
o Grief

o Panic attacks

o Stress from coping with a sickness

LiveHealth Online is the trade name of Health Management Corporation, a separate company providing telehealth services on behalf of Anthem Blue Cross.

Online counseling is not appropriate for all kinds of problems. If you are in crisis or have suicidal thoughts, it's important that you seek help immediately. Please call 1-800-784-2433
(National Suicide Prevention Lifeline) or 911 and ask for help. If your issue is an emergency, call 911 or go to your nearest emergency room. LiveHealth Online does not offer
emergency services.

1 LiveHealth Online user feedback survey, May 2015.

2 Prescription availability is defined by physician judgment and state regulations. LiveHealth Online is available in most states and is expected to grow more in the near future.

Please visit the map at livehealthonline.com for more details.

3 Appointments subject to availability of a therapist.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross
Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

After you log in at livehealthonline.com or with the app, select
LiveHealth Online Psychology. Next, you can read profiles of
therapists and psychologists. Once you select the one you
would like to see, schedule a visit online or by phone. At the
end of the first visit, you can set up future visits with the same
therapist if both of you feel it’s needed. You always have the
choice of the therapist you want to see.

What else do I need to know about LiveHealth
Online Psychology?

o You must be at least 18 years old to see a therapist
online and have your own LiveHealth Online account.

o Psychologists and therapists using LiveHealth Online do
not prescribe medications.

o Visits usually last about 45 minutes.

Get started today

It’s quick and easy to sign up for LiveHealth Online. Just go
to livehealthonline.com or download the mobile app at
Google Play™ or the App Store™.

Download on the androidappon

m AppStore ■ f* Google play

How much does a therapist visit cost?

The cost should be similar to what you’d pay for an office
therapy visit, depending on your benefits, copay or
coinsurance. You'll see what you owe before you start a visit
and any cost is charged to your credit card. The cost is the
same no matter when you have the visit — whether it’s a
weekday, the weekend, evening or a holiday.

How do l decide which therapist to see?

What do you do when you need care right away, but
it’s not an emergency?

The last place anyone wants to sit and wait hour after hour
is the emergency room (ER). And it can cost you more than
you might need to pay if you could get care from somewhere
else quickly.

You should know you have more options than just the ER.

First call your primary care doctor

He or she is the doctor you see for most care. When you call
this doctor, he or she will tell you if you should make an
appointment with the doctor or go to the ER. Your doctor may
even be able to give you advice on the phone or see you if it’s
later in the day or a weekend, so it’s important you try to
contact him or her first. Your doctor might even suggest you
go to a retail health clinic or urgent care.

But when you can’t see your doctor or if your doctor’s office is
closed, you can choose an option below. It often takes less
time than the ER and costs about the same as a doctor visit.
Plus, most are open weeknights and weekends.

Choose a care option that could save time and money

Retail health clinic — This is a clinic staffed by health care
experts who give basic health care services to “walk-in”
patients. Most often it is in a major pharmacy or retail store.

Walk-in doctor’s office - A doctor’s office that doesn’t require
you to be an existing patient or have an appointment. Can
handle routine care and common family illnesses.

Urgent care center — Doctors who treat conditions that
should be looked at right away but aren’t as severe as
emergencies. Can often do X-rays, lab tests and stitches.

Pick a care facility and call before you go

Ask:

o What are your hours?

o Tell them what has happened (for example, “I have a cut”
or “I twisted my ankle”). Then ask, do you have services
that I need?

o What age range do you treat?

o Are you a provider that is part of my health plan network?

What you pay

$ 100 -$ 250 *

$ 10- $40

ER visit

Retail health clinic, Walk in doctor’s office,
Urgent care center

*Average health plan copays. For many members, deductibles and coinsurance may apply, which can make an
even greater difference in the cost between an emergency room and alternate site of care.

When to use the ER

Always call 911 or go the ER if you think you could put your
health at serious risk by delaying care.

Why not be prepared now?

You can learn more at anthem.com/ca for:

o Urgent care that’s not an emergency - Go to

anthem.com/ca/findurgentcare. You can even take a quiz
to learn how to save time and money,
o ER alternatives - Go to anthem.com/ca and click on Find
Urgent Care. Click Search for Urgent Care and enter the
information to find a facility near you.

Anthem

BlueCross

235433CAMENABC Rev. 02/14

See the other side for examples
of when to go to the ER and
when to consider other options. ►

[TT1 iT a l

TTTil

Retail health clinic

Who usually
provides care

Sprains, strains

Animal bites

X-rays

Stitches

Mild asthma

Minor headaches

Back pain

Nausea, vomiting, diarrhea

Minor allergic reactions

Coughs, sore throat

Bumps, cuts, scrapes

Rashes, minor burns

Minor fevers, colds

Ear or sinus pain

Burning with urination

Eye swelling, irritation, redness or pain

Vaccinations

Physician assistant
or nurse practitioner

$10-$40

copay

Walk-in doctor’s office

Family practice
doctor

$10-$40

copay

Urgent care center

Internal medicine,
family practice,
pediatric and
ER doctors

$35-$75

copay

When to go to the ER

Some examples of ER medical emergencies are:

Any life-threatening or disabling condition

Severe shortness of breath

Cut or wound that won’t stop bleeding

Sudden or unexplained loss of consciousness

High fever with stiff neck, mental confusion
or difficulty breathing

Major injuries

Chest pain; numbness in the face, arm or leg;
difficulty speaking

Coughing up or vomiting blood

Possible broken bones

Options have different services and copays. Call and ask before you go.

Remember you have choices. If it’s not an emergency, call your doctor first or the 24/7 NurseLine. The phone number is on your ID
card. The nurse on the phone can help you decide what to do next.

If you are an HMO member, you should call your
primary care doctor’s office or medical group to find
out your ER alternatives for urgent care.

Be ready for whatever comes your way.

Learn more at anthem.com/ca/findurgentcare.

At Anthem Blue Cross, we're always
looking for new ways to save you
time, money and help you get more
value from your health care.

If you get care from a provider that is NOT part of your health plan network, you may have significantly higher out-of-pocket costs.

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

BlueCross.

BlueShield

Healthcare coverage when you are traveling or living abroad

As a Blue Cross and Blue Shield member, you take your healthcare benefits with you when you
are abroad. Through the BlueCard Worldwide® Program, you have access to doctors and hospitals
around the world.

To take advantage of the program:

• Always carry your current member ID card.

• Before you travel, contact your Blue Cross and
Blue Shield company for coverage details. Coverage
outside the United States may be different.

• If you need to locate a doctor or hospital, call the
BlueCard Worldwide Service Center (see number
below). An assistance coordinator, in conjunction
with a medical professional, will arrange a physician
appointment or hospitalization if necessary.

• If you need inpatient care, call the BlueCard Worldwide
Service Center (see number below). In most cases,
you should not need to pay upfront for inpatient care
at BlueCard Worldwide hospitals except for the out-
of-pocket expenses (noncovered services, deductible,
copayment and coinsurance) you normally pay. The
hospital should submit the claim on your behalf.

• In addition to contacting the BlueCard Worldwide
Service Center, call your BCBS company for precertifica-
tion or preauthorization. Refer to the phone number

on the back of your member ID card. Note: This number
is different from the phone number listed below.

• For outpatient and doctor care or inpatient care not
arranged through the BlueCard Worldwide Service
Center, you may need to pay upfront. Complete a
BlueCard Worldwide International claim form and send
it with the bill(s) to the BlueCard Worldwide Service
Center (the address is on the form). The claim form

is available from your BCBS company or online at
www.bluecardworldwide.com.

In an emergency,
go directly to the
nearest hospital.

To learn more about BlueCard Worldwide:

• Visit www.bluecardworldwide.com.

• Call your BCBS company.

• Call the BlueCard Worldwide Service Center at 1.800.810.2583
or collect at 1.804.673.1177, 24 hours a day, seven days a week.

TheBlueCard

Now, Home Is Where The Card Is®

Blue Cross, Blue Shield, the Blue Cross and Blue Shield symbols, BlueCard and BlueCard Worldwide are registered service marks
of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies.

N35-1 4-282

Benefit Summary

603439 INTERNET ARCHIVE

Principal Benefits for

Kaiser Permanente Traditional Plan (11/1/16 — 12/31/17)

Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have
questions about grandfathered health plans, please call our Member Service Contact Center.

Accumulation Period

The Accumulation Period for this plan is 1/1/16 through 12/31/16 (calendar year).

Out-of-Pocket Maximum(s) and Deductible(s)

For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation
Period once you have reached the amounts listed below.

Amounts Per Accumulation Period

Self-Only Coverage

(Family of one Member)

Family Coverage

Each Member in a Family of Entire Family of two or more

two or more Members

Plan Out-of-Pocket Maximum $1,500 $1 ,500 $3,000

Plan Deductible None None None

Drug Deductible $100 $100 Not Applicable

Professional Services (Plan Provider office visits) You Pay

Members

$3,000

None

Not Applicable

Most Primary Care Visits and most Non-Physician Specialist Visits $20 per visit

Most Physician Specialist Visits $20 per visit

Routine physical maintenance exams, including well-woman exams No charge

Well-child preventive exams (through age 23 months) No charge

Family planning counseling and consultations No charge

Scheduled prenatal care exams No charge

Routine eye exams with a Plan Optometrist No charge

Hearing exams No charge

Urgent care consultations, evaluations, and treatment $20 per visit

Most physical, occupational, and speech therapy $20 per visit

Outpatient Services You Pay

Outpatient surgery and certain other outpatient procedures $20 per procedure

Allergy injections (including allergy serum) $3 per visit

Most immunizations (including the vaccine) No charge

Most X-rays and laboratory tests No charge

Covered individual health education counseling No charge

Covered health education programs No charge

Hospitalization Services You Pay

Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs $500 per admission

Emergency Health Coverage You Pay

Emergency Department visits $1 00 per visit

Note: This Cost Share does not apply if admitted directly to the hospital as an inpatient for covered Services (see "Hospitalization
Services" for inpatient Cost Share).

Ambulance Services You Pay

Ambulance Services $1 00 per trip

Prescription Drug Coverage You Pay

Covered outpatient items in accord with our drug formulary guidelines:

Most generic items at a Plan Pharmacy or through our mail-order service $10 for up to a 100-day supply

Most brand-name items at a Plan Pharmacy or through our mail-order service $30 for up to a 100-day supply after Drug

Deductible ($100)

Most specialty items at a Plan Pharmacy 20% Coinsurance (not to exceed $150) for up to a

30-day supply

Durable Medical Equipment (DME) You Pay

DME items in accord with our DME formulary guidelines 20% Coinsurance

Mental Health Services You Pay

Inpatient psychiatric hospitalization $500 per admission

Individual outpatient mental health evaluation and treatment $20 per visit

4169146.8.1 .S000458426 - 603439 Internet Archive

(continues)

(continued)

Benefit Summary

Group outpatient mental health treatment $10 per visit

Chemical Dependency Services You Pay

Inpatient detoxification $500 per admission

Individual outpatient chemical dependency evaluation and treatment $20 per visit

Group outpatient chemical dependency treatment $5 per visit

Home Health Services You Pay

Home health care (up to 100 visits per Accumulation Period) No charge

Other You Pay

Skilled nursing facility care (up to 100 days per benefit period) No charge

Prosthetic and orthotic devices No charge

All Services related to covered infertility treatment 50% Coinsurance

Hospice care No charge

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket
maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to
the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies).

4169146.8.1 .S000458426 - 603439 Internet Archive

4169146.8. 1.S000458426

GOOD HEALTH

IS IN YOUR HANDS

o o o o

( )

Use the convenient features of
My Health Manager right from your
smartphone or other mobile device.

► Email your doctor's office

► View most test results

► Schedule or cancel routine appointments

► Refill most prescriptions

► View past visits

Just download the Kaiser Permanente app
at no cost from your preferred app site.

□ Available on the

App Store

I ™ T Are you registered? If you're

^ I already registered on kp.org, you're
all set to start using your Kaiser
Permanente app. If not, you'll need to go to
kp.org/registernow to set up your account
from a computer. Then use your new user ID
and password to activate the app.

Certain features of My Health Manager apply only to care you receive at Kaiser Permanente facilities.

Apple is a trademark of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of
Apple Inc. Google Play is a trademark of Google Inc.

Atlanta, GA 30305, 404-364-7000 • Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., in Maryland,
Virginia, and Washington, D.C., 2101 E. Jefferson St., Rockville, MD 20852 • Kaiser Foundation Health Plan of
the Northwest, 500 NE Multnomah St., Suite 1 00, Portland, OR 97232

1 30993_9/1/1 3-1 2/31/14

f#|

KAISER PERMANENTE® thrive

Connect to better health

Managing your care is easy, secure,
and convenient

^ Technology designed to help you thrive

Be empowered, stay informed, and get more out of your health plan.

Members can access all these features and more online or with our mobile app *

• Schedule and cancel
routine appointments.

• Email your doctor's office.

• View most lab results.

• Refill most prescriptions.

Print vaccination records for
school, sports, or camp.

Use tools to help you manage
your coverage and costs. f
Manage a family member's care.

m Manage your health anytime, anywhere

Get connected and see how easy it is to stay on top of your health.

Connect online when you register at kp.org.

Your first step is registering on kp.org. Once that's done, you can connect to these
great features anytime.

1. Have your health/medical record number handy.

2. Go to kp.org/register from a computer and follow the sign-on instructions.

Connect on the go with our mobile app.

The Kaiser Permanente mobile app gives you access to many of these great features
from your smartphone. Once you're registered on kp.org, you can download the
app anytime in 2 easy steps:

1. Using your smartphone, search for the Kaiser Permanente app on App Store SM
(iOS) or Google Play™ (Android™). *

2. Activate the app using your kp.org user ID and password. Learn more at

kp.org/mobile.

^Available when receiving care at Kaiser Permanente facilities, f These tools are not yet available on smartphones and tablets. *Apple is a trademark of Apple, Inc.,
registered in the U.S. and other countries. App Store is a service mark of Apple, Inc. Google Play and Android are trademarks of Google, Inc.

Kaiser Permanente health plans around the country: Kaiser Foundation Health Plan, Inc., in Northern and Southern California and Hawaii • Kaiser Foundation Health Plan
of Colorado • Kaiser Foundation Health Plan of Georgia, Inc., Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305, 404-364-7000 • Kaiser Foundation
Health Plan of the Mid-Atlantic States, Inc., in Maryland, Virginia, and Washington, D.C., 2101 E. Jefferson St., Rockville, MD 20852 • Kaiser Foundation Health Plan of the
Northwest, 500 NE Multnomah St., Suite 100, Portland, OR 97232

Please recycle. 60352322 September 2015

KAISER PERMANENTE® thrive

PEACE OF MIND

MAY BE JUST A PHON E CALL AWAY.

Not sure what kind of care you need? Our advice nurses can help. To
talk with an advice nurse or doctor or to schedule an appointment, call
our 24/7 Appointment and Advice line:

( 866 ) 454-8855

Get medical advice when you need it.

Our advice nurses are registered nurses who are specially trained to help
assess medical problems and provide advice over the phone, when
medically appropriate. They can often resolve a minor concern or advise
you on what to do next, including making a same-day or next-day
appointment.

We believe your concerns shouldn't go unanswered. Call our telephone
advice nurses anytime you need advice, 24 hours a day.

kp . org

KAISER PERMANENTE. thrive

GUARDIAN

INTERNET ARCHIVE

Group Number: 00418306
About Your Benefits:

Dental Benefit Summary

A visit to your dentist can help you keep a great smile and prevent many health issues. But dental care can be costly and you can be
faced with unforeseen expenses. Did you know, a crown can cost as much as $1,400*? Guardian dental insurance will help you pay
for it. With access to one of the largest network of dental providers in the country, who agreed to charge negotiated fees for their
services of up to 30% less than average charges in the same community, you will benefit from lower out-of-pocket costs, quality care
from screened and reviewed dentist, no claim forms to file, and excellent customer service. Enroll today and smile next time you see
your dentist!

1 http://health.costhelper.com/dental-crown.html.

With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist.

Your Dental Plan

PPO

Your Network is

DentalGuard Preferred

Your Monthly premium

$61.54

You and spouse/domestic partner

$125.06

You and child(ren)

$138.67

You, spouse/domestic partner and child(ren)

$202.26

Calendar year deductible

In-Network

Out-of-Network

Individual

$50

Family limit

3 per family

Waived for

Preventive

Charges covered for you (co-insurance)

In-Network

Out-of-Network

Preventive Care

100%

Basic Care

80%

Major Care

60%

50%

Orthodontia

Not Covered

Annual Maximum Benefit

$1500

Maximum Rollover

Yes

Rollover Threshold

$700

Rollover Amount

$350

Rollover In-network Amount

$500

Rollover Account Limit

$1250

Lifetime Orthodontia Maximum

Not Applicable

Dependent Age Limits

Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/09/2016
INTERNET ARCHIVE ALL ELIGIBLE EMPLOYEES Benefit Summary

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

A Sample of Services Covered by Your Plan:

PPO

Plan pays (on average)

\ In-network Out-of-network

Preventive Care

Cleaning (prophylaxis)

j 100%

100%

Frequency:

Once Every 6 Months

Fluoride Treatments

100%

Limits:

Under Age 14

Oral Exams

100%

Sealants (per tooth)

100%

X-rays

100%

Basic Care

Anesthesia*

80%

Fillings*

80%

Perio Surgery

80%

Periodontal Maintenance

80%

Frequency:

Once Every 6 Months

(Standard)

Repair & Maintenance of
Crowns, Bridges & Dentures

80%

Root Canal

80%

Scaling & Root Planing (per quadrant)

80%

Simple Extractions

80%

Surgical Extractions

80%

Major Care

Bridges and Dentures

60%

50%

Inlays, Onlays, Veneers**

60%

50%

Single Crowns

60%

50%

This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and
or Indemnity members, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or other
pathology when the tooth cannot be restored with amalgam or composite filing material; When Orthodontia coverage is for
"Children)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required by
your plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status
is maintained, if Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings and
periodontal maintenance procedures are combined in a 12 month period. ^General Anesthesia - restrictions apply. ^For PPO and or
Indemnity members, Fillings - restrictions may apply to composite fillings.

This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist,
your paycheck stub prevails.

Find A Dentist;

Manage Your Benefits:

Go to www.GuardianAnytimexom to access secure information
about your Guardian benefits including access to an image of your
ID Card. Your on-line account will be set up within 30 days after
your plan effective date..

EXCLUSIONS AND LIMITATIONS

■ Important Information about Guardian’s DentalGuard Indemnity and
DentalGuard Preferred Network PPO plans: This policy provides dental
insurance only. Coverage is limited to those charges that are necessary to
prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply.
The plan does not pay for: oral hygiene services (except as covered under
preventive services), orthodontia (unless expressly provided for), cosmetic or
experimental treatments (unless they are expressly provided for), any
treatments to the extent benefits are payable by any other payor or for which
no charge is made, prosthetic devices unless certain conditions are met, and
services ancillary to surgical treatment The plan limits benefits for diagnostic

Visit www.GuardianAnytimexom

Click on “Find A Provider”; You will need to know your plan,
which can be found on the first page of your dental benefit
summary.

consultations and for preventive, restorative, endodontic, periodontic, and
prosthodontic services. The services, exclusions and limitations listed above do
not constitute a contract and are a summary only. The Guardian plan
documents are the final arbiter of coverage. Contract # GP- 1 -DG2000 et al.

M PPO and or indemnity Special Limitation: Teeth lost or missing before a
covered person become: insured by this plan. A covered person may have one or
more congenitally missing teeth or have lost one or more teeth before he became
insured by this plan. We won’t pay for a prosthetic device which replaces such teeth
unless the device also replaces one or more natural teeth lost or extracted after the
covered person became insured by this plan. R3-DG2000

INTERNET ARCHIVE ALL ELIGIBLE EMPLOYEES Benefit Summary

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

Dental Maximum Rollover ®

Save Your Unused Claims Dollars For When You Need Them Most

Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account
(MRA). If you reach your Plan Annual Maximum in future years, you can use money from your MRA. To qualify for an
MRA, you must have a paid claim (not just a visit) and must not have exceeded the paid claims threshold during the
benefit year. Your MRA may not exceed the MRA limit. You can view your annual MRA statement detailing your
account and those of your dependents on www.GuardianAnytime.com.

Please note that actual maximum limitations and thresholds vary by plan. Your plan may vary from the one used below
as an example to illustrate how the Maximum Rollover functions.

Plan Annual
Maximum*

Threshold

Maximum Rollover Amount

In-Network Only Rollover
Amount

Maximum Rollover
Account Limit

$1500

$700

$350

$500

$1250

Maximum claims
reimbursement

Claims amount that
determines rollover
eligibility

Additional dollars added to
Plan Annual Maximum for
future years

Additional dollars added to
Plan Annual Maximum for
future years if only in-network
providers were used during the
benefit year

Plan Annual Maximum
plus Maximum Rollover
cannot exceed $2,750 in
total

* If a plan has a different annual maximum for PPO benefits vs. non-PPO benefits, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximum determines the Maximum
Rollover plan.

Here’s how the benefits work:

YEAR ONE: Jane starts with a $1,500 Plan Annual Maximum. She
submits $150 in dental claims. Since she did not reach the $700
Threshold, she receives a $350 rollover that will be applied to Year
Two.

YEAR TWO: Jane now has an increased Plan Annual Maximum of
$1,850. This year, she submits $50 in claims and receives an
additional $350 rollover added to her Plan Annual Maximum.

YEAR THREE: Jane now has an increased Plan Annual Maximum of
$2,200. This year, she submits $2,100 in claims. All claims are paid
due to the amount accumulated in her Maximum Rollover Account.

YEAR FOUR: Jane’s Plan Annual Maximum is $1,600 ($1,500 Plan
Annual Maximum + $100 remaining in her Maximum Rollover
Account).

For Overview of your Dental Benefits, please see About Your Benefit Section of this Enrollment Booklet.

NOTES:

You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may not exceed the MRA limit.

Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. For calendar year cases with an effective date in October, November
or December, the Maximum Rollover feature starts as of the first full benefit year. For example, if a plan starts in November of 2013, the claim activity in 2014 will be used and
applied to MRAs for use in 2015. #

Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3 months or less remaining in the benefit year, will not begin until
the start of the next full benefit year. Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members, Maximum Rollover starts
when coverage of Major services starts, or the start of the next benefit year if 3 months or less remain until the next benefit year. (Actual eligibility timeframe may vary. See your
Plan Details for the most accurate information.)

Guardian’s Dental Insurance is underwritten and issued by The Guardian Life Insurance Company of America or its subsidiaries, New York, NY. Products are not available in all
states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage.

Policy Form #GP-1-DG2000, etal.

$ 2,400

$ 2,200

$2,000

$ 1,800

$ 1,600

$ 1,400

$1,200

$1,000

$800

1 ^ f—

YEAR ONE YEAR TWO YEAR THREE YEAR FOUR

■Annual Max □ Rollover Balance

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent
to you in your language. For help, call us at the number listed on your ID card or 1-800-541-7846 for
Dental. For more help call the CA Dept of Insurance at 1-800-927-4357. English

Servicios de idiomas sin costo. Puede obtener un interprete. Le pueden leer los documentos y puede que le
envien algunos en espanol. Para obtener ayuda, llamenos al numero que figura en su tarjeta de
identificacion o al 1-800-541-7846 para servicios odontologicos. Para obtener mas ayuda, llame al
Departamento de Seguros de CA al 1-800-927-4357. Spanish

No Cost Language Services. You can get an interpreter and get documents read to you in your language.
For help, call us at the number listed on your ID card or 1-800-541-7846 for Dental. For more help call the
CA Dept, of Insurance at 1-800-927-4357. English

Servicios de idiomas sin costo. Puede obtener un interprete y que le lean los documentos en espanol. Para
obtener ayuda, llamenos al numero que figura en su tarjeta de identificacion o al 1-800-541-7846 para
servicios odontologicos. Para obtener mas ayuda, llame al Departamento de Seguros de CA al 1-800-927-
4357. Spanish

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koj daim yuaj ID los sis 1-800-541-7846 rau Kev Kho Hniav. Yog xav tau kev pab ntxiv hu rau Ca lub Caij
Meem Fai Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357. Hmong

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KajiH(j)opHHH (Department of Insurance) no Tejie<j>OHy 1-800-927-4357. Russian

Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo
sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong
ID card o sa 1-800-541-7846 para sa Dental. Para sa karagdagang tulong, tawagan ang CA Dept, of
Insurance sa 1-800-927-4357 Tagalog

Cac Dfch Vu Tr</ Giup Ngdn Ngtf MiSn Phi. Qu^ vi co the dtfdc nhan dich vu thong dich va dtftfc
ngtfdi khac doc giup cac tai lieu bang tieng Viet. Be dufdc giup dd, hay goi cho chiing toi tai so" dien
thoai ghi tren the hoi vien cua qu^ vi hoac goi so" 1-800-541-7846 cho dich vu nha khoa. De dude trd
giup them, xin goi Sd Bao Hiem California tai so" 1-800-927-4357. Vietnamese

GUARDIAN*

Kqiice, ■■QeF.riyaciFk^ctices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Effective: 05/01/2016

This Notice of Privacy Practices describes how Guardian and its subsidiaries may use and disclose your Protected
Health Information (PHI) in order to carry out treatment, payment and health care operations and for other purposes
permitted or required by law.

Guardian is required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy
practices concerning PHI. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve
the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all
PHI maintained by us. If we make material changes to our privacy practices, copies of revised notices will be made
available on request and circulated as required by law. Copies of our current Notice may be obtained by contacting
Guardian (using the information supplied below), or on our Web site at www.guardianiife.com/privacv-policv .

What is Protected Health Information (PHI):

PHI is individually identifiable information (including demographic information) relating to your health, to the health
care provided to you or to payment for health care. PHI refers particularly to information acquired or maintained by us as
a result of your having health coverage (including medical, dental, vision and long term care coverage).

In What Ways may Guardian Use and Disclose your Protected Health Information (PHI):

Guardian has the right to use or disclose your PHI without your written authorization to assist in your treatment, to
facilitate payment and for health care operations purposes. There are certain circumstances where we are required by law
to use or disclose your PHI. And there are other purposes, listed below, where we are permitted to use or disclose your
PHI without further authorization from you. Please note that examples are provided for illustrative purposes only and are
not intended to indicate every use or disclosure that may be made for a particular purpose.

Guardian has the right to use or disclose your PHI for the following purposes:

Treatment. Guardian may use and disclose your PHI to assist your health care providers in your diagnosis and
treatment. For example, we may disclose your PHI to providers to supply information about alternative
treatments.

Payment. Guardian may use and disclose your PHI in order to pay for the services and resources you may receive.

For example, we may disclose your PHI for payment purposes to a health care provider or a health plan. Such
purposes may include: ascertaining your range of benefits; certifying that you received treatment; requesting details
regarding your treatment to determine if your benefits will cover, or pay for, your treatment.

Health Care Operations. Guardian may use and disclose your PHI to perform health care operations, such as
administrative or business functions. For example, we may use your PHI for underwriting and premium rating
purposes. However, we will not use or disclose your genetic information for underwriting purposes and are
prohibited by law from doing so.

Appointment Reminders. Guardian may use and disclose your PHI to contact you and remind you of appointments.

Health Related Benefits and Services. Guardian may use and disclose PHI to inform you of health related benefits or
services that may be of interest to you.

Plan Sponsors. Guardian may use or disclose PHI to the plan sponsor of your group health plan to permit the plan
sponsor to perform plan administration functions. For example, a plan may contact us regarding benefits, service or
coverage issues. We may also disclose summary health information about the enrollees in your group health plan
to the plan sponsor so that the sponsor can obtain premium bids for health insurance coverage, or to decide whether
to modify, amend or terminate your group health plan.

GG-014346

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

Guardian is required to use or disclose vout PHI:

• To you or your personal representative (someone with the legal right to make health care decisions for you);

• To the Secretary of the Department of Health and Human Services, when conducting a compliance
investigation, review or enforcement action related to health information privacy or security; and

• Where otherwise required by law.

Guardian is Required to Notify You of any Breaches of Your Unsecured PHI.

Although Guardian takes reasonable, industry-standard measures to protect your PHI, should a breach occur, Guardian is
required by law to notify affected individuals. Under federal medical privacy law, a breach means the acquisition,
access, use, or disclosure of unsecured PHI in a manner not permitted by law that compromises the security or privacy of
the PHI.

Other Uses and Disclosures.

Guardian may also use and disclose your PHI for the following purposes without your authorization:

• We may disclose your PHI to persons involved in your care or payment for care, such as a family member or
close personal friend, when you are present and do not object, when you are incapacitated, under certain
circumstances during an emergency or when otherwise permitted by law.

• We may use or disclose your PHI for public health activities, such as reporting of disease, injury, birth and
death, and for public health investigations.

• We may use or disclose your PHI in an emergency, directly to or through a disaster relief entity, to find and tell
those close to you of your location or condition

• We may disclose your PHI to the proper authorities if we suspect child abuse or neglect; we may also disclose
your PHI if we believe you to be a victim of abuse, neglect, or domestic violence.

• We may disclose your PHI to a government oversight agency authorized by law to conducting audits,
investigations, or civil or criminal proceedings.

• We may use or disclose your PHI in the course of a judicial or administrative proceeding (e.g., to respond to a
subpoena or discovery request).

• We may disclose your PHI to the proper authorities for law enforcement purposes.

• We may disclose your PHI to coroners, medical examiners, and/or funeral directors consistent with law.

• We may use or disclose your PHI for organ or tissue donation.

• We may use or disclose your PHI for research purposes, but only as permitted by law.

• We may use or disclose PHI to avert a serious threat to health or safety.

• We may use or disclose your PHI if you are a member of the military as required by armed forces services.

• We may use or disclose your PHI to comply with workers' compensation and other similar programs.

• We may disclose your PHI to third party business associates that perform services for us, or on our behalf (e.g.
vendors).

• We may use and disclose your PHI to federal officials for intelligence and national security activities
authorized by law. We also may disclose your PHI to authorized federal officials in order to protect the
President, other officials or foreign heads of state, or to conduct investigations authorized by law.

• We may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under
the custody of a law enforcement official (e.g., for the institution to provide you with health care services, for the
safety and security of the institution, and/or to protect your health and safety or the health and safety of other
individuals).

• We may use or disclose your PHI to your employer under limited circumstances related primarily to
workplace injury or illness or medical surveillance.

We generally will not sell your PHI, or use or disclose PHI about you for marketing purposes without your
authorization unless otherwise permitted by law.

Your Rights with Regard to Your Protected Health Information (PHI):

Your Authorization for Other Uses and Disclosures . Other than for the purposes described above, or as otherwise
permitted by law. Guardian must obtain your written authorization to use or disclosure your PHI. You have the right to
revoke that authorization in writing except to the extent that: (i) we have taken action in reliance upon the authorization
prior to your written revocation, or (ii) you were required to give us your authorization as a condition of obtaining
coverage, and we have the right, under other law, to contest a claim under the coverage or the coverage itself.

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY (4/16)

GG-014346

Under federal and state law, certain kinds of PHI may require enhanced privacy protections. These forms of PHI include
information pertaining to:

• HIV/AIDS testing, diagnosis or treatment

• Venereal and /or communicable Disease(s)

• Genetic Testing

• Alcohol and drug abuse prevention, treatment and referral

• Psychotherapy notes

We will only disclose these types of delineated information when permitted or required by law or upon your prior written
authorization.

Your Right to an Accounting of Disclosures. An ‘accounting of disclosures’ is a list of certain disclosures we have
made, if any, of your PHI. You have the right to receive an accounting of certain disclosures of your PHI that were made
by us. This right applies to disclosures for purposes other than those made to carry out treatment, payment and health care
operations as described in this notice. It excludes disclosures made to you, or those made for notification purposes.

We ask that you submit your request in writing by completing our form. Your request may state a requested time
period not more than six years prior to the date when you make your request. Your request should indicate in what
form you want the list (e.g., paper, electronically). Our form for Accounting of Disclosure requests is available at
www.guardianlife.com/privacv~policv .

Your Right to Obtain a Paper Copy of This Notice. You have a right to request a paper copy of this notice even if
you have previously agreed to accept this notice electronically. You may obtain a paper copy of this notice by sending
a request to the contact information listed at the end of this notice.

Your Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with
Guardian or the Secretary of U.S. Department of Health and Human Services. If you wish to file a complaint with
Guardian, you may do so using the contact information below. You will not be penalized for filing a complaint.

Please submit any exercise of the Rights designated below to Guardian in writing using the contact information listed
below. For some requests, Guardian may charge for reasonable costs associated with complying with your requests; in
such a case, we will notify you of the cost involved and provide you the opportunity to modify your request before any
costs are incurred.

Your Right to Request Restrictions. You have the right to request a restriction on the PHI we use or disclose about you
for treatment, payment or health care operations as described in this notice. You also have the right to request a restriction
on the medical information we disclose about you to someone who is involved in your care or the payment for your care.

Guardian is not required to agree to your request; however, if we do agree, we will comply with your request until we
receive notice from you that you no longer want the restriction to apply (except as required by law or in emergency
situations). Your request must describe in a clear and concise manner: (a) the information you wish restricted; (b) whether
you are requesting to limit Guardian's use, disclosure or both; and (c) to whom you want the limits to apply.

Your Right to Request Confidential Communications. You have the right to request that Guardian communicate with
you about your PHI be in a particular manner or at a certain location. For example, you may ask that we contact you at
work rather than at home. We are required to accommodate all reasonable requests made in writing, when such requests
clearly state that your life could be endangered by the disclosure of all or part of your PHI.

Your Right to Amend Your PHI If you feel that any PHI about you, which is maintained by Guardian, is inaccurate or
incomplete, you have the right to request that such PHI be amended or corrected. Within your written request, you must
provide a reason in support of your request. Guardian reserves the right to deny your request if: (i) the PHI was not
created by Guardian, unless the person or entity that created the information is no longer available to amend it (ii) if we
do not maintain the PHI at issue (iii) if you would not be permitted to inspect and copy the PHI at issue or (iv) if the PHI
we maintain about you is accurate and complete. If we deny your request, you may submit a written statement of your
disagreement to us, and we will record it with your health information.

Your Right to Access to Your PHI. You have the right to inspect and obtain a copy of your PHI that we maintain in
designated record sets. Under certain circumstances, we may deny your request to inspect and copy your PHI. In an
instance where you are denied access and have a right to have that determination reviewed, a licensed health care
professional chosen by Guardian will review your request and the denial. The person conducting the review will not be
the person who denied your request. Guardian promises to comply with the outcome of the review.

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY (4/16)

GG-014346

How to Contact Us:

If you have any questions about this Notice or need further information about matters covered in this Notice, please call
the toll-free number on the back of your Guardian ID card. If you are a broker please call 800-627-4200. All others
please contact us at 800-541-7846. You can also write to us with your questions, or to exercise any of your rights, at the
address below:

Attention: Guardian Corporate Privacy Officer

National Operations

Address: The Guardian Life Insurance Company of America

Group Quality Assurance - Northeast
P.O. Box 2457
Spokane, WA 99210-2457

GG-014346

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

(4/16)

Guardian®

sync

Dental

Guardian’s network in the palm of your hand

The best way to save money through your dental benefits is to see a provider in your network. Guardian
makes it easy to find a dentist provider near you, online or on the go! Plus, you can access your member
ID card to present at your visit.

View ID Cards

< Member login required)

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Find a Provider

Search on the go! Guardian AnytimeSM Mobile

It’s fast and easy to find a provider from your smart phone
through our Guardian Anytime mobile app. It’s easy to
download and use! Simply search by location or name. Visit
www.GuardianAnvtime.com/mobile.

View/ Email/Print your Member ID Card

You no longer need to show your dental provider a paper ID
card. Simply access an image of your card through Guardian
Anytime Mobile and then email, print through wireless printer
or show the provider at your visit! You will need your
Guardian Anytime user ID and password for secure access to
your ID card image.

02012 The Guardian Life Insurance Company of
America. New York. NY all right* reserved

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Not registered for Guardian Anytime?

You can also find a provider and access your ID card at our
website www.quardiananvtime.com . Customize your search,
get side-by-side comparisons, create a quick list of “favorite”
providers and more

GUARDIAN

DENTAL

DISABILITY

LIFE

VISION

CRITICAL ILLNESS

CANCER

ACCIDENT

STOP LOSS

GuardianAnytime.com

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 1 0004. GUARDIAN® and the GUARDIAN G® logo are
registered service marks of The Guardian Life Insurance Company of America and are used with express permission.

It's Easy to Use Your
Guardian Benefits

Innovative tools that make it easy and convenient to use
your benefits, anytime, anywhere.

Guardian is committed to making it as easy as possible for you to use and understand
your benefits, with customer service you can depend on.

Whether online or by phone - Guardian is there for you.

Find a provider online or on your phone

• The best way to save on care

I * Simply click on Find a Provider and select your network

• Follow the easy steps to search

Guardian Anytime App

App available for both
iPhone and Android
smartphones

View/print your ID card at www.GuardianAnytime.com

No need for an ID card to use your Guardian benefits. Simply provide your Group ID
number to your doctor's office at the first visit.

However, if you'd like to print out a copy of your ID card, visit the Forms and Materials
section of www.GuardianAnytime.com - it's fast and easy.

Download the App at:

www.GuardianAnytime.com/

mobile

You can access:

Access to an array of tools

GuardianAnytime.com includes easy to use tools to help understand the value of your
benefits. This includes educational articles and cost estimator tools.

Real time assistance:

Speak to a live representative about your benefits, claims inquiries, or help using
www.GuardianAnytime.com.

Customer Response Unit: 1-800-627-4200

For members who have questions about their plan benefits, and for Dental Providers
to verify eligibility.

www.GuardianAnytime.com

GUARDIAN’

Dental products are underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Some products may
not be available in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs.
Documents are the final arbiter of coverage. Policy form # GP-1-DG2000.

File #2016-24961 Exp. 6/18

The Guardian Life Insurance Company of America®(Guardian), 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered
service marks of The Guardian Life Insurance Company of America and are used with express permission.

Your Vision
Benefits Summary

Get the best in eye care and eyewear with INTERNET ARCHIVE
GROUP and VSP® Vision Care.

Using your VSP benefit is easy.

• Create an account at vsp.com. Once your plan is effective,
review your benefit information.

• Find an eye care provider who’s right for you. The decision
is yours to make— choose a VSP doctor, a participating retail
chain, or any out-of-network provider. To find a VSP provider,
visit vsp.com or call 800.877.7195.

• At your appointment, tell them you have VSP. There’s no ID
card necessary. If you’d like a card as a reference, you can
print one on vsp.com.

That’s it! We’ll handle the rest— there are no claim forms to
complete when you see a VSP provider.

Best Eye Care

You’ll get the highest level of care, including a WellVision
Exam®- the most comprehensive exam designed to detect eye
and health conditions. Plus, when you see a VSP provider, you'll
get the most out of your benefit, have lower out-of-pocket costs,
and your satisfaction is guaranteed.

Choice in Eyewear

From classic styles to the latest designer frames, you’ll find
hundreds of options. Choose from featured frame brands
like bebe®, Calvin Klein, Cole Haan, Flexon®, Lacoste, Nike, Nine
West, and more 1 . Visit vsp.com to find a Premier Program
location that carries these brands. Prefer to shop online? Check
out all of the brands at Eyeconic.com, VSP's online eyewear
store.

Plan Information

VSP Coverage Effective Date: 11/01/2016
VSP Provider Network: VSP Choice

INTERNET ARCHIVE GROUP and VSP provide you with an
affordable eyecare plan.

Visit vsp.com or call 800.877.7195

for more details on your vision
coverage and exclusive savings
and promotions for VSP members.

Benefit

Description

Copay

Your Coverage with a VSP Provider

WellVision

Exam

• Focuses on your eyes and overall
wellness

• Every 12 months

$10

Prescription Glasses

$10

Frame

• $130 allowance for a wide selection
of frames

• $150 allowance for featured frame
brands

• 20% savings on the amount over your
allowance

• $70 Costco® frame allowance

• Every 12 months

Included in
Prescription
Glasses

Lenses

• Single vision, lined bifocal, and lined
trifocal lenses

• Polycarbonate lenses for dependent
children

• Every 12 months

Included in
Prescription
Glasses

Lens

Enhancements

• Standard progressive lenses

• Premium progressive lenses

• Custom progressive lenses

• Average savings of 20-25% on other
lens enhancements

• Every 12 months

$55

$95 - $105
$150 - $175

Contacts
(instead of
glasses)

• $130 allowance for contacts; copay
does not apply

• Contact lens exam (fitting and
evaluation)

• Every 12 months

Up to $60

Extra Savings

Glasses and Sunglasses

• Extra $20 to spend on featured frame brands. Go to
vsp.com/specialoffers for details.

• 20% savings on additional glasses and sunglasses,
including lens enhancements, from any VSP provider
within 12 months of your last WellVision Exam.

Retinal Screening

• No more than a $39 copay on routine retinal screening
as an enhancement to a WellVision Exam

Laser Vision Correction

• Average 15% off the regular price or 5% off the
promotional price; discounts only available from
contracted facilities

Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.

Lined Trifocal Lenses up to $65

0 . . w . . ^ Progressive Lenses up to $50

Single Vision Lenses up to $30 _ ~ „ l \

Lined Bifocal Lenses up to $50 r

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com
for details. Coverage information is subject to change. In the event of a conflict between this information
and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable
laws, benefits may vary by location.

'Brands/Promotion subject to change.

®2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam
are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon
Eyewear, Inc. All other company names and brands are trademarks or registered trademarks
of their respective owners.

Good news— life insurance
coverage is easy to
understand. This benefit
summary gives a basic
outline of life insurance
coverage including benefits
that can be used now, and
much more!

Anthem, i^j

BlueCross WM®

Your Life Insurance Benefits

Internet Archive

Benefits effective: 11/1/2016

Feel confident in knowing that your family is protected with Anthem
Blue Cross’ Group Term Life Insurance. Please review your benefit
certificate for specific plan details, eligibility definitions, limitations and
exclusions.

Group term life insurance benefit amount: Flat $25,000

Your family or beneficiary will get the benefit amount if you pass away.

Accidental death and dismemberment insurance benefit amount: Same as Life

Accidental Death and Dismemberment Insurance pays a benefit to your beneficiary if your death is caused by an
accident. You may also get part of this benefit if an accident results in the loss of sight, a limb, certain fingers or toes,
speech, hearing or certain types of paralysis (not able to move part of your body).

Benefits after age 65

You will still have benefits after you turn 65, though they will reduce as follows:

Reduced by 35% at age 70; 50% reduction at age 75
All benefits end at retirement.

Living Benefit (accelerated death benefit)

You can ask for up to 100% to a maximum of $250,000 of your group term life benefits to be paid while you are living, if
you are terminally ill with less than 12 months to live. If you take a Living Benefit payment, the amount your beneficiary
gets after your death will be reduced by the amount you were paid.

Waiver of premium

We may continue your life insurance coverage until you turn 65 if you become totally disabled and not able to work prior
to age 60. You will not pay premiums after the first six months after we approve your waiver of premium claim.

Conversion

If you leave your job - for any reason - you may be able to change your group life coverage to an individual policy. You
must apply for coverage and pay the first month’s premium for the individual policy within 31 days of the last day you
were employed.

Portability of life insurance

If you leave employment for reasons other than retirement or disability, this feature allows you to take your optional life
insurance coverage with you by paying the required premiums. Plus, the rates are typically lower than an individual policy.

Additional accidental death and dismemberment insurance benefits

Your AD&D coverage also includes extra benefits that also pay for certain losses: Seat Belt Benefit if you die in an auto
accident while wearing a seatbelt and Air Bag Benefit if you die in an auto accident while wearing a seatbelt in a car
that has an airbag; Child Education Benefit helps pay your eligible child’s college costs if you die in an accident;
Repatriation Benefit, helps pay costs to prepare and transport your body if you die in an accident more than 75 miles
from home; Common Carrier Benefits you die in a public transportation accident; Coma Benefits you are in a coma
due to an accident.

Resource Advisor

This support program comes with your life coverage to give you and your family private access to work/life resources, at
no additional cost to you, including: counseling sessions for qualifying events; identity theft victim recovery services;
legal and financial consultations; toll-free, 24/7 phone consultations and referrals from anywhere in the United States;
and unlimited access to Resource Advisor online resources at www.resourceadvisorca.anthem.com, program name
“ResourceAdvisor”. You can also access Resource Advisor benefits by calling (888) 209-7840.

Travel assistance

This program comes with your life coverage to give you access to emergency medical help, travel services and useful
tips for your trip if you travel more than 100 miles from home - all at no additional cost to you. To access benefits, visit
www.anthem.com. You can also access Travel assistance benefits by calling: US and Canada (866) 295-4890, other
locations (call collect) (202) 296-7482.

SpecialOffers@Anthem sm

This program gives you and your family money saving discounts on products and services that promote better health
and well-being. To find out more about SpecialOffers@Anthern sm discounts and benefits, go to
anthem.com/specialoffers.

Beneficiary support programs

If you should pass away, we’re here to help your beneficiary (the person who gets your life insurance benefit):

• Beneficiaries continue to have access to Resource Advisor services, including all the features described above,
plus they get three face-to-face visits with a counselor in the first six months after their loss.

• Beneficiary Companion services help them close accounts and settle important estate matters with one phone call.
That way, they can focus on healing.

• Beneficiaries can order copies of The Healing Book - Facing the Death - and Celebrating the Life - of Someone
You Love for children affected by the loss. This book can really help children at a time when they need it most -
and there’s no charge for it.

• Your beneficiary can choose to have your life insurance benefits paid through our Access Advantage account.

That way the funds can be used right away or when they are needed. Access Advantage accounts earn interest,
so important investment decisions can be made later, at a less stressful time.

This is not a contract. It is a partial listing of benefits and services that is dependent on the Plan Options chosen. This benefit overview is only one piece of your entire enrollment
package. All benefits and services are subject to the conditions, limitations, exclusions and provisions listed in the contract documents: the Certificate, Policy, and/or Trust
Agreement for this product. In the event of a conflict between the contract documents and this benefits description, the contract documents will prevail. If you have any
questions, please contact your Human Resources/Benefits manager.

Exclusions and limitations are listed in detail in the certificate, policy or trust agreement that applies to this product.

Life products underwritten by Anthem Blue Cross Life and Health Insurance Company, an independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem
Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

ACAL-2127 (5/12)

Meftife*

Summary of Benefits

Long Term Disability - LTD 60% to 10K 90 EP

I UMg .Term disability

Class Description

Monthly Benefit
Maximum Monthly Benefit
Minimum Monthly Benefit*

Elimination Period

Own Occupation Period
Social Security Integration
Benefit Duration

... ,

; (V-vV^r.

Rehabilitation Incentives
included in quote

(details in limitations and
definitions)

Employee Assistance Program

Survivor Benefit

Cost of Living Adjustment

‘The minimum monthly benefit is
incentives.

All Active Full Time Emplo yees (30 Hours)

60% of Predisability Earnings

$ 10 , 000.00 _

$ 100.00 ~ ~

90 Days or until the end of the STD Maximum Benefit Period.

24 months

Family Social Security —

RBDw/SSNRA ~

The later of Your Normal Retirement Age as defined by Social Security
or the period shown below:

Age on Date of

lo ur Disability , Benefit Duration

less than 60 to age 65

60 months
48 months
42 months
36 months
30 months
24 months
21 months

. 18 months

15 months

P,9 and over 12 months

Work Incentive

Rehabilitation Program Incentive
Family Care Incentive

Moving Expense Incentive

__ Employee Assistance Program is not included.

Included in this quote

Cost of Living Adjustment does not apply.

subject to overpayment situations and any applicable rehabilitation

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