EMPLOYEE BENEFITS GUIDE Effective Dates | January 1, 2020 – December 31, 2020 2

Table of Contents

Medical Benefits

Anthem BlueCross BlueShield Medical Plan Comparison 4

Find a Participating Provider/Verifying Provider Participation 6

Anthem BlueCross BlueShield Estimate Your Cost 7

Anthem BlueCross BlueShield Mobile App 7

Anthem BlueCross BlueShield Condition Care, NurseLine & Future Moms 9

Anthem BlueCross BlueShield LiveHealth Online 10

Dental Benefits

Anthem 12

Vision Benefits

Anthem 16

Health Savings Account

HSA Participant Information 23

Supplemental Voluntary Benefits

Short Term Disability 33

Accident Insurance 36

Critical Illness 40

Hospital Indemnity 48

Permanent Life & Long Term Care Rider 50

Other LMG Supplemental Benefits

Life & Long Term Disability 54

401(k) Retirement Benefits 55

Pre-Paid Legal 58

Identity Theft Protections 59

Employee Assistance Program 60

Travel Assistance Program 61

Mode Notices 63

Key Contacts 79

Key Contacts 80 3

Medical Benefits

Anthem BlueCross BlueShield Medical Plan Comparison 4

Option 2 | HealthKeepers Value Advantage Summary of Service Option 1 | Lumenos HSA GHSA 269 25/500 OA POS

Network In Network Out-of-Network In Network Out-of-Network

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited

Co-Insurance 10% 30% 10% 30%

PCP PCP PCP PCP 10% after deductible 30% after deductible $20 Co-Payment 30% after deductible Office Visits Specialist Specialist Specialist Specialist 10% after deductible 30% after deductible $40 Co-Payment 30% after deductible

Maternity Services 10% after deductible 30% after deductible No Charge 30% after deductible Office Visits

Durable Medical 10% after deductible 30% after deductible 10% after deductible 30% after deductible Equipment

Emergency Room Emergency Room Emergency Room Emergency Room Emergency & 10% after deductible Paid as in-network $100 Co-Payment Paid as in-network Urgent Care Urgent Care Urgent Care Urgent Care Urgent Care 10% after deductible 30% after deductible $40 Co-Payment 30% after deductible

Preventive Services No Charge 30% after deductible No Charge 30% after deductible

Outpatient Services Outpatient Services Outpatient Services Outpatient Services 10% after deductible 30% after deductible 10% after deductible 30% after deductible Hospital Services Inpatient Services Inpatient Services Inpatient Services Inpatient Services 10% after deductible 30% after deductible 10% after deductible 30% after deductible

Physical, Occupational or Physical, Occupational or Physical, Occupational or Physical, Occupational or Speech Therapy Speech Therapy Speech Therapy Speech Therapy 10% after deductible 30% after deductible $40 Co-Payment 30% after deductible Chiropractic Services Chiropractic Services Chiropractic Services Chiropractic Services 10% after deductible 30% after deductible $40 Co-Payment 30% after deductible Therapy Services Inpatient Mental Illness Inpatient Mental Illness Inpatient Mental Illness Inpatient Mental Illness and Substance Abuse and Substance Abuse and Substance Abuse and Substance Abuse 10% after deductible 30% after deductible 10% after deductible 30% after deductible Outpatient Mental Illkness and Outpatient Mental Illkness and Outpatient Mental Illkness and Outpatient Mental Illkness and Substance Abuse Substance Abuse Substance Abuse Substance Abuse 10% after deductible 30% after deductible No Charge 30% after deductible

Prescription Drugs *After Deductible

Tier 1 – Tier 2 $10 – $25 – $45 – $65 $10 – $25 – $45 – $65 Tier 3 - Tier 4 5

Summary of Service Option 3 | HealthKeepers 10 POS

Network In Network Out-of-Network

Individual | None Individual | $300 Annual Deductible Family | None Family | $600

Annual Out-of-Pocket Individual | $1,000 Individual | $2,000 Maximum Family | $2,000 Family | $4,000

Lifetime Maximum Unlimited Unlimited

Co-Insurance 10% 30%

PCP PCP $10 Co-Payment 30% after deductible Office Visits Specialist Specialist $20 Co-Payment 30% after deductible

Maternity Services No Charge 30% after deductible (Office Visits)

Durable Medical 10% after deductible 30% after deductible Equipment

Emergency Room Emergency Room Emergency & $100 Co-Payment Paid as in-network Urgent Care Urgent Care Urgent Care $20 Co-Payment 30% after deductible

Preventive Services No Charge 30% after deductible

Outpatient Services Outpatient Services 10% after deductible 30% after deductible Hospital Services Inpatient Services Inpatient Services 10% after deductible 30% after deductible

Physical, Occupational or Physical, Occupational or Speech Therapy Speech Therapy $20 Co-Payment 30% after deductible Chiropractic Services Chiropractic Services $20 Co-Payment 30% after deductible Therapy Services Inpatient Mental Illness Inpatient Mental Illness and Substance Abuse and Substance Abuse 10% after deductible 30% after deductible Outpatient Mental Illkness and Outpatient Mental Illkness and Substance Abuse Substance Abuse No Charge 30% after deductible

Prescription Drugs Tier 1 – Tier 2 $10 – $25 – $45 – $65 Tier 3 - Tier 4 6

Finding a Participating Provider/Verifying Provider Participation

There are several networks listed under the major insurance carriers so it important that you are referring to the correct one when searching for new providers or attempting to verify participation of existing ones.

FOR MEDICAL CALL: OA 25/500 and OA POS 10: 800-421-1880 Lumenos HSA: 800-451-1527 Visit Website www.Anthem.com

Identify Your Plan to Find Your Network Your Plan Your Anthem Network Lumenos HSA GHSA 269 PPO HealthKeepers Value Advantage 25/500 OA POS HealthKeepers HMO / POS HealthKeepers 10 POS HealthKeepers HMO / POS

FOR DENTAL CALL: Anthem Dental Complete 866-956-8607

FOR VISION CALL: Blue View Vision 866-723-0515 7

Compare quality and costs

at hospitals and other facilities on anthem.com

Did you know that different facilities may charge different amounts for the same service? Estimate your share of the costs before you get your care.

Higher prices don’t always mean better care. Compare facilities based on their quality measures for certain procedures — length of stay, patient experience, complications and more.

 Just log on to anthem.com and click on Estimate Your Costs.

} Simply search or browse for the procedure you are looking for and the tool will help guide you.

} You can easily compare facilities in your area.

Estimate Your Costs is just one of the many tools we have to help you manage your health care, simply and conveniently.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-HMO benefi ts underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi ts. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 11916ANMENABS Rev. 12/13 8

Access your network of doctors and manage your benefits in a way that’s convenient for you. Get our mobile app or view the same information from your tablet and computer.

1. Forget your ID card? We have an app for that. You’ll get access to an electronic version of your ID card when you download our app to your smartphone. You also can:

 Find a doctor or urgent care center and get driving directions there.

 Refi ll a prescription, locate a network pharmacy, compare drug costs, switch to home delivery, and more.

 Get cost estimates and provider ratings for the procedures you need.

2. Don’t like to download? No problem. Download the Anthem app If you have an Apple or Android device, you can: You can view our mobile website using the 1. Go to the Apple Store or Google Play. web browser on your smartphone. You’ll get 2. Search for Anthem Blue Cross and many of the same features we offer on our Blue Shield. mobile app. 3. Select the app and start the free download. 3. Prefer the traditional website experience? Access the full anthem.com website from To log in and use our app, you must be registered on our secure member site and your tablet or home computer. have a username and password. If you’re a member of Anthem Blue Cross and Blue Shield but haven’t registered, go to anthem.com from your computer and select Register Now.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain aff liatesi administer non-HMO benefi ts underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi ts. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 36483ANMENABS Rev. 03/14 9

Choose an easier way to better health Health and wellness programs designed for your unique needs

Whether you’re suffering from asthma, expecting a baby, } A book that shows changes you can expect for you and your or just fighting a cold, our health and wellness programs baby over the next nine months.

can help. They even include toll-free access to a nurse any } Useful tools to help you, your doctor and your Future Moms time, any day. nurse coach track your pregnancy and spot possible risks. You’ll also get tips and resources to help you make better Condition Care decisions and prepare for the birth of your baby. If you have a long-term health problem, ConditionCare is for 24/7 NurseLine you. It’s a program that helps people with asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart failure, You can call any time to talk to a registered nurse about your coronary artery disease (CAD) and more. When you join the health concerns. You can get answers to questions, whether program, we’ll give you the tools and resources you need you’re sick or not. to take charge of your health. You’ll also get: Need health care right away? A nurse can help you decide } 24/7 phone access to a nurse care manager who where to go if your doctor isn’t available. Going to the right can answer your questions and give you up-to-date place can save you time and money. And you can access information about your condition. better care, too. } A health review and follow-up calls if you need them.

} Tips on prevention and lifestyle choices to help you improve your quality of life.

Future Moms Get the support you need Having a baby is an exciting time! Future Moms can help you Call us to sign up and use these programs at no extra cost: have a healthy pregnancy and a healthy baby. Sign up as soon as you know you’re pregnant. You’ll get:  ConditionCare: 800-445-7922

} 24/7 phone access to a nurse coach you can talk to about  Future Moms: 800-828-5891 your pregnancy and your health. A nurse may also call you  24/7 NurseLine: 800-337-4770 from time to time to see how you’re doing.

Health and wellness programs are not covered services under the health plan, but are additions; these programs’ features are not guaranteed under your health plan certifi cate and could be discontinued at any time. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affi liate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. MVASH1316A Rev. 1/14 10

How to use LiveHealth Online on your computer

What you need To get started

To enjoy the best experience on LiveHealth Online, Once you have everything you need, close all other make sure you have: programs, such as:

} High-speed Internet access } WebEx

} A bandwidth of 384 kbps (500 kbps is best) } Skype

} A webcam or built-in camera } GoToMeeting } Audio capability These programs can interfere with LiveHealth Online.

Browser Next, it’s easy to start talking to a doctor: 1. Go to livehealthonline.com. Next, make sure you are using the right browser. LiveHealth Online works on: 2. Click Sign Up if you don’t have an account.

} Microsoft Internet Explorer (7.0 or later) 3. Click Login if you do have an account.

} Mozilla Firefox (3.6 or later) 4. Fill out information about yourself and your health issue.

} Safari (4.0 or later) 5. Search for a doctor in your area.

} Google Chrome (4.1 or later)

Also, in your settings, turn on: } JavaScript Where to go for help } Cookies Call the Customer Support Call Center 24/7 at Software 855-603-7985 whenever you need help with the website. They can reset passwords, help solve issues when the Before your visit, make sure you have the right service did not work or did not meet your expectations. software, too. LiveHealth Online works on:

} Windows (XP, Vista, 7 and 8)

} Macintosh OS X (10.6 or later)

Finally, you will need:

} Adobe Flash (10.1 or later)

} Adobe Reader (7 or later)

LiveHealth Online is the trade name of Health Management Corporation, a separate company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affi liate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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Dental Benefits

Anthem 12

Summary of Benefits Anthem Dental Essential Choice

LOUDOUN MEDICAL GROUP Anthem Blue Cross Blue Shield Dental Complete Network Effective Date: 1/1/19

WELCOME TO YOUR DENTAL PLAN! Regular dental checkups can help find early warning signs of certain health problems, which means you can get the care you need to get healthy. So, don’t skimp on your dental care, good oral care can mean better overall health!

Powerful and easily accessible member tools. Dentists in your plan network. • Ask a Hygienist: Dental members can simply email their • You’ll save money when you visit a dentist in your plan dental questions to a team of licensed dental network because Anthem and the dentist have agreed on professionals who in turn will respond in about 24 hours. pricing for covered services. Dentists who are not in your • Dental Health Risk Assessment: We want our dental plan network have not agreed to pricing, and may bill you members to better understand their oral health and their for the difference between what Anthem pays them and risk factors for tooth decay, gum disease and oral cancer. what the dentist usually charges. This easy to use online tool can help them do this. • To find a dentist by name or location, go to anthem.com • Dental Care Cost Estimator: In order to help our dental or call dental customer service at the number listed on member better understand the cost of their dental care, the back of your ID card. we offer access to a user-friendly, web-based tool that provides estimates on common dental procedures and Ready to use your dental benefits? treatments when using a network dentist. • Choose a dentist from the network • Mobile Capabilities: With our latest mobile application, • Make an appointment Anthem Anywhere, members can find a network dentist • Show the office staff your member ID card as well as view their claims. It’s available both for • Pay any deductible or copay that is part of your plan Android and Apple phones. Need to contact us? See the back of your ID card for how to call, write or email us.

Your dental benefits at a glance The following benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your policy.

In-Network Out-of-Network Coverage Year Calendar Year Annual Benefit Maximum • Per insured person • Diagnostic & Preventive Services are applied $1,250 $1,250 to the Annual Benefit Maximum Annual Maximum Carryover Yes Yes Orthodontic Lifetime Benefit Maximum ● Per eligible person $1,000 $1,000 Select one Deductible • Per insured person $50 $50 • Family maximum 3x single member deductible 3x single member deductible Deductible Waived for Diagnostic/Preventive Services Yes Yes

NA Out-of-Network Reimbursement 80th percentile

Anthem Health Plans of Virginia, Inc., trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 04/2018 13

In-Network Out-of-Network Dental Services Waiting Period Anthem Pays: Anthem Pays: Diagnostic & Preventive Services • Periodic dental exam 100% coinsurance 100% coinsurance No waiting period o Limited to two per 12 months • Teeth cleaning (prophylaxis) o Limited to one per 6 months; combined with periodontal maintenance • Bitewing X-rays o Limited to one set per 12 months • Full-Mouth or Panoramic X-rays o Limited to one per 60 months • Fluoride application o Limited to one per 12 months through age 14 • Sealant application o Limited to one per 60 months through age 14 • Space maintainer insertion o Limited to one per tooth space per lifetime through age 14 Basic (Restorative) Services 80% coinsurance 80% coinsurance No waiting period • Consultation (second opinion) o Limited to one per 12 months; only with X-rays and no other services • Amalgam (silver-colored) filling o Limited to one per tooth surface per 12 months • Composite (tooth-colored) filling o Limited to one per tooth surface per 12 months; posterior (back) fillings paid as an amalgam (silver-colored filling) • Brush biopsy (cancer test) o Limited to one per 12 months; all ages

Endodontics (Non-Surgical) 80% coinsurance 80% coinsurance No waiting period • Root Canal and retreatments o Limited to one per tooth per 24 months; permanent teeth only Endodontics (Surgical) 80% coinsurance 80% coinsurance No waiting period • Apicoectomy and apexification o Limited to one per tooth per 24 months; permanent teeth only Periodontics (Non-Surgical) 80% coinsurance 80% coinsurance No waiting period • Periodontal maintenance o Limited to two per 12 months, combined with teeth cleanings • Scaling and root planning o Limited to one per quadrant per 36 monthswhen the tooth pocket has a depth of four millimeters or greater Periodontics (Surgical) 80% coinsurance 80% coinsurance No waiting period • Periodontal surgery (osseous, gingivectomy, graft procedures) o Limited to one per quadrant per 36 months Oral Surgery (Simple) 80% coinsurance 80% coinsurance No waiting period • Simple extraction o Limited to one per tooth per lifetime Oral Surgery (Complex) 80% coinsurance 80% coinsurance No waiting period • Surgical extraction o Limited to one per tooth per lifetime Major (Restorative) Services 50% coinsurance 50% coinsurance No waiting period • Crowns, onlays, veneers o Limited to one per tooth per 84 months Prosthodontics 50% coinsurance 50% coinsurance No waiting period • Dentures and bridges o Limited to one per tooth/arch per 84 months • Implant placement o Limited to one per tooth/arch per 84 months; • Implant prosthodontics o Limited to one per tooth/arch per 84 months; paid as a non-implant crown, bridge, and/or denture Repairs/Adjustments 80% coinsurance 80% coinsurance No waiting period • Crown, denture, and bridge repairs o Limited to one per tooth per 12 months; not within 6 months of placement • Denture and bridge adjustments o Limited to one per tooth per 36 months; not within 6 months of placement

In-Network Out-of-Network Dental Services (continued) Waiting Period Anthem Pays: Anthem Pays:

Adult/Child Orthodontic Services 50% coinsurance 50% coinsurance No waiting period Through age 18 Cosmetic Teeth Whitening Not covered Not covered N/A o Limited to one per tooth (arch) per 12 months

NOTE: Cosmetic benefits, such as teeth bleaching, in an insurance policy may have income tax implications for both employer groups and plan members. For example, the dollar value of the cosmetic benefit may be considered part of an individual’s taxable income. For more information concerning the tax ramifications of cosmetic insurance benefits, please consult a legal or tax advisor. Additional Services and Programs

Anthem Whole Health Connection - Dental℠ Included • For members with certain health conditions, additional dental benefits are available without a deductible or waiting periods. Eligible services are paid at 100% and won’t reduce your coverage year annual maximum (if applicable) Accidental Dental Injury Benefit Included • Provides members 100% coverage for accidental injuries to teeth up to the coverage year annual maximum (if applicable). No deductibles, member coinsurance, or waiting periods apply Extension of Benefits Included • Following termination of coverage, members are provided up to 60 days to complete treatment started prior to their termination of coverage under the plan and eligible services will be covered International Emergency Dental Program Included • Provides emergency dental benefits while working or traveling abroad from licensed, English-speaking dentists. Eligible covered services will be paid 100% with no deductibles, member coinsurance, or waiting periods and won’t reduce the member coverage year annual maximum (if applicable)

Additional Limitations & Exclusions Below is a partial listing of non-covered services under your dental plan. Please see your policy for a full list.

Services provided before or after the term of this coverage - Services received before your effective date or after your coverage ends, unless otherwise specified in the dental plan certificate Orthodontics (unless included as part of your dental plan benefits) including orthodontic braces, appliances and all related services Cosmetic dentistry (unless included as part of you dental plan benefits) provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no pathologic conditions (cavities) exist Drugs and medications including intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care Analgesia, analgesic agents, and anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services. Extractions of third molars (wisdom teeth) that do not exhibit pathology symptoms or impact the oral health of the member Waiting periods for endodontic, periodontic and oral surgery services may differ from other Basic Services or Major Services under the same dental plan. There may be a waiting period of up to 24 months for replacement of congenitally missing teeth or teeth extracted prior to coverage under this plan.

This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your policy. In the event of a discrepancy between the information in this summary and the policy, your policy will prevail.

This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company, whichever is applicable.

See the dentist. We insist! It’s one of the best ways to take care of your whole body.

When you think of a trip to the dentist, is it about getting your teeth cleaned, checking for cavities or fixing a chipped tooth? That’s all important, but did you know that more than 90% of all diseases that affect your body can show signs and symptoms in your mouth?1 Makes going to the dentist even more important.

More than just teeth — it’s caring for all of you

Getting regular dental checkups can help find early warning signs of some health problems. That means you can get any health care you need — sooner. So go ahead and use your dental benefits to getmore out of your plan!

A good dental plan is all about the benefits

Here’s the big picture of what your benefits cover:

 Most preventive and diagnostic services at 100%. That includes things like regular cleanings and X-rays.

 More dental services, including an extra periodontal cleaning if you’re enrolled in certain care management programs.

SM  Discounts through SpecialOffers@Anthem . Discover more than 50 discounts on products and services that promote better health and well-being.

11699MUMENABS VPOD Rev. 02/18 16

98% of members can You don’t have to go far to find a dentist reach a dentist close to They’re usually nearby, so you shouldn’t have any home or work2 trouble finding one.

You can use dentists in your plan to save big! Website tools help you get the most from your plan

You’ll save money two ways: Want to learn more? Use the website that’s on your member 1. We set pricing rates with dentists in your plan, so they ID card or our Anthem Anywhere app to: usually charge less. } Find a dentist in your plan.

2. If, for some reason, a dentist in your plan charges more, } Order extra ID cards. you can’t be billed for the difference between what we pay } Find out the status of a claim. and what was charged. You can also go to the website on your member ID card to: Plus, you’ll save time and hassles because dentists in your plan file claims for you. } Get a health score for your gums and teeth, using our Dental Health Assessment tool. You’ll find out your risk for mouth cancer. Be sure to talk to your dentist Ready to see a dentist? about your results.

Great! It’s easy: } Email a dental hygienist your dental questions through our

} Search for a dentist online with the Find a Doctor tool. Ask a Hygienist tool. There’s no extra cost and you’ll get Remember, you could save out-of-pocket costs answers quickly and privately by email in about 24 hours.

by choosing a dentist in your plan. } See how much a treatment may cost with our Dental Care Cost

} Make an appointment. Estimator, so you’re prepared before you see the dentist.

} Show the office staff your member ID card.

} Pay your plan deductible or copay.

If you’ve still got benefit questions or need help using your plan, we’re here for you. You can:

 Call the Customer Service number on your ID card.

 Visit the website that’s on your ID card.

 Download the Anthem Anywhere mobile app.

1 Ae ee De ee S e M Sve ve 2012 ee.. 2 e 201. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-HMO benefi ts underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefi ts in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 17

Vision Benefits

Anthem 18

Blue View VisionSM Loudoun Medical Group

Welcome to your Blue View Vision plan! You have many choices when it comes to using your benefits. As a Blue View Vision plan member, you have access to one of the nation’s largest vision networks. You may choose from many private practice doctors, local optical stores, and national retail stores including LensCrafters®, Target Optical®, Sears Optical®, JCPenney® Optical and most Pearle Vision® locations. You may also use your in-network benefits to order eyewear online at Glasses.com and ContactsDirect.com. To locate a participating network eye care doctor or location, log in at anthem.com, or from the home page menu under Care, select Find a Doctor. You may also call member services for assistance at the number on the back of your ID card. Out-of-Network – If you choose to, you may instead receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement up to your maximum out-of-network allowance.

YOUR BLUE VIEW VISION PLAN BENEFITS IN-NETWORK OUT-OF-NETWORK FREQUENCY Routine Eye Exam Once every A comprehensive eye examination $10 copay Up to $35 allowance calendar year Eyeglass Frames $130 allowance, then 20% Once every One pair of eyeglass frames Up to $50 allowance off any remaining balance two calendar years Eyeglass Lenses (instead of contact lenses) One pair of standard plastic prescription lenses:  Single vision lenses $20 copay Up to $35 allowance Once every  Bifocal lenses $20 copay Up to $50 allowance calendar year  Trifocal lenses $20 copay Up to $75 allowance Eyeglass Lens Enhancements When obtaining covered eyewear from a Blue View Vision provider, you may choose to add any of the following lens enhancements at no extra cost.

 $0 copay No allowance Lenses (for a child under age 19) Same as covered  $0 copay when obtained Standard polycarbonate (for a child under age 19) eyeglass lenses  Factory scratch coating $0 copay out-of-network Contact Lenses (instead of eyeglass lenses) Contact lens allowance will only be applied toward the first purchase of contacts made during a benefit period. Any unused amount remaining cannot be used for subsequent purchases in the same benefit period, nor can any unused amount be carried over to the following benefit period.

 Elective conventional (non-disposable) $130 allowance, then 15% Up to $105 allowance OR off any remaining balance Once every  Elective disposable $130 allowance Up to $105 allowance calendar year OR (no additional discount)  Non-elective (medically necessary) Covered in full Up to $210 allowance

This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care doctor from your medical network. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member’s policy, which shall control in the event of a conflict with this overview. This benefit overview is only one piece of your entire enrollment package.

EXCLUSIONS & LIMITATIONS (not a comprehensive list – please refer to the member Certificate of Coverage for a complete list) Combined Offers. Not to be combined with any offer, coupon, or in-store Lost or Broken Lenses or Frames. Any lost or broken lenses or frames advertisement. are not eligible for replacement unless the insured person has reached his Excess Amounts. Amounts in excess of covered vision expense. or her normal service interval as indicated in the plan design. Sunglasses. Plano sunglasses and accompanying frames. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or Safety Glasses. Safety glasses and accompanying frames. contacts. Plano lenses or lenses that have no refractive power. Not Specifically Listed. Services not specifically listed in this plan as Orthoptics. Orthoptics or vision training and any associated supplemental covered services. testing. 19

In-network Member Cost OPTIONAL SAVINGS AVAILABLE FROM BLUE VIEW VISION IN-NETWORK PROVIDERS ONLY (after any applicable copay) Retinal Imaging - at member’s option can be performed at time of eye exam Not more than $39 Eyeglass lens upgrades When obtaining eyewear from a Blue View Vision  lenses (Adults) $75 provider, you may choose to upgrade your new  Standard Polycarbonate (Adults) $40 eyeglass lenses at a discounted cost. Eyeglass lens  Tint (Solid and Gradient) $15 copayment applies.  UV Coating $15  Progressive Lenses1  Standard $65  Premium Tier 1 $85  Premium Tier 2 $95  Premium Tier 3 $110  Anti-Reflective Coating2  Standard $45  Premium Tier 1 $57  Premium Tier 2 $68  Other Add-ons 20% off retail price Additional Pairs of Eyeglasses Anytime from any Blue View Vision network provider.  Complete Pair 40% off retail price  Eyeglass materials purchased separately 20% off retail price

Eyewear Accessories  Items such as non-prescription sunglasses, 20% off retail price lens cleaning supplies, contact lens solutions, eyeglass cases, etc. Contact lens fit and follow-up A contact lens fitting and up to two follow-up visits are  Standard contact lens fitting3 Up to $55 available to you once a comprehensive eye exam has  Premium contact lens fitting4 10% off retail price been completed.

Conventional Contact Lenses  Discount applies to materials only 15% off retail price

1 Please ask your provider for his/her recommendation as well as the available progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the available coating brands by tier. 3 Standard fitting includes spherical clear lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. 4 Premium fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.

Discounts are subject to change without notice. Discounts are not ‘covered benefits’ under your vision plan and will not be listed in your certificate of coverage. Discounts will be offered from in-network providers except where state law prevents discounting of products and services that are not covered benefits under the plan. Discounts on frames will not apply if the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Some of our in-network providers include:

ADDITIONAL SAVINGS AVAILABLE THROUGH ANTHEM’S SPECIAL OFFERS PROGRAM *

Savings on items like additional eyewear after your benefits have been used, non-prescription sunglasses, hearing aids and even LASIK laser vision correction surgery are available through a variety of vendors. Just log in at anthem.com, select discounts, then Vision, Hearing & Dental. * Discounts cannot be used in conjunction with your covered benefits.

OUT-OF-NETWORK If you choose to receive covered services or purchase covered eyewear from an out-of-network provider, network discounts will not apply and you will be responsible for payment of services and/or eyewear materials at the time of service. Please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, email address, or mailing address below. To download a claim form, log in at anthem.com, or from the home page menu under Support select Forms, click Change State to choose your state, and then scroll down to Claims and select the Blue View Vision Out-of-Network Claim Form. You may instead call member services at the number on the back of your ID card to request a claim form. To Fax: 866-293-7373 To Email: [email protected] To Mail: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111

Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Anthem Health Plans of Virginia, Inc., trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Blue View Vision FS 2017 20

Better health is right before your eyes It’s true with Blue View Vision Do you really need an eye exam if you’re seeing just fine? Absolutely.

Eye doctors can detect eye diseases like macular degeneration and glaucoma early on. And they’re often the first to find other health problems, such as high blood pressure, high cholesterol and diabetes, through regular eye exams. That’s why we make getting eye care easy and affordable. Blue View Vision benefits Incredible convenience Blue View VisionSMSM has one of the nation’s largest vision Plenty of choices Blue View Vision has one of the nation’s largest visinetworks.on networks. You can You access can independentaccess indepe optometrists,ndent With Blue View VisionSM, you can get your eye care and oophthalmologistsptometrists, ophthalmologists and opticians, Glasses.com, and opticians, ContactsDirect, 1-800 CONTACTS,1-800 CONTACTS, and c onvenientand convenient national national optical optical retailer retailer eyewear just about anywhere: ® ® stores includingincluding LensCrafters®, LensCrafters ,Pearle Pearle Vision®, Vision ,Target Target ® }} More doctors and locations. With over 36,000 eye OpticalOptical®,, Sears OpticalSM and JCPenney® Optical. doctors at more than 27,000 locations, you’re sure Sears OpticalSM and JCPenney® Optical. Ma ny of these stores have night-time and weekend to find an eye care professional that’s close to home Many of these stores have night-time and weekend hours, hours,so you canso you go whencan go it whenmakes it sense makes for sense you. To for fi ndyou. an To find or work. And you can even buy eyewear at a location an in-network provider near you, use the Find a Doctor in-network provider near you, use the Find a Doctor tool that’s different from your eye doctor. tool on on anthem.com. }} More freedom. Choose the style that works best for you! Vision benefits without borders No matter where work or play takes you, Blue View Vision’s international travel solution is ready to help if you lose or break your glasses during an international trip. You’ll have access to translation support and resources in 20 countries. From quick fix, temporary glasses delivered next day*to getting you in contact with the nearest trusted eye care provider, you can quickly get your trip back in focus. It’s all part of your Blue View Vision coverage.

13906ANMENABS VPOD Rev. 5/16 *Delivered within 24 hours in most cases. Availability based on the domiciled state of your plan benefits. 21

Lower costs in the network

We want you to be able to get your eye care and eyewear when you need it — at a price you can afford. Just remember, you’ll save time and money by using an eye doctor or optical retail store that’s in the network. And when you use your benefits at a network provider, you can include the following options at no additional cost:

}}Factory scratch coating on standard/basic eyeglass lenses

}}UV-blocking Transitions® lenses for covered dependents under age 19

}}Impact-resistant polycarbonate lenses for covered dependents under age 19

Serious savings on just about everything

With Blue View Vision, you can save beyond your benefits through in-network providers. If you buy an eyeglass frame that costs more than your allowance, you’ll save 20% off the balance. If you use your contact lens benefit to purchase conventional contact lenses and your cost is higher than your benefit allowance, you’ll get 15% off the balance.

Plus, you get:

}}35-40% off extra pairs of glasses anytime, from any network provider.

}}High-quality progressive lenses and anti-reflective coatings at different price levels, so you can control how much you spend.

}}Negotiated savings on other popular lens options and treatments.

}}20% off other upgrades, accessories and nonprescription sunglasses.

Working together for your total health

When you are covered by both our health and vision plans, your doctors can work together to keep you at your healthy best. For example, let’s say your eye doctor notices signs of diabetes or high blood pressure during your eye checkup. He or she can share that information with your primary care doctor. This helps your doctors get a better picture of your overall health.

To get help using your benefits, you can:

}}Call Customer Service at 1-866-723-0515. Representatives are available Monday through Saturday, 7:30 a.m. to 11 p.m. ET, and Sunday, 11 a.m. to 8 p.m. ET. After hours, our Blue View Vision automated telephone system is available.

}}Check us out online. Log in to anthem.com to review your benefi ts, 24/7.

Blue View Vision can help you see better. For more information, talk to your benefits manager.

* Discounts don’t apply to frames for which a manufacturer has imposed a no-discount policy.

What you’ve read here is a brief outline of the products and services of your plan. It is not a legal contract. To get the details of your benefi ts, exclusions and restrictions, please see your Certifi cate of Coverage.

Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Photochromic performance is infl uenced by temperature, UV exposure and lens material.

Laws in some states may prohibit network providers from discounting products and services that are not covered benefi ts under the plan.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-HMO benef tsi underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefi ts in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield 22

Health Savings Account

Anthem 23

Congratulations! Since you enrolled in the high deductible health plan {Anthem Lumenos Plan} you are eligible to contribute pre-tax dollars in to a qualified Health Savings Ac- count (HSA). 2020 Health Spending Account Participant Information Packet

Included in this packet:

Section 1: What is a Health Spending Account (HSA)?

Section 2: Your Options to Contribute Pre-tax Earnings to an HSA

Section 3: Establishing a Health Spending Account with Anthem

Section 4: How to contribute to the HSA plan

Section 5: Transferring your existing HSA to Anthem

Section 6: Frequently asked questions

Kristi Smith – [email protected] Maggie Colucci - [email protected]

Section 1: What is a Health Spending Account (HSA)? A Health Spending Account is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), HSA funds roll over and accumulate year to year if they are not spent. HSAs are owned by the individual. The funds contributed to an HSA can be used at a later time to cover health and dental expenses that are not covered by insurance, such as co-pays, deductibles, coinsurance, etc.

Section 2: Your Options to Contribute Pre-tax Earnings to an HSA Since you are enrolled in the LMG high deductible health plan, LMG will automatically contribute to your Health Spending Account (HSA) even if you choose not to. Your contributions are optional. Because LMG contributes to your HSA account, you do need to ensure you open the account so that funds may be deposited. 24

2020 Health Spending Account (HSA) Maximum Contributions Annual Annual Contri- LMG Annual Maximum Contribution bution Contribution* You May Contribute Coverage Level Maximum Maximum < 55 years old >=55 years old Employee Only $3,550 $4,550 $375 / $14.42 per pay $3,175 / $122.12 per pay (<55)

$4,175 / $160.58 per pay (55+) Employee + $7,100 $8,100 $750 / $28.84 per pay $6,350 / $244.24 per pay (<55) Dependents $7,350 / $282.70 per pay (+55)

LMG will contribute to your Health Spending Account if you are enrolled in the Anthem Lumenos HSA with HSA plan. LMG will contribute, regardless of whether you contribute to the plan.

- $14.42 per pay / up to $350 annually for individual coverage

- $28.84 per pay / up to $750 for employee + dependent coverage *Individuals age 55 or older can make an additional $1,000 per year in catch up contribution.

The Contribution Maximum includes both the LMG and employee contributions. PLEASE NOTE: You may NOT contribute to a qualified Health Savings Account (H S A) if you:  Are enrolled in another health plan through a spouse or parent.  You are claimed as a dependent on someone else’s tax return  You are enrolled in Medicare, Tricare or Tricare for Life (you can be eligible but cannot be enrolled to participate)  You are covered by a health care Flexible Spending Account, including spouse’s FSA. Limit- ed-Purpose FSA is allowed. Enclosed, please find the HSA New Enrollment Packet. If you have any questions please let us know.

Section 3: How to access your HSA plan through Anthem Everyone who enrolls in the high deductible health plan with Anthem will automatically be set up with an HSA plan. Participants will receive information in the mail from ACT WISE CDHP/FSA. One bank card will be issued for the employee participating. This communication will include instructions on how to access your account online. These bank cards are automatically issued without action required by participants. Section 4: Contributing to your HSA plan LMG will contribute to the account every pay period, regardless of whether the employee contributes. LMG will automatically contribute 25% of your annual deductible to your HSA account on your behalf. 25

2020 Health Spending Account (HSA) Employer Contribution Coverage Level Annual Deductible LMG Total Contribution (25% of Deductible) Employee Only $1,500 $375 / $14.42 per pay period Employee + Spouse/Child/Children/Family $3,000 $750 / $28.84 per pay period

The Federal Government will allow you to contribute up to the following pre-tax dollars in to your HSA in 2020. This amount includes LMG’s contribution to your plan. 2020 Health Spending Account (HSA) Annual Maximum Contributions Coverage Level Total Contribution LMG Contribution Maximum Maximum Allowable Additional You May Contribute in 2020*

Employee Only $3,550 $375 $3,175

Employee + Spouse/Child/ $7,100 $750 $6,350 Children/Family *LMG contribution counts as part of the total allowable contribution. **Employees age 55 or older may contribute and extra $1,000 annually.

Enclosed is a Health Saving Account (HSA) Contribution Form. You may elect to contribute a lump sum contribution at any time during the plan year or you can set up a regular payroll deduction that will be funded to your HSA each pay period. You may change your contributions at any time during the plan year. 26

2020 HSA CONTRIBUTION ELECTION FORM This agreement is to allow Loudoun Medical Group to withhold HSA contributions from my paycheck on a pre-tax basis.

Last Name: ______First Name: ______Date of Birth: ______Location: ______

2020 Health Spending Account (HSA) Maximum Contributions Coverage Level Annual Annual LMG Annual Maximum Contribution Contribution Contribution* Maximum Maximum You May Contribute < 55 years old >=55 years old

Employee Only $3,550 $4,550 $375 / $14.42 per pay $3,175 / $122.12 per pay (<55)

$4,175 / $160.58 per pay (55+) Employee + $7,100 $8,100 $750 / $28.84 per pay $6,350 / $244.24 per pay (<55) Dependents $7,350 / $282.70 per pay (+55) LMG will contribute to your Health Spending Account if you are enrolled in the Anthem Lumenos HSA with HSA plan. LMG will contribute, regardless of whether you contribute to the plan.

• $14.42 per pay / up to $350 annually for individual coverage

• $28.84 per pay / up to $750 for employee + dependent coverage

*Individuals age 55 or older can make an additional $1,000 per year in catch up contribution.

Your Election: Elect the contribution amount you want deducted from your paycheck. The contribution amount listed below will be deducted from your paycheck with the date noted below or the next possible payroll date (date must be on or after the first effective day of your HSA-compatible health plan coverage). Please include catch up contributions in your request- ed amount. OPTION 1: PER PAY PERIOD CONTRIBUTION HSA Contribution Amount (per paycheck): HSA Contribution Start Date: ____ / ____ / ____

OPTION ONE TIME LUMP SUM HSA Contribution Amount (lump sum): ______2: CONTRIBUTION HSA Contribution Date (pay date of deduction) ____ / ____ / ____ As a reminder, you are eligible to contribute to the HSA account when: • You are enrolled in an HSA-compatible health plan (i.e. high deductible health plan) • You are not covered under any other plan (FSA, Medicare or HSA non-compatible health plan) that would disqualify you from opening or contributing to an HSA account • You cannot be claimed by another individual for tax purposes as a dependent

______Employee signature Date

Please complete this form and fax or email to Human Resources for processing at (703) 443-8174 / [email protected] 27

Section 5: Transferring other HSA funds to Anthem LMG employer contributions and employee contributions collected pre-tax through payroll deduction must be deposited in to the Anthem PNC bank account. If you have an existing HSA with another bank, you may choose to roll those funds in to your account with PNC Bank. Employees also have the option to maintain their account(s) with other banks should they choose to, however employer and pre-tax employee payroll contributions with LMG must be deposited in the PNC Bank account through Anthem. If you choose to roll funds from other qualified health spending accounts in to the NEW account with PNC, you may follow the instructions provided on the next page. There are two ways to move funds from an existing HSA Account into the 2020 PNC Account: • A Rollover • A Trustee-to-Trustee Transfer

Note: Funds cannot be moved into a Health Savings Account directly from 401(k), 403(b) or 457 plans. Are there differences between a rollover and a trustee-to-trustee transfer into a BenefitWallet Account?

A Rollover Trustee-to-Trustee Transfer

Generally A rollover involves the deposit of A trustee-trustee-transfer involves funds by the you into the Anthem PNC HSA direct movement of funds from Account via a check written by you your existing HSA by the trustee of that HSA via check or ACH Direct from your existing HSA or a per- Deposit into your PNC Account. sonal check. Permitted Fre- One rollover per year per HSA Unlimited quency Tax Reporting PNC Bank will report the None required rollover on IRS form 5498-SA. Fees The Anthem PNC Bank does not The Anthem PNC Bank does not charge a fee. If you stay with charge a fee. If you stay with Benefit Wallet they will charge Benefit Wallet they will charge a maintenance fee. a maintenance fee. 28

How do I rollover funds in to PNC bank Account? Send a check written by you from your existing HSA or a personal check made payable to PNC #010163 Mail

PNC #010163

BIN 88163 Milwaukee, WI 53288-0163

Section 6: Frequently asked questions Read through the following FAQs to get more details and reach out to your benefits administrator or human resources representative if you have questions or concerns. Q: Do I need to do anything to open my new Anthem HSA? A: No. Your 2020 HSA account will be automatically opened when you enroll in the 2020 HSA medical plan. If Anthem is unable to open your account because of missing or insufficient information, you’ll get a letter explaining what is needed to get the account opened .

Q: Will there be an investment option for my HSA? What is the fee for investing my HSA funds? A: Yes, you will be able to invest in mutual funds once a minimum balance of $1,000 is reached in your account.

There will be a flat $2.25 per month charge when the investment account has been established and funds have been transferred into one or more of the mutual fund options. There are no additional investment transaction fees. If your HSA balance falls below $1,000, you will not be able to invest more money until your HSA gets above $1,000 again.

Q: How do I find information on my new Anthem HSA account, such as my balance or if a payment has been made? A: This is available at anthem.com or on the Anthem mobile app . You also can call the Customer Service phone number on your Anthem member ID card or new Anthem debit card.

Q: How do I put money into my new HSA, or change the amount I’m putting in ? A: Complete a 2020 H S A contribution election form. Completed forms can be emailed to [email protected] or faxed to 703-443-8174. 29

Q: How do I make sure I’m not charged for paper statements? A: To avoid the $1.50 monthly paper statement fee : 1. Log in at anthem.com. 2. Select Manage my HSA on the Spending Accounts page. 3. Choose Statements under Document Delivery Preferences . 4. Follow the instructions for opting into “electronic only” statements. You ’ll get a notification when your statement is available online to download and/or print.

Q: How do I make sure I’m receiving emails and/or text (SMS) messages? A: To sign up for electronic not ifications:

1. Log in at anthem.com.

2. Select Profile.

3. Choose Communication Preferences .

4. Provide your email address.

5. From the Spending Accounts page, select Manage my HSA.

6. Select the gear icon (it looks like this: * ) at the top right of the page to add your mobile phone number , then select which messages you would like to receive by email and/or text. 30

Making the most of your health savings account

Your health plan comes with a health savings account (HSA). HSAs save you money by lowering your taxable income. HSA

 }Set aside pre-tax dollars to pay for current and future qualifi ed medical expenses.

 }You determine the pre-tax amount taken out of your paycheck and placed in your account. Your employer will also contribute 50% to your account.

 }Any money left in your HSA rolls over from year to year, and it's yours to keep even if you change health plans, jobs or retire.

Activate your debit card Be sure to activate your debit card when it arrives in the mail. Then you can use it to pay for doctor visits, prescriptions, urgent care, lab tests and other qualifi ed health care expenses. See a full list of qualifi ed medical and dental expenses at irs.gov/pub502.

It's easy to manage your health plan and HSA Go to the Sydney Mobile app or anthem.com to register.

} View your account balance and review your plan benefi ts and claims.

} Set your account preferences and make sure we have your preferred email address. You’ll also want to opt in to receive eStatements and avoid paying a monthly paper statement fee.

} Set up one-time or recurring tax-free contributions for your HSA. Transfer money from your personal bank account or automatically deduct funds from your paycheck if offered by your employer.

} Check out the How it all Works tab to learn more about the benefi ts of an HSA. Get tips, watch a video or use a spending account calculator to help manage your expenses for the year.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia. Anthem Blue Cross and Blue Shield, and its affi liate Healthkeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

108286VAMENBVA VPOD Rev. 08/19 31

Investing your HSA dollars If your HSA balance is more than $1,000, you may be able to invest that money in mutual funds offered through PNC Bank. Once you’ve set up your investment account, you’ll be able to transfer funds online between your HSA and investment account. Go to anthem.com to learn more and to open an investment account. If you have funds in your investment account, there’s a $2.25 monthly fee.

Combine your HSAs If you have more than one HSA, it’s a good idea to combine your funds under Anthem with PNC Bank as the custodian. Here’s why:

 Keep it simple. You’ll have one user ID, one debit card, one mobile app, one statement and one Member Services team.

 Pay less in fees. You’ll stop paying fees to your other HSA custodian.

 Earn more interest. The more funds you have, the more interest you earn.  Have an easier time fi ling your taxes. You’ll have only one set of tax forms to fi ll out.

How to transfer funds 1. Your employer may distribute the HSA Transfer of Assets form, or you can visit anthem.com to download and print. Go to Spending Accounts under My Plan and select Manage your transactions. You will fi nd the Balance Transfer to New Custodian form under the Resources tab. 2. Complete, sign and return the form to your employer or send it to your previous HSA custodian.

How to roll over funds 1. Contact your current HSA custodian online or by phone to check your HSA balance. 2. Choose how to have your HSA dollars rolled over. 3. Deposit your funds into your new Anthem HSA.

More HSA perks

 The money you put into your HSA, the interest you earn and even the money you take out to pay for health care costs are all tax-free.  You can earn rewards by taking certain steps to improve your health. Money you earn for improving your health goes into an Extra Bucks Account. You can use it to pay for your health care costs after you’ve paid your deductible for the plan year. Also, any unused funds from a health reimbursement account (HRA) can be moved to an Extra Bucks Account.  In 2019 the total contribution limit is $3,500 for an individual and $7,000 for a family. If you’re 55 or older, you can contribute an extra $1,000 a year.

Check out how it all works Learn all about the benefi ts your plan offers and the tools that can help you manage your health care expenses. Just log in at anthem.com and select Spending Accounts under My Plan.

Questions about your HSA? Contact Member Services anytime at the number on your ID card or HSA debit card.

Anthem does not provide investment advice. Please contact an investment advisor if you need advice. Please consider the investment objectives, risks, charges and expenses of the mutual funds carefully before investing. For more complete information, please consult the prospectuses for each mutual fund and your HSA Investments Terms and Conditions, which can be found on the Portal and are available upon request by calling HSA Account Services toll-free number at 1-855-424-7211. Read these documents carefully before investing. You are not receiving any individual investment advice in connection with this program and should consult a fi nancial advisor before investing your cash. Devenir, LLC a registered broker-dealer, member FINRA/SIPC is providing brokerage services to you directly or through third parties. Devenir Investment Advisers, LLC, is a registered investment adviser and affi liated company of Devenir, LLC. Devenir Investment Advisers, LLC has selected, and Administrator has accepted, certain mutual funds for inclusion in the investment program. Bank and Devenir are not affi liated companies. Securities are: Not FDIC Insured • No Bank Guarantee • Not A Deposit Not Insured By Any Government Agency • May Lose Value 32

VOLUNTARY SUPPLEMENTAL BENEFITS 33

AFLAC GROUP DISABILITY G INSURANCE PLAN Policy Form C50000VA DI

Aflac can help you protect one of your most important assets. Your income.

All too often when we hear the words disability and insurance together, it conjures up an image of a catastrophic condition that has left an individual in an incapacitated state. Be it an accident or a sickness, that’s the stereotype of a disabling injury that most of us have come to expect.

What most of us don’t realize is that in addition to accidental injuries, conditions such as arthritis, heart disease, diabetes, and even pregnancy are some of the leading causes of disability that can keep you out of work and affect your income.

That’s where Aflac group disability insurance can help.

Our Aflac group disability plan can help protect your income by offering disability benefits to help you make ends meet when you are out of work. Our plan was created with you in mind and includes:

• Off-job only coverage. • Benefits that help you maintain your standard of living.

Understanding the facts can help you decide if the Aflac group Disability Plan makes sense for you.

FACT NO. 1 FACT NO. 2

DISABILITIES ACCOUNT FOR % $400BILLION 22 PER YEAR IN HEALTHCARE EXPENDITURES.1 OF ADULTS IN THE UNITED STATES HAVE SOME TYPE OF DISABILITY.2

1Disability Impacts ALL of US., Centers for Disease Control and Prevention, 2015 2“Prevalence of Disability and Disability Type Among Adults,” Morbidity and Mortality Weekly Report, CDC, 2015.

Underwritten by Continental American Insurance Company (CAIC) A proud member of the Aflac family of insurers 34

Here’s why the For more than 60 years, Aflac has been dedicated to helping provide Aflac group individuals and families peace of mind and financial security when they’ve disability plan needed it most. Our group disability plan is just another innovative way to is right for you. help make sure you’re well protected under our wing.

But it doesn’t stop there, having group short-term disability insurance from Aflac means that you will have added financial resources to help with medical costs or ongoing living expenses such as rent, mortgage or car payments.

The Aflac group disability plan benefits:

• Benefits are paid when you are sick or hurt and unable to work, up to 60 percent of your salary (up to 40% in states with state disability). • Minimum and Maximum Total Monthly Benefit – $300 to $6,000. • Premium payments are waived after 90 days of total disability (not available on 3 month benefit period). • Partial Disability Benefit.

Features: • Benefits are paid directly to you unless you choose otherwise. • Coverage is portable. That means you can take it with you if you change jobs (with certain stipulations). • Payroll Deduction – Premiums are paid through convenient payroll deduction. • Fast claims payment. Most claims are processed in about four days.

How it works

Aflac Group Disability Plan pays the certificate holder Aflac Group The certificate A physician Disability Advantage holder hurts his The determines the Nonoccupational back helping his certificateholder certificateholder coverage is selected friend move over visits the doctor. will be out of work with a 60% the weekend. for 1 month while 60% of salary benefit recovering. of his salary for the length of disability after the elimination period.

The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions. For more information, ask your insurance agent/producer, call 1.800.433.3036, or visit aflacgroupinsurance.com. 35

Benefits Overview

TOTAL DISABILITY This convenient, affordable disability income plan will help provide needed income if you become Totally Disabled and are unable to work due to a covered injury or illness. Total disability benefits will be payable monthly once the elimination period has been satisfied.

PARTIAL DISABILITY The Partial Disability Benefit helps you transition back into full-time work after suffering a disability. If you remain partially disabled and are only able to work earning less than 80 percent of your pre-disability income at any job, this plan will still pay you 50 percent of your selected monthly benefit for up to the maximum partial disability benefit period of 3 months after the elimination period. You do not have to have received the Total Disability benefit to receive the Partial Disability benefit.

WAIVER OF PREMIUM Premiums are waived after 90 days of Total Disability. After Total Disability benefits end, any premiums which become due must be paid in order to keep your insurance in force. This benefit is not available on plans with a 3-month benefit period.

PORTABILITY If you cease employment with your employer, you may elect to continue your coverage. In order to continue your coverage you must meet all of the requirements listed below.

• You must work full-time for another employer. • You must make a written application and pay the required premium to us within 31 days after the date your insurance would otherwise terminate. • You must continue to pay any required premiums.

The coverage you may continue is that which you had on the date your employment terminated. If you qualify for this portability privilege as described, then the same benefits, plan provisions, and premium rate shown in your certificate as previously issued will apply. Coverage may not be continued if you fail to pay any required premium or if the master policy terminates. Instructions for continuing coverage will be provided within your certificate of coverage.

What you need, when you need it. Group disability insurance pays cash benefits that you can use any way you see fit when you are unable to work due to an accident or sickness. 36

AFLAC GROUP ACCIDENT INSURANCE Policy Series C70000

Just because an accident can change your health, doesn’t mean it should change your lifestyle too.

Accidents can happen in an instant affecting you or a loved one. Aflac is designed to help families plan for the health care bumps ahead and take some of the uncertainty and financial insecurity out of getting better.

Protection for the unexpected, that’s the benefit of the Aflac Group Accident Plan.

After an accident, you may have expenses you’ve never thought about. Can your finances handle them? It’s reassuring to know that an accident insurance plan can be there for you in your time of need to help cover expenses such as:

• Ambulance rides • Major Diagnostic Testing • Emergency room visits • Burns • Surgery and anesthesia

Plan Features

• Benefits are paid directly to you, unless otherwise assigned. • Coverage is guaranteed-issue (which means you may qualify for coverage without having to answer health questions). • Benefits are paid regardless of any other medical insurance.

What you need, when you need it. Group accident insurance pays cash benefits that you can use any way you see fit. 37

BENEFIT Benefits Overview AMOUNT

INITIAL TREATMENT (once per accident, within 7 days after the accident, not payable for telemedicine services) Payable when an insured receives initial treatment for a covered accidental injury. This benefit is payable for initial treatment received under the care of a doctor when an insured visits the following:

Hospital emergency room with X-Ray / without X-Ray $325/$300 Urgent care facility with X-Ray / without X-Ray $325/$300 $120/$100 Employee Doctor’s office or facility (other than a hospital emergency room or urgent care) with X-Ray / without X-Ray $70/$50 Spouse and Child(ren) $200 (once per accident, within 90 days after the accident) AMBULANCE Payable when an insured receives transportation by a Ground professional ambulance service due to a covered accidental injury. $1,200 Air

MAJOR DIAGNOSTIC TESTING (once per accident, within 6 months after the accident) Payable when an insured requires one of the following exams: Computerized Tomography (CT/CAT scan), Magnetic Resonance Imaging (MRI), or $500 Electroencephalography (EEG) due to a covered accidental injury. These exams must be performed in a hospital, a doctor’s office, a medical diagnostic imaging center or an ambulatory surgical center.

BLOOD/PLASMA/PLATELETS (once per accident, within 6 months after the accident) Payable for each day that an insured $300 receives blood, plasma or platelets due to a covered accidental injury.

PAIN MANAGEMENT (once per accident, within 6 months after the accident) Payable when an insured, due to a covered accidental injury, is prescribed and receives a nerve ablation and/or block, or an epidural injection administered into $100 the spine. This benefit is only payable for pain management techniques (as shown above) that are administered in a hospital or doctor’s office. This benefit is not payable for an epidural administered during a surgical procedure.

CONCUSSION (once per accident, within 6 months after the accident) Payable when an insured is diagnosed by a doctor with $500 a concussion due to a covered accident.

COMA (once per accident) Payable when an insured is in a coma lasting 14 days or more as the result of a covered accident. For the purposes of this benefit, Coma means a profound state of unconsciousness caused by a covered $7,5 0 0 accident. $50 EMERGENCY DENTAL WORK (once per accident, within 6 months after the accident) Payable when an insured’s natural teeth are Extraction injured as a result of a covered accident. $200 Repair with a crown

FRACTURES (once per accident, within 90 days after the accident) Payable when an insured fractures a bone because of a covered accident and is treated by a doctor. If the fracture requires open reduction, 200% of the benefit is payable for Up to that bone. For multiple fractures (more than one bone fractured in one accident), we will pay a maximum of 200% of $4,000 the benefit amount for the bone fractured that has the highest dollar amount. For a chip fracture (a piece of bone that based on a is completely broken off near a joint), we will pay 25% of the amount for the affected bone. This benefit is not payable schedule for stress fractures.

DISLOCATIONS (once per accident, within 90 days after the accident) Payable when an insured dislocates a joint because of a covered accident and is treated by a doctor. If the dislocation requires open reduction, 200% of the benefit for that joint is payable. We will pay benefits only for the first dislocation of a joint. We will not pay for recurring dislocations of Up to the same joint. If the insured dislocated a joint before the effective date of his certificate and then dislocates the same $3,000 joint again, it will not be covered by the plan. For multiple dislocations (more than one dislocated joint in one accident), based on a we will pay a maximum of 200% of the benefit amount for the joint dislocated that has the highest dollar amount. For schedule a partial dislocation (joint is not completely separated, including subluxation), we will pay 25% of the amount for the affected joint. 38

BURNS (once per accident, within 6 months after the accident) Payable when an insured is burned in a covered accident and is treated by a doctor. We will pay according to the percentage of body surface burned. First degree burns are not covered.

Second Degree Less than 10% $60 At least 10% but less than 25% $120 At least 25% but less than 35% $300 35% or more $600 Third Degree Less than 10% $600 At least 10% but less than 25% $3,000 At least 25% but less than 35% $6,000 35% or more $12,000

EYE INJURIES Payable for eye injuries if, because of a covered accident, a doctor removes a foreign body from the $200 eye, with or without anesthesia.

LACERATIONS (once per accident, within 7 days after the accident) Payable when an insured receives a laceration in a covered accident and the laceration is repaired by a doctor. For multiple lacerations, we will pay a maximum of 200% of the benefit for the largest single laceration requiring stitches. Lacerations requiring stitches (including liquid skin adhesive):

Over 15 centimeters $800 5-15 centimeters $200 Under 5 centimeters $50 Lacerations not requiring stitches $25 OUTPATIENT SURGERY AND ANESTHESIA (once per accident, performed in hospital or ambulatory surgical center, within one year after the accident) Payable for each day that, due to a covered accidental injury, an insured has an outpatient surgical procedure performed by a doctor in a hospital or ambulatory surgical center. Surgical procedure does not $150 include laceration repair. If an outpatient surgical procedure is covered under another benefit in the plan, we will pay the higher benefit amount.

OUTPATIENT SURGERY AND ANESTHESIA (twice per accident, performed in a doctor’s office, urgent care facility, or emergency room; maximum of two procedures per accident, within one year of the accident) Payable for each day that, due to a covered accidental injury, an insured has an outpatient surgical procedure $25 performed by a doctor in a doctor’s office, urgent care facility or emergency room. Surgical procedure does not include laceration repair. If an outpatient surgical procedure is covered under another benefit in this plan, we will pay the higher benefit amount.

INPATIENT SURGERY AND ANESTHESIA (once per accident, within one year after the accident) Payable for each day that, due to a covered accidental injury, an insured has an inpatient surgical procedure performed by a doctor. The surgery $1,000 must be performed while the insured is confined to a hospital as an inpatient. If an inpatient surgical procedure is covered under another benefit in the plan, we will pay the higher benefit amount.

$250 TRANSPORTATION (greater than 100 miles from the insured’s residence, 3 times per accident, within 6 months after the accident) Plane Payable for transportation if, because of a covered accident, an insured is injured and requires doctor-recommended $100 hospital treatment or diagnostic study that is not available in the insured’s resident city. Any ground transportation

SUCCESSOR INSURED BENEFIT If spouse coverage is in force at the time of the employee’s death, the surviving spouse may elect to continue coverage. Coverage would continue according to the existing plan and would also include any dependent child coverage in force at the time. Surgical Procedures may include, but are not limited to, surgical repair of: ruptured disc, tendons/ligaments, hernia, rotator cuff, torn knee cartilage, skin grafts, joint replacement, internal injuries requiring open abdominal or thoracic surgery, exploratory surgery (with or without repair), etc., unless otherwise noted due to an accidental injury. 39

FAMILY MEMBER LODGING (greater than 100 miles from the insured’s residence, maximum of 30 days per accident, within 6 months after the accident) Payable for each night’s lodging in a motel/hotel/rental property for an adult member of the insured’s immediate family. For this benefit to be payable: $100 per day • The insured must be confined to a hospital for treatment of a covered accidental injury; • The hospital and motel/hotel must be more than 100 miles from the insured’s residence; and • The treatment must be prescribed by the insured’s treating doctor.

WELLNESS RIDER

$50 WELLNESS BENEFIT (once per calendar year) Payable for wellness tests performed as the result of preventive care, including tests and diagnostic procedures First year of ordered in connection with routine examinations. certificate and thereafter

BENEFIT ACCIDENTAL DEATH RIDER AMOUNT

$75,000 Employee ACCIDENTAL DEATH BENEFIT (within 90 days after the accident*) Payable if a covered accidental injury causes the insured to die. $ 37,5 0 0 Spouse and Child(ren)

ACCIDENTAL COMMON-CARRIER DEATH BENEFIT $150,000 Payable if the insured: Employee • Is a fare-paying passenger on a common carrier; • Is injured in a covered accident; and $100,000 • Dies within 90 days* after the covered accident. Spouse and Child(ren) *In Oregon and Utah, within 180 days after the accident; in Pennsylvania, there is no limitation on the number of days.

ORGANIZED ATHLETIC ACTIVITY RIDER

ORGANIZED ATHLETIC ACTIVITY BENEFIT We will pay an additional percentage of the benefit amount payable under the Aflac Group Accident plan for covered 20% accidental injuries sustained while participating in an organized athletic event. BENEFIT AFTER CARE BENEFITS AMOUNT

APPLIANCES (1 device per accident, within 6 months after the accident) Payable if, as a result of an injury received in a covered accident, a doctor advises the insured to use a listed medical appliance as an aid in personal locomotion.

Cane, Ankle Brace, Walking Boot, Walker, Crutches, Leg Brace, Cervical Collar, Wheelchair, Knee Scooter, Body $100 Jacket, Back Brace

ACCIDENT FOLLOW-UP TREATMENT (maximum of 6 per accident, within 6 months after the accident provided initial treatment is within 7 days of the accident) Payable for doctor-prescribed follow-up treatment for injuries received in a covered accident. $50 Follow-up treatments do not include physical, occupational or speech therapy. Chiropractic or acupuncture procedures are also not considered follow-up treatment.

FOLLOW-UP TRANSPORTATION (maximum of 3 per accident, within 6 months after the accident provided initial treatment is within 7 days of the accident) $400 Payable for transportation to follow-up treatment when a benefit is paid under the Accident Follow-Up Treatment Benefit. (See Accident Follow-Up Treatment Benefit for limitations.)

REHABILITATION UNIT (maximum of 15 days per confinement, no more than 30 days total per calendar year for each insured) Payable for each day that, due to a covered accidental injury, an insured receives treatment as an inpatient at a rehabilitation facility. For this benefit to be payable, the insured must be transferred to the rehabilitation facility for $150 treatment following an inpatient hospital confinement. per day We will not pay the rehabilitation facility benefit for the same days that the hospital confinement benefit is paid. We will pay the highest eligible benefit.

THERAPY (maximum of 10 per accident, beginning within 90 days after the accident provided initial treatment is within 7 days after the accident) Payable if because of injuries received in a covered accident, an insured has doctor-prescribed therapy treatment $50 in one of the following categories: physical therapy provided by a licensed physical therapist, occupational therapy provided by a licensed occupational therapist, or speech therapy provided by a licensed speech therapist.

BENEFIT HOSPITALIZATION BENEFITS AMOUNT

HOSPITAL ADMISSION (once per accident, within 6 months after the accident) Payable when an insured is admitted to a hospital and confined as an inpatient because of a covered accidental $2,000 injury. per This benefit is not payable for confinement to an observation unit, for emergency room treatment or for outpatient confinement treatment.

HOSPITAL CONFINEMENT (maximum of 365 days per accident, within 6 months after the accident) Payable for each day that an insured is confined to a hospital as an inpatient because of a covered accidental injury. If we pay benefits for confinement and the insured is confined again within 6 months because of the same accidental $500 injury, we will treat this confinement as the same period of confinement. per day This benefit is payable for only one hospital confinement at a time even if caused by more than one covered accidental injury. This benefit is not payable for confinement to an observation unit or a rehabilitation facility.

HOSPITAL INTENSIVE CARE (maximum of 30 days per accident, within 6 months after the accident) Payable for each day an insured is confined in a hospital intensive care unit because of a covered accidental injury. We will pay benefits for only one confinement in a hospital intensive care unit at a time, even if it is caused by more than one covered accidental injury. $500 If we pay benefits for confinement in a hospital intensive care unit and an insured becomes confined to a hospital per day intensive care unit again within 6 months because of the same accidental injury, we will treat this confinement as the same period of confinement. This benefit is payable in addition to the Hospital Confinement Benefit. 40

G AFLAC GROUP CRITICAL ILLNESS CI Aflac can help ease the financial stress of surviving a critical illness.

Chances are you may know someone who’s been diagnosed with a critical illness. You can’t help notice the difference in the person’s life—both physically and emotionally. What’s not so obvious is the impact a critical illness may have on someone’s personal finances.

That’s because while a major medical plan may pay for a good portion of the costs associated with a critical illness, there are a lot of expenses that may not be covered. And, during recovery, having to worry about out-of-pocket expenses is the last thing anyone needs.

That’s the benefit of an Aflac Group Critical Illness plan.

It can help with the treatment costs of covered critical illnesses, such as a heart attack or stroke.

More importantly, the plan helps you focus on recuperation instead of the distraction of out-of-pocket costs. With the Critical Illness plan, you receive cash benefits directly (unless otherwise assigned)—giving you the flexibility to help pay bills related to treatment or to help with everyday living expenses.

What you need, when you need it. Group critical illness insurance pays cash benefits that you can use any way you see fit. 41

Here’s why the Aflac For more than 60 years, Aflac has been dedicated to helping provide individuals G Group Critical Illness and families peace of mind and financial security when they’ve needed it most. plan may be right The Aflac Group Critical Illness plan is just another innovative way to help make CI for you. sure you’re well protected. But it doesn’t stop there. Having group critical illness insurance from Aflac means that you may have added financial resources to help with medical costs or ongoing living expenses.

The Aflac Group Critical Illness plan benefits include: • Critical Illness Benefit payable for: – Cancer – Heart Attack (Myocardial Infarction) – Stroke – Kidney Failure (End-Stage Renal Failure) – Major Organ Transplant – Bone Marrow Transplant (Stem Cell Transplant) – Sudden Cardiac Arrest – Coronary Artery Bypass Surgery – Non-Invasive Cancer – Skin Cancer • Health Screening Benefit

Features: • Benefits are paid directly to you, unless otherwise assigned. • Coverage is available for you, your spouse, and dependent children. • Coverage may be continued (with certain stipulations). That means you can take it with you if you change jobs or retire.

How it works

Aflac Group Critical Illness pays Aflac Group You experience You visit the A physician an Initial Diagnosis Benefit of Critical Illness chest pains emergency determines coverage is and numbness room. that you have selected. in the left arm. suffered a heart attack. $10,000

Amount payable based on $10,000 Initial Diagnosis Benefit.

For more information, ask your insurance agent/producer, call 1.800.433.3036, or visit aflacgroupinsurance.com. 42

Benefits Overview

COVERED CRITICAL ILLNESSES:

CANCER (Internal or Invasive) 100%

HEART ATTACK (Myocardial Infarction) 100%

STROKE (Ischemic or Hemorrhagic) 100%

KIDNEY FAILURE (End-Stage Renal Failure) 100%

BONE MARROW TRANSPLANT (Stem Cell Transplant) 100%

SUDDEN CARDIAC ARREST 100%

MAJOR ORGAN TRANSPLANT (25% of this benefit is payable for insureds placed on a transplant list for a major organ transplant) 100%

NON-INVASIVE CANCER 25%

CORONARY ARTERY BYPASS SURGERY 25%

INITIAL DIAGNOSIS We will pay a lump sum benefit upon initial diagnosis of a covered critical illness when such diagnoses is caused by or solely attributed to an underlying disease. Cancer diagnoses are subject to the cancer diagnosis limitation. Benefits will be based on the face amount in effect on the critical illness date of diagnosis.

ADDITIONAL DIAGNOSIS We will pay benefits for each different critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation.

REOCCURRENCE We will pay benefits for the same critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation.

CHILD COVERAGE AT NO ADDITIONAL COST Each dependent child is covered at 50 percent of the primary insured’s benefit amount at no additional charge. Children-only coverage is not available.

SKIN CANCER BENEFIT We will pay $250 for the diagnosis of skin cancer. We will pay this benefit once per calendar year.

WAIVER OF PREMIUM If you become totally disabled due to a covered critical illness prior to age 65, after 90 continuous days of total disability, we will waive premiums for you and any of your covered dependents. As long as you remain totally disabled, premiums will be waived up to 24 months, subject to the terms of the plan.

SUCCESSOR INSURED BENEFIT If spouse coverage is in force at the time of the primary insured’s death, the surviving spouse may elect to continue coverage. Coverage would continue at the existing spouse face amount and would also include any dependent child coverage in force at the time.

HEALTH SCREENING BENEFIT (Employee and Spouse only) We will pay $50 for health screening tests performed while an insured’s coverage is in force. We will pay this benefit once per calendar year. This benefit is only payable for health screening tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. This benefit is payable for the covered employee and spouse. This benefit is not paid for dependent children.

GROUP CRITICAL ILLNESS ADVANTAGE INSURANCE G OPTIONAL BENEFITS RIDER SUMMARY PAGE CI

WHAT WE WILL PAY COVERED OPTIONAL BENEFITS Illnesses Covered Percentage of Under Plan Maximum Benefit Benign Brain Tumor 100% Advanced Alzheimer’s Disease 25% Advanced Parkinson’s Disease 25%

These benefits will be paid based on the face amount in effect on the critical illness date of diagnosis.

We will pay the optional benefit if the insured is diagnosed with one of the conditions listed in the rider schedule if the date of diagnosis is while the rider is in force.

WHAT IS NOT COVERED, LIMITATIONS AND EXCLUSIONS, AND TERMS YOU NEED TO KNOW

All limitations and exclusions that apply to the critical illness plan also apply to the rider unless amended by the rider.

Date of Diagnosis is defined as follows:

• Advanced Alzheimer’s Disease: The date a doctor diagnoses the insured as incapacitated due to Alzheimer’s disease.

• Advanced Parkinson’s Disease: The date a doctor diagnoses the insured as incapacitated due to Parkinson’s disease.

• Benign Brain Tumor: The date a doctor determines a benign brain tumor is present based on examination of tissue (biopsy or surgical excision) or specific neuroradiological examination. Optional Benefit is one of the illnesses defined below and shown in the rider schedule: Advanced Alzheimer’s Disease means Alzheimer’s Disease that causes the insured to be incapacitated. Alzheimer’s Disease is a progressive degenerative disease of the brain that is diagnosed by a psychiatrist or neurologist as Alzheimer’s Disease. To be incapacitated due to Alzheimer’s Disease, the insured must:

• Exhibit the loss of intellectual capacity involving and impairment of memory and judgment, resulting in a • Require substantial physical assistance from another significant reduction in mental and social functioning, adult to perform at least three ADLs.

Underwritten by Continental American Insurance Company A proud member of the Aflac family of insurers

AG210844VA R1 IV (2/16) 45

GROUP CRITICAL ILLNESS ADVANTAGE INSURANCE G PROGRESSIVE DISEASES RIDER SUMMARY PAGE CI

WHAT WE WILL PAY COVERED PROGRESSIVE DISEASES Percentage of Illnesses Covered Under Plan Maximum Benefit Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease) 100%

Sustained Multiple Sclerosis 100%

This benefit is paid based on your selected Progressive Disease Benefit amount.

We will pay the benefit shown upon diagnosis of one of the covered diseases if the date of diagnosis is while the rider is in force.

WHAT IS NOT COVERED, LIMITATIONS AND EXCLUSIONS, AND TERMS YOU NEED TO KNOW

All limitations and exclusions that apply to the critical illness plan also apply to the rider unless amended by the rider. Date of Diagnosis is defined for each specified critical illness as follows:

• Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease): The date a Doctor Diagnoses an Insured as having ALS and where such Diagnosis is supported by medical records.

• Sustained Multiple Sclerosis: The date a Doctor Diagnoses an Insured as having Multiple Sclerosis and where such Diagnosis is supported by medical records. Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease) means a chronic, progressive motor neuron disease occurring when nerve cells in the brain and spinal cord that control voluntary movement degenerate, causing muscle weakness and atrophy, eventually leading to paralysis. Sustained Multiple Sclerosis means a chronic degenerative disease of the central nervous system in which gradual destruction of myelin occurs in the brain or spinal cord or both, interfering with the nerve pathways. Sustained Multiple Sclerosis results in one of the following symptoms for at least 90 consecutive days:

• Muscular weakness,

• Loss of coordination,

• Speech disturbances, or

• Visual disturbances.

If the coverage outlined in this summary will replace any existing coverage, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy.

This insert is subject to the terms, conditions, and limitations of Form Number C21303VA. aflacgroupinsurance.com | 1.800.433.3036 | 1.866.849.2970 fax Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. Continental American Insurance Company • Columbia, South Carolina

AG210845VA R1 IV (2/16) 46

GROUP CRITICAL ILLNESS ADVANTAGE INSURANCE G OCCUPATIONAL HIV RIDER SUMMARY PAGE CI

WHAT WE WILL PAY FOR 100% OCCUPATIONAL HIV The benefit is payable for the initial positive diagnosis of occupational HIV if the diagnosis results from an HIV-specific covered injury. We will pay the indicated percentages of the applicable face amount.

This benefit is payable once, and after the benefit is paid, the rider coverage will terminate. These benefits will be paid based on the face amount in effect on the critical illness date of diagnosis. WHAT IS NOT COVERED, LIMITATIONS AND EXCLUSIONS, AND TERMS YOU NEED TO KNOW If the coverage outlined in this summary will replace any existing coverage, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy. HIV means Human Immunodeficiency Virus.

HIV Positive means the presence of HIV antibodies in the blood. This must be evidenced by:

• A positive screening test enzyme-linked immunosorbent assay (ELISA) or

• A positive supplement test, such as the Western Blot All such tests must be approved by the Food and Drug Administration (FDA), and the interpretation of positive results must be in keeping with the manufacturer’s specifications. Occupational HIV refers to your testing positive for HIV as a direct result of an HIV-specific covered injury, subject to the following provisions:

• The HIV-specific covered injury must occur during the normal course of duties for the occupation in which the insured is regularly engaged. The HIV infection must result from accidental exposure to HIV-contaminated body fluids during the normal course of performing an occupation for which remuneration is earned.

• The insured must file an incident report (notice of exposure) with his employer within 48 hours of the positive test result. This report must:

– Be on a form acceptable to the company,

– Describe the nature of the exposure to HIV, and

– Be sent to the company as soon as reasonably possible after the HIV-specific covered injury.

• An insured must not have previously tested positive for HIV. If he had previously tested positive for HIV, he must have subsequently tested negative for HIV before the date of the HIV-specific covered injury.

• An insured must have a preliminary HIV screening test—such as an ELISA or other appropriate Food and Drug Administration (FDA) approved test (other than saliva or urine testing)— within 14 days of the covered injury at an authorized laboratory other than the laboratory of the insured’s employer. We must receive notification of the negative results as soon as reasonably possible. Thereafter, the insured must test HIV positive within 26 weeks of the date of that HIV-specific covered injury.

Underwritten by Continental American Insurance Company A proud member of the Aflac family of insurers

AG210843VA R1 IV (2/16) 47

GROUP CRITICAL ILLNESS ADVANTAGE INSURANCE G HEART EVENT RIDER SUMMARY PAGE CI

WHAT WE WILL PAY

Surgeries and Procedures Covered Under Plan Percentage of Maximum Benefit

Category 1- Specified Surgeries of the Heart

Mitral Valve Replacement or Repair 100%

Aortic Valve Replacement or Repair 100%

Surgical Treatment of Abdominal aortic aneurysm 100%

Coronary Artery Bypass Surgery 75%*

Category 2- Invasive Procedures and Techniques of the Heart

AngioJet Clot Busting 10%

Balloon Angioplasty (or Balloon valvuloplasty) 10%

Laser Angioplasty 10%

Atherectomy 10%

Stent Implantation 10%

Cardiac Catheterization 10%

Automatic Implantable (or Internal) Cardioverter Defibrillator (AICD) 10%

Pacemakers 10%

These benefits will be paid based on the face amount in effect on the critical illness date of diagnosis. *The 75% benefit available in the rider, combined with the partial benefit available in the certificate, equals a 100% benefit for coronary artery bypass surgery. Benefits are payable for the specified surgeries and procedures listed above when caused by a defined underlying disease, treatment is recommended by a doctor, and is not excluded by name or specific description. Benefits from each category are payable once per calendar year, per insured. If multiple procedures are performed at the same time, benefits will be payable only at the highest benefit level and will not exceed the percentage shown above.

Underwritten by Continental American Insurance Company A proud member of the Aflac family of insurers

AG210842VA R1 IV (2/16) 48

AFLAC GROUP HOSPITAL INDEMNITY G Policy Form C80100VA HI

The plan that can help with expenses and protect your savings.

Does your major medical insurance cover all of your bills?

Even a minor trip to the hospital can present you with unexpected expenses and medical bills. And even with major medical insurance, your plan may only pay a portion of your entire stay.

That’s how the Aflac Group Hospital Indemnity plan can help.

It provides financial assistance to enhance your current coverage. So you may be able to avoid dipping into savings or having to borrow to address out-of-pocket-expenses major medical insurance was never intended to cover. Like transportation and meals for family members, help with child care, or time away from work, for instance.

The Aflac Group Hospital Indemnity plan benefits include the following: • Hospital Confinement Benefit • Hospital Admission Benefit • Hospital Intensive Care Benefit • Intermediate Intensive Care Step-Down Unit

How it works

The Aflac Group Hospital Indemnity plan pays The The insured The The insured Aflac Group has a high physician is released Hospital Indemnity fever and admits the after two plan is selected. goes to the insured into days. emergency the hospital. room. $1,300

Amount payable was generated based on benefit amounts for: Hospital Admission ($1,000), and Hospital Confinement ($150 per day).

Benefits Overview G BENEFIT AMOUNT

HOSPITAL ADMISSION BENEFIT per confinement (once per covered sickness or accident per calendar year for each insured) HI Payable when an insured is admitted to a hospital and confined as an inpatient because of a covered accidental injury or covered sickness. We will not pay benefits for confinement to an observation unit, or for emergency room treatment or outpatient treatment. $1,000 We will not pay benefits for admission of a newborn child following his birth; however, we will pay for a newborn’s admission to a Hospital Intensive Care Unit if, following birth, he is confined as an inpatient as a result of a covered accidental injury or covered sickness (including congenital defects, birth abnormalities, and/or premature birth).

HOSPITAL CONFINEMENT per day (maximum of 31 days per confinement for each covered sickness or accident for each insured) Payable for each day that an insured is confined to a hospital as an inpatient as the result of a covered accidental injury or covered sickness. If we pay benefits for confinement and the insured becomes $150 confined again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable for only one hospital confinement at a time even if caused by more than one covered accidental injury, more than one covered sickness, or a covered accidental injury and a covered sickness.

HOSPITAL INTENSIVE CARE BENEFIT per day (maximum of 10 days per confinement for each covered sickness or accident for each insured) Payable for each day when an insured is confined in a Hospital Intensive Care Unit because of a covered accidental injury or covered sickness. We will pay benefits for only one confinement in a Hospital's Intensive Care Unit at a time. Once benefits are paid, if an insured becomes confined to a Hospital's $150 Intensive Care Unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable in addition to the Hospital Confinement Benefit.

INTERMEDIATE INTENSIVE CARE STEP-DOWN UNIT per day (maximum of 10 days per confinement for each covered sickness or accident for each insured) Payable for each day when an insured is confined in an Intermediate Intensive Care Step-Down Unit because of a covered accidental injury or covered sickness. We will pay benefits for only one confinement in an Intermediate Intensive Care Step-Down Unit at a time. $75 Once benefits are paid, if an insured becomes confined to a Hospital's Intermediate Intensive Care Step-Down Unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable in addition to the Hospital Confinement Benefit.

In order to receive benefits for accidental injuries due to a covered accident, an insured must be admitted within six months of the date of the covered accident.

LIMITATIONS AND EXCLUSIONS EXCLUSIONS • Suicide – committing or attempting to commit suicide, while sane or insane. We will not pay for loss due to: • Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally. • War – voluntarily participating in war, any act of war, or military conflicts, declared • Racing – riding in or driving any motor-driven vehicle in a race, stunt show or speed or undeclared, or voluntarily participating or serving in the military, armed forces, or test in a professional or semi-professional capacity. an auxiliary unit thereto, or contracting with any country or international authority. • Illegal Occupation – voluntarily participating in, committing, or attempting to commit (We will return the prorated premium for any period not covered by the certificate a felony or illegal act or activity, or voluntarily working at, or being engaged in, an when the insured is in such service.) War also includes voluntary participation in an illegal occupation or job. insurrection, riot, civil commotion or civil state of belligerence. War does not include • Sports – participating in any organized sport in a professional or semi-professional acts of terrorism. capacity. 50

Transamerica Universal Life with Long Term Care How it Works

 At death: Pays death benefit to beneficiary  For Terminal Illness: Advances up to 75% of death benefit while living  For Facility Nursing or Home Health Care: Advances 4% of death benefit/month for Long Term Care costs (25 months)  Extension of Benefits: Extends the 4% of benefit/month for Long Term Care for additional 25 months  When death benefit is depleted by Long Term Care benefits, the policy provides a paid-up policy at 25% of original face value

Example: $100,000 policy

 Employee dies: Payout =$100,000  Employee diagnosed w/terminal illness: Payout = Up to $75,000 while still living  Employee requires Long Term Care: Payout = $4,000/month for 25 months, then Extension of Benefits pays $4,000/month for an additional 25 months.  Premium payments waived during Long Term Care.  Final paid-up value of policy = $25,000  Long Term Care benefits paid after a 90-day elimination period 53

OTHER LMG SPONSORED SUPPLEMENTAL BENEFITS 2454

Each eligible employee is automatically enrolled in the following LMG paid benefits

• Basic Life Insurance • Long Term Disability

• Accidental Death & Dismemberment • Employee Assistance

In addition, you can elect to purchase additional life insurance under the Voluntary Life Insurance plan. For specific details, please see Human Resources.

Increments of $10,000 to a maximum of $300,000, not Employee Supplemental Coverage to exceed five times earnings

Increments of $5,000 to a maximus of $150,000 not to Spousal Supplemental Coverage exceed 50% of the employee's covered amount

14 Day to 6 Months : $250 Child(ren) Supplemental Coverage 6 Months to Age 19 : $10,000 (up to age 25 if a full-‐time student) Employee Guarantee Issue $120,000 Spouse Guarantee Issue $40,000 Child(ren) Guarantee Issue $10,000

Voluntary Life Rates Are Shown Monthly Employee Life Insurance Employee AD&D Insurance Spouse Life Insurance Employee Age Rates per $1,000 Rates per $1,000 Rates per $1,000 Less Than 30 $0.045 $0.025 $0.07 30 – 34 $0.055 $0.025 $0.08 35 – 39 $0.085 $0.025 $0.11 40 – 44 $0.155 $0.025 $0.18 45 – 49 $0.275 $0.025 $0.30 50 – 54 $0.425 $0.025 $0.45 55 – 59 $0.645 $0.025 $0.67 60 – 64 $1.075 $0.025 $1.10 65 – 69 $1.965 $0.025 $1.99 70 – 74 $2.785 $0.025 $2.81 75 + $6.045 $0.025 $6.07

*Spouse Voluntary Rates Are Calculated Using The Employee’s Age 55

401k Retirement Savings & Employee Profit Sharing Plan

LMG employees may elect to change their 401k elections at any time. You can start, stop or change your payroll contributions or make changes to your fund allocations. You can even direct or redirect your contributions from traditional pre-tax to Roth after-tax contributions. Online. Register now at vanguard.com/register to check your balance, conduct transactions, research investments, use financial planning tools, and more. You will need your plan number to sign up: 097553.* Fund and expense information is also available at https://retirementplans.vanguard.com/PubFundChart/loudoun/2348

By phone. Call the 24-hour interactive VOICE® Network at 800-523-1188. You will need a personal identification number (PIN) to use VOICE. To create a PIN, follow the prompts.

On Your Mobile Device Go to vanguard.com/bemobile to download the Vanguard app so you can access your account on the go.

With personal assistance. Vanguard Participant Services associates are available to assist you at 800-523-1188 Monday through Friday from 8:30 a.m. to 9 p.m., Eastern time.

Minimum Contribution Per Pay Maximum Contribution Per Pay Max Annual Contribution

$10 or 1% 100% of pay $19,500* < age 55 $26,000* >/= age 55 *Maximum annual contribution includes both pre-tax and after-tax (Roth) contributions. IMPORTANT NOTE: THIS PLAN HAS AUTO ENROLLMENT!!!

LMG 401k Retirement Savings Program features AUTO ENROLLMENT

The LMG 401k Plan is administered by Vanguard and is an auto enrollment plan. As an auto enrollment plan, all eligible employees will automatically be enrolled in the 401k plan when they become eligible. The automatic deferral rate is 4%. Employees may choose to elect less or more, up to the maximum amount allowable for the plan year.

Employees will receive information at their home address from Vanguard that includes a instructions on how to log on to their account. Employees may log on and cancel their contribution, reduce it or increase it.

If you do not receive information from Vanguard you should contact them directly at 1-800-523-1188.

PROFIT SHARING

LMG contributes to the 401k plan via profit sharing. The profit sharing does not match your contributions but instead takes a percentage of your salary and deposits that on your behalf in to your 401k plan.

Profit Sharing Eligibility:

- One year of service - Worked at least 1,000 hours in the profit sharing year - Actively employed on December 31 of the profit sharing year 56

401k Retirement Savings & Employee Profit Sharing Plan Employees do not need to contribute to the 401k plan in order to be eligible for profit sharing. LMG will make a Profit Sharing contribution to all employees who meet the eligibility criteria. All profit sharing contributions must distributed in to an employee’s LMG 401k plan.

You become eligible for profit sharing contributions on the first day of the quarter following your one year anniversary.

HIRE DATE: July 2, 2012

ONE YEAR ANNIVERSARY: July 2, 2013

YOU BECOME ELIGIBLE FOR PROFIT October 1, 2013 (1st of quarter following one SHARING PROGRAM: year anniversary)

*ELIGIBLE COMPENSATION: All income earned between 1st paycheck dated in October 2013 through last pay check in 2013.

If your *eligible compensation between October 1 and December 31 was $10,000 and the profit sharing contribution in 2013 was 6%, LMG will deposit $600 deposited in to your 401k plan.

If your *eligible compensation between October 1, 2013 and December 31, 2013 was $60,000 and the profit sharing contribution in 2013 was 6%, LMG will deposit $3,600 in to your 401k plan.

LMG is reviews profit sharing figures each year to determine what the company will be able to provide to employees through profit sharing. Profit Sharing distributions are determined during the first quarter of the following year and distributions are deposited in to employee 401k accounts by September of the following year.

LMG determines Profit Sharing contribution for the prior year………………………………………………………………… March LMG makes contributions to employee 401k accounts in lump sum or over several installments…...... Between April and September

Vesting Schedule

You are always 100% vested in your own contributions.

There is a vesting schedule for Profit Sharing Contributions that is based on years of service.

Profit Sharing Contributions

Years of Service Percentage

Less than 2 0% 2 20% 3 40% 4 60% 5 80% 6 100% 57

401k Retirement Savings & Employee Profit Sharing Plan Questions / Support

If you have questions regarding the LMG 401k Retirement Savings plan or any of the LMG benefit programs, you may contact your HR team directly.

Maggie Colucci 703-737-6033

Frequently Asked Questions:

Can I call LMG HR to have my 401k deductions stopped?

No, you need to make changes to your 401k contributions through Vanguard. If you lose or forget your login or wish to do this via telephone instead of online you can call Vanguard at 1-800-523-1188.

Can I make changes to my 401k contributions at any time during the plan year?

Yes, you can make changes at any time by visiting your account on-line or by calling Vanguard directly.

Will my payroll deductions automatically be cut off should I reach my annual maximum contribution?

Yes, your deductions will be stopped at the annual maximum contribution.

Do I have to contribute to the 401k plan to be eligible for the Profit Sharing plan?

No, eligible employees do not have to be participating in the 401k plan in order to receive the profit sharing.

Does the Profit Sharing bonus have to be deposited in to the Vanguard account set up for me by LMG?

Yes, the Profit Sharing bonus is deposited in to a Vanguard retirement account in the employee’s name. It may not be directed to any other account until such time that employment with LMG ends. 58

Worry Less. Live More. Affordable identity theft protection for one low monthly fee.

Your identity is personal. Keep it that way. LegalShield Identity Theft Plan provides identity monitoring as well as top-of-the-line identity theft restoration from Kroll Advisory Solutions. LegalShield Identity Theft Plan covers you and your spouse (or domestic partner).

Credit Report Secure web access to your up-to-date credit Protect you and your report based on data from Experian spouse’s good name.

Get the best identity theft Detailed analysis of your Personal Credit Score 720 Credit Score/Analysis coverage for you and your with your first credit report spouse, and discover what it’s like to worry less and Activate continuous credit monitoring of your live more. Monitoring/ Experian credit file via our secure website. Activity Alerts E-mail alerts notify you of activity on your credit file.

Identity Restoration Kroll Advisory Solutions, the experts in identity theft restoration, will step in and Services ta ke over the restoration process for you, should you face an identity theft issue.

What if you’re a victim? In the event that identity theft ever does occur, we’ve partnered with the world’s leading consulting company in identity theft restoration, Kroll Advisory Solutions, to restore your identity. The experts at Kroll are ready to provide you with the information you need to take action, or, if you choose to sign a limited power of attorney, Kroll will take action for you by:

• Explaining your rights and educating you on the restoration process

• Issuing fraud alerts to all three national repositories, relevant government agencies and affected banks and credit card companies Only • Assisting you in working with banks, creditors, collection agencies, credit card companies and law enforcement personnel to dispute all $12.95 fraudulent accounts a month • Continuing identity restoration until your identity is back to what it was before the fraud occurred

www.legalshield.com/info/idtnm

Marketed by: Pre-Paid Legal Services, Inc. and subsidiaries; Pre-Paid Legal CasualtySM, Inc.; Pre-Paid Legal Access, Inc.; In FL: Pre-Paid Legal Services, Inc. of Florida; In VA: Legal Service Plans of Virginia, Inc.; and PPL Legal Care of Canada Corporation Please refer to the website below for a description of plan beneﬁts, limitations and exclusions. 59

$15.95

www.LegalShield.com/info/standardplan 30 60

ACI’s Employee Assistance Program (EAP) provides professional and confidential services to help employees and family members address a variety of personal, family, life, and work-related issues. Confidential and professional assessment and referral services for employees and their family members EAP and Work-Life Benefits: From the stress of everyday life to relationship issues or even work- related concerns, the EAP can help with any issue affecting overall health, well-being and life management.

• Unlimited Telephonic Clinical Assessment and Referral • Up to 3 Sessions of Professional Assessment for Employees and Family Members • Unlimited Child Care and Elder Care Referrals • Legal Consultation for Unlimited Number of Issues per Year • Financial Consultation for Unlimited Number of Issues per Year • Unlimited Pet Care Consultation • Unlimited Education Referrals and Resources • Unlimited Referrals and Resources for any Personal Service • Unlimited Community-based Resource Referrals • Online Legal Resource Center • Affinity™ Online Work-Life Website • myACI App for Mobile Access • Multicultural and Multilingual Providers Available Nationwide

EAP benefits are free of charge, 100% confidential, available to all family members regardless of location, and easily accessible through ACI’s 24/7, live-answer, toll-free number. EAP services are provided by ACI Specialty Benefits, under agreement with Reliance Standard Life Insurance Company. Reliance Standard Life Insurance Company is licensed in all states (except New York), the District of Colombia, Puerto Rico, the U.S. Virgin Islands and Guam. In New York, insurance products and services are provided through First Reliance Standard Life Insurance Company, Home Office: New York, NY. Product availability and features may vary by state.

Additional Questions? Contact Human Resources or contact ACI Specialty Benefits toll-free at 855-RSL-HELP (855-775-4357) [email protected] http://rsli.acieap.com 3261

24-Hour Travel Assistance Services

Through your group coverage with Reliance Standard, you automatically receive travel assistance services provided by On Call International (On Call), pursuant to an agreement between Reliance Standard and On Call. On Call is a 24-hour, toll-free service that provides a comprehensive range of information, referral, coordination and arrangement services designed to respond to most medical care situations and many other emergencies you may encounter when you travel. On Call also offers pre-trip assistance including passport/visa requirements, foreign currency and weather information. The following is an outline of the On Call emergency travel assistance service program. For a complete description of all services and the program terms and limitations, please request a Description of Covered Services from your employer. Covered Services When traveling more than 100 miles from home or in a foreign country, On Call offers you and your dependents the following services: Pre-Trip Assistance Emergency Personal Services • Inoculation requirements information • Urgent message relay • Passport/visa requirements • Interpretation/translation services • Currency exchange rates • Emergency travel arrangements • Consulate/embassy referral • Recovery of lost or stolen luggage/personal possessions • Health hazard advisory • Legal assistance and/or bail bond • Weather information Medical Services Include: Emergency Medical Transportation* • Medical referrals for local physicians/dentists • Emergency evacuation • Medical case monitoring • Medically necessary repatriation • Prescription assistance and eyeglasses replacement • Visit by family member or friend • Convalescence arrangements • Return of traveling companion • Return of dependent children * The services listed above are subject to a maximum combined single • Return of vehicle limit of $250,000. Return of vehicle is subject to $2,500 maximum limit. • Return of mortal remains How It Works At any time before or during a trip, you may contact On Call for emergency assistance services. It is recommended that you keep a copy of this summary with your travel documents. Simply detach the wallet card below to ensure convenient access to the On Call phone numbers. TO REACH ON CALL VIA INTERNATIONAL CALLING: Go to http://www.att.com/esupport/traveler.jsp?group=tips for complete dialing instructions. It is recommended that you do this prior to departing the US, find the access code from the country you will be visiting, and note it on the cut-out card below so you will have the information readily available in case of an emergency. (AT&T provides English-speaking operators and the ability to place collect calls to On Call, whereas local providers may encounter difficulty placing collect calls to the US.) Preferred 3 Color Administered by Provided with your benefitsPMS 7546 C coverage through PMS 7461 C

PMS 109 C

Gradient PMS 109 C to Transparent On Call International is not affiliated with Reliance Standard Life Insurance Company or First Reliance Standard Life Insurance Company. Reliance Standard is not responsible for the content of the On Call travel assistance services, and is not responsible for, and cannot be held liable for, any services provided or not provided by On Call. Reliance Standard Life Insurance Company is licensed in all states (except New York), the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. In New York, insurance2 Colorproducts and services are provided through First Reliance Standard Life InsurancePMS Company, 7546 C Home Office: New York, NY. On Call is not responsible for the unavailability or results of any medical, legal or transportation services. You are responsible for obtaining all services not directly provided by On Call and for the expenses associated with them. PMS 7546 C at 60%

Travel assistance servicesPMS 109are C provided by On Call International (On Call) under the terms and conditions of a service agreement 24-hour travelPreferred 3 Color assistance Gradient PMS 7546 C with Reliance Standard.PMS On 109 Call C to T ransparentInternational is not affiliated with PMS 7461 C Reliance Standard or with AT&T. PMS 109 C Gradient Reliance Standard is not responsible for the content of the On Call PMS 109 C to Transparent provided through travel assistance services, and is not responsible for, and cannot be held liable for, any services provided or not provided by On Call. 1 Color 2 Color PMS 7546 C Reliance Standard Life Insurance Company is licensed in all PMS 7546 C at 60% states (except New York), the District of Columbia, Puerto Rico, For emergency medical, legal and travel assistance informationPMS and 109 C Gradient Guam and the U.S. Virgin Islands. In New York State, benefits are referral service 24 hours a day, 365 days a year, call the numbers PMSbelow. 109 C to Transparent To place a collect call, dial the INTERNATIONAL COUNTRY CODE: underwritten by First Reliance Standard Life Insurance Company, Home Office: New York,PMS NY.7546 C ______1followed Color by On Call’s collect call number. On Call is not responsible for the unavailability or results of any Gradient In the U.S., toll free Worldwide, collect medical, legal or transportation services. You are responsible for PMS 7546 C PMS 7546 C to Transparent Gradient obtaining all services not directly provided by On Call and for the (800) 456-3893 (603) 328-1966PMS 7546 C to Transparent expenses associated with them.

RS-2110 (8/12)

Grayscale

100% Black

60% Black

Gradient Grayscale 100% Black to Transparent

Reversed 100% Black

PMS 7546 C 60% Black Gradient White to Transparent Gradient 100% Black to Transparent

Reversed

PMS 7546 C

Gradient White to Transparent 62

Model Notices 63

For Employers Who Offer a Health Plan to Some or All Employees Health Insurance Exchange Notice

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

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

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For more information about your coverage offered by your employer, please check your summary plan How Can I Get More Information?description or contact: Maggie Colucci 224-D Cornwall Street, N.W., Suite 403 Leesburg, Virginia 20176 (703) 737-6033 [email protected]

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

This section contains information about any health coverage offered by your employer. If you decide to PART complete an application for coverage in the Marketplace, you will be asked to provide thisB: Information About Health Coverage Offered by Your Employer information. This information is numbered to correspond to the Marketplace application.

3. Employer name 4. Employer Identification Number (EIN) Loudoun Medical Group 54-1988843

5. Employer address 6. Employer phone number 224-D Cornwall Street, N.W., Suite 403 (703) 737-6033

7. City 8. State 9. ZIP code Leesburg Virginia 20176

10. Who can we contact about employee health coverage at this job? Maggie Colucci

11. Phone number 12. Email address (703) 737-6033 [email protected]

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to: þ Some employees. Eligible employees are: All full time active employees, employees working 30 hours or more per week • With respect to dependents:

þ We do offer coverage. Eligible dependents are: Spouse, dependents up until the age of 26

R If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. Note: Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other

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factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in thisNotice of Special Enrollment Rights plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you or your dependent(s) lose coverage under a state Children’s Health Insurance Program (CHIP) or Medicaid, you may be able to enroll yourself and your dependents. However, you must request enrollment within 60 days after the loss of CHIP or Medicaid coverage. If you or your dependent(s) become eligible to receive premium assistance under a state CHIP or Medicaid, you may be able to enroll yourself and your dependents. However, you must request enrollment within 60 days of the determination of eligibility for premium assistance from state CHIP or Medicaid. To request special enrollment or obtain more information, contact Maggie Colucci at 224-D Cornwall Street, N.W., Suite 403, Leesburg, Virginia 20176, (703) 737-6033, [email protected].

Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a Wellness Program Disclosurereward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact Maggie Colucci at 224-D Cornwall Street, N.W., Suite 403, Leesburg, Virginia 20176, (703) 737-6033, [email protected] and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

Notice of Privacy Practices Loudoun Medical Group 224-D Cornwall Street, N.W., Suite 403 Leesburg, Virginia 20176 (703) 737-6033 www.lmgdoctors.com

Privacy Official:

Maggie Colucci 224-D Cornwall Street, N.W., Suite 403 Leesburg, Virginia 20176 (703) 737-6033 [email protected]

Effective Date: 01/01/2019 Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights You have the right to:

• Get a copy of your health and claims records • Correct your health and claims records • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family and friends • Provide disaster relief • Market our services and sell your information Our Uses and Disclosures We may use and share your information as we:

• Help manage the health care treatment you receive • Run our organization • Pay for your health services

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• Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests and work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. • We are not required to agree to your request, and we may say “no” if it would affect your care. Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you

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• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us at: Maggie Colucci 224-D Cornwall Street, N.W., Suite 403 Leesburg, Virginia 20176 (703) 737-6033 [email protected] • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696- 6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. • We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care • Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes • Sale of your information Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Run our organization

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• We can use and share your information to run our organization and contact you when necessary. • We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans. Example: We use health information about you to develop better services for you. Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Help with public health and safety issues We can share health information about you for certain situations such as:

• Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations. • We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:

• For workers’ compensation claims • For law enforcement purposes or with a law enforcement official

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• With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

WomenIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the s Health and Cancer Rights Act (WHCRA) Notices Enrollment NoticeWomen’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy -related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply: $0.0 deductible (in-network) and 0% coinsurance (in-network) and $0.0 deductible (out-of-network) and 0% coinsurance (out-of-network). If you would like more information on WHCRA benefits, call your plan administrator at (703) 737-6033.

Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides Annual Noticebenefits for mastectomy -related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call your plan administrator at (703) 737-6033 for more information.

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Mental Health Parity and Addiction Equity Act (MHPAEA) The Mental Health Parity and Addiction Equity Act of 2008 generally requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays and deductibles) and treatment limitations (such as annual visit limits) applicable to mental health or substance use disorder benefits are no Disclosure more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. For information regarding the criteria for medical necessity determinations made under the Loudoun Medical Group with respect to mental health or substance use disorder benefits, please contact your plan administrator at (703) 737-6033.

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) Employer’s Children’s Health Insurance Program (CHIP) Notice If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877- KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2019. Contact your State for more information on eligibility —

ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-855-692-5447 Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: https://medicaid.georgia.gov/health-insurance- Website: http://myakhipp.com/ premium-payment-program-hipp Phone: 1-866-251-4861 Phone: 678-564-1162 ext 2131 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx 12

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Healthy Indiana Plan for low-income adults 19-64 Phone: 1-855-MyARHIPP (855-692-7447) Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 COLORADO – Health First Colorado (Colorado’s IOWA – Medicaid Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: Website: http://dhs.iowa.gov/Hawki https://www.healthfirstcolorado.com/ Phone: 1-800-257-8563 Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health- plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 1-785-296-3512 Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218 KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: https://chfs.ky.gov Medicaid Website: Phone: 1-800-635-2570 http://www.state.nj.us/humanservices/dmahs/clients/medicaid / Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 LOUISIANA – Medicaid NEW YORK – Medicaid Website: Website: https://www.health.ny.gov/health_care/medicaid/ http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-800-541-2831 Phone: 1-888-695-2447

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public- Website: https://medicaid.ncdhhs.gov/ assistance/index.html Phone: 919-855-4100 Phone: 1-800-442-6003 TTY: Maine relay 711 MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-862-4840 Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: Website: http://www.insureoklahoma.org https://mn.gov/dhs/people-we-serve/seniors/health- Phone: 1-888-365-3742 care/health-care-programs/programs-and-services/other- insurance.jsp Phone: 1-800-657-3739

73 MISSOURI – Medicaid OREGON – Medicaid Website: Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.dss.mo.gov/mhd/participants/pages/hipp.htm http://www.oregonhealthcare.gov/index-es.html Phone: 573-751-2005 Phone: 1-800-699-9075 MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP http://www.dhs.pa.gov/provider/medicalassistance/healthinsur Phone: 1-800-694-3084 ancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462 NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: http://www.ACCESSNebraska.ne.gov Website: http://www.eohhs.ri.gov/ Phone: (855) 632-7633 Phone: 855-697-4347, or 401-462-0311 (Direct Rite Share Line) Lincoln: (402) 473-7000 Omaha: (402) 595-1178 NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: http://dhcfp.nv.gov/ Website: http://www.scdhhs.gov Medicaid Phone: 1-800-992-0900 Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Website: https://www.hca.wa.gov/ Phone: 1-888-828-0059 Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Website: http://mywvhipp.com/ Phone: 1-800-440-0493 Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ Website: CHIP Website: http://health.utah.gov/chip https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-877-543-7669 Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Website: https://wyequalitycare.acs-inc.com Phone: 1-800-250-8427 Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cf m Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cf m CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

(For use by single-employer group health plans) General Notice of COBRA Rights

Continuation Coverage Rights Under COBRA You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This Introductionnotice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of- pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a What is COBRA continuation coverage?life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

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• You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

• The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator When is COBRA continuation coverage available?has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

• The end of employment or reduction of hours of employment; • Death of the employee; • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to:

Maggie Colucci Human Resources Director 224-D Cornwall Street, N.W., Suite 403 Leesburg, Virginia 20176 (703) 737-6033 [email protected]

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation How is COBRA continuation coverage provided?coverage will be offered to each of the qualified beneficiaries. Each qualified bene ficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to Disability extension of 18-month period of COBRA continuation coverage

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an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, Second qualifying event extensiothe spouse and dependent children in your family can get up to 18 additional months of COBRA continuationn of 18-month period of continuation coverage coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and Are there other coverage options besides COBRA Continuation Coverage?your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee If you have questions Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.

To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family Keep your Plan informed of address changesmembers. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Loudoun Medical Group MagPlan contact informationgie Colucci 224-D Cornwall Street, N.W., Suite 403, Leesburg, Virginia 20176 (703) 737-6033 [email protected]

General FMLA NoticeEMPLOYEE RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT

EligibleThe United employees States who wor Dekp forar atment covered o empf Laborloyer can W takeage up and to 12 Hour weeks Divisionof unpaid, job -protected leave in a Leave Entitlements12-month period for the following reasons: • The birth of a child or placement of a child for adoption or foster care; • To bond with a child (leave must be taken within 1 year of the child’s birth or placement); • To care for the employee’s spouse, child, or parent who has a qualifying serious health condition; • For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job; • For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse, child, or parent. An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness. An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees may take leave intermittently or on a reduced schedule. Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.

While employees are on FMLA leave, employers must continue health insurance coverage as if the Benefits & Protectionsemployees were not on leave. Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with equivalent pay, benefits, and other employment terms and conditions. An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave, opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.

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An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA Eligibility Requirementsleave. The employee must: • Have worked for the employer for at least 12 months; • Have at least 1,250 hours of service in the 12 months before taking leave;* and • Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite. *Special “hours of service” requirements apply to airline flight crew employees.

Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30Requesting Leave-days’ notice, an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures. Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is or will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which FMLA leave was previously taken or certified. Employers can require a certification or periodic recertification supporting the need for leave. If the employer determines that the certification is incomplete, it must provide a written notice indicating what additional information is required.

Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under Employer Responsibilitiesthe FMLA, the employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility. Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as FMLA leave.

Employees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a Enforcementprivate lawsuit against an employer. The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective bargaining agreement that provides greater family or medical leave rights.

1-866-4-USWAGE For additional information or to file a complaint:

(1-866-487-9243) TTY: 1-877-889-5627

U.S. Department of Labor | Wage www.dol.gov/whdand Hour Division

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Payroll Contributions (bi-weekly)

Base Rate with 10% Base Rate Tobacco Surcharge Anthem BCBS | Lumenos HSA GHSA 269 **LMG Contributes 25% of the Deductible Each Month to the HSA Account Single $31.25/Month Family $62.50/Month Employee $92.94 $102.23 Employee + Child $201.60 $221.76 Employee + Children $222.45 $244.70 Employee + Spouse $258.90 $284.79 Family $385.00 $423.50 Anthem BCBS | HealthKeepers Value Advantage 25/500 OA POS Employee $142.48 $156.73 Employee + Child $293.79 $323.17 Employee + Children $314.63 $346.10 Employee + Spouse $361.24 $397.36 Family $531.67 $584.84 Anthem BCBS | HealthKeepers 10 POS Employee $227.41 $250.16 Employee + Child $451.74 $496.91 Employee + Children $472.57 $519.83 Employee + Spouse $539.95 $593.94 Family $783.02 $861.33 Anthem Dental Employee $11.70 Employee + Child $24.41 Employee + Children $32.32 Employee + Spouse $25.15 Family $32.32 Anthem Vision Employee $2.47 Employee + Child $5.20 Employee + Children $5.20 Employee + Spouse $4.96 Family $8.43 80

Key Contacts

Have Questions, Problems or Concerns? Should you need any personal assistance understanding your benefits, claims or other insurance related information, the following are your carrier contact numbers and websites. There is a wealth of information regarding your plans, claims and other online resources. We recommend that your first step be to call the insurance carrier. You will need your ID number or Social Security Number along with the date of service and provider name (when applicable). If you require further assistance, please contact your Client Advocate at The Meltzer Group or Human Resources. Please have the same information available when contacting The Meltzer Group or Human Resources.

Healthkeepers: 800‐421‐1880 Medical Anthem BlueCross BlueShield HSA 800‐451‐1527 www.anthem.com 866-956-8607 Dental Anthem BlueCross BlueShield www.anthem.com/mydentalvision 866-723-0515 Vision Anthem BlueCross BlueShield www.anthem.com/mydentalvision Maggie Colucci 703-737-6033 Loudoun Medical Group Director of Human Resources [email protected] Sherry Heuer 703-737-6007 Loudoun Medical Group Payroll Manager [email protected] Kristi Smtih 571-209-1809 ext. 6046 Loudoun Medical Group HR/Payroll Administrator [email protected] Lynn Martin 703-737-6001 ext. 6136 Loudoun Medical Group HR/Payroll Administrator [email protected] Patti Lyles 703-737-6001 ext. 6181 Loudoun Medical Group HR/Payroll Administrator [email protected] Karla Quigley 240-387-2190 NFP Client Advocate [email protected] Leah Sangster 301-214-7013 NFP Account Executive leah.sangster@nfp. com Nicole Mosby 240-387-2191 NFP Account Executive [email protected] Maryum Hassan 443-731-3184 NFP Client Relations Specialist [email protected]

This benefit brochure is only intended as a brief summary of your benefits. Please note that all Benefits are subject to the contractual terms, limitations and exclusions as set forth in the master contracts of the carriers. If this summary conflicts in any way with the carrier Certificate of Coverage (COC), Riders and/or Amendments, those documents shall prevail. It is highly recommended that you review the carrier COC for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.