Canon Virginia, Inc. 2018 Benefits Guide

Lifecare:Li Accountability for one’s health 2018

Table of Contents

Lifecare 3 Annual Enrollment Period 5 Benefit Eligibility 9 Medical Plans 10 Health & Wellness Integrated Model 15 LiveHealth 16 EAP 17 Dental Plan 18 Vision Plan 19 Network Access 21 Prescription Drug Plan 22 Eligibility 29 Domestic Partners 31 Enrollment 32 Qualifying Life Status Events 34 Healthcare Contributions 35 Disability 39 Life Insurance 41 Employee Savings Plan 44 Flexible Spending Accounts 46 Legal Resources 48 Liberty Mutual 49 Smart Move Program 49 Paid Time Off 50 Employee Events and Services 53 Contact List 54 Legal Notices 55

The plan information described in this enrollment guide is intended to give you a brief description of the Canon Benefits Program. Should there be any discrepancy between this guide and the actual plan documents, the provisions of the plan documents will apply.

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You are Canon’s most important asset. That’s why Canon continues to offer a comprehensive benefits program to all employees. We want to provide you with the necessary information and essential tools to help you lead a healthy, happy and productive lifestyle.

LIFECARE is everyone’s responsibility and should be taken seriously. It enhances the well-being for your own health - physical, emotional and financial. Canon’s future depends on you being at your best in order to continue to develop innovative ideas, meet new challenges and build the “NEXT” Canon.

Take this opportunity and do take advantage of the benefit programs and tools that Canon offers. This is your time to evaluate your health plan options for 2018! Read through this guide and make sure your benefit elections are the best for you and any covered family members.

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Look What Offers You**

Health Benefits

• Annual Physicals – no cost * (in-network) • Anthem MyHealth Coach • Medical & Prescription Drug coverage • Anthem Live Health Online • Health Flexible Spending Account • Anthem 24/7 Nurselline • Anthem Personal Health Consultant • Behavioral Health • Anthem Chronic Condition Care Nurse Support • Smoking Cessation Program • Flu Shot Program • Anthem Future Moms Program • Fitness Center Discounts • Dental & Vision Coverage

Work Life Benefits

• Dependent Care Flexible Spending Account • Domestic Partner Benefits • Tuition Assistance • Lifestyle Coaching • Paid Time Off (PTO) • Stress Management Webinars • Family Leave Benefits ** • Wellness Programs • Mail Order Delivery of Prescriptions • Paid Holidays • EAP Resource & Referral Support • Legal Resources • Paid Bereavement Leave • Apps & Virtual ID Cards

Financial

• 401(k) Pretax Savings • Basic Life Insurance • Employer Matching Contributions • Accidental Death & Dismemberment (AD&D) • Profit Sharing Contributions • Optional Life Insurance for Yourself and Dependents • Investment Advice • Long Term Disability Insurance • Automatic Savings Escalation • Supplemental Income Protection

* Benefits are determined based on location of services and claim coding submitted by the physician.

** Eligibility for these programs may vary based on your medical plan or Canon service.

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Lifecare:Li Accountability for one’s health 2018

2018 Annual Enrollment Period

Opens October 19, 2017 12:00 AM Eastern Time Closes November 9, 2017 11:59 PM Eastern Time

What’s New for 2018?

Benefit Type of Change Description Anthem EPO Medical Plan Plan Design Add Chiropractic Care at 100% coverage up to a maximum of $750 per calendar year (see SPD for details) Anthem EPO Medical Plan Plan Design Increase Emergency Room Copay to $150, waived if admitted within 24 hours Anthem PPO Medical Plan Plan Design Increase Emergency Room Copay to $200 and then 80% coverage; waived if admitted within 24 hours Anthem EPO Medical Plan Payroll Deduction Employee contributions increasing Anthem PPO Medical Plan Payroll Deduction Employee contributions increasing

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Lifecare:Li Accountability for one’s health 2018

Go Online to Make Your 2018 Benefit Elections

Follow these tips:

• You should have the following information available when you enroll: full name, date of birth, social security number (not immediately required) and address for all dependents. • You must go from start to finish during the enrollment process. If you stop in the middle of the session and later return to complete your enrollment, your information you previously entered will NOT be saved. • The website will time you out after 15 minutes of inactivity. • Print your confirmation statement directly from the web to keep for your records. • Screenshots of any page in the enrollment system, other than the Confirmation Page, will not be accepted as proof of coverage. • Operating Systems supported by this website are MAC (OS X), Windows XP, 7 and 8.1, supporting browsers (Internet Explorer 10.x and 11.x, Firefox and Chrome (latest version). Internet Explorer 8.x and 9.x are not supported.

If you have any questions about enrollment, please call the Canon Benefit Center at 800-290-8379 (Monday – Friday, 9am Eastern Time – 6pm Eastern Time)

Step 1: Step 6: Get informed: Read this guide for information Review your Personal Information. Click about your 2018 options. “continue” Step 2: Step 7: Go to www.canonvirginiabenefits.com to enroll or Review your Dependent Information and make changes add/delete dependents as applicable. Click “continue” Step 3: Step 8: Enter Employer Portal number Go through every screen and answer the questions 2018 Benefits – 94802 and make your benefit elections. Do not close out of your session until you have reached the Confirmation Page or your elections will not be saved. Step 4: Step 9: Enter your Username and Password Pre-Confirmation Page. Review your elections and First time users: if there are any changes click on the pencil next to Your username is based on your Canon employee the section and make changes. ID. Put a 9 in front of your Canon ID (i.e. if your Canon ID is 479999 then your username will be 9479999) If you have already used the enrollment site: Enter your username and password Step 5: Step 10: Click Enroll Confirmation Page – print a copy of your confirmation page for your record

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What happens if I do nothing during Open Enrollment?

If you don’t make a change during open enrollment, most of your benefit elections will continue automatically. However you must re-enroll in the Dependent Care FSA each year. Additionally, you must actively indicate that you, and your Spouse/Domestic Partner or civil union partner, if covered under your medical plan, do NOT use any form of tobacco product to avoid the $50.00 per month surcharge for each of you.

CHOOSE CAREFULLY! You can’t change your benefits during the year unless you have a qualified life event change. The Internal Revenue Service (IRS) limits when you can make changes to your benefits. Therefore the benefit choices you make during Annual Open Enrollment will remain in effect for the entire 2018 calendar year unless you have a corresponding life event. For more information on how to enroll, please refer to the Enrollment section of this Lifecare document.

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Remember to…

Review Benefit Information: Check Your Employee Contributions:

Review the 2018 benefit changes Verify the deductions taken from your paycheck to be sure they match the coverage you requested. Call the Canon Benefits Center with any questions If you find an error in your deductions, M-F, 9am – 6pm at 1-800-290-8379 contact [email protected].

Make Any Changes By the End of the Annual Update Your Home Address: Enrollment: It is your responsibility to notify Canon Make sure to verify the coverage you currently immediately of any address changes. If you are have in place and that it meets your needs. unsure how to verify/update your address, contact the Benefits department at [email protected].

Check your Benefit Confirmation: Verify and Update Your Beneficiaries:

A statement showing your benefits is generated Periodically review your Life Insurance and online whenever you go through the enrollment Employee Savings Plan beneficiaries. process. You should always review this and keep a copy of your records. The Confirmation Statement Beneficiary inquires for Vanguard should be made is the only document that will be accepted as to www.vanguard.com proof of any benefit elections you claim to have Beneficiary inquires for your Life insurance should made. be made to [email protected].

Protect Your Information:

Periodically change your Passwords. Save your Username and Passwords in a secure location.

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Lifecare:Li Accountability for one’s health 2018

Benefit Eligibility

Full-time regular employees of Canon are eligible for a full array of benefits as outlined in the chart below.

Benefit Effective Date of Coverage Medical & Prescription Drug Coverage First day of active employment Dental & Vision Coverage First day of active employment Flexible Spending Accounts (FSA) First day of active employment Life Insurance 90 days from first day of active employment for non-exempt members. 30 days from first day of active employment for exempt members. Short and Long Term Disability 90 days from first day of active employment for non-exempt members. 30 days from first day of active employment for exempt members. 401(k) Plan 30 days from first day of active employment

If you are a new hire, look out for important information from:

• The Vanguard Group about participating in our 401(k) Plan – the Canon Employee Savings and Retirement Plan. • HMS, our dependent eligibility auditor. If you elect to cover your dependents for medical and/or dental coverage, you must comply with this audit in the timeframe provided.

You have 31 days from your date of hire, or from a life status event (birth, adoption, loss of coverage) to make your online benefit elections.

If you do not log into the benefit enrollment site and make an election within 31 calendar days, you will not have Medical, Prescription Drug, Dental, Vision, Flexible Spending Accounts and Supplemental and Dependent Life Insurance coverage.

Outside of your new hire enrollment period, you may not change your elections during the year unless you have a corresponding life event (such as a marriage, divorce, birth or adoption, etc.). Any changes to your elections must be consistent with your qualified change in family status and you must log into the benefit enrollment website to make your elections – generally within 31 days of the event.

The plan information described in this enrollment guide is intended to give you a brief description of the Canon Benefits Program. Should there be any discrepancy between this guide and the actual plan documents, the provisions of the plan documents will apply.

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Medical Plans

A Choice of Medical Plans to Meet Your Needs

• Canon Virginia offers a choice of two medical plans, an EPO and a PPO through Anthem Blue Cross and Blue Shield. • You can choose the medical plan that’s best for you and your family. • EPO Plan – A plan that has lower copays on physician charges, hospital facility charges and lower employee contributions. With the EPO plan, you do not have the ability to go out of the network. • PPO Plan – A plan that has higher copays on physician charges, higher hospital facility charge coinsurance. With the PPO plan, you have the ability to go out of the network but will be subject to higher costs. • The EPO and PPO plans both use the same network of providers, the Anthem National PPO (Blue Care PPO). So no matter which plan you choose, you have the same large network of providers to choose from.

No matter which plan you choose (the EPO or the PPO) both cards will

have the PPO symbol at the bottom of the card. This represents the National PPO network that both the

EPO and PPO plans utilize.

• Both the EPO and the PPO plan cover routine expenses like doctor’s office visits as well as hospitalization and surgery. • Both plans cover prescription coverage through Express Scripts. • If you are covered under either plan, you will have an Anthem Blue Cross Shield medical card and an Express Scripts prescription drug card.

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2018 Medical Plan Design Comparison

EPO Plan PPO Plan In-Network Out-of-Network In-Network Out-of-Network Cost Sharing Annual Deductible No deductible N/A $250 per Member $500 per Member $500 per Family $1,000 per Family Annual Out of Pocket $2,000 per Member N/A $3,000 per Member $4,500 per Member Max $4,000 Per Family $7,000 per Family $9,000 per Family Lifetime Maximum N/A N/A N/A N/A Hospital Benefits Inpatient Plan pays 100%, subject N/A Plan pays 80% after Plan pays 70% of R&C, to $200 copay deductible, subject to subject to deductible $250 copay Mental Health / Plan pays 100%, subject N/A Plan pays 80% after Plan pays 60% of R&C, Substance Abuse to $200 copay deductible, subject to subject to deductible $250 copay Outpatient Surgery Plan pays 100%,, subject N/A Plan pays 90% after Plan pays 70% of R&C, to $100 copay deductible, subject to subject to deductible $100 copay Pre-Surgical / Pre- Plan pays 100% N/A Plan pays 80% Plan pays 60% of R&C, Admission Testing subject to deductible Emergency Room / Plan pays 100% after N/A Plan pays 80% after Plan pays 80% after Facility (copay waived if $150 copay deductible, subject to deductible, subject to admitted within 24 hours) $200 copay $200 copay Other Facility Benefits Home Health Care Plan pays 100% N/A Plan pays 80% Plan pays 60% of R&C, 100 visits maximum per subject to deductible calendar year Skilled Nursing Facility Plan pays 100%, subject N/A Plan pays 80% Plan pays 60% of R&C, 100 days maximum per to $200 copay subject to deductible calendar year per illness or condition

Facility and Medical Benefits Chemotherapy / Plan pays 100%, subject N/A Plan pays 100%, subject Plan pays 60% of R&C, Radiation Therapy to $20/$35 copay to $25/$45 copay subject to deductible Diagnostic X-Ray / Lab Covered 100%, subject to N/A Plan pays 80% Plan pays 60%, subject Tests (Non-Routine) $35 copay to deductible CT/MRI/PET Scans Plan pays 100%, subject N/A Plan pays 80%, subject Plan pays 60%, subject to $50 copay to $50 copay to deductible

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EPO EPO PPO PPO In-Network Out-of-Network In-Network Out-of-Network Facility and Medical Benefits Physical / Occupational / Plan pays 100%, subject N/A Plan pays 100%, subject Plan pays 60%, subject Speech Therapy to $35 copay to $25/$45 copay to deductible Medical Benefits Office Visit - Plan pays 100%, subject N/A Plan pays 100%, subject Plan pays 60%, subject Primary Care/Specialist to $20/$35 copay to $25/$45 copay to deductible Urgent Care Plan pays 100%, subject N/A Plan pays 100%, subject Plan pays 60%, subject to $30 copay to $40 copay to deductible LiveHealth OnLine Plan pays 100%, subject N/A Plan pays 100%, subject Plan pays 60%, subject to $15 copay to $20 copay to deductible Adult Annual Physical Plan pays 100% N/A Plan pays 100% Plan pays 60%, subject Exam age 19 and Over to deductible Well Child Care Plan pays 100% N/A Plan pays 100% Plan pays 60%, subject to deductible Well Woman Care Plan pays 100% N/A Plan pays 100% Plan pays 60%, subject to deductible Routine Immunizations Plan pays 100% N/A Plan pays 100% Plan pays 60%, subject to deductible Diagnostic Plan pays 100% N/A Plan pays 100% Plan pays 60%, subject Mammography (Routine) to deductible Diagnostic X-Ray Plan pays 100% N/A Plan pays 100% Plan pays 60%, subject (Routine) to deductible Diagnostic Labs (Routine) Plan pays 100% N/A Plan pays 100% Plan pays 60%, subject with Adult Physical to deductible Surgery Plan pays 100% N/A Plan pays 80% Plan pays 60%, subject to deductible Bariatric Surgery Covered at the benefit N/A Covered at the benefit Covered at the benefit level of the services level of the services level of the services billed billed billed Assistant Surgery Plan pays 100% N/A Plan pays 80% Plan pays 60%, subject to deductible

Maternity Care – Pre & Plan pays 100% N/A Plan pays 80% Plan pays 60%, subject Post Natal Care to deductible Consultations Plan pays 100% N/A Plan pays 100% after Plan pays 60%, subject $25/$45 copay to deductible Anesthesia for routine Plan pays 100% N/A Plan pays 80% Plan pays 60%, subject colonoscopy covered at to deductible the same level as routine colonoscopy Allergy Testing & Plan pays 100%, subject N/A Plan pays 80% Plan pays 60%, subject Treatment – Copay only to $20/$35 copay to deductible applies to office visit Routine Vision Care Not Covered Not Covered Not Covered Not Covered

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EPO EPO PPO PPO In-Network Out-of-Network In-Network Out-of-Network Routine Foot Care Not Covered Not Covered Not Covered Not Covered Infertility Treatment Plan pays 50% Not Covered Plan pays 50% Plan pays 50% subject Artificial Insemination to deductible (limited to 6 per lifetime) Durable Medical Plan pays 100% N/A Plan pays 80% Plan pays 60%, subject Equipment includes to deductible Prosthetics & Orthotics Hearing Aids Not Covered Not Covered Not Covered Not Covered Air and Ground Plan pays 100%, subject Covered at the in- Plan pays 80%, subject Covered at in-network Ambulance to $50 copay network level at to $50 copay level at charges charges Chiropractic Care Plan pays 100% up to Not Covered Plan pays 80% up to max Plan pays 60% up to max of $750 per of $750 per calendar max of $750 per calendar year year calendar year, subject to deductible

Outpatient Mental Health Plan pay 100%, subject N/A Plan pays 100%, subject Plan pays 60%, subject / Substance Abuse – to $20 copay to $25 copay to deductible unlimited visits per calendar year Prescription EPO PPO Prescription Drugs – Generic - $10/$20 Generic - $15/$30 Member Pays (Retail/Mail) Formulary - $30/$60 Formulary - $35/$70 Administered by Express Scripts (you will have a Non-Formulary - $50/$100 Non-Formulary - $60/$120 different card for prescription) Specialty - $50/$100 Specialty -$60/$120 Note: This is not a complete list of covered services. Please refer to your plan document for a more detailed list of covered services.

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Out of Pocket (OOP) Maximum

The Out of Pocket (OOP) Maximum is the maximum that a member will pay in a covered medical expense in a calendar year. As you incur expenses, they are applied to this accumulator. Once you have reached the maximum for the calendar year, all future covered expenses incurred for the remainder of the calendar year are paid in full. Note – there is a different maximum accumulator for In Network vs Out of Network expenses.

What types of expenses are included from the Out of Pocket (OOP) Maximum?

Included Excluded Medical office visit copays Non covered medical expenses Expenses applied towards medical plan Plan penalties deductible Member coinsurance Services in excess of plan limitations Amount paid towards non-preferred brand with a generic equivalent Vision plan expenses Dental expenses Out of network charges that are greater than the allowed amount Prescription copays

Precertification Rules

Precertification is a required review of a service, treatment or admission for a benefit coverage determination which must be obtained prior to the service, treatment or admission start date. For emergency admissions, your or your physician must notify Anthem within 2 business days after the admission or as soon as possible within a reasonable period of time. For childbirth admissions, precertification is not required unless there is a complication and/or the mother and baby are not discharged at the same time.

Please call the Customer Service telephone number on your ID card to confirm the most current list and requirements.

Failure to Obtain Precertification Penalty If you or your non network provider do not obtain the required precertification, a penalty may apply and your out of pocket costs will increase. This does not apply to medically necessary services from a network BlueCard provider.

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Anthem Medical Management Tools Health and Wellness Integrated Health Model

Our members’ total well-being is our No. 1 priority

Our Healthy Lifestyles program lets members set and achieve personal health goals with online coaches, customized tools, progress tracking and more.

With Anthem’s Integrated Health Model, you can team up with an Anthem Nurse who can act as a dedicated health coach for your entire family. The health coach will work with you on-on-one to help manage specific conditions to improve your health. Family members on your health plan can also work with the same health coach at no additional cost. Your coach may refer you to one of our first-rate wellness programs.

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LiveHealth Online

Sometimes you need a doctor and thanks to the internet, you can connect to one anytime, anywhere – whether it’s in the middle of the night or the middle of a road trip. Sign up for Live Health Online and have a face to face conversation with a physician on your computer or mobile device. Download the app or sign up online.

• Immediate access to in-network providers 24 hours a day, 365 days a year • Secure and private 2-way video chats with board-certified doctors • LOWER copays than a regular office visit • Prescriptions are sent to your pharmacy, if needed and allowed by your state. Your applicable prescription copay will apply when filling your prescriptions.

Some of the commonly treated conditions are:

• Cough and cold • Minor rashes • Allergies • Ear Pain • Fever • Flu • Pink Eye

Go to www.livehealthonline.com to register or obtain services or call them at 1-800-603-7985

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Employee Assistance Program

The Resources to Make a Difference

The Employee Assistance Plan (EAP) offers a variety of services ranging from mental health and substance abuse counseling to child care referrals and financial counseling.

Call the EAP at 1-866-621-0554 or log onto www.anthemeap.com for more information.

EAP Services

The EAP offers you and your family the opportunity to speak confidentially to an experienced and credentialed counselor (up to 5 free sessions). If necessary, you may be referred to qualified resources in your community. Call the EAP to get advice about:

• Alcohol and drug addiction issues • Mental health concerns, including depression and anxiety

Financial Consultation Services

If you have questions about education funding, estate planning, retirement planning, debt management, investing or other financial matters, the EAP provides financial counseling.

Work / Life Resource and Referral Services

This service provides assistance with family-related issues such as day care and elder care. Services include:

• Child Care – Referrals to family day care providers, child care centers and agencies in your geographic area; information packets on topics such as adoption, find a preschool that suits your child, teen issues and more. • Elder Care – Referrals to nursing homes or home health care agencies in your area; information packets on caring for seniors.

Legal Consultation Services

You can call to obtain legal counseling on topics such as family law, consumer problems, housing, criminal problems, accidents, wills and taxation. You’ll receive a 25% discount if you retain a plan attorney for ongoing legal assistance.

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Dental Plan

Dental Benefits Keep You Smiling

The Anthem PPO Dental Plan provides coverage for a variety of dental services. By using a participating Dental Blue Complete dentist, you’ll usually pay less. That’s because

dentists who participate in this network have agreed to charge discounted rates for their services. You have the option of enrolling in the Dental /Vision plan separate from the Medical/Prescription Plan.

Dental Service Benefit In-Network Out-of-Network Annual Deductible Individual $25 $50 Family 3 x single 3 x single Maximum Annual $2,000 $1,500 Benefit Per person Per person Preventive Services Plan pays 100% 100% No deductible Basic Services (includes Plan pays 80% Plan pays 80% of r/c fillings, root canals, After deductible repair/re-cementing of crowns) Major Services Plan pays 60% Plan pays 60% r/c (includes crowns, After deductible bridges) Orthodontics Plan pay 50% Plan pays 50% r/c (dependent children) After deductible

Service Frequency Exam and Cleanings Twice per calendar year (every 6 months) X-Rays - Single Film Limited to four films per 12-month period X-Rays – Complete Series Limited to once every 3 years Sealants limited to first & second molars Once every 24 months per tooth for dependents through age 15

Refer to the Summary Plan Document for a more detailed list of covered services.

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Vision Plan

Eye Exams Are Good For Everyone

In-Network

Anthem Blue View Vision members have access to one of the nation’s largest vision networks. Blue View Vision is the only vision plan that gives members the ability to use their in-network benefits at 1-800-CONTACTS, or choose a private practice eye doctor, or go to LensCrafter, Sears Optical, Target Optical, JCPenney Optical and most Pearle Vision locations.

Out-of-Network

If you choose to, you may 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 of your out-of- network allowance. In network benefits and discounts will not apply. Discounts do not apply to out-of- network services. Blue View Vision is only for routine eye care. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network.

Vision Plan Benefits In-Network Out-of-Network Routine Eye Exam (every 12 months) $0 copay $50 allowance Eyeglass Frames (every 24 months) $150 allowance; 20% off $70 allowance any remaining balance Standard Plastic Eyeglass Lenses (once every 12 months) Single (1 pair) $25 copay $50 allowance Bifocal (1 pair) $25 copay $75 allowance Trifocal (1 pair) $25 copay $100 allowance Lenticular (1 pair) $25 copay $125 allowance Eyeglass Lens Enhancements No allowance on Lens Transitions Lenses (child under 19) $0 copay Enhancements when Standard Polycarbonate (child under 19) $0 copay obtained out-of- Factory Scratch Coating $0 copay network Contact Lenses (every 12 months) Elective Conventional Lenses $150 allowance; 15% off $105 allowance remaining balance Elective Disposable Lenses $150 allowance; no add’l $105 allowance discount Non-Elective Contact Lenses Covered in full $210 allowance You may choose contact lenses instead of eyeglass lenses and receive an allowance toward the cost of a supply of contact lenses.

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Optional Savings available from In-Network In-Network Member Cost (after any applicable Providers Only copay) Retinal Imaging – at member’s option can be performed at time of eye exam Eyeglass lens upgrade - Transitions lenses (adults) $75 When obtaining eyewear - Standard Polycarbonate (adults) $40 from a Blue View Vision - Tint (solid & gradient) $15 provider, you may choose to - UV Coating $15 upgrade your new eyeglass - Progressive Lenses lenses at a discount cost. - Standard $65 Eyeglass lens copay applies. - Premium Tier 1 $85 - Premium Tier 2 $95 - Premium Tier 3 $110 - Anti-Reflective Coating - Standard $45 - Premium Tier 1 $57 - Premium Tier 2 $68 - Other Add-ons and Services 20% off retail price Additional Pairs of Eyeglasses - Complete Pair 40% off retail price Anytime from any Blue View - Eyeglass materials purchased $25 off retail price Vision network provider separately Eyewear Accessories Items such as non-prescription 20% off retail price sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc. Contact lens fit and follow-up - Standard contact lens fitting Up to $55 A contact lens fitting and up - Premium contact lens fitting 10% off retail price to two follow-up visits are available to you once a comprehensive eye exam has been completed Conventional Contact Lenses - Discount applies to materials only 15% off retail price Some of the additional savings available through our Special Offers Program:

1-800-Contacts For this and other great offers, Save $20 on orders of $100 or login to member services, select more and get free shipping After your benefits for the discounts, then Vision, Hearing & coverage period have been used, Dental you can save on contact lenses with this offer Laser vision corrective surgery For this and other great offers, Discount per eye (LASIK) login to member services, select discounts, then Vision, Hearing & Dental Please refer to the plan document for more detain information on this benefit.

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Network Access

There are multiple ways you can access Anthem’s Blue Cross Blue Shield:

Website Mobile App Telephone

Anthem’s mobile app Anthem’s user-friendly website Anthem’s dedicated lets you quickly find a customer service team makes finding a doctor and doctor and view your (1-844-249-5373) is here to estimating your costs easier than identification card. ever. Just go to help you and your covered www.anthem.com to access the dependents better site.

How do I verify if my current providers are “In-Network”?

If the doctor, hospital or health care facility you visit is part of your insurance company’s network, you’ll get your health care at lower prices. If you go out of your network for health care, it can become a lot more expensive.

So, how do you verify if your current provider(s) are in the network or how can you find a doctor in the network?

1. Go to www.anthem.com 2. Click on the Popular Task Icon

3. Select “Find a Doctor” 4. Under Search as a Guest, select “Search by selecting a Plan or Network” 5. Select what type of care you are searching for (medical, dental, vision) 6. Select what state you want to search 7. Select a plan/network a. Medical – National PPO (Blue Card PPO) b. Dental – Dental Blue Complete c. Vision – Blue View Vision 8. Select Continue 9. Enter specific criteria 10. Select Search

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Prescription Drug Plan

Canon continues to offer a competitive prescription drug program with our pharmacy benefit manager, Express Scripts Inc. (ESI), to curb this exorbitant increase through clinical programs and combined purchasing power. However, this is not enough and therefore… We need your help! Become an educated consumer of prescription drugs and ask your doctor to prescribe the lowest cost, most effective medication. Millions of people save on prescription drugs by choosing safe, effective, lower-cost alternatives. You can, too!

Here are some tips to help manage Canon’s overall cost and therefore YOUR share of the cost of prescription drugs:

1. Ask your physician to prescribe the lowest cost, most effective medication covered under our Plan. Take an active role and assist your physician on making wise choices by: a. Requesting that your physician prescribe a 90 day supply for any maintenance medications you take for chronic medical conditions – it will cost you less! b. Using ESI’s “Price A Medication”, which can be found on www.express- scripts.com or through Express Scripts mobile phone application tool to find out the most affordable alternative to discuss with your doctor. c. Maintaining your treatment plan. There is a lot of waste when you do not take the medication as prescribed as well as relapses which result in additional prescriptions and, of course, more cost. 2. Whenever possible, use a Preferred Brand or Generic drug from the ESI Formulary list. ESI has negotiated the best price for these drugs which helps manage costs…Yours and Canon’s! 3. Find out if the pharmaceutical manufacturer of the drug you are taking offers a program to help you pay for it. This specifically applies to specialty medications filled through the Accredo Specialty Pharmacy. 4. Always follow your doctor’s instructions!

New Affordable Care Act Preventive Items

The Affordable Care Act (ACA) requires employers to cover certain preventive items in full. Express Scripts has developed a standard list of the required preventive medications based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) recommendations. Effective January 1, 2018, certain preventative medications in the following categories are covered at $0 copay for eligible members: Aspirin, Folic Acid, Contraceptives, Breast Cancer and Iron Supplements.

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2018 Prescription Copay

EPO Prescription Drug Plan

Four-Tier Open Retail Pharmacy - 30-Day Mail Order & 90 Days at Retail Supply – Formulary supply (1,2,3) Maintenance Medications Only (1,2,3) Tier 1 – Generic $10 $20 Tier 2 – Plan Preferred $30 + Brand Differential $60 + Brand Differential Tier 3 – Non-Preferred $50 + Brand Differential $100 + Brand Differential Tier 4 – Specialty $50 + Brand Differential $100 + Brand Differential

PPO Prescription Drug Plan

Four-Tier Open Retail Pharmacy - 30-Day Mail Order & 90 Days at Retail Supply – Formulary supply (1,2,3) Maintenance Medications Only (1,2,3) Tier 1 – Generic $15 $30 Tier 2 – Plan Preferred $35 + Brand Differential $70 + Brand Differential Tier 3 – Non-Preferred $60 + Brand Differential $120 + Brand Differential Tier 4 – Specialty $100 + Brand Differential $120 + Brand Differential

1. Not all brand medications have generic equivalents. You will only pay the brand differential for a brand that has a generic equivalent. 2. The cost of a drug is determined by the strength, days’ supply, when and where you choose to purchase, i.e., mail-order, 90 days at a retail & 30 days at retail. 3. Certain FDA approved prescription smoking cessation, generic and single source contraceptive drugs for women and child-bearing capacity, will be covered at $0 copay.

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2018 Formulary Exclusions

Canon will continue to offer a competitive prescription drug plan with Express Scripts, Inc. Please keep in mind pharmacy formularies change every year so it is possible that some drugs you are taking in 2017 will be reclassified in 2018. For example, a medication currently covered as a Tier 2 Preferred Drug in 2017 might be covered as a Tier 3 Non-Preferred Drug in 2018; conversely, some drugs that are Tier 3 Non-Preferred in 2017 might be considered a Tier 2 Preferred Brand in 2018. In addition, some drugs may no longer be covered in 2018 that were covered in 2017. In this situation, there is always a viable alternative which will be available to you. If your physician prescribes a medication that is on the Formulary Exclusion list, in most cases you will pay the full retail price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives.

For a current list of Formulary Exclusions, please go to www.canonvirginiabenefits.com. The 2018 Prescription Formulary Exclusion list is under the Benefits Information tab under Prescription.

2018 Compound Medication Exclusions

The FDA defines a compound medication as one that requires a licensed pharmacist to combine, mix or alter the ingredients of a medication when filling a prescription. The FDA does not verify the quality, safety and/or effectiveness of comp0und medications. Example of when compound medicine is filled: An individual who does not swallow pills and fills a prescription for a compound medicine in liquid form that is not otherwise available. Generally compound medications are not maintenance medications.

For a list of the most current Compound Management Exclusion List, please go to www.canonvirginiabenefits.com and go to the Benefits Information Tab under Prescription.

If you are taking a compound medication that contains an ingredient that is excluded:

1. Talk to your doctor about the covered alternatives 2. Ask your doctor, if applicable, to call in a new prescription to your pharmacy 3. If there is a medical reason preventing you from being able to take the covered alternative to the newly excluded drug, see the section on the appeals process.

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2018 Prescription Management Programs Before certain drugs will be covered, a prescription management program review may be required. This process allows Express Scripts to obtain information from your doctor to evaluate the prescription and determine whether it qualifies for coverage under Canon’s plan. . Prior Authorization: If you are filling your prescription through a retail pharmacy, mail order, or specialty pharmacy, your pharmacist will be notified that the drug cannot be filled without prior authorization and that your physician must call the number on your ID card to get approval for the prescription. . Drug Quantity Management: To ensure safe and effective drug therapy, certain covered medicines may have quantity restrictions. These quantity restrictions are based on clinically approved guidelines and are subject to periodic review and change.

Here’s how prior authorization works: Express Scripts pharmacists regularly review the most current research on newly approved medicines and existing medicines and consult with independent licensed doctors and pharmacists to determine which medicines have been proven to be effective. The prior authorization program includes medicines with a variety of different uses.

The first time you try to fill a prescription that needs prior authorization at a retail pharmacy your pharmacist should explain that more information is needed from your doctor to determine whether the medicine is covered by your plan. The pharmacist will ask your doctor to call the Express Scripts Prior Authorization department to find out if the medicine is covered. Prior authorization phone lines are open 24/7 – so a determination can be made right away.

Here’s how Drug Quantity Management works: The FDA, medical researchers and medicine manufacturers look at individual medicines to determine a recommended maximum quantity considered safe. This is especially important for medicines that are challenging to take in the proper dose such as inhalers or nose sprays. These medicines are then added to a DQM program.

What are my options?

• If the pharmacist can’t reach your doctor, and you need your prescription right away, you can ask your pharmacist about filling a small supply of your prescription until your doctor can be consulted. You may have to pay full price for this small supply.

• If our plan doesn’t cover the medicine that was originally prescribed, ask your doctor about getting another prescription for a medicine that is covered. You’ll get that medicine at a standard copay.

• You can fill the original prescription at full price.

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STEP THERAPY- Avoid paying more for the medicine you need!

Step therapy simply means making sure you get safe and proven-effective medicine for your condition – at the lowest possible cost to you and Canon. Medicines are grouped in categories, or “steps.”

 Here’s how step therapy works: • First-line medicines – These are the first step and are typically generic and lower-cost brand-name medicines. They are proven to be safe and effective, as well as affordable. In most cases, they provide the same health benefit as more expensive medicines, but at a lower cost. • Second-line medicines – These are the second and third steps and are typically brand- name medicines. They are best suited for the few patients who don’t respond to first-line medicines. They’re also the most expensive options.

How do you find out if a first-line medicine is right for you?

Only your doctor can make that decision.

Log in to your account at express-scripts.com or call Express Scripts at the number on your member ID card to find out if step therapy applies to the medicine your doctor prescribed.

If it does, you can see a list of first-line alternatives. You can give that list to your doctor to choose the medicine our plan covers that best treats your condition.

What happens if your doctor gives you a prescription that’s not on the first-line list?

The first time you try to fill the prescription, whether it’s in person or submitted through mail order to the Express Scripts Pharmacy, your pharmacist should explain that step therapy requires you to try a first-line medicine before a second-line medicine is covered.

Since only your doctor can change your current prescription, either you or your pharmacist need to speak with your doctor to request a first-line medicine that’s covered by your plan.

If you need your prescription right away, you may ask your pharmacist to fill a small supply until you can consult your doctor.

NOTE: You might have to pay full price for this small supply.

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Important Things to Know About How Pharmacies Fill Prescriptions

Remember, if a brand drug has a generic equivalent, you have a choice: choose the generic OR pay the higher copay PLUS the Brand Differential (difference in cost between the generic and brand). This applies regardless of whether or not your physician indicates “dispense as written” on the prescription. The Brand Differential does NOT have an Out-of-Pocket Maximum and it does NOT apply towards your medical plan deductible.

. If there is no generic equivalent available for your brand prescription, you will receive the brand and pay only the applicable brand copay.

. In many states, as long as the doctor has NOT indicated “Dispense as Written” the pharmacy is required by law to substitute a generic for a brand drug. If a generic is available, and state law allows, you will receive the generic and pay the lowest copay.

. If your physician prescribes the brand drug and indicates “Dispense as Written”, you will receive the brand and will pay the brand copay PLUS the Brand Differential.

. If you request the brand drug instead of the generic equivalent, and state law allows, you will receive the brand and will pay the brand copay PLUS the Brand Differential.

Appealing Brand Differential and Drug Exclusions

. If there is a medical reason you cannot use the Preferred Alternative to an Excluded Drug; or . If there is a medical reason you cannot use the Generic Equivalent of a Brand Drug

Have your prescribing doctor call ESI at 1-800-417-1764 (M – F, 8am - 9pm EST)

The standard response time for a decision related to brand differential medical exceptions and excluded drugs is within the earlier of: 7 business days from when your physician submits the required medical documentation or 15 business days of the appeal being initiated.

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Home Delivery & Accredo (ESI Specialty Pharmacy)

Setting Up New Prescription With Mail Order For The First Time • Step 1: Ask your doctor if there is a generic equivalent of your prescription available. If there is, and you continue taking the brand, you will pay the copay PLUS the Brand Differential. • Step 2: Ask your doctor to write TWO prescriptions. PRESCRIPTION # 1: should be for a 30-day supply to be filled at a participating pharmacy while you wait for the Express Scripts Home Delivery. PRESCRIPTION # 2: should be for 90 days, with refills for up to one year, as appropriate. • Mail – Complete the order form and mail it with your new 90 day prescription to ESI Home Delivery. You can access the form online by logging in to www.express-scripts.com/canon. • Fax - Doctor can fax prescription to 1-800-837-0959. Fax must include member ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription. • Make sure Express Scripts has a credit card number or checking account number on file for payment (to be supplied on the mail-service order form). • ESI does NOT automatically send out mail-order refills, you MUST request your mail order be sent to you by calling 1-844-578-5438, or, login to www.express-scripts.com to schedule your refills. You will receive your order within 8-11 days after ESI Home Delivery confirms it.

Setting Up New Specialty Prescription With Accredo You must use ESI’s Accredo Specialty Pharmacy to fill your prescription specialty medicine. These types of drugs may be injected, infused or taken by mouth. Specialty medicine often needs special storage and handling and it must be delivered quickly and a nurse or pharmacist should monitor you during your treatment.

You also get: • Free delivery that is reliable, secure and sent anywhere you choose. • Extra help when you need it - like injection training and side effect monitoring. • Proactive outreach to confirm your refills. • Free standard supplies. • Nurses and pharmacists who can help you 24 hours a day, every day.

It’s easy and fast to order – choose one of these ways: 1. Fax – Your doctor may fax your prescription to 1-800-837-0959. 2. Mail – You or your doctor may mail your prescription order to Accredo. 3. Phone – Your doctor may also call and speak to a registered pharmacist at 1-800-803-2523 during normal business hours of 8:00 am – 11:00 pm EST (Monday to Friday) or 8:00 am – 5:00 pm EST (Saturday) - closed on Sunday.

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Eligibility

Who is eligible for benefits?

You can cover your spouse, domestic partner and your eligible children (until the end of the month in which they turn 26). Children you can cover include:

• Your biological/adopted child • A child placed with you for adoption • Your stepchild (your spouse’s adopted/biological child) • A child for whom you are legal court-appointed guardian • Your domestic partner’s biological/adopted child or a child placed for adoption with your domestic partner, if you cover your domestic partner • Children who are handicapped can be covered at any age.

No person may be covered as a dependent of more than one employee and no person may be covered as both an employee and a dependent.

Social Security Numbers

Canon is required to report the social security numbers of all covered dependents to our medical providers so they can submit them to the government to ensure proper coordination of benefits with Medicare. Please be assured that Canon and our benefit providers comply with all privacy and security laws related to use and transmission of your Protected Health Information (PHI).

Dependent Eligibility Audit

Canon requires you to verify dependent eligibility through periodic audits of dependents. It is considered fraud and an intentional misrepresentation of material fact to enroll an ineligible dependent, or to maintain coverage for a person who no longer meets the dependent eligibility rules. After the enrollment period closes, if your dependents have not already been audited, you will be contacted by our verification auditor, HMS, to request documents to support your dependent’s eligibility for coverage.

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Dependent Eligibility for Benefits

Canon requires you to verify dependent eligibility through periodic audits of dependents. It is considered fraud and an intentional misrepresentation of material fact to enroll an ineligible dependent, or to maintain coverage for a person who no longer meets the dependent eligibility rules. After the enrollment period closes, if your dependents have not already been audited, you will be contacted by our verification auditor, HMS, to request documents to support your dependents eligibility for coverage.

Within 10 business days of completing your benefits election you will receive a notice from Canon’s dependent auditor, HMS, requesting proof of your dependents eligibility for benefits. If you do not receive this notice within 10 business days of completing your election, please contact HMS directly via phone M-F, 8am-8pm ET at 866-868-8991 or via the web at www.auditos.com.

Please note: claiming non-receipt of HMS’s letter does not release you or your obligation to comply with the audit by the given deadline.

Dependent Required Documentation

Spouse 1 –Marriage certificate AND; 2 - Proof of current marriage (if married more than 60 days) Domestic Partner Domestic Partner Certification Form AND; 2 – Proof of current relationship (if domestic partners for more than 60 days) a. Statement of bill in partner’s name at the employee’s address listed in the last 60 days Your Biological Birth Certificate listing you as a parent OR Paternity Document listing you as a parent. Child Your Adopted Child Certificate of Adoption listing you as the adoptive parent A child for whom Court Order of Legal Guardianship listing your or your spouse as legal guardian. Note: If spouse alone holds legal you or your spouse guardianship, spousal documents (above) are also required. have legal guardianship Your Step Child 1 – Birth Certificate listing your spouse as parent OR Paternity Document listing your spouse as a parent AND; 2 – Marriage Certificate AND; 3 – Proof of current marriage (if married more than 60 days) a. First page of your most recently filed 1040 OR b. Statement or bill in spouse’s name at employee’s address, dated in the last 60 days. Domestic Partner’s 1 – Birth Certificate listing Domestic Partner as parent OR Paternity Document listing Domestic Partner as a parent Biological Child AND; 2 – Domestic Partner Required Documentation AND; 3 – Proof of Current Domestic Partner: Statement or bill in Domestic Partner’s name at the employee’s address, dated in the last 60 days. Domestic Partner’s 1 – Certificate of Adoption listing Domestic Partner as a parent AND; Adopted Child 2 – Domestic Partner Required Documentation (above) A child for whom 1 – Court Order of Legal Guardianship listing Domestic Partner as legal guardian AND; your Domestic 2 – Domestic Partner Required Documentation (above) Partner has legal guardianship

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Domestic Partner Coverage

Eligibility Requirements for a Domestic Partner

To meet the eligibility requirements to be a same or opposite gender domestic partner, both the member and the partner must:

• Be at least 18 years or older • Have lived together for at least 6 months and have a serious, committed relationship • Be financially interdependent (i.e. share the cost of food and housing) • Not be related to each other in a way that would prohibit legal marriage, and, • Not be legally married to anyone else; or, • Have registered as domestic partners pursuant to a domestic partner ordinance or law or have entered into a same sex civil union, where permitted.

Note: The Plan excludes common law marriage, whether same or opposite sex.

TAXATION

The IRS requires that Canon report the full value of this health coverage as taxable income to the employee subject to withholding and FICA (no pre-tax)

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Enrollment

What you need to know to enroll:

You are able to enroll or make changes to your benefits during the designated open enrollment period each year or within 31 days of a life status event.

• You should have the following information available when you enroll: o Full name o Date of Birth o Social Security Number for all dependents (although not immediately required) o Address for all dependents • You must go from start to finish during the enrollment process. If you stop in the middle of the session and later return to complete your enrollment, your information will NOT be saved. • The website will time you out after 15 minutes of inactivity. • Print your confirmation statement directly from the web to keep for your records. • Screenshots of any page in the enrollment system, other that the confirmation page will not be accepted as proof of coverage. • Operating Systems supported by this website: o Mac (OS X), Windows XP, 7 and 8.1 o Supporting browsers (Internet Explorer 10.x and 11.x, o Firefox and Chrome (latest versions only) o Internet Explorer 8.x and 9.x and Safari are not supported

If you have any questions on enrollment, please contact the Benefits Call Center at 1-800-290-8379 (Monday – Friday, 9am EST to 6pm EST)

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How to enroll or change your benefits:

1. Get informed, read this guide about your benefit options 2. Go to http://www.canonvirginiabenefits.com 3. Enter the Employer Portal # 94802 (2018) 4. Enter your Username and Password

New Hires – The first time you enter the site, your Username is based on your CVI Employee ID. Put 9 in front of your 6-digit Canon ID#. For example, if your CVI ID# is 123456 then your User ID is 9123456. Note: this is ONLY for new hires that have only had the 6-digit CVI ID#. If you have signed in previously, you can’t use this method to sign in.

If you have already used this enrollment website (or were able to enroll last year), your username and password are the ones that you set up the last time you enrolled. If you have forgotten your User ID and/or Password, you will need to contact the Benefits Call Center at 1-800-290-8379 for help or select Forgot User ID/Password. Your EIN (Employee Identification Number) would be 999 and your previous 4-digit CVI ID#. For example, if your previous ID number was 1234, then your EID would be 9991234. Click “Enroll Now”

5. Review your Personal Information and click “Continue” 6. Review Dependent Information and Add/Delete Dependents as applicable. Click “Continue”.

Review your dependent information and Add/Delete dependents as applicable and then click “Continue”. Note: This section does not indicate benefit coverage. However a dependent must be listed here in order for them to appear as an option to cover them under your medical and/or dental coverage.

Additionally, listing a spouse or child in this section is what triggers the Spouse/Domestic Partner Life Insurance and/or Child Life Insurance Options. If you want to select life insurance coverage for any dependent, you need to have them listed as a dependent first, even if you do not elect medical/dental coverage for them.

7. Go through every screen and answer the questions and make your benefit elections (do not close out your session until you have reached the Confirmation Page or your elections will not be saved). 8. Pre-Confirmation page - Review your elections and if there are any sections you would like to change, click on the pencil next to that section and make your changes. Make the applicable changes and click “Continue”. If satisfied with your elections, click on the “Continue” button on the bottom of the Pre-confirmation page. 9. Confirmation Page – print a copy of your Confirmation page for your records.

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Qualifying Life Status Events

You can’t change your benefits during the year unless you have a qualified life event change.

The Internal Revenue Service (IRS) limits when you can make changes to your benefits. Therefore the benefit choices you make will remain in effect for the entire plan year unless you have a corresponding life event.

You can only enroll and/or change your benefits during one of the following life status events:

Examples of Common Qualified Life Events for Changing Health Benefits:

Event What You Can Do Time Frame to Make the Change Marriage / Enter a Domestic • Add coverage for yourself and/or 31 Days Partner Relationship dependents • Change between plans Divorce / End Domestic Partner • Remove ex-spouse/domestic partner 31 Days Relationship • Change between plans Birth, Adoption, Placement for • Add coverage for yourself and/or 31 Days Adoption dependents • Change between plans Loss of Coverage Under Another • Add coverage for yourself and/or your 31 Days Plan Due to Loss of Eligibility dependents

Employee contributions for mid-year changes begin with the first full paycheck following the effective date of the change.

Please refer to the Summary Plan Description for more information on changing your benefits during the year.

Federal tax rules require that benefit changes be consistent with the life event. If the requested change does not meet these rules, it will not be permitted.

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2018 Healthcare Contributions

Employee contributions for 2018 medical coverage will continue to be determined by four coverage levels:

• Employee Only • Employee + Child (ren) • Employee + Spouse • Employee + Family

If you are enrolled in a medical plan in 2017 and do not make any changes to your medical coverage for 2018, your coverage election will continue and you will pay the corresponding 2018 employee contributions.

IMPORTANT NOTES:

• TOBACCO SURCHARGE APPLIES TO EMPLOYEE AND COVERED SPOUSE/DOMESTIC PARTNER OR CIVIL UNION PARTNER AUTOMATICALLY. You MUST log onto the enrollment website www.canonvirginiabenefits.com to OPT OUT of the Tobacco Surcharge for yourself and if applicable, your covered spouse/Domestic Partner or civil union partner or you will be charged an additional $50 per month for you or your spouse/DP or civil union partner or $100 per paycheck if you both use tobacco products. NOTE: If you certified in 2017 that you were enrolled in a cessation program you will need to log onto the enrollment website to update your response to the question or you will be subject to the surcharge.

• SPOUSAL SURCHARGE If you have a spouse/Domestic Partner or civil union partner covered under your medical plan and he/she is eligible for medical coverage under another employer’s plan as either an active or retired employee, you will be charged an additional $50 per month. If you paid this surcharge in 2017, it will continue in 2018 unless you log onto the website and certify that your spouse/Domestic Partner or civil union partner is no longer eligible for medical coverage through his/her own employer or retiree medical plan. NOTE: If you certified in 2017 that your spouse/DP or civil union partner is eligible for active medical coverage through his/her current employer or a retiree plan (not Medicare) but is not able to enroll at this time you will need to log onto the enrollment website to update your response to the question or you will be subject to the surcharge.

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Employee Contributions

The following pages include the contributions which will be charged for medical and dental benefits you may elect.

Domestic Partner Coverage Tax Treatment

Due to IRS and other federal and state tax rules and regulations, employers that offer health insurance benefits to a Domestic Partner must follow certain guidelines regarding pre-tax and post- tax payroll deductions and the calculation of imputed income. A non-dependent Domestic Partner and his/her children are treated differently under federal tax laws.

Pre vs. Post Tax

Pre-tax dollars can only be used for dependents that meet the federal definition of a dependent. Post-tax deductions must be taken for dependents covered by you who do not meet the federal definition of a dependent. The tax code does not align with Canon’s coverage of Domestic Partners and Domestic Partners’ children and therefore your employee contributions for coverage of a Domestic Partner and Domestic Partner’s children are not eligible to be deducted on a pre-tax basis.

Imputed Income

Imputed income is the estimated value of Canon’s financial contribution towards the benefit coverage that is provided to Domestic Partners and Domestic Partner’s children. The value of Canon’s contribution must be reported to the IRS as taxable wages earned.

Note: If you believe that your tax treatment for medical and dental coverage should be changed because you got married, please send an email with a copy of your marriage certificate to: [email protected].

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2018 - Hourly Deductions per Paycheck

MEDICAL - EPO Pre-Tax Post- Imputed Canon Pays Total You Hourly Tax Income Pay Coverage Level EE Only $26.26 n/a n/a $103.20 $26.26

EE + Spouse $66.41 n/a n/a $257.25 $66.41 EE + Domestic Partner $26.26 $40.15 $154.05 $257.25 $66.41

EE + Child/Children $60.18 n/a n/a $198.74 $60.18

Family $84.73 n/a n/a $336.02 $84.73 EE + DP + DP Child/Children $26.26 $58.47 $232.82 $336.02 $84.73 EE + EE Child + DP + DP Children $60.18 $24.55 $137.28 $336.02 $84.73 OR MEDICAL - PPO Pre-Tax Post- Imputed Canon Pays Total You Pay Hourly Tax Income Coverage Level EE Only $36.76 n/a n/a $103.20 $36.76

EE + Spouse $92.65 n/a n/a $257.24 $92.65 EE + DP $36.76 $55.89 $154.04 $257.24 $92.65

EE + Child/Children $81.18 n/a n/a $198.74 $81.18

Family $118.84 n/a n/a $336.02 $118.84 EE + DP + DP Child/Children $36.76 $82.09 $232.82 $336.02 $118.85 EE + EE Child + DP + DP $81.18 $37.67 $137.28 $336.02 $118.85 Children

Dental Pre-Tax Post- Imputed Canon Pays Total You Hourly Tax Income Pay Coverage Level EE Only $1.23 n/a n/a $5.93 $1.23

EE + Spouse $2.97 n/a n/a $11.37 $2.97 EE + DP $1.23 $1.74 $5.43 $11.37 $2.97

EE + Child/Children $2.99 n/a n/a $12.06 $2.99

EE + Family $5.57 n/a n/a $21.31 $5.57 EE + DP + DP Child/Children $1.23 $4.34 $15.38 $21.31 $5.57 EE + EE Child + DP + DP $2.99 $2.58 $9.24 $21.41 $5.57 Children

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2018 - Salary – Deduction Amounts per Paycheck

MEDICAL – EPO Pre-Tax Post- Imputed Canon Pays Total You Salary Tax Income Pay Coverage Level EE Only $56.90 n/a n/a $223.60 $56.90

EE + Spouse $143.89 n/a n/a $557.37 $143.89 EE + DP $56.90 $86.99 $337.77 $557.37 $143.89

EE + Child/Children $130.40 n/a n/a $430.61 $130.40

Family $183.58 n/a n/a $728.05 $183.58 EE + DP + DP Child/Children $56.90 $126.68 $504.45 $728.05 $183.58 EE + EE Child + DP + DP Children $130.40 $53.19 $297.44 $728.05 $183.59

OR MEDICAL – PPO Pre-Tax Post- Imputed Canon Pays Total You Pay Salary Tax Income Coverage Level EE Only $79.64 n/a n/a $223.61 $79.64

EE + Spouse $200.75 n/a n/a $557.36 $200.75 EE + DP $79.64 $121.11 $336.76 $557.36 $200.75

EE + Child/Children $175.88 n/a n/a $430.61 $175.88

Family $257.50 n/a n/a $728.05 $257.50 EE + DP + DP Child/Children $79.64 $177.86 $504.44 $728.05 $257.50 EE + EE Child + DP + DP Children $175.88 $81.62 $297.44 $728.05 $257.50

Dental Pre-Tax Post-Tax Imputed Canon Pays Total You Pay Salary Income Coverage Level EE Only $2.68 n/a n/a $12.86 $2.68

EE + Spouse $6.44 n/a n/a $24.63 $6.44 EE + DP $2.68 $3.76 $11.77 $24.63 $6.44

EE + Child/Children $6.48 n/a n/a $26.14 $6.48

EE + Family $12.08 n/a n/a $46.17 $12.08 EE + DP + DP Child/Children $2.68 $9.40 $33.32 $46.17 $12.08 EE + EE Child + DP + DP Children $6.48 $5.60 $20.03 $46.17 $12.08

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Disability

Short Term Disability

Short Term Disability is a type of insurance that pays a percentage of your salary for a specified amount of time, if you are ill or injured, and cannot perform the duties of your job. It is not compensable if it is a job-related injury. Canon Virginia provides this benefit to eligible members at no cost to the employee.

Eligibility • Non-Exempt Members – After 90 days of employment • Exempt Members – After 30 days of employment

How it Works • For the first 7 calendar days following a qualified disability, you must use your own PTO time (or go unpaid if you do not have enough PTO time). • On the 7th calendar day following a qualified disability, UNUM starts to pay short-term disability.

Payment • Non-Exempt Members – receive a total of 66.67% of base pay • Exempt Members – receive a total of 80% of base pay • Manager and Above – receive a total of 100% of base pay

What to do if you need to request short-term disability:

• Notify your manager or supervisor of your absence from work. • To submit your claim and/or leave request to UNUM via telephone, call the toll-free number (800-995-7839). • To submit your claim and/or leave request via the UNUM website, go to www.unum.com and follow the claim submission instructions. • If you are eligible for leave, a certification of health care provider form may be required. If so, it will be mailed in your initial leave packet within 2 business days of filing your leave. You will be provided a minimum of 15 days from the date the leave is requested to complete and return this form to UNUM. • Provide your health care provider with a signed and dated copy of the authorization form. This form authorizes the release of medical information needed to evaluate your disability claim. • Once you have filed your Short Term Disability claim, fax a copy of the signed and dated disability authorization to UNUM Benefits Center at 800-447-2498 or submit your authorization electronically at www.unum.com/claims.

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Long Term Disability

Serious illnesses or accidents can come out of nowhere. They can interrupt your life, and your ability to work for months – even years. Long term disability can pay up to 60% of your income, so you have financial support to manage your disability and your household.

Long Term Disability insurance is an insurance policy that protects an employee from loss of income in the event that he or she is unable to work due to illness, injury, or accident for a long period of time. Long term disability insurance does not provide insurance for work-related accidents or injuries that are covered by workers compensation insurance.

Eligibility

• Six months waiting period of a qualified disability

Payment

• Monthly benefit is 60% of monthly earnings to a maximum of $10,000 per month • Maximum period of payment is 2 years if you are unable to perform you own occupation and up to age 64 for any occupation.

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Life Insurance

How does life insurance work?

Everyone knows that life insurance pays out when the covered person dies. The idea is to protect loved ones from a sudden loss of financial support. At Canon Virginia, we offer 2 different types of life insurance.

Term Life insurance will pay out the death benefit if the name person dies within the defined term (while employed), but if the named person does not die, no portion of the premiums will be returned to the policyholder. It simply insures against loss of life, and the relatively low premiums reflect this.

Whole Life insurance has no predefined term; it provides death benefit protection over the “whole” life of the insured, as long as premiums are paid. A whole life policy also combines an investment component with the insurance component; it accumulates a cash value which the insured can withdraw or borrow against over their lifetime. However, compared to other forms of investing, life insurance policies tend to offer a relatively low rate of return.

Life Insurance Type Coverage Amount Premium Contributions * Basic Life and AD&D Insurance 2.5 covered earnings, up to Noncontributory ** $800,000 Supplemental Employee Life 1x or 2x covered earnings up to Contributory ** Insurance $800,000 Spousal / DP Life Insurance Increments of $5,000 up to 100% Contributory ** of the employee rate (anything over $50,000 requires underwriting) Child Life Insurance $2,500 $7,500 Contributory ** $5,000 $10,000

* The IRS requires you to be taxed on the value of employer provided group term life insurance over $50,000. The taxable value of this life insurance is called “imputed income”. Even though you don’t receive cash, you are taxed as through you received cash in an amount equal to the value of this coverage.

** Noncontributory insurance is insurance for which an employee is not required to make premium contributions. Contributory insurance is insurance for which an employee is required to make premium contributions.

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Age Reduction on Basic Life Insurance, Accidental Death & Dismemberment (AD&D) and Supplemental Life Insurance.

The face value of your Basic, AD&D and Supplemental Life Insurance will decrease as follows:

Date of Reduction Coverage Will Decrease to:

Age 70 65% of your coverage amount

Age 75 50% of your coverage amount

Calculating Life Insurance Benefit Amounts, Covered Earnings is defined as:

Your current annual base salary, excluding overtime pay, bonus pay or any other special compensation not received as base salary.

Electing, Adding or Increasing Coverage

You can elect Supplemental and Dependent Life Insurance within 31 days of your date of hire. During the annual open enrollment, you have the option to increase, decrease or cancel your coverage. If you are on a leave of absence as of January 1st, an election to increase life insurance will not be effective until you return to work.

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Whole Life Insurance

Whole Life offers “living benefits” you can use when you need them, as well as a death benefit.

• Whole Life accumulates cash value. • Contains a living benefit option rider. If you are diagnosed with a terminal illness, you can request up to 199% of your policy’s benefit amount. • Contains long term care benefits.

Three reasons to buy Whole Life

1. Whole life rates

2. Age-based premiums based on your age when you purchase

3. Guaranteed issue

Critical Care Insurance

Critical Care pays a lump-sum benefit at the diagnosis of a covered illness. You choose the level of coverage from $5,000 to $50,000. You use the money any way you see fit.

Covered Conditions:

• Heart attack • Major organ failure • Occupational HIV • Benign brain tumor • Blindness • End-stage renal failure • Coronary artery bypass surgery – pays 25% of lump-sum benefit • Stroke (time limitations) • Coma (time limitations) • Permanent paralysis (time limitations)

Note: These benefits are NOT on the open enrollment website. The enrollment period for these benefits is in the Spring of each year.

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Canon Employee Savings Plan

Our plan provides you with a convenient way to save for retirement

Quick Facts • You are eligible to contribute to the 401(k) plan after 30 days of employment. • Automatic Enrollment – If you do not actively elect to participate or opt out, Canon will enroll you at a pre-tax contribution rate of 3% of eligible pay and your payroll deduction will start on the later of 30 days of employment or the date that your contribution election is transmitted to Canon. • If you want to change your contribution amount or the funds in which your contributions are invested, you may contact Vanguard at any time. • If you are automatically enrolled, your contribution rate will increase by one percentage point each year on the anniversary of your enrollment until it reaches the lesser of 10% or the IRS limit. You can change the amount of your annual increase, the month of your annual increase, or both by contacting Vanguard.

Company Match • Canon matches the fist 6% of your before-tax contributions. You will receive 100% of the first 1% and 50% on the next 5% you contribute. • To maximize your full company matching contributions, make sure your before-tax contributions continue throughout the year.

Investment • Unless you elect a different investment fund, your contributions will be invested in the Vanguard Target Retirement Fund whose target year is closest to the year in which you turn age 65 (normal retirement age). You can change your investment direction before you are automatically enrolled or anytime by contacting Vanguard.

Vesting • You are always 100% vested in the money that you contribute to the plan. You become 100% vested in the company match after 2 years of service.

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Roth IRA

A Roth IRA is a special retirement account that you fund with post-tax income (you can’t deduct your contributions on your income taxes). Once you have done this, all future withdrawals that follow Roth IRA regulations are tax free.

There is no up-front tax deduction for Roth IRA contributions, as there is with a traditional IRA. On the other hand, Roth distributions are tax-free when you follow the rules. And because every penny you stash in a Roth IRA is your money—not a tax-subsidized gift from Uncle Sam—you can tap your contributions (but not your earnings on those contributions) at any time, tax-free and penalty-free.

Beneficiary Management

It’s important to name a beneficiary and to make sure your beneficiary designation is up to date, even if you have a will. That’s because your beneficiary designation supersedes your will regarding Plan assets. If you don’t name a beneficiary or keep your designation up to date, your savings in the Plan could be distributed to an unintended heir after you die. Naming a beneficiary will help ensure that your heirs are protected and that your savings are distribute according to your intentions. If you don’t check your beneficiary designation from time to time to ensure that it is still correct, certain life events such as marriage, birth or adoption of a child, or divorce could require you to make a change.

Take Action

• Log onto your account at www.vanguard.com/retirementplans.com • Select My Profile • Select Beneficiaries

Not Registered for Online Account Access? - Go to www.vanguard.com/retirementplans.com. You will need the Canon Plan Number of 091510.

Forgot Your User ID and/or Password? - Go to www.vanguard.com/retirementplans.com and select Forgot User Name. Then follow the online instructions or contact a Vanguard Participant Services associate at 1-800-523-1188.

Questions? - Contact a Vanguard Participant Services associate at 1-800-523-1188. Associates are available Monday through Friday from 8:30am to 9pm EST.

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Flexible Spending Accounts

A Simple Way to Save

Flexible Spending Accounts (FSAs) allow you to set aside pretax dollars through easy payroll deductions to pay for eligible health and dependent care expenses. An FSA offers you significant tax savings since your contribution to the FSA is deducted from your paycheck on a pre-tax basis. That means your taxable income decreases and you pay less tax.

Healthcare FSA • Contribute from $100 to $2,600 per year • You are permitted to rollover up to $500 in unused contributions from 2017 to 2018 to help pay for unreimbursed eligible expenses. • Covers unreimbursed medical, dental, vision, and prescription drug expenses • Over the counter medications cannot be paid from a Health Savings account unless prescribed by a doctor.

Note: If you are currently enrolled and do not make any changes during the annual open enrollment, Canon will automatically enroll you in the Healthcare FSA in 2018 with your 2017 goal amount. This is in addition to the amount up to $500 that rolled over from 2017 to 2018.

Dependent Care FSA • Contribute from $100 to $5,000 per year • Covers day care expenses for your child under age 13 and/or your elderly parents so you and, if married, your spouse can work (Does NOT cover health care expenses for your dependents). If at any time during an audit we discover you elected a Dependent Care FSA but you do not have a child under age 13 or an elderly parent requiring day care, the annual amount you elected will be put into the Health Care Flexible Account.

Note: If you are currently enrolled and you do not make changes during Annual Enrollment, Canon will NOT automatically enroll you in the HC FSA in 2018. You must make that election yourself on the enrollment site or Canon will default you to a zero dollar goal amount.

Looking for more information?

Go to www.healthequity.com and click on

“Learn” at the top of the page and then click on “Flexible Spending Accounts”

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Health Care FSA Card

If you were not enrolled in the 2017 HC FSA and enroll for the 2018 plan year, you will receive a secure, VISA branded HC FSA card in late December 2017. If you are already a participant in 2017, your existing card will remain valid in 2018 and be replenished based on your 2018 election. If you would like to request additional HC FSA cards for eligible dependents to use you may contact Health Equity at 1-877-713-7712 (available 24/7) and request up to an additional two cards at no cost to you. Note: If more than three HC FSA cards are issued to you, you will be charged $5 per additional card. How the HC FSA Card Works Your full 2018 HC FSA goal amount will be loaded and available on your HC FSA card. As long as your healthcare provider accepts VISA cards, you can use your card to pay directly from your HC FSA for eligible expenses at the time of transaction.* While your HC FSA card provides the convenience of not having to use out-of-pocket funds, you may still need to submit receipts if your provider doesn’t capture the information the IRS requires to substantiate, or validate a purchase at the point of sale.

File all FSA claims by April 30 Remember to only use your HC FSA card for qualified expenses for you of the following year. and your eligible dependents. Your eligible HC FSA expenses must be incurred during the coverage period. This means the medical treatment It is your responsibility to or services must take place during the coverage period, not when you ensure that all your eligible are billed or pay for the care you received. expenses are received at the Health Equity FSA claims unit by Know your balance! the deadline. This includes all necessary substantiation of FSA The card only works when there are sufficient funds in your account to transactions. cover an expense. To check your balance, sign into the mobile app, log into the member portal or contact HealthEquity using the number on the If you are on a leave of absence back of your card. as of January 1, your New Year elections will not be effective Documentation that doesn't show all required information will not be until you begin receiving Canon substantiated and will require additional documentation. Substantiation paychecks in the New Year can be submitted through the mobile app, on the member portal, mailing, faxing or email.

* Save all receipts. In the event your transaction must be substantiated, you must provide a receipt of the transaction.

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Legal Resources

Protect Yourself and Your Family

Legal Resources is an employee benefit that provides high- quality legal services to employees, helping them to lead lives free of major legal expenses. You can also use this benefit for your spouse and any unmarried children under the age of 19 who reside with you and full- time students up to the age of 23.

Low Cost, Great Value

With Legal Resources, you get comprehensive legal coverage on a broad range of services for an affordable low monthly rate. There are no co-pays and the cost of the plan does not change, no matter how often you use it.

Fully Covered Services

The most often needed legal services are covered at 100%. That means that you, your spouse and qualifying dependents pay no attorney fees when using these services.

• Identify Theft • General Advice • Wills and Estate Planning • Credit Protection • Traffic Violations

Quality Attorneys

Members have access to a network of top-rated, full service law firms locally and over 13,000 attorneys nationwide.

$18 Per Month

Enroll within 31 days from your date of hire or during open enrollment.

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Liberty Mutual

We know employees work hard. That’s why Liberty Mutual has partnered with Canon Virginia, Inc. to offer you exclusive savings on quality auto and home insurance. * Call Al Burke at 757-258-0338 ext. 53345 or visit Liberty Mutual at http://www.libertymutual.com to learn more or get a free quote.

* Discounts and savings are available where state laws and regulations allow, and may vary by state. To the extent permitted by law, applicants are individually underwritten; not all applicants may qualify.

The Torch is a Liberty Mutual site that provides engaging insurance-relevant content and deals to policyholders and prospective customers. The Torch spotlights partners who align with Liberty Mutual’s mission to help customer’s live safer, more secure lives.

The Deals Page of the Torch includes exclusive offers that are better than or different from other similar promotions.

Deductions for Liberty Mutual are not payroll deductions. You must contact Liberty Mutual to enroll in this product.

https://www.libertymutual.com/safe-and-smart-living.com

SmartMove Program

A Comprehensive Managed Move with Cash Back Incentives

• Personal Move Coordinator • Free of Cost • Cash Rebates • Discounts • Concierge Service on Vacation Rentals

Contact SmartMove at 1-800-645-6560

www.SMARTMOVE.com

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Paid Time Off

• PTO: One type of leave with one set of rules • Use in 15 minute increments • Can be used for any reason (sick, vacation, personal) • Must use all paid time off before going unpaid (exception is FMLA approved absences)

Hired Date of Hire 3 Months 6 Months January 12 hours (January) 12 hours (April) 56 hours (July) February 12 hours (February) 12 hours (May) 48 hours (August) March 12 hours (March) 12 hours (June) 40 hours (September) April 12 hours (April) 12 hours (July) 32 hours (October) May 12 hours (May) 12 hours (August) 24 hours (November) June 12 hours (June) 12 hours (September) 16 hours (December) July 12 hours (July) 12 hours (October) 80 hours (January) August 12 hours (August) 12 hours (November) 72 hours (February) September 12 hours (September) 12 hours (December) 64 hours (March) October 12 hours (October) 12 hours (January) 56 hours (April) November 12 hours (November) 12 hours (February) 48 hours (May) December 12 hours (December) 12 hours (March) 40 hours (June)

How do I earn PTO time?

Service Time Receive Each January Earn Each Week Total PTO Hours Each Year Less than 5 years 80 hours 0 hours per week 80 hours 5-9 years 80 hours .77 hours per week 120 hours 10+ years 80 hours 1.539 hours per week 160 hours

Special Leave and Service Awards

Members are recognized for continued years of service with the company. At each 5-year anniversary, employees are eligible to receive additional PTO hours, an additional one-time cash payment and a special lapel pin.

Service PTO Hours Cash Payment Pin 5 years 24 hours $150 05 Year Star Lapel Pin 10 years 24 hours $300 10 Year Star Lapel Pin 15 years 24 hours $500 15 Year Star Lapel Pin 20 years 40 hours $1,000 20 Year Star Lapel Pin 25 years 40 hours $1,000 25 Year Star Lapel Pin 30 years 40 hours $1,000 30 Year Star Lapel Pin

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Carry-Over Maximums

All PTO hours over the carry-over maximums listed below will automatically be paid out in cash at the end of the year.

Service Time Carry-Over Maximum < 5 years 80 hours 5-9 years 120 hours 10+ years 160 hours

Cash-Out Option

Members may also voluntarily cash out any amount of their PTO balance between the cash-out minimum and the carry-over maximum.

Sevice Time Cash-Out Minimum Carry-Over Maximum < 5 years 24 hours 80 hours 5-9 years 24 hours 120 hours 10+ years 24 hours 160 hours

Shutdown Leave

The Company has 2 paid shutdowns per year, August and December. Based upon your hire date, you may be paid for all or part of these shutdowns.

Employed Shutdown Time 151 or more days 40 hours 150 – 120 days 30 hours 119 – 90 days 20 hours 89 days or less 0 hours

Depending on your work location, you may be required to work during a shutdown. If you work during these times (and have been actively employed for 3 months), you will have the option to convert your shutdown to PTO or have them paid out to you.

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Other Types of Leave

• 12 Paid Holidays o New Year’s Day o Martin Luther King Day o President’s Day o Easter o Memorial Day o Independence Day o Labor Day o Thanksgiving (2 days) o Christmas o 2 Floating • Marriage Leave – 40 hours with proper notification • Jury Leave – Based on subpoena • Bereavement Leave – 1, 2 or 3 days based on the relationship

Based upon company operational needs, select areas will follow a different holiday and shutdown schedule than that outlined on the standard company calendar and some areas may require members to work during a holiday.

Members may receive additional pay for a holiday or convert their holiday pay to PTO leave. Your department manager will inform you regarding specific schedules that apply to your area. In order to convert any worked holiday time to PTO, you must be actively employed for at least 3 months.

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Employee Services and Events

Employee Services

As a Canon member, you have access to many services such as:

• On-Site Fitness Center • Member Benefit Days • On-Site Mammography Unit • Notary Services • On-Site ATM from Langley Federal Credit Union • Travel Service Representative to help with things such as rental cars, hotels, air fare • Discounted Movie Tickets • Discounted Busch Gardens tickets • And More!

Employee Events

• Employee Appreciation Day • Company Picnic • Thanksgiving Turkeys • Holiday Party

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Contact List

CVI Benefits Flexible Spending Account (FSA)

[email protected] Provider: Health Equity Customer Service: 1-877-713-7712 m

Medical Plans (EPO / PPO) Prescription

Provider: Anthem Blue Cross & Blue Provider: Express Scripts (ESI) Shield Customer Service: 1-844-578-5439 Customer Service: 1-844-256-9082 Prescription Group: CVIRX01 Pre-Certification: 1-844-256-9082 Website: www.express-scripts.com 24/7 Nurse line: 1-800-700-9184 EAP/Behavioral Health: 1-855-873-4932 Provider Services: 1-800-676-2583 International Coverage: 1-804-673- 1177 Medical Group: 003330157 Network: National PPO (Blue Card PPO) Website: www.anthem.com

Dental Plan Dependent Auditor

Provider: Anthem Blue Cross & Blue Provider: HMS Shield Customer Service: 1-866-868-8991 (M-F 8am- Customer Service: 1-866-956-8607 8pm EST) Dental Group: 003330157 Website: www.auditos.com Network: Dental Blue Complete Website: www.anthem.com

Vision Plan Employee Savings Plan Provider: Anthem Blue Cross & Blue Shield Provider: Vanguard Customer Service: 1-866-723-0515 Customer Service: 1-800-523-1188 Vision Group: 003330157 Plan: 091510 Network: Blue View Vision Website: www.vanguard.com/retirementplans.c

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Website: www.anthem.com om

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information

With key parts of the health care law having taken effect in 2014, there is a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice 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. It 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 November 2017 for coverage starting as early as January 1, 2018.

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

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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.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or refer to the contact information on the following page.

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.

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

PART B: Information About Health Coverage Offered by Your Employer

This section contains information about any health coverage offered by Canon Virginia, Inc. and Canon Environmental Technologies, Inc. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

3. Plan Sponsor name 4. Plan Sponsor Employer Identification Number (EIN)

Canon Virginia, Inc. 11-2780017

5. Plan Sponsor address 6. Plan Sponsor phone number

12000 Canon Boulevard 757-881-6000

7. City 8. State 9. ZIP code

Newport News Virginia 23606

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

Human Resources

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Canon Virginia, Inc. offers a health plan to eligible employees. Eligible employees are full time regular, not temporary, employees regularly scheduled to work at least 35 hours per week.

With respect to dependents, we do offer coverage. Eligible dependents are a spouse; domestic partner; dependent children who are under 26 years of age; and domestic partner’s dependent children who are under 26 years of age, as long as the domestic partner is covered under the Plan.2

This coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. Even though this coverage is intended 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 factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week, if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process.

2 This description is intended to be a brief and general description of the eligibility requirements for employees (and their dependents) under the health care plan options Canon Virginia, Inc. sponsors for its eligible employees and the eligible employees of its affiliates. This description does not include all eligibility requirements. If there is a discrepancy between this description and the Plan Documents, the Plan Documents control. All Plan terms, including eligibility requirements, may be changed at any time.

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NOTICE OF PRIVACY PRACTICES

(Effective 2013; Revised September 2017)

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.

Canon Virginia, Inc.’s Group Health Plans are required by law to maintain the privacy of your Health Information and to provide you with this notice of their legal duties and privacy practices with respect to your Health Information and to notify you following a breach of unsecured Health Information. This notice is being issued to comply with the requirements of the Privacy Rules under the Health Insurance Portability and Accountability Act (“HIPAA Privacy Rules”).

WHO SHOULD READ THIS NOTICE? This notice is for participants enrolled in any group health plan sponsored by Canon Virginia, Inc. and its affiliates (collectively “CVI”).

WHAT IS HEALTH INFORMATION? For purposes of this notice, your “health (or medical) information” is information that identifies you and relates to your past, present or future physical or mental health or condition; the provision of health care to you; or the past, present, or future payment for health care furnished to you. It includes genetic information as defined under Title I of the Genetic Information Nondiscrimination Act of 2008.

WHAT HEALTH PLANS ARE COVERED BY THIS NOTICE? The following health plans are covered by this notice (collectively the “Plans”):

Canon Virginia, Inc. Medical Welfare Plan (providing medical, prescription drug, behavioral health and vision benefits);

Canon Virginia, Inc. Dental Plan; and

Canon Virginia, Inc. Section 125 Plan

The term “we,” “our” or “us” in this notice refers to the Plans listed above and may include third-party administrators and selected CVI employees, who conduct plan administration functions. The term “you” or “your” refers to employees and dependents who are participants in a health plan covered by this notice.

Because insurers of health plans are obligated to send a notice of privacy practices under the HIPAA Privacy Rules, you may also receive a privacy notice from an insurer. The insurer’s notice will apply only to the plan it insures. This notice will apply for all the self-funded health plans sponsored by CVI listed above.

HOW ARE THE PLANS ADMINISTERED? The Plans do not have employees. Instead, employees of CVI, or third-party administrators retained by CVI, administer the Plans. The third-party administrator administers the Plans in a way similar to the way a health insurance company administers an insured health plan. Each third-party administrator has contractually agreed to keep your Health Information confidential, in compliance with HIPAA Privacy Rules. In addition, certain CVI

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employees perform administrative services for the Plans. When CVI employees perform plan administration functions on behalf of the Plans, they keep your Health Information separate and do not share it with other employees within CVI unless permitted by the HIPAA Privacy Rules as summarized in this notice.

WHAT ARE 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 do provide written requests to share your information beyond the disclosures described below, you may change your mind and notify us in writing at any time.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

HOW MAY YOUR HEALTH INFORMATION BE USED OR DISCLOSED? The following categories describe the different ways your health information may be used or disclosed. Each permitted use or disclosure falls within one of these categories. However, not every specific use or disclosure permitted in each category is described.

Payment. Your health information will be used for payment purposes. Payment includes, among other things:

• Paying claims from providers for any covered treatment and services provided to you • Determining disputed claims, eligibility for benefits, coordination of benefits, and cost sharing arrangements • Asserting our right to subrogation and reimbursement • Examining medical necessity • Obtaining payment under stop loss insurance • Conducting utilization review

We may not however use or disclose any Health Information that is genetic information for underwriting purposes.

Example When you obtain a covered health service, your provider may submit health information to us, and we may create or access health information to arrange payment of the claim.

Treatment. Your health information may be disclosed to health care providers (doctors, nurses, technicians, dentists, pharmacists, hospitals and other individuals who are involved in your care) in connection with your treatment.

Example Your health information may be disclosed to your pharmacist who may request it to coordinate a pending prescription with prior prescriptions.

Health Care Operations. Your health information may be used to operate and administer the Plans. These operations include, among other things, engaging in care coordination, case management, disease management, risk assessment, premium determination, audit functions, detection of fraud and abuse and quality assessments and improvement activities. We may not however use or disclose any Health Information that is genetic information for underwriting purposes.

Example If you are diagnosed with a chronic disease, your health information may be used for purposes of disease management. This means you may be contacted by our disease management specialists about possible treatment alternatives.

Plan Sponsor. Your health information may be disclosed to or used by CVI, as Plan Sponsor, for the purpose of conducting plan administration functions, as permitted by the HIPAA Privacy Rules. CVI will not, however, use or

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disclose your health information created by or received from the Plans for any employment-related functions, without your authorization.

Business Associates. Third-party administrators, auditors, attorneys, consultants and the like (“business associates”) will be hired to assist in operating and administering the Plans. Our business associates may use or disclose your health information to perform the services for which they have been hired. To protect your health information, each business associate must sign a contract limiting its ability to use and disclose health information and requiring it to implement appropriate safeguards.

Communication with You and Your Family. Generally, the CVI Benefits Department will not discuss your health information with you or your family members without a specific signed authorization, unless it relates to basic eligibility or enrollment questions. Rather, inquiries from you or your family members will be directed to the appropriate third-party administrator (e.g., Anthem).

Unless you object, the third-party administrator may disclose your health information to a family member, other relative, person authorized by law, or any other person you identify as involved in your care or the payment related to your care. Only health information relevant to that person’s involvement in your care or the payment related to your care will be disclosed. You can restrict this disclosure at any time, subject to certain limitations. If you are incapacitated or in the event of an emergency, the third-party administrator will exercise professional judgment to determine whether a disclosure of this type is in your best interest.

Example The third-party administrators for the Plans will communicate with a covered employee about the claims payment information relating to the covered spouse or dependent of such employee, unless the covered spouse or dependent has requested (and the Plan has agreed)that the use or disclosure of such information is restricted.

Health Education. Your health information may be used to inform you about treatment alternatives or other health related benefits and services that may be of interest to you.

Judicial or Administrative Proceedings. Your health information may be disclosed in response to a court or administrative order, subpoena, discovery request or other lawful process if certain conditions are met and the required assurances are received.

As Required by Law. Your health information may be disclosed if such disclosure is required by law (e.g., to federal governmental agencies, such as the Department of Health and Human Services for the purpose of determining compliance with HIPAA Privacy Rules).

Public Health Activities. Your health information may be disclosed to public health or other appropriate authorities to lessen a serious and imminent threat to the health or safety of you or the public, including abuse of a vulnerable adult or child, subject to certain limitations and conditions. Your health information may also be disclosed to a coroner or medical examiner to determine cause of death or as authorized by law or to a funeral director as necessary to enable them to carry out their duties.

Parents of Minors. Health information of a minor child, in most cases, will be disclosed to a parent or guardian of that minor, subject to certain limitations imposed by State law.

Research. Your health care information may be used for the purpose of conducting research, provided measures are taken to protect your privacy.

Workers’ Compensation. Your health information may be used to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.

Other Permitted Uses and Disclosures. Your Health Information also may be disclosed to prevent abuse, neglect or domestic violence; for health oversight activities; for the purpose of conducting research; for law enforcement purposes; to coroners, medical examiners or funeral directors; for purposes of organ donations; to avert a serious threat to health or safety and/or for specialized governmental functions.

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Your Authorization. Notwithstanding the above, the Plans must seek your authorization for most uses and disclosures of health information for marketing purposes or health information contained in psychotherapy notes.

To use or disclose your health information for reasons other than the categories listed above, we must obtain a signed written authorization from you. You may authorize, in writing, the use or disclosure of your health information to any person and for any purpose specified in the authorization. You may revoke such authorization in writing at any time, but your revocation will not impact any uses or disclosures that occurred while your authorization was in effect. In certain instances, your employment with CVI may be conditioned on you signing and not revoking an authorization.

WHAT ARE YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION?

This section describes your rights regarding your health information. All requests relating to any of the rights described in this section must be made in writing and must be submitted as follows:

For medical, dental, vision, behavioral health or health care reimbursement account benefits, submit requests by calling the toll-free Member Services number on your plan ID card.

For prescription drugs, submit requests by calling the toll-free Member Services number on your Prescription Drug ID card.

For any other issues related to your health information, if you are unsure where to submit your request, or if you need assistance with a request, send a written request to:

Canon Group Health Plan Privacy Official Benefits Department Canon Virginia, Inc. 1200 Canon Boulevard Newport News, VA 23606

Right to Access. You may request to inspect and copy your health information. You may also choose to have your health information transmitted directly to an entity or person you clearly designate, if required by law or if practicable. If you request a copy, we may charge a reasonable fee for the costs of copying, mailing or other associated supplies. If we are unable to provide you with access to your requested health information within 30 days of your request, we will provide you with written notice of the extension which specifies the reasons for the extension and a projected timeframe in which you will receive access to the information. You will receive written notification if your request is denied. If your Health Information is maintained electronically, you have a right to obtain a copy of it in an electronic format. We will provide a copy in the electronic form and format you request, if the information can be readily produced in that form and format. If the information cannot be readily produced in that form and format, we will work with you to determine a mutually agreeable form and format. If we cannot agree on an electronic form and format, you will receive a paper copy. You may also choose to have your Health Information transmitted directly to an entity or person you clearly designate.

Right to Amend. If your health information is incorrect or incomplete, you may request that it be amended. Your request must include a reason supporting the amendment. You will receive written notification if your request is denied. If your request is denied, you have the right to submit a written statement disagreeing with the denial, which will be appended to the health information in question.

Right to an Accounting (List) of Disclosures. You may request a list of the disclosures of your health information, if any, that have been made other than disclosures made to you or authorized by you or for payment or health care operations. Your request must state a time period for which the accounting of disclosures will be provided, not to exceed the preceding six years from the date of the request. If you request a list more than once in a 12-month period, you may be charged a reasonable cost-based fee. You will be notified of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.

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Right to Request Restrictions. You may request a restriction of the health information that is disclosed about you to your family members, or for purposes of payment or health care operations. Generally, the Plan is not required to agree to such a restriction. If we do agree to the request, but we were not required to do so, we will abide by your restriction unless we need to use your health information to provide emergency treatment. In addition, we may generally elect to terminate the restriction at any time.

A covered entity (such as a health care provider) must comply with a requested restriction if the disclosure is to a health plan for purposes of payment or health care operations and the health information relates to a health care item or service for which an individual paid in full out-of-pocket. For example, if you receive medical care and choose to pay the provider for the entire amount of care in full out-of-pocket, you can request that the provider not disclose such information to the Plans and the provider must agree to such request.

Right to Request Confidential Communications. If disclosure of your health information could endanger you, you may request that communication with you about health matters occur by alternative means or at an alternative location. For example, you may request that you only be contacted at work or by mail. Your request must include a statement that use or disclosure may endanger you and specify how or where you wish to be contacted.

Right to Notification of Breach. You have a right to receive notice following an unauthorized access, use or disclosure of your Health Information if that unauthorized access, use or disclosure is considered a “breach” as defined by the HIPAA Privacy Rules.

Right to a Paper Copy of This Notice. This notice is available on your company’s intranet website. You may also request a paper copy of this notice at any time by sending a written request to the Canon Corporate Benefits Department at the address above.

Complaints. If your privacy rights have been violated, you may file a complaint with the Canon privacy officer or with the secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. Complaints must be made in writing and submitted to either to:

Canon Group Health Plan Privacy Department of Health and Human Services Official Benefits Department Canon Virginia, Inc. Office of Civil Rights 1200 Canon Boulevard Newport News, VA 23606 Hubert H. Humphrey Building

(757) 881-6000 200 Independence Ave. S.W. Room 509F HHH Building

Washington, D.C. 20201

(877) 696-6775

www.hhs.gov/ocr/privacy/hipaa/complaints/

WHEN IS THIS NOTICE EFFECTIVE AND CAN WE CHANGE IT? This notice was originally effective April 14, 2003 and is restated effective September 2017. This notice will remain in effect until we replace it. The plans are required by law to abide by the terms of this notice, as may be amended from time to time. We reserve the right to change this notice at any time and for any reason. We reserve the right to make the revised or changed notice effective for health information we currently maintain as well as any information received in the future. A copy of our most current notice will be posted in your local human resources department and on your company’s intranet site.

If you have any questions about this notice, please contact the Benefits Department, Canon Virginia, Inc. at (757) 881-6000.

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4852-9886-1881\1 10/13/2017

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HIPAA Notice Of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse/domestic partner) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage) (60 days if enrollment is due to loss of eligibility for Medicaid or CHIP coverage or becoming eligible for a premium subsidy through Medicaid or CHIP). In addition, 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 31 days after the marriage, birth, adoption, or placement for adoption. Your special enrollment rights are described further in the paragraphs below. Events that may qualify for a special enrollment during the year include the following situations: . Loss of Other Coverage. You, your spouse/domestic partner or dependent were eligible but declined enrollment previously (either when initially eligible, at annual enrollment or when a change in status event occurred) because of other health coverage that is subsequently lost due to: . Divorce or legal separation; . Death; . Cessation of dependent status; . Loss of HMO or similar coverage because you changed your residence or work place and as a result coverage is no longer available; . Changes in the plan that make you, your spouse/domestic partner or your dependent no longer eligible; . Employer contributions toward the cost of coverage being terminated; . Termination of employment; . Reduction in hours; . Loss of coverage under Medicaid or a state Children’s Health Insurance Program (“CHIP”); or Loss of coverage due to nonpayment of premiums or fraud is not a special enrollment event. Exhaustion of COBRA Coverage. If you or a dependent are enrolled in COBRA when you decline coverage under this Plan, you must exhaust your COBRA coverage in order to qualify for a special enrollment. COBRA will be deemed to be exhausted for this purpose if it ends for any reason other than your or your dependent’s failure to pay premiums or termination for cause (such as fraud). COBRA would therefore be deemed to be exhausted if it ended for any of these reasons: . Another employer or responsible entity fails to remit premiums for the coverage as a whole (but not if you or a dependent lose coverage for your or your dependent’s nonpayment). . Loss of HMO or similar coverage because of change in residence or work place that makes coverage unavailable where there is no other COBRA continuation coverage available. If you lose coverage as explained above, and if you are eligible for coverage under the Plan, you can add yourself and any dependents who satisfy the Plan’s eligibility rules. If your dependent loses coverage as explained above, and if you and that dependent are eligible for coverage under the Plan, you can add yourself and that dependent.

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New Dependents. You may add coverage for yourself, your spouse and new dependents following: . Your marriage . Birth, adoption or placement for adoption of your child . Gaining Eligibility for a Premium Subsidy through Medicaid or CHIP: If you become eligible for Medicaid or CHIP premium assistance subsidy that can be applied toward your cost of coverage under Canon’s Health Plan, you may enroll yourself and your dependents for coverage.

To elect additional coverage because of a special enrollment event, you must log onto the enrollment portal (www.canonbenefits.com) or contact the Benefits Service Center at (800) 290- 8379 within 31 days of the date on which the special enrollment event occurs (except if you lose coverage under Medicaid or CHIP or become eligible for the premium subsidy under Medicaid or CHIP, your deadline is 60 days). Canon may request that you supply written proof to substantiate the occurrence of the special enrollment event, such as written evidence of loss of other coverage, a signed marriage certificate or a signed certificate of the birth, adoption or placement for adoption of a child. If you have any questions about this notice, please contact the Plan Administrator at (757) 881-6237.

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Important Notice From Canon Virginia, Inc. About Your Prescription Drug Coverage And Medicare (This Notice Applies Only To The Prescription Drug Benefits Provided Under The Canon Virginia, Inc. Medical Welfare Plan.)

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Canon Virginia, Inc. under the prescription drug coverage provided under the Canon Virginia, Inc. Medical Welfare Plan and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Canon Virginia, Inc. has determined that the prescription drug coverage offered under the Canon Virginia, Inc. Medical Welfare Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current prescription drug coverage will not be affected. You will still be eligible for prescription drug coverage under prescription drug coverage offered under the Canon Virginia, Inc. Medical Welfare Plan.

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Your current coverage under the Canon Virginia, Inc. Medical Welfare Plan pays for other health expenses in addition to prescription drugs, and you will still be eligible to receive all your current health, prescription drug, and vision benefits even if you choose to enroll in a Medicare prescription drug plan.

If you do decide to join a Medicare drug plan and drop your current coverage under the Canon Welfare Benefit Plan, you will not be eligible to reenroll in the Canon Welfare Benefit Plan until the next annual enrollment period with an effective date of the following January 1 unless you have a status change event that allows you to elect coverage under the Canon Virginia, Inc. Medical Welfare Plan. You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with the Canon Virginia, Inc. Medical Welfare Plan and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage

For further information on the Canon Virginia, Inc. Medical Welfare Plan, contact Jackie Wall at (757) 881-6000. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if the prescription drug coverage under the Canon Virginia, Inc. Medical Welfare Plan changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

. Visit www.medicare.gov . Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help . Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: October 14, 2017 Name of Entity/Sender: Canon Virginia, Inc. Contact--Position/Office: Jackie Wall – Human Resources Specialist, Benefits Dept. Address: 1200 Canon Boulevard, Newport News, VA 23606 Phone Number: (757) 881-6000

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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

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, 2017. 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: http://dch.georgia.gov/medicaid Website: http://myakhipp.com/ - Click on Health Insurance Premium Payment (HIPP) Phone: 1-866-251-4861 Phone: 404-656-4507 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/ default.aspx ARKANSAS – Medicaid INDIANA – Medicaid

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Website: http://myarhipp.com/ Healthy Indiana Plan for low-income adults 19-64 Phone: 1-855-MyARHIPP (855-692-7447) Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864 COLORADO – Medicaid IOWA – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Website: http://www.dhs.state.ia.us/hipp/ Medicaid Customer Contact Center: 1-800-221-3943 Phone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Website: http://www.dhhs.nh.gov/oii/documents/hippa Phone: 1-785-296-3512 pp.pdf Phone: 603-271-5218 KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://chfs.ky.gov/dms/default.htm 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: http://dhh.louisiana.gov/index.cfm/subhome/1 Website: http://www.nyhealth.gov/health_care/medicai /n/331 d/ Phone: 1-888-695-2447 Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public- Website: http://www.ncdhhs.gov/dma assistance/index.html Phone: 919-855-4100 Phone: 1-800-442-6003 TTY: Maine relay 711 MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/MassHealth Website: http://www.nd.gov/dhs/services/medicalserv/ Phone: 1-800-462-1120 medicaid/ Phone: 1-844-854-4825 MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://mn.gov/dhs/ma/ Website: http://www.insureoklahoma.org Phone: 1-800-657-3739 Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pag Website: http://healthcare.oregon.gov/Pages/index.aspx es/hipp.htm http://www.oregonhealthcare.gov/index- Phone: 573-751-2005 es.html Phone: 1-800-699-9075

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MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcareProgr Website: http://www.dhs.pa.gov/hipp ams/HIPP Phone: 1-800-692-7462 Phone: 1-800-694-3084

NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: http://dhhs.ne.gov/Children_Family_Services/ Website: http://www.eohhs.ri.gov/ AccessNebraska/Pages/accessnebraska_index.aspx Phone: 401-462-5300 Phone: 1-855-632-7633 NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: http://dwss.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: http://www.hca.wa.gov/free-or-low-cost- Phone: 1-888-828-0059 health-care/program-administration/premium- payment-program Phone: 1-800-562-3022 ext. 15473 TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Website: http://www.dhhr.wv.gov/bms/Medicaid%20E Phone: 1-800-440-0493 xpansion/Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Website: Website: Medicaid: http://health.utah.gov/medicaid https://www.dhs.wisconsin.gov/publications/p1/p10095. CHIP: http://health.utah.gov/chip 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_a ssistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_a ssistance.cfm CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since July 31, 2017, or for more information on special enrollment rights, contact either:

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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/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 10/31/2017)

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Important Legal Notices

Annual Notice Of Women’s Health And Cancer Rights Act

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires group health plans that provide coverage for mastectomies to also cover reconstructive surgery and prostheses following mastectomies.

The law mandates that a member receiving benefits for a medically necessary mastectomy who elects breast reconstruction after the mastectomy will also receive coverage for:

• Reconstruction of the breast on which the mastectomy has been performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses; and • Treatment of physical complications of all stages of mastectomy, including lymphedemas.

This coverage will be provided in consultation with the attending physician and the patient, and will be subject to the same annual deductible and co- insurance that apply to other medical and surgical benefits provided under the Canon Welfare Benefit Plan.

If you would like more information on WHCRA benefits, please call your Plan Administrator at (757) 881-6237.

Statement Of Rights Under The Newborns' And Mothers' Health Protection Act

Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section.

However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.

Also, under federal law, plans and issuers may not set the level of benefits or out-of- pocket costs so that any later portion of the 48-hour (or 96-hour as applicable) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, a plan or issuer may not, under federal law, require that you, your physician, or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours as applicable). However, you may be required to obtain precertification for any days of confinement that exceeds 48 hours (or 96 hours). For information on precertification, contact your Plan Administrator.

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018– 12/31/2018 Canon Virginia, Inc: Anthem EPO Coverage for: Individual + Family | Plan Type: EPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc- glossary/ or call (844) 256-9082 to request a copy.

Important Questions Answers Why This Matters: What is the $0. See the Common Medical Events chart below for your costs for services this plan covers. overall deductible? Are there services No. You will have to meet the deductible before the plan pays for any services. covered before you meet your deductible? Are there No. You don't have to meet deductibles for specific services. other deductibles for specific services? What is the out-of- $2,000/individual or The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for $4,000/family for In-Network other family members in this plan, they have to meet their own out-of-pocket limits until the this plan? Providers. overall family out-of-pocket limit has been met.

What is not included Services deemed not medically Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket necessary by Medical limit? Management and/or Anthem, Penalties for non-compliance, Premiums, balance-billing charges, and health care this plan doesn't cover. Will you pay less if Yes, Blue Card PPO. This plan uses a provider network. You will pay less if you use a provider in you use a network See www.anthem.com or call the plan’s network. You will pay the most if you use an out-of-network provider, and you provider? (844) 256-9082 for a list might receive a bill from a provider for the difference between the provider’s charge and what of network providers. your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist?

IN/L/A/CanonUSAIncEPO-EPO/NA/ORM14/NA/01-18 1 of 10

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Common Out-of-Network Limitations, Exceptions, & Other Services You May Need In-Network Provider Medical Event Provider Important Information (You will pay the least) (You will pay the most) Primary care visit to treat an $20/visit Not covered ------none------injury or illness Specialist visit $35/visit Not covered ------none------If you visit a health Vision exam (routine): Not covered. care provider’s You may have to pay for services that Preventive care screening aren't preventive. Ask your provider if office or clinic / / No charge Not covered immunization the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood $20/visit Not covered ------none------If you have a test work) Imaging (CT/PET scans, MRIs) $50/visit Not covered ------none------If you need drugs Tier 1 - Typically Generic Not covered Not covered to treat your Tier 2 - Typically Preferred / Not covered Not covered illness or Brand condition Tier 3 - Typically Non-Preferred Not covered Not covered More information / Specialty Drugs Carved out to ESI. about prescription is drug coverage Tier 4 - Typically Specialty available at Not covered Not covered (brand and generic) www.[insert].

Facility fee (e.g., ambulatory No charge Not covered ------none------If you have surgery center) outpatient surgery Physician/surgeon fees No charge Not covered ------none------Emergency room care $150/visit Covered as In-Network Copay waived if admitted. If you need Emergency $50/visit Covered as In-Network ------none------immediate medical transportation medical attention Urgent care $30/visit Not covered ------none------If you have a Facility fee (e.g., hospital room) $200/visit Not covered ------none------hospital stay Physician/surgeon fees No charge Not covered ------none------If you need Office Visit Office Visit Office Visit mental health, Outpatient services $20/visit Not covered ------none------behavioral health, Other Outpatient Other Outpatient Other Outpatient * For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 2 of 10

What You Will Pay Common Out-of-Network Limitations, Exceptions, & Other Services You May Need In-Network Provider Medical Event Provider Important Information (You will pay the least) (You will pay the most) or substance No charge Not covered ------none------abuse services Inpatient services $200/visit Not covered ------none------Office visits $15/pregnancy first 1 visit Not covered One copayment per pregnancy for Childbirth/delivery professional both office visits and No charge Not covered If you are services childbirth/delivery professional pregnant services. Maternity care may include Childbirth/delivery facility $200/visit Not covered tests and services described elsewhere services in the SBC (i.e. ultrasound.) 120 visits/benefit period for In- Home health care No charge Not covered Network Providers. Rehabilitation services $35/visit Not covered *See Therapy Services section If you need help Habilitation services $35/visit Not covered recovering or have 100 days limit/benefit period for In- other special Skilled nursing care $200/visit Not covered Network Providers. health needs *See Durable medical Durable medical equipment No charge Not covered equipment Section Hospice services No charge Not covered ------none------Children’s eye exam $20/visit Not covered If your child *See Vision Services section needs dental or Children’s glasses Not covered Not covered eye care Children’s dental check-up Not covered Not covered *See Dental Services section

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (adult) • Hearing aids • Infertility treatment • Long- term care • Non-emergency care when traveling outside • Routine foot care unless you have been • Weight loss programs the U.S. diagnosed with diabetes.

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Abortion • Bariatric surgery • Chiropractic care

• Private-duty nursing only covered in the • Routine eye care (adult) home.70 visits/benefit period.

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 3 of 10

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

ATTN: Grievances and Appeals, P.O. Box 105568, Atlanta GA 30348-5568 Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform

Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 4 of 10

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow hospital delivery) controlled condition) up care)

 The plan’s overall deductible $0  The plan’s overall deductible $0  The plan’s overall deductible $0  Specialist copayment $35  Specialist copayment $35  Specialist copayment $35  Hospital (facility) copayment $200  Hospital (facility) copayment $200  Hospital (facility) copayment $200  Other copayment $20  Other copayment $20  Other copayment $20

This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services like: like: like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $2,010

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $0 Deductibles $0 Deductibles $0 Copayments $600 Copayments $550 Copayments $865 Coinsurance $0 Coinsurance $0 Coinsurance $0 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $96 Limits or exclusions $6,041 Limits or exclusions $0 The total Peg would pay is $696 The total Joe would pay is $6,591 The total Mia would pay is $865

The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of 10

Language Access Services:

(TTY/TDD: 711)

Albanian (Shqip): Nëse keni pyetje në lidhje me këtë dokument, keni të drejtë të merrni falas ndihmë dhe informacion në gjuhën tuaj. Për të kontaktuar me një përkthyes, telefononi (844) 256-9082

Amharic (አማርኛ)፦ ስለዚህ ሰነድ ማንኛውም ጥያቄ ካለዎት በራስዎ ቋንቋ እርዳታ እና ይህን መረጃ በነጻ የማግኘት መብት አለዎት። አስተርጓሚ ለማናገር (844) 256-9082 ይደውሉ።

.(844) 256-9082

Armenian (հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք անվճար ստանալ օգնություն և տեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար զանգահարեք հետևյալ հեռախոսահամարով՝ (844) 256-9082:

(844) 256-9082.

(844) 256-9082

(844) 256-9082

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(844) 256-9082.

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Language Access Services: German (Deutsch): Wenn Sie Fragen zu diesem Dokument haben, haben Sie Anspruch auf kostenfreie Hilfe und Information in Ihrer Sprache. Um mit einem Dolmetscher zu sprechen, bitte wählen Sie (844) 256-9082.

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Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele (844) 256-9082.

(844) 256-9082

Hmong (White Hmong): Yog tias koj muaj lus nug dab tsi ntsig txog daim ntawv no, koj muaj cai tau txais kev pab thiab lus qhia hais ua koj hom lus yam tsim xam tus nqi. Txhawm rau tham nrog tus neeg txhais lus, hu xov tooj rau (844) 256-9082.

Igbo (Igbo): Ọ bụr ụ na ị nwere ajụjụ ọ bụla gbasara akwụkwọ a, ị nwere ikike ịnweta enyemaka na ozi n'asụsụ gị na akwụghị ụgwọ ọ bụla. Ka gị na ọkọwa okwu kwuo okwu, kpọọ (844) 256-9082.

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Indonesian (Bahasa Indonesia): Jika Anda memiliki pertanyaan mengenai dokumen ini, Anda memiliki hak untuk mendapatkan bantuan dan informasi dalam bahasa Anda tanpa biaya. Untuk berbicara dengan interpreter kami, hubungi (844) 256-9082.

Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero (844) 256-9082

(844) 256-9082

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Language Access Services:

(844) 256-9082

Kirundi (Kirundi): Ugize ikibazo ico arico cose kuri iyi nyandiko, ufise uburenganzira bwo kuronka ubufasha mu rurimi rwawe ata giciro. Kugira uvugishe umusemuzi, akura (844) 256-9082.

Korean (한국어): 본 문서에 대해 어떠한 문의사항이라도 있을 경우, 귀하에게는 귀하가 사용하는 언어로 무료 도움 및 정보를 얻을 권리가 있습니다. 통역사와 이야기하려면 (844) 256-9082 로 문의하십시오.

(844) 256-9082.

(844) 256-9082.

(844) 256-9082

Oromo (Oromifaa): Sanadi kanaa wajiin walqabaate gaffi kamiyuu yoo qabduu tanaan, Gargaarsa argachuu fi odeeffanoo afaan ketiin kaffaltii alla argachuuf mirgaa qabdaa. Turjumaana dubaachuuf, (844) 256-9082 bilbilla.

Pennsylvania Dutch (Deitsch): Wann du Frooge iwwer selle Document hoscht, du hoscht die Recht um Helfe un Information zu griege in dei Schprooch mitaus Koscht. Um mit en Iwwersetze zu schwetze, ruff (844) 256-9082 aa.

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(844) 256-9082

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Language Access Services:

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(844) 256-9082.

Samoan (Samoa): Afai e iai ni ou fesili e uiga i lenei tusi, e iai lou ‘aia e maua se fesoasoani ma faamatalaga i lou lava gagana e aunoa ma se totogi. Ina ia talanoa i se tagata faaliliu, vili (844) 256-9082.

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Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar con un intérprete, llame al (844) 256-9082.

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(844) 256-9082.

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.(844) 256-9082

(844) 256-9082.

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Language Access Services: It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368- 1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018– 12/31/2018 Canon Virginia: Anthem PPO Coverage for: Individual + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc- glossary/ or call (844) 256-9082 to request a copy.

Important Questions Answers Why This Matters: What is the $250/individual or $500/family Generally, you must pay all of the costs from providers up to the deductible amount before overall deductible? for In-Network Providers. this plan begins to pay. If you have other family members on the plan, each family member $500/individual or must meet their own individual deductible until the total amount of deductible expenses paid /family for Out-of- $1,000 by all family members meets the overall family deductible. Network Providers. Are there services Yes. Preventive care, Primary This plan covers some items and services even if you haven’t yet met the deductible amount. covered before you Care visit, Specialist visit, and But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible? Vision exam for In-Network services without cost-sharing and before you meet your deductible. See a list of covered Providers. preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there No. You don't have to meet deductibles for specific services. other deductibles for specific services? What is the out-of- $3,000/individual or The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for $7,000/family for In-Network other family members in this plan, they have to meet their own out-of-pocket limits until the this plan? Providers. $4,500/individual or overall family out-of-pocket limit has been met. $9,000/family for Out-of- Network Providers. What is not included Services deemed not medically Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket necessary by Medical limit? Management and/or Anthem, Penalties for non-compliance, Premiums, balance-billing charges, and health care this plan doesn't cover. Will you pay less if Yes, Blue Card PPO. This plan uses a provider network. You will pay less if you use a provider in you use a network See www.anthem.com or call the plan’s network. You will pay the most if you use an out-of-network provider, and you provider? (844) 256-9082 for a list might receive a bill from a provider for the difference between the provider’s charge and what of network providers.

IN/L/A/CanonVirginia-PPO/NA/TJGBN/NA/01-18 1 of 10

your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist?

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Common Out-of-Network Limitations, Exceptions, & Other Services You May Need In-Network Provider Medical Event Provider Important Information (You will pay the least) (You will pay the most) Primary care visit to treat an $25/visit deductible does 40% coinsurance ------none------injury or illness not apply $45/visit deductible does Specialist visit 40% coinsurance ------none------If you visit a not apply health Vision exam (routine)-Not Covered. care provider’s You may have to pay for services that office or clinic Preventive care screening aren't preventive. Ask your provider if / / No charge 40% coinsurance immunization the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood $25/visit deductible does 40% coinsurance ------none------work) not apply If you have a test $50/visit then Imaging (CT/PET scans, MRIs) 40% coinsurance ------none------20% coinsurance If you need drugs Tier 1 - Typically Generic Not covered Not covered to treat your Tier 2 - Typically Preferred / Not covered Not covered illness or Brand condition Tier 3 - Typically Non-Preferred Not covered Not covered More information / Specialty Drugs Carved out to ESI. about prescription is drug coverage Tier 4 - Typically Specialty available at Not covered Not covered (brand and generic) www.[insert].

Facility fee (e.g., ambulatory 20% coinsurance 40% coinsurance ------none------If you have surgery center) outpatient surgery Physician/surgeon fees 20% coinsurance 40% coinsurance ------none------If you need Emergency room care $200/visit then Covered as In-Network Copay waived if admitted. * For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 2 of 10

What You Will Pay Common Out-of-Network Limitations, Exceptions, & Other Services You May Need In-Network Provider Medical Event Provider Important Information (You will pay the least) (You will pay the most) immediate 20% coinsurance medical attention Emergency $50/visit then Covered as In-Network ------none------medical transportation 20% coinsurance $40/visit deductible does Urgent care 40% coinsurance ------none------not apply $250/admission deductible Facility fee (e.g., hospital room) 30% coinsurance ------none------If you have a does not apply hospital stay Physician/surgeon fees 20% coinsurance 40% coinsurance ------none------Office Visit Office Visit Office Visit $25/visit deductible does If you need 40% coinsurance ------none------Outpatient services not apply mental health, Other Outpatient Other Outpatient Other Outpatient behavioral health, 40% coinsurance ------none------or substance 20% coinsurance abuse services $250/admission deductible Inpatient services 40% coinsurance ------none------does not apply Office visits 20% coinsurance 40% coinsurance Childbirth/delivery professional Maternity care may include tests and 20% coinsurance 40% coinsurance If you are services services described elsewhere in the pregnant Childbirth/delivery facility $250/admission deductible SBC (i.e. ultrasound.) 30% coinsurance services does not apply Home health care 20% coinsurance 40% coinsurance 120 visits/benefit period. $25/visit deductible does Rehabilitation services 40% coinsurance not apply *See Therapy Services section If you need help Habilitation services 20% coinsurance 40% coinsurance recovering or have $250/admission then other special Skilled nursing care 40% coinsurance 100 days limit/benefit period. 20% coinsurance health needs *See Durable medical equipment Durable medical equipment 20% coinsurance 40% coinsurance Section Hospice services 20% coinsurance 40% coinsurance ------none------$25/visit deductible does Children’s eye exam 40% coinsurance If your child not apply *See Vision Services section needs dental or Children’s glasses Not covered Not covered eye care Children’s dental check-up Not covered Not covered *See Dental Services section

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 3 of 10

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (adult) • Hearing aids • Long- term care • Routine foot care unless you have been diagnosed with diabetes. • Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Abortion • Bariatric surgery • Chiropractic care $750 maximum/benefit period. • Infertility treatment 6/lifetime for Artificial • Most coverage provided outside the United • Private-duty nursing only covered in the Insemination. States. See www.bcbsglobalcore.com home. 70 visits/benefit period.

• Routine eye care (adult)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

ATTN: Grievances and Appeals, P.O. Box 105568, Atlanta GA 30348-5568 Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform

Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 4 of 10

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow hospital delivery) controlled condition) up care)

 The plan’s overall deductible $250  The plan’s overall deductible $250  The plan’s overall deductible $250  Specialist copayment $45  Specialist copayment $45  Specialist copayment $45  Hospital (facility) copayment $250  Hospital (facility) copayment $250  Hospital (facility) copayment $250  Other copayment $25  Other copayment $25  Other copayment $25

This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services like: like: like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $2,010

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $250 Deductibles $107 Deductibles $250 Copayments $300 Copayments $290 Copayments $315 Coinsurance $688 Coinsurance $27 Coinsurance $283 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $96 Limits or exclusions $6,041 Limits or exclusions $0 The total Peg would pay is $1,334 The total Joe would pay is $6,465 The total Mia would pay is $848

The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of 10

Language Access Services:

(TTY/TDD: 711)

Albanian (Shqip): Nëse keni pyetje në lidhje me këtë dokument, keni të drejtë të merrni falas ndihmë dhe informacion në gjuhën tuaj. Për të kontaktuar me një përkthyes, telefononi (844) 256-9082

Amharic (አማርኛ)፦ ስለዚህ ሰነድ ማንኛውም ጥያቄ ካለዎት በራስዎ ቋንቋ እርዳታ እና ይህን መረጃ በነጻ የማግኘት መብት አለዎት። አስተርጓሚ ለማናገር (844) 256-9082 ይደውሉ።

.(844) 256-9082

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(844) 256-9082.

(844) 256-9082

(844) 256-9082

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(844) 256-9082

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Language Access Services: German (Deutsch): Wenn Sie Fragen zu diesem Dokument haben, haben Sie Anspruch auf kostenfreie Hilfe und Information in Ihrer Sprache. Um mit einem Dolmetscher zu sprechen, bitte wählen Sie (844) 256-9082.

Greek (Ελληνικά) Αν έχετε τυχόν απορίες σχετικά με το παρόν έγγραφο, έχετε το δικαίωμα να λάβετε βοήθεια και πληροφορίες στη γλώσσα σας δωρεάν. Για να μιλήσετε με κάποιον διερμηνέα, τηλεφωνήστε στο (844) 256-9082.

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(844) 256-9082

Hmong (White Hmong): Yog tias koj muaj lus nug dab tsi ntsig txog daim ntawv no, koj muaj cai tau txais kev pab thiab lus qhia hais ua koj hom lus yam tsim xam tus nqi. Txhawm rau tham nrog tus neeg txhais lus, hu xov tooj rau (844) 256-9082.

Igbo (Igbo): Ọ bụr ụ na ị nwere ajụjụ ọ bụla gbasara akwụkwọ a, ị nwere ikike ịnweta enyemaka na ozi n'asụsụ gị na akwụghị ụgwọ ọ bụla. Ka gị na ọkọwa okwu kwuo okwu, kpọọ (844) 256-9082.

Ilokano (Ilokano): Nu addaan ka iti aniaman a saludsod panggep iti daytoy a dokumento, adda karbengam a makaala ti tulong ken impormasyon babaen ti lenguahem nga awan ti bayad na. Tapno makatungtong ti maysa nga tagipatarus, awagan ti (844) 256-9082.

Indonesian (Bahasa Indonesia): Jika Anda memiliki pertanyaan mengenai dokumen ini, Anda memiliki hak untuk mendapatkan bantuan dan informasi dalam bahasa Anda tanpa biaya. Untuk berbicara dengan interpreter kami, hubungi (844) 256-9082.

Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero (844) 256-9082

(844) 256-9082

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Language Access Services:

(844) 256-9082

Kirundi (Kirundi): Ugize ikibazo ico arico cose kuri iyi nyandiko, ufise uburenganzira bwo kuronka ubufasha mu rurimi rwawe ata giciro. Kugira uvugishe umusemuzi, akura (844) 256-9082.

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(844) 256-9082.

(844) 256-9082.

(844) 256-9082

Oromo (Oromifaa): Sanadi kanaa wajiin walqabaate gaffi kamiyuu yoo qabduu tanaan, Gargaarsa argachuu fi odeeffanoo afaan ketiin kaffaltii alla argachuuf mirgaa qabdaa. Turjumaana dubaachuuf, (844) 256-9082 bilbilla.

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Language Access Services:

(844) 256-9082.

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Samoan (Samoa): Afai e iai ni ou fesili e uiga i lenei tusi, e iai lou ‘aia e maua se fesoasoani ma faamatalaga i lou lava gagana e aunoa ma se totogi. Ina ia talanoa i se tagata faaliliu, vili (844) 256-9082.

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Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar con un intérprete, llame al (844) 256-9082.

Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Makipag-usap sa isang tagapagpaliwanag, tawagan ang (844) 256-9082.

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(844) 256-9082.

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.(844) 256-9082

(844) 256-9082.

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Language Access Services: It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368- 1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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