IMPORTANT PLAN INFORMATION: You have two medical plan options. You may enroll in one or both. Additional benefits are available to add if you enroll in the Fixed Indemnity Medical Plan.

STEP 1: You MUST complete the Enrollment Form as part of your New Hire Process.

STEP 2: Elect or decline all benefits on the Enrollment Form.

STEP 3: You MUST Sign and Date the bottom of the form, even if you decline coverage.

STEP 4: Return the Enrollment Form to your Branch Manager.

STEP 5: Keep the Benefits at a Glance page for your records.

The MEC Wellness/Preventive Plan is an employer-sponsored, self-funded plan that has been deemed to be in compliance with ACA rules and regulations. More information about Preventive Services may be found on the government website at: https://www.healthcare.gov/coverage/preventive-care-benefits. For questions or assistance, please call CareBasic Staffing Customer Service at 1-866-798-0803.

Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
For Enrollees of California: In order to enroll in the Fixed Indemnity Medical Benefit, you and any dependent must have minimum essential coverage and be enrolled in major medical coverage.
The CareBasic Fixed Indemnity Medical, Prescription Drug, Dental and Vision Plans are underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois under Policy Series Numbers 25.1204, 26.1214, 26.212, and 26.213. The Term Life and Short-Term Disability Plans are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois under Policy Series Number 62.200.

For questions or assistance, please call CareBasic Staffing Customer Service at 1-866-798-0803.

CBS/MEC PVM v26.1

The Fixed Indemnity Medical Plan pays a flat amount for a covered event caused by an accident or illness. If the covered event costs more, you pay the difference. But if the covered event costs less, you keep the difference.

Outpatient Benefits¹	Inpatient Benefits
Physician Office Visit (Virtual or In-Person)	$70 per day	Standard Care	$300 per day
Diagnostic (Lab)	$90 per day	Intensive Care Unit Maximum⁵	$400 per day
Diagnostic (X-Ray)	$200 per day	Inpatient Surgery	$2,000 per day
Ambulance Services	$350 per day	Anesthesia	$400 per day
Physical, Speech, or Occupational Therapy	$50 per day	Skilled Nursing⁶	$100 per day
Emergency Room Benefit—Sickness	$150 per day	Annual Inpatient Maximum⁷	No Limit
Emergency Room Benefit—Accident²	$300 per day	Accidental Loss of Life, Limb & Sight
Outpatient Surgery	$500 per day	Employee/Spouse	$20,000
Anesthesia	$200 per day	Dependent (6 months to 26 years)	$5,000
Annual Outpatient Maximum	$2,200	Dependent (15 days to 6 months)	$2,500
Prescription Drugs (via reimbursement)³,⁴	Wellness Care
Annual Maximum	$600	Wellness Care (one per year)	$75
Generic Coinsurance / Brand Coinsurance	70% / 50%

Teladoc Health
As an enrollee in the Fixed Indemnity medical plan, you have the option to obtain telehealth, primary care or mental health services through Teladoc Health. Please see the Summary Plan Description for additional details.

¹all outpatient benefits are subject to the outpatient maximum ²covers treatment for off the job accidents only ³not subject to outpatient maximum ⁴To file a claim for reimbursement, save your receipt and remit to Planned Administrators, Inc. ⁵pays in addition to standard care benefit ⁶for stays in a skilled nursing facility after a hospital stay ⁷subject to internal limits of plan

Waiting Period/Coinsurance	Annual Maximum Benefit	$750	Deductible	$50
Coverage A	None / 80%	Exams, Cleanings, Intraoral Films, and Bitewings
Coverage B	None / 60%	Fillings, Oral Surgery, and Repairs for Crowns, Bridges and Dentures
Coverage C	None / 50%	Periodontics, Crowns, Endodontics, Bridges and Dentures

	In-Network	Out-of-Network
You Pay	Plan Pays	You Pay³	Plan Pays
Eye Exam¹ (including dilation)	$10 Copay	100%	100%	$35
Standard Contact Lens Fit Exam (includes follow up)	Up to $55	$0	100%	$0
Premium Contact Lens Fit Exam (includes follow up)	100%, after 10% discount	$0	100%	$0
Frames (once every 24 months)	80%, after $110 allowance	20% plus $110 allowance	100%	$55
Standard Plastic Lenses (single, bifocal, trifocal)¹,²	$25 Copay	100%	100%	$25-$55
Contact Lenses (Conventional) (materials only)¹	85%, after $110 allowance	15% plus $110 allowance	100%	$88
Contact Lenses (Disposable) (materials only)¹	100%, after $110 allowance	$110 allowance	100%	$88
Contact Lenses (Medically Necessary) (materials only)¹	$0 Copay	100%	100%	$200

¹Once every 12 months ²$15 higher in AK, CA, HI, OR, WA ³After plan payment

Employee Amount	$10,000 (reduces to $7,500 at 65; $5,000 at 70)	Child Amount (6 mos to 26 yrs old)	$5,000
Spouse Amount	$5,000 (terminates at age 70)	Infant Amount (15 days to 6 mos)	$1,000

Benefit Amount	60% of base pay up to $150 per week
Waiting Period/Maximum Benefit Period	7 days for injury or sickness/up to 26 weeks

The optional MEC Wellness/Preventive Benefit DOES NOT cover medical services. This plan provides coverage for preventive services such as immunization and routine health screening. It does not cover conditions caused by accident or illness.

MONTHLY MEC PREMIUM	MEC
Employee Only	$58.19
Employee + Child(ren)	$65.79
Employee + Spouse	$71.00
Employee + Family	$80.87

¹ For more information about preventive services, please visit www.healthcare.gov. ² This coverage is not available to residents of HI, or PR.

WEEKLY LIMITED BENEFITS PREMIUM	Medical	Dental	Vision	Term Life	STD
Employee Only	$15.98	$5.40	$2.42	$0.60	$4.20
Employee + Child(ren)	$26.54	$14.58	$6.54	$0.90	-
Employee + Spouse	$30.36	$10.80	$4.84	$0.90	-
Employee + Family	$40.44	$20.52	$9.20	$1.80	-

These are the standard limitations and exclusions. As they may vary by state, please see your summary plan description (SPD) for a more detailed listing.

No benefits will be paid for loss caused by or resulting from:

• Intentionally self-inflicted injuries, suicide or any attempt while sane or insane
• Declared or undeclared war
• Serving on full-time active duty in the armed forces
• The covered person's commission of a felony
• Work-related injury or sickness, whether or not benefits are payable under workers' compensation or similar law or
• With regard to the accidental loss of life, limb or sight benefit - sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, or bacterial or viral infection regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning.

No benefits will be paid for:

• Eye examinations for glasses, any kind of eye glasses, or vision prescriptions
• Hearing examinations or hearing aids
• Dental care or treatment other than care of sound, natural teeth and gums required on account of injury to the covered person resulting from an accident that happens while such person is covered under the policy, and rendered within 6 months of the accident
• Services rendered in connection with cosmetic surgery, except cosmetic surgery that the covered person needs for breast reconstruction following a mastectomy or as a result of an accident that happens while such person is covered under the policy. Cosmetic surgery for an accidental injury must be performed within 90 days of the accident causing the injury and while such person's coverage is in force
• Services provided by a member of the covered person's immediate family.

No benefits will be paid for over-the-counter products or medications or for drugs and medications dispensed while you are in a hospital.

The plan will pay only for procedures specified on the Schedule of Covered Procedures in the group policy. Many procedures covered under the plan have limitations. For more detailed information on covered procedures or limitations, please see your summary plan description.

No Life Insurance benefits will be payable under the policy for death caused by suicide or self-destruction, or any attempt at it within 24 months after the person's coverage under the policy became effective.

No benefits will be paid for any materials, procedures or services provided under worker's compensation or similar law; non-prescription lenses, frames to hold such lenses, or non-prescription contact lenses; any materials, procedures or services provided by an immediate family member or provided by you; charges for any materials, procedures, and services to the extent that benefits are payable under any other valid and collectible insurance policy or service contract whether or not a claim is made for such benefits.

The Fixed Indemnity medical/Rx, accidental loss of life, limb, or sight, dental, term life, and vision plans are not available to residents of Hawaii, New Hampshire, or Puerto Rico.

No benefits are payable under this coverage in the following instances:

• Attempted suicide or intentionally self-inflicted injury
• Voluntary taking of poison; voluntary inhalation of gas; voluntary taking of a drug or chemical. This does not apply to the extent administered by a licensed physician. The physician must not be you or your spouse, you or your spouse's child, sibling or parent, or a person who resides in your home
• Declared or undeclared war or act of war
• Your commission of or attempt to commit a felony, or any loss sustained while incarcerated for the felony
• Your participation in a riot
• If you engage in an illegal occupation
• Release of nuclear energy
• Operating, riding in, or descending from any aircraft (including a hang glider). This does not apply while you are a passenger on a licensed, commercial, nonmilitary aircraft; or
• Work-related injury or sickness.

Short-Term Disability benefits are not available to persons who reside in California, Hawaii, New Hampshire, New Jersey, New York, or Rhode Island.

For frequently asked questions and network information for the Fixed Indemnity Medical Plan, visit https://www.paisc.com/limited-benefit-faqs. For questions and a full list of preventive services covered by the MEC Wellness/Preventive Plan, as well as the MEC SBC, please visit https://www.paisc.com/products-services/specialty-administration/aca-plans. A paper copy is also available, free of charge, by calling CareBasic Staffing Customer Service 1-866-798-0803.

PLEASE NOTE: To make changes or cancel coverage by telephone call (800) 269-7783. Your pin code for enrolling/making changes is 400 + ____ (last four digits of your SSN). Your pin code for enrolling/making changes is 646 + ____ (last four digits of your SSN) for your MEC plan. Your Company has chosen to take your payroll deductions on a Post-Tax basis.
CareBasic Staffing Customer Service: 1-866-798-0803

• Once enrolled, members can call this number for questions regarding plan coverage, ID card, claim status, and policy booklets and to add, change, or cancel coverage.
• Customer Service Call Center hours are M - F, 8:30 a.m. to 8 p.m. Eastern Standard Time. Bilingual representatives are available.
• Members can also visit www.paisc.com and click on "Members."