Explanation and Limitations for Plan A. Annual Maximum UNLIMITED UNLIMITED. See page 4 for services that require Carewise Health preauthorization

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1 Page 1 of 6 Benefit Description Individual Deductible Family Deductible Individual OOP Family OOP UFCW LOCAL 711 AND RETAIL STORES GROUP # s S1644 / S1645 SCHEDULE OF MEDICAL BENEFITS FOR PLAN A All benefits are subject to the deductible except where noted otherwise NEVADA PPO NETWORK BEECH STREET Explanation and Limitations for Plan A PPO Providers (In-Network) Non-PPO Providers (Out of Network) $300 COMBINED $900 COMBINED $6,850 UNLIMITED $13,700 UNLIMITED Annual Maximum UNLIMITED UNLIMITED Inpatient Hospital Outpatient Hospital See page 4 for services that require Carewise Health preauthorization Inpatient Physician See page 5 for important Inpatient Hospital notes In / Outpatient Surgery Bariatric Surgery Non-network facility charges for bariatric surgery performed at a non-network outpatient surgical center is limited to $1,000 Limited to $1,000 Emergency Room Services If you need immediate medical attention Emergency R&C Non Emergency Urgent Care If you need immediate medical attention Adult Routine Exam $150 max per person (EMPLOYEE AND SPOUSE ONLY) Age 40-50: 1 every 2 years Age 50+: 1 per year

2 Page 2 of 6 Preventive Services Services and supplies required by Health Care Reform Age and frequency guidelines apply to covered preventive care Includes breast pumps Not subject to deductible if PPO BENEFIT Female Contraceptives Injectables, Implants & IUD s. Oral (generic only) thru pharmacy. No RX copay BENEFIT Office Visits $25 copay Not subject to deductible if PPO Sterilization Female Not subject to deductible if PPO Male Contact Carewise Health for maternity program Preauthorization required only if hospital stay is more than 48 hours for vaginal delivery or 96 hours for C-section Maternity Prenatal and Postnatal Office Visits for all females* *Codes for prenatal visits should be filed separate from global maternity to ensure member coverage at 100% with no cost sharing Ultrasound Diagnostic ONLY for all females Delivery expenses for dependent child T COVERED BENEFIT BENEFIT Outpatient Radiology Plan payments are paid at the higher coinsurance level by using the Preferred Partner Network Preferred Partner Network facilities: Steinberg Diagnostic Medical Imaging Pueblo Medical Imaging See page 4 for services that require Carewise Health preauthorization Preferred Partner Network Non Preferred Providers (Beech Street/Viant) 70% of. Non-PPO Providers Outpatient Lab See page 4 for services that require Carewise Health preauthorization Dental Services (Limited) Only covered if due to injury / accident to sound natural teeth up to the Supplemental Benefit of $750 up to $ % up to $750 Radiation / Chemotherapy Proton Radiation therapy- (codes 77520, 77522, 77523, 77525) requires Carewise Health preauthorization.

3 Page 3 of 6 Newborn Circumcision Covered if performed during initial inpatient stay or Up to 6 months of age if performed in office Supplemental Accident 1st 100% within 90 days of accident up to $ % up to $750 Physical Therapy Chiropractic Requires Golden Health Service providers Requires GHS preauthorization Limited to 30 visits per year Not subject to copay or deductible Submit all claims directly to GHS GHS claims address: 5717 Pacesetter Street North Las Vegas NV BENEFITS Podiatry Care Requires use of Podiatry Plan Organization of California providers Requires PPOC preauthorization - Includes orthotics Not subject to copay or deductible Submit all claims directly to PPOC BENEFIT Acupuncture $25 copay if PPO Not subject to deductible Hearing Aids Up to $400 per ear during any 3 year period 100% up to $ % up to $400 Cochlear Hearing Implants Home Health / Skilled Nursing / Hospice Must be in lieu of acute hospitalization Inpatient Mental Health / Chemical Dependency Network is Mines & Associates requires Pre-auth Mail claims directly to: Mines & Associates: W. Centennial Rd. Littleton, CO 80127

4 Page 4 of 6 Outpatient Mental Health / Chemical Dependency Network is Mines & Associates $25 copay for PPO. Not subject to deductible if PPO Mail claims directly to: Mines & Associates: W. Centennial Rd. Littleton, CO TMJ Services provided by an M.D only APPLIANCE T A COVERED BENEFIT 60 % of R&C Durable Medical Equipment over $1,500 If under $1,500 submit LOMN, purchase price and HCPC codes at the time the claim is submitted Breast pumps - See preventive services benefit Outpatient Dialysis See pg 5 for payment schedule Transplants PREAUTHORIZATION REQUIREMENTS (FAILURE TO PREAUTHORIZE WILL RESULT IN A 20% PENALTY- RETRO PREAUTHORIZATIONS ALLOWED) Preauthorization/Carewise Health (877) for Inpatient/Outpatient surgeries and the following diagnostic procedures Allergy Testing o Allergen Specific IgE (RAST, PRIST, RIST, etc.) o Quantitative o Qualitative Cardiac monitors (including vent monitors) o Ambulatory - complete Echocardiography o Complete Imaging Procedures - CAT Scan o Abdomen o Bone Density Study o Bone Scan o Cyst Aspiration o Lower Extremity o Maxillofacial Area o Needle Biopsy o Pelvis o Placement Rad Fields o Skull/Orbit/Ear Imaging Procedures - CAT Scan (cont.) o Soft Tissue/Neck o Spine o Sterotactic o Localization thorax; upper extremity Magnetic Resonance Imaging (MRI) o Abdomen o Bone Marrow o Brain Magnetic Resonance Imaging (MRI) Continued o Breast o Chest o Extremity, Upper o Extremity, Lower o Face/Neck/Orbit o Myocardium o Pelvis o Spinal Cord o TMJ Myocardial Perfusion Imaging (e.g. Thalium) Positron Emission Tomography: (PET) Scan SPECT Scan o Abcess Localization o Bone & Joint o Brain o Cardiac o CSF o Kidney o Liver o Tumor Localization Polysomnography o Sleep Studies - 3 or more parameters Photochemotherapy o Treatment Series

5 Page 5 of 6 DIALYSIS BENEFITS Dialysis Treatment Outpatient/All Dialysis Facilities REQUIRES CAREWISE HEALTH PREAUTHORIZATION In-center Hemodialysis Treatment - $ per treatment Home Hemodialysis Treatment - $ per treatment Home Hemodialysis Training - $ per day Continuous Ambulatory Peritoneal Dialysis (CAPD) - $ per day CAPD Training - $ per day Continuous Cycling Peritoneal Dialysis (CCPD) - $ per day CCPD Training - $ per day The above list gives all-inclusive rates except for laboratory services, which will be paid separately. INPATIENT HOSPITAL (FAILURE TO PREAUTHORIZE WILL RESULT IN A 20% PENALTY- RETRO PREAUTHORIZATION ALLOWED) N EMERGENCY ADMISSIONS REQUIRES CAREWISE HEALTH PREAUTHORIZATION PRIOR TO ADMISSION EMERGENCY ADMISSIONS HOSPITAL IS REQUIRED TO OBTAIN A PREAUTHORIZATION FROM CAREWISE HEALTH ON THE FIRST BUSINESS DAY OR LATER THAN 72 HOURS AFTER ADMISSION Patients who live within the Coalition service area (within 25 miles of a Coalition hospital) need to use a Coalition facility for elective inpatient admissions to obtain the highest level of benefits. For a severe or life threatening emergency, the closest hospital should be used until the patient can be stabilized. There may be other situations when a non-coalition Hospital may be necessary, which would need to be approved by Carewise Health. Contact the Fund Office for additional information. The Plan requires the use of a Coalition hospitalist when admitted to a Coalition facility with the following exceptions: Maternity, pediatric care, and this Plan is secondary. The Plan will only reimburse consultation visits from non-participating hospitalists and non-specialists.

6 Page 6 of 6 T COVERED Not limited to: work related, cosmetic, custodial care, vision exams, vision correction surgery, educational training, infertility, speech therapy, occupational therapy, hearing exams, dental service other than injury to sound natural teeth up to the Supplemental Accident Benefit of $750.00, dependent child delivery charges, and any service not medically necessary. Please call Fund Office for specific non-covered services. TES *********ELIGIBILITY IS BASED ON A MONTH TO MONTH BASIS********* ALL CLAIMS MUST HAVE THE PLAN MEMBERS GROUP # (S1644 / S1645) ON THE CLAIM FORM OR IT MAY GET REJECTED ( HCFA FORMS- BOX 11 UB FORMS- BOX 62) FILING LIMIT- 90 days from incurred date and in no event later than 1 year from incurred date. APPEAL TIME FRAME- 180 days from the day the claim was processed. CONTACT INFORMATION Mail claims to: JAS, Inc., 4885 South 900 East, Suite # 202, Salt Lake City, Utah Fund Office Customer Service: (800) Precertification Company: Carewise Health (877) PPO Network / Beech Street: (800) Mines & Associates: (800) Golden Health Services (GHS): (702) Podiatry Plan Organization of California (PPOC): (800) Vision Plan / V.S.P: (800) Prescription Plan CATAMARAN: (888) DISCLAIMER This is not a guarantee of Benefits. This is a general summary of the benefits available under this plan and not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant s eligibility and benefits are based upon the information currently available. Both are subject to change without notice. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier if other coverage is involved.