2024 Asphalt Drum Mixers, Inc. Benefits Guide

EMPLOYEE BENEFITSGUIDE 2024

BENEFITSDESIGNEDTOSUPPORTYOU

AtAsphaltDrumMixers,weknowourdedicatedemployees—YOU—arekeytoouroverallsuccess. Offeringacomprehensivebenefitspackageisanimportantpartofyouroverallcompensation.Each yearwereviewourbenefitspackagetoensurethatweareprovidingyouandyourfamilywithquality planoptionsatanaffordablecost.

ThisBenefitsGuideisdesignedtohelpyou:

1.Betterunderstandthebenefitsweoffersothatyoucanchoosetheplansthatarerightfor youandyourfamily.

2.Knowwhattoexpectwhenyouuseyourbenefits(i.e.,whatyourplancovers,howmuchyou willpay,etc.).

Pleasetakethetimetocarefullyreviewyourplanoptionsandbesuretosharethisguidewithyour familymembersiftheyareorwillbecoveredbyanyoftheplans.

ELIGIBILITY

YouareeligibletoenrollintheAsphaltDrumMixersbenefitsifyouareafull-timeemployeeworkingat least30hoursperweek.Yourbenefitsareeffectivethefirstdayofthemonthfollowing1monthof continuousfull-timeemployment.

CoveringYourFamilyMembers

Manyoftheplansoffercoverageforyoureligiblefamilymembers,including:

Yourspouse.

Yourchildrentoage26,regardlessofstudent,marital,ortax-dependentstatus(includingastepchild, legally-adoptedchild,achildplacedwithyouforadoption,orachildforwhomyouarethelegal guardian).

Yourdependentchildrenofanyagewhoarephysicallyormentallyunabletocareforthemselves.

Yourbenefitsbeginthefirstday ofthemonthfollowing1month ofcontinuousfull-time employment.

ENROLLINGANDMAKINGCHANGES

WhentoSignUpforBenefits

NewEmployees

Asanewemployee,youmustenrollinbenefitswithin30daysofyourdateofhire.Ifyoudonotenroll within30days,youwillneedtowaituntilthenextopenenrollmentperiodtoenroll.

CurrentEmployees

Openenrollmentistheonlytimeduringtheyearthatyoucanchangeyourbenefitsunlessyou experienceaqualifyinglifeevent.Duringtheopenenrollmentperiod,youcannewly-enrollincoverageor makechangestoyourcurrentelections.

AtAsphaltDrumMixers,anannualopenenrollmentperiodisconducted.Anychangesyoumake duringopenenrollmentbecomeeffectiveApril1standremaineffectivethroughMarch31st.

ChangingYourBenefitsDuringtheYear

Asstatedabove,youcannotchangeyourbenefitsduringtheyearunlessyouexperienceaqualifyinglife event.Themostcommonqualifyinglifeeventsare:

Marriage,legalseparation,ordivorce.

Birthofachild(includingadoption).

Lossofothercoverage(e.g.,childturns26andlosescoveragethroughparent’splan).

Thereareother,lesscommonlifeeventsthatallowyoutochangeyourbenefits.PleasecontactHuman Resourcesforacompletelistofqualifyinglifeevents.

Torequestabenefitschange,notifyhumanresourceswithin30daysofthequalifyinglifeevent.Change requestssubmittedafter30dayscannotbeaccepted.Pleasenote:Youmayneedtoprovideproofofthe event,suchasamarriagecertificateorrecordofbirth.

Ifyourspousequalifiesforhealth insurancethroughtheirworkplace,they canonlybeenrolledassecondary coveragethroughADM.

MEDICAL

AsphaltDrumMixersoffermedicalinsuranceplansadministeredbyQ3BusinessTechnology Corporation.Pleasetakethetimetounderstandthefeaturesoftheplan.

Questionsregardingbenefitsorclaims?

Q3BusinessTechnologyCorporationistheTPA(thirdpartyadministrator)foryourMedicalPlan.You cancontactabenefitspecialistwhowillassistyouwithbenefitorclaimquestions.Benefitspecialist areavailableMonday-Friday,8amto5pm.

Accessatwww.q3online.comOR260.492.9979

ParkviewSignatureCareEPO

Thishealthplanusesanetworkofproviders:SignatureCareEPO.Ifyouchosetoseekservicesoutside oftheParkviewSignatureCarenetwork,youwillpaysignificantlymoreandsomecoveragewillhave NObenefit,apartfromemergencyhealthcareservices.PleasecontactQ3toverifycoveragebefore utilizinganon-networkprovider.

MEDICAL

YouwillpaylessoutofyourpocketwhenyouchooseaParkviewSignatureCareEPOnetworkprovider. LocateaParkviewSignatureCareEPOnetworkproviderbycontactingQ3atwww.q3online.com

ThetablebelowsummarizesthekeyfeaturesoftheGRANDFATHEREDmedicalplan.Thecoinsurance amountslistedreflecttheamountyoupayforservices.Pleaserefertotheofficialplandocumentsfor additionalinformationoncoverageandexclusions.

NeedtoKnow:Asamember,youwillhaveaccesstoyourbenefitplaninformationthroughthesecure memberportalatwww.q3online.com.

GroupNumberforLogin:Q316019

WHERETOGOWHENYOUNEEDCARE

Knowwheretogoforyourhealthcare.

Whereyougoformedicalservicescanmakeabigdifferenceinhowmuchyoupayandhowlongyouwait toseeahealthcareprovider.Usethechartbelowtohelpyouchoosewheretogoforcare.Locatea ParkviewSignatureCareEPOdoctororfacilityatwww.q3online.com

WaitTime Cost MedicalServices

Highest $$$ EmergencyRoom

Medium $$ UrgentCare

Longest

Moderate

Shortest

AppropriateFor

Serious,life-threateningconditions andissuesrequiringimmediate attention

Non-life-threateningbuturgent situations

Non-emergencyconditionslike allergies,flu,rash,orpinkeye

Preventivecare,routinecheckups,managingchronicconditionsVariableAppointmentbased

Savemoneyandtimeby choosingtherightplacetogo foryourhealthcare.

PARKVIEWSIGNATURECAREEPO

PARKVIEWSIGNATURECAREEPO

PRESCRIPTIONDRUGPROGRAM

Sav-Rx–PrescriptionDrugProgram

AsphaltDrumMixersmedicalplanincludesprescriptiondrugbenefitsthroughSav-Rx.Sav-Rxoffers prescriptiondrugbenefitsthroughhomedeliverymail-orderserviceandnationwideretailpharmacy locations.

PriorAuthorization

PriorauthorizationfromSav-Rxisrequiredforsomemedications.Onceapproved,theauthorizationis validforuptooneyear.Ifaprescriptiondrugrequiringauthorizationisnotapprovedforcoverage undertheplan,youwillberesponsibleforpayingthefullcostofthemedicine.

UnderstandingPrescriptionTerminology

WhatisaPreferredBrand?

Themedicationsontheformularylistarechosenbasedoncomparativeclinicaleffectiveness,safety profiles,andopportunitiestohelpcontaincost.

•$4GenericDrugProgramavailableatWalmart,Target,CVS,andKroger

WhatisNon-PreferredBrand?

Non-formularybranddrugsaretypicallythosethathaveagenericequivalent,arehighercost,orare newlyreleasedtothemarket.

WhatareSpecialtyDrugs?

Thesearemedicationsthatareusuallyhigh-costpharmaceuticalproductsthatagenerally,butnot exclusively,biotechnicalinnature.

WhatisMailOrder/HomeDelivery?

Thisisacost-effectivewaytoordera90-daysupplyofmedicine.Sav-Rx’shomedeliveryservice providesaconvenientwaytohelpyoureceiveyourmaintenancemedicationsrighttoyourdooror mailbox.

NeedtoKnow:

Yourplanhasalistofspecialtydrugsthatareexcludedbutmosthavepatientassistanceprograms.

SAMARITANFUNDPROGRAM

GUIDANCERESOURCES

TELEMEDICINESERVICES

Quality,ConvenientCare.

AsanemployeeenrolledintheemployersponsoredMedicalPlan,youandyourcoveredfamily memberswillhave24/7accesstoaphysician.WithParkviewOnDemand,youcanreceivequalityadult andpediatricgeneralmedicalcarefora$40copaywhenutilizingaphysicianwithinthenetwork designedinyourMedicalPlan.

EasyAccesstoanAffordableSolution!

Doctorsareavailablearoundtheclocktotreatmanycommon,non-emergencyadultandpediatric issues.Allyouneedisaphoneorlaptop.Anyprescribedprescriptionscanbesubmitteddirectlytothe pharmacyofyourchoice. DownloadtheParkviewAppon

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DENTAL

AsphaltDrumMixersoffersdentalinsuranceadministeredbyQ3BusinessTechnologyCorporation.You donotneedtobeenrolledinthehealthinsuranceplantoenrollindentalinsurance.

Thetablebelowsummarizesthekeyfeaturesofthedentalplan.Thecoinsuranceamountslistedreflect theamountyoupayforservices.Pleaserefertotheofficialplandocumentsforadditionalinformation oncoverageandexclusions.

VISION

AsphaltDrumMixersoffersvisioninsurancethroughMetLife.Thisplanallowsyoutochooseanyeyecare provider.However,youwillmaximizetheplanbenefitswhenyouchooseanetworkprovider.Locatea MetLifenetworkprovideratwww.metlife.com/vision.

Thetablebelowsummarizesthekeyfeaturesofthevisionplan.Pleaserefertotheofficialplan documentsforadditionalinformationoncoverageandexclusions.

In-NetworkVisionBenefits

WellVisionExam

Frame

Lenses

•Oneeverycalendaryear(twoperyearfor dependentchildren*)

•$130allowance+20%offamountoveryour allowance

•Everyothercalendaryear(oneperyearfor dependentchildren*)

•Everycalendaryear(morefrequentlenses forchildrenmaybecoveredinfullif prescriptionchanges*)

Upto$45 $10

Contacts

•Includedwithoutcopayments

•Everycalendaryear(inlieuofglasses)

*Dependentchildrenarecoveredtotheendofthemonthinwhichtheyturnage26.

Upto$70 $10

LIFEINSURANCE

Lifeandaccidentaldeathanddismemberment(AD&D)insuranceprovidesfinancialprotectionforthose whodependonyouforfinancialsupport.

BasicLifeandAD&DInsurance

AsphaltDrumMixersprovidesyouwithbasiclifeandAD&Dinsuranceatnocosttoyou.

•EmployeelifeandAD&Dinsurancebenefit:$15,000.

•SpouselifeandAD&Dinsurancebenefit:$7,500.

•DependentChildrenlifeandAD&Dinsurancebenefit:Under6months:$1,000.Over6months: $7,500.

SupplementalLifeandAD&DInsurance

Dependingonyourpersonalsituation,basiclifeandAD&Dinsurancemightnotbeenoughcoveragefor yourneeds.AsphaltDrumMixersprovidesyoutheoptiontopurchaseadditionallifeandAD&Dinsurance atgroupratesthroughOneAmerica.Youmayalsopurchasecoverageforyourspouseandeligiblechildren. Youmustpurchaseadditionalcoverageforyourselfinordertopurchasecoverageforyourspouseand/or child(ren).

Usethecalculatoratwww.oneamerica.comtodeterminehowmuchcoverageyouneed.

Coverageoptions:

•Employee:$1,000increments($10,000minimum)upto$300,000or5xannualsalary,whicheverisless; guaranteeissue:$100,000.

•Spouse:$500increments($5,000minimum)upto50%oftheemployeecoverageamountor$250,000, whicheverisless;guaranteeissue:$25,000.

•Dependentchildren:Birthto6months:$1,000;6monthstoage19(or26ifafull-timestudent): $2,500,$5,000,$7,500,OR$10,000;guaranteeissue:ElectedAmount.

Supplementalliferatesarebasedonage.Benefitswillreduceto65%atage65andto50%atage70.

IfyoupurchaselifeandAD&Dinsurancewhenyouarefirsteligibletoenroll,youmaypurchaseup totheguaranteeissueamountswithoutcompletingastatementofhealth(evidenceofinsurability).

Ifyoudonotenrollwhenfirsteligibleandchoosetoenrollduringafutureopenenrollmentperiod, youwillberequiredtosubmitevidenceofinsurabilityforanyamountofcoverage.Coveragewillnot takeeffectuntilapprovedbyOneAmerica.

SUPPLEMENTALLIFEINSURANCEPROVISIONS

SupplementalLifeandAD&DInsurance:InformationtoKnow

Anyamountofcoveragerequestedasalateenrolledorinexcessoftheguaranteedissueamountwill firstrequiremedicalunderwritingandwrittenapprovalbyOneAmerica.

YouareresponsibleforinformationHRofanychangesinyourliferelationshipsthatimpactyour designatedbeneficiary.

GuaranteedIncreaseinBenefit(GIB)allowsyoutheavailabilitytoacceptanadditionalamountof coverageofferedbyOneAmericaduringopenenrollmentwithoutprovidingEvidenceofInsurability. However,yourtotalcoveragecannotexceed5timesyourannualsalaryorthemaximumamount showninthecontract.Currenteligibleenrolleeswillbeoffereda$10,000or10%ofcurrentcoverage guaranteedbenefitincrease,whicheverisgreater,duringopenenrollment.

ConversionandPortabilityisavailablewithyourOneAmericaLifeplan.

WhenyouexperienceachangethatimpactsyourVolLifeandAccidentcoverageyouareableto takethatcoveragewithyou,atyourexpense.

Pleasevisitwww.oneamerica.com/keepmybenefitstoapplyforVolLife&AccidentInsurance portabilityandconversion.

YouMUSTsubmitallrequiredinformationandformstoOneAmerica within31daysofterminationofyourgroupbenefits.

SUPPLEMENTALLIFEINSURANCE

VoluntarySupplementalLife–Bi-WeeklyPayrollDeductionIllustration

ComplianceNotices

NoticeofSpecialEnrollmentRights

Ifyouaredecliningenrollmentforyourselforyourdependents(includingyourspouse)becauseofotherhealthinsuranceor grouphealthplancoverage,youmaybeabletoenrollyourselfandyourdependentsinthisplanifyouoryourdependents loseeligibilityforthatothercoverage(oriftheemployerstopscontributingtowardyouroryourdependents’othercoverage). However,youmustrequestenrollmentwithin30daysafteryouroryourdependents’othercoverageends(orafterthe employerstopscontributingtowardtheothercoverage).Inaddition,ifyouhaveanewdependentasaresultofmarriage, birth,adoption,orplacementforadoption,youmaybeabletoenrollyourselfandyourdependents.However,youmust requestenrollmentwithin30daysafterthemarriage,birth,adoption,orplacementforadoption.

Ifyouaredecliningenrollmentforyourselforyourdependents(includingyourspouse)whilecoverageunderMedicaidora stateChildren’sHealthInsuranceProgram(CHIP)isineffect,youmaybeabletoenrollyourselfandyourdependentsin thisplanifyouoryourdependentsloseeligibilityforthatothercoverage.However,youmustrequestenrollmentwithin60 daysafteryouroryourdependents’MedicaidorCHIPcoverageends.Ifyouoryourdependents(includingyourspouse) becomeeligibleforastatepremiumassistancesubsidyfromMedicaidoraCHIPprogramwithrespecttocoverageunder thisplan,youmaybeabletoenrollyourselfandyourdependents(includingyourspouse)inthisplan.However,youmust requestenrollmentwithin60daysafteryouoryourdependentsbecomeeligibleforthepremiumassistance.

NoticeofPatientProtection

Ifyourhealthplangenerallyrequiresthedesignationofaprimarycareprovider,youhavetherighttodesignateanyprimary careproviderwhoparticipatesinournetworkandwhoisavailabletoacceptyouoryourfamilymembers.Forchildren,you maydesignateapediatricianastheprimarycareprovider.Untilyoumakethisdesignation,thehealthplangenerallymay designateoneforyou.Forinformationonhowtoselectaprimarycareprovider,andforalistoftheparticipatingprimary careproviders,contactyourplanadministratororyourHumanResourcesDepartment.

Youdonotneedpriorauthorizationfromthehealthplanorfromanyotherperson(includingaprimarycareprovider)in ordertoobtainaccesstoobstetricalorgynecologicalcarefromahealthcareprofessionalinournetworkwhospecializesin obstetricsorgynecology.Thehealthcareprofessional,however,mayberequiredtocomplywithcertainprocedures, includingobtainingpriorauthorizationforcertainservices,followingapre-approvedtreatmentplan,orproceduresfor makingreferrals.Foralistofparticipatinghealthcareprofessionalswhospecializeinobstetricsorgynecology,contactyour planadministratororHumanResourcesDepartment.

Women’sHealthandCancerRightsActNotice

Ifyouhavehadoraregoingtohaveamastectomy,youmaybeentitledtocertainbenefitsundertheWomen’sHealthand CancerRightsActof1998(WHCRA).Forindividualsreceivingmastectomy-relatedbenefits,coveragewillbeprovidedina mannerdeterminedinconsultationwiththeattendingphysicianandthepatient,for:

•Allstagesofreconstructionofthebreastonwhichthemastectomywasperformed;

•Surgeryandreconstructionoftheotherbreasttoproduceasymmetricalappearance;

•Prostheses;and

•Treatmentofphysicalcomplicationsofthemastectomy,includinglymphedema.

Thesebenefitswillbeprovidedsubjecttothesamedeductiblesandcoinsuranceapplicabletoothermedicalandsurgical benefitsprovidedunderthisplan.IfyouwouldlikemoreinformationonWHCRAbenefits,contactthePlanAdministrator.

Newborns’andMothers’HealthProtectionActNotice

Grouphealthplansandhealthinsuranceissuersgenerallymaynot,underFederallaw,restrictbenefitsforanyhospital lengthofstayinconnectionwithchildbirthforthemotherornewbornchildtolessthan48hoursfollowingavaginaldelivery, orlessthan96hoursfollowingacesareansection.However,Federallawgenerallydoesnotprohibitthemother'sor newborn'sattendingprovider,afterconsultingwiththemother,fromdischargingthemotherorhernewbornearlierthan48

ComplianceNotices

hours(or96hoursasapplicable).Inanycase,plansandissuersmaynot,underFederallaw,requirethataproviderobtain authorizationfromtheplanortheinsuranceissuerforprescribingalengthofstaynotinexcessof48hours(or96hours).

Michelle’sLawNotice

Michelle’sLawwassignedintolaweffectiveJanuary1,2010.Thislawgenerallyallowsseriouslyillorinjuredfulltime collegestudents,whoarecoveredundertheirparent’shealthinsuranceplan,totakeuptooneyearofmedicallynecessary leaveofabsenceiftheleavenormallywouldcausethedependentchildtoloseeligibilityforcoverageundertheplandueto lossofstudentstatus.FortheMichelle’sLawextensionofeligibilitytoapply,adependentchild’streatingphysicianmust providewrittencertificationofmedicalnecessity(i.e.,certificationthatthedependentchildsuffersfromaseriousillnessor injurythatnecessitatestheleaveofabsenceorotherenrollmentchangethatwouldotherwisecauselossofeligibility).

*UnderthePatientProtectionandAffordableCareAct,grouphealthplansarerequiredtooffercoveragetodependent childrenuptoage26,regardlessofstudentstatus.

HIPAANoticeofPrivacyPractices

TheHealthInsurancePortabilityandAccountabilityActof1996("HIPAA")requiresthatwemaintaintheprivacyofprotected healthinformation,givenoticeofourlegaldutiesandprivacypracticesregardinghealthinformationaboutyouandfollowthe termsofournoticecurrentlyineffect.Participantsininsuredgrouphealthplansmayalsoreceiveanoticeofprivacy practicesfromthoseplans.YoumayrequestacopyofthecurrentPrivacyPractices,explaininghowmedicalinformation aboutyoumaybeusedanddisclosedandhowyoucangetaccesstothisinformation.

AsRequiredbyLaw.WewilldiscloseHealthInformationwhenrequiredtodosobyinternational,federal,stateorlocallaw. Youhavetherighttoinspectandcopy,righttoanelectroniccopyofelectronicmedicalrecords,righttogetnoticeofa breach,righttoamend,righttoanaccountingofdisclosures,righttorequestrestrictions,righttorequestconfidential communications,righttoapapercopyofthisnoticeandtherighttofileacomplaintifyoubelieveyourprivacyrightshave beenviolated.

GrandfatheredPlanNotice

AsphaltDrumMixersbelievesthisplanisa‘‘grandfatheredhealthplan’’underthePatientProtectionandAffordableCare Act(theAffordableCareAct).AspermittedbytheAffordableCareAct,agrandfatheredhealthplancanpreservecertain basichealthcoveragethatwasalreadyineffectwhenthatlawwasenacted.Beingagrandfatheredhealthplanmeansthat yourplanmaynotincludecertainconsumerprotectionsoftheAffordableCareActthatapplytootherplans,forexample,the requirementfortheprovisionofpreventivehealthserviceswithoutanycostsharing.However,grandfatheredhealthplans mustcomplywithcertainotherconsumerprotectionsintheAffordableCareAct,forexample,theeliminationoflifetime limitsonbenefits.

Questionsregardingwhichprotectionsapplyandwhichprotectionsdonotapplytoagrandfatheredhealthplanandwhat mightcauseaplantochangefromgrandfatheredhealthplanstatuscanbedirectedtotheplanadministrator.Youmayalso contacttheEmployeeBenefitsSecurityAdministration,U.S.DepartmentofLaborat1–866–444–3272or www.dol.gov/ebsa/healthreform.Thiswebsitehasatablesummarizingwhichprotectionsdoanddonotapplyto grandfatheredhealthplans.

ComplianceNotices

ImportantNoticefromAsphaltDrumMixersAboutYourPrescriptionDrug CoverageandMedicare(CREDITABLE)

Pleasereadthisnoticecarefullyandkeepitwhereyoucanfindit.Thisnoticehasinformationaboutyourcurrent prescriptiondrugcoveragewithAsphaltDrumMixersGroupHealthPlanandaboutyouroptionsunder Medicare’sprescriptiondrugcoverage.Thisinformationcanhelpyoudecidewhetherornotyouwanttojoina Medicaredrugplan.Ifyouareconsideringjoining,youshouldcompareyourcurrentcoverage,includingwhich drugsarecoveredatwhatcost,withthecoverageandcostsoftheplansofferingMedicareprescriptiondrug coverageinyourarea.Informationaboutwhereyoucangethelptomakedecisionsaboutyourprescriptiondrug coverageisattheendofthisnotice.

TherearetwoimportantthingsyouneedtoknowaboutyourcurrentcoverageandMedicare’sprescriptiondrug coverage:

1.Medicareprescriptiondrugcoveragebecameavailablein2006toeveryonewithMedicare.Youcangetthis coverageifyoujoinaMedicarePrescriptionDrugPlanorjoinaMedicareAdvantagePlan(likeanHMOor PPO)thatoffersprescriptiondrugcoverage.AllMedicaredrugplansprovideatleastastandardlevelof coveragesetbyMedicare.Someplansmayalsooffermorecoverageforahighermonthlypremium.

2.AsphaltDrumMixershasdeterminedthattheprescriptiondrugcoverageofferedbytheAsphaltDrumMixers GroupHealthPlanis,onaverageforallplanparticipants,expectedtopayoutasmuchasstandardMedicare prescriptiondrugcoveragepaysandisthereforeconsideredCreditableCoverage.Becauseyourexisting coverageisCreditableCoverage,youcankeepthiscoverageandnotpayahigherpremium(apenalty)ifyou laterdecidetojoinaMedicaredrugplan.

WhenCanYouJoinAMedicareDrugPlan?

YoucanjoinaMedicaredrugplanwhenyoufirstbecomeeligibleforMedicareandeachyearfromOctober15th toDecember7th

However,ifyouloseyourcurrentcreditableprescriptiondrugcoverage,throughnofaultofyourown,youwill alsobeeligibleforatwo(2)monthSpecialEnrollmentPeriod(SEP)tojoinaMedicaredrugplan.

WhatHappensToYourCurrentCoverageIfYouDecidetoJoinAMedicareDrugPlan?

IfyoudecidetojoinaMedicaredrugplan,yourcurrentAsphaltDrumMixersGroupHealthPlancoveragewill notbeaffected.IfyoukeepyourcurrentcoverageandelectMedicarePartD,yourAsphaltDrumMixersGroup HealthPlancoveragemaycoordinatewithyourMedicarePartDcoverage.IfyoudodecidetojoinaMedicare drugplananddropyourcurrentAsphaltDrumMixersGroupHealthPlancoverage,beawarethatyouandyour dependentswillnotbeabletogetthiscoverageback,unlessyouhaveaqualifyinglifeeventoruntilthenext openenrollment.

WhenWillYouPayAHigherPremium(Penalty)ToJoinAMedicareDrugPlan?

YoushouldalsoknowthatifyoudroporloseyourcurrentcoveragewithAsphaltDrumMixersanddon’tjoina Medicaredrugplanwithin63continuousdaysafteryourcurrentcoverageends,youmaypayahigherpremium (apenalty)tojoinaMedicaredrugplanlater.

ComplianceNotices

Ifyougo63continuousdaysorlongerwithoutcreditableprescriptiondrugcoverage,yourmonthly premiummaygoupbyatleast1%oftheMedicarebasebeneficiarypremiumpermonthforeverymonth thatyoudidnothavethatcoverage.Forexample,ifyougonineteenmonthswithoutcreditablecoverage, yourpremiummayconsistentlybeatleast19%higherthantheMedicarebasebeneficiarypremium.You mayhavetopaythishigherpremium(apenalty)aslongasyouhaveMedicareprescriptiondrugcoverage. Inaddition,youmayhavetowaituntilthefollowingOctobertojoin.

ForMoreInformationAboutThisNoticeOrYourCurrentPrescriptionDrugCoverage

Contactthepersonlistedbelowforfurtherinformation.

NOTE:You’llgetthisnoticeeachyear.YouwillalsogetitbeforethenextperiodyoucanjoinaMedicare drugplan,andifthiscoveragethroughAsphaltDrumMixerschanges.Youalsomayrequestacopyofthis noticeatanytime.

ForMoreInformationAboutYourOptionsUnderMedicarePrescriptionDrugCoverage

MoredetailedinformationaboutMedicareplansthatofferprescriptiondrugcoverageisinthe“Medicare& You”handbook.You’llgetacopyofthehandbookinthemaileveryyearfromMedicare.Youmayalsobe contacteddirectlybyMedicaredrugplans.

FormoreinformationaboutMedicareprescriptiondrugcoverage:

•Visitwww.medicare.gov

•CallyourStateHealthInsuranceAssistanceProgram(seetheinsidebackcoverofyourcopyofthe “Medicare&You”handbookfortheirtelephonenumber)forpersonalizedhelp

•Call1-800-MEDICARE(1-800-633-4227).TTYusersshouldcall1-877-486-2048.

Ifyouhavelimitedincomeandresources,extrahelppayingforMedicareprescriptiondrugcoverageis available.Forinformationaboutthisextrahelp,visitSocialSecurityonthewebatwww.socialsecurity.gov, orcallthemat1-800-772-1213(TTY1-800-325-0778).

Remember:KeepthisCreditableCoveragenotice.IfyoudecidetojoinoneoftheMedicaredrug plans,youmayberequiredtoprovideacopyofthisnoticewhenyoujointoshowwhetherornot youhavemaintainedcreditablecoverageand,therefore,whetherornotyouarerequiredtopaya higherpremium(apenalty).

NameofEntity/Sender:Q3BusinessTechnologyCorp.

Contact--Position/Office:FortWayne,INClaimsOffice

Address:P.O.Box15952FortWayne,IN46885

PhoneNumber:(206)492-9979or(877)251-8342

ComplianceNotices

PremiumAssistanceUnderMedicaidandtheChildren’sHealthInsuranceProgram(CHIP)

IfyouoryourchildrenareeligibleforMedicaidorCHIPandyou’reeligibleforhealthcoveragefromyouremployer,your statemayhaveapremiumassistanceprogramthatcanhelppayforcoverage,usingfundsfromtheirMedicaidorCHIP programs.Ifyouoryourchildrenaren’teligibleforMedicaidorCHIP,youwon’tbeeligibleforthesepremiumassistance programsbutyoumaybeabletobuyindividualinsurancecoveragethroughtheHealthInsuranceMarketplace.Formore information,visitwww.healthcare.gov.

IfyouoryourdependentsarealreadyenrolledinMedicaidorCHIPandyouliveinaStatelistedbelow,contactyourState MedicaidorCHIPofficetofindoutifpremiumassistanceisavailable.

IfyouoryourdependentsareNOTcurrentlyenrolledinMedicaidorCHIP,andyouthinkyouoranyofyourdependents mightbeeligibleforeitheroftheseprograms,contactyourStateMedicaidorCHIPofficeordial1-877-KIDSNOWor www.insurekidsnow.govtofindouthowtoapply.Ifyouqualify,askyourstateifithasaprogramthatmighthelpyoupay thepremiumsforanemployer-sponsoredplan.

IfyouoryourdependentsareeligibleforpremiumassistanceunderMedicaidorCHIP,aswellaseligibleunderyour employerplan,youremployermustallowyoutoenrollinyouremployerplanifyouaren’talreadyenrolled.Thisiscalleda “specialenrollment”opportunity,andyoumustrequestcoveragewithin60daysofbeingdeterminedeligiblefor premiumassistance.Ifyouhavequestionsaboutenrollinginyouremployerplan,contacttheDepartmentofLaborat www.askebsa.dol.govorcall1-866-444-EBSA(3272).

Ifyouliveinoneofthefollowingstates,youmaybeeligibleforassistancepayingyouremployerhealthplan premiums.ThefollowinglistofstatesiscurrentasofJanuary31,2024.ContactyourStateformore informationoneligibility.

ALABAMA-Medicaid

Website:http://myalhipp.com/ Phone:1-855-692-5447

ARKANSAS–Medicaid

Website:http://myarhipp.com/ Phone:1-855-MyARHIPP(855-692-7447)

COLORADO–HealthFirstColorado(Colorado’s MedicaidProgram)&ChildHealthPlanPlus(CHP+)

HealthFirstColoradoWebsite: https://www.healthfirstcolorado.com/ HealthFirstColoradoMemberContactCenter: 1-800-221-3943/StateRelay711

CHP+:https://hcpf.colorado.gov/child-health-plan-plus CHP+CustomerService:1-800-359-1991/StateRelay711

HealthInsuranceBuy-InProgram (HIBI):https://www.mycohibi.com/ HIBICustomerService:1-855-692-6442

ALASKA-Medicaid

TheAKHealthInsurancePremiumPaymentProgram

Website:http://myakhipp.com/ Phone:1-866-251-4861

Email:CustomerService@MyAKHIPP.com

MedicaidEligibility: https://health.alaska.gov/dpa/Pages/default.aspx

CALIFORNIA–Medicaid

HealthInsurancePremiumPayment(HIPP)Program

Website:http://dhcs.ca.gov/hipp

Phone:916-445-8322

Fax:916-440-5676

Email:hipp@dhcs.ca.gov

FLORIDA–Medicaid

Website:

https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. com/hipp/index.html

Phone:1-877-357-3268

ComplianceNotices

GEORGIA–Medicaid

GAHIPPWebsite:https://medicaid.georgia.gov/healthinsurance-premium-payment-program-hipp

Phone:678-564-1162,Press1

GACHIPRAWebsite:

https://medicaid.georgia.gov/programs/third-partyliability/childrens-health-insurance-program-reauthorization-act2009-chipra

Phone:(678)564-1162,Press2

IOWA–MedicaidandCHIP(Hawki)

MedicaidWebsite:

https://dhs.iowa.gov/ime/members

MedicaidPhone:1-800-338-8366

HawkiWebsite:http://dhs.iowa.gov/Hawki

HawkiPhone:1-800-257-8563

HIPPWebsite:https://dhs.iowa.gov/ime/members/medicaid-ato-z/hipp

HIPPPhone:1-888-346-9562

KENTUCKY–Medicaid

KentuckyIntegratedHealthInsurancePremiumPayment Program(KI-HIPP)Website:

https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx

Phone:1-855-459-6328

Email:KIHIPP.PROGRAM@ky.gov

KCHIPWebsite:https://kidshealth.ky.gov/Pages/index.aspx

Phone:1-877-524-4718

KentuckyMedicaidWebsite:https://chfs.ky.gov/agencies/dms

MAINE–Medicaid

EnrollmentWebsite:

https://www.mymaineconnection.gov/benefits/s/?language=en_ US

Phone:1-800-442-6003;TTY:Mainerelay711

PrivateHealthInsurancePremiumWebpage:

https://www.maine.gov/dhhs/ofi/applications-forms

Phone:1-800-977-6740;TTY:Mainerelay711

MINNESOTA–Medicaid

Website:

https://mn.gov/dhs/people-we-serve/children-andfamilies/health-care/health-care-programs/programs-andservices/other-insurance.jsp

Phone:1-800-657-3739

MONTANA–Medicaid

Website:

http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

Phone:1-800-694-3084

Email:HHSHIPPProgram@mt.gov

INDIANA–Medicaid

HealthyIndianaPlanforlow-incomeadults19-64 Website:http://www.in.gov/fssa/hip/ Phone:1-877-438-4479

AllotherMedicaid

Website:https://www.in.gov/medicaid/ Phone1-800-457-4584

KANSAS–Medicaid

Website:https://www.kancare.ks.gov/ Phone:1-800-792-4884

HIPPPhone:1-800-967-4660

LOUISIANA–Medicaid

Website:www.medicaid.la.govorwww.ldh.la.gov/lahipp

Phone:1-888-342-6207(Medicaidhotline)or 1-855-618-5488(LaHIPP)

MASSACHUSETTS–MedicaidandCHIP

Website:https://www.mass.gov/masshealth/pa Phone:1-800-862-4840

TTY:711

Email:masspremassistance@accenture.com

MISSOURI–Medicaid

Website:

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone:573-751-2005

NEBRASKA–Medicaid

Website:http://www.ACCESSNebraska.ne.gov

Phone:1-855-632-7633

Lincoln:402-473-7000

Omaha:402-595-1178

NEWHAMPSHIRE–Medicaid NEVADA–Medicaid

MedicaidWebsite:http://dhcfp.nv.gov

MedicaidPhone:1-800-992-0900

Website:https://www.dhhs.nh.gov/programsservices/medicaid/health-insurance-premium-program Phone:603-271-5218

TollfreenumberfortheHIPPprogram:1-800-852-3345, ext.5218

ComplianceNotices

NEWJERSEY–MedicaidandCHIP

MedicaidWebsite:

http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ MedicaidPhone:609-631-2392

CHIPWebsite:http://www.njfamilycare.org/index.html

CHIPPhone:1-800-701-0710

NORTHCAROLINA–Medicaid

Website:https://medicaid.ncdhhs.gov/ Phone:919-855-4100

OKLAHOMA–MedicaidandCHIP

Website:http://www.insureoklahoma.org Phone:1-888-365-3742

PENNSYLVANIA–MedicaidandCHIP

Website:https://www.dhs.pa.gov/Services/Assistance/Pages/H IPP-Program.aspx

Phone:1-800-692-7462

CHIPWebsite:Children'sHealthInsuranceProgram(CHIP) (pa.gov)

CHIPPhone:1-800-986-KIDS(5437)

SOUTHCAROLINA–Medicaid

Website:https://www.scdhhs.gov

Phone:1-888-549-0820

TEXAS–Medicaid

Website:http://gethipptexas.com/ Phone:1-800-440-0493

VERMONT–Medicaid

Website:HealthInsurancePremiumPayment(HIPP)Program |DepartmentofVermontHealthAccess Phone:1-800-250-8427

WASHINGTON–Medicaid

Website:https://www.hca.wa.gov/ Phone:1-800-562-3022

WISCONSIN–MedicaidandCHIP

Website:

https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone:1-800-362-3002

NEWYORK–Medicaid

Website:https://www.health.ny.gov/health_care/medicaid/ Phone:1-800-541-2831

NORTHDAKOTA–Medicaid

Website:https://www.hhs.nd.gov/healthcare Phone:1-844-854-4825

OREGON–Medicaid

Website:http://healthcare.oregon.gov/Pages/index.aspx Phone:1-800-699-9075

RHODEISLAND–MedicaidandCHIP

Website:http://www.eohhs.ri.gov/ Phone:1-855-697-4347,or 401-462-0311(DirectRIteShareLine)

SOUTHDAKOTA-Medicaid

Website:http://dss.sd.gov Phone:1-888-828-0059

UTAH–MedicaidandCHIP

MedicaidWebsite:https://medicaid.utah.gov/

CHIPWebsite:http://health.utah.gov/chip Phone:1-877-543-7669

VIRGINIA–MedicaidandCHIP

Website:https://coverva.dmas.virginia.gov/learn/premiumassistance/famis-select

https://coverva.dmas.virginia.gov/learn/premiumassistance/health-insurance-premium-payment-hippprograms

Medicaid/CHIPPhone:1-800-432-5924

WESTVIRGINIA–MedicaidandCHIP

Website:https://dhhr.wv.gov/bms/ http://mywvhipp.com/ MedicaidPhone:304-558-1700

CHIPToll-freephone:1-855-MyWVHIPP(1-855-699-8447)

WYOMING–Medicaid

Website:https://health.wyo.gov/healthcarefin/medicaid/prog rams-and-eligibility/ Phone:1-800-251-1269

ToseeifanyotherstateshaveaddedapremiumassistanceprogramsinceJanuary31,2024,orformoreinformationon specialenrollmentrights,contacteither:

U.S.DepartmentofLabor EmployeeBenefitsSecurityAdministration www.dol.gov/agencies/ebsa 1-866-444-EBSA(3272)

U.S.DepartmentofHealthandHumanServices CentersforMedicare&MedicaidServices www.cms.hhs.gov 1-877-267-2323,MenuOption4,Ext.61565

ComplianceNotices

YourRightsandProtectionsAgainstSurpriseMedicalBills

Whenyougetemergencycareoraretreatedbyanout-of-networkprovideratanin-networkhospitalorambulatorysurgical center,youareprotectedfrombalancebilling.Inthesecases,youshouldn’tbechargedmorethanyourplan’scopayments, coinsuranceand/ordeductible.

Whatis“balancebilling”(sometimescalled“surprisebilling”)?

Whenyouseeadoctororotherhealthcareprovider,youmayowecertainout-of-pocket-costs,likeasuchasacopayment, coinsurance,ordeductible.Youmayhaveadditionalcostsorhavetopaytheentirebillifyouseeaproviderorvisitahealth carefacilitythatisn’tinyourhealthplan’snetwork.

“Out-of-network”meansprovidersandfacilitiesthathaven’tsignedacontractwithyourhealthplantoprovideservices.Outof-networkprovidersmaybepermittedtobillyouforthedifferencebetweenwhatyourplanpaysandthefullamount chargedforaservice.Thisiscalled“balancebilling.”Thisamountislikelymorethanin-networkcostsforthesameservice andmightnotcounttowardyourplan’sdeductibleorannualout-of-pocketlimit.

“Surprisebilling”isanunexpectedbalancebill.Thiscanhappenwhenyoucan’tcontrolwhoisinvolvedinyourcare—like whenyouhaveanemergencyorwhenyouscheduleavisitatanin-networkfacilitybutareunexpectedlytreatedbyanoutof-networkprovider.Surprisemedicalbillscouldcostthousandsofdollarsdependingontheprocedureorservice.

Youareprotectedfrombalancebillingfor:

Emergencyservices

Ifyouhaveanemergencymedicalconditionandgetemergencyservicesfromanout-of-networkproviderorfacility,the mosttheycanbillyouisyourplan’sin-networkcost-sharingamount(suchascopayments,coinsurance,anddeductibles). Youcan’tbebalancebilledfortheseemergencyservices.Thisincludesservicesyoumaygetafteryou’reinstable condition,unlessyougivewrittenconsentandgiveupyourprotectionsnottobebalancedbilledforthesepost-stabilization services.

Certainservicesatanin-networkhospitalorambulatorysurgicalcenter

Whenyougetservicesfromanin-networkhospitalorambulatorysurgicalcenter,certainproviderstheremaybeout-ofnetwork.Inthesecases,themostthoseproviderscanbillyouisyourplan’sin-networkcost-sharingamount.Thisappliesto emergencymedicine,anesthesia,pathology,radiology,laboratory,neonatology,assistantsurgeon,hospitalist,orintensivist services.Theseproviderscan’tbalancebillyouandmaynotaskyoutogiveupyourprotectionsnottobebalancebilled.

Ifyougetothertypesofservicesatthesein-networkfacilities,out-of-networkproviderscan’tbalancebillyou,unlessyou givewrittenconsentandgiveupyourprotections.

You’reneverrequiredtogiveupyourprotectionsfrombalancebilling.Youalsoaren’trequiredtogetout-ofnetworkcare.Youcanchooseaproviderorfacilityinyourplan’snetwork.

Whenbalancebillingisn’tallowed,youalsohavethefollowingprotections:

•You’reonlyresponsibleforpayingyourshareofthecost(likethecopayments,coinsurance,anddeductiblethatyouwould payiftheproviderorfacilitywasin-network).Yourhealthplanwillpayanyadditionalcoststoout-of-networkprovidersand facilitiesdirectly.

•Generally,yourhealthplanmust:

oCoveremergencyserviceswithoutrequiringyoutogetapprovalforservicesinadvance(alsoknownas“prior authorization”).

oCoveremergencyservicesbyout-of-networkproviders.

oBasewhatyouowetheproviderorfacility(cost-sharing)onwhatitwouldpayanin-networkproviderorfacilityand showthatamountinyourexplanationofbenefits.

oCountanyamountyoupayforemergencyservicesorout-of-networkservicestowardyourin-networkdeductibleand out-of-pocketlimit.

Ifyoubelieveyou’vebeenwronglybilled,contactthefederalNoSurprisesHelpDeskat1-800-985-3059.Visit www.cms.gov/nosurprises/consumersformoreinformationaboutyourrightsunderfederallaw.

ComplianceNotices

You’reneverrequiredtogiveupyourprotectionsfrombalancebilling.Youalsoaren’t requiredtogetcareout-of-network.Youcanchooseaproviderorfacilityinyourplan’s network.

Whenbalancebillingisn’tallowed,youalsohavethefollowingprotections:

•Youareonlyresponsibleforpayingyourshareofthecost(likethecopayments,coinsurance,and deductiblesthatyouwouldpayiftheproviderorfacilitywasin-network).Yourhealthplanwillpay out-of-networkprovidersandfacilitiesdirectly.

•Yourhealthplangenerallymust:

o Coveremergencyserviceswithoutrequiringyoutogetapprovalforservicesinadvance (priorauthorization).

o Coveremergencyservicesbyout-of-networkproviders.

o Basewhatyouowetheproviderorfacility(cost-sharing)onwhatitwouldpayan in-networkproviderorfacilityandshowthatamountinyourexplanationofbenefits.

o Countanyamountyoupayforemergencyservicesorout-of-networkservicestoward yourdeductibleandout-of-pocketlimit.

Ifyoubelieveyou’vebeenwronglybilled,youmaycontacttheEmployeeBenefitsSecurity Administrationataskebsa.dol.govor1-866-444-3272.

Visitwww.dol.gov/agencies/ebsaformoreinformationaboutyourrightsunderfederallaw.

Pleaserefertotheofficialplandocumentsformorecompletedescriptionsofthebenefitplans.Intheeventofanyinconsistenciesor discrepanciesbetweentheinformationprovidedinthisguideandtheofficialplandocuments,theofficialplandocumentswillprevail. AsphaltDrumMixersreservestherighttoamend,suspendorterminateanybenefitplan,inwholeorinpart,atanytimewithoutnotice, includingmakingchangestocomplywithandexerciseitsoptionsunderapplicablelaws.Theauthoritytomakesuchchangesrestswith thePlanAdministrator.Toviewthesummaryplandescriptionsandcertificatesofcoverage,visitwww.admasphaltplants.com.Youmay contactHumanResourcestorequestaprintedcopyofthesummaryplandescriptionandotherofficialplanorprogramdocuments,which willbeprovidedatnocosttoyou.

www.admasphaltplants.com