2026 Benefits Guide - WBE

2026 Benefits Guide

Overview Employee Benefits Overview At Willapa Bay Enterprises, we believe our employees are the foundation of our success. To support your wellbeing and that of your family, we offer a comprehensive benefits program designed to provide flexibility, choice, and peace of mind.

Details on eligibility, enrollment, and plan options are provided in the following pages. We encourage you to review this information carefully to make the best choices for you and your family.

Eligibility Your spouse, domestic partner, and dependent children under the age of 26 are eligible for coverage. Please note that if you elect to cover a domestic partner, imputed income may apply in accordance with IRS guidelines.

Changing your Coverage Mid-Year (Qualifying Life Event) Make your benefit elections carefully, including any decision to waive coverage. Pre-tax elections remain in effect for the plan year unless you experience an IRS-qualified life event, such as: • • • • • •

Marriage, divorce, or legal separation Birth, adoption, or death of a dependent Gain or loss of other group coverage Change in a dependent’s eligibility (e.g., due to age) Change in work hours affecting eligibility Relocation in or out of the plan’s service area

Open Enrollment You may only change your benefit elections during open enrollment (June 2nd, 2026 – June 23rd, 2026) unless you experience a qualifying life event (see above section for more details).

Elections take effect July 1, 2026.

MedicalBenefits Medical and RX Benefits I CAS Plan Highlights Network Deductible - Individual / Family Per calendar year Out of Pocket Max - Individual / Family Per calendar year Office Visits Preventative (Well checks, Annual Exams) Office Visits Specialist Telehealth Visits Behavioral Health Acupuncture Chiropractic Naturopath Occupational / Physical / Speech Therapy Urgent Care / Hospital Services Urgent Care Inpatient Outpatient Emergency Room Labs & Diagnostics * pre-authorization required Basic Testing (Lab & X-Ray) Complex Imaging (MRI, CT) RX & Mail Order RX * $1,000 monthly limit RX Copay (Retail - 30 days) (Retail Pharmacy - 30 Days)

Mail Order Copay (90 days) (Mail Order Pharmacy - 30 Days)

Phone Number Email Address Website

First Choice $500 individual / $1,500 family $6,850 individual / $13,750 family covered in full $20 copay $40 copay $20 copay $40 copay $20 copay, 12 visits per year $20 copay, 24 visits per year $40 copay $20 copay, 25 visits per year $20 copay 20% after deductible 20% after deductible $150 copay + 20% after deductible

20% after deductible 20% after deductible*

$5 copay $20 copay* $20 copay* 50% copay* $10 copay $40 copay* $40 copay* 50% copay*

Customer Service (855)373-8232 info@casbenefits.com https://www.casbenefits.com/

This is intended as a convenient summary of the major points of benefit plans. This does not cover all provisions, limitations, and exclusions. The official plan documents, policies and certificates of insurance govern in all cases and are available for your inspection at any time.

Dental&VisionBenefits Dental Benefit I Principal Financial Plan Highlights Network Deductible - Individual / Family Per calendar year Benefit Maximum Frequency Exams Copay Frequency Services Preventive Services Basic Services Major Services

Phone Number Provider Search

Principal $0 individual / $0 family $3,000 per person every calendar year $0 copay 2 every calendar year covered at 100% covered at 100% covered at 80% Customer Service (800)986-3343 www.principal.com/dentist

Vision Benefit I Principal Financial Plan Highlights Network Exams Copay Frequency Glasses & Contacts Copay Frequency Allowance

Phone Number Provider Search

VSP Choice $10 copay every calendar year $10 copay every calendar year $250 Customer Service (800)986-3343 https://www.vsp.com/eye-doctor

Vision HRA Reimbursement Allowance

for any balances over $250 (up to $600) Maximum reimbursement of $350

This is intended as a convenient summary of the major points of benefit plans. This does not cover all provisions, limitations, and exclusions. The official plan documents, policies and certificates of insurance govern in all cases and are available for your inspection at any time.

LifeandAD&DBenefits Life and AD&D Coverage I Principal Financial Willapa Bay Enterprises provides eligible employees working a minimum of 40hrs a week with a Basic Life and Accidental Death and Dismemberment benefit through Principal at no cost to you.

This benefit is $20,000. Benefits begin reducing at age 65.

Voluntary Life and AD&D Coverage I Principal Financial Willapa Bay Enterprises offers voluntary life and AD&D insurance; some employees may have additional life insurance needs and can choose to purchase supplemental coverage. Please note: You may need to provide health information if you elect over the guaranteed issue amount or if you have previously been eligible to elect voluntary life benefits.

You can purchase supplemental Life/AD&D insurance as follows: •

Employee: Electing in $10,000 increments, an employee can elect between $10,000 and $500,000. The guaranteed issue amount is $150,000.

•

Spouse: Electing in $5,000 increments, an employee can elect between $5,000 and $150,000. The guaranteed issue amount is $10,000.

•

Child(ren): An employee can elect $10,000 per child.

Cost per $1,000 of benefit Age Employee - Life Employee - AD&D

< 25 25-29 30-34 35-39 40-44 45-49 50-54 60-64 65-69 70+ $0.086 $0.096 $0.116 $0.186 $0.296 $0.546 $0.866 $1.016 $1.826 $3.556 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034

Total Cost per $1,000

$0.120 $0.130 $0.150 $0.220 $0.330 $0.580 $0.900 $1.050 $1.860 $3.590

Spouse - Life Spouse - AD&D

$0.086 $0.096 $0.116 $0.186 $0.296 $0.546 $0.866 $1.016 $1.826 $3.556 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034 $0.034

Total Cost per $1,000

$0.120 $0.130 $0.150 $0.220 $0.330 $0.580 $0.900 $1.050 $1.860 $3.590

Child(ren)

$10,000 per child enrrolled

Total Cost

$2.00 per family

This is intended as a convenient summary of the major points of benefit plans. This does not cover all provisions, limitations, and exclusions. The official plan documents, policies and certificates of insurance govern in all cases and are available for your inspection at any time.

Willapa Bay Enterprises - PPO Plan Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2026-06/30/2027 Coastal Administrative Services: Medical Plan Coverage for: EE/EE+SP/EE+CH(n)/FAM | 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, contact CAS customer service at 855-373-8232. 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.casbenefits.com or call 855-373-8232 to request a copy.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

For network providers: $500 individual / $1,500 family For out-of-network providers: $1,000 individual / $3,000 family

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

What is the out-of-pocket limit for this plan?

For network providers: $6,850 individual / $13,750 family For out-of-network providers: $13,700 individual / $27,500 family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-ofpocket limit has been met.

What is not included in the out-of-pocket limit?

Copayments for certain services, premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

Will you pay less if you use a network provider?

This plan covers some items and services even if you haven’t yet met the deductible amount. But a Yes. Preventive care and primary care copayment or coinsurance may apply. For example, this plan covers certain preventive services without services are covered before you meet cost sharing and before you meet your deductible. See a list of covered preventive services at your deductible. https://www.healthcare.gov/coverage/preventive-care-benefits/.

There is no additional deductible amount you must meet before this plan begins to pay for specific No services.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will Yes. See www.casbenefits.com or call pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the 855-373-8232 for a list of network difference between the provider’s charge and what 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 providers. your provider before you get services.

Do you need a referral to see No, you do not need a referral to see a specialist. a specialist?

You can see the specialist you choose without permission from this plan.

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

Common Medical Event

If you visit a health care provider’s office or clinic

If you have a test

Services You May Need Primary care visit to treat an injury or illness

$20 copay/visit deductible waived

50% coinsurance after deductible

Specialist visit

$40 copay/visit deductible waived

50% coinsurance after deductible

Preventive care/screening/ immunization

No charge

50% coinsurance after deductible

Diagnostic test (x-ray, blood work)

20% coinsurance after deductible

50% coinsurance after deductible

Imaging (CT/PET scans, MRIs)

20% coinsurance after deductible

50% coinsurance after deductible

Tier 1 If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.prescyptives.com

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Tier 2

Tier 3

Specialty drugs (Tier 4)

$5 copay/prescription (retail) $10 copay/prescription (mail order) $20 copay/prescription up to a $1,000 monthly limit (retail) $40 copay/prescription up to $1,000/monthly (mail order) $20 copay/prescription up to $1,000/monthly (retail) $40 copay/prescription up to $1,000/monthly (mail order) 50% copay up to $1,000/monthly

Limitations, Exceptions, & Other Important Information

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive.

Then check what your plan will pay for.

Preauthorization is required.

Not covered

Not covered

Not covered

Preventive drugs: No charge Covers up to a 30-day supply (retail subscription); 31-90 day supply (mail order prescription).

Specialty medications are limited up to a 30-day supply

Not covered

* For more information about limitations and exceptions, see the plan or policy document at www.casbenefits.com

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Common Medical Event

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

If you are pregnant

Services You May Need

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Limitations, Exceptions, & Other Important Information

Facility fee (e.g., ambulatory surgery center)

20% coinsurance after deductible

50% coinsurance after deductible

Preauthorization is required.

Physician/surgeon fees

20% coinsurance after deductible

50% coinsurance after deductible

Anesthesia: 20% coinsurance after deductible

Emergency room care

Subject to deductible, $150 copay and 20% coinsurance

Subject to deductible, $150 Copay waived if directly admitted. copay and 20% coinsurance

Emergency medical transportation

20% coinsurance after deductible

20% coinsurance after deductible

Urgent care

$20 copay/visit deductible waived

50% coinsurance after deductible

Facility fee (e.g., hospital room)

20% coinsurance after deductible

50% coinsurance after deductible

Physician/surgeon fees

20% coinsurance after deductible

50% coinsurance after deductible

Outpatient services

$20 copay/visit deductible waived

50% coinsurance after deductible

Inpatient services

20% coinsurance after deductible

50% coinsurance after deductible

Office visits

$20 copay/visit deductible waived

50% coinsurance after deductible

Childbirth/delivery professional services

20% coinsurance after deductible

50% coinsurance after deductible

Childbirth/delivery facility services

20% coinsurance after deductible

50% coinsurance after deductible

* For more information about limitations and exceptions, see the plan or policy document at www.casbenefits.com

Preauthorization is required.

Preauthorization is required.

Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

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Common Medical Event

Services You May Need Home health care

Rehabilitation services

If you need help recovering or have other special health needs

Habilitation services

Skilled nursing care

If your child needs dental or eye care

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) 20% coinsurance after deductible Outpatient: $20 copay/visit deductible waived Inpatient: 20% coinsurance after deductible Outpatient: $20 copay/visit deductible waived Inpatient: 20% coinsurance after deductible 20% coinsurance after deductible

Limitations, Exceptions, & Other Important Information

50% coinsurance after deductible 50% coinsurance after deductible

50% coinsurance after deductible 50% coinsurance after deductible

Durable medical equipment

20% coinsurance after deductible

50% coinsurance after deductible

Hospice services

20% coinsurance after deductible

Children’s eye exam

No charge

50% coinsurance after deductible 50% coinsurance after deductible

Children’s glasses

Not covered

Not covered

Children’s dental check-up

No charge

50% coinsurance after deductible

* For more information about limitations and exceptions, see the plan or policy document at www.casbenefits.com

Outpatient Physical, Speech, Hearing & Occupational Therapy limited to 25 visits/calendar year.

Inpatient Physical, Speech, Hearing & Occupational Therapy limited to 30 days/calendar year. (Preauthorization is required.)

120 days/calendar year Preauthorization is required.

Preauthorization is required for durable medical equipment in excess of $500.

Preauthorization is required for hospice services.

See Vision Plan

Page 4 of 6

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.)

• Long Term Care • Routine Foot Care • Cosmetic Surgery • Dental Care • Hearing Aids • Bariatric Surgery • Infertility Treatment • Non-emergency care when traveling outside the U.S. Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Naturopathy • Acupuncture • Chiropractic Care

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: the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or https://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: 1-855-373-8232 Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

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.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 855-373-8232 To see examples of how this plan might cover costs for a sample medical situation, see the next section.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

* For more information about limitations and exceptions, see the plan or policy document at www.casbenefits.com

Page 5 of 6

EMPLOYEE BENEFIT GUIDE

855-373-8232 7am-4pm PST | Monday- Friday

casbenefits.com

Urgent Care Clinics

Take Care of Yourself

ER wait time is at an all-time high and it can cost you more out-of-pocket. If you need care right away and it is not a medical emergency, try other options.

Use Your Preventative Care Benefits

When you can’t see your primary care doctor, you can still get care without visiting the ER. Retail health clinics, walk-in doctor’s offices and urgent care centers can take less time and cost about the same as a regular doctor visit. Plus, most are open weeknights and weekends.

• Retail Health Clinic — A clinic staffed by medical professionals who provide basic medical services to “walk-in” patients. Usually in a major pharmacy or retail store.

• Walk-in Clinic — A doctor’s office where you don’t already have to be a patient or have an appointment. Can handle routine care and common family illnesses.

• Urgent Care Center — Doctors who treat illnesses or injuries that should be looked at right away but aren’t emergencies. Can often do x-rays, lab tests and stitches .

Getting regular checkups and exams can help you stay healthy and catch problems early when they’re easier to treat.

That’s why health plans offer all the preventive care services and immunizations at no cost to you.

As long as you see a doctor or use a pharmacy in the network, you won’t have to pay anything for these services. If you want to visit a doctor or pharmacy outside the network, you may have to pay out-of-pocket charges.

Preventive vs. Diagnostic Care — What’s the difference?

Preventive care helps protect you from getting sick. If your doctor recommends you have services even though you have no symptoms, that’s preventive care. Diagnostic care is when you have symptoms and your doctor recommends services to determine what’s causing those symptoms.

Your employer provides Healthcare Bluebook FREE as a benefit, so you can shop for medical procedures at in-network facilities in your area to find the best price and get an out-of-pocket cost estimate. It’s easy!

In minutes, you can find hundreds to thousands of dollars in savings with a simple search and get a cost estimate before you schedule care.

LOGIN AND FIND A FAIR PRICE! Scan the QR code with your phone or use the link below to access Healthcare Bluebook. healthcarebluebook.com/cc/CAS

Search for your medical procedure to access price information as well as a list of in-network facilities in your area. Use the green, yellow, and red color signs to guide you to Fair Price™ (green) facilities.

What is a Fair Price?

A Fair Price is the reasonable amount you should expect to pay for a procedure or medical service.

Check out the reverse side for an example of dramatic price differences and out-of-pocket cost estimate.

GET A COST ESTIMATE Select a Fair Price™ (green) facility and you’ll see your estimated out-of-pocket cost pertaining to the selected in-network facility as well as details correlated to your deductible.

© 2024 Healthcare Bluebook All Rights Reserved LIT20388

Introducing AccessCAS www.casbenefits.com/AccessCAS Understanding your benefits and managing a claim shouldn’t add stress to your life. You should always have the guidance you need to know how to get the most out of your benefits, and we’re here to do just that.

Get the forms and resources you need to quickly and simply manage your healthcare online.

• Download and send your ID card directly to your provider’s office • Check claim status • View your benefits coverage • Find a provider

SET UP A NEW ACCOUNT You will need to set up an account through www.casbenefits.com/AccessCAS to view your latest benefits information.

•

Select the option to “Register”

•

Register for a “Member” portal

•

Enter personal information and select “Submit”

•

An Activation Email will be sent to the email address you used to register. Please use this email to activate your account.

CAS PORTAL - MOBILE ACCESS Android:

1. On your device, open Chrome.

2. Go to www.casbenefits.com/AccessCAS 3. Click Access CAS button 4. Sign in iPhone & IPad

1. On your device, open Safari / Chrome.

2. Go to www.casbenefits.com/AccessCAS 3. Click Access CAS button 4. Sign in 5. Find and tap the Share icon.

6. Find and tap: Add to Home Screen.

Questions?

(855) 373-8232 customerservice@casbenefits.com

Save big on your hospital bills.

Your company gives you free access to Goodbill as part of your employee benefits.

With Goodbill, you can save up to 100% through hospital discounts.

“A fantastic experience. Saved me 25% on my total hospital bill. I will continue to use this service forever!

Carsen S.

Patient

How it works

Frequently Asked Questions

Hospital sends initial estimate

How do you save me money?

We contact you for info

Our member concierge reaches out to guide you through a few steps.

We secure 501(r) discounts you may be eligible for.

Nonprofit hospitals—which make up the majority of hospitals in the U.S.—are required to provide these income-based discounts to patients. We quickly screen your eligibility using your household size and income, and if you qualify, we guide you through the application process.

You save money

How much could I save?

After your visit, we review your charges before your bill is finalized.

If you qualify, we help you apply for discounts of up to 100% off.

Questions?

Get in touch!

Visit us

goodbill.com/cas

Email us

Hundreds or thousands of dollars for a single visit, especially if you haven’t met your out-of-pocket limit for the year. This benefit also helps your company keep your premiums low.

members@goodbill.com

Call us

(206) 759-7344

Find a Provider

WWW.FCHN.COM

Step 1 Go to your internet browser and type in www.fchn.com to access the First Choice Health website.

Step 2 Click the Find Care button. Begin your search by (A) entering a Last Name, First Name or Hospital in the first field (optional), (B) entering a City, Zip Code or Address in the second field (required), or (C) enter a Specialty in the third field (optional).

(A) OPTIONAL

(B) REQUIRED

(C) OPTIONAL

Search

Step 3 Search button to move to the next step.

Select the search

Please Note: A pop-up window will appear in your browser.

Step 4 Click on the second option “Employer/Group ID” and enter the Group ID number located on your ID Card. If you do not know your Group ID number, you may search using the third option “Employer/ Group/Trust Name” and enter in the name of your employer or group.

Enter the Group Number found on your ID card.

Continued on the next page.

Step 5 Select the option that pertains to your Benefit Plan and click the Continue button to move to the next step.

Please Note: If you choose to search by the Entire First Choice Health PPO Network, you may receive providers that are not participating for your Plan.

XXXX - Group Name Your Network Name

Finish Your Search You will receive a list of search results along with a map which displays the first ten (10) providers.

You can further refine your results using the filters on the left-hand side.

Please Note: If you perform a search by a specific clinic, you must select the clinic to view the preferred providers at that clinic.

Click the map pins to view provider location.

Apply filters: PCP, Distance, Date of Visit, Languages Spoken, and Gender.

Click on a provider to view more details.

If you need assistance locating a provider or scheduling an appointment, please contact a Customer Care Representative at the phone number located on your ID Card Monday through Friday, 8am to 5pm PST.

©2020 First Choice Health

Principar

Willapa Bay Enterprises Corporation

Vision

Effective Date: July 1, 2026

•

Vision for All members VSP choice network Benefit

Covered charges Exams

$0 copay

Prescription glasses

$10 copay

Frequency 1 per 12 months

Lenses

Single vision, lined bifocal, lined trifocal, and lenticular lenses; polycarbonate lenses for dependent children under age 18

1 pair per 12 months

Frames*

$250 allowance for a wide selection of frames; 20% off amount over allowance 1

1 set per 12 months

Elective contacts

Necessary contacts2

Up to$60 copay for standard and premium elective contact lens exams (fitting and evaluation)

1 per 12 months

$250 allowance for elective contacts $25 copay

Instead of lens and frames benefit 1 per 12 months

Covered in full for members who have specific conditions.

Instead of lens and frames benefit

Lens enhancements1

Most popular options are covered after a copay, saving members an average of 2025%. Members should see their doctor for special pricing on additional lens enhancements.

Additional savings 1

Savings on laser vision correction and additional pairs of prescription glasses and non-prescription sunglasses.

Non-network providers Benefit3

Covered charges

Frequency

Vision exams

Up to$45

1 per 12 months

Single vision lenses

Up to$30

1 pair per 12 months

Lined bifocal lenses

Up to$50

1 pair per 12 months

Lined trifocal lenses

Up to$65

1 pair per 12 months

Lenticular lenses

Up to$100

1 pair per 12 months

Frames

Up to$70

1 set per 12 months

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392 Today's Date: May 20, 2025

Prepared by: Jason Bren

Page 4 of 6

Willapa Bay Enterprises

2026 Vision HRA Reimbursement Request Form Employee Name

Employee Phone Number

Employee Address

City, State, Zip

Employee Date of Birth

Vision Care Expenses Patient Name

Relationship to Employee

Type of Expense

Date of Service

Total Charge

Amount to Be Reimbursed

Exam Lenses / Frames Contacts Exam Lenses / Frames Contacts Exam Lenses / Frames Contacts

PROOF OF EXPENSES MUST INCLUDE: For Vision

Accepted

Patient’s name

EOB – Explanation of Benefits

Name and address of provider

Itemized bill from Provider

Amount charged Type of service Date of service Note: Please do not send credit card receipts, cashed checks or copies of checks. They are not acceptable receipts for reimbursement. Completing this form does not guarantee reimbursement.

I hereby request payment from my vision reimbursement arrangement for the expenses listed above. I certify that I have not been reimbursed for these expenses from any other vision plan.

Signature of Employee

Date

2026 Benefit Election Form CAS Medical Plan Highlights Network Deductible - Individual / Family Out of Pocket Max - Individual / Family Office Visits Preventative (Well checks, Annual Exams) Office Visits / Specialists + Behavioral Specialist Telehealth Visits Acupuncture / Chiro Chiropractic Urgent Care / Hospital Services Urgent Care Inpatient / Outpatient Emergency Room Labs & Diagnostics Basic Testing (Lab & X-Ray) Complex Imaging (MRI, CT) RX & Mail Order RX RX Copay (Retail - 30 days) Mail Order Copay (90 days)

First Choice $500 individual / $1,500 family $6,850 individual / $13,750 family covered in full $20 copay / $40 copay $40 copay $20 copay $20 copay (visit limits apply) $20 copay, 24 visits per year

Medical Enrollment Select One Employee Employee + Spouse Employee + Child(ren) Employee + Family Waiving Coverage Declining Coverage

$20 copay 20% after deductible $150 copay + 20% after deductible 20% after deductible 20% after deductible $5 / $20 / $20 / 50% $10 / $40 / $40 / 50%

Principal Dental Plan Highlights Network Deductible - Individual / Family Benefit Maximum Services Preventive Services Basic Services Major Services

Principal $0 individual / $0 family $3,000 per person per year covered at 100% covered at 100% covered at 80%

Dental Enrollment Select One Employee Employee + Spouse Employee + Child(ren) Employee + Family Waiving Coverage Declining Coverage

Principal Vision + Vision HRA Plan Highlights Network Services + Materials Exam Materials (Glasses / Frames or Contacts) Vision HRA Reimubrsement

VSP Choice $10 copay, 1 every 12 months $10 copay, 1 every 12 months up to $600 with HRA up to $350 allowance

Employee Name Employee Signature

Vision Enrollment Select One Employee Employee + Spouse Employee + Child(ren) Employee + Family Waiving Coverage Declining Coverage

Date

Policyholder: WILLAPA BAY ENTERPRISES Group dental insurance Benefit summary for all members Your coverage renews every July 1 What's available to me?

Dental insurance helps pay for all, or a portion, of the costs associated with dental care, from routine cleanings to root canals.

Eligibility Eligible employees

All active, full-time employees Calendar-year deductible

Coinsurance your policy pays

In-network

Out-of-network

In-network

Out-of-network

Preventive

$0

$0

100%

100%

Basic

$0

$50

100%

80%

Major

$0

$50

80%

50%

Additional provisions Family deductible

3 times the per person deductible amount

Combined maximum

Your calendar year year maximum for preventive, basic, and major in-network services are combined.

Your calendar year year maximum for preventive, basic, and major out-of-network services are combined. In-network calendar year year maximums are $3,000 per person or out-of-network calendar year year maximums are $3,000 per person.

Your services applied to the in-network deductible will apply to the out-of-network deductible and vice versa.

Maximum accumulation

Included

Plan type

Unscheduled

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Who can buy coverage?

• You may buy coverage if you're an active, full-time employee. Seasonal, temporary, or contract employees aren't eligible. o If you’re on regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time off, you’re still considered actively at work, as long as you’re fulfilling your regular duties and were working the day immediately prior to your time off. o You must enroll within 31 days of being eligible. If you don’t, you’ll have to wait until the next open enrollment period, or qualifying event.

Additional eligibility requirements may apply.

Which procedures are covered, and how often?

Preventive Routine exams

Twice per calendar year

Routine cleanings

Twice per calendar year

Bitewing X-rays

Once per calendar year

Full mouth X-rays

Once every 60 months

Fluoride

Once per calendar year (covered only for dependent children under age 15)

Sealants

Covered only for dependent children under age 15; once per tooth each 36 months

Harmful habit appliance

Covered only for dependent children under age 15

Basic Emergency exams

Twice per calendar year

Periodontal maintenance

If three months have passed since active surgical periodontal treatment; four per calendar year

Fillings

Replacement fillings every 24 months

Oral surgery

Simple and complex

General anesthesia / IV sedation

Covered only for specific procedures

Simple endodontics

Root canal therapy for anterior teeth

Complex endodontics

Root canal therapy for molar teeth

Non-surgical periodontics, including scaling and root planing

Once per quadrant per 24 months

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Periodontal surgical procedures

Once per quadrant per 36 months

Occlusal guards (night guards)

One guard per 36 months

Major Crowns

Each 84 months per tooth if tooth cannot be restored by a filling

Core buildup

Each 84 months per tooth

Implants

Each 84 months per tooth

Bridges

84 months old (initial placement / replacement)

Dentures

60 months old (initial placement / replacement)

Repairs

Partial denture, bridge, crown, relines, rebasing, tissue conditioning and adjustment to bridge/denture, within policy limitations

Additional benefits Prevailing charge

When you receive care from an out-of-network-provider, benefits will be based on the 90th percentile of the usual and customary charges.

Maximum accumulation

Some of your unused annual benefit maximum can be carried over to the next year. To qualify, you must have had a dental service performed within the calendar year and used less than the maximum threshold. The threshold is equal to the lesser of 50% of the out-of-network maximum benefit or $1,000. If the qualification is met, 50% of the threshold is carried over to next year's maximum benefit. Individuals with fourth quarter effective dates will start qualifying for rollover at the beginning of the next calendar year. You can accumulate no more than four times the carry over amount. The entire accumulation amount will be forfeited if no dental service is submitted within a calendar year

Periodontal program

If you’re pregnant or have diabetes or heart disease, you may receive scaling and root planing covered at 100% (if dentally necessary), or one additional cleaning (routine or periodontal) subject to deductible and coinsurance.

Second opinion program

You may be eligible for second opinions from dental providers at 100%. This program makes sure you get the best advice to make an informed decision about your care.

Cancer treatment oral health program

If you have cancer and are undergoing chemotherapy or head/neck radiation therapy, you may receive up to three fluoride treatments every 12 months covered at 100% plus one additional routine cleaning.

General anesthesia program

If you have autism, Down syndrome, cerebral palsy, muscular dystrophy, or spina bifida you may receive general anesthesia or intravenous sedation coverage. Services must be administered in a dental office. All other contractual limitations apply.

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How do I find a network dentist?

When you receive services from a dentist in our network, your cost may be lower. Network dentists agree to lower their fees for dental services and not charge you the difference. You’ll have access to the Principal Plan Dental network, with more than 117,000 dentists nationwide. Visit principal.com/dentist to find a dentist or call 800-247-4695.

What if my dentist isn't in the network?

You can refer your dentist to our network. Please submit the dentist’s name and information by calling 800-247-4695, or submitting a form at principal.com/refer-dental-provider.

What are the limitations and exclusions of my coverage?

• Missing tooth provision –This means the initial placement of bridges, partials, dentures, and implant services to replace teeth missing before this coverage starts may not be covered. If the policy your employer purchased replaces coverage with another carrier, continuous coverage under the prior plan may be applied and you may be eligible for coverage to replace teeth missing before this coverage started.

Your effective date with your current employer, along with the employer's effective date with Principal are used to determine coverage. MIssing tooth provision doesn’t apply to pediatric essential benefits.

• Frequency limitations for services are calculated to the month and exact date from the last date of service or placement date.

There are additional limitations to your coverage. Please review your booklet for more information. We strongly recommend submitting a predetermination to determine benefits.

U1P1

Yes

U1P2

No

U2P1

Yes

U2P2

No

U3P1

Yes

U3P2

No

principal.com This is a summary of dental coverage insured by or with administrative services provided by Principal Life Insurance Company. This outline is a brief description of your coverage. It is not an insurance contract or a complete statement of the rights, benefits, limitations and exclusions of the coverage. If there is a discrepancy between the policy and this document, the actual policy provision prevails. For complete coverage details, refer to the booklet. © 2024 Principal Financial Services, Inc., Principal, Principal and symbol design and Principal Financial Group are trademarks and service marks of Principal Financial Services, Inc., a member of the Principal Financial Group.

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Policyholder: WILLAPA BAY ENTERPRISES Group term life insurance Benefit summary for all members Your coverage renews every July 1.

What's available to me?

Protect what means the most to you – the people you love. If something were to happen to you, your life insurance proceeds would go to the people you've designated as your beneficiaries.

Benefit $20,000

You

Guaranteed issue1

Benefit reduction2

If you're under 70: $20,000

35% reduction at age 70 with an additional If you're 70 or 20% reduction older: The lesser at age 75 of $20,000 or the amount with the prior carrier

1

Amount of coverage you may buy within 31 days of initial eligibility for coverage without providing health information.

2 As you get older, your life insurance benefit amount decreases. Age reductions apply to the benefit amount after providing health information.

Who receives coverage?

• You'll receive coverage if you’re an active, full-time employee. Seasonal, temporary, or contract employees aren't eligible. o If you’re on a regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time off, you’re still considered actively at work, as long as you’re fulfilling your regular duties and were working the day immediately prior to your time off.

Additional eligibility requirements may apply.

Do I need to provide health information?

Benefit amounts up to the guaranteed issue shown in the table above won't require health information.

What benefits does Accidental Death and Dismemberment (AD&D) provide?

If you're accidentally injured on or off the job, you may receive a benefit equal to your life benefit.

Loss

AD&D Benefit

Loss of life, loss of both hands or both feet or one hand and one foot, or loss of sight of both eyes

100%

Loss of one hand, or one foot, or sight of one eye

50%

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Loss of thumb and index finger on the same hand

25%

Seatbelt / airbag - If you die in a car accident while wearing a seat belt or protected by an airbag

$10,000

Repatriation - If you die at least 100 miles from your home

Up to $2,000

Education - If your children are enrolled in an accredited post-secondary school at the time of your death

$3,000/year for up to 4 years

Career adjustment - If your spouse attends an accredited post-secondary school after you die

$1,000/year for up to 2 years

Child care - Child care reimbursement for your dependent children under age 13 when you die

Up to $300/month for 1 year

Loss of use or paralysis - total loss of movement for 12 consecutive months or permanent paralysis Quadriplegia

100%

Paraplegia, hemiplegia, or loss of use of both hands or both feet or one hand and one foot.

50%

Loss of use of one arm, one leg, one hand or one foot

25%

Loss of speech and/or hearing - total loss for 12 consecutive months Loss of speech and hearing in both ears

100%

Loss of speech or hearing in both ears

50%

Loss of hearing in one ear

25%

Additional benefits: Accelerated death benefit

If you're terminally ill, you may be able to receive a portion of your life benefit.

Coverage during disability

If you're disabled, you may be able to continue your coverage and not pay premium.

Conversion of terminated coverage

If coverage terminates, you may be able to convert coverage to an individual policy.

The benefit summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet.

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Policyholder: WILLAPA BAY ENTERPRISES Group voluntary term life insurance Benefit summary for all members Your coverage renews every July 1.

What's available to me?

Protect what means the most to you – the people you love. If you passed away, your life insurance proceeds would go to the people you've designated as your beneficiaries.

You

Benefit

Minimum

Select a benefit in increments of $10,000

$10,000

Guaranteed issue1 If you're under 70: $100,000

Maximum $500,000

35% reduction at age 70 with an additional 20% reduction at age 75

$150,000

35% reduction at age 70 with an additional 20% reduction at age 75

If you're 70 or older: $10,000 Your spouse3

Select a benefit in increments of $5,000

$5,000

If your spouse is under 70: $10,000 If your spouse is 70 or older: $10,000

Your child(ren)3

Benefit reduction2

Options4: • $10,000

1

Amount of coverage you may buy within 31 days of initial eligibility for coverage without providing health information.

2 As you get older, your life insurance benefit amount decreases.

3 Amount of coverage may not exceed 50% of your benefit.

4 Dependent children under 14 days old receive a $1,000 benefit.

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Who can buy coverage?

• You may buy coverage if you’re an active, full-time employee working 30 hours a week. Seasonal, temporary, or contract employees can't purchase. o If you’re on a regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time off, you’re still considered actively at work, as long as you’re fulfilling your regular duties and were working the day immediately prior to your time off. o You must enroll within 31 days of being eligible. If you don’t, you may need to provide health information for review, or if you have a qualifying event. o If you and your spouse are both employed at WILLAPA BAY ENTERPRISES and are eligible for benefits, you're not eligible to have benefits as both an employee and a spouse.

• If you’re covered, you may buy coverage for your dependents, if they’re not confined at home, in a hospital or skilled nursing facility (this is referred to as Period of Limited Activity).

Additional eligibility requirements may apply.

Do I need to provide health information?

Benefit amounts over the guaranteed issue shown in the table above for you and your spouse may require you to provide health information.

May I increase my benefit later?

• You may be able to enroll for or increase your benefit and your dependent’s benefit two increments per year during your open enrollment period without providing health information.

• If you have a qualifying life event (marriage, birth of a child, etc.), you may enroll or increase your benefit up to the guaranteed issue amount within 31 days without having to provide health information.

What benefits does Accidental Death and Dismemberment (AD&D) provide?

If you or your spouse are accidentally injured on or off the job, you may receive a benefit equal to your life benefit.

Loss

AD&D Benefit

Loss of life, loss of both hands or both feet or one hand and one foot, or loss of sight of both eyes

100%

Loss of one hand, or one foot, or sight of one eye

50%

Loss of thumb and index finger on the same hand

25%

Seatbelt / airbag - If you die in a car accident while wearing a seat belt or protected by an airbag

$10,000

Repatriation - If you die at least 100 miles from your home

Up to $2,000

Education - If your children are enrolled in an accredited post-secondary school at the time of your death

$3,000/year for up to 4 years

Public transportation - If you die while you're a passenger on 100% public or commercial transportation Helmet - If you die while operating or riding as a passenger on a motorcycle while wearing a helmet

$10,000

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Loss of use or paralysis - total loss of movement for 12 consecutive months or permanent paralysis Quadriplegia

100%

Paraplegia, hemiplegia, or loss of use of both hands or both feet or one hand and one foot.

50%

Loss of use of one arm, one leg, one hand or one foot

25%

Loss of speech and/or hearing - total loss for 12 consecutive months Loss of speech and hearing in both ears

100%

Loss of speech or hearing in both ears

50%

Loss of hearing in one ear

25%

Additional benefits: Accelerated death benefit

If you're terminally ill, you may be able to receive a portion of your life benefit.

Coverage during disability

If you're disabled, you may be able to continue your coverage and not pay premium.

Portability

If you no longer qualify for coverage, you may be able to continue coverage for yourself and your covered dependents.

Conversion of terminated coverage

If coverage terminates, you may be able to convert coverage to an individual policy.

What are the limitations and exclusions of my coverage?

This benefit summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet.

principal.com This is a summary of voluntary term life coverage insured by or with administrative services provided by Principal Life Insurance Company. This outline is a brief description of your coverage. It is not an insurance contract or a complete statement of the rights, benefits, limitations and exclusions of the coverage. If there is a discrepancy between the policy and this document, the actual policy provision prevails. For complete coverage details, refer to the booklet. © 2024 Principal Financial Services, Inc., Principal® , Principal Financial Group® , and Principal and the logomark design are registered trademarks of Principal Financial Services, Inc., a Principal Financial Group company, in the United States and are trademarks and service marks of Principal Financial Services, Inc., in various countries around the world.

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Discounts and services

Save money. Improve your life.

Use discounts and services available through your group benefits. These discounts are not insurance.

Laser vision correction

Imagine your life free from glasses and contacts. You, your spouse, and dependent children save $800 with featured providers LasikPlus, TLC Laser Eye Centers, or The LASIK Vision Institute. Or receive 15% off standard pricing or 5% off promotional pricing on LASIK through the National Lasik Network's 600 locations. Administered by LCA Vision. principallasik.com | 888-647-3937

Hearing aid program

Protect your hearing health to improve your quality of life. You, your spouse, children, parents, and grandparents can get discounts up to 48% off hearing aids, including rechargeable and Bluetooth options, with a 60-day trial to ensure full satisfaction. You can also receive a free hearing consultation at any of the 3,000+ locations nationwide. Administered by Start Hearing. www.starthearing.com/partners/principallife | 877-890-4694

Emotional health support line

Get help when you’re feeling overwhelmed or need support. You, your spouse, and dependent children can call this free, confidential support line 24/7 to reach licensed behavioral health clinicians who can provide emotional support, tips for coping, and referrals to local resources. If your employer offers an employee assistance program (EAP), use it instead.

800-424-4612

Available with your dental insurance Principal oral health center

Get the information you need to make better decisions about oral health care. You can go online and submit a dental care question and get a response from a dentist in one business day. A dental cost estimator shows approximate costs in a ZIP code. And you can access articles about dental health topics plus get information about how dental coverage works. http://c3.go2dental.com/scontent/

Teeth whitening

Share a smile you can be proud of. You, your spouse, and dependents can save 20% on a dentist-invented teeth whitening technology from GLO Science. Available for home use, it’s fast and sensitivity-free so you can smile with confidence. gloscience.com/principal and use discount code PRINCIPAL

23

Available with your life insurance Travel assistance

Ease some of the worries of traveling—whether in the U.S. or internationally. You, your spouse, and dependent children have access to a variety of benefits provided through AXA Assistance1. These services include travel and medical assistance plus emergency medical evacuation benefits. Assistance is available for travel 100+ miles away from home for up to 120 consecutive days. Available with group term life insurance only. principal.com/travelassistance

Will & Legal Document Center

Consider preparing your simple legal documents online. These online resources and tools, provided by ARAG®2, are easy-to-use. You and your spouse can prepare, print, and store essential legal documents — such as a will, living will, healthcare power of attorney, durable power of attorney, and medical treatment authorization for minors. Plus, you can access estate planning tools and resources, and a personal information organizer. principal.araggroup.com Enter your group policy number: 1129650

Identity theft kit

Be proactive in protecting one of your most important assets—your identity. If your identity is stolen, despite your best efforts, you’ll get valuable tips on how to restore it. principalaraggroup.com Enter your group policy number: 1129650

Beneficiary support

Get help coping with the death of a loved one. Beneficiaries receive help coping with the emotions and financial decisions that surface when a loved one dies. Services include grief support from Magellan Healthcare and financial review from Principal®. Spouses and dependents receive three months of free online will preparation services provided by ARAG®2 Information is provided after the loss of a loved one.

principal.com Insurance products issued by Principal Life Insurance Company®, a member of the Principal Financial Group®, Des Moines, IA 50392.

The discounts and services listed here are available to members, and/or their dependents or beneficiaries, with group coverage underwritten by or with administrative services provided by Principal Life Insurance Company. The discounts and services are not a part of the policy or contract and may be changed or discontinued at any time.

For group life and dental policies issued in New York: travel assistance, Will & Legal Document Center, identity theft kit, emotional health support line, beneficiary support and teeth whitening are not available; laser vision correction and hearing aid program are only available with dental or vision insurance. ARAG Services, LLC, AXA Assistance USA, Inc., LCA Vision, Magellan Healthcare, Magellan Health Services of California, Inc.— Employer Services, Start Hearing, and VSP are not affiliated with any company of the Principal Financial Group®. Third party providers are solely responsible for their products and services.

1

Participants are responsible for any incurred fees or expenses.

Indemnified transportation services are administered by AXA Assistance USA, Inc. and underwritten by a third party licensed insurance company.

2

The use of the services provided

by ARAG Services, LLC should not be considered as a substitute for consultation with an attorney.

Neither your employer nor Principal® is responsible for any loss, injury, claim, liability, or damages related to the use of the ARAG legal document service.

Principal®, Principal Financial Group®, and Principal and the logomark design are registered trademarks of Principal Financial Services, Inc., a Principal Financial Group company, in the United States and are trademarks and service marks of Principal Financial Services, Inc., in various countries around the world.

24 GP58554C-19 (SP1285C) | 03/2023 | 2720220-032023 | ©2023 Principal Financial Services, Inc.

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 January 31, 2023. Contact your State for more information on eligibility –

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

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

ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspx

CALIFORNIA – Medicaid Website: Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)

FLORIDA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecover y.com/hipp/index.html Phone: 1-877-357-3268

GEORGIA – Medicaid GA HIPP Website: https://medicaid.georgia.gov/healthinsurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-partyliability/childrens-health-insurance-program-reauthorizationact-2009-chipra Phone: (678) 564-1162, Press 2

IOWA – Medicaid and CHIP (Hawki) Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaida-to-z/hipp HIPP Phone: 1-888-346-9562

KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov

MAINE – Medicaid Enrollment Website: https://www.mymaineconnection.gov/benefits/s/?language=en _US Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-977-6740 TTY: Maine relay 711

MINNESOTA – Medicaid Website: http://mn.gov/dhs/people-we-serve/seniors/healthcare/health-care-programs/programs-and-services/medicalassistance.jsp 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 Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

KANSAS – Medicaid Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-766-9012

LOUISIANA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

MASSACHUSETTS – Medicaid and CHIP Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: (617) 886-8102

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

NEVADA – Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

NEW JERSEY – Medicaid and CHIP Medicaid Website: 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

NORTH CAROLINA – Medicaid Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

PENNSYLVANIA – Medicaid and CHIP Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPPProgram.aspx Phone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437)

SOUTH CAROLINA – 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: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427

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

NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/programsservices/medicaid/health-insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext.

5218

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

NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

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

UTAH – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

VIRGINIA – Medicaid and CHIP Website: https://www.coverva.org/en/famis-select https://www.coverva.org/en/hipp Medicaid/CHIP Phone: 1-800-432-5924

WEST VIRGINIA – Medicaid and CHIP Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

WISCONSIN – Medicaid and CHIP

WYOMING – Medicaid

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

Website: https://health.wyo.gov/healthcarefin/medicaid/programs-andeligibility/ Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since January 31, 2023, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272) Menu Option 4, Ext. 61565

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov Error! Hyperlink reference not valid.1-877-267-2323,

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 ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 1/31/2026)

COBRA General Notice You’re getting this notice because you recently gained coverage under a group health plan. This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.

Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”

You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

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

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies • Your spouse’s hours of employment are reduced • Your spouse’s employment ends for any reason other than his or her gross misconduct • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.

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

Questions? Please call Dawn Mallory at 360-268-7515

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment • Death of the employee • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Willapa Bay Enterprises.

How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

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

Are there other coverage options besides COBRA Continuation Coverage?

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

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period to sign up for Medicare Part A or B, beginning on the earlier of:

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• •

The month after your employment ends The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage. If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare. For more information visit https://www.medicare.gov/medicare-and-you.

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

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

Women’s Health and Cancer Rights Act (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All stages of reconstruction of the breast on which the mastectomy was performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses • Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply: [$500 deductible, 20% coinsurance Annual Notice Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call your plan administrator at the number at the footer of this document.

Questions? Please call Dawn Mallory at 360-268-7515

Newborn and Mother’s Health Protection Act (NMHPA) Group health plans and health insurance issuers generally may not, under federal law, 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 cesarean section.

However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic Information Nondiscrimination Act of 2008 The Genetic Information Nondiscrimination Act of 2008 (GINA) provides broad protections in employment and health coverage against the improper collection, use or disclosure of individuals’ genetic information.

Title I of GINA prohibits group health plans and health insurance issuers from discriminating based on genetic information and from collecting genetic information.

Title II of GINA, which applies to employers with 15 or more employees, protects job applicants and employees from employment discrimination based on their genetic information.

GINA defines “genetic information” to mean information about: • An individual’s genetic tests.

• The genetic tests of family members of the individual.

• The manifestation of a disease or disorder in family members of the individual.

• Genetic information also includes any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by the individual or any family member of the individual.

• The genetic information of any fetus carried by a pregnant woman and the genetic information of any embryo legally held by an individual or family member using assisted reproductive technology are also considered genetic information protected by GINA.

Notice of Privacy Practices Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

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

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Your Choices - You have some choices in the way that we use and share information as we: • Answer coverage questions from your family and friends • Provide disaster relief • Market our services and sell your information Our Uses and Disclosures - We may use and share your information as we: • Help manage the health care treatment you receive • Run our organization • Pay for your health services • Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests and work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a copy of health and claims records • You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records • You can ask us to correct your health and claims records if you think they are incorrect or • incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six • years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Questions? Please call Dawn Mallory at 360-268-7515

Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in payment for your care • Share information in a disaster relief situation • If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission: • Marketing purposes • Sale of your information Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways.

Help manage the health care treatment you receive • We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Run our organization • We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans. Example: We use health information about you to develop better services for you.

Pay for your health services • We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan • We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Questions? Please call Dawn Mallory at 360-268-7515

Help with public health and safety issues We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Do research • We can use or share your information for health research.

Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director • We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions • We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

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

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

Questions? Please call Dawn Mallory at 360-268-7515

Your Rights and Protections Against Surprise Medical Bills When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-ofnetwork providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for: Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care outof-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections: • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

• Your health plan generally must: o Cover emergency services without requiring you to get approval for services in advance (prior authorization). o Cover emergency services by out-of-network providers. o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

Questions? Please call Dawn Mallory at 360-268-7515

Patient Protection Model Disclosure When applicable, it is important that individuals enrolled in a plan or health insurance coverage know of their rights to (1) choose a primary care provider or a pediatrician when a plan or issuer requires designation of a primary care physician; or (2) obtain obstetrical or gynecological care without prior authorization. Accordingly, the interim final regulations regarding patient protections under section 2719A of the Affordable Care Act require plans and issuers to provide notice to participants of these rights when applicable. The notice must be provided whenever the plan or issuer provides a participant with a summary plan description or other similar description of benefits under the plan or health insurance coverage. This notice must be provided no later than the first day of the first plan year beginning on or after September 23, 2010.

The following model language can be used to satisfy the notice requirement: For plans and issuers that require or allow for the designation of primary care providers by participants or beneficiaries, insert: CAS generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. [If the plan or health insurance coverage designates a primary care provider automatically, insert: Until you make this designation, [name of group health plan or health insurance issuer] designates one for you.] For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the [plan administrator or issuer] at [insert contact information].

For plans and issuers that require or allow for the designation of a primary care provider for a child, add: For children, you may designate a pediatrician as the primary care provider.

For plans and issuers that provide coverage for obstetric or gynecological care and require the designation by a participant or beneficiary of a primary care provider, add: You do not need prior authorization from [name of group health plan or issuer] or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the CAS at 855-373-8232

Special Enrollment Notice This notice is being provided to make certain that you understand your right to apply for group health coverage. You should read this notice even if you plan to waive health coverage at this time.

Loss of Other Coverage If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this Plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

Example: You waived coverage under this Plan because you were covered under a plan offered by your

Questions? Please call Dawn Mallory at 360-268-7515

spouse's employer. Your spouse terminates employment. If you notify your employer within 30 days of the date coverage ends, you and your eligible dependents may apply for coverage under this Plan.

Marriage, Birth or Adoption If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption. Example: When you were hired, you were single and chose not to elect health insurance benefits. One year later, you marry. You and your eligible dependents are entitled to enroll in this Plan. However, you must apply within 30 days from the date of your marriage.

Medicaid or CHIP If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.

Example: When you were hired, your children received health coverage under CHIP and you did not enroll them in this Plan. Because of changes in your income, your children are no longer eligible for CHIP coverage.

You may enroll them in this Plan if you apply within 60 days of the date of their loss of CHIP coverage.

Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with CAS 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: • 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.

• Willapa Bay Enterprises has determined that the prescription drug coverage offered by CAS 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?

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If you decide to join a Medicare drug plan, your current [Insert Name of Entity] coverage will [or will not] be affected. Please see the attached explanation of the prescription drug coverage plan provisions/options that Medicare eligible individuals have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current CAS coverage, be aware that you and your dependents will not be able to get this coverage back.

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 CAS 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…

Contact the person listed below for further information. 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 this coverage through CAS 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.

• 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).

Questions? Please call Dawn Mallory at 360-268-7515