Our Mission: Consistently provide client experiences focused on what they value most.

2014 Limited Benefit Indemnity Plan Benefit Guide

*This plan does not satisfy an employee’s obligation to maintain coverage under the Affordable Care Act’s “individual mandate” beginning 2014.*

Issued by:

DMC167Rev2/2013 © Copyright 2011 – Pan-American Benefits Solutions Insurance Agency

Marketed by:

2014 Open Enrollment What is New In 2014? We are very excited about a new employee benefits package that is being offered to all employees of PrideStaff during this year’s Open Enrollment. The plan for this year offers meaningful and competitive benefits at an affordable cost, designed to be a true value to our employees. The limited benefit indemnity plan will be fully insured by a rated “A” carrier; Pan-American Life Insurance Company.

How To Enroll Enrollment is easy, fast and convenient. You will be able to enroll Online or through our toll free Enrollment Center Dedicated Line in just a few minutes. Online: You can easily and conveniently enroll online 24/7 at www.mypalic.com/enroll. Your ID is your 9 digit SSN, and your Password is your last 4 digits of your SSN. By Phone: To enroll now, call the toll free Enrollment Center Dedicated Line and a representative will answer your questions and enroll you over the phone.

Enrollment Center Dedicated Line

1-877-385-3601 Monday through Friday, 8:00 AM – 5:00 PM, CST.

Full bilingual (English-Spanish) services

After You Enroll

Please refer to your New Hire Enrollment and Effective Date Calendar on page 17 for your eligibility period. Once you enroll in the plan, you will receive your ID Card(s) by mail. You will also be able to visit and register into our online member portal at mypalic.com for 24-hour access to: • Review claims and EOBs • Access plan documents • See your benefits

• Find in-network providers • Print ID cards • Download forms

• Frequently Asked Questions • And much more…

The information provided in this guide is a brief outline of benefits. Your certificate of coverage governs the terms and conditions of your plan. 2

Please keep this guide with you for future references.

Limited Benefit Indemnity Plan Pays BENEFIT DESCRIPTION

BASIC PLAN

ENHANCED PLAN

$400 first day when admitted as an inpatient into a hospital room

$600 first day when admitted as an inpatient into a hospital room

$400 per day Overall calendar year max subject to 30 days total for any inpatient stay in a hospital except skilled nursing

$600 per day Overall calendar year max subject to 30 days total for any inpatient stay in a hospital except skilled nursing

Intensive Care Benefit If the participant is confined in a hospital intensive care unit

$800 per day Up to 15 days calendar year max (applied to overall calendar year max)

$1,200 per day Up to 15 days calendar year max (applied to overall calendar year max)

Substance Abuse Must be diagnosed and admitted as an inpatient in a substance abuse unit

$200 per day Up to 15 days calendar year max (applied to overall calendar year max)

$300 per day Up to 15 days calendar year max (applied to overall calendar year max)

Mental Illness Must be diagnosed and admitted as an inpatient into a mental illness unit

$200 per day Up to 30 days calendar year max (applied to overall calendar year max)

$300 per day Up to 30 days calendar year max (applied to overall calendar year max)

Skilled Nursing Must be admitted in skilled nursing facility following a covered hospital stay of at least 3 days

$200 per day Up to 30 days max per stay

$300 per day Up to 30 days max per stay

$75 per visit $300 calendar year max

$100 per visit $400 calendar year max

HOSPITAL ADMISSION BENEFIT • Pays in addition to Hospital Confinement • Once per admission, once per diagnosis • Benefit will not be payable for the same or related injury or illness

DAILY HOSPITAL CONFINEMENT BENEFIT • Must be admitted as an inpatient into a hospital room • If hospital confinement falls into a category below a different maximum applies

DOCTOR’S OFFICE VISIT • Covers a non-routine doctor’s office visit • Routine exams, medical treatment and injections are not covered OUTPATIENT DIAGNOSTIC LAB, X-RAY and ADVANCED STUDIES • Lab (glucose test, urinalysis, CBC) • X-Ray (chest, broken bones) • Advanced Studies (including CT Scan, MRI, and others) • When hospital confinement is not required; and does not include routine exams

$20 Lab per test

$20 Lab per test

(up to 3 tests per calendar year)

(up to 3 tests per calendar year)

$70 X-Ray per test

$70 X-Ray per test

(up to 2 tests per calendar year)

(up to 2 tests per calendar year)

$1,000 Advanced Studies

$1,000 Advanced Studies

(Refer to schedule of benefits)

(Refer to schedule of benefits)

$1,200 calendar year max

$1,200 calendar year max

3

Limited Benefit Indemnity Plan Pays BENEFIT DESCRIPTION

BASIC PLAN

ENHANCED PLAN

LUMP SUM SURGICAL Lump Sum benefit payable for Inpatient/Outpatient Surgeon Fee; The benefit will be based on place of service and complexity of procedure if an outpatient procedure

$500 lump sum for inpatient $250 lump sum for outpatient $50 lump sum for outpatient minor $500 calendar year max

$500 lump sum for inpatient $250 lump sum for outpatient $50 lump sum for outpatient minor $1,000 calendar year max

LUMP SUM ANESTHESIA 25% of the amount paid under the lump sum surgical benefit

$125 lump sum for inpatient $62.50 lump sum for outpatient $12.50 lump sum for outpatient minor $125 calendar year max

$125 lump sum for inpatient $62.50 lump sum for outpatient $12.50 lump sum for outpatient minor $250 calendar year max

WELLNESS BENEFIT Routine exams, including cancer screening and PSA, mammograms, and well child care immunizations

$75 per visit $150 calendar year max

$150 per visit $150 calendar year max

EMERGENCY ROOM SICKNESS VISIT Covers any ER visit as the result of an illness

$75 per visit $300 calendar year max

$75 per visit $300 calendar year max

THIS POLICY DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE (MAJOR MEDICAL COVERAGE) AND DOES NOT SATISFY THE REQUIREMENT OF MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT.

Group Medical Accident

With Accidental Death & Dismemberment

Accident Benefit* Deductible Accidental Death Accidental Dismemberment

Up to $2,500 per occurrence $100 deductible per accident, per insured $5,000 Up to $5,000

Initial Treatment Period........................................................................................... 12 weeks (Initial treatment must be incurred within 12 weeks of the date of the accident) Benefit Period.......................................................................................................... 52 weeks (Expenses must be incurred within 52 weeks of the date of the accident) The insured's loss must occur within one year of the date of the accident Depending on the state of issue, medical accident insurance is issued by Pan-American Life Insurance Company on policy form number SM-2003 or by Zurich American Insurance Company or Fairmont Specialty. *Pays “Off the Job” Accident Medical Benefits for Covered Expenses that result directly, and from no other cause, than from a covered accident. Medical Accident is NOT available to residents in AK, MD, RI, WA and WY.

4

Prescription Drug Plan Included with Both Plans

$10/$30 Co-Pay Fully Insured Drug Plan* Generic** - $10 co-pay for 30 day supply Preferred Brand Name- $30 co-pay for 30 day supply Non-Preferred Brand Name*** – 100% Discounted price $200 maximum per month per member for generic and preferred brand name drugs. After $200 maximum is attained, you will receive discounts on your prescription drugs. Over 2200 preferred brand drugs included on formulary listing Mail order available 90 day supply **The purchase of generic drugs will cost you $10 or the cost charged by the pharmacy, which ever is less. ***Cost is based on the contracted pharmacy discount price that RxEDO has negotiated for the medication, plus a dispensing fee.

Using Your Prescription Drug Plan is Easy Select a convenient pharmacy near you and verify with them that the pharmacy is still in the network. Present your ID card, pay the appropriate amount and you’re done.

Nationwide Pharmacy Network and Mail Order Services The Rx retail pharmacy network consists of over 60,000 national, regional and local chains and independent pharmacies. The Prescription Drug Plan also offers fully integrated mail order services that provide members the convenience of home delivery. The network currently manages over 2 million members located in all 50 states.

For Customer Service and updated formulary listing call 1-888-879-7336.

Superior Customer Service Feel free to contact the Customer Service center if you have additional questions. The knowledgeable Customer Service representatives respond to physicians, members and pharmacies quickly and accurately. The Prescription Drug Help Desk provides toll-free assistance eight hours a day/five days a week at 1-800-522-7487.

Sample Prescription Drugs

Generic

Formulary Brand

Rimatadine

Augmentin

BLOOD PRESSURE

Lisinopril

Mavik

CHOLESTEROL LOWERING

Lovastatin

Lipitor

ANTIBIOTIC

Pharmacy Network Some of the participating pharmacies include: Costco CVS Pharmacy K-Mart Target

*If a Brand Name Prescription Drug is dispensed in lieu of an available Generic Prescription Drug, then in addition to the Brand Co-payment, the participant would be responsible for the difference in cost between the Brand Name Prescription Drug and its Generic alternative. Prices subject to change.

Rx benefits are provided by RxEDO, Inc. www.rxedo.com Pan-American Life and RxEDO, Inc. are not affiliated.

5

Walgreens Walmart And many more…

PPO Provider Network Included with Both Plans

Using In-Network Providers Can Stretch Your Benefits Dollars Your plan includes access to the First Health Network, which is more than a PPO Network, it is a full service Managed Care Organization offering savings opportunities on a national, directly contracted basis. It provides access to more than 5,000 Hospitals and 550,000 Physicians and health care professionals nationwide. First Health is committed to patient safety at a high level by exercising care in the selection and evaluation of providers for our network. Thorough credentialing and recredentialing processes minimize unfavorable risks, which in turn, impacts clinical and cost outcomes. In addition to the First Health Network, our members also have access to a secondary or Wrap Network that provides them and their covered dependants a broader access to Physicians and health care professionals in urban, suburban, and rural areas.

To locate in-network Physicians or Hospitals call 1-800-236-3609 or visit www.providerlocator.com/palicfh to search online

Follow These Steps 1.Select the specialty and/or type of provider you want to locate. 2.(Optional) Complete these fields if searching for a specific provider. 3.Select location by city, state, or zip code. 4.(Optional) You can also select the distance from your location. 5.Click here to start your search.

PPO Provider services are provided by Competitive Health, Inc. Pan-American Life and Competitive Health are not affiliated.

6

Telehealth Services Included with Both Plans

24/7 Physician Care when you need it! AmeriDoc provides member access to services from participating physicians in a national network of U.S. licensed and based physicians, many of whom are board-certified, who use electronic health records, telephone consultations and online video consultations to diagnose, recommend treatment and write short term prescription for non DEA-controlled medications when appropriate*. Physicians are available 24 hours a day, 365 days a year, allowing members to conveniently access healthcare for their families from their home, work or on-the-go, as opposed to more expensive and time consuming alternatives like the doctor’s office or emergency room.

Benefits • Physicians available anytime, 24/7/365 • Convenience of obtaining medical care at work, home, or on-the-go • Save money by avoiding in-office doctor’s visits • Quality care from physicians who can provide consultations, diagnose, recommend treatment and write short term prescriptions for non DEA-controlled medications when appropriate* • Speak to a physician in most cases in less than 30 minutes, but within 3 hours guaranteed • Physician reviews and updates on-line health record when performing a medical consultation • Secure, personal and portable electronic health records • Consultations are included in your plan at no additional cost

Ideal to use… • When you don’t have the time to go the doctor’s office • When your primary care physician is not available • After normal hours of operation • For non-emergency medical care • When on vacation or out of town

For common conditions like… • Sinus Infections • Respiratory Conditions • Urinary Tract Infections • Allergies • Bronchitis • Poison Ivy • Pink Eye • Cold or Flu & more…

For more information visit www.ameridoc.com or call 1-877-263-7409 *Network physicians are medical doctors (M.D.s) in all states except OK, where they are doctors of osteopathy (D.O.s) Online video consultations not available in TX. Telehealth services are not insurance products and access to them is provided by AmeriDoc, LLC. www.ameridoc.com Pan-American Life and AmeriDoc, LLC are not affiliated.

7 Telehealth services do not replace the primary care physician. AmericDoc, LLC does not guarantee that a prescription will be written and network physicians operate subject to state regulations. Network physicians do not prescribe DEA-controlled substances and reserve the right to deny care for potential misuse of services.

Member Advocacy Included with Both Plans

Members Can Have Personalized Advocacy Services Pan-American Benefits Solutions understand the “ins and outs” of the healthcare and insurance worlds. We make healthcare work for the insureds. No more hassles. No more frustrations. Member Advocacy makes it easy and simple to get help. Members just need to make one call to Pan-American Benefits Solutions and talk with an advocacy service representative.

Member Advocacy helps… • Review and help resolve insurance claims • Negotiate billing and payment arrangements with providers • Contact local programs which can reduce out-of-pocket medical expenses • Find low or no cost prescription drug programs

• Mitigate billing issues so members can focus on getting better

And…much more!

The Service Representative will… • Take the time to listen to the members • Assess the issue or problem • Make the necessary follow-up arrangements • Protect the members privacy and keep their information confidential • Act quickly and efficiently

8

Global Repatriation Included with Both Plans

Peace of Mind for You and Your Family Global Repatriation is a worldwide benefit designed to help families when a member or a covered dependent suffers a loss of life due to a covered accident or illness while traveling 100 miles or more away from their permanent residence. Travel within the United States and abroad is included. Our Global Repatriation benefit makes all the necessary arrangements for the transportation of a covered member’s remains to anywhere in the United States and includes repatriation of foreign nationals to their home countries. Arrangements must be coordinated with the member service center and covers up to $20,000 in expenses. We recognize travel may be an important part of your family’s lifestyle. Have peace of mind knowing your family is protected.

Global Repatriation benefit is provided by AXA Assistance USA. www.axa-assistance.us Pan-American Life and AXA Assistance USA are not affiliated. See policy for exclusions and limitations.

Member Services Our member service representatives are responsible for ensuring that customers receive the best assistance with their questions and concerns. Pan-American Benefits Solutions customer service representatives interact with customers to provide information in response to inquiries about products and services. They communicate with administrators and members through a variety of means; by telephone, by e-mail, fax or mail.

We can assist members, companies and providers with: • Member Advocacy • ID Cards • Policy Information • Member Eligibility • Verification of Benefits

• Prescription Benefits • PPO Network Information • Account Management • Claims • And more!

Monday through Friday, 7:30 AM – 5:00 PM, Central Time.

1-877-569-3075 Full bilingual (English-Spanish) services

9

Frequently Asked Questions 1. Is PanaMed Major Medical coverage? No. PanaMed is a limited benefit indemnity plan. This is not basic health insurance or major medical coverage and is not designed as a substitute for either coverage. PanaMed pays a fixed benefit amount to help cover the cost of common medical services. The plan is not designed to cover the costs of serious or chronic illnesses. It contains specific dollar limits that will be paid for medical services which may not be exceeded. Specific dollar limits are listed in the summary of benefits. 2. Does PanaMed have any exclusions or limitations? Benefits are subject to certain exclusions, limitations, and terms for keeping the benefits in force. For example the following services are not covered by this plan: infertility treatments, cosmetic surgery, counseling for mental illness or substance abuse, obesity, weight reduction or dietetic control, physical therapy, spinal manipulation, acupuncture. This is a partial list of services that are generally not covered. Members should refer to their certificate to determine which services are covered and to what extent. Additional information can be found in our web portal at www.mypalic.com. 3. Will the PanaMed plan provide an indemnity benefit to any Physician or Hospital? Yes. The member is free to seek the services of any licensed Physician or accredited Hospital. There is no requirement that the Physician or Hospital belong to a PPO network to receive benefits. 4. What is a PPO and the advantage for using? PPO is the abbreviation for Preferred Provider Organization. This organization of providers (referred to as a “network”) has agreed to provide their services as a negotiated discount, reducing your out of pocket cost. While PanaMed may be used at any hospital or physician’s office, members are encouraged to utilize the PPO network for discounted provider prices. 5. How does a member determine which providers participate in the network? PPO participation may be verified with a simple phone call or online. The toll free number and website link can be found in your enrollment guide, ID card, and in our web portal. The insured is responsible for verifying the current PPO participation of their provider. 6. Is there a pre-existing condition exclusion on the plan? Because this is a limited benefit indemnity plan there are no pre-existing condition exclusions. However there are certain circumstances where pregnancy is not covered if conception occurred prior to the insured’s effective date of coverage. This exclusion does not apply to residents of California, Idaho, Montana, and Texas, or to North Carolina groups. 7. Can dependents be insured by PanaMed? Yes. If the member is covered by PanaMed, dependents are also eligible for coverage. 8. Are Medicare and Medicaid recipients eligible for PanaMed? Yes. However, under Medicare and Medicaid policies, PanaMed is considered primary coverage. As a result, with PanaMed, Medicare and/or Medicaid coverage may be reduced or discontinued. 9. Can the PanaMed plan be used if the insured has separate health insurance? Yes. The specified benefits pay irrespective of any other private group coverage. 10. Is the member allowed to assign benefits to his or her healthcare provider? Yes. Benefits are automatically assigned to the member’s healthcare provider. If the member would like to receive the benefit payment directly, complete the medical claim form and sign the authorization of payment section. 11. Are chiropractor visits covered under the PanaMed plan? Only charges billed as a physician office visit are covered. Charges billed as treatment and/or manipulations are not covered. 12. How is the payment for a surgical procedure determined? Any payment for covered services is subject to the insured’s eligibility at the time of service, limitations/exclusions set forth in the policy provisions and the information submitted with your claim by your medical provider. For benefit information on a specific surgical procedure please contact our member service department. You will need to provide the CPT code for the surgery from your physician. 13. Does the PanaMed Plan address an employee’s obligations to maintain coverage under the “individual mandate?” No. 14. Is PanaMed COBRA eligible? Yes. PanaMed is COBRA eligible for employer groups with 20 or more employees.

10

Limited Benefit Indemnity Plan Exclusions and Limitations. Additional Exclusions and Limitations can be found at www.panamericanbenefits.com. Exclusions and Limitations may be affected by state law. Benefits are not provided for Loss, Injury or Illness of a Covered Person which results directly or indirectly, wholly or partly from: A. Insurrection, rebellion, participation in a riot, commission of or attempting to commit an assault, battery, felony, or act of aggression. B. Declared or undeclared war or acts thereof, including terrorist acts. C. Accidental Bodily Injury occurring while serving on full-time active duty in any Armed Forces of any country or international authority (any premium paid will be returned by Us pro-rata for any period of active-full time duty). D. Any Injury or Illness arising out of or in the course of work for wage or profit. E. Any Injury or Illness covered by any Worker’s Compensation Act, Occupational Disease Law or similar law. F. Except in regard to Medical benefits, bodily injuries received while the Covered Person was operating a motor vehicle under the influence of alcohol as evidenced by a blood alcohol level in excess of the state legal intoxication limit. G. Charges for which: (1) there is no legal obligation to pay, or (2) no charge is made, or (3) in the absence of coverage, no charge would be made. H. Charges incurred after Termination of Coverage. I. Charges for care or services furnished by any agency or program funded by federal, state or local government. This does not apply to Medicaid or where prohibited by law. J. Charges which are not Medically Necessary (as defined) for treatment of Illness or Injury. K. Charges for services which are not related to and consistent with the treatment of any Injury or Illness of the Covered Person. L. Unless specifically provided for in the plan, charges for routine physicals or general health exams, unless they are necessary for the diagnosis and treatment of an Illness. M. Charges for medical care, services, or supplies which are not furnished or prescribed by a Doctor (as defined). N. Charges for experimental or investigational treatment, procedures for research purposes, or practices when not generally recognized as accepted medical practices. O. Charges for care, treatment, services or supplies that are not approved or accepted as essential to the treatment of an Injury or Illness by any of the following: The American Medical Association; The U.S. Surgeon General; The U.S. Department of Public Health; The National Institute of Health; or the professional review organization(s) which administer the Utilization Review Program. P. Charges related to cosmetic surgery or Dental Care done to beautify a person without medical or dental indication of Injury or Illness. Q. Unless specifically provided in the Plan, charges for Dental treatment or Oral Surgery. R. Unless specifically provided in the Plan, charges for treatment of Substance Abuse Disorders or Mental Illness Disorders. S. Unless specifically provided in the Plan, charges for refractions, eyeglasses or hearing aids or their fitting. T. Unless specifically provided in the Plan, charges in connection with obesity, weight reduction, or dietetic control, except for morbid obesity or disease etiology. U. Unless specifically provided in the Plan, charges for treatment or services for temporomandibular joint dysfunction or TMJ pain syndrome, orofacial, or myofascial syndrome whether medical or dental in scope. V. Charges for reversal procedures in connection with previous male or female sterilization. W. Unless specifically provided in the Plan, charges for routine immunizations and vaccinations, including but not limited to polio, mumps, measles, small pox, DPT, or tine tests. X. Charges for services in the nature of educational or vocational testing or training. Y. Any charges for elective abortions. Z. Radial keratotomies. AA. Any charges in excess of the Plan maximums for Organ or Tissue Transplants as shown in the Summary of Benefits. BB. Charges for treatment of male or female infertility; in vitro and in vivo fertilization of an ovum; or artificial insemination. CC. Charges for stand-by surgeons, pediatricians, anesthesiologists, anesthetists, or other Doctor as defined by the Plan; or stand-by supplies, equipment, rooms, or any other service, supply or treatment not actually used in the care or treatment of an Illness or Injury. DD. Charges made by; durable medical equipment recommended by; or drugs dispensed by; a physician, surgeon, nurse or other Doctor (as defined) who: 1. Normally lives with the Plan Participant; or 2. Is a member of the Plan Participant’s family; or 3. Is the Plan Participant’s Plan Sponsor. EE. Charges for Custodial Care. FF. Charges related to smoking cessation. GG. Charges for the treatment of the following: Codependency; Social, occupational, or religious maladjustments; Compulsive gambling; Chronic marital or family problems when not related to the primary focus of treatment which must be a diagnosable mental disorder.

11

Missed Premiums FAQs Payroll Deduction with Option for Direct Payment Q: What is a “missed premium”? A: A “missed premium” represents a benefit coverage period for which no payment has been made.

Q: What is a benefit coverage period? A: If you are paid weekly, a coverage period can begin on a Monday following your payroll deduction and extend through Sunday. Of course, the coverage period begin and end dates are flexible, and are customized to your employer payroll cycle. Coverage periods continue as long as you continue to make payments. Your benefits are paid for in advance on the first day of the week of the coverage period.

Q: How does a missed premium occur? A: A missed premium occurs when either (1) your paycheck, after deductions, is not enough to cover your full insurance premium, or (2) you do not make a direct premium payment to Pan-American for one or more benefit coverage periods.

Q: What if my paycheck is not enough to cover my full premium? A: Partial payments cannot be accepted. If your paycheck is not enough to cover your full premium, no deduction will be made. You must then make your premium payment directly to Pan-American. Full premium includes your medical coverage and any other coverage in which you are enrolled, such as dental or vision. You should review your paycheck stub to determine if your premium has been paid.

Q: Can I make a partial payment? A: Partial payments cannot be accepted. You must remit the full premium to Pan-American. Full premium includes your medical coverage and any other coverage in which you are enrolled, such as dental or vision.

Q: What happens if I miss a premium payment? A: If you do not pay one or more premiums, you will have no benefit coverage for that time period and any claims you incur will not be paid. You can miss up to six consecutive weekly premium payments before your benefits will be terminated. If you do not make a payment by the end of the 6th coverage week, your benefits will be terminated for non-payment of premium. If you are terminated for non-payment of premium, you may qualify for reinstatement within ninety (90) days from the date you were last eligible. You will be notified of your coverage termination by US Mail. Because termination for non-payment of premium is not a qualifying event, you will not be eligible for coverage continuation through COBRA. Termination for reasons other than non-payment of premium may be eligible for COBRA coverage continuation.

Q: How will I know which coverage periods I’ve missed? A: Pan-American will mail to you a monthly statement of account, which will identify the coverage periods for which you have missed premium payments. Your statements will also be available through Pan-American’s Member Web Portal at www.mypalic.com.

Q: Can I select the weeks I wish to pay? A: You can select the week or weeks you wish to pay, but you must pay consecutive weeks (which could be more than one) from the 1st week you select to pay to the current coverage week (or billing period). For example, if you have 4 weeks of missed premium and you select to pay Week 2, you must pay Weeks 2, 3 and 4. If you choose to pay Week 3, you must pay Weeks 3 and 4. The end result is that you will have a “gap” in your coverage for the weeks you elect not to pay. Claims incurred during any “gap” in coverage will be denied.

Q: How do I pay my missed premium? A: You can access Pan-American’s Member Portal at www.mypalic.com to view the status of your account and make payment by credit or debit card. Alternatively, you can pay by completing the attached “Missed Premium Payment Form”(which will be included in your Fulfillment Package and is available online at www.mypalic.com) and mailing it with your personal check, cashier check or money order to: Department 1363, Pan-American Life Insurance Company, Worksite, P.O. Box 62600, New Orleans, LA, 70162-2600.

Q: Will I receive a receipt for my payment(s)? A: No payment receipt will be mailed. If payment is by payroll deduction, your check stub is confirmation of your premium payment. If you pay via the Member Web Portal, you will receive an e-mail confirmation of your payment and your charge will appear on your credit card statement. If you pay by personal check, your cancelled check is proof of payment.

Q: If my employment ends, am I still eligible for insurance benefits? A: No, if your employment terminates, you cannot continue coverage by paying missed premiums. You could, however, be eligible for coverage continuation through COBRA. Your employer should contact you regarding your COBRA eligibility.

Q: Other questions? A: You may contact Member Services at (877) 569-3075.

12 DM-C-F29exp/9/2012

Dental/Vision Combo (Buy-Up Option) Pan-American Life’s fully insured comprehensive dental plan provides members and their covered dependents with the Preventive Care, Basic Care, and Major Care Services they need. To help minimize out-of-pocket dental expenses members have access to the DentalGuard Preferred Select Network, one of the industry’s largest dental preferred provider networks with dentists in over 140,000 locations across the country. Members are free to visit any dentist or specialist they wish. However, by visiting a dentist within the DentalGuard Preferred Select Network, members can save money. How? • DentalGuard Preferred Select Network dentists are up to 35% less than what most dentists usually charge1. • By taking advantage of the lower fees offered by in-network providers, members can stretch their annual plan maximums further.

Outline of Dental Benefits Dental Benefits (per insured)

Basic Plan

Charges we cover (coinsurance) Preventive - Type I Basic - Type II Major - Type III Calendar Year Deductible Preventive - Type I Basic - Type II & Major - Type III Calendar Year Maximum - (Types I - III) Waiting Period Preventive - Type I Basic - Type II Major - Type III2

80% 60% 40% Waived $50 $1,000 None None 12 Months

depend on the dentist’s location and type of service. reduce major care waiting period for groups with prior dental coverage by the amount of time employee was covered on the prior plan if employee was covered on the prior plan the day before current dental coverage was effective.

1Savings 2Will

Preventive Care - Type I: • • • • •

Oral evaluations - 2 per calendar year. Prophylaxis (cleanings) - 2 per calendar year. Fluoride - 1 per calendar year. Dependents to age 14. Bitewing X-Rays - 1 series per calendar year. Space maintainers.

Continue on the next page 13 Group dental insurance is issued by Pan-American Life Insurance Company on form number DEN-06-P. Coverage is not available in all states. Dentist is Group dental insurance by Pan-American Life Insurance Company on formbenefit number DEN-06-P. not available in limitations, all states. Dentist is not obligated to provideisaissued discount for a non-covered service. Like most group programs, ourCoverage productsishave exclusions, waiting not obligated to provide a discount for a non-covered service. Like most group benefit programs, our products have exclusions, limitations, waiting periods and terms for keeping them in force. Please contact us for complete details. periods and terms for keeping them in force. Please contact us for complete details.

Dental/Vision Combo (Buy-Up Option) Basic Care - Type II: • Sealants - 1 per tooth every 3 years. Dependents to age 14. • Fillings - Amalgam, silicate, acrylic, synthetic porcelain and composite filling materials. • Simple extractions. • Denture repair or bridges - 1 per 2 years, limited to 20% replacement cost. • X-Rays (diagnostic, full or panoramic) - 1 every 5 years.

• Re-cementing inlays, onlays, and crowns. • General anesthesia and analgesic for oral surgery. • Oral surgery - Removal of teeth. Extraction of tooth root. Alveolectomy, alveoplasty, and frenectomy. Excision oral tissue. Re-implantation or transplantation natural tooth. Excision tumor or cyst. • Antibiotic injections administered by a dentist. • Preauthorization required for all services over $300.

Major Care - Type III: • Periodontics - Root scaling and planning, once per quadrant in any 24 month period. • Endodontics - Root canal therapy. • Dentures and bridge work - Initial placement only for natural tooth extracted while covered. Replacement after 10 years from placement if cannot be repaired. Realigning/Rebasing Dentures only once in any 2 year period.

• Inlays/Onlays/Crowns and other prosthetics - If unable to restore with filling materials. Replacement after 10 years of original placement. Will not apply if replacement is due to extraction of functioning natural teeth while covered. • Missing tooth exclusion - Only replace teeth lost during time covered by our policy. • Preauthorization required for all services over $3

To locate a DentalGuard Preferred Select network dentist call 1-877-569-3075, or go to www.GuardianLife.com, and follow these steps:

1. 2. 3. 4.

Go to "Find a Provider" under "Contact Us" on the right side of the home page. Select “Find a Dentist”. Select “PPO” for “Select Your Dental Plan”. Choose “DentalGuard Preferred Select" when it asks for "Select Your Dental Network".

The Dental plan is an available option for employers who offer the PanaMed Medical plan. If offered by the employer employees can choose to enroll in one or both plans (PanaMed only, Dental only, PanaMed and Dental). When choosing both plans, employees must elect the same coverage tier in both product options. For example, if they elect Employee + Spouse on PanaMed Medical, then they must elect Employee + Spouse for Dental as well.

Dental Provider Network services are provided by The Guardian Life Insurance Company of America. www.guardianlife.com. Pan-American Life and The Guardian Life Insurance Company of America are not affiliated.

14 Group dental insurance is issued by Pan-American Life Insurance Company on form number DEN-06-P. Coverage is not available in all states. Dentist is not obligated to provide a discount for a non-covered service. Like most group benefit programs, our products have exclusions, limitations, waiting periods and terms for keeping them in force. Please contact us for complete details.

Dental/Vision Combo (Buy-Up Option) See rates on next page. Highlights • Discount Vision Plan • No health restrictions, can be used immediately • No limits on frequency of use • No paperwork • 30 day money-back guarantee on eyewear • Low price guarantee on eyeglasses • Discounts on LASIK surgery included

Members save 10% to 60% off provider retail prices on eyeglasses, contacts, eye exams and surgical procedures from more than 12,000 locations nationwide.

Coast to Coast Vision™ network is the most comprehensive in the United States and includes ophthalmologists, optometrists, independent optical centers and national chain locations such as Pearle Vision, JCPenney Optical, Sears Optical, Target Optical, LensCrafters, EyeMasters and QualSight LASIK.

Discount Vision Plan Savings Benefits

In-Network

Eye Exams

10% to 30% off provider retails fees

Prescriptions Eyeglasses Frames Lenses (single, bifocal, trifocal, and non-standard) Specialty Coatings and Tints

20% to 60% off provider retails fees

Contact Lenses Mail Order Service

10% to 40% off provider retails fees

LASIK (refractive surgery)

40% to 50% off the overall national average

Vision Provider services are not insurance and are provided by New Benefits, Ltd. For provider look-up: www.coasttocoastvision.com. Pan-American Life and New Benefits, Ltd. are not affiliated. The discount vision plan contains a 30 day cancellation period. Not available in KS, UT, VT, and WA. For a full list of disclosures, visit www.dmpodisclosures.com.

15

Weekly Premium Rates PanaMed Weekly Rates*

BASIC PLAN

ENHANCED PLAN

Employee

$22.22

$28.83

Employee + Spouse

$44.15

$58.36

Employee + Child(ren)

$37.01

$48.21

Family

$61.23

$81.26

*Rates include insurance and non-insurance products. For the cost of the insurance product offered by Pan-American Life, contact your Pan-American Life agent. Certain benefits are not available in all states. If you reside in Oklahoma, Kansas and Massachusetts your plan will include certain mandated benefits. If you reside in Connecticut, New Jersey, New York and Vermont please enroll by calling our Enrollment Center Dedicated Line or through our online system. See page 2 for those options. If you reside in Hawaii or Maine coverage is not available. If you reside in New Hampshire coverage is only available if you work outside of New Hampshire. If you reside in Massachusetts, please note, this health plan, alone, does not meet Minimum Creditable Coverage standards and will not satisfy the individual mandate that you have health insurance. Refer to the Exclusions and Limitations page.

Dental / Vision Buy-up Option Weekly Rates

BASIC PLAN

Member

$6.01

Member + Spouse

$12.06

Member + Child(ren)

$13.28

Family

$21.00

Add Short Term Disability – (Employee Only) SHORT TERM DISABILITY BENEFIT •15 day elimination period for accident or illness • Pays up to 66 % of basic income with a maximum weekly benefit amount of $300

Cost to Add Short Term Disability

Up to $300 per week Up to a maximum of 13 weeks

Weekly

Employee Only

$3.86 This Group is domiciled in the state of CALIFORNIA.

16 Pan-American Benefits Solutions, Inc. does business as Pan-American Benefits Solutions Insurance Agency in the state of California. PanaMed is issued by Pan-American Life Insurance Company on policy form number GER-1991-1, GER-2004-1, GER-2007-1, PA-102401-POL, GER-2006-1, PA-102401-POL-FL, PA-102401-POL-IN, PA-102401-POL-IA , GER-2010-I(LA), GER-2007-I(OR), GER-2007-1(WA) or PA-102401-POL-WY. There are no exclusions for pre-existing conditions except for pregnancy in most states. The plan will not pay benefits for any care provided prior to the coverage effective date or if the insured is confined in a hospital at the time the coverage is effective. Hospital does not include a nursing home, convalescent home or extended care facility. Coverage is not available in all states. Like most group benefit programs, our products have exclusions, limitations, waiting periods and terms for keeping them in force. Rates subject to change.

New Hire Enrollment 2014 plan year Coverage starts the first Monday after the first deduction Enroll Week of

Deduction

Effective date

12/23/2013

1/3/14

1/6/2014

12/30/2013

1/10/14

1/13/2014

1/6/2014

1/17/14

1/20/2014

1/13/2014

1/24/14

1/27/2014

1/20/2014

1/31/14

2/3/2014

1/27/2014

2/7/14

2/10/2014

2/3/2014

2/14/14

2/17/2014

2/10/2014

2/21/14

2/24/2014

2/17/2014

2/28/14

3/3/2014

2/24/2014

3/7/14

3/10/2014

3/3/2014

3/14/14

3/17/2014

3/10/2014

3/21/14

3/24/2014

3/17/2014

3/28/14

3/31/2014

3/24/2014

4/4/14

4/7/2014

3/31/2014

4/11/14

4/14/2014

4/7/2014

4/18/14

4/21/2014

4/14/2014

4/25/14

4/28/2014

4/21/2014

5/2/14

5/5/2014

4/28/2014

5/9/14

5/12/2014

5/5/2014

5/16/14

5/19/2014

5/12/2014

5/23/14

5/26/2014

5/19/2014

5/30/14

6/2/2014

5/26/2014

6/6/14

6/9/2014

6/2/2014

6/13/14

6/16/2014

6/9/2014

6/20/14

6/23/2014

6/16/2014

6/27/14

6/30/2014

6/23/2014

7/3/14

7/7/2014

6/30/2014

7/11/14

7/14/2014

17

New Hire Enrollment 2014 plan year Coverage starts the first Monday after the first deduction Enroll Week of

Deduction

Effective date

7/7/2014

7/18/14

7/21/2014

7/14/2014

7/25/14

7/28/2014

7/21/2014

8/1/14

8/4/2014

7/28/2014

8/8/14

8/11/2014

8/4/2014

8/15/14

8/18/2014

8/11/2014

8/22/14

8/25/2014

8/18/2014

8/29/14

9/1/2014

8/25/2014

9/5/14

9/8/2014

9/1/2014

9/12/14

9/15/2014

9/8/2014

9/19/14

9/22/2014

9/15/2014

9/26/14

9/29/2014

9/22/2014

10/3/14

10/6/2014

9/29/2014

10/10/14

10/13/2014

10/6/2014

10/17/14

10/20/2014

10/13/2014

10/24/14

10/27/2014

10/20/2014

10/31/14

11/3/2014

10/27/2014

11/7/14

11/10/2014

11/3/2014

11/14/14

11/17/2014

11/10/2014

11/21/14

11/24/2014

11/17/2014

11/28/14

12/1/2014

11/24/2014

12/5/14

12/8/2014

12/1/2014

12/12/14

12/15/2014

12/8/2014

12/19/14

12/22/2014

12/15/2014

12/26/14

12/29/2014

12/22/2014

1/2/15

1/5/2015

12/29/2014

1/9/15

1/12/2015

18

NOTES ______________________________________________________

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

19

NOTES ______________________________________________________

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

20