140Square.coop

2020 Product Offerings

Medical

&

Prescription Drug Plan Information

Medical Provider Networks

40 Square has two different Provider Networks you can access. If you are seeking care in Minnesota or

the bordering states, you will likely use the PreferredOne network. The PreferredOne provider and

facility listings can be found at www.40Square.coop. Scroll to the bottom of the home page and click

on “See Listings” to search for a clinic or hospital.

40 Square also offers a national network, MultiPlan, for when you are traveling within the United

States or have kids away at college.

Plan$1,500

Deductible$2,500

Deductible$3,500

Deductible*$4,500

Deductible*$5,500

Deductible*$6,550

Deductible*$7,900

Deductible

Benefit In-Network In-Network In-Network In-Network In-Network In-Network In-NetworkAnnual Deductible(embedded)• Individual• Family

$1,500$3,000

$2,500$5,000

$3,500$7,000

$4,500$9,000

$5,500$11,000

$6,550$13,100

$7,900$15,800

Benefit Percentage & Out-of-Pocket Maximum (embedded and includes deductible, coinsurance, co-pays)• Individual• Family

Deductible and 20%, except where

noted below.

$3,000$6,000

Deductible and 25%, except where

noted below.

$7,150$14,300

Deductible and 20%, except where

noted below.

$4,500$9,000

Deductible and 20%, except where

noted below.

$6,550$13,100

Deductible and 25%, except where

noted below.

$6,750$13,500

Deductible and 30%, except where

noted below.

$6,750$13,500

Deductible then 100% covered,

except where noted below.$7,900

$15,800Office Visits (Illness and Injury)• Primary Care• Specialist• Retail Health Clinic• Urgent Care• E-Visits

$40$75$20$50$15

$40$75$20$50$15

20%20%20%20%20%

20%20%20%20%20%

25%25%25%25%25%

30%30%30%30%30%

Deductible then 100% covered

Routine Preventive Care Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Hospital and Professional ServicesInpatient, Outpatient, and Emergency Room

20% 25% 20% 20% 25% 30% Deductible then 100% covered

Prescription DrugsRetail• Generic• Formulary• Non-formulary

Mail-Order• Generic• Formulary• Non-formulary

Specialty (per script)

31-Day Supply$10$40

$10090-Day Supply

$25$100$250

20% to $350

31-Day Supply$10$40

$10090-Day Supply

$25$100$250

25% to $350

20%

20%

20%

20%

25%

25%

30%

30%

Deductible then 100% covered

Deductible then 100% covered

Preventive drugs are covered at a copay

Benefit Out-of-NetworkBenefit Percentage & Out-of-Pocket Maximum (Includes deductible, coinsurance)

Deductible: Individual $10,000 and Family $20,000Benefit Percentage: 50%Maximum Out-of-Pocket: Individual $30,000 and Family $60,000

2020 Health Plan Offerings

40SQ.PUB.1001.2020

*HSA Compatible Plan This is a benefit summary only and does not outline all the benefits and exclusions under the plan. Please see the full legal plan document for details.

Contact Information: 8011 34th Ave. S., Suite 148| Bloomington, MN 55425

1-844-205-9579 | www.40Square.coop

medtrakrx.com

PRESCRIPTION DRUG Benefits

Welcome to MedTrakRx! As your health plan’s trusted prescription drug plan, we are happy to answer your

questions. You can find answers to our most commonly asked questions below.

Will I receive an ID card? If you are new to the plan in 2020, you will receive a 40 Square Health Plan identification card

(ID) in the mail. There is a MedTrakRx logo on this card. Show this card to your pharmacist when you get a prescription

filled on or after January 1, 2020.

Where can I fill my prescriptions?

• Retail Pharmacies. To find out which pharmacies participate, you can log on to MedTrakRx by

going to 40Square.coop, click on Plan Participants then click on Pharmacy locator, or call

MedTrakRx at 1-800-771-4648.

• Performance 90 Pharmacies. These pharmacies are able to fill 90-day supplies of maintenance medications. To find

out which pharmacies participate, you can log on to MedTrakRx by going to 40Square.coop, click on Plan Participants

then click on Pharmacy locator, or call MedTrakRx at 1-800-771-4648.

• EnvisionMail. Mail order can be used to fill 90-day supplies of maintenance medications. The Orchard Mail Order

Enrollment Form should be sent with new written prescriptions from your doctor. Once your initial order has been

processed, subsequent new prescriptions can be faxed from your doctor, or you can continue to mail in new written

prescriptions you receive. Allow two weeks from receipt for delivery.

Is my drug a Formulary or non-Formulary drug? Please refer to the copay structure table within the tables below. You

will pay either the Generic copay or the Brand copay for drugs on the formulary. To determine if your medication is

covered, please refer to the MedTrakRx Select Formulary, which can be found by logging on to www.medtrakrx.com

and clicking on Members →Login Forms and Downloads. Please ask your doctor to prescribe a Generic or Formulary drug

whenever possible.

If you have a combined Medical/Rx Deductible, how does MedTrakRx coordinate with my Health Plan? On January

1st, and the rest of the calendar year, Members are required to pay the total discounted cost of prescriptions until the

combined Medical/Rx deductible under the High Deductible Health Plan is met. After meeting your deductible, you are

responsible for any coinsurance or copays until you reach your Out-of-Pocket Maximum. MedTrakRx will automatically

submit all Rx claims data to your Health Insurance Plan Administrator for reimbursement. These claims will be reimbursed

in accordance with the High Deductible Health Plan rules.

Will I pay more if I choose to fill a Brand drug when a Generic equivalent is available? Yes. If your brand drug has a

generic equivalent, you will pay higher copay, in addition to the difference in cost between the brand and generic

prescription. The difference in cost is not applicable towards the annual Deductible nor the annual Out of Pocket Maximum.

This Plan encourages the use of Generic drugs because in most cases, Generics are just as effective as Brands, and much

less expensive. Please ask your physician and your pharmacist to prescribe and dispense Generic drugs whenever possible.

If your prescription is filled within the state of Minnesota, you will likely be dispensed a Generic drug, as the state of

Minnesota is a mandated generic drug state. If a physician prescribes medication, the pharmacy will automatically fill the

generic equivalent, unless it indicates “Dispense as Written”, in which the brand name will be provided.

How can I find out more about cost savings? Go to Medtrakrx.com. Register online to view important benefit information.

Click on Rx Price Finder to find the cost of specific drugs and lower cost alternatives. Please discuss this information with

your doctor. Switching to the preferred alternative will save you and your health plan money.

What is the difference between a brand and a Generic? Cost. The FDA requires that a generic drug have the same quality

and performance as its brand counterpart. Generics are less expensive because they are not required to repeat costly

clinical trials the brand drug completed, along with lower advertising, marketing and promotion costs. To find out if your

drug offers a lower cost alternative, go to medtrakrx.com and price a medication under Rx Price Finder.

What if a doctor prescribes a drug and the pharmacy offers a generic instead? Generic drugs provide significant value

to both you and your employer. The FDA requires that generics have the same strength, purity and stability as the original

brand product so they work the same as their brand equivalent. Whenever possible, you should use the generic over the

brand equivalent, which will save you and your health plan money without sacrificing effectiveness.

medtrakrx.com

$1,500 Plan

Participating Pharmacy: Retail Performance 90

Mail Service

Maximum Day Supply Allowed: 31 90 90

Generic Copay: $10 $25 $25

Formulary Brand Copay: $40 $100 $100

Non-Formulary Brand Copay: $100 $250 $250

Specialty Medication Copay: 20% of the cost up to $350 with a 30 day supply allowed per fill

Annual Rx / Medical

Combined Out-of-Pocket

Maximum:

$3,000 per Individual, $6,000 per Family beginning every January 1st. Once you

have met this amount, you will pay $0 copay until the end of the benefit year,

December 31st.

$2,500 Plan

Participating Pharmacy: Retail Performance 90

Mail Service

Maximum Day Supply Allowed: 31 90 90

Generic Copay: $10 $25 $25

Formulary Brand Copay: $40 $100 $100

Non-Formulary Brand Copay: $100 $250 $250

Specialty Medication Copay: 25% of the cost up to $350 with a 30 day supply allowed per fill

Annual Rx / Medical Combined

Out-of-Pocket Maximum: $7,150 per Individual, $14,300 per Family beginning every January 1st. Once you

have met this amount, you will pay $0 copay until the end of the benefit year,

December 31st.

$3,500 Plan

Participating Pharmacy: Retail Performance 90

Mail Service

Maximum Day Supply Allowed: 31 90 90

Generic Copay: 20% of cost

20% of cost 20% of cost

Formulary Brand Copay: 20% of cost

20% of cost 20% of cost

Non-Formulary Brand Copay: 20% of cost

20% of cost 20% of cost

Preventive Generic*: $10 $25 $25

Preventive Formulary Brand*: $40 $100 $100

Preventive Non-Formulary Brand*: $100 $250 $250

Annual Rx / Medical

Combined Deductible:

$3,500 per Individual, $7,000 per Family beginning every January 1st. Once

you have met this amount, you will pay the above copays until the end of the

benefit year, December 31st, or until you reach the Out-of-Pocket maximum

as stated below.

*Note: Preventive Medications are N/A towards Deductible.

Annual Rx / Medical Combined

Out-of-Pocket Maximum: $4,500 per Individual, $9,000 per Family beginning every January 1st. Once you

have met this amount, you will pay $0 copay until the end of the benefit year,

December 31st.

medtrakrx.com

$4,500 Plan

Participating Pharmacy: Retail Performance 90

Mail Service

Maximum Day Supply Allowed: 31 90 90

Generic Copay: 20% of cost

20% of cost 20% of cost

Formulary Brand Copay: 20% of cost

20% of cost 20% of cost

Non-Formulary Brand Copay: 20% of cost

20% of cost 20% of cost

Preventive Generic*: $10 $25 $25

Preventive Formulary Brand*: $40 $100 $100

Preventive Non-Formulary Brand*: $100 $250 $250

Annual Rx / Medical

Combined Deductible:

$4,500 per Individual, $9,000 per Family beginning every January 1st. Once

you have met this amount, you will pay the above copays until the end of the

benefit year, December 31st, or until you reach the Out-of-Pocket maximum

as stated below.

*Note: Preventive Medications are N/A towards Deductible.

Annual Rx / Medical Combined

Out-of-Pocket Maximum: $6,550 per Individual, $13,100 per Family beginning every January 1st. Once you

have met this amount, you will pay $0 copay until the end of the benefit year,

December 31st.

$5,500 Plan

Participating Pharmacy: Retail Performance 90

Mail Service

Maximum Day Supply Allowed: 31 90 90

Generic Copay: 25% of cost

25% of cost 25% of cost

Formulary Brand Copay: 25% of cost

25% of cost 25% of cost

Non-Formulary Brand Copay: 25% of cost

25% of cost 25% of cost

Preventive Generic*: $10 $25 $25

Preventive Formulary Brand*: $40 $100 $100

Preventive Non-Formulary Brand*: $100 $250 $250

Annual Rx / Medical

Combined Deductible:

$5,500 per Individual, $11,000 per Family beginning every January 1st. Once

you have met this amount, you will pay the above copays until the end of the

benefit year, December 31st, or until you reach the Out-of-Pocket maximum

as stated below.

*Note: Preventive Medications are N/A towards Deductible.

Annual Rx / Medical Combined

Out-of-Pocket Maximum: $6,750 per Individual, $13,500 per Family beginning every January 1st. Once you

have met this amount, you will pay $0 copay until the end of the benefit year,

December 31st.

medtrakrx.com

$6,550 Plan

Participating Pharmacy: Retail Performance 90

Mail Service

Maximum Day Supply Allowed: 31 90 90

Generic Copay: 30% of cost

30% of cost 30% of cost

Formulary Brand Copay: 30% of cost

30% of cost 30% of cost

Non-Formulary Brand Copay: 30% of cost

30% of cost 30% of cost

Preventive Generic*: $10 $25 $25

Preventive Formulary Brand*: $40 $100 $100

Preventive Non-Formulary Brand*: $100 $250 $250

Annual Rx / Medical

Combined Deductible:

$6,550 per Individual, $13,100 per Family beginning every January 1st. Once

you have met this amount, you will pay the above copays until the end of the

benefit year, December 31st, or until you reach the Out-of-Pocket maximum

as stated below.

*Note: Preventive Medications are N/A towards Deductible.

Annual Rx / Medical Combined

Out-of- Pocket Maximum: $6,750 per Individual, $13,500 per Family beginning every January 1st. Once you

have met this amount, you will pay $0 copay until the end of the benefit year,

December 31st.

$7,900 Plan

Participating Pharmacy: Retail Performance 90

Mail Service

Maximum Day Supply Allowed: 31 90 90

Generic Copay: Deductible then 100% covered

Formulary Brand Copay: Deductible then 100% covered

Non-Formulary Brand Copay: Deductible then 100% covered

Preventive Generic*: $10 $25 $25

Preventive Formulary Brand*: $40 $100 $100

Preventive Non-Formulary Brand*: $100 $250 $250

Annual Rx / Medical

Combined Deductible:

$7,900 per Individual, $15,800 per Family beginning every January 1st. Once

you have met this amount, you will pay the above copays until the end of the

benefit year, December 31st, or until you reach the Out-of-Pocket maximum

as stated below.

*Note: Preventive Medications are N/A towards Deductible.

Annual Rx / Medical Combined

Out-of-Pocket Maximum: $7,900 per Individual, $15,800 per Family beginning every January 1st. Once you

have met this amount, you will pay $0 copay until the end of the benefit year,

December 31st.

What if I have more questions? We want to help you! We highly encourage you to call a MedTrakRx Pharmacy Benefit

Advisor at 1-800-771-4648 or visit our website at www.Medtrak.com. In addition, if you encounter any issues when visiting

your local pharmacy, please ask the pharmacist to call us so we can assist them right away!

This is practical information regarding your Prescription Benefit Plan. For a more detailed description of your Health Plan,

please refer to your Summary Plan Description (SPD) provided to you by your employer and/or the Medical Benefits

provider. If you have any questions, please call MedTrakRx at 1-800-771-4648.

800.771.4648 | medtrakrx.com Additional medications may be included in this list from time to time in compliance applicable laws and regulations.

MedTrakRx makes no representations regarding its compliance with applicable legal requirements.

2020 Preventive Medication List Brands and Generics Your pharmacy benefit plan includes coverage before your deductible has been met for certain preventive medications. You may or may not have a copay for these medications. These drugs help protect against or manage a medical condition. Preventive drugs are intended to maintain your quality of life and keep you from developing other health conditions. This is a listing of the most commonly prescribed preventive drugs. The list is not all-inclusive and is subject to change. It also does not account for drugs which are excluded and/or limited by your specific plan design and/or formulary. For questions regarding medications not listed or other pharmacy related inquiries, please call MedTrakRx at 800-771-4648

Anticoagulants/Antiplatelets

ASA/dipyridamole BEVYXXA BRILINTA Cilostazol Clopidogrel Dipyridamole ELIQUIS Enoxaparin Fondaparinux FRAGMIN Jantoven Prasugrel SAVAYSA Warfarin XARELTO

Bone Disease

Alendronate Calcitonin Spray FOSAMAX+D Ibandronate Risendronate

Cardiovascular Agents

Anti-Arrhythmic Agents

Amiodarone Disopyramide Dofetilide Flecainide Mexiletine MULTAQ Pacerone Propafenone Quinidine

Sorine

Anti-Anginal Agents

Isosorbide Dinitrate Isosorbide Mononitrate Minitran injections Nitroglycerin capsule Nitroglycerin patch Nitroglycerin sub-lingual

Cathartics and Laxatives

Bisacodyl Enemas Fiber tablets/powders Magnesium Citrate Metamucil Milk of magnesia PEG-3350/electrolytes Stool Softeners

Cholesterol Lowering Agents

HMG-CoA Reductase Inhibitors

Atorvastatin Fluvastatin LIVALO Lovastatin Pravastatin Rosuvastatin Simvastatin Simvastatin/Ezetimibe ZYPITAMAG

Other agents

ANTARA

Cholestyramine Light Powder Cholestyramine Powder Colestipol granules Colesevelam Colestipol tablets Ezetimibe Fenofibrate Fenofibrate Micronized FIBRICOR Gemfibrozil LIPOFEN Niacin ER Omega-3-Acids VASCEPA

Depression

Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline

Diabetes

Diagnostic Agents & Supplies

GLUCAGON INSULIN SYRINGES LANCETS LANCET DEVICES METERS PEN NEEDLES TEST STRIPS

Insulins

ADMELOG AFREZZA

800.771.4648 | medtrakrx.com Additional medications may be included in this list from time to time in compliance applicable laws and regulations.

MedTrakRx makes no representations regarding its compliance with applicable legal requirements.

APIDRA BASAGLAR FIASP HUMALOG/HUMULIN LANTUS LEVEMIR NOVOLOG/NOVOLIN TOUJEO TRESIBA

Non-Insulin Agents

Acarbose ADLYXIN ALOGLIPTAN AVANDIA BYDUREON BYETTA CHLORPROPAMIDE FARXIGA Glimepiride Glipizide Glipizide/Metformin Glyburide Glyburide/Metformin INVOKANA JANUVIA JARDIANCE Metformin Metformin ER Miglitol Nateglinide NESINA ONGLYZA OZEMPIC Pioglitazone Pioglitazone/Glimepiride Pioglitazone/Metformin Repaglinide SEGLUROMET STEGLATRO STEGLUJAN SYMLINPEN TANZEUM Tolbutamide TRADJENTA TRULICITY VICTOZA

Hormonal Contraceptives

Oral Injectable PATCH

Hypertension

ACE Inhibitors and Combinations

Benazepril Benazepril/HCTZ Captopril Captopril/HCTZ Enalapril Enalapril/HCTZ Fosinopril Fosinopril/HCTZ Lisinopril Lisinopril/HCTZ Moexipril Moexipril/HCTZ Perindopril Quinapril Quinapril/HCTZ Ramipril Trandolapril

ARBs and Combinations

Candesartan Candesartan/HCTZ Irbesartan Irbesartan/HCTZ Losartan Losartan/HCTZ Olmesartan Olmesartan/HCTZ Telmisartan Telmisartan/HCTZ Valsartan Valsartan/HCTZ

Beta Blockers

Acebutolol Atenolol Atenolol/Chlorthalidone Betaxolol Bisoprolol

Bisoprolol/HCTZ Carvedilol Esmolol Injection Labetalol Metoprolol Metoprolol/HCTZ Nadolol Pindolol Propranolol Sotalol

Calcium Channel Blockers

Afeditab CR Amlodipine Cartia XT Diltiazem Felodipine Isradipine Matzim LA Nicardipine Nifedipine Nimodipine Nisoldipine Taztia XT Verapamil

Mixed Combination Agents

Amlodipine/Atorvastatin Amlodipine/Benazepril Amlodipine/Olmesartan Amlodipine/Valsartan Amlodipine/Valsartan/HCTZ Olmesartan/Amlodipine/HCTZ Telmisartan/Amlodipine Trandolapril/Verapamil

Diuretics

Acetazolamide Amiloride Amiloride/HCTZ Bumetamide Chlorothiazide Chlorthalidone Furosemide Hydrochlorothiazide Indapamide Mannitol Injection

800.771.4648 | medtrakrx.com Additional medications may be included in this list from time to time in compliance applicable laws and regulations.

MedTrakRx makes no representations regarding its compliance with applicable legal requirements.

Methazolamide Metolazone Osmitrol Injections Spironolactone Spironolactone/HCTZ Torsemide

Immunizations

DIPTHERIA HAEMOPHILUS INFLUENZAE B HEPATITIS A and B HUMAN PAPILLOMAVIRUS INFLUENZA MEASLES MENINGOCOCCAL MUMPS PERTUSSIS PNEUMOCOCCAL POLIOVIRUS ROTAVIRUS RUBELLA SHINGLES TETANUS TYPHOID VARICELLA

Respiratory Disorders

ADVAIR HFA AIRDUO Albuterol Tablets Albuterol Nebulizer Soln Albuterol Sulfate HFA Albuterol Syrup ALVESCO ANORO ELLIPTA ARCAPTA ARNUITY ARMONAIR ASMANEX ATROVENT HFA BEVESPI BREO ELLIPTA BROVANA Budesonide Suspension COMBIVENT

Cromolyn Sodium DULERA Epinephrine Injection EPIPEN EPIPEN JR FLOVENT Fluticasone/Salmeterol Aer Ipratropium Soln Ipratropium/Albuterol Soln Levalbuterol HFA Levalbuterol Soln Montelukast PEAK FLOW METERS PROAIR PROVENTIL PULMICORT QVAR SEREVENT SPACER DEVICES SPIRIVA STIOLTO SYMBICORT Terbutaline Theophylline TRELEGY ELLIPTA UTIBRON VENTOLIN Wixela Aer Zafirlukast

Smoking Deterrents

Bupropion SR 150mg CHANTIX Nicotine Gum Nicotine Lozenge Nicotine Patch NICOTROL INHALER NICOTROL NASAL SPRAY

Vitamins

Fluoride Preparations Children’s Multivitamin PRENATAL VITAMINS

!!!!!!!!!!!!!!!!!!!!!!!

24x7 Access to a Licensed Medical Doctor!

Are you sick? Call HealthiestYou first! We provide you round the clock access to a doctor that can handle up to 70% of typical doctor’s office visits from the comfort of your own home with NO CONSULT FEES! Register and access your HealthiestYou account online at member.healthiestyou.com! Doctor Hotline: 1-866-703-1259 !!

Your New Guide to Better Health!Stressed out? Let HealthiestYou guide you to improved health and happiness with a custom wellness program designed just for you! It’s ABSOLUTELY FREE with your membership. Register and access your wellness program at program.healthiestyou.com/register

Huge Prescription Savings!Need a prescription? HealthiestYou provides you with a location based custom prescription search tool that can save you up to 85% on your prescription and will OFTEN BEAT YOUR COPAY. It’s also FREE with your membership. Access the prescription search awesomeness at member.healthiestyou.com

Pssst! HealthiestYou is Awesome. !

| support@healthiestyou.com | 480.779.4360!

Top 50 HY Diagnoses 1- ACUTE UPPER RESPIRATORY INFECTIONS OF UNSPECIFIED SITE2- ACUTE SINUSITIS UNSPECIFIED3- ACUTE PHARYNGITIS4- URINARY TRACT INFECTION5- ACUTE BRONCHITIS6- ACUTE CONJUNCTIVITIS UNSPECIFIED7- UNSPECIFIED OTITIS MEDIA8- STREPTOCOCCAL SORE THROAT9- ALLERGIC RHINITIS CAUSE UNSPECIFIED10- COUGH11- INFECTIVE OTITIS EXTERNA UNSPECIFIED12- ACUTE NASOPHARYNGITIS (COMMON COLD)13- OTALGIA UNSPECIFIED14- OTHER ACUTE PAIN15- CONTACT DERMATITIS, NOS16- RASH AND OTHER NONSPECIFIC SKIN ERUPTION17- VAGINITIS AND VULVOVAGINITIS UNSPECIFIED18- CANDIDIASIS OF VULVA AND VAGINA19- ABDOMINAL PAIN UNSPECIFIED SITE20- CELLULITIS AND ABSCESS OF UNSPECIFIED SITES21- ACUTE CYSTITIS22- HERPES SIMPLEX WITHOUT COMPLICATION23- FEVER UNSPECIFIED24- ACUTE TONSILLITIS25- PAIN, LOW BACK26- UNSPECIFIED DENTAL CARES27- UNSPECIFIED VIRAL INFECTION28- INFECTIOUS COLITIS ENTERITIS AND GASTROENTERITIS29- CONJUNCTIVITIS, VIRAL NOS30- INFLUENZA WITH OTHER RESPIRATORY MANIFESTATIONS31- OTHER ACUTE OTITIS EXTERNA32- ACUTE GOUTY ARTHROPATHY33- EXERCISE-INDUCED BRONCHOSPASM34- UNSPECIFIED CONSTIPATION35- NAUSEA WITH VOMITING36- CROUP37- UNSPECIFIED ESSENTIAL HYPERTENSION38- DEHYDRATION39- CONJUNCTIVITIS, MUCOPURULENT40- ALLERGIC URTICARIA41- TOBACCO USE DISORDER42- DIARRHEA OF PRESUMED INFECTIOUS ORIGIN43- INSECT BITE NONVENOMOUS OF TRUNK WITHOUT INFECTION44- CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OTHER SPECIFIED AGENTS45- SCABIES46- ACUTE SWIMMERS' EAR47- DIARRHEA, NOS48- MYALGIA AND MYOSITIS UNSPECIFIED49- HERPES ZOSTER WITHOUT COMPLICATION50- EXTERNAL HEMORRHOIDS WITHOUT COMPLICATION

Ancillary Offerings

Vision, Dental & Life

40 Square Health Plan Trust Dental Highlight Sheet

www.reliancestandard.com

Plan Benefit Preventive Services 100% Basic Services 50% Major Services 50%

Deductible $50/Calendar Year For Basic and Major Services Waived for Preventive

$150 Deductible Maximum per Family Maximum (per person) $1,000 per insured per calendar year PPO Passive Network – Incentive to go in-network Allowance 90th U&C (no penalty going out –of-network) Waiting Period None Annual Open Enrollment Yes

Sample Procedure Listing (Current Dental Terminology © American Dental Association.)

Type 1 Type 2 Type 3 Routine Exam (1 in 6 months)

Bitewing X-rays (1 in 12 months)

Full Mouth/Panoramic X-rays

(1 in 5 years)

Periapical X-rays

Cleaning (1 in 6 months)

Fluoride for Children 13 and under

(1 in 6 months)

Sealants (age 15 and under)

Space Maintainers

Restorative Amalgams

Restorative Composites

Crown Repair

Denture Repair

Simple Extractions

Complex Extractions

Anesthesia

Onlays

Crowns (1 in 10 years per tooth)

Prosthodontics (fixed bridge; removable

complete/partial dentures) (1 in 10 years)

Endodontics (nonsurgical)

Endodontics (surgical)

Periodontics (nonsurgical)

Periodontics (surgical)

Monthly Rates

Employee Only (EE) $42.60EE + 1 $85.76EE + 2 or More $154.24

Carrier: Reliance Standard Life Insurance Company

Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered.

Limitations Any treatment which is for cosmetic purposes, except as specifically listed in the Table of Dental Procedures. Any procedure which is not shown on the Table of Dental Procedures. For orthodontic treatment. Any benefits which the plan member is entitled to under any workmen's compensation or similar law. Services not required for necessary care and treatment or are not within the generally accepted parameters of care. Any procedure begun before the plan member was covered under the dental expense benefit. Initial placement of any dental prosthesis or prosthetic crown unless such placement is needed because of the extraction of one or more teeth while the plan member is covered. Because of war or any act of war, declared or not.

Dental NetworkTo find a dental provider in the network, simply to go www.reliancestandard.com, then click the “find dental and vision providers near you” icon under the “I am an employee / individual” column of the home page, then click “find a dentist”, then input requested zip code and “Classic PPO” if network is requested, and finally click on “search now”.

In-Network Plan Highlights

• If the member chooses a frame exceeding theframe allowance, he/she will receive a 20%discount off the excess amount

• Enjoy 20% off additional non-covered complete

pairs of prescription glasses and sunglasses

• Contact lens exam, fitting and follow-uphave a maximum member cost of $60

• Get special pricing on lens options• For LASIK or PRK, save an average of 15% off the

usual price—or 5% off the promotional price—with VSP and a contracted laser surgery center

• VSP network includes access to retail chains

• Costco® Optical and Visionworks® retail chainaffliate providers offer members an in-networkexperience

• Costco frames are the wholesale equivalent,no membership required for eye exam;Visionworks frames match in-networkallowance, Visionworks stores includeEyeMasters® and many more

• These retail chain affliates may offer VSPsavings on LASIK or PRK

• Find a provider at reliancestandard.com/dental-vision or call VSP at 800.877.7195

Sharper Vision Specifics

• Members pay a $10 annual deductible on examsand $25 annual deductible on materials

• Frequency for Exam-Lenses-Frame is 12-

12-24 months

• Contacts are in lieu of other lens benefits.

Sharper Vision – Option A [V20021]

The VSP Choice Network includes more than 27,000 providers and 43,000 access points.

Sharper Vision Benefits VSP Choice Network Out-of-Network

Annual Eye Exam 100% covered* covers up to $45*

Single Vision Lenses 100% covered* covers up to $30*

Bifocal Lenses 100% covered* covers up to $50*

Trifocal Lenses 100% covered* covers up to $65*

Lenticular Lenses 100% covered* covers up to $100*

Frame covers up to $150* covers up to $75*

Contact Lenses covers up to $150 covers up to $120

Progressive lenses covered up to bifocal allowance with a member cost of $55-175

*subject to $10 annual deductible on exams and $25 annual deductible on materials

Monthly Rates

3-tiered rates

Employee $ 9.40

Employee & One Dependent $ 18.80

Employee & Two or More $ 26.92

he VSP Choice Network includes more than 27,000 providers and 43,000 access points.

Sharper Vision – Option B [V20001]

The VSP Choice Network includes more than 27,000 providers and 43,000 access points.

Sharper Vision Benefits VSP Choice Network Out-of-Network

Annual Eye Exam 100% covered* covers up to $45*

Single Vision Lenses 100% covered* covers up to $30*

Bifocal Lenses 100% covered* covers up to $50*

Trifocal Lenses 100% covered* covers up to $65*

Lenticular Lenses 100% covered* covers up to $100*

Frame covers up to $130* covers up to $70*

Contact Lenses covers up to $130 covers up to $105

Progressive lenses covered up to bifocal allowance with a member cost of $55-175

*subject to $10 annual deductible on exams and $25 annual deductible on materials

Monthly Rates

3-tiered rates

Employee $ 8.52

Employee & One Dependent $ 17.01

Employee & Two or More $ 24.36

40 Square Health Plan Trust - Vision Highlight SheetSharper Vision (VSP Network)We do everything in our power to make sure you and your employees are satisfied. That includes offering Sharper Vision, our vision plans featuring the VSP® nationwide network. Choose a VSP provider and VSP guarantees 100% satisfaction.

VSP Vision Limitations and Exclusions • Please check for availability in your state.

• Covered Expenses will not include, and no benefits will be payable for, expenses incurred for:

1 ) E ye exam more than once in any 12-month period or lenses more than once in any 12-monthperiod.

2) Frames more than once in any 24-month period.

3) E lective contact lenses more than once in any 12-month period. Contact lenses and associated expensesare in lieu of any other lenses or frame benefit.

4) M edically necessary contact lenses more than once in any 12-month period. The treating providerdetermines if an insured meets the coverage criteria for this benefit. This benefit is in lieu of electivecontact lenses.

• Any procedure to change the shape of the cornea in order to reduce myopia.

• R efitting of contact lenses after the initial 90-day fitting period.

• Contact lens insurance policies or service contracts.

• A dditional office visits associated with contact lens pathology.

• Contact lens modification, polishing or cleaning.

• Orthoptics or vision training and any associated supplemental testing.

• P lano lenses (lenses with refractive correction of less than plus or minus .50 diopter) except as specificallyallowed in the frames benefit section of the Plan Benefits.

• T wo pairs of glasses in lieu of bifocals.

• R eplacement of spectacle lenses, frames, and/or contact lenses furnished under this plan that are lost ordamaged, except at the normal intervals when services are otherwise available.

• M edical or surgical treatment of the eyes.

• Claims filed more than 180 days after completion of the service. An exception is if the Insured shows it wasnot possible to submit the proof of loss within this period.

• T he following materials, over and above the covered expense for the basic material: blended lenses, oversizedlenses, and photochromic or tinted lenses except pink #1 and #2.

1) Coating or laminating of the lens or lenses.

2) Corrective vision treatments that are experimental.

3) Corneal refractive therapy (CRT).

• Costs for services and/or materials that exceed the maximum covered expense.

• S ervices or materials that are cosmetic, including plano contact lenses to change eye color and artisticallypainted contact lenses.

• S ervices and/or materials not specifically included in the Schedule as covered Plan Benefits.

• Local, state and/or federal taxes, except where law requires us to pay.

• M embership fees for any retail center in which an Affliate or Open Access provider office may be located.

• Covered persons may be required to purchase a membership in such entities as a condition of accessing PlanBenefits.

Voluntary Group Term LifeInsurance

40 Square Health Plan Trust Life Highlight Sheet

ELIGIBILITY Employees: Each Active Member, except any person working on a temporary or seasonal basis. Dependents: You must be insured in order for your Spouse or Dependent children to be covered.Dependents are:

Your legal spouse under age 70. Spouse coverage terminates at age 75.

Your unmarried financially dependent children* age 14 days to 20 years (to 26 years if full‐time student).*natural and adopted children upon finalization of adoption;stepchildren and foster children living with you.Age limit does not apply to handicapped children. A person may not have coverage as both an Employee andDependent.Only one insured spouse may cover Dependent children.

BENEFIT AMOUNT Employee: Choose from a minimum of $10,000 to a maximum of $100,000 (in $10,000 increments).

Spouse: $10,000 or $20,000

Eligible Dependent Child(ren): 14 Days to 6 months: $1,000 Age 6 months to 20 years of age (26, if full‐time student): $10,000

GUARANTEED ISSUE (INITIAL ELIGIBILITY PERIOD ONLY) Employee: Under age 70 - $100,000

Age 70 or Older - None Spouse: Under Age 60 - $20,000

Age 60 or Older - NoneChild: all child amounts are guaranteed issue.

Guaranteed Issue is subject to underwriting rules and is not available in all circumstances.

CONTRIBUTION REQUIREMENTSCoverage is employee paid.

BENEFIT REDUCTION DUE TO AGE (applicable to employee coverage) AT AGE FACE AMOUNT REDUCES TO:

75‐79 60% of available or in force amount at age 74

80‐84 35% of available or in force amount at age 74

85‐89 27.5% of available or in force amount at age 74

90‐94 20% of available or in force amount at age 74

95‐99 7.5% of available or in force amount at age 74

100 + 5% of available or in force amount at age 74

FEATURES Living Benefit Rider (expressed as Accelerated Death Benefit in

some states and Imminent Death Benefit in PA)FMLA/MSLA Continuation

Portability Waiver of Premium

EXCLUSIONS Death by suicide is not covered during the first two years an insured’s insurance is in force. Insurance coverage is incontestable after it has been in force two years during the insured’s lifetime, except for non‐payment of premium.

For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits.

This Plan Highlights is a brief description of the key features of the RSL insurance plan. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS‐8349, et al.

www.RelianceStandard.com

15

8011 34th Ave. South, Suite 148Bloomington, MN 55425Co-op: 1-844-205-9579Customer Service: 1-877-314-9737

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