Plan Year 2018 - Pallet Logistics of America [PDF]

Benefit Plan Enrollment Guide

Plan Year 2018

Dear Employee, Effective January 1st, 2018, Pallet Logistics will continue to offer two medical plan options. We will continue to offer a major medical plan through UnitedHealthcare that provides unlimited coverage for physician office visits, prescription drugs and hospitalization after the applicable cost share. Covered hospital services are unlimited and covered at 100% after the member has met the applicable deductible and coinsurance cost share. Preventive care is covered at 100% and is not subject to any member cost sharing. Also offered is an Essential Preventive Plan + Limited Benefit Indemnity Plan administered by Century Healthcare that will provide preventive care benefits in addition to limited medical plan options that include: • • • • • • •

Physician visits Diagnostic, x-ray or lab testing Hospital confinement Inpatient and outpatient surgery Adult and child wellness visits Physical therapy Prescription Drugs and much more

Eligible preventive services are paid at 100% when performed by an in-network physician. That means that you pay nothing out of pocket for access to a variety of medical screenings, exams, and immunizations which may help reduce your risk of developing health conditions in the future and avoid expensive treatment down the road. The Essential Preventive Plan meets the minimum essential coverage as required by the new health care reform law and satisfies the individual requirements under the Affordable Care Act associated with the individual mandate penalty. Included with the Essential Preventive Plan is a Limited Benefit Indemnity Plan, also provided by Century Healthcare, that will provide supplemental benefits. Although limited medical is not a major medical plan it is designed to help cover some of the costs of everyday medical needs for services such as doctor's office visits, diagnostic tests, x-rays, hospitalization, prescriptions, access to a doctor over the phone, 24/7 Nurseline and more. We will also continue to offer dental, vision, and other elective benefits. In the following pages you will find plan summaries that detail each of the benefits included in our plans, along with how much each of them pays. You will also find important information regarding additional benefits and services included in your plan.

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IMPORTANT INFORMATION ABOUT WHAT HAPPENS IF YOU DON’T ENROLL IN HEALTHCARE COVERAGE If you do not have health coverage in 2018, you may have to pay a penalty. This penalty is sometimes called a "fine," "individual responsibility payment," or "individual mandate.“

The penalty is calculated one of 2 ways. If you or your dependents do not have insurance that qualifies as minimum essential coverage you will pay whichever of these amounts is higher. For detailed information, including a personal fee estimator, you can visit: https://www.healthcare.gov/fees/fee-for-not-being-covered/.

It's important to remember that even if you pay the penalty you will still not have health insurance coverage and will still be responsible for 100% of the cost of your medical care.

The penalty increases every year and is adjusted for inflation. You will pay the 2018 penalty on your 2019 federal income tax return. It's important to remember that even if you pay the penalty you still do not have any health insurance coverage and therefore responsible for 100% of the cost of your medical care. To assist you with filing your taxes and determining your actual penalty, Pallet will issue a 1095-C to include it with your tax return. NOTE: By enrolling in the Minimum Essential Coverage (MEC) plan you and your enrolled family members can avoid the above penalties.

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Table of Contents Page Benefit Overview

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Medical Coverage • • •

Essential Preventive Benefits Limited Benefit Indemnity Benefits Major Medical PPO Plan

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Dental Coverage

27

Vision Coverage

29

Life and Accidental Death and Dismemberment Insurance

31

Voluntary Products

34

Rate Summary

39

Contacts

44

Summary of Benefits and Coverage- Minimum Essential Coverage

44

Required Notices

50

Benefits Overview

2018 Benefits Overview We will continue to offer the same benefit options as last year to include:

Medical 1. Essential Preventive Care Benefits + Limited Medical Indemnity Plan – Century Health • 100% Preventive Care Coverage • Limited Reimbursement for Medical Services • Prescription Drug Discount Card (New Vendor: HealthCare Highways) • Healthiest you Telemedicine (Unlimited Calls with a Physician and $0 cost per Consultation/Call) • 24-Nurseline • $10,000 Term Life and AD&D Insurance Benefit • $5,000 Critical Illness Benefit • Health Advocate 2. Major Medical Plan - UnitedHealth Care

Dental – Careington Dental •

Option to Purchase Dental Reimbursement Plan

Vision – Davis Vision •

Option to Purchase Vison Coverage

Aflac •

Option to Purchase Aflac Coverage • Universal Coverage • Accident Coverage • Critical Care and Recovery Coverage • Cancer Care Plan • Hospital

This Benefit Guide contains a brief overview of the plans outlined above. It is important to note that some of the benefit plans illustrated in this enrollment guide require a minimum amount of participation, and if the participation requirements are not met, the plan(s) may not be available. This booklet highlights the main features of many of the benefit plans sponsored by Pallet Logistics of America. Full details of these benefits are contained in the legal documents governing the plans. If there is any discrepancy or conflict between the plan documents and the information presented here, the plan documents will govern. In all cases, the plan documents are the exclusive source for determining rights and benefits under the the plans. Pallet Logistics of America reserves the right to change or discontinue the plans at any time. Participation in the plans does not constitute an employment contract. Pallet Logistics of Americas reserves the right to modify, amend, or terminate any benefit plan or practice described in this guide. Nothing in this guide guarantees that any new plan provisions will continue in effect for any period of time. This guide services as a summary of material modifications as required by the Employee Retirement Income Security Act of 1974, as amended.

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2018 Open Enrollment Who is Eligible?

If you are a full-time employee (working 30 or more hours per week), you and your eligible dependents can enroll in the benefits described in this guide. New hires will become eligible for benefits on the 1st of the month following 60 days from the date of hire.

How to Enroll

The first step is to review your benefit options and evaluate your needs for the year by reviewing your benefits outlined in this guide.

Current Employees

Enrollment counselors will be on-site at your work location during specified times between November 7th through November 17th to answer questions and enroll you in your benefits or give you the opportunity to decline coverage for the 2018 plan year. Employees hired after October 2017 who do not currently have benefits and wish to enroll are required to sit with an enrollment specialist to review all benefit plans. Your supervisor will inform you of the specific dates the enrollers will be at your location.

Note to ALL employees:

• Once you have made your elections, you will not be able to change them until the next open enrollment period unless you have a qualifying event. • You will be automatically enrolled in the Essential Preventive Plan + Limited Benefit Indemnity Plan unless you decline coverage by the enrollment deadline. • If you are currently receiving a subsidy for coverage purchased though the federal health exchange, you will no longer be eligible to receive the subsidy.

How to Make Changes Beyond Open Enrollment

Unless you have a qualified change in status due to a life event, you cannot make changes to the benefits you elect until the next open enrollment period. Life events include marriage, divorce, legal separation, birth or adoption of a child, change in child’s dependent status, death of spouse, child or other qualified dependent, change in residence due to an employment transfer for you or your spouse, or losing or gaining coverage elsewhere. You have 30 days from a qualifying event to make changes to your current coverage. If you have one of these situations, please contact Human Resources at (972) 850-5017.

The information provided in this guide is a brief outline of benefits. Your certificate of coverage governs the terms and conditions of your plan. If you would like to see a copy of this certificate, please contact your HR Department. 6

Medical Coverage

Essential Preventive Plan Century Healthcare

Included as part of Pallet Logistics of America benefit offering is an Essential Preventive Plan which will cover eligible preventive services at 100% when performed in-network. That means that you pay nothing out of pocket for access to a variety of medical screenings, exams, and immunizations which may help reduce your risk of developing health conditions in the future and avoid expensive treatment down the road. The Essential Preventive Plan meets the minimum essential coverage as required by the new health care reform law and satisfies the individual requirements under the Affordable Care Act associated with the individual mandate penalty.

Understanding Preventive Care

Preventive care is the first step in knowing how healthy you are. The goal is to “prevent” serious health conditions by detecting problems early on. Preventive care includes screenings, tests, medicines and counseling performed or prescribed by your doctor or other health care provider to test for conditions which may develop even when you don’t have signs or symptoms of an injury or illness. Your provider is able to deliver treatment which can prevent you from getting sick and by counseling you on beneficial lifestyle changes or offering prophylactic treatment.

Difference Between Preventive and Diagnostic Services

A preventive procedure starts with the intent of confirming your good health although you may appear asymptomatic. Diagnostic services differ in that they are requested in order to identify the cause of a reported health condition.

Services are considered Preventive Care when a person:

• Does not have symptoms indicating an abnormality • Has had a screening done within the recommended age and gender guidelines with the results being considered normal • Has had a diagnostic service with normal results, after which the physician recommends future preventive care screenings using the appropriate age and gender guidelines • Has a preventive service that results in diagnostic care or treatment being done at the same time and as an integral part of the preventive service (e.g. polyp removal during a preventive colonoscopy), subject to benefit plan provisions

Services are considered Diagnostic Care when:

• Services are ordered due to current issues or symptoms(s) that require further diagnosis • Abnormal test results on a previous preventive or diagnostic screening test requires further diagnostic testing or services • Abnormal test results found on a previous preventive or diagnostic service requires the same test be repeated sooner than the normal age and gender guideline recommendations would require

Are Preventive Care Services covered only when performed in-network?

Yes, these preventive services are only covered under the Essential Preventive Plan when performed by an innetwork provider. Your plan includes access to one of the largest preferred provider organization (PPO) networks. Details for locating an in-network provider can be found in the PPO Provider Network section of this guide.

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Essential Preventive Plan Century Healthcare

Covered Preventive Services for Adults

Additional Covered Preventive Services for Women

Screenings for:

• Abdominal aortic aneurysm (one-time screening for men of specified ages who have ever smoked) • Alcohol misuse • Blood pressure • Cholesterol (for adults of certain ages or at higher risk) • Colorectal cancer (for adults over 50) • Depression • Type 2 diabetes (for adults with high blood pressure) • HIV (for all adults at higher risk) • Obesity • Tobacco use • Syphilis (for all adults at higher risk)

• Contraception (FDA approved contraceptive methods, sterilization procedures) • Well-woman visits (to obtain recommended preventive services for women under 65)

Screenings for:

• Breast cancer (mammography every 1 to 2 years for women over 40) • Cervical cancer (for sexually active women) • Chlamydia infection (for younger women and other women at higher risk) • Domestic and interpersonal violence • Gestational diabetes (for those at high risk) • Gonorrhea (for all women at higher risk) • Osteoporosis (for women over age 60 depending on risk factors)

Counseling for:

• Alcohol misuse • Aspirin use for men and women of certain ages and cardiovascular risk factors • Diet (for adults with higher risk for chronic disease) • Obesity • Sexually transmitted infection (STI) prevention (for adults at higher risk) • Tobacco use (including programs to help you stop using tobacco)

Counseling for:

• BRCA (counseling about genetic testing for women at higher risk) • Breast cancer chemoprevention (for women at higher risk) • Contraception (education and counseling) • Domestic and interpersonal violence • Folic acid supplements (for women of childbearing ages)

Immunizations:

• Doses, recommended ages, and recommended populations vary. • Diphtheria, pertussis, tetanus (DPT) • Hepatitis A • Hepatitis B • Herpes zoster • Human papillomavirus (HPV) • Influenza (Flu) • Measles, mumps, rubella (MMR) • Meningococcal (meningitis) • Pneumococcal (pneumonia) • Varicella (chicken pox)

Additional services for pregnant women:

• Anemia screenings • Bacteriuria urinary tract or other infection screenings • Breast feeding interventions to support and promote breast feeding after delivery • Expanded counseling on tobacco use • Gestational diabetes (screening for women 24 to 28 weeks pregnant) • Hepatitis B counseling (at the first prenatal visit) • Rh incompatibility screening, with follow-up testing for women at higher risk

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Essential Preventive Plan Century Healthcare

Covered Preventive Services for Children

Immunizations:

From birth to age 18. Doses, recommended ages, and recommended populations vary. • Diphtheria, pertussis, tetanus (DPT) • Hæmophilus influenzæ type b • Hepatitis A • Hepatitis B • Human papillomavirus (HPV) • Inactivated poliovirus • Influenza (Flu) • Measles, mumps, rubella (MMR) • Meningococcal (meningitis) • Pneumococcal (pneumonia) • Rotavirus • Varicella (chicken pox)

Screenings and assessments for: • • • • • • • • • • • • • • • • • • • • •

Alcohol and drug use (for adolescents) Autism (for children at 18 and 24 months) Behavioral issues Blood pressure (screening for children) Cervical dysplasia (for sexually active females) Congenital hypothyroidism (for newborns) Depression (screening for adolescents) Developmental (screening for children under age 3, and surveillance throughout childhood) Dyslipidemia (screening for children at higher risk of lipid disorders) Hearing (for all newborns) Height, weight and body mass index measurements Hæmatocrit or hemoglobin Hæmoglobinopathies or sickle cell (for newborns) HIV (for adolescents at higher risk) Lead (for children at risk of exposure) Medical history Obesity Oral health (risk assessment (for young children) Phenylketonuria (PKU) (newborns) Tuberculin testing (for children at higher risk of tuberculosis) Vision (screening as part of physical exam, not separate eye exam)

Medications and supplements:

• Gonorrhea preventive medication for the eyes of all newborns • Iron supplements (for children ages 6 to 12 months at risk for anemia)

Counseling for:

• Fluoride (prescription chemoprevention supplements for children without fluoride in their water source) • Obesity • Sexually transmitted infection (STI) prevention (for adolescents at higher risk)

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Essential Preventive Plan Century Healthcare

Prescription Drug Coverage*

The following chart shows categories of pharmaceuticals available to you at no cost. As lists may change, please note that in order to determine which specific drugs or brands within each of the below categories are covered under your prescription benefits, you will need to contact Healthcare Highways Rx at 844-636-7506 or go online to www.hchrx.com for more information.

Item

Availability

Aspirin

Adult men and women 45 years or more

Generic, Over-the-Counter (OTC)

Adult women Up to 55 years

Generic, Over-the-Counter (OTC)

Folic Acid supplements Iron supplements

6 – 12 months

Fluoridated drugs

6 months – 5 years

Tobacco Cessation

Adult men and women

Coverage

Brand, Generic, Over-the-Counter (OTC) Brand, Generic Generic or Over-the-Counter (OTC) only on nicotine replacement products Limit to Generic Zyban

Additional Covered Preventive Services for Women Oral Contraceptives

Generic, single source brands

Emergency contraception

Generic, Over-the-Counter (OTC), single source brands**

Injectable contraceptives

Adult women

Transdermal patch

Generic, single source brands** Generic, single source brands**

Diaphragm and cervical cap

Generic, single source brands**

*Under PPACA, certain medications and prescription drugs that prevent illness and disease are covered at no-cost as long as services are rendered by a physician who participates in the plan’s network. This chart lists the preventive medications that are covered at 100% under the Essential Preventive Plan. In order for these medications to be covered at 100%, a prescription is required from your physician, including overthe-counter (OTC) drugs. Drugs may be subject to quantity limitations. **Single

source brands are brand named drugs which do not have generic alternatives.

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Limited Benefit Indemnity Plan Century Healthcare

Century Healthcare’s Limited Benefit Indemnity Plan pays fixed benefit amounts to help cover the costs of common medical services, provides you with access to discounted PPO Network rates and is here to assist you in reducing medical costs and stressful billing situations. The Limited Benefit Indemnity Plan is a benefit plan that pays clearly defined, fixed amounts to help you cover the cost of common medical services, such as doctor’s office visits, hospitalization, intensive care, accidents, and much more. This Limited Benefit Indemnity Plan is designed to provide the most value for everyday healthcare expenses as opposed to plans that cover major illness and catastrophic injuries. In the following pages you will find a benefit grid that details each of the benefits included in our plans, along with how much each of them pays. You will also find important information regarding additional benefits and services included in your plan.

How to get the best from your Plan 1. 2. 3. 4. 5. 6. 7.

Call or go online to locate an in-network provider (details in the PPO Provider Network section of this guide) Schedule your appointment Visit provider and present ID card Provider files claim PPO Network applies discounts and forwards claim to Century Healthcare/WebTPA (insurance carrier) If the claim is less than the allowable benefit amount in your plan, you owe nothing If the claim is more than the allowable benefit amount in your plan, you will owe the balance to the provider

NOTE – While the Limited Benefit Indemnity Plan benefits may be used at any hospital or physician’s office, members are encouraged to utilize the PPO Network for discounted provider prices.

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Limited Benefit Indemnity Plan Century Healthcare Benefit Description

Plan Pays

Group Term Life Employee Term Life Spouse Term Life Child(ren) Term Life

$10,000 $10,000 $2,000

Hospital Indemnity Benefit • Must be admitted as an inpatient into a hospital room • If hospital confinement falls into a category below a different maximum applies

$500 per day Overall calendar year max subject to 60 days total for any inpatient stay in a hospital

Intensive Care $1,000 per day Up to 30 days calendar year max (applied to overall calendar year max)

If the participant is confined in a hospital intensive care unit Substance Abuse

$250 per day Up to 30 days calendar year max (applied to overall calendar year max)

Must be diagnosed and admitted as an inpatient in a substance abuse unit Mental Illness

$250 per day Up to 30 days calendar year max (applied to overall calendar year max)

Must be diagnosed and admitted as an inpatient into a mental illness unit Skilled Nursing Facility

$250 per day Up to 60 days calendar year max (applied to overall calendar year max)

Must be admitted in skilled nursing facility following a covered hospital stay of at least 3 days Doctor’s Office Benefit Benefit pays one benefit per day if the patient is seen by a doctor for an illness or injury

$75 per day 4 days per calendar year

Outpatient Diagnostic Labs • Includes glucose test, urinalysis, CBC, and others • When hospital confinement is not required and the test is ordered or performed by a doctor

$25 per day 3 days per calendar year

Outpatient Diagnostic Radiology • Includes chest, broken bones, and others • When hospital confinement is not required and the test is ordered or performed by a doctor

$70 per day 2 days per calendar year

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Limited Benefit Indemnity Plan Century Healthcare Benefit Description

Plan Pays Plan

Outpatient Advanced Studies • Includes CT Scan, MRI, and others • When hospital confinement is not required and the test is ordered or performed by a doctor

$500 per day 1 day per calendar year

Inpatient Surgical Benefit • Surgery must be performed due to an illness or injury as an inpatient stay in a hospital • Minor surgical procedures are excluded

$500 per day 1 surgery per calendar year

Inpatient Anesthesia Benefit 25% of the amount paid under the inpatient surgical benefit

$125 per calendar year

Outpatient Surgical Benefit • Surgery must be performed due to an illness or injury at an outpatient surgical facility center or hospital outpatient surgical facility • Minor surgical procedures are excluded

$250 per day 1 surgery per calendar year

Outpatient Anesthesia Benefit 25% of the amount paid under the outpatient surgical benefit

$62.50 per calendar year

Emergency Room Sickness Benefit Pays one benefit per day for services received in an ER as a result of an illness

$75 per day 2 days per calendar year

Outpatient Surgical Facility Pays one benefit per day for surgery performed at an outpatient surgical facility center or hospital outpatient surgical facility

N/A

THE LIMITED BENEFIT INDEMNITY PLAN ALONE DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE (MAJOR MEDICAL COVERAGE); HOWEVER, IT IS A COST-EFFECTIVE PLAN OF LIMITED MEDICAL BENEFITS THAT PROVIDES AN ALTERNATIVE TO THE HIGH COST OF HEALTHCARE.

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Group Medical Accident With AD&D

Included with the Limited Benefit Indemnity Plan Covered Charges

• Hospital room and board, and general nursing care, up to the semi-private room rate • Hospital miscellaneous expense during Hospital Confinement such as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take-home drugs) or medicines, therapeutic services and supplies • Doctor’s fees for surgery and anesthesia services • Doctor’s visits, inpatient and outpatient • Hospital Emergency care • X-ray and laboratory services • Prescription Drug expense • Dental treatment for Injury to Sound Natural Teeth • Registered nurse expense.

Plan Pays Accident Benefit per occurrence

Up to $5,000

Deductible per accident, per insured

$100 deductible

Accidental Death & Dismemberment

$15,000 Employee $7,500 Spouse $3,000 Child(ren)

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Essential Preventive + Limited Benefit Indemnity Plan - FAQ Sheet Does the Limited Benefit Indemnity Plan 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. 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.

Will the Limited Benefit Indemnity Plan provide an indemnity benefit for 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, except for preventive services must be performed in-network.

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 your Limited Benefit Indemnity Plan may be used at any hospital or physician’s office, members are encouraged to utilize the PPO network for discounted provider prices.

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.

Are Medicare and Medicaid recipients eligible for this plan?

Yes. However, under Medicare and Medicaid policies, the Limited Benefit Indemnity Plan is considered primary coverage. As a result, with the Limited Benefit Indemnity Plan , Medicare and/or Medicaid coverage may be reduced or discontinued.

Can the Essential Preventive Plan + Limited Benefit Indemnity Plan be used if the insured has separate health insurance? Yes. The specified benefits pay irrespective of any other private group coverage.

Does the Essential Preventive Plan + Limited Benefit Indemnity Plan address an employee’s obligations to maintain coverage under the “individual mandate?”

Yes. However, while the employee is a participant in the Essential Preventive Plan + Limited Benefit Indemnity Plan, the employee will not be eligible for a premium subsidy in connection with any plan offered on an Exchange established under the current provisions of the Affordable Care Act.

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Essential Preventive + Limited Benefit Indemnity Plan - FAQ Sheet Continued… Are Preventive Care Services covered only when performed in-network?

Yes, preventive services are only covered under the Essential Preventive Plan when performed by an innetwork provider.

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 the PPO Provider Network section of this guide and on your ID card. The insured is responsible for verifying the current PPO participation of their provider.

Can dependents be insured in this plan?

Yes. If the member enrolls in the Essential Preventive Plan + Limited Benefit Indemnity Plan, dependents are also eligible for coverage.

If I am currently eligible for a subsidy to purchase insurance through the Federal Exchange, will I still be eligible for the subsidy if I enroll in the Essential Preventive Plan? No, you will no longer be eligible for a subsidy if you are enrolled in the Essential Preventive Plan.

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Prescription Drug Discount Card

Included with the Limited Benefit Indemnity VALUE Plan Prescription Savings Card Providing meaningful health savings in innovative ways.

• Accepted at over 58,000 pharmacies, including all major chains and most independent pharmacies. • Cardholders save up to 80% on prescription drug purchases. • Discounts available on thousands of prescription drugs Certain prescription drugs qualify for an additional discount of up to $5 off. • Everyone in your family can use the same card, and we will not sell your personal information. Your information will be kept private. • This card is perfect even for those who have insurance. It can benefit those with high deductibles and those who are taking medications not currently covered by their insurance provider.

The mobile app provides easy, on-the-go access to your personalized health information. Once you have your member ID number, download the app to take advantage of the benefits your pharmacy plan offers. WITH THE MOBILE APP IN YOUR POCKET: • Stay on top of medication refills. See when refills are due, get refill reminders and quickly contact your pharmacy. • Show your doctor exactly what medications you are taking. • Pull up your medication history anytime. • Learn about medication side effects and interactions. • Find network pharmacies by ZIP code or location, then check and compare current prescription prices. • Learn ways to save on your prescription by switching from brand name to generic or splitting a higher dosage pill. • Track individual and family spend Pharmacy discounts are Not insurance, and are Not intended as a Substitute for Insurance. The discount is only available at participating pharmacies.

Contact Information: www.hchrx.com Member Service Support Center: 844-636-7506 Hours: 24 / 7 / 365 18

Telemedicine – HealthiestYou

Included with the Limited Benefit Indemnity Plan

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Telemedicine – HealthiestYou Included with Basic & Premier Plans

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Member Advocacy

Included with the Limited Benefit Indemnity Plan

Member Advocates are in-house representatives who work exclusively on behalf of our members to reduce medical costs and stressful billing situations. They are able to help member find community programs, hospitals, pharmaceutical companies, and provider offices which have affordable treatment costs. Also, they serve as a single point-of-contact to help resolve on-going or challenging billing issues. Member Advocates are available to speak with members individually, as well as their physicians and medical facilities, ensuring that everyone has a full understanding of how the benefits work and can make the most informed choices with regard to planning medical treatment. There is no cost for the program. Member Advocacy is a benefit for all members enrolled in the plan.

Advocates can assist you with: • • • • • • •

They help lower costs by:

Medical bills & Prescription costs Lab work & X-rays CAT Scans/MRIs Scheduling surgical procedures Durable medical equipment Diabetic supplies Complicated claims and billing issues

• Negotiating balances regarding medical bills • Finding providers that offer sliding-scale treatment pricing • Arranging payment plans for previously incurred bills • Requesting discounted lump-sum payments to settle balances • Locating community programs for specialized services or frequently recurring expenses due to chronic conditions • Contacting discount pharmacies

1-866-695-8622 Monday through Friday, 7:00 AM – 8:00 PM, Central Time Full bilingual (English-Spanish) services

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PPO Provider Network

For Preventive Only Plan AND Limited Benefit Indemnity Plan

Using In-Network Providers Can Stretch Your Benefit Dollars Your plan includes access to the MultiPlan Network, one of the largest Preferred Provider Organization (PPO) in the nation, to offer you:

Savings

Negotiated discounts that result in significant cost savings for you when you choose to see a participating provider. A MultiPlan logo on your health insurance card tells both you and your provider that a MultiPlan discount applies, and your out-of-pocket costs are reduced by the discounted amount.

Choice

Access to over 4,600 hospitals, 95,000 ancillary facilities and 695,000 healthcare professionals.

Quality

MultiPlan applies rigorous criteria when credentialing providers for participation in the Multiplan Network, so you can be assured you are choosing your healthcare provider from a high-quality network. The term in-network describes doctors, hospitals, and other health care professionals who work with Multiplan to charge lower discounted provider prices for your medical services.

To search for in-network Doctors or Facilities call 1-888-371-7427 or visit www.multiplan.com and follow these simple steps below:

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24 Hour Nurseline

Included with the Limited Benefit Indemnity Plan

Key Features of 24 Hour Nurseline Access Registered Nurses

Enjoy immediate access to licensed, registered nurses through one toll-free number 24 hours per day, 365 days per year.

Home Care Advice

Unlimited home-care advice and recommendations based on more than 600 physician-approved guidelines from registered nurses.

Decision Support

Decision support for certain high-cost, high-practicevariation health conditions and diagnoses.

Nutrition & Wellness Information

Information on a wide range of health and medical concerns including nutrition and wellness topics.

Audio Library

Audio health information library of more than 1,100 recorded topics and more than 550 topics also available in Spanish.

Available 24 hours per day, 365 days per year (866) 796-1857 Pin 526

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Major Medical PPO Plan UnitedHealthcare

We know that when people know more about their health and health care, they can make better informed health care decisions. We want to help you understand more about your health care and the resources that are available to you. • myuhc.com® – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor and hospital and much, much more. • 24-hour nurse support – A nurse is a phone call away and you have other health resources available 24-hours a day, 7 days a week to provide you with information that can help you make informed decisions. Just call the number on the back of your ID card. • Customer Care telephone support – Need more help? Call a customer care professional using the toll-free number on the back of your ID card. Get answers to your benefit questions or receive help looking for a doctor or hospital.

Annual Deductible Individual Family

Out-Of-Pocket Individual Family Physician Office Visit Charges Preventive Care

Primary Care Physician

Specialist Physician Hospital Services Inpatient Outpatient Emergency Room (accidental Injury) Emergency Room (non-emergency) Urgent Care Facilities Labs & X-rays (simple, in outpatient setting) Labs & X-rays (MRI, CT scan, PET scan, etc.)

Designated Network

Network

Out-of-Network

$5,000 $10,000

$5,000 $10,000

No Limit No Limit

Designated Network

Network (includes deductibles & copays)

Out-of-Network

$6,350 $12,700

$6,350 $12,700

No Limit No Limit

Designated Network

Network

Out-of-Network

100% $35 copay for first 4 visits 80% after deductible thereafter $35 copay for first 4 visits 80% deductible thereafter

100% $35 copay for first 4 visits 80% after deductible thereafter $70 copay for first 4 visits 80% deductible thereafter

No benefit

80% after deductible

80% after deductible

No benefit

80% after deductible

80% after deductible

No benefit

80% after deductible

80% after deductible

No benefit

80% after deductible

80% after deductible

No benefit

Prescription Drugs Retail (30 Day Supply) Tier 1 – Generic Tier 2 – Preferred Brand Name Tier 3 – Non-Preferred Brand Name Prescription Drugs Mail Order (90 Day Supply) Tier 1 – Generic Tier 2 – Preferred Brand Name Tier 3 – Non-Preferred Brand Name

No benefit

No benefit

Any Network Pharmacy

Out-of Network

$20 copay $40 copay $75 copay

No benefit

$50 $100 $187.50

No benefit

This Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Certificate of Coverage (COC), Riders, and/or Amendments, those documents shall prevail. It is recommended that you review these documents for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage. 24

Prescription Drug Benefits

Included with United Healthcare Major Medical PPO Plan Your pharmacy benefit plan helps you and your eligible family members get the prescription drugs you need at affordable costs. We look forward to helping you make informed decisions about your medicine. We understand that it is important to get the right prescription drug at the right time. Your plan’s pharmacy network can help.

Get the most out of your pharmacy benefit services

• We provide access to a wide variety of U.S. Food and Drug Administration (FDA) approved prescription medications. • Our programs and tools are designed to help you make informed decisions about your choice of prescription medications and pharmacy products. • The more you know about what choices are available, the better you can decide what is best to meet your health needs.

Choose a pharmacy that’s in our network

• You have access to over 64,000 retail pharmacies including all large national chains, many local, community pharmacies and the OptumRx® Mail Service Pharmacy. • If you fill your prescriptions outside our network of pharmacies you may pay a higher cost or your prescriptions may not be covered.

Find a pharmacy

• Log into myuhc.com®, click the “Manage My Prescriptions” button and enter your zip code under “Locate a Pharmacy”. • Or call the toll-free member 972-850-5017 on the back of your health plan ID card and a representative can help you.

What you pay

• Simply show your health plan ID card to the pharmacist. Your pharmacist will tell you how much you owe for the prescription. • Or call the number on the back of your health plan ID card.

Over 64,000 pharmacies in our network

25

Non-Member Discount

26

Dental Insurance

Dental Benefits Careington Dental

Annual Deductible Individual Family Maximum Benefit Per Calendar Year

Category

Plan Pays $0

Type 1: Preventive & Diagnostic a. Oral Exams, including prophylaxis b. Bitewings, per film c. X-ray, panoramic or cephalometric d. Sealants / topical fluoride e. Space maintainers Type 2: Major Restorative a. Crowns, bridges & dentures b. Pre-fabricated crowns c. Crown build-up procedures Type 3: Minor Restorative a. Fillings b. Crown, bridge and denture repairs c. Relining or rebasing dentures Type 4: Endodontics a. Root canals, apicoectomies b. Root amputation c. Therapeutic pulpotomy, retrograde fillings, apexification, hemisection Type 5: Periodontics (Lifetime Maximum of $500) a. Tissue grafts or bone surgery b. Gingivectomy (per quadrant), periodontal scaling, periodontal splinting, root planning c. Gingival curettage (per quadrant) d. Gingivectomy (per tooth) Type 6: Oral Surgery a. Surgeries Level 1 (ex. Removal of exostosis) b. Surgeries Level 2 (ex. Removal of impacted tooth) c. Surgeries Level 3 (ex. Simple extraction) Type 7: General Anesthesia and IV a. IV, first half hour general, each additional 1/4 hour general Type 8: Orthodontia Types 1 through 7 subject to annual maximum of: $1,000 Types 2, 5, 6a, 7 and 8 are subject to 12 month waiting period

Careington Dental PPO Network* To access a Careington Dental PPO provider visit: www.careington.com/co/centuryPPO *This is not an insured product. It is a discount program offering services through participating providers

28

$1,000 $36.00 $4.80 $36.00 $10.20 $108.00 $180.00 $60.00 $48.00 $42.00 $24.00 $60.00 $192.00 $96.00 $48.00 $96.00 $60.00 $36.00 $24.00 $120.00 $66.00 $36.00 $72.00 $500

Vision Insurance

Vision Benefits Davis Vision

The Davis Vision Plan is a premier full-service plan that offers choice, flexibility, and maximum value through a Davis Vision Preferred Provider. We also have arrangements with high quality retail chains as affiliate providers. Whether your employees choose a preferred or affiliate provider, they will receive a covered-in-full benefit experience. Davis Vision Preferred Providers • Davis Vision has 60,000 access points nationwide. Davis Vision preferred providers are located in retail, neighborhood, medical and professional settings. Retail Chain Affiliate Providers • Visionworks, Walmart Vision Center, Costco Optical and other high quality retail chains. To find an in-network provider, call 1-800-999-5431 or visit www.davisvision.com

Benefit Description

Plan Benefit

Frequency

$10 copay

every 12 months

$15 copay

every 12 months

Up to $200 at Vision Works or $150 at other participating provider; 20% discount on any overage

every 24 months

covered in full

every 24 months

up to $150; 15% discount on any overage

every 12 months

Up to 8 boxes Up to 4 boxes

every 12 months

Exam Focuses on your eye health and overall wellness Prescription Glasses/Lenses • single, bifocal, trifocal lenses Frames - Retail

• Frames purchased at Vision Works or any other in-network retailer

Frames - Davis Vision Frame Collection (in lieu of retail allowance) • PREMIER: includes designer frames such as, Gant®, Perry Ellis®, Elizabeth Arden®, Jill Stuart®, and Candies®. • DESIGNER: includes stylish designers such as Cosmopolitan®, South Hampton®, Chelsea Morgan®, Bongo®, Levi’s, Converse®, and Robert Mitchel®. • FASHION: includes fashionable styles such as Legacy and Tempo. Contact Lens - Retail (in lieu of frames and lenses) • Contact lenses purchased at Vision Works or any other in-network retailer Contact Lens – Davis Vision Collection (in lieu of frames and lenses) Collection Contact Lenses: • Disposable • Planned Replacement 30

Life Insurance

Basic Life and AD&D Insurance Liberty Mutual Basic Life & AD&D

Basic Term Life Insurance is an important part of your financial security, especially if others depend on you for support. Accidental Death & Dismemberment (AD&D) insurance is designed to provide a benefit in the event of accidental death or dismemberment. The company provides Basic Life and AD&D to all eligible employees at no cost to you.

Basic Life and AD&D (100% Employer Paid) Basic Life and Accidental Death & Dismemberment Benefit

$10,000 65% of the scheduled amount @ age 65 50% of the scheduled amount @ age 70

Benefit Reduction Schedule

32

33

Voluntary Products

Voluntary Products Aflac

Universal Coverage Features

• All products act as “Family Disability” coverage. • All products pay cash benefits directly to the policyholder, above and beyond any other insurance in force. • All products are 100% portable at the same group rate for life. • All products are available to cover an individual or any immediate family members (spouse & children). • All products provide for tax‐free claim payouts and claims are paid within 4 – 7 business days or sooner.

Accident Coverage

Pays cash for any possible/conceivable accident that would require medical attention. • Provides 24/7 coverage, on and off the job, for injuries of any kind. • Provides cash directly for minor cuts and bruises all the way up to major and severe accidents. • Provides initial hospital confinement benefits of $1,800 for the first night alone. • Provides guaranteed issue accidental‐death life insurance benefits for those on the program. • Provides for an annual wellness benefit of $60 per year/per family whether the plan is used or not.

Critical Care and Recovery Coverage

Pays cash upon event/diagnosis and on‐going treatment. • A specified event may include; Heart Attack, Stroke, Bypass Surgery, Coma, End Stage Renal Failure & Paralysis • Provides $7,500 initial diagnosis benefit when a specified health event occurs. • Provides coverage for admittance into an ICU of $800 per day for day 1-7 and then $1,300 per day for days 8-15. Also provides a $4,000 for Heart Valve Surgery and Surgery for Abdominal Aortic Aneurysm. • Provides daily hospitalization payout of $500 per day for hospital confinement. • Provides continuing care benefit for extended care, therapy, physician visits, dialysis & much more.

Cancer Care Plan

Pays cash upon diagnosis and on‐going treatment to battle cancer. • Provides coverage of a $4,000 initial diagnosis benefit when internal cancer or a specified disease is first diagnosed. • Provides coverage of $600 benefit per week for Chemotherapy. • Provides coverage of $300 p/day for hospital confinement through the 1st 30 days; $600 per day for 31+ days. • Provides benefit for surgeries, continued care, extended care, anesthesia and skin cancer diagnoses, etc. • Provides benefit for experimental treatment for cancer which is often not covered at all by health insurance. • Provides for an annual wellness benefit of $75 per year/per person whether the plan is used or not.

Hospital

Pays cash for illnesses and accidents that require hospitalization and/or surgery. • Provides cash benefits for hospital confinements; rehabilitation facility treatment and hospital emergency room. • Provides coverage for pregnancy/child birth; works as an excellent maternity program. • Choose the coverage level that’s right for you. Options include $500, $1,000, $1,500 or $2,000. • Provides benefit for surgeries, including both inpatient and outpatient. • Provides benefit for specific diagnostic exams as listed in the policy.

*See specific policy brochures for exact breakdowns; the above is merely a summary for illustrative purposes only.

35

Voluntary Products IDShield

36

Voluntary Products LegalShield

37

Voluntary Products Leaders Life

38

Rate Summary Weekly

Essential Preventive Plan + Limited Benefit Indemnity Plan Employee Contribution Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

$40.50 $123.60 $114.75 $220.82

Pallet Logistics Contribution

TOTAL Monthly Premium

Paycheck Deduction

$40.50 $40.50 $40.50 $40.50

$80.99 $164.09 $155.25 $261.32

$9.35 $28.52 $26.48 $50.96

Employee Contribution is Based on Salary (2 Examples Provided Below) UnitedHealthcare Major Medical PPO Plan The rates displayed are an illustration of the cost. The actual employee contribution for an Employee Only will be based on 9.5% of your annual salary divided by 12. You will pay 100% of the additional premium cost to add any dependents.

Based on an Annual Salary of $23,750 Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

SAMPLE

SAMPLE

SAMPLE

SAMPLE

Employee Contribution

Pallet Logistics Contribution

TOTAL Monthly Premium

Paycheck Deduction

$738.57 $738.57 $738.57 $738.57

$926.59 $2,038.48 $1,714.19 $2,965.07

$43.39 $299.98 $225.14 $513.81

$188.02 $1,299.91 $975.62 $2,226.50

UnitedHealthcare Major Medical PPO Plan The rates displayed are an illustration of the cost. The actual employee contribution for an Employee Only will be based on 9.5% of your annual salary divided by 12. You will pay 100% of the additional premium cost to add any dependents.

Based on an Annual Salary of $50,000

Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

SAMPLE

SAMPLE

SAMPLE

SAMPLE

Employee Contribution

Pallet Logistics Contribution

TOTAL Monthly Premium

Paycheck Deduction

$395.83 $1,507.72 $1,183.43 $2,434.31

$530.76 $530.76 $530.76 $530.76

$926.59 $2,038.48 $1,714.19 $2,965.07

$91.55 $347.94 $273.10 $561.76

All medical, dental and vision, deductions are taken on a pre-tax basis. This means more take home pay for you. Payroll deductions will begin with your first paycheck in 2018.

Rate Summary Weekly

Voluntary Dental Plan Employee Contribution

Pallet Logistics Contribution

TOTAL Monthly Premium

Paycheck Deduction

$21.63 $37.63 $50.63 $66.63

$0 $0 $0 $0

$21.63 $37.63 $50.63 $66.63

$4.99 $8.68 $11.68 $15.38

Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

Voluntary Vision Plan Employee Contribution

Pallet Logistics Contribution

TOTAL Monthly Premium

Paycheck Deduction

$10.05 $16.42 $16.38 $26.43

$0 $0 $0 $0

$10.05 $16.42 $16.38 $26.43

$2.32 $3.79 $3.78 $6.10

Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

Voluntary Legal Shield Plan

Employee Only Employee + Family

Voluntary ID Shield Plan

Employee Contribution

Paycheck Deduction

$3.91 $4.37

$3.91 $4.37

Employee Only Employee + Family

Voluntary Combo – Legal & ID Shield Plan

Employee Only Employee + Family

Employee Contribution

Paycheck Deduction

$5.98 $7.82

$5.98 $7.82

Employee Contribution

Paycheck Deduction

$2.07 $4.37

$2.07 $4.37

Rate Summary Aflac - Weekly

TEXAS EMPLOYEES ACCIDENT COVERAGE INDIVIDUAL ONLY $7.80 INSURED + SPOUSE $10.23 ONE-PARENT FAMILY $11.94 TWO-PARENT FAMILY $14.73 CANCER CARE COVERAGE INDIVIDUAL ONLY INSURED + SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY

$7.32 $12.45 $7.32 $12.45

HOSPITAL CHOICE COVERAGE Age Age 50 – 59 18 – 49 INDIVIDUAL ONLY $11.79 $11.91 INSURED + SPOUSE $17.55 $18.54 ONE-PARENT FAMILY $14.49 $14.61 TWO-PARENT FAMILY $17.67 $18.66 CRITICAL CARE COVERAGE Age Age 18 - 35 36 – 45 $4.11 $5.82 $7.89 $10.44 $6.99 $8.25 $8.94 $11.37

INDIVIDUAL ONLY INSURED + SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY

Age 60 - 75 $12.60 $20.34 $14.73 $20.46

Age 46 - 55 $8.58 $16.08 $10.62 $17.04

Age 56 - 70 $11.88 $22.92 $14.97 $24.54

SHORT TERM DISABILITY COVERAGE ANNUAL INCOME

$22,000

$24,000

$26,000

$28,000

$30,000

$32,000

$34,000

$36,000

$38,000

$40,000

MONTHLY BENEFIT

$1,100

$1,200

$1,300

$1,400

$1,500

$1,600

$1,700

$1,800

$1,900

$2,000

AGE 18 – 49

$8.25

$9.00

$9.75

$10.50

$11.25

$12.00

$12.75

$13.50

$14.25

$15.00

AGE 50 – 64

$10.23

$11.16

$12.09

$13.02

$13.95

$14.88

$15.81

$16.74

$17.67

$18.60

AGE 65 – 74

$12.21

$13.32

$14.43

$15.54

$16.65

$17.76

$18.87

$19.98

$21.09

$22.20

Rate Summary Aflac - Weekly

OKLAHOMA EMPLOYEES ACCIDENT COVERAGE INDIVIDUAL ONLY $7.80 INSURED + SPOUSE $10.23 ONE-PARENT FAMILY $11.94 TWO-PARENT FAMILY $14.73 CANCER CARE COVERAGE INDIVIDUAL ONLY $7.32 INSURED + SPOUSE $12.45 ONE-PARENT FAMILY $7.32 TWO-PARENT FAMILY $12.45 HOSPITAL CHOICE COVERAGE Age Age 50 – 59 18 – 49 $12.00 $12.15 INDIVIDUAL ONLY $17.91 $18.90 INSURED + SPOUSE $14.79 $14.88 ONE-PARENT FAMILY $18.00 $19.02 TWO-PARENT FAMILY

INDIVIDUAL ONLY INSURED + SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY

CRITICAL CARE COVERAGE Age Age 18 - 35 36 – 45 $4.11 $5.82 $7.89 $10.44 $6.99 $8.25 $8.94 $11.37

Age 60 - 75 $12.84 $20.76 $15.00 $20.88

Age 46 - 55 $8.58 $16.08 $10.62 $17.04

Age 56 - 70 $11.88 $22.92 $14.97 $24.54

SHORT TERM DISABILITY COVERAGE ANNUAL INCOME

$22,000

$24,000

$26,000

$28,000

$30,000

$32,000

$34,000

$36,000

$38,000

$40,000

MONTHLY BENEFIT

$1,100

$1,200

$1,300

$1,400

$1,500

$1,600

$1,700

$1,800

$1,900

$2,000

AGE 18 – 49

$8.25

$9.00

$9.75

$10.50

$11.25

$12.00

$12.75

$13.50

$14.25

$15.00

AGE 50 – 64

$10.23

$11.16

$12.09

$13.02

$13.95

$14.88

$15.81

$16.74

$17.67

$18.60

AGE 65 – 74

$12.21

$13.32

$14.43

$15.54

$16.65

$17.76

$18.87

$19.98

$21.09

$22.20

Rate Summary

Leaders Life - Monthly

Contact Information Administrator

Phone Number

Policy Number

Web Address

Essential Preventive Plan + Limited Benefit Indemnity Plan

Century Healthcare

(877) 685-2432

CHC5235

www.centuryhealthcare.com

PHCS Limited Benefit Network

PHCS

(888) 371-7427

n/a

www.multiplan.com/chc

Healthcare Highways Rx

(844) 636-7506

n/a

www.hchrx.com

Health Advocate

(866) 695-862

n/a

Healthiest You

(866) 703-1259

n/a

www.healthnowmd.com

Nurseline

(866) 796-1857

Pin #526

n/a

Voluntary Dental

Careington Dental

(866) 222-2558

n/a

www.careington.com

Voluntary Vision

Davis Vision

(800) 999-5431

n/a

www.davisvision.com

Term Life

The Standard

(800) 628-8600

n/a

www.standard.com

Basic Life and AD&D

Liberty Mutual

(800) 225-2467

TBD

https://www.libertymutual.com/li fe-insurance

Century Healthcare

(877) 685-2432

n/a

www.centuryhealthcare.com

UnitedHealthcare

See Back of Your ID Card

03U6291

www.myuhc.com

Aflac

(800) 992-3522

n/a

www.aflac.com

Amy Tullis

(817) 371-2375

n/a

https://www.legalshield.com/ https://www.idshield.com/

Liberty Mutual

(800) 227-8620

n/a

http://www.BDAlifeservices.com

Type of Benefit Plan

Pharmacy Benefits Health Advocacy Telemedicine Services 24 Hour Nurseline Program

Accident Medical & Accidental Death

Major Medical Plan

www.members.healthadvocate.com

Accident Coverage Hospital Coverage Cancer Care Plan Critical Care & Recovery Coverage LegalShield / IDShield Employee Assistance Program

Pallet Logistics of America Human Resources

Jennifer Schwab

(972) 850-5017

44

Required Notices

45

Required Notices

46

Required Notices

47

Required Notices

48

Required Notices

49

Pallet Logistics of America 2018 Annual Employer Notices Health Care Reform

Required Notices

The new federal health reform law focuses on establishing new state based mechanisms for obtaining coverage and for establishing federal standards to oversee benefit designs and costs of coverage. Most of the significant reforms, including Exchanges and guarantee issue requirements, became effective in 2014. Other less significant reforms have already been implemented with the 2011, 2012 and 2013 plan years. Some of the recent changes to health plan benefits include the elimination of pre-existing conditions, no life-time limits or annual limits on certain plan benefits, as well as requiring individuals to purchase health insurance (or be subject to possible penalties when filing your tax return). Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act ("HIPAA") deals primarily with how Pallet Logistics of America can enforce eligibility and enrollment for health care benefits. Examples of some of the HIPAA requirements include:

1.

Special enrollment periods are available during the year to you and your eligible dependents (in certain circumstances) that lose other health care coverage if you enroll within 31 days after losing the other health care coverage.

1.

If you are not enrolled for health care coverage and add an eligible dependent (i.e. marriage), you can enroll yourself and your other eligible dependents within 31 days of the event. If you add an eligible dependent (i.e. birth, adoption or placement for adoption), you can enroll yourself and your newly acquired eligible dependents within 31 days of the event.

The Plan will not base eligibility rules or waiting periods on any of the following factors: health status, mental or physical medical condition, and genetic information, evidence of insurability or disability. Evidence of insurability will not be required when health care coverage is requested during a special enrollment period or during an annual enrollment. However, the Plan may continue to provide for the exclusion of specified health conditions and apply lifetime maximums on either specific benefits or all benefits provided under the Plan. These restrictions also do not preclude the Plan from applying differing benefit levels, benefit schedules or premium rates in certain situations as provided under HIPAA. Changing Your Elections In general, your annual pre-tax benefit elections are irrevocable for the plan year, January 1, 2018 through December 31, 2018. However, if you experience a Change in Status or special enrollment event that directly affects your eligibility for coverage; you may change your election within 31 days of the event. Under limited circumstances, an election change based solely on a Change in Status must be consistent with your Change in Status (i.e. if a child is born to you, you add coverage for that child). In general: Change in Status events provide more opportunities for you to make an election change than do special enrollment rights. If your event could be considered both a Change in Status event and a special enrollment right, you may make any change allowed by either a Change in Status or special enrollment right. Contact the Pallet Logistics of America Benefits Department at 972-850-5017, for more information on the requirements for making an election change based on a Change in Status event or special enrollment right. Change in Status Events that Permit Election Changes for Health Benefits and Life Insurance Benefits: • Change in marital status: you may elect coverage for yourself and/or your newly acquired spouse or drop coverage for your spouse if you divorce, legally separate, have your marriage annulled or your spouse dies. • Change in your number of dependents: you may elect coverage for your newborn, adopted child or a child placed with you for adoption. You may drop coverage if a dependent child dies. Change in employment status: you may add or drop coverage consistent with a change in employment status of you, your spouse or dependents that affect the benefit eligibility under this plan or under the employee benefit plan of your spouse or dependents. You, your spouse or dependent experience a change in employment status when any of the following occur and benefit eligibility is affected: begin or end employment, take part in a strike or lockout, begin or return from an approved leave of absence, switch from hourly to salaried, switch from union to non-union or vice versa, reduce or increase the number of hours you work or any similar change that affects your eligibility 50

• • •

Required Notices

under the plan. Dependent eligibility: you may add or drop your child in the event he or she becomes or ceases to be eligible under the plan. Change in residence: you may change your coverage option if you move and it significantly affects your benefit availability.

Additional Change in Status Events that Permit Election Changes for Health Benefits Only: • Family and Medical Leave Act (FMLA) – certain election changes are permitted when you start an FMLA leave or when you return from an FMLA leave. • Judgment, decree or order resulting from a divorce, legal separation, annulment or change in legal custody (including a “qualified medical child support order” or QMCSO) that requires health coverage for an Associate’s child or foster child. • You, your spouse or your dependent become entitled to or lose eligibility for Medicare or Medicaid. • You, your spouse or your dependent gain eligibility under another employer’s plan. • A significant change in your cost for health coverage. • A Change in Status that results in a “special enrollment right” under the Health Insurance Portability and Accountability Act (HIPAA). Please refer to the section below for more information. You must complete a Change Form and return it to the Pallet Logistics of America Benefits Department within 31 days of the Change in Status. If you miss this 31 day period, you will not be able to change your coverage until the following Annual Enrollment period, unless you have another Change in Status that affects your eligibility under the plan. Special Enrollment Rights Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you may be entitled to enroll in a group health plan at times other than initial eligibility or the Annual Enrollment period. You have special enrollment rights if you and/or your eligible dependents lose other group health coverage or you gain a new dependent. If either of these events occurs, you must enroll within the 31 day time limit explained here or you will lose your special enrollment rights for that event. If you are declining enrollment 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 the medical and/or dental plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). Loss of eligibility does not include a loss of coverage that occurs because you fail to pay premiums on a timely basis, if your other coverage is terminated for cause or your voluntary termination of COBRA continuation coverage. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself or your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption or placement for adoption. You must request enrollment in the medical and/or dental plan no later than 31 days after the event giving rise to your special enrollment right, by completing and returning a new Benefit Enrollment and Change Form. If you fail to request enrollment within the 31 day time period, you and your dependents will lose the special enrollment rights for that event. If your special enrollment right occurs because you lost other coverage or married, your enrollment is effective on the first day of the month after your Benefits Department receives your properly completed Change Form. If your special enrollment right occurs because of a new dependent child, coverage is effective on the date of the birth, adoption or placement for adoption. If you or your dependent is eligible, but not enrolled, for health coverage under the Pallet Logistics of America medical plan, you and/or your dependent may enroll in the plan if (i) your Medicaid or CHIP coverage is terminated as a result of loss of eligibility or (ii) you and/or your dependent become eligible for premium assistance under Medicaid or CHIP. However, to be eligible for this special enrollment opportunity, you must request coverage under the group health plan within 60 days after the date you and/or your dependent become eligible for premium assistance under Medicaid or CHIP or the date you or your dependent’s Medicaid or state-sponsored CHIP coverage ends. For more information on Medicaid and CHIP, please see the section below entitled Medicaid/CHIP. To request enrollment due to a special enrollment right or obtain more information, contact the Pallet Logistics of America Benefits Department at 972-850-5017. 51

Required Notices

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 August 10, 2017. Contact your State for more information on eligibility –

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

FLORIDA – Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

GEORGIA – Medicaid Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

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

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: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

52

IOWA – Medicaid Website: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp Phone: 1-888-346-9562

KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Required Notices NEW HAMPSHIRE – Medicaid

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 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

LOUISIANA – Medicaid

NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447 MAINE – Medicaid

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

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

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

MASSACHUSETTS – Medicaid and CHIP

NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840 MINNESOTA – Medicaid

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

Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-careprograms/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739

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

MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178 NEVADA – Medicaid Medicaid Website: https://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

SOUTH DAKOTA - Medicaid

OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthip pprogram/index.htm Phone: 1-800-692-7462 RHODE ISLAND – Medicaid Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820

WASHINGTON – Medicaid

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

Website: http://www.hca.wa.gov/free-or-low-cost-healthcare/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

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

WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

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

WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282 53

WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

Required Notices

To see if any other states have added a premium assistance program since August 10, 2017, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Family and Medical Leave Act (FMLA) Under the Family and Medical Leave Act (FMLA), you may be eligible for up to 12 weeks of unpaid leave for certain family and medical reasons and continue your benefits at active employee rates. You are eligible for FMLA leave if you have been employed by Pallet Logistics of America for at least one year and worked at least 1,250 hours over the previous 12 months. You may be eligible to take FMLA leave: • After the birth or adoption of your child or if a child is placed with you for adoption • To care for your spouse, child or parent who has a serious health condition (including medical conditions resulting from military service) • If you have a serious health condition that makes you unable to perform your job You may choose to either continue benefits on the same basis as if you continued working (were an active employee) or revoke your health benefit election (i.e. cancel your benefits) while you are on FMLA leave. If you revoke your benefit election while on FMLA leave, your election can be reinstated when you return to work. If you continue your benefits while on FMLA leave, you must pay your share of the cost for your benefits coverage during your period of FMLA leave. If your leave is unpaid (or paid and does not cover the entire cost), you are responsible for paying your portion of the premiums directly to the insurer. If you fail to make a premium payment, your coverage will be terminated. If your coverage terminates while you are on FMLA leave, your coverage can resume when you return from your FMLA leave of absence. For more information about FMLA leave and your benefit coverage while on FMLA leave, please contact Pallet Logistics of America Benefits Department. Mental Health Parity Act (1996) (MHPA) and Mental Health Parity and Addiction Equity Act (2008) (MHPAEA) The Pallet Logistics of America medical plan complies with the Mental Health Parity Act of 1996 (“MHPA”). Pursuant to such compliance, the annual and lifetime limits on Mental Health Benefits, if any, will not be less than the annual and lifetime plan limits on other types of medical and surgical services (if any limits apply). The plan does utilize cost containment methods, applicable for Mental Health Benefits, including cost-sharing, limits on the number of visits or days of coverage, and other terms and conditions that relate to the amount, duration and scope of Mental Health Benefits. Newborns' and Mothers' Health Protection Act (NMHPA) The Pallet Logistics of America medical plan will comply with all required provisions of the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) with respect to health benefits provided under this plan. The plan will not 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. You only need to pre-certify maternity hospital stays if the hospital stay will be longer than the periods specified above. However, you must still precertify any hospital admission during your pregnancy that is not due to delivery or is in excess of the applicable timeframes outlined above. In addition, the plan will not require that a provider obtain authorization from the plan and insurer for prescribing a length of stay not in excess of the above periods. However, the NMHPA generally does not prohibit the mother’s or newborn’s attending provider, after consulting with and obtaining consent from the mother, from discharging the mother and/or her newborn earlier than 48 hours (or 96 hours as applicable).

54

Required Notices

Women’s Health and Cancer Rights Act (WHCRA)

The Pallet Logistics of America medical plan complies with all required provisions of the Women’s Health and Cancer Rights Act of 1998 (WHCRA) with respect to health benefits provided under this plan. The plan will cover certain breast reconstruction and other benefits in connection with a mastectomy. If you elect breast reconstruction in connection with a mastectomy, coverage is available in a manner determined in consultation with you and your physician for (1) all stages of reconstruction of the breast on which the mastectomy was performed, (2) surgery and reconstruction of the other breast to produce a symmetrical appearance, (3) prosthesis and (4) treatment of physical complications for all stages of mastectomy, including lymphedemas. Such coverage remains subject to the terms of the Plan, including normal deductible, copay and coinsurance provisions. Genetic Information Nondiscrimination Act of 2008 (GINA) The Pallet Logistics of America medical plan will comply with all required provisions of GINA with respect to health benefits and coverage under this plan. The plan will not discriminate on the basis of genetic information, including information about manifestation of a disease or disorder in a family, in addition to information about genetic tests. Furthermore, genetic information will not be requested or required for underwriting purposes or before enrollment, participants and covered dependents will not be required to undergo genetic testing and genetic information will not be used to adjust premiums or contributions for groups under the Pallet Logistics of America medical plan. However, the plan and/or employer may use, in accordance with GINA, a minimum necessary amount of genetic testing results in order to make a determination about a claim payment where such information is necessary and/or required. For more information about GINA, please contact your Benefits Department. Michelle’s Law Subject to future regulations and the Affordable Care Act, the Pallet Logistics of America medical plan will comply with all required provisions of Michelle’s Law with respect to health benefits provided under this plan to dependent children over the age of 18 who are enrolled in an institution of higher education on a full-time basis. If the dependent child is enrolled on a full-time basis and subsequently loses his/her full-time status at his/her institution of higher education as a result of taking a “medically necessary leave of absence” (as defined under Michelle’s Law) due to a serious illness or injury, coverage for the dependent under the Pallet Logistics of America medical plan will not terminate until the earlier of (i) the date that is one year after the first day of the medically necessary leave of absence or (ii) the date coverage would otherwise terminate under the plan. The student/dependent on leave is entitled to the same benefits as if he/she had not taken a leave. If coverage changes during the student’s leave, then this law applies in the same manner as the prior coverage. Please note that under the Affordable Care Act, group health plans and issuers are generally required to provide dependent coverage to age 26 regardless of student status of the dependent. Nonetheless, under some circumstances, such as a plan that provides dependent coverage beyond age 26, Michelle's Law provisions may apply. For more information about Michelle’s Law and your dependent’s benefit coverage under Michelle’s Law, please contact the Pallet Logistics of America Benefits Department. Consolidated Omnibus Budget Reconciliation Act (COBRA) Important Information about Your Right to COBRA Continuation Coverage This contains important information about your right to group health plan continuation coverage, which is a temporary extension of coverage under the Plan after you (and/or your qualified dependent) would otherwise lose group health coverage under the Plan. The right to this continuation coverage (COBRA continuation coverage) was created by Federal law under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Under COBRA, you may elect to temporarily continue your group health coverage for yourself and any eligible dependents covered by the Pallet Logistics of America group health plans on the day your (or your qualified dependents) group health benefits ceased because of a qualifying event. You and your eligible dependents are eligible to elect COBRA continuation coverage even if you (or they) have health coverage under another group health plan. Please read this section carefully as it generally explains COBRA continuation coverage, when it may be available to you and your eligible dependents and what you (and they) need to do to protect the right to receive it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

55

Required Notices

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 Benefits Department. Eligibility for COBRA Continuation Coverage COBRA continuation coverage is continuation of group health plan coverage when coverage would otherwise end because of a life event known as a “qualifying event”. Specific qualifying events are listed later in this section. After a qualifying event, COBRA continuation coverage must be offered to each plan participant who is a “qualified beneficiary”. You, your spouse and your dependent children could become qualified beneficiaries if group health coverage under the plan is lost because of a qualifying event. Qualified beneficiaries who elect COBRA continuation coverage must pay the full cost of COBRA continuation coverage. Qualifying Events and COBRA Continuation Coverage The qualifying events for COBRA continuation coverage and the maximum COBRA continuation coverage periods are shown in the charts that follow. Employee COBRA Continuation Coverage If you are an employee of Pallet Logistics of America and are covered by Pallet Logistics of America’s health plan you have the right to COBRA continuation coverage (for the period stated) if you lose coverage due to the following qualifying events: Qualifying Event

Maximum Continuation Period

Termination of your employment (for reasons other than gross misconduct)

18 months

Reduction in your hours of employment with loss of eligibility for benefits 18 months Spouse of an Employee COBRA Continuation Coverage If you are the spouse of an employee of Pallet Logistics of America and are covered by Pallet Logistics of America’s health plan, you have the right to COBRA continuation coverage (for the period stated) if you lose coverage due to the following qualifying events: Qualifying Event The employee’s termination of employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment with loss of eligibility for benefits The death of the employee Divorce or legal separation from the employee The employee’s entitlement to Medicare

Maximum Continuation Period 18 months 36 months 36 months 36 months

Dependent Children of an Employee COBRA Continuation Coverage Dependent children of an employee of Pallet Logistics of America who are covered by Pallet Logistics of America’s health plan have the right to COBRA continuation coverage (for the period stated) if they lose coverage due to the following qualifying events: Qualifying Event The employee’s termination of employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment with loss of eligibility for benefits The death of the employee The employee’s divorce or legal separation The employee’s entitlement to Medicare Loss of eligible dependent status (i.e., reach maximum age, lose full-time student status)

Maximum Continuation Period 18 months 36 months 36 months 36 months 36 months

The maximum period of COBRA continuation coverage is measured from the date of the loss of coverage due to the applicable qualifying event specified above. The plan will offer COBRA continuation coverage to a qualified beneficiary only after the Pallet Logistics of America Benefits Department has been properly notified that a qualifying event has occurred. 56

Required Notices

You must notify the Pallet Logistics of America Benefits Department within sixty (60) days of the following qualifying events: divorce or legal separation of the employee; spouse or a dependent child losing eligibility for coverage as a dependent under the plan, or Medicare entitlement. You must provide this notice to the Pallet Logistics of America Benefits Department within the sixty (60) day deadline or your right to COBRA continuation coverage will be lost and will not be reinstated. Notice requirements are detailed below. A special rule applies if you drop coverage for your spouse and/or eligible dependent children because you are planning to divorce. In such a case, your spouse and/or dependent children who had previously been covered under the plan would be entitled to elect COBRA continuation coverage for up to thirty-six (36) months from the date the divorce is final, but only if the Pallet Logistics of America Benefits Department is notified of the divorce within sixty (60) days from the date of final judgment. No retroactive coverage before the date of divorce is available. If it is determined that an individual is not eligible for COBRA continuation coverage, the Pallet Logistics of America Benefits Department will notify such individual of his or her failure to qualify for COBRA continuation coverage. This notice will explain why the individual is not entitled to COBRA continuation coverage and will be sent within fourteen (14) days after the receipt of the individual’s notice of a qualifying event. Subsequent Qualifying Event If a subsequent qualifying event that is not your termination of employment or reduction in work hours (such as your divorce, legal separation, your death or your dependent child ceasing to be eligible under the plan) occurs during an initial eighteen (18) month period of coverage, COBRA continuation coverage may be extended for your eligible dependents who are qualified beneficiaries for up to a maximum period of thirty-six (36) months measured from the date of the first qualifying event. An event shall not be a subsequent qualifying event unless that event would cause a loss of coverage under the Plan independent of the initial qualifying event. The covered employee will not be eligible for an extension of your maximum 18month period of COBRA continuation coverage for a subsequent qualifying event. Notice of a subsequent qualifying event must be given to the Pallet Logistics of America Benefits Department within a maximum of sixty (60) days in order to extend COBRA continuation coverage. If you fail to inform the Pallet Logistics of America Benefits Department, you will lose your right to extend your COBRA continuation coverage and this right will not be reinstated. Notice requirements are detailed below. Please see the special COBRA continuation coverage for Disabled Persons section of this guide for information on disability as a subsequent qualifying event. Notice Requirements In most cases, the Pallet Logistics of America Benefits Department (or such other assigned individual, entity, or department) will notify you of your right to elect COBRA continuation coverage. However, if your eligible dependent has a qualifying event as a result of your divorce, legal separation, Medicare entitlement or lose their status as a dependent, you or your covered dependent must properly notify the Pallet Logistics of America Benefits Department within a maximum of sixty (60) days of the qualifying event. In addition, if you have a child born, legally adopted or placed for adoption with you during your period of COBRA continuation coverage, you must notify the Pallet Logistics of America Benefits Department within sixty (60) days of the event in order to cover the child. Notice must be submitted to the Pallet Logistics of America Benefits Department at 4100 Platinum Way, Dallas, TX 75237, on the written form approved by the Benefits Department. The form must be completed and submitted to the Pallet Logistics of America Benefits Department before the end of the applicable deadline. The forms, information and deadlines for certain events are outlined in the table below. Event Requiring Notice Divorce or Legal Separation Dependent becomes ineligible under the plan Medicare entitlement Determination of disability Determination of non-disability status Marriage Birth, Adoption or Placement for Adoption

Deadline for Notice Within 60 days from date of final court judgment Within 60 days from date of ineligibility Within 60 days from date of entitlement Within 60 days of disability determination and before the end of the maximum 18 month COBRA continuation coverage period Within 30 days of the Social Security Administration’s determination of nondisability Within 31 days from the date of marriage Within 60 days from date of the event

Failure to properly provide the required notice may result in loss of any COBRA continuation right and, if lost, this right will not be reinstated. The Pallet Logistics of America Benefits Department is the designated recipient for all COBRA continuation coverage notices. They may be reached at: 972-850-5017, 4100 Platinum Way, Dallas, TX 75237. 57

Required Notices

Electing COBRA Continuation Coverage Once the Pallet Logistics of America Benefits Department receives notice that a qualifying event has occurred, COBRA continuation coverage will then be offered to each qualified beneficiary. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. However, you may elect COBRA continuation coverage on behalf of your spouse and parents may elect COBRA continuation coverage on behalf of their children. If you wish to elect COBRA continuation coverage, you must notify the Pallet Logistics of America Benefits Department within a maximum of sixty (60) days of the later of: (i) the date of the qualifying event or (ii) the date you received your COBRA notice. If you choose to continue benefits for yourself and your eligible dependent, before the maximum sixty (60) day election deadline, your coverage will continue uninterrupted. If you (or your eligible dependent) fail to elect COBRA continuation coverage within the maximum sixty (60) days after you are notified by Pallet Logistics of America, you will lose your right to COBRA continuation coverage and that right will not be reinstated. You must also keep Pallet Logistics of America Benefits Department informed of all the information needed to meet its obligation of both providing notice to you of your right to COBRA continuation coverage and providing the actual COBRA continuation coverage. Such information includes your current contact information and administrative information about yourself, your spouse and/or dependents. You or your spouse's election to take COBRA continuation coverage can also be an election to cover all the other qualified beneficiaries in the family, unless the election is specific as to which qualified beneficiaries are to be covered. You must notify the Pallet Logistics of America Benefits Department to request alternate coverage if you move outside the service area of the benefit network for your elected coverage. Alternate coverage will be made available (if available) to you not later than the date of the relocation or the first day of the month following the month in which the request is made. Health Care Exchange - Notice There may be other coverage options for you and your family. For example, you will be able to buy coverage through the Health Insurance Marketplace during the Marketplace’s open enrollment period. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away and you can see what your premium, deductibles and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for a tax credit through the Marketplace. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days. Special Enrollment Events and COBRA If you have a child born to, adopted or placed for adoption with you during your period of COBRA continuation coverage, you must notify the Pallet Logistics of America Benefits Department and elect coverage within sixty (60) days of the child's birth, adoption or placement for adoption. If you get married during your COBRA continuation coverage, you may add your new spouse to your COBRA continuation coverage if you notify the Pallet Logistics of America Benefits Department within thirty-one (31) days of the date of the marriage. A new dependent may be a participant under this coverage for the remainder of your maximum COBRA continuation period (eighteen (18), twenty-nine (29) or thirty-six (36) months, depending on the applicable qualifying event). Cost and Payment of COBRA Premiums You must pay the full cost for COBRA continuation coverage (plus a two percent (2%) administrative fee). Pallet Logistics of America will determine this cost, but it generally cannot exceed one hundred two percent (102%) of the plan's cost for providing coverage to similar situated covered active employees and their covered dependents. COBRA premiums are subject to change annually. If you and your covered dependents are receiving an additional eleven (11) months of COBRA continuation coverage due to disability as the qualifying event, Pallet Logistics of America will determine COBRA premium which will not exceed one hundred fifty percent (150%) of the plan's cost for providing coverage, if the disabled qualified beneficiary is part of the COBRA continuation coverage group or one hundred two percent (102%) if the disabled qualified beneficiary is not receiving COBRA continuation coverage. Once an election for COBRA continuation coverage is made, you (or your covered dependents) have a maximum of fortyfive (45) days from the date of election to pay the premium for the current month and any retroactive COBRA premiums then due for the elected coverage. Although coverage is retroactive to the date of loss of coverage due to the initial qualifying event, no COBRA continuation coverage benefits will be paid until this first COBRA premium is received by Pallet Logistics of America. If payment is not received within the forty-five (45) day period, then coverage will either be revoked retroactively or not become effective. You will lose your right to COBRA continuation coverage and it will not be reinstated.

58

Required Notices

All subsequent COBRA premium payments are due on the first day of the month. The plan allows a thirty (30) day grace period for payment of required COBRA premiums (except the first payment previously discussed). Even if you do not receive a bill, you must still submit your COBRA premium payments within the required time period. The thirty (30) day grace period does not apply to the forty-five (45) day period for payment of the initial COBRA premium. If your COBRA premium payment is not postmarked by the last day of the grace period, your COBRA continuation coverage will end as of the last day of the last month for which a full COBRA premium payment was made. If timely payment of the COBRA premium is made to the plan in an amount that is not more than fifty dollars ($50) or ten percent (10%) less than the required COBRA premium payment, then the amount paid is deemed to satisfy the plan’s requirement for full COBRA premium payment, unless Pallet Logistics of America notifies the qualified beneficiary of the amount of the deficiency and allows thirty (30) days for payment of the deficiency to be made. COBRA premiums can be paid by you or by a third party on your behalf. Here are a few other details about COBRA premium payments you need to be aware of: • • • •

No late or reminder notices will be sent for payments that have not been made. Once COBRA continuation coverage is terminated, it cannot be reinstated. All terms and conditions that apply to active participants in the plan are also applicable to COBRA continuation coverage participants. All rules and procedures for filing and determining benefit claims and appeals under the plan that apply to active employees also apply to COBRA continuation coverage.

Trade Act Credit The Trade Act of 2002 created a tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PGBC) (eligible individuals) and pay for health coverage. Under the new tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including COBRA continuation coverage. If you have questions about these tax provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at (866) 628-4282. TTD/TTY callers may call toll-free at (866) 626-4282. More information about the Trade Act is also available at www.doleta.gov/tradeact/2002act_index.asp. Responses to Information Regarding a Qualified Beneficiary's Right to Coverage Upon request, the plan must inform health care providers regarding the qualified beneficiary's right to coverage during the applicable grace periods. In addition, the plan is required to respond to inquiries from health care providers regarding the qualified beneficiary's right to coverage during the election period and his or her right to retroactive coverage if COBRA continuation coverage is elected.

Changes in Benefits under COBRA If you or any covered dependents elect COBRA continuation coverage, benefits will be the same as were in effect at the time of your qualifying event. You will be able to change your plan coverage option during annual enrollment to the same extent as similarly situated active employees. If the group health plan benefits of active employees change, benefits for qualified beneficiaries on COBRA continuation coverage will also change in the same manner. Special COBRA Continuation Coverage for Disabled Persons If you (and your covered dependents) are receiving eighteen (18) months of COBRA continuation coverage and your qualifying event is a termination of employment or a reduction of hours, your maximum COBRA continuation coverage period may be extended by eleven (11) months to up to a maximum of twenty-nine (29) months in total provided the following requirements are met: • The Social Security Administration determines that you (or your dependent who is a qualified beneficiary) are disabled within the meaning of the Social Security Act; • This disability exists as of the date of the qualifying event or at any time during the first sixty (60) days of COBRA continuation coverage following the qualifying event; and • The disability lasts at least until the end of the eighteen (18) month period of COBRA continuation coverage. Notice of the determination of disability under the Social Security Act must be provided to Pallet Logistics of America within the initial eighteen (18) month coverage period and within sixty (60) days after the latest of: (1) the date of the Social Security Administration determination of disability; (2) the date on which the qualifying event occurs; (3) the date on which the qualified beneficiary loses coverage; or (4) the date on which the qualified beneficiary is informed of the obligation to provide the notice of disability. If you fail to properly notify Pallet Logistics of America within the deadline above, you will lose your right to the extension of COBRA continuation coverage and this right will not be reinstated. Please refer to the Notice Requirements section above for information about proper notice to the plan. 59

Required Notices

If the Social Security Administration determines later that the qualified beneficiary is no longer disabled, Pallet Logistics of America must be properly notified within thirty (30) days of the Social Security Administration’s determination. This notice will end the extended COBRA continuation coverage for all qualified beneficiaries within the coverage group. Failure to notify Pallet Logistics of America that a qualified beneficiary is no longer disabled will result in termination of COBRA continuation coverage for all qualified beneficiaries within the coverage group effective on the date of the Social Security Administration determination and such coverage will not be reinstated. When the disabled qualified beneficiary becomes eligible for Medicare, Pallet Logistics of America must be properly notified to end the extended coverage for the affected disabled qualified beneficiary. Please refer to the Notice section above for information about proper notice to the plan. COBRA Continuation Coverage and Medicare If your dependent is receiving COBRA continuation coverage and you become entitled to Medicare benefits, your coverage will end but COBRA continuation coverage for your qualified dependents may continue for up to thirty-six (36) months measured from the date of the initial qualifying event. In addition, if you become entitled to Medicare and then later terminate employment (for reasons other than gross misconduct) or have a reduction in hours, your qualified dependents who are eligible for COBRA continuation coverage will be eligible for thirty-six (36) months of COBRA continuation coverage measured from the date you became entitled to Medicare. However, you will only be eligible for eighteen (18) months of COBRA continuation coverage measured from the qualifying event. Termination of COBRA Continuation Coverage COBRA continuation coverage shall not be provided beyond the earliest of the following dates: • The date the maximum COBRA continuation coverage period expires based upon the qualifying event; •

The date the plan is terminated and no other group health plan is provided to active employees;

•

The last day of the month preceding the month for which the qualified beneficiary fails to pay the premium for COBRA continuation coverage by the last day of the grace period;

•

The date the qualified beneficiary first becomes entitled to Medicare, including Medicare entitlement due to End Stage Renal Disease (ESRD), after the person elects COBRA continuation coverage;

•

The date that initial payment is not received within a maximum of forty-five (45) days after the election of COBRA continuation coverage is made;

•

The date the qualified beneficiary first becomes covered under another group health plan or policy after the date the person elects COBRA continuation coverage; or

•

For a disabled qualified beneficiary receiving COBRA continuation coverage during the eleven (11) month disability extension period (and their covered family members), the date the disabled person receives a final determination by the Social Security Administration that he or she is no longer "disabled." This final determination shall end COBRA continuation coverage for all qualified beneficiaries as of the later of either: (a) the first day of the month following thirty (30) days from the final determination date; or (b) the end of the COBRA continuation coverage period based on the initial qualifying event without regard to a disability extension.

If your COBRA continuation coverage is terminated for any of the reasons noted above, your coverage will end and will not be reinstated. In the event that your COBRA continuation coverage is terminated before the end of the maximum coverage period, Pallet Logistics of America will notify you of the termination of your coverage as soon as administratively possible. This notice will explain why and when COBRA continuation coverage has ended. Contact Information for COBRA Administrator 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. (address and phones of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

60

Required Notices

Keep the Plan Informed In order to protect your family’s rights, you should keep the Pallet Logistics of America Benefits Department informed of any changes in the address of family members. You should also keep a copy of all COBRA notices that you receive or send in your own records. Plan Contact Information Information about the plan may be obtained by contacting the Pallet Logistics of America Benefits Department at 4100 Platinum Way, Dallas, TX 75237. Notice of Privacy Practices This Notice is for Pallet Logistics of America employees/retirees (and their dependents) participating in the Company health plans (medical, dental, and vision), which together have been designated as the Company Healthcare Arrangement (the “Plan”). If you are not currently participating in these plans, but begin participating in the future, this Notice will apply to you once you begin participating. 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. Under the Health Insurance Portability and Accountability Act (HIPAA), the Plan is required to: •

take reasonable steps to ensure the privacy of your personally identifiable health information;

•

give you this Notice of our legal duties and privacy practices with respect to medical information about you (the participant); and

•

follow the terms of this Notice.

In addition to the requirements above, this Notice is intended to inform you about: •

The Plan’s uses and disclosures of Protected Health Information (PHI);

•

Your privacy rights with respect to your PHI;

•

The Plan’s duties with respect to your PHI;

•

Your right to file a complaint with the Plan and to the Secretary of the U.S. Department of Health and Human Services; and

•

The person or office to contact for further information about the Plan’s privacy practices.

The term “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, electronic). If you have any questions about this Notice, please contact the Privacy Officer at Pallet Logistics of America. The contact information for the Privacy Officer is as follows: Privacy Officer Pallet Logistics of America 4100 Platinum Way Dallas, TX 75237 Who Will Follow This Notice This Notice describes the health information practices of the Plan, and that of third parties that provides services to the Plan. All references to “you” include employee/retiree participants and their dependent(s) who participate in the Plan.

Our Pledge Regarding Medical Information The Plan understands that medical information about you and your health is personal. The Plan is committed to protecting medical information about you. The Plan creates a record of the health care claims reimbursed under the Plan for Plan administration purposes. This Notice applies to all of the health records that the Plan maintains. Your personal doctor or health care provider may have different policies or Notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic. This Notice will tell you about the ways in which the Plan may use and disclose medical information about you. It also describes the Plan’s obligations and your rights regarding the use and disclosure of medical information. 61

Notice of PHI Uses and Disclosures Required PHI Uses and Disclosures

Required Notices

Upon your request, the Plan is required to give you access to certain PHI in order to inspect and copy it.

Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate or determine the Plan’s compliance with the privacy regulations. Uses and Disclosures to carry out Treatment, Payment and Health Care Operations The Plan and its business associates will use PHI without your consent, authorization or opportunity to agree or object to carry out treatment, payment and health care operations. The Plan also will disclose PHI to the Plan Sponsor, Pallet Logistics of America, for purposes related to treatment, payment and health care operations. The Plan Sponsor has amended its plan documents to protect your PHI as required by federal law. Treatment is the provision, coordination or management of health care and related services. It also includes, but is not limited to, consultations and referrals between one or more of your providers. For example, the Plan may disclose to a treating orthodontist the name of your treating dentist so that the orthodontist may ask for your dental X-rays from the treating dentist. Payment includes, but is not limited to, actions to make payment (including billing, claims management, subrogation, plan reimbursement, reviews for medical necessity and appropriateness of care, utilization review and preauthorization) for the health care services you receive. For example, the Plan may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational or medically necessary or to determine whether the Plan will cover the treatment. The Plan may also share medical information with a utilization review or precertification service provider. Likewise, the Plan may share medical information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments. Furthermore, the Plan may, for payment purposes, take actions to make coverage determinations. For example, the Plan may tell a doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan. Health care operations include, but are not limited to, quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts. It also includes disease management, case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. For example, the Plan may use information about your claims to refer you to a disease management program, project future benefit costs or audit the accuracy of its claims processing functions. Other examples include the Plan using your health information to review the performance of our staff and vendors. The Plan may also use your information and the information of other members to plan what services the Plan needs to provide, expand, or reduce. The Plan may disclose your health information as necessary to others who the Plan contracts with to provide administrative service, which includes the Plan’s lawyers, auditors, accreditation services, and consultants, for instance. Uses and Disclosures that Require Your Written Authorization Your express written authorization must be received before the Plan sells any PHI about you. Also, your written authorization generally will be obtained before the Plan will use or disclose psychotherapy notes about you from your psychotherapist. Psychotherapy notes are separately filed notes about your conversations with your mental health professional during a counseling session. They do not include summary information about your mental health treatment. The Plan may use and disclose such notes when needed by the Plan to defend against litigation filed by you. In addition, your written authorization is required for any marketing communication which includes a communication about a product or service that encourages you to buy or sue the product or service being marketed. However, if there is no direct or indirect fee to the Plan, an authorization is not required. Moreover, communications the Plan makes about its own health care products or services, communications for treatment purposes, and communications for purposes of case management or Personal Health Support or to recommend alternative treatments, therapies, providers or settings of care are accepted from the authorization requirement. Use and Disclosures that Require that you be given an Opportunity to Agree or Disagree Prior to the Use or Release Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if: The information is directly relevant to the family or friend’s involvement with your care or payment for that care; and You have either agreed to the disclosure or have been given 62 an opportunity to object and have not objected.

Required Notices

Uses and Disclosures for which Consent, Authorization or Opportunity to Object is not Required

Use and disclosure of your PHI is allowed without your consent, authorization or request under the following circumstances: To Avert a Serious Threat to Health or Safety. The Plan may disclose your health information if the Plan decides that the disclosure is necessary to prevent serious harm to the public or to an individual. The disclosure will only be made to someone who is able to prevent or reduce the threat. Organ and Tissue Donation. If you are an organ donor, the Plan may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Military and Veterans. If you are a member of the armed forces, the Plan may release medical information about you as required by military command authorities. The Plan may also release medical information about foreign military personnel to the appropriate foreign military authority. Workers’ Compensation. similar programs.

The Plan may release medical information about you for workers’ compensation or

Public Health Risks. The Plan may disclose medical information about you for public health activities. These activities generally include the following: • to prevent or control disease, injury or disability; • to report births and deaths; • to report child abuse or neglect; • to report reactions to medications or problems with products; • to notify people of recalls of products they may be using; • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; • to notify the appropriate government authority if the Plan believes a participant has been the victim of abuse, neglect or domestic violence. The Plan will only make disclosure if you agree or when required or authorized by law. Health Oversight Activities. The Plan may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Law Enforcement. The Plan may release medical information if asked to do so by a law enforcement official: •

in response to a court order, subpoena, warrant, summons or similar process;

•

to identify or locate a suspect, fugitive, material witness, or missing person;

•

about the victim of a crime if, under certain limited circumstances, the Plan is unable to obtain the person’s agreement;

•

about a death the Plan believes may be the result of criminal conduct;

•

about criminal conduct at the hospital; and

•

in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. The Plan may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. The plan may also release medical information about patients of a hospital to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities. The Plan may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, the Plan may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institutions. 63

Rights of Individuals Right to Request Restrictions on PHI Uses and Disclosures

Required Notices

You may request the Plan to restrict uses and disclosures of your PHI to carry out treatment, payment or health care operations, or to restrict uses and disclosures to family members, relatives, friends or other persons identified by you who are involved in your care or payment for your care. For example, you could ask that the Plan not use or disclose information about a surgery you had. The Plan is not required to agree to your request. You or your personal representative will be required to complete a form to request restrictions on uses and disclosures of your PHI. To request restrictions, you must make your request in writing to the Privacy Officer, c/o Pallet Logistics of America, at 4100 Platinum Way, Dallas, TX 75237. In your request, you must tell the Plan (1) what information you want to limit; (2) whether you want to limit the Plan’s use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Right to Inspect and Copy PHI You have the right to inspect and copy medical information that may be used to make decisions about your Plan benefits. You also have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as the Plan maintains the PHI.

“Designated Record Set” includes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for health plan; or other information used in whole or in part by or for the covered entity to make decisions about individuals. Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set. The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained offsite. A single 30 day extension is allowed if the Plan is unable to comply with the deadline. To inspect and copy medical information that may be used to make decisions about you or to inspect and copy a designated record set, you must submit your request in writing to the Privacy Officer, c/o Pallet Logistics of America at 4100 Platinum Way, Dallas, TX 75237. If you request a copy of the information, the Plan may charge a fee for the costs of copying, mailing or other supplies associated with your request. If access is denied, you or your personal representative will be provided with a written denial setting forth the basis for the denial, a description of how you may exercise those review rights and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services. Right to Amend PHI You have the right to request the Plan to amend your PHI or a record about you in a designated record set for as long as the PHI is maintained in the designated record set or by the Plan. To request an amendment, your request must be made in writing and submitted to: Privacy Officer, c/o Pallet Logistics of America at 4100 Platinum Way, Dallas, TX 75237. In addition, you must provide a reason that supports your request. The Plan has 60 days after the request is made to act on the request. A single 30 day extension is allowed if the Plan is unable to comply with the deadline. The Plan may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, the Plan may deny your request if you ask the Plan to amend information that: • • •

is not part of the medial information kept by or for the Plan; was not created by the Plan, unless the person or entity that created the information is no longer available to make the amendment; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.

If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI. 64

The Right to Receive an Accounting of PHI Disclosures

Required Notices

At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting need not include PHI disclosures made: (1) to carry out treatment, payment or health care operations; (2) to individuals about their own PHI; or (3) prior to the compliance date. If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided. If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting. To request an accounting of disclosures, your request must be made in writing and submitted to the Privacy Officer, c/o Pallet Logistics of America at 4100 Platinum Way, Dallas, TX 75237. In addition, you must provide a reason that supports your request and in what form you want the list (for example, paper or electronic). The Right to Request Confidential Communications You have the right to request that the Plan communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that the Plan only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Officer, c/o Pallet Logistics of America at 4100 Platinum Way, Dallas, TX 75237. The Plan will not ask you the reason for your request. The Plan will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. The Right to Receive a Paper Copy of This Notice Upon Request You have a right to receive a paper copy of this Notice even if you have previously received a copy or agreed to receive this Notice electronically. You may also obtain a copy of this Notice on the intranet. To obtain a paper copy of this Notice, please contact the Privacy Officer, c/o Pallet Logistics of America at 4100 Platinum Way, Dallas, TX 75237. A Note about Personal Representatives You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms: •

A power of attorney for health care purposes, notarized by a notary public;

•

A court order of appointment of the person as the conservator or guardian of the individual; or

•

An individual who is the parent of a minor child.

The Plan retains discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect. This also applies to personal representatives of minors. The Plan's Duties The Duty to Notify in Case of a Breach The Plan is required by law to notify any affected individuals of a breach of unsecured PHI. The Plan’s Rights and Responsibilities to Change This Notice The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with Notice of its legal duties and privacy practices.

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Required Notices

This Notice is effective beginning April 14, 2003 and the Plan is required to comply with the terms of this Notice. However, the Plan reserves the right to change their privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy practice is changed, a revised version of this Notice will be provided to all past and present participants and beneficiaries for whom the Plan still maintains PHI. You will receive a copy of any revised Notice from the Plan by mail or by e-mail, but only if e-mail delivery is offered by the Plan and you agree to such delivery. Any revised version of this Notice will be distributed within 60 days of the effective date of any material change to the uses or disclosures, the individual’s rights, the duties of the Plan or other privacy practices stated in this Notice. Minimum Necessary Standard When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. However, the minimum necessary standard will not apply to the following situations: •

Disclosures to or requests by a health care provider for treatment;

•

Uses or disclosures made to the individual;

•

Disclosures made to the Secretary of the U.S. Department of Health and Human Services;

•

Uses or disclosures that are required by law; and

•

Uses or disclosures required for the Plan’s compliance with legal regulations.

This Notice does not apply to information that has been de-identified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. In addition, the Plan may use or disclose “summary health information” to Pallet Logistics of America for obtaining premium bids or modifying, amending or terminating the Plan, which summarizes the claims history, claims expenses or type of claims experienced by individuals for whom Pallet Logistics of America has provided health benefits under the Plan; and from which identifying information has been deleted in accordance with HIPAA. Your Right to File a Complaint with the Plan or the HHS Secretary If you believe that your privacy rights have been violated, you may complain to the Privacy Officer, c/o Pallet Logistics of America at 4100 Platinum Way, Dallas, TX 75237. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, D.C. 20201. The Plan will not retaliate against you for filing a complaint. Conclusion PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations. For More Information or to Report a Problem If you have questions and would like additional information, you may contact the Pallet Logistics of America Benefits Department at 972-850-5017, who can put you in contact with the Privacy Officer at Pallet Logistics of America, 4100 Platinum Way, Dallas, TX 75237. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. There will be no retaliation against you for filing a complaint

66

Required Notices

Important Notice from Pallet Logistics of America About 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 Pallet Logistics of America 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: 1. 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. 2. Pallet Logistics of America has determined that one the of prescription drug coverages offered by Pallet Logistics of America, UnitedHealthcare medical plan, 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 the UnitedHealthcare 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. The MEC/Limited Indemnity plan through Century Healthcare is not considered creditable coverage. _________________________________________________________________________ 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? If you decide to join a Medicare drug plan, your current Pallet Logistics of America coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Pallet Logistics of America coverage, be aware that you and your dependents will be able to get this coverage back at open enrollment or due 67 to a qualifying event.

Required Notices

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 Pallet Logistics of America and do not 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 Pallet Logistics of America ’s Benefits Department at 972-850-5017 for further information. NOTE: You will 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 Pallet Logistics of America changes. You also may request a copy of this notice at any time. CMS Form 10182-CC Updated April 1, 2011 - 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 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, 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 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 will 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) for personalized help call 1-800-MEDICARE (1-800-6334227). 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).

68

Required Notices

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Pallet Logistics of America Position/Office: Benefits Department 4100 Platinum Way, Dallas, TX 75237 972-850-5017 New Health Insurance Marketplace Coverage Options and Your Health Coverage When key parts of the health care law took effect in 2014, there was a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that does not meet certain standards. The savings on your premium that you are eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. An employersponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution – as well as your employee contribution to employer – offered coverage – is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact Pallet Logistics of America ’s Benefits Department. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. 69