IT IS UNDERSTOOD AND AGREED THAT THE FOLLOWING MODIFICATIONS SHALL BE MADE:

1. Magellan Rx, the Plan’s Pharmacy Benefits Manager (PBM), is now called Prime Therapeutics Management LLC. The specialty pharmacy is now called Prime Therapeutics Pharmacy LLC specialty pharmacy. Covered Persons can contact the PBM at the phone number listed on the health plan identification card for more information. All associated references throughout the Plan document will be updated accordingly.
2. In the SCHEDULE OF MEDICAL BENEFITS – BLACK PLAN section of the Plan document, the following changes will be made to the Comprehensive Medical Benefit:
   A. The In-Network Deductibles per Plan Year will change to $1,000 per Covered Person and $2,000 per Family.
   B. The In-Network Total Maximum Out-of-Pockets per Plan Year will change to$6,000 per Covered Person and $12,000 per Family.
3. In the UTILIZATION REVIEW PROGRAM section of the Plan document, the MANDATORY SELECT SURGICAL PROCEDURE AND OUTPATIENT SERVICE CERTIFICATION subsection will be deleted in its entirety and replaced with the following:
   MANDATORY SELECT SURGICAL PROCEDURE AND OUTPATIENT SERVICE CERTIFICATION
   If a Covered Person’s treatment includes any of the services listed below, the treatment should be reviewed before its inception regardless of whether or not the treatment is in lieu of hospitalization. However, the Plan does not require certification for emergency services.
   A. Select surgical procedures
   B. Durable Medical Equipment if the purchase price or forecasted total rental cost will be $2,500 or more
   C. Home Health Care
   D. Custom-made Orthotic or Prosthetic Appliance if the purchase price will be$2,500 or more
   E. Outpatient oncology treatment (chemotherapy or radiation therapy)
   F. Enteral and total parenteral nutrition therapy
   G. Outpatient infusion or injection of select products

NOTES:

1. The list of select surgical procedures that require certification can be accessed by logging on to the Claim Administrator’s Website address printed on the health plan identification card or by calling the Claim Administrator at the telephone number printed on the health plan identification card.
2. Equipment for administering nutrition therapy is not subject to the enteral and total parenteral nutrition therapy certification requirement; however, such products will be reviewed as part of a Covered Person’s eligible charges under the Durable Medical Equipment certification requirement included in the service list above.
3. The infusion or injection of medications that are self-administered or that are administered in most Outpatient settings generally requires certification if the per-dosage cost is $2,000 or more per 30-day supply. For purposes of this provision, the cost will be calculated using either the actual per-dosage cost of the medication or the cost of a 30-day supply of the medication, whichever cost calculation is higher. However, when otherwise eligible for Plan coverage, antibiotics, post-transplant medication regimens, spinal injections, steroid injections, or therapeutic injections for osteoarthritis of the knee will not be subject to the Plan’s certification requirement. Total parenteral nutrition (TPN) will not be subject to the Outpatient infusion or injection certification requirement; however, such products will be reviewed as part of a Covered Person’s eligible treatment under the Outpatient enteral and total parenteral nutrition therapy certification requirement included in the service list above. Additionally, medications related to an oncology diagnosis will also not be subject to the Outpatient infusion or injection certification requirement; however, such drugs will be reviewed as part of a Covered Person’s eligible treatment under the Outpatient oncology treatment certification requirement included in the service list above. A Covered Person can call the Certification telephone number on the health plan identification card to determine if a prescribed medication is subject to the Plan’s Certification Requirement.

In addition to the standard certification requirement for the Outpatient infusion or injection of select products as included in the service list above, the Plan will require those infusions and injections to be purchased or administered at the most cost-effective site of service that is able to safely and appropriately provide the Covered Person with the treatment (examples of cost-effective sites of service include, but are not necessarily limited to, a Physician’s office, a pharmacy, or a free-standing infusion center). In order to determine the most cost-effective site of service that is able to safely and appropriately provide or administer the product prescribed, the Utilization Review Firm or Plan may consider factors such as the Covered Person’s need for continuity of care during a course of treatment related to a serious or complex medical condition, the proximity of the Covered Person’s home to an available lower-cost site of service, or the use of a particular facility because of the limited distribution of a prescribed medication. The Plan will not cover costs for or associated with the Outpatient infusion or injection of select products if the Covered Person does not use the most cost-effective site of service that can safely and appropriately provide the treatment. A Covered Person can call the Certification telephone number on the health plan identification card to find the most cost-effective site of service that can safely and appropriately provide or administer the product prescribed.

A Covered Person must call the Certification telephone number on the health plan identification card as soon as possible before receiving the above-listed services, but in no event later than two business days after the services were rendered.

4. The following provision will be added to the COVERED CHARGES section of the Plan document:
   Enteral and Total Parenteral Nutrition Therapy
   Charges for Medically Necessary nutrition therapy will be covered when administered enterally (i.e., by feeding tube) or parenterally (i.e., by intravenous administration) as the sole source of nutrition where the Covered Person has any of the following conditions that require tube feedings/parenteral infusions to provide sufficient nutrients to maintain weight and strength commensurate with the Covered Person’s overall health status:
   • A permanent non-function or disease of the structures that normally permit food to reach the small bowel. In general, a permanent impairment means that, in the judgment of the Physician and substantiated in the medical record, the condition is of long and indefinite duration (ordinarily at least three months, but less if the nutrition therapy is the sole source of nutrition, e.g., postoperatively).
   • A non-permanent non-function of the structures that normally permit food to reach the small bowel where the need is on a short-term basis postoperatively or after a medical event and where the Covered Person is expected to return to normal function (e.g., post-esophageal surgery or post-cerebral vascular accident that impairs swallow reflex).
   • A disease of the small bowel that impairs digestion and absorption of an oral diet. Appropriate nutrients, administration supplies, and equipment are considered Medically Necessary for Covered Persons who meet criteria for enteral or parenteral feedings, including prescribed over-the-counter products. Enteral nutrition products administered orally, and related supplies, are not covered.
5. The following note will be added to the PARTICIPANT ELIGIBILITY REQUIREMENTS: SPECIAL RULES FOR ALL EMPLOYEES section of the Plan document: NOTE: In the event the Plan changes the timeframe within which the Annual Open Enrollment Period will be held and Plan elections will go into effect, the Standard Measurement, Administrative, and Stability Periods will be revised accordingly. An Employee’s status at the time the Plan changes when the Annual Open Enrollment Period is held and Plan elections go into effect will continue until the end of the Standard Stability Period that is in place at the time of this Plan change. Thereafter, the Employee will be considered under the new Standard Measurement, Administrative, and Stability Periods.
6. The ANNUAL OPEN ENROLLMENT PERIOD section of the Plan document will be deleted in its entirety and replaced with the following:

ANNUAL OPEN ENROLLMENT PERIOD

Beginning in 2024 and for every year thereafter, the Plan will offer an Annual Open Enrollment Period in November each year for eligible individuals and their dependents to enroll or re-enroll for coverage under this Plan. For those individuals and their dependent(s) who enroll or re-enroll during the Annual Open Enrollment Period offered in November 2024, their elections will go into effect on January 1, 2025. For eligible individuals and their dependent(s) who enroll or re-enroll for coverage under this Plan during any other Annual Open Enrollment Period, their elections will go into effect on January 1 following the Annual Open Enrollment Period.
An eligible individual may complete a new election form and return it to the Plan Administrator during the Annual Open Enrollment Period before the first day of the subsequent Plan Year. Further, the Plan Administrator may require an eligible individual to complete a new election form for a subsequent Plan Year. If neither one of these situations applies, an individual’s election from the previous Plan Year shall automatically continue for the subsequent Plan Year.
Employees who satisfy the Participant Eligibility Requirements for full-time Employees as described in the Participant Eligibility Requirements: Full-Time Employees section of the Plan document and who continue to be eligible for Participant Coverage may enroll or re-enroll for coverage under the Plan during the Annual Open Enrollment Period.
Any other Employee will be eligible to enroll or re-enroll for coverage under the Plan during the Annual Open Enrollment Period if he or she averaged 30 or more hours per week during the preceding 12-month Standard Measurement Period. Alternatively, an Employee who is eligible for coverage during his or her Initial Stability Period will be able to enroll or re-enroll for coverage under the Plan during the Annual Open Enrollment Period but coverage and the election will both terminate upon the expiration of the Initial Stability Period, unless the Employee maintains his or her eligibility for coverage under the terms of the Plan.

7. In the DEFINITIONS section of the Plan document, the MEDICALLY NECESSARY definition will be revised to read as follows:
   MEDICALLY NECESSARY
   The term “Medically Necessary” means a service, medicine, or supply that satisfies the requirements described in this section.
   A. Requirements. A service, medicine, or supply is Medically Necessary if it satisfies all of the following requirements:
   • It must be within the standards of good medical practice for the diagnosis or treatment of an Illness or Injury within the organized medical community.
   • It must be legal.
   • It must be ordered by a Physician or Physician’s Assistant. However, the fact that a service, medicine, or supply is ordered by a Physician or Physician’s Assistant does not mean that the service, medicine, or supply is Medically Necessary.
   • It must be commonly and customarily recognized throughout the Physician’s profession as appropriate in treating the diagnosed Illness or Injury.
   • It must be provided at an appropriate level of care to treat the diagnosed Illness or Injury.

B. Exclusions. Services, medicines, or supplies that are not Medically Necessary shall include, but shall not be limited to, the following items:

1. Procedures that are of unproven value or of questionable current usefulness.
2. Procedures that tend to be repetitive when performed in combination with other procedures.
3. Diagnostic procedures that are unlikely to provide a Physician with additional information when they are used repeatedly.
4. Procedures that are not ordered by a Physician or Physician’s Assistant or that are not documented in the patient’s medical records.
5. Services, medicines, and supplies furnished for the personal comfort or convenience of the patient.

A determination that a service, medicine, or supply is not Medically Necessary may apply to all or a portion of the service, medicine, or supply. The Plan Administrator, in its sole discretion, shall make the final determination as to whether a service, medicine, or supply is Medically Necessary.

8. In the DEFINITIONS section of the Plan document, the BENEFIT YEAR definition will be deleted in its entirety.

All other provisions of the Plan shall remain in effect and unchanged

The undersigned has caused this amendment to be duly adopted and effective as of January 1, 2025.