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

1. The following changes will be made to the SCHEDULE OF MEDICAL BENEFITS – BLACK PLAN section of the Plan document:
   A. The OUTPATIENT PHYSICIAN VISITS benefit will be revised to read as follows:
   
   

BENEFITS	IN-NETWORK	OUT-OF-NETWORK
OUTPATIENT PHYSICIAN VISITS (includes office visits and Telemedicine e-visits) Telemedicine E-Visits Billed by Amwell	$0 co-payment per visit, then 100% (Deductible waived)	Not applicable
Non-Specialist’s Fee for Office Visits and Telemedicine E-Visits	$20 co-payment per visit, then 100% (Deductible waived)	70% after Deductible
Specialist’s Fee for Office Visits and Telemedicine E-Visits	$35 co-payment per visit, then 100% (Deductible waived)	70% after Deductible
All Other Charges Billed in connection with the Examination:	Paid the same as any other Illness; annual frequency limits and cost-sharing provisions such as Deductibles, Coinsurance, or co-payments may apply depending upon the type of service rendered.	Paid the same as any other Illness; annual frequency limits and cost-sharing provisions such as Deductibles, Coinsurance, or co-payments may apply depending upon the type of service rendered.

NOTE: The term “Non-Specialist” means a Physician, Physician’s Assistant, Nurse Practitioner, or other eligible provider who provides Medical Care in family practice, general practice, outpatient or intensive outpatient Behavioral Care services, internal medicine, obstetrics and gynecology, or pediatrics. For the purposes of this benefit, the term “Medical Care” does not include any services otherwise addressed the Plan document (e.g., chiropractic care). The term “Specialist” means a Physician with advanced education and training in a recognized medical specialty who is not a Non-Specialist as defined above. Specialists are often licensed or certified in their medical specialty.

2. The SCHEDULE OF PRESCRIPTION DRUG BENEFITS – BLACK PLAN section of the Plan document will be revised to read as follows:

SCHEDULE OF PRESCRIPTION DRUG BENEFITS – BLACK PLAN
PRESCRIPTION DRUGS
Prescription Drug Card Program

Co-payment per generic prescription drug – $10
Co-payment per brand-name prescription drug – $20
A Covered Person may fill a prescription for up to and including a 30-day supply for the above-stated co-payment amounts. If a prescribing Physician requests more than a 30-day supply of a drug, a 60- to 90-day supply of a covered prescribed medication can be purchased at a participating pharmacy for the applicable Mail Service Program co-payment specified below.

Mail Service Program
Co-payment per generic prescription drug – $20
Co-payment per brand-name prescription drug – $40
The Mail Service Program is specifically designed to provide the Covered Person with
maintenance drugs for up to and including a 90-day supply.

*Drugs Included in the Medication Assistance Program through AscendPBM: Special coverage terms apply to certain high-cost drugs and Specialty Prescription Drugs included in the Medication Assistance Program through AscendPBM; contact the Pharmacy Benefits Manager (PBM) to learn the co-payment that will be charged and other special terms that may apply
NOTES:

1. The pharmacy will dispense generic drugs unless the prescribing Physician requests “Dispense as Written” (DAW) or a generic equivalent is not available. If the Covered Person refuses an available generic equivalent and the prescribing Physician has not requested DAW, the Covered Person must pay the applicable co-payment plus the difference in price between the brand-name drug and its generic equivalent.
2. Certain over-the-counter drugs will be covered under the Plan and shall be subject to the generic co-payments shown above. A Physician’s prescription for these products is required.
3. In accordance with the requirements of Health Care Reform, the Plan provides coverage for certain preventive care medications without any cost-sharing provisions such as medical Deductibles or prescription drug co-payments. Preventive care medications include, but are not limited to, certain FDA-approved contraceptive agents, certain smoking cessation intervention products when prescribed by a Physician, and
   breast cancer medications that lower the risk of cancer or slow its development. For more information about eligible preventive care medications, Covered Persons can contact the Pharmacy Benefits Manager (PBM) at the telephone number on the front of
   the identification card.
4. Certain immunizations administered at a pharmacy within the designated network, including any injection/administration fees charged by the pharmacy, will be covered by the Plan through the Prescription Drug Card Program at 100% (no prescription drug
   co-payment will be applied). Covered Persons can contact the PBM for more information on how to find a pharmacy within the designated network that administers these immunizations.
5. The Plan requires that specific criteria be met before certain high-cost brand-name medications are covered. The Covered Person must have tried a lower-cost PBM-approved equivalent medication before the Plan will cover the brand-name drug. Alternatively, a brand-name drug may be covered if the Covered Person’s Physician contacts the PBM and provides evidence of the prior utilization or proof of failed
   therapy and the PBM authorizes the brand-name medication. If a Covered Person chooses to fill a prescription for certain brand-name drugs without first trying a PBM-approved equivalent medication or getting an authorization from the PBM, coverage may be denied and the Covered Person may have to pay the full cost of the drug.
6. Certain prescription drugs may be acquired through the Plan’s International Prescription Program vendor and may be available to Covered Persons with reduced or no cost-sharing provisions such as prescription drug co-payments. For more information about prescription drugs available through the International Prescription Program vendor, including the co-payment that will be charged or other special
   coverage terms that will apply, the covered person can contact the PBM using the information on his/her identification card.
7. For any Covered Person who meets the necessary individual qualifications to receive external assistance through variable program benefits for prescribed medication(s), the Plan has the right, at its sole discretion, to require the use of a particular, preferred, or mandated program(s). When utilizing the Plan’s preferred (or mandated) procurement avenue, the Covered Person’s financial liability may be variable, reduced, or eliminated as determined by the Employer. Therefore, any whole or partial benefit for which a Covered Person individually qualifies is not a covered benefit under the Plan. Contact the PBM for more information about these program.
8. Eligible prescriptions for a Specialty Prescription Drug must be filled through the designated specialty pharmacy network or that drug purchase will generally not be eligible for coverage under the Plan. Contact the PBM or OptiMed Specialty Pharmacy for more information about this program. As used in this benefit, the term “Specialty Prescription Drug” means a prescription drug identified on the drug list maintained by the PBM that includes drugs typically used to treat complex medical conditions. Specialty Prescription Drugs may be injectable medications, high-cost medications, or medications with special delivery and storage requirements (e.g., they may require refrigeration). Specialty Prescription Drug purchases will be limited to a 30-day dispensing supply.

3. The following changes will be made to the SCHEDULE OF MEDICAL BENEFITS – ORANGE PLAN section of the Plan document

• A. The OUTPATIENT PHYSICIAN VISITS benefit will be revised to read as follows:
  
  

BENEFITS	IN-NETWORK	OUT-OF-NETWORK
OUTPATIENT PHYSICIAN VISITS (includes office visits and Telemedicine e-visits)	Telemedicine E-Visits Billed by Amwell $0 co-payment per visit, then 100%	Not applicable
Non-Specialist’s Fee for Office Visits and Telemedicine E-Visits	$10 co-payment per visit, then 100%	80% after Deductible
Specialist’s Fee for Office Visits and Telemedicine E-Visits	$10 co-payment per visit, then 100%	80% after Deductible
All Other Charges Billed in Connection with the Examination	Paid the same as any other Illness; annual frequency limits and cost-sharing provisions such as Deductibles, Coinsurance, or co-payments may apply depending upon the type of service rendered	Paid the same as any other Illness; annual frequency limits and cost-sharing provisions such as Deductibles, Coinsurance, or co-payments may apply depending upon the type of service rendered

NOTE: The term “Non-Specialist” means a Physician, Physician’s Assistant, Nurse Practitioner, or other eligible provider who provides Medical Care in
family practice, general practice, outpatient or intensive outpatient Behavioral Care services, internal medicine, obstetrics and gynecology, or pediatrics. For
the purposes of this benefit, the term “Medical Care” does not include any services otherwise addressed the Plan document (e.g., chiropractic care). The
term “Specialist” means a Physician with advanced education and training in a recognized medical specialty who is not a Non-Specialist as defined above.
Specialists are often licensed or certified in their medical specialty.

B. The IMMEDIATE CARE CENTER VISITS benefit will deleted in its entirety and replaced with the following:

BENEFITS	IN-NETWORK	OUT-OF-NETWORK
URGENT CARE CENTER VISITS	Physician’s Fee for an Examination $20 co-payment per visit, then 100%	80% after Deductible
All Other Charges Billed in Connection with the Examination	Paid the same as any other Illness; annual frequency limits and cost-sharing provisions such as Deductibles, Coinsurance, or co-payments may apply depending upon the type of service rendered	Paid the same as any other Illness; annual frequency limits and cost-sharing provisions such as Deductibles, Coinsurance, or co-payments may apply depending upon the type of service rendered

4. The SCHEDULE OF PRESCRIPTION DRUG BENEFITS – ORANGE PLAN section of the Plan document will be revises to read as follows:

SCHEDULE OF PRESCRIPTION DRUG BENEFITS – ORANGE PLAN
PRESCRIPTION DRUGS

Prescription Drug Card Program

Co-payment per generic prescription drug $10
Co-payment per brand-name prescription drug $20
A Covered Person may fill a prescription for up to and including a 30-day supply for the above-stated co-payment amounts. If a prescribing Physician requests more than a 30-day supply of a drug, a 60- to 90-day supply of a covered prescribed medication can be purchased at a participating pharmacy for the applicable Mail Service Program co-payment specified below.

Mail Service Program

Co-payment per generic prescription drug $20
Co-payment per brand-name prescription drug $40
The Mail Service Program is specifically designed to provide the Covered Person with maintenance drugs for up to and including a 90-day supply.
*Drugs Included in the Medication Assistance Program through AscendPBM Special coverage terms apply to certain high-cost drugs and Specialty Prescription Drugs included in the Medication Assistance Program through AscendPBM; contact the Pharmacy Benefits Manager (PBM) to learn the co-payment that will be charged and other special terms that may apply.
NOTES:

1. The pharmacy will dispense generic drugs unless the prescribing Physician requests “Dispense as Written” (DAW) or a generic equivalent is not available. If the Covered Person refuses an available generic equivalent and the prescribing Physician has not requested DAW, the Covered Person must pay the applicable co-payment plus the difference in price between the brand-name drug and its generic equivalent.
2. Certain over-the-counter drugs will be covered under the Plan and shall be subject to the generic co-payments shown above. A Physician’s prescription for these products is required.
3. In accordance with the requirements of Health Care Reform, the Plan provides coverage for certain preventive care medications without any cost-sharing provisions such as medical Deductibles or prescription drug co-payments. Preventive care medications include, but are not limited to, certain FDA-approved contraceptive agents, certain smoking cessation intervention products when prescribed by a Physician, and
   breast cancer medications that lower the risk of cancer or slow its development. For more information about eligible preventive care medications, Covered Persons can contact the Pharmacy Benefits Manager (PBM) at the telephone number on the front of the identification card.
4. Certain immunizations administered at a pharmacy within the designated network, including any injection/administration fees charged by the pharmacy, will be covered by the Plan through the Prescription Drug Card Program at 100% (no prescription drug co-payment will be applied). Covered Persons can contact the PBM for more information on how to find a pharmacy within the designated network that administers these immunizations.
5. The Plan requires that specific criteria be met before certain high-cost brand-name medications are covered. The Covered Person must have tried a lower-cost PBM-approved equivalent medication before the Plan will cover the brand-name drug. Alternatively, a brand-name drug may be covered if the Covered Person’s Physician contacts the PBM and provides evidence of the prior utilization or proof of failed
   therapy and the PBM authorizes the brand-name medication. If a Covered Person chooses to fill a prescription for certain brand-name drugs without first trying a PBM-approved equivalent medication or getting an authorization from the PBM, coverage may be denied and the Covered Person may have to pay the full cost of the drug.
6. Certain prescription drugs may be acquired through the Plan’s International Prescription Program vendor and may be available to Covered Persons with reduced or no cost-sharing provisions such as prescription drug co-payments. For more information about prescription drugs available through the International Prescription Program vendor, including the co-payment that will be charged or other special coverage terms that will apply, the covered person can contact the PBM using the information on his/her identification card.
7. For any Covered Person who meets the necessary individual qualifications to receive external assistance through variable program benefits for prescribed medication(s), the Plan has the right, at its sole discretion, to require the use of a particular, preferred, or mandated program(s). When utilizing the Plan’s preferred (or mandated) procurement avenue, the Covered Person’s financial liability may be variable, reduced, or eliminated as determined by the Employer. Therefore, any whole or partial benefit for which a Covered Person individually qualifies is not a covered benefit under the Plan. Contact the PBM for more information about these program.
8. Eligible prescriptions for a Specialty Prescription Drug must be filled through the designated specialty pharmacy network or that drug purchase will generally not be eligible for coverage under the Plan. Contact the PBM or OptiMed Specialty Pharmacy for more information about this program. As used in this benefit, the term “Specialty Prescription Drug” means a prescription drug identified on the drug list maintained by the PBM that includes drugs typically used to treat complex medical conditions. Specialty Prescription Drugs may be injectable medications, high-cost medications, or medications with special delivery and storage requirements (e.g., they may require refrigeration). Specialty Prescription Drug purchases will be limited to a 30-day dispensing supply.

5. The following changes will be made to the PRESCRIPTION DRUG BENEFIT section of the Plan document

A. Biotech/speciality drugs will be removed from the list of COVERED PRODUCTS.

B. The following will be added to the list of EXCLUDED PRODUCTS:

High-cost prescription drugs and Specialty Prescription Drugs, unless designated as covered by the Plan Administrator or the PBM (The Plan has the right, at its sole discretion, to require the use of the designated specialty pharmacy or use of a particular, preferred, or mandated program(s) before coverage for these products is available under the Prescription Drug Benefit. Coverage for certain products may be only be available if the Covered Person participates in all program requirements set forth in the PBM’s Medication Assistance Program or if available patient advocacy programs fail to provide a solution and alternative sourcing opportunities are not available.)

GENERAL PLAN EXCLUSIONS AND LIMITATIONS

The following provision will be added to the GENERAL PLAN EXCLUSIONS AND LIMITATIONS section of the Plan document:
Select High-Cost or Injectable Medications Charges for select high-cost or injectable medications when self-administered or
administered in most Outpatient settings. The list of the select high-cost or injectable medications ineligible for Plan coverage when self-administered or administered in most Outpatient settings can be viewed by logging on to the Claim Administrator’s Website address printed on the back of the Covered Person’s identification card or by calling the Claim Administrator at the telephone number printed on the back of the Covered Person’s identification card.

Exclusion will not apply

This exclusion will not apply to select high-cost or injectable medications that are determined to be eligible for Prescription Drug Benefit coverage by the Pharmacy Benefits Manager; in such an instance, coverage for the high-cost or injectable medication is solely eligible for coverage under the Prescription Drug Benefit and will not be covered as a medical expense except as specifically noted within this benefit. This exclusion will also not apply to select high-cost or injectable medications administered to a Covered Person while confined on an Inpatient basis, or while a Covered Person is receiving treatment from an ambulatory surgical center or an emergency room. Professional fees for the administration of the select high-cost or injectable medication will be eligible only when it is Medically Necessary that the medication be professionally administered to the Covered Person by a Physician or other eligible medical provider performing within the legally appointed scope of his or her license.

In the DEFINITIONS section of the Plan document, the USUAL AND CUSTOMARY definition will be revised to read as follows:

USUAL AND CUSTOMARY

The term “Usual and Customary” refers to the designation of an allowable reimbursement amount as being the average and typical amount accepted by a Physician or other provider of services, supplies, medications, or equipment that does not exceed the general level of allowable reimbursement amount accepted by other providers rendering or furnishing such care or treatment within the same area. The term “area” in this definition means a county or other area as is necessary to obtain a representative cross section of such charges. Due consideration will be given to the nature and severity of the condition being treated and
any medical complications or unusual circumstances that require additional time, skill, or expertise.

NOTE: For claims that are subject to the No Surprises Act, the No Surprises Act governs the calculation of the payment amount by the Plan for purposes of determining both (1) the Covered Person’s cost-sharing requirement, and (2) the total payment, net of the Covered Person’s cost-sharing requirement, to the Physician or other provider. For example, these amounts may be calculated using the Qualifying Payment Amount, which is generally the median of the Plan’s contracted rate with In-Network Providers for the same item or service in the same geographic area. The payment amount for other Out-of-Network claims may be calculated in this same manner, subject to the Plan Administrator’s discretion.

All other Provisions of the plan shall remain in effect and unchanged.