Amendment to the Employer-funded Medical Reimbursement Plan

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

Under the Limit on Benefits section of the BENEFITS article, the maximum amount per Benefit Year that may be reimburses to the Participant for Medical Expenses incurred under the Employer’s group health Black Plan is 50 percent of each claim applied toward the in-network deductible of the Participant and the Participant’s enrolled Dependents under the Black Plan (up to $500 per Covered Person and $1,000 per family). The Participant must pay the other 50 percent of each claim applied toward the in-network deductible under the Black Plan (up to $500 per Covered Person and $1,000 per family).

Example: A Covered Person is enrolled in single coverage under the Employer’s group health Black Plan and incurs three claims toward the $1,000 in-network deductible under the Black Plan within the same Benefit Year. The Plan will reimburse 50% of each claim, up to the $500 maximum Plan benefit. The Covered Person is responsible for the balance of each claim until the deductible is satisfied.

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