You don t need to meet any deductibles in this Plan. This is a medical expense reimbursement plan. There is no network.

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1 This is only a summary. The SBC shows you how you and the plan would share the cost for covered healthcare services. If you want more detail about your coverage and costs, you can get the complete terms in the Plan document by calling or You can view the Glossary at or call to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Will you pay less if you use network provider? Do you need a referral to see a specialist? $0 Yes This Plan has no out-ofpocket limit. There is no deductible on this Plan. This Plan reimburses you up to the balance in your Employee Account for the cost of medical expenses (including deductibles) you have paid (and for which you didn t receive reimbursement from any other source) to the extent those medical expenses are tax deductible under Internal Revenue Code ( IRC ) Section 213. IRC Section 213 generally allows you to deduct expenses you incur for the diagnosis, cure, mitigation, or prevention of disease or injury. You don t need to meet any deductibles in this Plan. This Plan will reimburse your deductible costs and any other tax deductible medical expenses that you have paid. You don t need to meet any deductibles in this Plan. There is no out-of-pocket limit on this Plan. You will remain responsible to pay all medical expenses that exceed the balance in your Employee Account. t applicable because there is no out-of-pocket limit on your expenses. This is a medical expense reimbursement plan. There is no network. This Plan does not require you to obtain a referral to see the specialist you choose.

2 This Plan may reimburse you for your deductibles, copayments, coinsurance and balance billing amounts, regardless of whether your provider was in-network or out-of-network. This is not your primary insurance policy. This Plan will reimburse you for out-of-pocket medical expenses, up to the balance of your Employee Account. You bear any remaining costs after your primary insurance coverage and your Employee Account balance under this Plan have been exhausted. Common Medical Event Services You May Need Your Cost If You Use an In-network Provider Your Cost If You Use an Out-of-network Provider Limitations & Exceptions If you visit a health care provider s office or clinic Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/immunization innetwork than for out-ofnetwork providers, your cost will be lower (maybe zero) if you use an innetwork provider. This Plan will reimburse you for certain out-of-pocket costs not paid by your primary health insurance policy, if there are any such costs after using an in-network provider. innetwork than for outof-network providers, your cost will be higher if you use an out-of-network provider. This Plan will reimburse you for certain out-of-pocket costs not paid by your primary health insurance policy, and those costs will likely be higher if you use outof-network providers. Your reimbursement is limited to the balance in your Employee Account. Also, this Plan only reimburses you for medical expenses that are tax deductible under Internal Revenue Code Section 213 (generally, expenses you incur for the diagnosis, cure, mitigation, or prevention of disease or injury). If you have a test Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) under If you visit a health care provider s office or clinic under If you visit a health care provider s office or clinic under If you visit a health care provider s office or clinic

3 Common Medical Event Services You May Need Network Provider Out-of-network Provider Limitations, Exceptions & Other Important Information If you need drugs to treat your illness or condition Generic drugs Preferred brand drugs n-preferred brand drugs Specialty drugs network than for outof-network providers, your cost will be lower (maybe zero) if you use a network provider. This Plan will reimburse you for certain out-of-pocket costs not paid by your primary health insurance policy, if there are any such costs after using a- network provider. network than for outof-network providers, your cost will be higher if you use an out-of-network provider. This Plan will reimburse you for certain out-of-pocket costs not paid by your primary health insurance policy, and those costs will likely be higher if you use out-of-network providers. The drug must be prescribed or be insulin, and the amount reimbursed is limited to the balance of your Employee Account. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees under If you need drugs to treat your illness or condition under If you need drugs to treat your illness or condition Your reimbursement is limited to the balance in your Employee Account. Also, this Plan only reimburses you for medical expenses that are tax deductible under Internal Revenue Code Section 213 (generally, expenses you incur for the diagnosis, cure, mitigation, or prevention of disease or injury).

4 Common Medical Event If you need immediate medical attention Services You May Need Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Network Provider Out-of-network Provider Limitations, Exceptions & Other Important Information If you have a hospital stay Physician/surgeon fee If you need mental health, behavioral health, or substance abuse services If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Outpatient services Inpatient services Office visits Childbirth/delivery professional services Childbirth/delivery facility services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service Children s Eye exam Children s Glasses Children s Dental check-up network than for out-ofnetwork providers, your cost will be lower (maybe zero) if you use a network provider. This Plan will reimburse you for certain out-of-pocket costs not paid by your primary health insurance policy, if there are any such costs after using a- network provider. network than for out-ofnetwork providers, your cost will be higher if you use an out-of-network provider. This Plan will reimburse you for certain out-of-pocket costs not paid by your primary health insurance policy, and those costs will likely be higher if you use out-of-network providers. Your reimbursement is limited to the balance in your Employee Account. Also, this Plan only reimburses you for medical expenses that are tax deductible under Internal Revenue Code Section 213 (generally, expenses you incur for the diagnosis, cure, mitigation, or prevention of disease or injury).

5 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover: This Plan will reimburse you only for tax-deductible medical expenses (i.e., expenses you incur for the diagnosis, cure, mitigation, or prevention of disease or injury). The following is a list of some expenses that would not be covered by this Plan. (This isn t a complete list. Check your Plan document and IRS Publication 502, available at for other excluded services.) Bariatric surgery, unless for a specific disease diagnosed by a doctor Cosmetic surgery, hair removal, hair transplant, or teeth whitening services Fertility treatment expenses, unless they are tax-deductible medical expenses Health club dues Premiums for insurance Medicines and drugs brought in (or ordered shipped) from another country n-prescription drugs and medicines, except insulin Private-duty nursing care, unless providing medical, not personal or household services Weight loss programs, unless the treatment is for a specific disease diagnosed by a doctor Other Covered Services This Plan will reimburse you for tax-deductible medical expenses up to the balance in your Employee Account. The following is a list of some expenses that would be covered by this Plan. (This isn t a complete list. Check your Plan document and IRS Publication 502, available at for other covered services.) Acupuncture Hearing aids Routine eye care Chiropractic services for medical care Routine foot care Dental care (if not cosmetic) n-emergency medical care outside the U.S., if the services would be tax-deductible if performed within the U.S. Your Rights to Continue Coverage: If your contributions to this Plan cease, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to continue contributions to the Plan. Please note: The application of COBRA to this Plan differs from a typical health plan because benefits under this Plan generally begin afte retirement. (Under a typical health plan, coverage would begin immediately following active employment.) Any such rights to continue contributions may provide benefits from this Plan after retirement. The right to continue COBRA contributions will be limited in duration. Self-pay contributions may be significantly higher than the contributions paid during your employment. Other limitations on your rights to continue contributions may also apply. See the COBRA General tice, which you can obtain from the Trust Office if you do not have a copy. For more information on your rights to continue contributions, contact the Plan administrator at You may also contact the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Appeal Rights: If you have a complaint or are dissatisfied with a denial of claim under your Plan, you have the right to appeal the denial. For questions about your rights, questions about this notice, or other Plan assistance, you can contact: The William C. Earhart Co. at or P.O. Box 4148, Portland, Oregon You may also contact the U.S. Department of Labor, Employee Benefits Security Administration at or Language Access Services: Para obtener asistencia en español, llame al

6 This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. If you want more detail about your coverage and costs, you can get the complete terms in the Plan document by calling or Peg is having a baby (9 months of in-network pre-natal care and a hospital delivery) Amount owed to providers: $7,540 Primary health policy pays: $6,750 This Plan reimburses Patient: $790* Patient pays out-of-pocket: $0* Sample care costs ($): Hospital charges (mother) 2,700 Childbirth/delivery prof. services 2,100 Hospital charges (baby) 900 Anesthesia 900 Diagnostic/Laboratory tests 500 Prescriptions 200 Radiology 200 Vaccines, other preventive 40 Total 7,540 Patient pays ($): Deductibles 500 Copays 150 Coinsurance 0 Limits or exclusions 140 Total Before Reimbursement 790 Reimbursement from this Plan 790* Total Peg would pay after reimbursement 0* *Assumes the patient has a balance of at least $790 in his or her Employee Account before seeking reimbursement. See Plan Section 3.1 for details. Managing Joe s type 2 diabetes (a year of routine in-network care of a well-controlled condition) Amount owed to providers: $5,000 Primary health policy pays: $3,800 This Plan reimburses Patient: $1,200* Patient pays out-of-pocket: $0* Sample care costs ($): Prescriptions 2,900 Medical Equipment and Supplies 1,300 Office Visits and Procedures 700 Laboratory tests 100 Total 5,000 Patient pays ($): Deductibles 500 Copays 150 Coinsurance 0 Limits or exclusions 550 Total Before Reimbursement 1,200 Reimbursement from this Plan 1,200* Total Joe would pay after reimbursement 0* *Assumes patient has a balance of at least $1,200 in his or her Employee Account before seeking reimbursement. See Plan Section 3.1 for details. Mia s Simple Fracture (in-network emergency room visit and follow up care) Amount owed to providers: $1,900 Primary health policy pays: $850 This Plan reimburses Patient: $1,050* Patient pays out-of-pocket: $0* Sample care costs ($): Emergency room care 800 Medical Equipment (crutches) 100 Diagnostic test (x-ray) 400 Rehabilitation services (physical ther) 600 Total 1,900 Patient pays ($): Deductibles 700 Copays 50 Coinsurance 300 Limits or exclusions 0 Total Before Reimbursement 1,050 Reimbursement from this Plan 1,050* Total Mia would pay after reimbursement 0* *Assumes patient has a balance of at least $1,050 in his or her Employee Account before seeking reimbursement. See Plan Section 3.1 for details.