Appendix A. Out-of-Network - In-Network for emergencies only Annual Deductible $250

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1 Medical / Hearing ( PPO for employees whose residence is outside of the HMO Zip Code service area) Out-of-Network - In-Network for emergencies only $250 Appendix A Employee Choice of either BCN HMO or Two-Person Per Plan pays / Particpant pays 80% / 20% Employee Choice of either PPO or PPO In-Network Out-of-Network In-Network Out-of-Network $1,350 $2,700 $3,900 $2,700 $5,400 $7,800 90% / 10% 70% / 30% $250 $1,000 Out-Of-Pocket Maximum (includes Out-Of-Pocket Maximum (includes Out-Of-Pocket Maximum (includes $1,000 $3,000 $6,000 $1,000 $2,000 80% / 20% 60% / 40% Two-Person $5,000 $10,000 Per $2,000 $6,850 $14,000 $2,000 $4,000 Other Medical Provisions Other Medical Provisions Other Medical Provisions Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Telemedicine Copayment Copayment Retail Clinic Visits Doctor's Office Visits Urgent Care Emergency Room Preventive Care $15 Copayment $25 Copayment $35 Copayment $100 Copayment $15 Copayment $25 Copayment $35 Copayment $100 Copayment and and and $75 Copayment C.B.A (Expires 07/31/2021) 1 of 5

2 Employee Choice of either BCN HMO or Medical / Hearing Hearing Exams & Hearing Aids Audiometric Exam, Hearing Aid Evaluation, Ordering & Fitting, and Hearing Aid Conformity test Hearing Aids Prescription Drug Benefit Schedule Retail Pharmacy Generic Preferred Brand Non-Preferred Brand ( PPO for employees whose residence is outside of the HMO Zip Code service area) 100% of approved amount every 36 months 90% of approved amount after deductible Employee Choice of either PPO or 100% of approved amount every 36 months PPO In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network 100% up to $1,500 90% of approved amount after deductible 100% up to $1,500 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Copays $10 $35 Combined with Medical. Paid at 90% after Deductible Copays Combined with Medical. Mail Order Copays Paid at 90% after Copays Deductible Generic Preferred Brand $40 $40 Non-Preferred Brand $70 $70 Prescription Out of Pocket ACA Compliant Limits Limit ACA Compliant Limits $3,300 Combined with Medical Out of Pocket Limits $3,300 $6,600 Combined with Medical Out of Pocket Limits $10 $35 $6, C.B.A (Expires 07/31/2021) 2 of 5

3 Employee Premiums (Weekly) Hired After Contract Date ( PPO for employees whose residence is outside of the HMO service area) $40 Notes: Medical, Rx, Dental, Vision, are bundled for enrollment. Premiums shown are for all coverages. PPO $40 Health Savings Account (HSA) Employees who elect the BCN or the PPO plan for out-of-service area participants may not have a Health Savings Account because the plans do not qualify under IRS rules for HSAs. Optium Bank Company Fixed Annual Contribution: Two Person $1,000 $1,500 Deposits made: 50% Q1, 25% Q2, 25% Q3 Additional Performance-Based Company Contribution according to attachment of Management Incentive Plan Financial goal at: Threshold Target $1,675 Maxium $2,850 Employees who elect the BCN or the PPO plan for out-of-service area participants may not have a Health Savings Account because the plans do not qualify under IRS rules for HSAs C.B.A (Expires 07/31/2021) 3 of 5

4 Dental {MetLife or Midwestern Dental} Dental Frequency Limitations Midweatern Dental Admimistrator MetLife Midweatern Dental $50 s Proposed to Midwestern Dental Two Person $100 $100 Perventive Services (Not Class I - 100% subject to Deductible) Class II - 70% Class III - 50% Class IV (Ortho)- 50% Other Services Annual Maximum $1,400 Orthodontia Eligible members Children to age 19 Orthodontia Deductible $50 (Lifetime) Orthodontia Maximum $1,400 (Lifetime) MetLife Covered services may have limitations and/or exclusions. For example, if two methods are available, the less expensive method may be covered in full, while the more expensive method may be only partially covered. For each plan of treatment, the patient should consult with his or her Midwestern office for options, costs and limitations. Routine exams and cleanings covered 2x/yr, 4x/yr for periodontal cleanings; Space maintainers covered to age 19; Sealants covered 1x/3yrs for children under the age of 14; Bitewing x-rays covered 1x/yr; Full-mouth x-rays covered 1x/5yrs; Fillings covered 1x/tooth per year; Major restorations (inlays, onlays, crowns, etc.) covered 1x/tooth/10yrs; Endodontic treatment, including root canal, covered 1x/2yrs; Periodontal surgery covered 1x/2yrs; Bridges and Dentures - 10yr limit on replacement; Dental implants covered 1x/tooth/10yrs C.B.A (Expires 07/31/2021) 4 of 5

5 Vision {EyeMed} Life Insurance {Cigna LINA} Voluntary Benefits {Cigna LINA} EyeMed Employee Basic Life Employee Optional $62,500 In-Network Out-of-Network Insurance Life Insurance Vision Exam (In-Network Basic AD&D $50,000 Basic AD&D $15 Copay Plan pays $35 Benefits Only) Dependant Optional In-Network Lenses-per pair (single lens, bifocal and trifocal lenticular) Contacts Frames Frequency Limitations EyeMed 85% of balance over $80 In-Network 85% of balance over $75 In-Network Plan pays: $50/pr for single vision $60/pr for bifocal $70/pr for trifocal $80/pr for lenticular $70/pr for standard progressive $80 Out-of-Network (Plan pays $80) Plan pays $25 Exams and eyeglass lenses covered 1x/yr Frames and Contact lenses 1x/2yrs Life Insurance Accident Insurance Critical Illness Insurance ID Theft C.B.A (Expires 07/31/2021) 5 of 5