Enrollment Packet

“DPC – Medical Expense Plan #100”

Prepared Exclusively For:

Big Tree Medical Home Medical DPC Benefit Plan

Prepared By:

Group Benefit Services (GBS)

www.gbs-tpa.com

“Quality People & Technology, Delivering Best in Class Performance”

DPC Medical Expense Plan #100 MONTHLYEmployee Only: $150.00Employee & Child(ren): $270.00Employee & Spouse Only: $290.00Employee & Full Family: $400.00

DENTAL MONTHLYEmployee Only: $37.00Employee & Child(ren): $63.00Employee & Spouse Only: $80.00Employee & Full Family: $104.00

VISION MONTHLYEmployee Only: $12.00Employee & Child(ren): $18.00Employee & Spouse Only: $22.00Employee & Full Family: $33.00

Big Tree Medical Home Current Rates

Big Tree Medical – Medical Expense Plan #100 1 | P a g e

Summary Plan Description Big Tree Medical

Direct Primary Care

“DPC - Medical Expense Plan #100”

Prepared Exclusively For:

Big Tree Medical Service Members

Group Benefit Services (GBS)

www.gbs-tpa.com

“Quality People & Technology, Delivering Best in Class Performance”

IMPORTANT DISCLOSURE: The benefits described in this benefit summary provides only limited benefits. This program is not an alternative to comprehensive major medical coverage. The plan does not provide major medical or comprehensive medical coverage and is not designed or intended to replace any major medical insurance. Further, this program does not meet minimum essential health benefits as described in the Affordable Care Act.

Big Tree Medical – Medical Expense Plan #100 2 | P a g e

The Limited Benefit Medical Expense Plan offers employees access to limited medical and wellness benefits.

Part A: Cost Sharing Cost Sharing Descriptions PHCS Network Non-Network Calendar Year Plan Deductible:

$0 $0

Not covered Not covered

• Single• Family Unit

Maximum Annual Out-of-Pocket (Including Deductibles and Co-pays) • Single• Family Unit

$7,350 x 2

Not Covered Not Covered

Part B: Summary of Coverage

Limited Benefit Medical Benefit Descriptions: PHCS Network

Coinsurance Non-Network Coinsurance

Benefit Limit Descriptions

1. Big Tree Medical Services (Available 24/7):• Office Visits• Virtual Care Encounters• Weight Loss Management Program• Smoking Cessation Program• Big Tree Prescription Program (Rx)• Diabetes Care Management Program• Mental Health Services• Wellness Benefit Services

100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered

N/A N/A N/A N/A N/A N/A N/A N/A

No annual visit limit No annual visit limit No annual visit limit No annual visit limit No annual visit limit No annual visit limit No annual visit limit No annual visit limit

2. Non Big Tree Doctor Office Services:• General Practitioner Office Visits• Specialist Office Visits• Urgent Care Office Visits• Chiropractic Office Visits

Dr. Office Visits due to illness or accident are eligible for benefits. Benefits will be paid directly to your provider. Proof of provider payment will be mailed directly to the member via EOB or electronically through the GBS member web portal.

$25 Dr. Co-pay $50 Dr. Co-pay $50 Dr. Co-pay $25 Dr. Co-pay

$25 Dr. Co-pay $50 Dr. Co-pay $50 Dr. Co-pay $25 Dr. Co-pay

Visit Limits Per Year Visit Limits Per Year Visit Limits Per Year Visit Limits Per Year

There is a combined maximum visit limit

outside of the Big Tree Medical program of 10 visits (Example: 5 GP Visits + 5 Specialist Visits = 10 visits).

3. Diagnostic Lab Service Program:

Lab Providers: LabCard / LabCorp The lab benefit will be paid directly to Quest Diagnostics or LabCorp. Proof of provider payment will be mailed directly to the member via EOB or electronically through the GBS member web portal.

100% Covered1 Not covered 10 annual lab tests limit per year

1 Only Lab services incurred through Quest Diagnostics, LabCorp will be covered at 100%.

Big Tree Medical – Medical Expense Plan #100 3 | P a g e

4. Preventive Care (MEC):• Preventive Lab Services• Routine Physical Exam• Mammograms – must be over age 40• Pap Smears• Prostate Exam – must be over age 50• Routine Immunizations• Well Child Care Exam

100% 100% 100% 100% 100% 100% 100%

Not covered Not covered Not covered Not covered Not covered Not covered Not Covered

The listing of preventive care benefits is

An example. For a complete listing of preventive, go to

https://www.healthcare.gov/coverage/preventive-

care-benefits/

5. Annual Hearing Examination:Upon providing a copy of the claim from a licensedhearing provider, the Plan will reimburse the member2 for1 hearing exam per calendar year.

100% 100% $100 Maximum Benefit Per Year

6. Annual Vision Examination:Upon providing a copy of the claim from a licensed visionprovider, the Plan will reimburse the member3 for 1 visionexam per calendar year.

100% 100% $100 Maximum Benefit Per Year

7. Diabetic Management Program: LivongoThe diabetic management program is provided throughLivongo. Claim payments will be paid directly to theprovider of services.

100% Covered4 Not Covered 100% Through Livongo including test strips.

Part C: Summary of Prescription Drug Benefits through Big Tree Medical Big Tree Medical Generic Prescription Drug Benefit: Copayment Amount

The copayments shown are Generic Retail Prescription Co-payment Options (30 day supply) applied to each prescription Any generic medication provided through Big Tree: Covered at 100% Name Brand Discount Program: Not Covered

Maximum Annual Prescription Drug Benefit: Limit Amount Maximum Annual Prescription Benefit Limit per Participant for Part C 125 Generic fills per year

Monthly Premium

Coverage Class: Single Only: $150.00 Single + Child(ren): $270.00 Single + Spouse Only: $290.00 Full Family: $400.00

2 Member can arrange for EFT deposits for reimbursements. 3 Member can arrange for EFT deposits for reimbursements. 4 Only diabetic claims for glucometers and test strips incurred through Livongo will be covered at 100%.

9996

-RC

208

2 00

0156

-----

M(*

)D()V

()

2015

0630

T09

Sh: 0

Bin

2J1

86 E

nv [2

] Blk

Pck

1 C

Sets

1 o

f 1

Member

Pharmacy PlanGroup #: 90800 DPC Plan #100Member: JOAN SAMPLE Member ID: 123456789

Toll Free: (800) 995-356924/7 IVR: (417) 799-0090www.gbs-tpa.com

Rx (30 Day Supply): Generic: Covered at 100%Annual Maximum: 125 Generic fills Preferred Name Brand: Not Covered

Medical PlanIn-Network Plan Benefits: Deductible: $0Big Tree Office/Virtual Visit $0 Copay Urgent Care/Specialist $50 CopayGP Visit/Chiropractic $25 Copay

Eligibility and Benefits

Medical Claims

Additional Discounts

9996-RC

2083 000156----- M(*)D

()V()

20150630T09 Sh: 0 Bin 2J186 Env [2] BlkPck 1 C

Sets 1 of 1

Preferred Lab 100% Coverage:

Outside the PHCS Service Area:

To Verify Eligibility and Benefits Contact:Group Benefit Services (GBS)Toll Free: (800) 995-3569 / IVR: (417) 799-0090 Monday-Friday: 8:00am - 5:00pm (CT)www.gbs-tpa.com

Send Medical Claims To : Group Benefit Services (GBS) PO Box 211547 Eagan, MN 55121-2747 GBS EDI #80241

See your Plan Document for the complete list of benefits, limits, and exclusions. This card is for identification only. It is not a guarantee of eligibility.

See your Plan Document for the complete list of benefits, limits, and exclusions. This card is for identification only. It is not a guarantee of eligibility.

www.multiplan.com800-922-4362

Big Tree Medical Home

(573)814-1170www.BigTreeMedicalHome.com

SAMPLE ONLY MEDICAL DPC CARD

Big Tree Medical HomeDental Plan

OPTIONAL VOLUNTARY DENTAL BENEFITS (If elected by Participant)

The following Deductibles, Benefits, and plan maximums are per Plan Participant, per Plan year: “Calendar Year” Dental Benefit Deductible and Benefit Limit Summary: Amount Annual Deductible per Participant (Deductible waived for Class 1 Services) $25 Maximum Number of Deductibles for Family x 2 Maximum Annual Benefit Limit for Class 1, 2 and 3 Services $1,500 Maximum Lifetime Benefit Limit for Class 4 Services (Orthodontia) $1,500

Dental Benefit Coinsurance Levels Based Upon Class: Benefits Benefit Type Class 1 Services 100% Preventive Care Class 2 Services 90% Repair and Restoration Class 3 Services 60% Major Dental Repair Class 4 Services 60% Orthodontics

All charges except preventive care are limited to Usual and Customary Fees calculated at the 90th percentile.

The Deductible amount, if any, which is listed above, is the amount each Participant must pay each Calendar Year toward Covered Expenses. Once the Deductible is satisfied, additional Covered Expenses will be reimbursed according to the percentages set forth above, subject to the limitations and exclusions set forth in this Article.

16.01. Covered Expenses The following is a brief description of the types of expenses that will be considered for coverage under the Plan, subject to the limitations contained in the Summary of Benefits. Charges must be for services and supplies customarily employed for treatment of the dental condition, and rendered in accordance with ADA accepted standards of practice. Coverage will be limited to Usual and Customary fees.

A. Class 1 Services (Preventive Care)

1. Routine oral examinations and prophylaxis (cleaning, scaling and polishing teeth), but not morethan once each in any period of 6 consecutive months;

2. Periapical x-rays, as required, and bitewing x-rays once in any period of 6 consecutive months;

3. Full mouth x-rays, but not more than once in any period of 60 consecutive months or,

4. Panoramic x-rays, but not more than once in any period of 60 consecutive months (onlyPanoramic or Full mouth x-rays – not both);

5. Sealants for Dependent Children under age 16, but not more than once in any period of 36consecutive months;

6. Topical application of fluoride for Dependent Children under age 14, but not more than once inany period of 6 consecutive months;

7. Space maintainers (not made of precious metals) that replace prematurely lost teeth forDependent Children under age 16. No payment will be made for duplicate space maintainers;and

8. Palliative Emergency treatment of an acute condition requiring immediate care.

Big Tree Medical Home Dental Plan

B. Class 2 Services (Repair and Restoration)

1. All Medically Necessary x-rays;

2. Amalgam, silicate, acrylic, synthetic porcelain and composite filling restorations to restorediseased or accidentally broken teeth. Gold foil restorations are not eligible;

3. Simple extractions;

4. Endodontics, including pulpotomy, direct pulp capping and root canal treatment;

5. Anesthetic services, except local infiltration or block anesthetics, performed by, or under thedirect personal supervision of, and billed for by a Dentist, other than the operating Dentist orhis or her assistant;

6. Periodontal examinations, treatment and surgery; and

7. Consultations

C. Class 3 Services (Major Dental Repair)Prosthodontic services (initial installation or replacement of bridgework or dentures) will be coveredonly when a Participant has been covered continuously for at least 12 months, unless otherwise requiredby applicable law.

1. Inlays, gold fillings, crowns, and initial installation of full or partial dentures or fixedbridgework to replace one or more natural teeth;

2. Repair or re-cementing of crowns, inlays, bridgework or dentures and relining of dentures

3. Unless otherwise required by applicable law, replacement of an existing denture or fixedbridgework, or the addition of teeth to an existing partial removable denture or bridgework, toreplace one or more natural teeth:

a. Where the existing denture or bridgework was installed at least five years prior to itsreplacement and it cannot be made serviceable; or

b. Where the existing denture is an immediate temporary denture, and necessary replacementby the permanent denture takes place within 12 months;

4. Osseous Surgery;

5. Oral Surgery;

6. Periodontal scaling;

7. Post and core;

8. Re-lines;

9. Stainless steel crowns; and

D. Class 4 Services (Orthodontics) Only if allowed as depicted in benefit summaryOrthodontic services will be eligible only when provided to covered Dependents who are under age 19when treatment is received.

1. Preliminary study, including cephalometric radiographs, diagnostic casts and treatment plan;

Big Tree Medical Home Dental Plan

2. Interceptive, interventive or preventive orthodontic services;

3. Fixed and removable appliance placement, and active treatment per month after the first month;and

4. Extractions in connection with orthodontic services.

16.02. Exclusions and Limitations The following exclusions and limitations are in addition to those set forth in the Articles entitled “General Limitations and Exclusions,” and “Summary of Benefits.”

A. Adjustments. Charges for services to alter vertical dimension (work done or appliance used to increasethe distance between nose and chin); to restore or maintain occlusion (work done or appliance used tochange the way the top and bottom teeth meet or mesh); to replace tooth structure lost as a result ofabrasion or attrition; for splinting; or for treatment of disturbances of the temporomandibular joint;

B. After the Termination Date. The Plan will not pay for services or supplies furnished after the datecoverage terminates, even if payments have been predetermined for a course of treatment submittedbefore the termination date. However, benefits for covered dental expenses Incurred for the followingprocedures will be payable as though the coverage had continued in force:

1. A prosthetic device, such as full or partial dentures, if the Dentist took the impression andprepared the abutment teeth while the patient was a Participant in the Plan, and delivers andinstalls the device within two months following termination of coverage;

2. A crown, if the Dentist prepared the tooth for the crown while the patient was a Participant inthe Plan, and installs the crown within two months following termination of coverage; and

3. Root canal therapy if the Dentist opened the tooth while the patient was a Participant in thePlan, and completes the treatment within two months following termination of coverage;

C. Cosmetic. Charges for cosmetic dental work. This includes, but is not limited to, characterization ofdentures and services to correct congenital or developmental malformations.

This exclusion will not apply to cosmetic work needed as a result of Accidental Injuries, but damageresulting from biting or chewing is not considered an Accidental Injury. This exclusion also does notapply to covered Orthodontic Treatment;

D. Education. Charges for instruction in oral hygiene, plaque control or diet;

E. Experimental. Charges for Experimental dental care, implantology or dental care which is notcustomarily used or which does not meet the standards set by the American Dental Association;

F. Late Enrollee. Charges for crowns, bridgework, dentures, periodontics and orthodontics Incurred duringthe first 24 months of coverage for a late enrollee, unless such services and supplies are needed as aresult of Accidental Injury sustained by the Participant. (Damage resulting from biting or chewing is notconsidered an Accidental Injury.) “Late enrollee” means a person who enrolls for coverage during anannual enrollment period because he or she failed to enroll when first eligible for coverage or during aspecial enrollment period;

G. Miscellaneous. The Plan does not cover any charge, service or supply which is:

1. For treatment other than by a Dentist or Physician, except:a. Cleaning, scaling and application of fluoride performed by a licensed dental hygienist

under the supervision of a Dentist; and

Big Tree Medical Home Dental Plan

b. Non-Experimental services performed at a dental school under the supervision of a Dentist,if the school customarily charges patients for its services;

2. For local infiltration anesthetic when billed for separately by a Dentist;

3. For personalization or characterization of dentures or veneers or any cosmetic procedures orsupplies;

4. For oral hygiene or dietary instruction;

5. For a plaque control program (a series of instructions on the care of the teeth);

6. For implants, including any appliances and/or crowns and the surgical insertion or removal ofimplants;

7. For periodontal splinting;

8. For consultations, charges for failure to keep a scheduled visit, or charges for completion of aclaim form;

9. For substances or agents which are administered to minimize fear, or charges for analgesia,unless the patient is handicapped by cerebral palsy, mental retardation or spastic disorder;

10. For replacement of a lost, missing or stolen prosthetic device;

11. Not equal to accepted standards of dental practice, including charges for services or supplieswhich are Experimental;

12. Paid, payable or required to be provided under any no-fault or equivalent automobile insurancelaw. Any uninsured motorist will be considered to be self-insured;

13. Charges for missed appointments or completion of claim forms;

14. Covered under the “Medical Benefits” Article of the Plan; and

15. Services performed by a Physician or other Provider enrolled in an education or trainingprogram when such services are related to the education or training program, except asspecifically provided herein;

H. Missing Appliances. Charges for replacement of lost, missing or stolen appliances or prosthetic devices;

I. More Expensive Course of Treatment. In all cases involving covered services in which the Providerand the Participant select a more expensive course of treatment than is customarily provided by the dentalprofession, consistent with sound professional standards of dental practice for the dental conditionconcerned, coverage under the Plan will be based upon the charge allowed for the lesser procedure;

J. Not Recommended. Charges for services or supplies which are not recommended and approved by aDentist or Physician;

K. Orthognathic Surgery. For Surgery to correct malpositions in the bones of the jaw;

L. Personalization. For expenses for services or supplies that are cosmetic in nature, including charges forpersonalization or characterization of dentures;

Big Tree Medical Home Dental Plan

M. Replacements. Charges for replacement made within five years after the last placement of any prostheticappliance, crown, inlay or onlay restoration, or fixed bridge. This exclusion is waived if replacement isneeded because the appliance, crown, inlay, onlay or bridge, while in the oral cavity, is damaged beyondrepair due to Injury sustained by the Participant. (Damage resulting from biting or chewing is notconsidered an Accidental Injury);

N. Single Provider Care. In the event a Participant transfers from the care of one Provider to that of anotherduring a course of treatment, or if more than one Provider performs services for one or more dentalprocedures, the Plan shall consider only such expense as would be appropriate had a single Providerperformed the services. An appropriate expense in this case will be the Usual and Customary fee;

O. Splinting. For crowns, fillings or appliances that are used to connect (splint) teeth, or change or alter theway the teeth meet, including altering the vertical dimension, restoring the bite (occlusion) or arecosmetic.

16.03. Pre-determination of Dental Benefits If a Participant’s proposed course of treatment reasonably can be expected to involve dental charges of $300 or more, a description of the procedures to be performed and an estimate of the charges therefore may be filed with the Plan Administrator or Third Party Administrator prior to the commencement of the course of treatment. However, approval is not required prior to treatment. Any pre-determination of dental benefits is provided only as a convenience to the Participant.

If requested, the Plan Administrator or Third Party Administrator will notify the Employee, and the Dentist or Physician, of the pre-determination based upon such proposed course of treatment.

In determining the amount of benefits available, consideration will be given to alternate procedures, services, supplies and courses of treatment which may be performed to accomplish the required result. The pre-determination is not a guarantee of payment or approval of a benefit. After treatment is received, a claim must be filed as a post-service claim, which will be subject to all applicable Plan provisions.

Monthly PremiumCoverage Class:

Single Only: $37.00Single + Child(ren): $63.00

Single + Spouse Only: $80.00Full Family: $104.00

Big Tree Medical Home Vision Plan

OPTIONAL VOLUNTARY VISION BENEFITS (If elected by Participant)

The following Deductibles, Copayments, and Benefits are per Plan Participant, per Plan year: “Calendar Year” Vision Benefit Deductible and Benefit Limit Summary: Amount Annual Deductible per Participant $25 Maximum Number of Deductibles for Family x 2 Vision Coinsurance 90% Maximum Annual Benefit Limit per Participant $600

Vision Expense Benefit Descriptions: Benefits Limits1

Eye exam, per participant $100 Maximum 12 - month period Frame-type lenses, per pair – Single Vision $120 Maximum 12 - month period Frame-type lenses, per pair – Bi-focal $130 Maximum 12 - month period Frame-type lenses, per pair – Tri-focal $140 Maximum 12 - month period Frame-type lenses, per pair – Lenticular $150 Maximum 12 - month period Frames $130 Maximum 24 - month period Contact Lenses 90 / 10 (Plan Limit) 12 - month period

17.01. Additional Covered Expenses Subject to the limits in the Summary of Benefits, the Plan pays the Usual and Customary fees for vision care services, as follows:

A. Enrolled in a Training Program. Services performed by a Physician or other Provider enrolled in aneducation or training program when such services are related to the education or training program;

B. Eye Refractions. Eye refractions, eyeglasses, contact lenses, or the vision examination for prescribingor fitting eyeglasses or contact lenses (except for aphakic patients, and soft lenses or sclera shellsintended for use in the treatment of Disease or Injury);

C. Radial Keratotomy. Radial keratotomy or other plastic surgeries on the cornea in lieu of eyeglasses;

D. Recommended. Recommended and approved by a Physician or optometrist;

17.02. Exclusions and Limitations

17.03. The following exclusions and limitations are in addition to those set forth in the Articles entitled “General Limitations and Exclusions,” and “Summary of Benefits”:

A. Benefit Limitation: A Participant can use the benefit to secure either eye glasses with frames orcontact lenses (not both)

B. Missed Consultations. Consultations, charges for failure to keep a scheduled visit, or charges forcompletion of a claim form;

C. Greater Coverage. Any charges that are covered under a medical or health plan that reimburses agreater amount than this Plan;

D. Non-Prescription Lenses. Charges for lenses ordered without a prescription;

E. Orthoptics. Charges for orthoptics (eye muscle exercises)

1 These limits are in addition to all other Plan exclusions, limitations and provisions set forth in this Plan. Please review the Plan Document carefully to determine benefits available.

Big Tree Medical HomeVision Plan

F. Safety Goggles or Sunglasses. Charges for safety goggles or sunglasses, including prescription type;and

Vision Training. Charges for vision training or subnormal vision aids.

Monthly PremiumCoverage Class:

Single Only: $12.00Single + Child(ren): $18.00

Single + Spouse Only: $22.00Full Family: $33.00

SAMPLE ONLY

DENTAL / VISION CARDS

Group Benefit Services Third-Party Administration Project Based Services Outsourcing Services Plaza Towers Building 1736 E. Sunshine Suite 200 Springfield, Missouri 65804

(800) 995-3569 (417) 883-8088 Fax (417) 883-8261

AUTHORIZATION AGREEMENT FOR EFT

AUTOMATIC DEPOSITS (ACH CREDITS)

I hereby authorize Group Benefit Services (GBS) to initiate deposits (ACH credits) into my account for all employee claim payments – including reimbursements for Flexible Spending Accounts (medical and/or childcare), reimbursements for HRA (RDA), and member and provider filed claims payable to member. I further authorize GBS to initiate debit entries, if necessary, to adjust for any credit entries made to my account in error.

TYPE OF ACCOUNT (circle one) Checking Savings DEPOSITORY (BANK) NAME ________________________ BRANCH _________________________ CITY _________________________ STATE ________ ZIP ______________ TRANSIT/ABA No. ________________ ACCOUNT ______________________

This authority is to remain in full force until GBS and DEPOSITORY (BANK) has received written notification from me (or either of us) of its termination, in such time and in such manner as to afford GBS and DEPOSITORY (BANK) a reasonable opportunity to act on it.

Date: Printed Name: Signature:

NOTICE: The information contained in this document, and any attachments accompanying this transmission, may be legally privileged and/or confidential and protected health information. This information is intended for use of the individual(s) and/or entity identified above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to protect the information after its stated need has been fulfilled. If you are not the intended recipient, or an employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any disclosure, print, copying, forwarding, or distributing of this information is strictly prohibited. If you have received this communication in error, please notify the sender immediately, by telephone or return fax, to advise of wrongful receipt and confirm your understanding of this Notice. Thank You.