SAVINGS HIGHWAY GROUP PLANPlans A, B, and CIncludes Minimum Essential Coverage

Maximizing savings and providing cutting-edge solutions to help you effectively manage your health care costs

SERVICE FLEXIBILITY INTEGRITY

AN AFFORDABLE ACA QUALIFIED AND ERISA COMPLIANT HEALTH PLAN SOLUTION

Sponsored by:SB/A CooperativeAdministered by:Free Market Administrators, LLC

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Free Market Administrators, LLCFree Market Administrators, LLC (FMA) is a Third Party Administrator headquartered in Addison, Texas.• FMA was created with over 100 years of

experience in health care at the Senior Executive Level.

• FMA is committed to creating value for our broad client base of both fully insured, major medical, and self-funded clients.

• FMA remains focused on not only exceeding the highest ethical standards and upholding the utmost integrity for our clients, but also redefining the way our clients look at the world of health care benefits.

• FMA has over 20,000 members• FMA works with all major leasable PPO

networks plus access to Reference Based Pricing.

Serve You RxSince 1987, Serve You Rx has been the pharmacy benefit manager (PBM) of choice for employee benefit brokers and consultants, their clients, including employers, unions, coalitions, and governmental entities, as well as third party administrators who are looking for a valuable partner to effectively manage prescription drug costs. Serve You Rx offers:• Stability• Consistency• Flexibility• Customized plan designs

• Consultative clinical support• Robust trend management programs and

strategies• Exceptionally focused member and client

service• Quality-driven, Serve You Rx owned

and operated mail service and specialty phar-macies

• Over 66,000 pharmacies nationwide• Privately owned and headquartered in

Milwaukee, Wisconsin• Wholly-owned mail order pharmacy

The SB/A CoOp is a Non-Profit “Agency” Cooperative Corporation that does not buy or sell products or services but acts as the “Legal Collective Agent” of all the Cooperative Members to facilitate advantageous contractual relation-ships for and between the members. The SB/A CoOp may legally “aggregate” small employers

together without becoming a Multiple Employer Welfare Association (MEWA) or acting as a Multiple Employer Trust (MET). The SBA CoOp sponsors the unique ERISA Employer Healthcare Benefits Plans that are ACA qualified when attached to ACA Minimum Essential Coverage.

Partners of Savings Highway Group Plan

SB/A CoOp

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The SB/A CoOp was formed in 2017 as a Non-Profit “Agency” Cooperative Corporation to provide for employer/employee health care benefits in the small and large group employer marketplace. Each group employer CoOp Member can sponsor a Partially Self-Funded ERISA Employer Welfare Benefit Plan for the benefit of its employees and their dependents. Called the “SB/A Cooperative Sponsored Freedom Plan,” it is an ERISA health plan for sponsoring employers offered in conjunction with Preventive Care Benefits. The employer’s claim exposure is protected via an

“Aggregate Stop Loss Fund (ASLF)” owned by the SB/A CoOp Employer Members.

Each SB/A CoOp Employer Member has its own SB/A Cooperative Sponsored Freedom Plan funded claim account adminis-tered by Free Market Administrators, the Plan Administrator. The employer’s maximum claim liability is limited to the 12-month level funding of its claim account. The Member Employers own the funds and will receive the defined surplus on a calendar year basis following a (12/18) accounting period.

The purpose for which the SB/A CoOp is organized is to foster the development of Partially Self-Funded healthcare benefit arrangements which include the use of Level Funded ERISA compliant “Limited Benefit Plans,” the use of Employer funded “Aggregate Stop Loss” coverage and reinsur-ance consistent with applicable state and federal laws, including ERISA. To act primarily as the legal agent for all the Cooperative Members in arranging for and facilitating ERISA compliant and ACA qualified employer/employee health benefit plans that are administered by a legal Third Party Administra-tor (TPA). Brokers/Agents that are members of SBA CoOp and who are compenstated by SB/A CoOp, market the SB/A CoOp and “The SB/A Freedom Plans.”

To participate and take advantage of the SB/A Freedom Plans options,

the following is required:

1. Broker and Employers must join the SB/A CoOp – complete the SB/A CoOp Membership Agreement and pay the annual $24 membership fee ($2.00/month).

2. Broker completes the SB/A CoOp Compensation form, Broker W-9, and Broker Information Form – this is a one- time requirement.

3. Employer completes the Group Information Form.

4. Employees complete the SB/A Sponsored Freedom Plan Employee Enrollment Form. For larger employer groups, Employers can submit an electronic eligibility spreadsheet.

The SB/A CooperativeEfficiency | Savings | Simplicity | Freedom

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PPO Network PHCS

BASIC BENEFITSDeductible - Individual / Family None

Telemedicine – 24 Hr Virtual Clinic $0 Copay for Telemedicine

Primary Care Physician (PCP) Office Visits 3 PCP Visits at $20 Copay Providers limited to Family Practice, Internal Medicine, Pediatrician, OB/GYN – per person per year. office and other outpatient services. All other visits subject to Coinsurance.

Specialist Care Subject to Coinsurance

Prescription Drugs Subject to Coinsurance Generic / Brand $500 Maximum on any Prescription/mo.

Inpatient & Outpatient Hospital Subject to Coinsurance

Behavioral Health Care Subject to Coinsurance Inpatient/Outpatient Limited to 30 Days

Chiropractic Care (Limited to Spinal Adjustments) Subject to Coinsurance

Medical Imaging & X-Ray Subject to Coinsurance

Emergency Room & Ambulance Subject to Coinsurance

Urgent Care Facility Subject to Coinsurance

Durable Medical Equipment Subject to Coinsurance

ACA Preventive Care Services - Minimum Essential Coverage (MEC) Preventive Care coverage paid at 100% Adult, Women, Child - Immunization, Screenings, & Services MEC not subject to Annual Maximum or Coinsurance Percentages

Careington Dental & Vision Discounted Benefits Included at No Additional Cost provided by Free Market Administrators as an additional benefit. Discount Fee Schedule

ENHANCED BENEFITSExtra Inpatient Hospital & Outpatient Surgery and Professional Services Applicable to Plan C Only Excludes Outpatient Drugs, Kidney Dialysis, Chemo Therapy, & All Other Infusion Therapy

Annual Maximum Benefit Covered Applicable to Plan C Only

Limitations Applies to Plan C Extra Benefits Only

Basic & Enhanced BenefitsCoinsurance on Base Plan (Percentage of Covered Benefits by Plan) 50% of $10,000

Annual Out-of-Pocket Maximum $5,000 Individual $10,000 Family

Annual Maximum Benefit Covered $10,000 Individual $20,000 Family

Out of Network Coverage See Provisions and Exclusions

BASIC & EXTRA ENHANCED BENEFIT SUMMARY

BASIC BENEFITS (Base Plan)

EXTRA ENHANCED BENEFITS

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Savings Highway Group Plan ASummary Plan of Coverage

Annual Maximum BenefitIndividual $10,000

Family $20,000

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PPO Network PHCS

BASIC BENEFITSDeductible - Individual / Family NoneTelemedicine - 24 Hr Virtual Clinic $0 Copay for TelemedicinePrimary Care Physician (PCP) Office Visits 3 PCP Visits at $20 Copay Providers limited to Family Practice, Internal Medicine, Pediatrician, OB/GYN – per person per year. All other visits office and other outpatient services. subject to Coinsurance. Specialist Care Subject to CoinsurancePrescription Drugs Subject to Coinsurance Generic / Brand $500 Maximum on any Prescription/mo.Inpatient & Outpatient Hospital Subject to CoinsuranceBehavioral Health Care Subject to Coinsurance Inpatient/Outpatient Limited to 30 DaysChiropractic Care (Limited to Spinal Adjustments) Subject to CoinsuranceMedical Imaging & X-Ray Subject to CoinsuranceEmergency Room & Ambulance Subject to CoinsuranceUrgent Care Facility Subject to CoinsuranceDurable Medical Equipment Subject to CoinsuranceACA Preventive Care Services - Minimum Essential Coverage (MEC) Preventive Care coverage paid at 100% Adult, Women, Child - Immunization, Screenings, & Services MEC not subject to Annual Maximum or Coinsurance PercentagesCareington Dental & Vision Discounted Benefits Included at No Additional Cost provided by Free Market Administrators as an additional benefit. Discount Fee Schedule

EXTRA ENHANCED BENEFITSExtra Inpatient Hospital & Outpatient Surgery and Professional Services Applicable to Plan C Only Excludes Outpatient Drugs, Kidney Dialysis, Chemo Therapy, & All Other Infusion TherapyAnnual Maximum Benefit Covered Applicable to Plan C OnlyLimitations Applies to Plan C Extra Benefits Only

BASIC & EXTRA ENHANCED BENEFITSCoinsurance on Base Plan (Percentage of Covered Benefits by Plan) 50% of First $10,000 80% of Next $10,000Annual Out-of-Pocket Maximum $7,000 Individual $14,000 FamilyAnnual Maximum Benefit Covered $20,000 Individual $40,000 FamilyOut of Network Coverage See Provisions and Exclusions

BASIC BENEFITS (Base Plan)

BASIC & EXTRA ENHANCED BENEFIT SUMMARY

EXTRA ENHANCED BENEFITS

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Savings Highway Group Plan BSummary Plan of Coverage

Annual Maximum BenefitIndividual $20,000

Family $40,000

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PPO Network PHCS

BASIC BENEFITSDeductible - Individual / Family NoneTelemedicine - 24 Hr Virtual Clinic $0 Copay for TelemedicinePrimary Care Physician (PCP) Office Visits 3 PCP Visits at $20 Copay Providers limited to Family Practice, Internal Medicine, Pediatrician, OB/GYN – per person per year. office and other outpatient services. All other visits subject to Coinsurance.Specialist Care Subject to CoinsurancePrescription Drugs Subject to Coinsurance Generic / Brand $500 Maximum on any Prescription/mo.Inpatient & Outpatient Hospital Subject to CoinsuranceBehavioral Health Care Subject to Coinsurance Inpatient/Outpatient Limited to 30 DaysChiropractic Care (Limited to Spinal Adjustments) Subject to CoinsuranceMedical Imaging & X-Ray Subject to CoinsuranceEmergency Room & Ambulance Subject to CoinsuranceUrgent Care Facility Subject to CoinsuranceDurable Medical Equipment Subject to CoinsuranceACA Preventive Care Services - Minimum Essential Coverage (MEC) Preventive Care coverage paid at 100% Adult, Women, Child - Immunization, Screenings, & Services MEC not subject to Annual Maximum or Coinsurance PercentagesCareington Dental & Vision Discounted Benefits Included at No Additional Cost provided by Free Market Administrators as an additional benefit. Discount Fee Schedule

ENHANCED BENEFITSExtra Inpatient Hospital & Outpatient Surgery and Professional Services Covered at 100% Excludes Outpatient Drugs, Kidney Dialysis, Chemo Therapy, If Admitted & All Other Infusion TherapyAnnual Maximum Benefit Covered $25,000 Individual $50,000 FamilyLimitations See Provisions and Exclusions

Basic & Enhanced BenefitsCoinsurance on Base Plan (Percentage of Covered Benefits by Plan) 50% of First $10,000 80% of Next $10,000Annual Out-of-Pocket Maximum $7,000 Individual $14,000 FamilyAnnual Maximum Benefit Covered Basic $20,000 Individual Basic $40,000 Family Enhanced $25,000 Individual Enhanced $50,000 FamilyOut of Network Coverage See Provisions and Exclusions

BASIC BENEFITS (Base Plan)

BASIC & EXTRA ENHANCED BENEFIT SUMMARY

EXTRA ENHANCED BENEFITS

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Savings Highway Group Plan CSummary Plan of Coverage

Annual Maximum BenefitIndividual $20,000 + $25,000 Enhanced Family $40,000 + $50,000 Enhanced

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Annual Deductible None

Member Annual Out-of-Pocket Maximum None

Co-Insurance Percentage covered (Plan Pays Based on Contracted Amounts) 100%

Preventative Care Covered at 100%

Pharmacy Benefit 100% of ACA mandated prescription, i.e. Birth Control

Annual Maximum of Covered Services No Annual Maximum

Routine Well Care – As Provided Under the Affordable Care Act (ACA)

Adult Preventative Services - Screenings and Services Listed Below are Eligible

1. Abdominal Aortic Aneurysm 9. Diet Counseling Covered at 100%

2. Alcohol Misuse 10. Obesity Covered at 100%

3. Aspirin 11. Sexually Transmitted Infection (STI) Covered at 100%

4. Blood Pressure 12. Syphilis Covered at 100%

5. Cholesterol 13. HIV Covered at 100%

6. Colorectal Cancer 14. Tobacco Use Covered at 100%

7. Depression 15. Immunization Vaccines Covered at 100%

8. Type 2 Diabetes Covered at 100%

Women Preventative Services – Screenings and Services Listed Below are Eligible

1. Anemia 12. Gestational Diabetes Covered at 100%

2. Bacteriuria Urinary Tract 13. Gonorrhea Covered at 100%

3. BRCA 14. Hepatitis B Covered at 100%

4, Breast Cancer Mammography 15. Human Immunodeficiency Virus (HIV) Covered at 100%

5. Breast Cancer Chemoprevention 16. Human Papillomavirus (HPV) DNA Test Covered at 100%

6. Breastfeeding 17. Osteoporosis Covered at 100%

7. Cervical Cancer 18. Rh Incompatibility Covered at 100%

8. Chlamydia Infection 19. Tobacco Use Covered at 100%

9. Contraception 20. Sexually Transmitted Infections (STI) Covered at 100%

10. Domestic and Interpersonal Violence 21. Syphilis Covered at 100%

11. Folic Acid Supplements 22. Well Woman Visits Covered at 100%

Child Preventative Services – Screenings and Services Listed Below are Eligibile

1. Alcohol and Drug Use 14. Hematocrit or Hemoglobin Covered at 100%

2. Autism 15. Hemoglobinopathies or Sickle Cell Covered at 100%

3. Behavioral 16. HIV Covered at 100%

4. Blood Pressure 17. Immunization Vaccines Covered at 100%

5. Cervical Dysplasia 18. Iron Supplements Covered at 100%

6. Congenital Hypothyroidism 19. Lead Exposure Covered at 100%

7. Depression 20. Medical History Covered at 100%

8. Developmental 21. Obesity Covered at 100%

9. Dyslipidemia 22. Oral Health Covered at 100%

10. Fluoride Supplements 23. Phenylketonuria (PKU) Covered at 100%

11. Gonorrhea 24. Sexually Transmitted Infection Covered at 100%

12. Hearing 25. Tuberculin Testing Covered at 100%

13. Height, Weight and Body Mass Index 26. Vision Covered at 100%

Minimum Essential Coverage ACA Annual Benefits

All Employer Plans – MEC Covered Services Minimum Essential Coverage

(MEC Plan) In-Network Provider (PPO) Only

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• Preventative Care, Wellness Visits, Pap Smears, Flu Shots, Immunizations, and more• Primary Care, Specialist, and Urgent Care Visits Plus X-rays, CT and MRI Scans, Lab and

Diagnostic Services• Prescription Drugs – ACA at 100% (includes Birth Control), plus all others at indicated co-insurance up to

threshold limit using the Serve You Rx pharmacy card at your favorite pharmacy• Inpatient/Outpatient Behavioral Health Care benefits limited to 30 days• Pharmacy benefits are eligible for Rx discounts above base plan threshold• Pharmacy prescription coverage is limited to $500 per prescription per month• Employee must be actively at work for their coverage to be effective on their initial effective date• Out-of-network provider charges will be subject to negotiated reimbursement and covered member may be subject

to balance billing by the provider• Certificates of coverage cannot be changed for 12 months from effective date except as regulated by law• No Medical Underwriting is required• No Pre-Existing Condition clauses apply to the Basic Benefit provisions• No Waiting Periods apply to Basic Benefit provisions• All medical claims over $5,000 are subject to claims auditor review for medical necessity, permissibility, and

appropriateness of charges.• Plans A, B, and C are available to employer groups with 2 or more enrolled. • Patient is eligible for “Contractual Discounts” in excess of Annual Maximum benefits as “Patient Pay Responsibility.”

Extra Enhanced Benefits - Inpatient and Outpatient Benefit Provisions & Exclusions (Plan C only):• Extra Enhanced Inpatient Hospital & Outpatient Hospital Surgery Benefit Services are in addition to base benefits.

Annual Maximum benefit is limited to stated annual amounts – Plan C $25,000 Individual / $50,000 Family.• Inpatient/Outpatient Behavioral Healthcare benefits limited to 30 days/visits per year.• Emergency Room, Lab, X-ray, and Imaging are covered if admitted to an Inpatient Hospital stay.• Extra Enhanced Inpatient/Outpatient Benefit provision is effective 60 days after the effective date of the member.• Extra Enhanced Inpatient Hospital & Outpatient Surgery Benefit Plan C – ($25,000 Individual / $50,000 Family)

provision is subject to a 12/6 pre-existing condition provision. Conditions which exist 12 months before the effective date will be excluded from coverage for the first 6 months of coverage. Maternity inpatient hospital and outpatient services are effective 10 months after the effective date.

• Outpatient Drugs, Kidney Dialysis, Chemo Therapy, and all other Infusion Therapy is excluded from coverage under Extra Enhanced Inpatient Hospital & Outpatient Surgery Benefit provision.

Exclusions from coverage:• Any hospital confinement that began on or before the

effective date is excluded from plan coverage• Workers Compensation injuries and illness• Cosmetic surgery procedures – exceptions to some

reconstructive surgeries• Bariatric/Gastric Sleeve surgery• Sex transformation / change surgery

Plan Provisions and Exclusions

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Savings Highway Group Plan Employer Application SIGNATURE REQUIRED

Plan A: $10,000 Individual / $20,000 Family

Plan B: $20,000 Individual / $40,000 Family

No. Enrolled Fixed Cost + Claim Account + Total Cost

Age 18 to 49 years (Employee Age)

Employee Only _________ $193.00 + $81.00 = $274.00 _________

Employee + 1 _________ $268.00 + $171.00 = $439.00 _________

Employee + Family _________ $318.00 + $243.00 = $561.00 _________

Age 50 to 64 years (Employee Age)

Employee Only _________ $193.00 + $104.00 = $297.00 _________

Employee + 1 _________ $268.00 + $218.00 = $486.00 _________

Employee + Family _________ $318.00 + 311.00 = $629.00 _________

Plan A Total Monthly Cost _________

No. Enrolled Fixed Cost + Claim Account + Total Cost

Age 18 to 49 years (Employee Age)

Employee Only _________ $198.00 + $135.00 = $333.00 _________

Employee + 1 _________ $268.00 + $284.00 = $552.00 _________

Employee + Family _________ $318.00 + $405.00 = $723.00 _________

Age 50 to 64 years (Employee Age)

Employee Only _________ $198.00 + $173.00 = $371.00 _________

Employee + 1 _________ $268.00 + $363.00 = $631.00 _________

Employee + Family _________ $318.00 + $518.00 = $836.00 _________

Plan B Total Monthly Cost _________

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Savings Highway Group Plan Employer Application SIGNATURE REQUIRED

Broker Name (print) ______________________________________________________________________________________________________________

Date of Acceptance ______________________________________________________________________________________________________________

Employer Group Name ___________________________________________________________________________________________________________

Effective Date of Plan _____________________________________________________________________________________________________________

Authorized Employer Signature ____________________________________________________________________________________________________

Employer Name Printed___________________________________________________________________________________________________________

Savings Highway Group Plan Employer Application

No. Enrolled Fixed Cost + Claim Account + Total Cost Age 18 to 49 years (Employee Age) Employee Only _________ $203.00 + $189.00 = $392.00 _________ Employee + 1 _________ $273.00 + $397.00 = $670.00 _________ Employee + Family _________ $323.00 + $567.00 = $890.00 _________

Age 50 to 64 years (Employee Age) Employee Only _________ $203.00 + $242.00 = $445.00 _________ Employee + 1 _________ $273.00 + $508.00 = $781.00 _________ Employee + Family _________ $323.00 + $725.00 = $1,048.00 _________

Plan C Total Monthly Cost _________

Plans A, B, and C Grand Total Monthly Cost _________

Plan C: $20,000 Individual / $40,000 Family with Addl. $25,000 / $50,000 In/Outpatient Benefit

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Footnotes

PPO (Preferred Provider): Health care plans utilize providers that are within a network with general pricing and care agreements. You may choose any provider within your network. The SB/A Freedom Plans utilize PHCS, one of the largest provider networks in the country.Deductible: With the SB/A Freedom Plans, there are no deductibles. However, in traditional health care, a deduct-ible is the amount you owe for health care services your health care plan covers, before your plan begins to pay. For example, if your deductible was $5000, your plan will not pay anything until you’ve met your $5000 deductible for covered health care services subject to the deductible..24hr Virtual Clinic – 24/7/365 Virtual Medical Consultations. Immediate access to licensed Doctors and Nurses could be the first step in determining care needs or if an in-office visit is needed. The use of telemedicine has shown to reduce the stress of illness or injury and improve occupational health, ergonomic health, early symptom intervention, and behavior health. Make unlimited telemedicine calls for common issues not requiring recurring consultation. Chronic issues requiring recurring consultation limited to 3 consult calls per person per year.Co-Insurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 50%) of the allowed amount of the service. The plan pays for the rest of the allowed amount. These plans provide for first dollar coverage with a 50/50 co-insurance. For example, if you have a 50% co-insurance on the first $10,000 of covered health care services, the plan would pay $5000.00 and you would pay $5000.00. If your plan had a component of 80/20 for the next $10,000 portion of a $20,000 base plan, the plan would pay 80% and you would pay 20%, or $8000.00 from the plan and $2000.00 from you. Note: A copay is offered for limited PCP services. Copays are a specific amount that you pay at the point of service for a visit to a provider.Pharmacy: Prescription pharmacy benefit contains the same zero deductible co-insurance provisions of all the plans contained within. Upon exhaustion of benefit plan, discounts are still available to all enrollees but without the co-insurance split.Inpatient/Outpatient: These are the hospitalization and professional services, medical and surgical professional services, ER/Urgent care, lab, X-ray and imaging, ambulance, chiropractic care, and inpatient/outpatient behavioral healthcare, provided for in the base plans.Affordable Care Act (ACA): Correctly named the Patient Protection and Affordable Care Act. Congress signed into law the ability to obtain health insurance in all 50 states without fear of rejection for pre-existing conditions. There were subsidies for those whose incomes were below a pre-set threshold, and without subsidies would be unaffordable. Congress also mandated that citizens could receive an annual physical and required screenings and lab services under the Affordable Care Act, Minimum Essential Coverage (MEC) provision.Careington Discount Dental Plan: The Careington Dental Point-of-Sale Discount Plan is not part of your medical benefits plan. Careington negotiates with dental providers nationwide to reduce costs, and has its own fee schedule. The Careington Dental Discount Plan is not insurance and is not intended to replace insurance. Inpatient Hospitalization and Outpatient Surgery, Professional Services: The Extra Enhanced Benefit (Plan C Only), extends care for medical and surgical costs when an extended hospital stay is authorized and patient is admitted. This Extra Enhanced Benefit (Plan C only) will also cover Outpatient (surgery only) hospitaliza-tion and professional services, and requires admittance. Excluded are outpatient drugs, kidney dialysis, chemo therapy, and all other infusion drugs. Extended benefits component will be second to pay after base plan annual benefits are reached.Out–Of-Pocket maximum (annual): This is the highest amount you will pay out of your own pocket as an individual or family for covered health care services within the limits of each plan.Annual Maximum of Coverage: The maximum amount of benefits and services named in the plan documents. This includes the base plan and extended benefits subject to plan description. For example: Plan C would have a maximum annual benefit amount of $20,000 Individual / $40,000 Family for the base plan, and $25,000 Individual / $50,000 Family for the extended benefit component. See plan details.

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