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Effective 06/01/2025Your Benemax Health Plan® Summary of BenefitsWinstanley Enterprises LLCPPO Planmybenemax.comThis information is a summary only. Please refer to the Plan Document, Subscriber Certificate and any amendments and/or riders for complete plan details.

2* Represents services supplemented by your employer, via Benemax. PLAN DETAILS – BCBS Preferred Blue PPO Ded II With BenemaxOut-of-Network services are combined with in-network services for the first $4,500 of claims and will be paid the same as in-network claims. After the combined $4,500 in total claims is met, there is an additional member deductible of $3,000, then co-insurance of 20% to 40%. Charges considered over usual and customary for the services provided are the member’s responsibility. For a listing of participating providers, visit www.bluecrossma.com/findadoctor or call the number on your BCBS ID card. You may also call Benemax at 800-528-1530 for assistance. The Benemax Health Plan® integrates a fully insured component from Blue Cross Blue Shield of Massachusetts (BCBS) and an employer-funded component from Winstanley Enterprises LLC into a single benefit package. The BCBS plan has an annual deductible of $4,500 per member ($9,000 family maximum). Members are responsible for the first $800 for a single plan ($1,600 family maximum) of the deductible. Winstanley Enterprises LLC, via Benemax, pays the remaining deductible in full on your behalf less applicable co-pays. In addition, the co-insurance and co-pays due after the BCBS deductible is met, are also supplemented. Below is a brief reference of frequently used services and your final cost after your claims have been processed by both BCBS and Benemax. Covered Services Your Cost Routine office visits & tests No cost Routine eye exam (1 every 24 months) No cost Diabetic management services (first two clinic visits) No cost Office visits by your PCP, OBGYN, Nurse Practitioner, Telemedicine * $25 co-pay Office visits performed by Specialists or Chiropractor * $40 co-pay Mental health or substance abuse treatment * $25 co-pay Acupuncture visit (12 visits per year) * $40 co-pay Short-term rehabilitation therapy (up to 60 visits per calendar year) * $40 co-pay Urgent care * $40 co-pay Emergency room visits (co-pay waived if admitted) * $250 co-payServices that apply to deductibleDeductible: $800 per individualDay surgery in hospital, ambulatory or surgical day care facility * Deductible then $0 co-payInpatient hospital services * Deductible then $0 co-payDiagnostic lab work and x-rays (non-routine)* Deductible then $0 co-payComplex imaging (MRI/CT/PET)* Deductible then $0 co-payDurable medical equipment * Deductible then $0 co-payPediatric Dental Benefits (for members under age 19)Group 1: Preventive and diagnostic services (oral exams, x-rays)No CostGroup 2: Basic restorative services (filings, root canals, periodontal)$50 deductible then 25% co-insuranceGroup 3: Major restorative services (tooth replacement, crowns)$50 deductible then 50% co-insurance

3 PRESCRIPTION DRUGS (Rx) HOW YOUR HEALTH PLAN WORKSThe chart below will help you understand who pays for what and when.Your ProviderBCBSBenemaxYouBenemax posts a Benemax Explanation of Benefits (EOB) on your Claims Connection portal. You are responsible to pay the amount due to your provider as shown on the Benemax EOB.You or a member of your Family visits your provider (doctor/hospital) and shows both their BCBS ID card and their Benemax Card. Click here to learn more about why showing your Benemax card is important.Your Doctor or Provider will bill BCBS.BCBS will process your claim, notify your provider, and send a Claims Summary to you and your provider.Benemax receives a report of your claims from BCBS. Benemax reviews your claim and makes additional payments on behalf of your employer.When you receive your BCBS claims summary or a provider bill, log in to Claims Connection to view your member responsibility as stated on the Benemax EOB before making a final payment to your provider. How do I read and understand my Benemax Explanation of Benefit (EOB)? Click here.PillarRx Cost Share Assistance ProgramMembers who take an eligible medication can be eligible to get their medication for $0-$35 by using manufacturer’s coupons. If you are taking an eligible medication, you will receive a letter and a phone call asking you to join the program. Important! Make sure you enroll; if you decline to enroll, you will be required to pay 30% of the cost of the medication.Prescription Drugs (RX) Your cost BCBS approved at retail participating pharmacy(retail up to 30 days supply)Tier 1 - $25Tier 2 - $45Tier 3 - $65Tier 4 - $125BCBS approved at Mail order (Caremark/CVS) (Mail order up to 90-day supply) Tier 1 - $50Tier 2 - $90Tier 3 - $130Tier 4 - $375When purchasing approved prescription medications, members are responsible for the co-payments listed below.

4 ONLINE RESOURCESClaims ConnectionClaims Connection allows you to monitor your own individual claims, and ensure you are making the appropriate payment to your provider.Want to learn more? Need help accessing the portal?Your Benemax EOBYour Benemax Explanation of Benefit (EOB) contains all the important information about your claim(s) and should be your guide in determining what balance you owe to your providers. How do I read and understand my Benemax Explanation of Benefit (EOB)?Contact CenterAccess our contact directory to learn about our departments and what questions we can help answer. Link with solid fillLink with solid fillYour BCBS plan includes coverage for medical and behavioral health services via telehealth online video visits. You can consult with medical professionals, 24/7/365, and schedule visits right from your mobile device or home computer. For conditions such as bronchitis, sinus infections, pinkeye, or for behavioral health issues such as depression, anxiety, and sleep difficulties. https://member.bluecrossma.com/login*Telehealth visits are charged at time of service. Benemax will automatically reimburse the cost of a BCBS approved telehealth visit to the extent that it exceeds the member’s cost shown on your benefit page.  TELEHEALTH SERVICES NEED HELP?Upload with solid fillOpen envelope with solid fillQuestionsBenemax Independent Member Advocates can handle your benefit questions and claims issues. Best of all, our advocates work for you—not the insurance company—so your interests are our only priority. 800-528-1530benemax.service@onedigital.comInformation HubClaim SubmissionBenemax receives an auto-crossover on claims from your health insurance carrier. If you do not see your claim listed on Claims Connection, you/your provider(s) may submit claims using any method below. Send us an EOB or Claims Summary and a copy of the Provider Bill. Electronic Upload Email: benemax.claims@onedigital.comFax: 508-242-6198Mail: PO Box 950, Medfield, MA 02052Open envelope with solid fillInternet with solid fill. Your Benemax PlanExplaining Benemax to ProvidersClaims Connection & Your EOBYour Benemax ID CardBenemax Contact InformationVideo camera with solid fillLink with solid fillLink with solid fillVideo camera with solid fillLink with solid fillInformation HubMyBenemax.com offers online customer service, member education, and helpful tools and resources to assist with all your benefit questions. Visit our links below to learn more.Interactive: Click on the video & link icons below to learn more! If you are accessing via printed paper, visit mybenemax.com for more information.

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