2023 Benefit Guide - Jay Bee Oil - GoWv

Oil & Gas Drilling into The Future Proud participant in the insurance program of Employee Benefits Guide Plan Year: January 1, 2023—December 31, 2023

Table of Contents • Available Benefits 2 • Eligibility 2 • Pre-Tax Section 125 2 • Qualifying Life Event 3 • Medical Benefits 4 • Dental Benefits 7 • Vision Benefits 8 • Health Reimbursement Arrangement (HRA) 9 • Notes 10 • Employee Resources 11 • Glossary of Terms 12 • Annual Disclosure Notices 13 This Benefit Guide contains highlights of the JAY-BEE OIL & GAS Benefits Program. For more information, refer to the Summary Plan Descriptions for the Welfare Plan, which are available through the Human Resources Department. The official and controlling provisions of the Plans are contained in the Plan Documents, which include the master policies with insurance Providers. Should there be a conflict between this guide and the Plan Documents; the Plan Documents will be the final authority. The Plans are administered by JAY-BEE OIL & GAS which has discretionary authority to interpret and apply the Plans’ provisions and make the rules necessary for their day-to-day operation. The content provided in this booklet has been prepared for informational and educational purposes only and is not intended to provide investment, legal, or tax advice. 1

Overview At JAY-BEE OIL & GAS, our employees are our most valuable asset. We understand how critical it is for employees to have a flexible and comprehensive benefits program - one that can fit different stages of life. You can choose the plans that best suit your individual needs, taking into consideration the benefits that are most important to you and your family. We encourage you to review each section and to discuss your benefit options with your family members. Available Benefit Programs:  Medical & Prescription Coverage  Dental Coverage  Vision Coverage  Health Reimbursement Arrangement (HRA) Eligibility Employees Employees are eligible to participate in the JAY-BEE OIL & GAS insurance plans if they are working a minimum of 30 hours per week. Coverage will become effective the first of the month following a 60 day waiting period. You must enroll in the insurance program within 30 days of becoming eligible for coverage. Dependents A dependent is defined as the legal spouse and/or dependent child(ren) of the employee or the spouse. The term “child” includes any of the following: • A biological child • A step child • A child for whom legal guardianship has been awarded to the employee or the employee’s spouse. Dependent children may be covered, under the JAY-BEE OIL & GAS plan(s), until the end of the month in which they reach the age of 26 (regardless of student status). Pre-tax Benefits: Section 125 JAY-BEE OIL & GAS allows employees to deduct medical, dental and vision premiums on a pre-tax basis. This means you do not pay federal, state, or Social Security and Medicare (FICA) taxes on your premiums, thereby reducing your taxable income. Employees may opt-out of having premiums deducted on a pre-tax basis, please see your plan administrator for details. 2

Overview Qualifying Life Event Please keep in mind that benefit elections and their payroll deductions cannot be changed until the next Open Enrollment period unless you, your spouse, or your dependent child(ren) experience an IRS-defined Qualifying Life Event. Qualifying Life Events include: • Marriage • Eligibility for Medicare or Medicaid • Divorce • Special Enrollment Right (excluding domestic partners) • Birth or adoption of a child • Significant change in the cost of coverage for you or • Death of spouse, or child your spouse attributable to your spouse’s employment • Change in employment of spouse • Loss of dependent status • Loss of coverage with a spouse • Changing from full-time to part-time employment or from part-time to full-time employment • Court Order You are responsible to notify the Human Resources Department within 30 days of your Qualifying Life Event (QLE). The QLE will NOT be processed until all documentation supporting the change is submitted to HR. If outside the 30 day window there is NO guarantee the carrier will approve. 3

Medical You may receive care and services from network and out-of-network providers and facilities — but staying in the network can help lower your costs. There is no additional cost to you for seeing a network provider for preventive care. Staying in-network gives you the best benefit, but Highmark does offer an out-of-network allowance schedule as well. In this case, you may see any provider you wish. You will also be responsible for filing the claim with Highmark for reimbursement and paying any balances over the allowed benefit to the non-participating provider. Plan Year Deductible: The deductible is a specified dollar amount that you must pay for certain covered services per plan year. There are individual and family deductibles depending on your coverage tier selection, which must be met before your plan will pay for certain services. Once your deductible is met, some services may only require a copay. Plan Year Out-of-Pocket Maximum: The plan year out-of-pocket maximum is the amount of covered expenses - including deductible, coinsurance, and copayments - that must be paid by you, either individually or combined as a covered family. Once the out-of-pocket maximum for the relevant coverage tier (individual or family) is met, covered services that would require a copayment or coinsurance will be covered by Highmark in full. There are separate out-of-pocket maximums for In-Network services and Out-of-Network services. 4

Medical SuperBlue Plus 2010 Plan Option In-Network Out-of-Network Plan Feature $6,000 / $12,000 $12,000 / $24,000 Contract Year Deductible $9,100 / $17,200 - (Individual/Family) $25 copay $25 copay, then 40% coinsurance Out-of-Pocket Maximum $35 copay $35 copay, then 40% coinsurance $0 copay Deductible, then 40% coinsurance (Individual/Family) Deductible, then 20% coinsurance Deductible, then 40% coinsurance Office Visits Deductible, then 20% coinsurance Deductible, then 40% coinsurance Primary Care Physician Deductible, then 20% coinsurance Deductible, then 40% coinsurance Deductible, then 20% coinsurance Deductible, then 40% coinsurance Specialist Deductible, then 20% coinsurance Deductible, then 40% coinsurance Routine Wellness Visits Non-Hospital Services $300 copay, then 20% coinsurance $300 copay, then 20% coinsurance Lab Testing $50 copay $50 copay, then 40% coinsurance X-rays Complex Imaging $0 copay $0 copay (MRI, PET, CT) Office Surgery Deductible, then 20% coinsurance Deductible, then 40% coinsurance Hospitalization Inpatient Care Deductible, then 20% coinsurance Deductible, then 40% coinsurance Emergency Services Emergency Room Visit 5 Urgent Care Ambulance Mental Health Office Visits Outpatient Therapy Rehabilitative

Prescription Drugs Prescription Drug Retail Mail Order Deductible 30-day Supply 90-day Supply Generic Preferred Brand No Deductible Non-Preferred Brand Preferred Specialty 30% coinsurance 30% coinsurance $10 minimum $10 minimum 30% coinsurance 30% coinsurance $10 minimum $10 minimum 30% coinsurance 30% coinsurance $75 minimum $75 minimum 30% coinsurance 30% coinsurance $300 minimum $300 minimum 6

Dental Dental insurance helps pay for all, or a portion, of the costs associated with dental care, from routine cleanings to root canals. You may choose to receive care and services from providers both inside and outside of the network. Staying in-network gives you the best benefit, but United Concordia Dentak does offer an out-of-network allowance schedule as well. In this case, you may see any provider you wish, but you will be responsible for all payments up-front. For a complete list of in-network providers near you, visit www.unitedconcordia.com/ find-a-dentist/#/. Advantage Plus Preferred Provider Network In-Network Out-of-Network Deductible (Individual/Family) $50 / $150 $50 / $150 Annual Maximum $1,500 Class 1 Preventive & Diagnostic Plan pays 100% Plan pays 100% Deductible does not apply Deductible does not apply Class 2 Basic Restorative and Major Surgical Including: Exams, X-rays, Cleanings, Fluoride Treatments, Sealants, and Palliative Treatment Class 3 Major Restorative Plan pays 80% after deductible Plan pays 80% after deductible Orthodontia Including: Fillings, Simple Extractions, Endodontics, Periodontics, Oral Surgery, and General Anesthesia Plan pays 50% after deductible Plan pays 50% after deductible Including: Inlays, Onlays, Crowns, Prosthetics, Implants, and Dentures Plan pays 50% to a lifetime maximum of $1,000 for covered members up to age 19 who meet treatment criteria 7

Vision The vision plan offers employees and covered family member’s services for routine eye care, including eye exams, eyeglasses (lenses and frames), or contact lenses. At the time of service, routine vision examinations and basic optical needs will be covered as shown on the plan’s schedule of benefits. Cosmetic services, as well as any upgrades, will be additional if chosen at the time of the appointment. To find a provider near you, go to www.vsp.com. Coverage Type VSP Plan In-Network Routine Eye Examination $15 copay Frames Retail Plan pays up to $220, then 20% discount on overage Lenses Basic Single Vision $25 copay Basic Bifocal $25 copay Basic Trifocal $25 copay Lenticular (post-cataract) $25 copay Contact Lenses Medically Necessary Plan pays $170, you pay balance 8

Health Reimbursement Arrangement To reduce your out-of-pocket medical expenses, JAY-BEE OIL & GAS will contribute to the employees HRA. For the 2023 plan year, employees must pay the first $3500 toward the plan year deductible. JAY-BEE OIL & GAS will reimburse the remaining $2500 through the HRA. Employees are responsible for paying the provider. 9

Notes 10

Employee Resources BENEFIT GROUP # CONTACT PHONE WEBSITE / EMAIL JAY-BEE OIL & GAS - Natalie Haddix (304) 933-3878 [email protected] www.jaybeeoil.com Medical 09101411 Highmark West (888) 644-2583 www.HighmarkBCBSWV.com Virginia Dental 450440-069 United Concordia (866) 851-7568 www.ucci.com Vision 30086581- VSP (800) 877-7195 www.vsp.com 0066 Health Reimbursement 09101411 Highmark West (888) 644-2583 www.HighmarkBCBSWV.com Arrangement (HRA) Virginia GO-WV - Lori Miller Smith (304) 344-9867 [email protected] www.gowv.com Blue Ridge Risk Partners - Brittany Stewart- (304) 848-6976 Brittany.Stewart-Snodgrass@ Snodgrass BlueRidgeRiskPartners.com Northwestern Mutual - Adam Rowh (304) 624-5400 [email protected] www.northwesternmutual.com/ financial/advisor/adam-rowh/ Lifetime Benefit Solutions COBRA Michael Day CoreService3@ (877) 672-1833 lifetimebenefitsolutions.com www.LifetimeBenefitSolutions.com 11

Glossary of Terms Beneficiary The person you, as the policyholder, designate to receive the proceeds paid out by the insurance Jay-Bee Oil & Gas for your Life and AD&D coverage. Carrier The insurance Jay-Bee Oil & Gas COBRA (or State Continuation) is a governmental act that allows employees to COBRA / State Continuation continue paying for and receiving their insurance coverage for a specific length of time after losing eligibility. Coinsurance The percentage of costs of a covered health care service you pay after you have paid your deductible. Copay The dollar amount you can expect to pay for certain covered services, such as a doctor’s office visit. This amount may OR may not go towards satisfying your deductible amount. Deductible The initial amount of expenses an individual must pay before receiving benefits under a policy. Dependent Employee’s legal spouse, domestic partner, natural children, or court-ordered Eligible Employee children Employees who have met their waiting period requirements for insurance and are working the specified number of hours. HIPAA The Health Insurance Portability and Accountability Act provides federal legislation for protection of privacy, portability, and continuity of health insurance coverage. HRA Health Reimbursement Arrangement—Employer-funded accounts to reimburse HSA employees for IRS eligible incurred expenses; generally available for medical and Short/Long-Term Disability prescription claims. Health Savings Account—Employee-funded account in conjunction with an IRS qualified high deductible medical plan. Money is contributed on a pre-tax basis to cover eligible medical, prescription, dental, and vision claims. Funds are employee- owned and rollover annually. Policy that protects an employee from loss of income in the event of being unable to work due to illness, injury, or accident for a specified period of time. Maximum Out-of-Pocket The financial ‘safety net’ which includes the deductible and co-insurance up to a specified amount before the plan pays 100% of claims. Network The listing of providers which have contracted to provide services to insureds at negotiated prices. Primary Care Physician A provider which delivers basic or general care with the intention to be the patient’s first level of contact for medical care. Qualified Life Event A Life change which results in an employee becoming eligible to enroll or change Waiting Period benefits for themselves or eligible dependents. The period of time an employee is required to work prior to becoming eligible for benefits. 12

Annual Disclosure Notices COBRA Notice of Privacy Practices Act (HIPAA) Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of For purposes of the health benefits offered under the Plan, the Plan uses and 1985, COBRA qualified beneficiaries (QBs) generally are eligible for group discloses health information about you and any covered dependents only as coverage during a maximum of 18 months for qualifying events due to needed to administer the Plan. To protect the privacy of health information, employment termination or reduction of hours of work. Certain qualifying access to your health information is limited to such purposes. The health plan events, or a second qualifying event during the initial period of coverage, options offered under the Plan will comply with the applicable health information may permit a beneficiary to receive a maximum of 36 months of coverage. privacy requirements of federal Regulations issued by the Department of Health and Human Services. The Plan’s privacy policies are described in more detail in COBRA coverage is not extended for those terminated for gross the Plan’s Notice of Health Information Privacy Practices or Privacy Notice. Plan misconduct. Upon termination, or other COBRA qualifying event, the former participants in Jay-Bee Oil & Gas-sponsored health and welfare benefit plan are employee and any other QBs will receive COBRA enrollment information. reminded that the employer’s Notice of Privacy Practices may be obtained by submitting a written request to the Human Resources Department. For any Qualifying events for employees include voluntary/involuntary termination of insured health coverage, the insurance issuer is responsible for providing its own employment, and the reduction in the number of hours of employment. Privacy Notice, so you should contact the insurer if you need a copy of the Qualifying events for spouses/domestic partners or dependent children insurer’s Privacy Notice. include those events above, as well as the covered employee becoming entitled to Medicare; divorce or legal separation of the covered employee; Newborns’ and Mothers’ Health Protection Act death of the covered employee; and the loss of dependent status under the plan rules. If a QB chooses to continue group benefits under COBRA, they must Group health plans and health issuers generally may not, under federal law, complete an enrollment form and return it to the Plan Administrator with the restrict benefits for any hospital length of stay in connection with childbirth for the appropriate premium due. Upon receipt of premium payment and mother or newborn child to less than 48 hours following a vaginal delivery, or less enrollment form, the coverage will be reinstated. Thereafter, premiums are than 96 hours following a cesarean section. However, federal law generally does due on the 1st of the month. If premium payments are not received in a not prohibit the mother’s or newborn’s attending provider, after consulting with timely manner, Federal law stipulates that your coverage will be cancelled the mother, from discharging the mother or her newborn earlier than 48 hours (or after a 30-day grace period. If you have any questions about COBRA or the 96 hours as applicable). In any case, plans and issuers may not, under federal Plan, please contact the Plan Administrator. law, require that a provider obtain authorization from the plan or issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours if applicable). Women’s Health and Cancer Rights Act (WHCRA) The Women’s Health and Cancer Rights Act (WHCRA) provides protections Premium Assistance Under Medicaid & the Children’s for individuals who elect breast reconstruction after a mastectomy. Under Health Insurance Program (CHIP) WHCRA, group health plans offering mastectomy coverage must also provide coverage for certain services relating to the mastectomy, in a If you or your children are eligible for Medicaid or CHIP and you’re eligible for manner determined in consultation with the attending physician and the health coverage from your employer, your state may have a premium assistance patient. Required coverage includes all stages of reconstruction of the program that can help pay for coverage, using funds from their Medicaid or CHIP breast on which the mastectomy was performed, surgery and reconstruction programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t of the other breast to produce a symmetrical appearance, prostheses, and be eligible for these premium assistance programs, but you may be able to buy treatment of physical complications of the mastectomy, including individual insurance coverage through the Health Insurance Marketplace. For lymphedema. Written notice about the availability of these mastectomy- more information, visit www.healthcare.gov. related benefits must be delivered to participants in a group health plan upon enrollment and then each year afterwards. If you or your dependents are already enrolled in Medicaid or CHIP, contact your State Medicaid or CHIP office to find out if premium assistance is available. Notice Regarding Special Enrollment If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these If you are waiving enrollment in the Medical plan for yourself or your programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW dependents (including your spouse/domestic partner) because of other or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your health insurance coverage, you may, in the future, be able to enroll yourself state if it has a program that might help you pay the premiums for an employer- or your dependents in the Medical plan, provided that you request sponsored plan. enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement If you or your dependents are eligible for premium assistance under Medicaid or for adoption, you may be able to enroll yourself and your dependents CHIP, as well as eligible under your employer plan, your employer must allow provided that you request enrollment within 30 days after the marriage, birth, you to enroll in your employer plan if you aren’t already enrolled. This is called a adoption, or placement for adoption. “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). For a complete copy of the Children’s Health Insurance Program (CHIP) Notice, including contact information for resources in your state, visit: https://www.dol.gov/sites/default/ files/ebsa/laws-and-regulations/laws/chipra/model-notice.doc 13



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