BJ's Embroidery 2021 Final

PREPARED FOR YOU BY:At BJ's Embroidery, Inc., our employees are our most important 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:You work hard every day, and BJ's Embroidery, Inc. is working hard to provide you with a unique and exceptional Benefits Program.This Benefit Guide contains highlights of the BJ's Embroidery, Inc. Benefits Program. For more information, refer to the Summary Plan Descriptions for the Benefits Plan and the 401(k) 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 carriers. 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 BJ's Embroidery, Inc. 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.Employee Benefits Guide Medical & Prescription Coverage Dental Coverage Vision Coverage2021



BENEFITS PLAN YEARThe BJ's Embroidery, Inc. benefits plan year runs from January 1, 2021 through December 31, 2021. You will not be able to make changes to your elections during the plan year unless you experience a qualifying life event.QUALIFYING LIFE EVENTPlease 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: ELIGIBILITYEMPLOYEESEmployees are eligible to participate, in the BJ's Embroidery, Inc. insurance plans, if they are working a minimum of 30 hours per week. Coverage will become effective on the 90th day from their date of hire. If you change from part time to full time you are eligible --the first of the month following the change in status. You must enroll in the insurance program, within 30 days of becoming eligible for coverage.DEPENDENTSYou must notify the Human Resources Department within 30 days of your Qualifying Life Event. Documentation supporting the change will be required.1•Marriage•Divorce•Birth or adoption of a child•Death of spouse, domestic partner,or child•Change in employment of spouse•Loss of coverage with a spouse•Changing from full time to part time--employment or from part time to-full time employment-•Court Order•Eligibility for Medicare or Medicaid•Special Enrollment Right (excludingdomestic partners)•Significant change in the cost ofcoverage for you or your spouse ordomestic partner attributable to yourspouse s employment’•Loss of dependent statusA 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 natural child•A step child•A child for whom legal guardianship has been awarded to theemployee or the employee s spouse.’Dependent children may be covered, under the BJ s Embroidery ’plan(s), until the end of the month in which they reach the age of 26 (regardless of student status).

Plan OptionBlueChoice AdvantageBronze 6000 BlueChoice AdvantageSilver 5000BlueChoice AdvantageGold 1000 Plan FeatureIn network Benefits-Out of network - -BenefitsIn network Benefits-Out of network - -BenefitsIn network Benefits-Out of network - -BenefitsContract Year Deductible (Individual/Family)$6,000 / $12,000$12,000 / $24,000$5,000 / $10,000$10,000 / $20,000$1,000 / $2,000$2,000 / $4,000Out of Pocket Maximum- -(Individual/Family) $8,300 / $16,600$16,600 / $33,200 $8,300 / $16,600$16,600 / $33,200 $5,750 / $11,500$11,500 / $23,000Office Visits Primary Care Physician$40 copayDeductible, then $100 copay$0 copayDeductible, then $70 copay$15 copayDeductible, then $50 copaySpecialist Deductible, then $50 copayDeductible, then $100 copay$50 copayDeductible, then $70 copay$30 copayDeductible, then $50 copayRoutine Wellness Visits$0 copayDeductible, then $0 copay$0 copayDeductible, then $0 copay$0 copayDeductible, then $0 copayNon Hospital Services -Outpatient Lab TestingDeductible, then $25 copayDeductible, then $100 copay$25 copayDeductible, then $50 copay$15 copay Deductible, then $65 copayX rays-Deductible, then $55 copayDeductible, then $200 copay$50 copayDeductible, then $100 copay$30 copay Deductible, then $80 copayComplex Imaging (MRI, PET, CT) Deductible, then $250 copayDeductible, then $400 copay$250 copayDeductible, then $350 copay$200 copayDeductible, then $250 copayOffice SurgeryDeductible, then $300 copayDeductible, then $400 copay$300 copayDeductible, then $400 copay$200 copayDeductible, then $300 copayHospitalization Inpatient Care (per admission)Deductible, then 40% coinsuranceDeductible, then 60% coinsuranceDeductible, then $500 copayDeductible, then $600 copayDeductible, then $400 copayDeductible, then $500 copayEmergency Services Emergency Room VisitDeductible, then 40% coinsuranceIn Network -Deductible, then 40% coinsuranceDeductible, then $250 copayIn network -deductible, then $250 copayDeductible, then $250 copayIn network -deductible, then $250 copayUrgent Care $70 copay$70 copay$50 copay$50 copay$50 copay$50 copayAmbulanceDeductible, then $50 copayIn network -deductible, then $50 copay$50 copay$50 copayDeductible, then $30 copayIn network -deductible, then $30 copayMental Health Office Visits$40 copayDeductible, then $100 copay$0 copayDeductible, then $70 copay$15 copayDeductible, then $50 copayOutpatient Therapy Physical, speech, occupational Deductible, then $50 copayDeductible, then $100 copay$50 copayDeductible, then $70 copay$30 copayDeductible, then $50 copayMedical and Prescription Drug BenefitsUtilize in network providers for the most cost effective care.--

3BJ s Embroidery 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.Pre tax Benefits: Section 125-Medical and Prescription Drug BenefitsPrescription Drugs (30 day supply)BlueChoice AdvantageBronze 6000BlueChoice AdvantageGold 1000 BlueChoice AdvantageSilver 5000DeductibleCombined with Medical$250 per person$450 per personGeneric Deductible, then $20 copay $10 copay $10 copay Preferred BrandDeductible, then $50 copay Deductible, then $40 copay Deductible, then $45 copay Non Preferred Brand-Deductible, then $70 copay Deductible, then $70 copay Deductible, then $65 copay SpecialtyDeductible, then up to $150 copayDeductible, then 50% to a maximum of $150 Deductible, then up to $150 copayHow to Search for Providers1. Go to www.CareFirst.com and select Providers & Facilities, then Find a Doctor or Healthcare Facility, followed by Search Now2. A new window with the provider search tool will open. You can go under your CareFirst account or as a guest. If you choose to search as a guest, you are asked to enter your city, state, or zip code (or allow your location to be detected). Choose your network () and click Continue. 3. On the next page, you will be able to enter names or specialties, as well as choose a category from the drop down list. You can also change the sort order to sort results Alphabetically or by Distance and Rating.-

Dental BenefitsBJ s Embroidery, Inc. offers a PPO dental plan. You and your covered family members receive the greatest benefit ’when you use In Network Dentists. While the plan permits you to use any provider, out of network providers can bill “-” - -for the difference between the dentist s actual charges and CareFirst s reimbursement amount. ’’BlueDental PlusPreferred Provider NetworkIn Network-Out of Network- -Deductible (Individual/Family)$25 / $75$50 / $150Annual Maximum$2,000Class 1 Preventive & DiagnosticPlan pays 100%Plan pays 100%Including: Exams, X rays, Flouride Treatments, Sealants, and Palliative -Emergency Treatment, ProphylaxisClass 2 Basic RestorativePlan pays 80% after deductiblePlan pays 80% after deductibleIncluding: Surgical Periodontic Services, Endodontics, Oral Surgery, Direct Placement Fillings, Periodontal Scaling and Root Planning, and Simple ExtractionsClass 3 Major RestorativePlan pays 50% after deductiblePlan pays 50% after deductibleIncluding: Bridges, Inlays, Onlays, Crowns, Prosthetics, Dentures, and ImplantsOrthodontia Not Covered4How to Search for Providers1. Go to www.CareFirst.com and select Providers & Facilities, then Find a Doctor or Healthcare Facility, followed by Search Now2. A new window with the provider search tool will open. You can go under your CareFirst account or as a guest. If you choose to search as a guest, you are asked to enter your city, state, or zip code (or allow your location to be detected). Choose your network (BlueDental Plus) and click Continue. 3. On the next page, you will be able to enter names or specialties, as well as choose a category from the drop down list. You can also change the sort order to sort results Alphabetically or by Distance and Rating.-

Vision BenefitsThe 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.Coverage TypeBlueVision PlusIn network -Out of network- -Routine Eye Examination with dilation $10 copayPlan pays $45, you pay balanceFramesDavis Vision Collection$0 copay- Retail Chain Provider$130 allowance, then 20% discount on overagePlan pays $60, you pay balanceSpectacle LensesBasic Single Vision $20 copayPlan pays $52, you pay balanceBasic Bifocal$20 copayPlan pays $82, you pay balanceBasic Trifocal$20 copayPlan pays $101, you pay balanceLenticular (post cataract)-$20 copayPlan pays $181, you pay balanceContact Lenses in lieu of eyeglassesMedically NecessaryFormulary: $0 copayPlan pays $285, you pay balanceDavis Vision Collection$20 copay- Non Collection Elective-$20 copay; plan pays up to $60, then 15% discount on overagePlan pays $112, you pay balance5How to Search for Providers1. Go to www.CareFirst.com and select Providers & Facilities, then Find a Doctor or Healthcare Facility, followed by Search Now2. A new window with the provider search tool will open. You can go under your CareFirst account or as a guest. If you choose to search as a guest, you are asked to enter your city, state, or zip code (or allow your location to be detected). Choose your network BlueVision, BlueVision Plus, Pediatric Vision (Davis Vision) is the full (“” network name) and click Continue. 3. On the next page, you will be able to enter names or specialties, as well as choose a category from the drop down list. You can also change the sort order to sort results Alphabetically or by Distance and Rating.-

BENEFITGROUP #CONTACTPHONEWEBSITE / EMAILMedical265B CareFirst (877) 526 8390 -CareFirst.com DentalVisionKeller Stonebraker Insurance- Holly Landers(301) 302 [email protected] s Embroidery Inc. ’- Beth Hull(301) 733 [email protected] Resources6



Women s Health and Cancer Rights Act (WHCRA)’The Women s Health and Cancer Rights Act (WHCRA) provides protections ’for individuals who elect breast reconstruction after a mastectomy. Under WHCRA, group health plans offering mastectomy coverage must also provide coverage for certain services relating to the mastectomy, in a manner determined in consultation with the attending physician and the patient. Required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications of the mastectomy, including lymphedema. Written notice about the availability of these mastectomy related benefits must be delivered to participants in a group -health plan upon enrollment and then each year afterwards.Notice Regarding Special EnrollmentIf you are waiving enrollment in the Medical plan for yourself or your dependents (including your spouse/domestic partner) because of other health insurance coverage, you may, in the future, be able to enroll yourself or your dependents in the Medical plan, provided that you request 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 for adoption, you may be able to enroll yourself and your dependents provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.Notice of Privacy Practices Act (HIPAA)For purposes of the health benefits offered under the Plan, the Plan uses and discloses health information about you and any covered dependents only as needed to administer the Plan. To protect the privacy of health information, access to your health information is limited to such purposes. The health plan options offered under the Plan will comply with the applicable health information 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 the Plan s Notice of Health Information Privacy ’Practices or Privacy Notice. Plan participants in company sponsored health -and welfare benefit plan are reminded that the employer s Notice of Privacy ’Practices may be obtained by submitting a written request to the Human Resources Department. For any insured health coverage, the insurance issuer is responsible for providing its own Privacy Notice, so you should contact the insurer if you need a copy of the insurer s Privacy Notice.’Newborns and Mothers Health Protection Act’ ’ Group health plans and health issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother s or newborn s attending provider, after ’’consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal 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).Premium Assistance Under Medicaid & the Children s Health Insurance ’Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you re eligible for ’health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren t eligible for Medicaid ’or CHIP, you won t be eligible for these premium assistance programs, but you ’may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. 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. 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 programs, contact your State Medicaid or CHIP office or dial 1 877 KIDS --NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer sponsored plan.-If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren t already enrolled. This is ’called a 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-ANNUAL NOTICE DISCLOSURESCOBRAUnder the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, COBRA qualified beneficiaries (QBs) generally are eligible for group coverage during a maximum of 18 months for qualifying events due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.COBRA coverage is not extended for those terminated for gross misconduct. Upon termination, or other COBRA qualifying event, the former employee and any other QBs will receive COBRA enrollment information.Qualifying events for employees include voluntary/involuntary termination of employment, and the reduction in the number of hours of employment. Qualifying events for spouses/domestic partners or dependent children include those events above, as well as the covered employee becoming entitled to Medicare; divorce or legal separation of the covered employee; 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 complete an enrollment form and return it to the Plan Administrator with the appropriate premium due. Upon receipt of premium payment and enrollment form, the coverage will be reinstated. Thereafter, premiums are due on the 1 of the month. If premium payments are not received in a timely manner, stFederal law stipulates that your coverage will be cancelled after a 30 day -grace period. If you have any questions about COBRA or the Plan, please contact the Plan Administrator.Please note, if the terms of the Plan and any response you receive from the Plan Administrator s representatives conflict, the Plan document will control.’7

Keller Stonebraker Insurance800 733 2530 www.kellerstonebraker.com--▪ Hagerstown, MD Frederick, MD Baltimore, MD Cumberland, MD▪▪▪Ellicott City, MD Myersville, MD Keyser, WV Waynesboro, PA ▪▪▪