Sponsored by:SB/A CooperativeAdministered by:FreeMarketAdministrators.com

SB/A Freedom Protect Plans A, B, and CMaximizing savings and providing cutting-edge solutions to help you effectively manage your health care costs

SERVICE FLEXIBILITY INTEGRITY

Marketed by:

AN AFFORDABLE ERISA HEALTH PLAN SOLUTION

2

Learn more and enroll at DACHealthcare.com

120

Did you know that over 30 million Americans are without access to affordable health care?

The SB/A Freedom Protect Plans Offer Affordable Health Solutions

The SB/A Freedom Protect plans marketed by DAC are not your typical health coverages. The plans are a partially self-funded health care coverage program regulated by ERISA. ERISA (Employee Retirement Income Security Act) is the Federal Law that sets the standards for over 60% of employer established health care plans in private and public sector industry. The SB/A Freedom Protect plans are not Health Insurance. They are an ERISA medical health benefit plan.

Imagine zero deductible, first dollar coverage, no medical underwriting, no pre-existing condition exclusions, Affordable Care Act (ACA) mandated coverages, and more – plus nationwide preferred provider networks that includes over 4000 primary hospitals and most licensed board-certified physicians. The SB/A Freedom Protect plans offer “no deductible” coverage with the flexibility, affordability, and usability so you can now effectively manage your health care. You purchase the amount of coverage that you believe best fits your needs and lifestyle. The SB/A Freedom Protect plan is not for everyone – if your annual coverage needs are expected to exceed The SB/A Freedom Protect plans annual limitations, you should consider additional industry available options.

Come join us for a brief overview of The SB/A Freedom Protect plans health care – the way you always wanted it to be!

3 120

The SB/A Freedom Protect Plan Options

Plans A and B

Learn more and enroll at DACHealthcare.com

PLAN A PLAN B Individual $285 | Family $425 Individual $365 | Family $580 Wellness Base Plan Base Plan Care Benefits Annual Benefit Limit Annual Benefit Limit (PCB) Individual $7,500 Individual $20,000 Family $15,000 Family $40,000

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

Annual Deductible None None None

Co-Insurance Percentage Covered 100% 50% Co-Insurance 50% Co-Insurance

(Plan Pays based on Contracted Amounts) on first $7,500 on first $10,000

plus 80% of next $10,000

Member Annual Out-of-Pocket Maximum None Individual $3,750 Individual $7,000

Family $7,500 Family $14,000

Primary Care Office Visits Covered by SB/A $20 co-pay per visit $20 co-pay per visit

Providers limited to Internal Medicine, Family Freedom Protect Plan (Limited to 3 visits - (Limited to 3 visits -

Practice, Pediatrician, and OB/GYN – Office and excluded from excluded from

Other Outpatient Services (CPT-4 99201-99215) Out-of-Pocket Maximum Out-of-Pocket Maximum

of $3,750.) of $7,000)

Additional visits at Additional visits at

Co-Insurance to $7,500 Co-Insurance to $20,000

Inpatient/Outpatient Hospitalization and Profess- Covered by SB/A 50% Co-Insurance 50% Co-Insurance

ional Services, Medical and Surgical Professional Freedom Protect Plan on first $7,500 on first $10,000

Services, ER/Urgent Care, Lab, X-ray and Imaging, plus

Ambulance Service, Chiropractic Care, 80% of next $10,000

Inpatient/Outpatient Psych and Substance Abuse

Inpatient (Medical and Surgical) and Outpatient Covered by SB/A Not applicable Not applicable

(Surgical only) Hospitalization and Professional Freedom Protect Plan

Services. Excludes Outpatient Drugs, Kidney Dialysis,

Chemo Therapy, and All Other Infusion Drugs

Affordable Care Act Wellness Covered at 100% Covered by MEC Covered by MEC

Wellness Care Benefits Wellness Benefits

Prescription Pharmacy Benefit 100% of 50% Co-Insurance 50% Co-Insurance

ACA Mandated on first $7,500 on first $10,000

Prescriptions, plus 80% of next $10,000

i.e. Birth Control

24 Hour Virtual Clinic – Online and Covered by SB/A 100% 100%

Telephonic Doctor Calls Freedom Protect Plan No co-payment required No co-payment required

Careington Dental Discounted Benefits Covered by SB/A Fee Schedule Fee Schedule

Freedom Protect Plan

Annual Maximum of Covered Services No Annual Maximum Individual $7,500 Individual $20,000

Family $15,000 Family $40,000

ACA MEC Wellness Care Benefits - As provided under the Affordable Care Act

Adult, Women, Child Preventative Services Covered at 100% Covered by Covered by

Screening and Services Wellness Care Benefits (PCB) Wellness Care Benefits (PCB)

1 1 1

2

3 3 3

4

5 5

6 6

9 9

10

11

See all Footnotes on page 8*

7 7

8

12

4120

The SB/A Freedom Protect Plan Options

Plan C

PLAN C PLAN D

Individual $455 | Family $745 Individual $560 | Family $955 Wellness Care Base Plan Base Plan Benefits Annual Benefit Limit Annual Benefit Limit (PCB) Individual $20,000 Individual $20,000 Family $40,000 Family $40,000

plus Extended Benefit plus Extended Benefit In/Outpatient Services In/Outpatient Services Individual $25,000 Individual $100,000 Family $50,000 Family $200,000 In-Network Provider In-Network Provider In-Network Provider (PPO) Only (PPO) Only (PPO) Only

Annual Deductible None None None

Co-Insurance Percentage Covered 100% 50% Co-Insurance 50% Co-Insurance (Plan pays based on Contracted Amounts) on first $10,000 on first $10,000 plus 80% of next $10,000 plus 80% of next $10,000

Member Annual Out-of-Pocket Maximum None Individual $7,000 Individual $7,000 Family $14,000 Family $14,000

Primary Care Office Visits Covered by SB/A $20 co-pay per visit $20 co-pay per visit Providers limited to Internal Medicine, Family Freedom Protect Plan (Limited to 3 Visits. Excluded from (Limited to 3 Visits. Excluded from Practice, Pediatrician, and OB/GYN – Office and Out-of-Pocket Maximum Out-of-Pocket Maximum Other Outpatient Services (CPT-4 99201-99215) of $7,000) of $7,000) Additional visits at Additional visits at Co-Insurance to $20,000 Co-Insurance to $20,000

Inpatient/Outpatient Hospitalization and Profess- Covered by SB/A 50% Co-Insurance 50% Co-Insurance ional Services, Medical and Surgical Professional Freedom Protect Plan on first $10,000 on first $10,000 Services, ER/Urgent Care, Lab, X-ray and Imaging, plus 80% of next $10,000 plus 80% of next $10,000 Ambulance Service, Chiropractic Care, Inpatient/Outpatient Psych and Substance Abuse

Inpatient (Medical and Surgical) and Outpatient Covered by SB/A 100% of next $25,000 100% of next $100,000 (Surgical only) Hospitalization and Professional Freedom Protect Plan up to plan limits up to plan limits Services. Excludes Outpatient Drugs, Kidney Dialysis, for individual for individual Chemo Therapy, and All Other Infusion Drugs or family $50,000 or family $200,000

Affordable Care Act Wellness Covered at 100% Covered by Covered by Wellness Benefits Wellness Care Benefits Wellness Care Benefits

Prescription Pharmacy Benefit 100% of 50% Co-Insurance 50% Co-Insurance ACA Mandated on first $10,000 on first $10,000 Prescriptions, plus 80% of next $10,000 plus 80% of next $10,000 No plan coverage above No plan coverage above i.e. Birth Control first $20,000 first $20,000

24 Hour Virtual Clinic – Online and Covered by SB/A 100% – 100% – Telephonic Doctor Calls Freedom Protect Plan No co-payment required No co-payment required

Careington Dental Discounted Benefits Covered by SB/A Fee Schedule Fee Schedule Freedom Protect PlanAnnual Maximum of Covered Services No Annual Maximum Individual $20,000 Individual $20,000 Family $40,0000 Family $40,000 First In-Outpatient Services First In/Outpatient Individual $25,000 Individual $100,000 Family $50,000 Family $200,000 Next In/Outpatient Services Next In/Outpatient ServicesACA MEC Wellness Care Benefits – As provided under the Affordable Care Act (ACA)

Adult, Women, Child Preventative Services Covered at 100% Covered by Covered by Screening and Services Wellness Care Benefits (PCB) Wellness Care Benefits (PCB)

1 1 1

2

3 3 3

4

5 5

6 6

7 7

9 9

10

8

12

11

See all Footnotes on page 8*

NOTES:

Learn more and enroll at DACHealthcare.com

5 120

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% up to plan coverage limits

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% up to plan coverage limits

2. Alcohol Misuse 10. Obesity Covered at 100% up to plan coverage limits

3. Aspirin 11. Sexually Transmitted Infection (STI) Covered at 100% up to plan coverage limits

4. Blood Pressure 12. Syphilis Covered at 100% up to plan coverage limits

5. Cholesterol 13. HIV Covered at 100% up to plan coverage limits

6. Colorectal Cancer 14. Tobacco Use Covered at 100% up to plan coverage limits

7. Depression 15. Immunization Vaccines Covered at 100% up to plan coverage limits

8. Type 2 Diabetes Covered at 100% up to plan coverage limits

Women Preventative Services – Screenings and Services Listed Below are Eligible

1. Anemia 12. Gestational Diabetes Covered at 100% up to plan coverage limits

2. Bacteriuria Urinary Tract 13. Gonorrhea Covered at 100% up to plan coverage limits

3. BRCA 14. Hepatitis B Covered at 100% up to plan coverage limits

4, Breast Cancer Mammography 15. Human Immunodeficiency Virus (HIV) Covered at 100% up to plan coverage limits

5. Breast Cancer Chemoprevention 16. Human Papillomavirus (HPV) DNA Test Covered at 100% up to plan coverage limits

6. Breastfeeding 17. Osteoporosis Covered at 100% up to plan coverage limits

7. Cervical Cancer 18. Rh Incompatibility Covered at 100% up to plan coverage limits

8. Chlamydia Infection 19. Tobacco Use Covered at 100% up to plan coverage limits

9. Contraception 20. Sexually Transmitted Infections (STI) Covered at 100% up to plan coverage limits

10. Domestic and Interpersonal Violence 21. Syphilis Covered at 100% up to plan coverage limits

11. Folic Acid Supplements 22. Well Woman Visits Covered at 100% up to plan coverage limits

Child Preventative Services – Screenings and Services Listed Below are Eligibile

1. Alcohol and Drug Use 14. Hematocrit or Hemoglobin Covered at 100% up to plan coverage limits

2. Autism 15. Hemoglobinopathies or Sickle Cell Covered at 100% up to plan coverage limits

3. Behavioral 16. HIV Covered at 100% up to plan coverage limits

4. Blood Pressure 17. Immunization Vaccines Covered at 100% up to plan coverage limits

5. Cervical Dysplasia 18. Iron Supplements Covered at 100% up to plan coverage limits

6. Congenital Hypothyroidism 19. Lead Exposure Covered at 100% up to plan coverage limits

7. Depression 20. Medical History Covered at 100% up to plan coverage limits

8. Developmental 21. Obesity Covered at 100% up to plan coverage limits

9. Dyslipidemia 22. Oral Health Covered at 100% up to plan coverage limits

10. Fluoride Supplements 23. Phenylketonuria (PKU) Covered at 100% up to plan coverage limits

11. Gonorrhea 24. Sexually Transmitted Infection Covered at 100% up to plan coverage limits

12. Hearing 25. Tuberculin Testing Covered at 100% up to plan coverage limits

13. Height, Weight and Body Mass Index 26. Vision Covered at 100% up to plan coverage limits

Minimum Essential Coverage (MEC) Annual Benefits

Minimum Essential Coverage MEC Covered Services (MEC) In-Network Provider (PPO) Only

6

The SB/A Freedom Protect Group Plans covers: • 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-pays or indicated

co-insurance up to threshold limit using the ProCare Rx pharmacy card at your favorite pharmacy• Telemedicine (24 Hour Virtual Clinic)• Inpatient/Outpatient Psych/Substance Abuse benefits limited to 30 days/visits per year• Pharmacy benefits are eligible for Rx discounts above base plan threshold• Pharmacy prescription coverage is limited to $500 per prescription per month• All plan benefit services are eligible for PPO network discounts for services above the stated annual maximum

threshold• 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.

Downgrades may be made at any time upon written request.• 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. • Exclusions from coverage: • Any hospital confinement that began on or before the effective date is excluded from plan coverage

• Pharmacy Specialty Drugs are excluded • Workers Compensation injuries and illness • Cosmetic surgery procedures – exceptions to some reconstructive surgeries • Bariatric/Gastric Sleeve surgery • Sex transformation / change surgery

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• Inpatient/Outpatient Psych/Substance Abuse benefits limited to 30 days/visits per year (Base Plans and Extra

Enhanced combined.)• Extra Enhanced Inpatient Hospital & Outpatient Surgery Benefits. Annual Maximum benefit is limited to stated

annual amounts – Plan C $25,000 Individual / $50,000 Family. • Emergency Room, Lab, X-ray and Imaging are covered if admitted to an Inpatient Hospital stay.• 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.

Plan Provisions and ExclusionsLearn more and enroll at DACHealthcare.com

120

Partners of The SB/A Freedom Protect PlansLearn more and enroll at DACHealthcare.com

7

Have Questions?Familiarize yourself with The SB/A Freedom Protect Plans

by taking our brief online training at DACHealthcare.com under Agent Resources or contact Customer Service at 303-566-0353.

How to Use Your Plan ...

1. To obtain medical benefits, simply present your Freedom Plan ID card to your health care provider to confirm eligibility and benefits.

2. Your health care provider will bill your plan administrator for eligible services.

For example: your provider visit charge is $1,500.00. Your provider will then bill the plan for $1,500. The plan administrator adjudicates the bill, bringing it down to $900.00. Your 50/50 coinsurance would leave your final bill at $450.00.

If you are utilizing your plan co-pays, for limited services during physician visits, expect only a $20.00 co-pay charge.

For example: you are going in for a limited medical procedure such as a checkup or bruise while hiking (specific CPT codes). Your visit will cost you $20.00 at point-of-sale.

120

SB/A CoOp

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 relationships 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 SB/A CoOp will sponsor the unique ERISA Supple-mental Health Care Plans that are ACA qualified when offered in tandem with a High Deductible Health Plan (HDHP) or Preventive Care Benefits.

Free Market AdministratorsHeadquartered in Addison, Texas

Free Market Administrators (FMA) was created with over 100 years of experience in health care at the Senior Executive Level. We are committed to creating value for our broad client base of both fully insured major medical and self-funded clients. FMA continues to be a critical measure for which we have maintained the highest performance standards within the industry. FMA remains focused on not only exceeding the highest ethical standards in the industry, while upholding the utmost integrity for our clients, but also redefining the way our clients look at the world of health care benefits.

8120

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 Protect Plans utilize the First Health Network, one of the largest provider networks in the country.Deductible: With the SB/A Freedom Protect Plan, there are no deductibles. However, in traditional health care, a deductible 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.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.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.Co-Pays: Health care plans may contain co-pays. Co-pays are a specific amount that you pay at the point of service for a visit to a provider. Co-pays are especially useful for plans that have high deductibles so that an en-rollee can anticipate the up front cost, and receive limited services at Family Practice, Pediatricians, OB/GYN, and Internal Medicine. The SB/A Freedom Protect Plans use Co-Pays in addition to Co-Insurance for an even more robust care system for families and individuals.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 psych and substance abuse. Except as noted in the exclusions, all services generally occur outside of an extended stay of more than 24 hours.Inpatient/Outpatient (Inpatient = greater than 24 hours hospital stay): The extended benefit component if chosen, extends care for medical and surgical costs when an extended stay is greater than 24 hours. This extended benefit will also cover Outpatient (surgical only) hospitalization and professional services. Excluded are outpatient drugs, kidney dialysis, chemo therapy, and all other infusion drugs. Extended benefit component will be second to pay after base plan annual benefits are reached.Affordable Care Act: 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. SB/A Freedom Protect Plans under ERISA contain all of the most desirable components of the ACA required by Congress.Pharmacy: ProCare Rx www.procarerx.com Prescription pharmacy benefit contains the same zero deductible co-insurance provisions of all the plans contained within. Point-of-sale costs are negotiated in advance and contain discounts up to 80% at which point the 50/50 coinsurance is applied. Upon exhaustion of benefit plan, discounts are still available to all enrollees but without the co-insurance split.24 Hour Virtual Clinic www.24hrvc.com is a national 24/7 benefit, with calls answered by licensed physicians with access to the MIB (Medical information Bureau) to help you obtain the correct care and/or prescription in a timely manner.Careington Discount Dental Plan: Your SB/A Freedom Protect Medical Benefits Plan also includes Careington Discount Dental Plan. Careington negotiates with dentists nationwide to reduce what they charge. As a member receive from 20% to 60% off on most dental procedures. Expect some of the best, and unlimited, discounts on your dental care. The Careington dental discount plan is not insurance and is not intended to replace insurance. Please refer to the FAQ’s on SBAFreedomProtect.com about dental for complete disclosure. 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. See plan details.

Learn more and enroll at DACHealthcare.com

Footnotes

11

1

2

3

4

5

6

7

8

9

10

12