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SEAFARERS HEALTH AND BENEFITS PLAN

Margaret R. Bowen Administrator

November 2023

5201 Auth Way
Camp Springs, Maryland 20746-4275 (301) 899-0675

Dear Plan Level S Participant:

The Trustees of the Seafarers Health and Benefits Plan would like to remind you of certain Plan provisions. This letter contains important information about your benefits. We suggest that you keep this letter with the other information that you have received from the Plan.

Women’s Health and Cancer Rights Act
The Plan would like to remind eligible participants that if you, or any eligible dependent, have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). The Plan provides surgical benefits for mastectomies and reconstruction of the breast, and surgery and reconstruction of the other breast if needed to produce a symmetrical appearance. In addition, the Plan provides benefits for prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this Plan. Therefore, the following deductibles and coinsurance apply.

| Plan Level S
Deductible | $100 per person for outpatient services

Co-Insurance In-Network

30%
Includes mammograms or diagnostic related services for mammograms; subject to deductible;

Co-Insurance Out-of-Network

35%
Includes	mammograms	or	diagnostic	related	services	for mammograms; subject to deductible;

Hospital Costs Limitations | Benefits for all hospital costs for each hospitalization are limited to a total of $50,000.00 or 31 days of confinement, whichever is reached first.

If you have any questions with regard to the information contained in this letter, please call the Claims Department at 1-800-252-4674.

Sincerely,

BOARD OF TRUSTEES