HELPING YOU UNDERSTAND

Your Benefit Choices

2021
This is a high-level benefits guide of certain benefits your employer offers. The information in this booklet is intended as a general
outline of the benefits offered under your employers benefits program and should not be considered legal, investment or other
benefits advice. Specific details and plan limitations are provided in the Summary Plan Descriptions (SPD), which is based on
the official Plan Documents that may include policies, contracts and plan procedures. The SPD and Plan Documents contain
all the specific provisions of the plans. In the event that the information in this brochure differs from the Plan Documents, the
Plan Documents will prevail. Benefit plans are subject to change, amendment, or termination without notice to or the
agreement of any employee/participant. All protected health information is confidential, pursuant to the Health Insurance
Portability and Accountability Act of 1996. If you have any questions about your Guide, contact Human Resources.
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives
you more choices about your prescription drug coverage. Please see the “Notices” Section in the back of this benefits booklet.

2 | BENEFITS GUIDE
CONTENTS
4 PLAN YEAR NEWS AND ONLINE BENEFIT ENROLLMENT

5 GROUP INSURANCE ELIGIBILITY

6 MEDICAL COVERAGE INTRODUCTION

7 BLUE CROSS BLUE SHIELD (BCBS) MEDICAL & RX

9 BLUE CROSS BLUE SHIELD (BCBS) VIRTUAL VISITS

10 HEALTH SAVINGS ACCOUNTS (HSA)

12 FLEXIBLE SPENDING ACCOUNTS (FSA)

14 KINDBODY FERTILITY BENEFITS

15 DENTAL INSURANCE

17 VISION INSURANCE

21 BASIC LIFE AND AD&D INSURANCE

22 SUPPLEMENTAL BENEFITS

23 DISABILITY BENEFITS

25 MENTAL HEALTH & WELLBEING

27 VOLUNTARY BENEFITS

28 VALUE-ADDED BENEFITS

29 401(k) PLAN

30 RIVIAN PAYROLL CALENDAR

31 PROVIDER CONTACT INFORMATION

32 REQUIRED NOTICES AND OTHER INFORMATION

40 GLOSSARY OF TERMS

3 | BENEFITS GUIDE
 WELCOME
BENEFITS MENU | ENROLLMENT GUIDE

Your Benefit Period

BENEF I T S O F F ERED
JANUARY 01, 2021- DECEMBER 31, 2021

MY HEALTH
Medical | Blue Cross Blue Shield of MI
ENROLLMENT
(BCBSM) All team members have access to our online benefits enrollment
platform 24/7 where you have the ability to enroll, select or change
Dental Core & Buy-Up plans | Delta Dental
your benefits online during the annual open enrollment period, new
Vision Core & Buy-Up plans | EyeMed Vision hire orientation, and for qualifying events.
Core & Buy-Up plans | VSP Flexible Spending
 Accessible 24/7;
Accounts | iSolved Benefit Services  View all benefit plan options and your elections;
Health Savings Accounts | Health Equity  View important carrier forms and links;
 Report a qualifying life event; and
 Make changes to beneficiary designations and more.
MY LIFE
STD & LTD | UNUM
Life and AD&D | UNUM ENROLLMENT INSTRUCTIONS:
Supplemental Life and Disability Insurance | 1. Go to Workday using Rivian’s Single Sign On (SSO)
UNUM 2. Click on the ‘Inbox’ notification in the upper right hand corner of
Fertility Coverage | KindBody Workday
ID Theft & LegalShield | IDShield 3. Click ‘Let’s Get Started’ on the New Hire inbox notification, and
Mental Wellbeing Platform | Modern Health enroll in your benefits
Wellbeing Text Coaching | Sibly 4. Make sure to submit your elections, and print your confirmation
statement
Note: If you have dependents that you will be enrolling it is
MY EXTRAS required to submit birth certificates, marriage licenses or the
domestic partner affidavit for your elections to be processed
Pet Insurance | Nationwide
Meditation App | Headspace
Child Care Concierge | Kinside READY TO ENROLL?
EAP | UNUM Go to https://www.myworkday.com/rivian/d/home.htmld
Travel Assistance | UNUM

1. Do you plan to enroll an eligible dependent(s)?

If so, make sure to have their social security numbers and birthdates available. You
cannot enroll your dependent(s) without this information.

2. Have you recently been married/divorced or had a baby?

If so, remember to add or remove any dependent(s) and/or update your beneficiary
Helpful Tips To designation.
Consider Before 3. Did any of your covered children reach their 26th birthday this year?
If so, they may no longer be eligible for benefits, unless they meet specific criteria.
You Enroll

4 | BENEFITS GUIDE
 ELIGIBILITY
RULES | REQUIREMENTS

EMPLOYEE ELIGIBILITY
You (Team Member) are eligible to participate if
you are full-time and work a minimum of 20
hours per week. Your coverage will be effective The term ‘child’ refers to any
your date of hire. of the following:
 A natural (biological) child
 A stepchild
DEPENDENT ELIGIBILITY  A legally adopted child
You may also enroll eligible dependents for  A foster child
benefits coverage. A ‘dependent’ is defined as  A child for whom legal guardianship has been
the legal spouse and/or ‘dependent child(ren)’ awarded to the participant or the participant’s
of the plan participant or the spouse. spouse/domestic partner
 Disabled dependents may be eligible if
requirements set by the plan are met
DOMESTIC PARTNER ELIGIBILITY
You may enroll your eligible partner for benefits
coverage. Domestic Partner (DP) is a term that
refers to an unmarried partner of the same or
opposite sex.

The chart provided below explains who is eligible for coverage under each benefit plan type:

Individual Medical/Rx Dental Vision Disability Life FSA

You, if full-time employee
working a minimum of 20 hours or more      
per week

Your Spouse     

Dependent Child up to Age 26 (End of

    
Calendar Year)

Domestic Partner    

Qualifying Life IMPORTANT

Events You cannot make changes to these elections
during the year unless you experience a
If you have a Qualifying Life Event and want to request a mid- qualified family status change, which must be
year change, you must notify the Benefits Team at reported to the Benefits team at
benefits@Rivian.com and complete your election changes benefits@Rivian.com within 30 days of the
within 30 days following the event. Be prepared to provide
event
documentation to support the Qualifying Life Event.
If you separate from employment, COBRA
Common life events include; Marriage, Divorce, New
Dependent, Loss/gain of available coverage by you or any of continuation of coverage may be available as
your dependents. applicable by law. COBRA Continuation
details can be found in the notices section of
*A full list of qualifying events can be found in the ‘Required
Notices’ section of this benefits guide. this employee benefit guide.

5 | BENEFITS GUIDE
 MEDICAL
NETWORK INFORMATION | COMMON TERMS | RIVIAN OPT- OUT CREDIT

COMMON INSURANCE TERMS PPO | In-Network & Out-of-Network Benefits

The PPO Plan options offered through Blue Cross Blue Shield (BCBS) provide the
A COPAYMENT (COPAY) is a freedom to see any provider when you need care. When you use providers from within the
fixed amount you pay to receive PPO network, you receive benefits at the discounted network cost.
services.
• Most expenses, such as office visits, emergency room and prescription drugs are
Your co-payment(s) will count
covered by a copay.
towards your out-of-pocket
• Other expenses are subject to a deductible and coinsurance.
maximum but not your deductible.
(e.g., $30 for every visit to the PPO HSA | In-Network & Out-of-Network Benefits
doctor), while your insurance
company pays the rest. The PPO HSA plans are similar to the PPO Plans in that you have the option to choose
any provider when you need care. However, in exchange for a lower per-paycheck cost,
A PREMIUM is the amount you you must satisfy a higher deductible that applies to almost all health care expenses,
pay for insurance, using pre-tax including those for prescription drugs.
or post-tax dollars. • All expenses are your responsibility until the deductible is reached, with the exception
of preventive care, which is covered at 100% when you visit an In-Network provider
A DEDUCTIBLE is the amount of • Once the deductible is met, you are responsible for coinsurance for medical expenses
money you are responsible for and a copay for prescription drug expenses.
paying each year before the plan
Enrolling in this plan allows you to contribute tax free dollars to a health savings account
begins to pay for covered
(HSA). Any dollars that you (and your employer) wish to contribute can be used towards
services, with the exception of
any eligible medical, Rx, dental and vision expenses that you may incur while covered
preventive care services, which
under the plan. See HSA section of this guide for additional details.
are covered at 100% In-Network.

COINSURANCE This is your RIVIAN MEDICAL/RX OPT OUT CREDIT

share of the expense of covered
services after your deductible has
Available to Employee & Spouse
been paid when the company
plan is paying a percentage. The • Employee Medical/RX Opt out credit: If you have medical/RX insurance
coinsurance rate is usually a outside of Rivian, you are eligible for an additional $100.00 credit per
percentage. paycheck in the form of an employee/RX opt out credit
• Spouse Medical/RX Opt out credit: If you are married and your spouse
OUT-OF-POCKET (OOP) has medical/RX insurance outside of Rivian, you are eligible for an
MAXIMUM is the most you pay additional $23.08 credit per paycheck in the form of a Spouse/RX Opt out
per Plan Year for health care
expenses and applies to
credit
deductibles, flat-dollar copays and
coinsurance for all covered Please note the following:
services – including cost-sharing • If you and your spouse both have medical/RX insurance outside of Rivian,
amounts for prescription drugs. you are only eligible for the Employee Medical/RX Opt out credit and
Once this limit is met, the plan will cannot receive both
cover all in-network services at • If you are not married, you are not eligible for the Spouse Medical/RX Opt
100% until the end of the plan
out credit
year.

*OUT-OF-NETWORK charges in If you do not complete benefit elections within the first 14 days of
the above plans are subject to employment, you will automatically be enrolled in the Employee Only
reasonable and customary tier of the Blue Cross Blue Shield of Michigan (BCBSM) PPO Health
limitations, which means you are Savings Account (HSA) 3500 plan, and will receive the Rivian HSA
responsible for charges over this
contributions.
amount in addition to separate
deductible and coinsurance. Any
services received from an out-of- You will have the opportunity to change your benefit elections during
network provider, with the Open Enrollment which occurs during the first two weeks of November
exception of a true emergency, with an effective date of January 1st of the following year.
will not be covered

6 | BENEFITS GUIDE
 MEDICAL
BLUE CROSS BLUE SHIELD OF MICHIGAN (BCBSM) | PLAN COMPARISON
All US Employees are eligible to enroll in these plans

BCBSM PPO BCBSM PPO HSA

IN-NETWORK BENEFITS PPO 250 PPO 1000 PPO HSA 1400 PPO HSA 3500
DEDUCTIBLE
Single $250 $1,000 $1,400 $3,500
Two Person/Family $500 $2,000 $2,800 $7,000
EMPLOYER HSA CONTRIBUTIONS
$750 $1,250
Single N/A N/A
($28.85 per pay) ($48.08 per pay)
$1,500 $2,500
Two Person N/A N/A
($57.69 per pay) ($96.15 per pay)
Family N/A $2,000 $3,000
COINSURANCE (applies after deductible is met) N/A
($76.92 per pay) ($115.38 per pay)

Member Cost Share % 20% up to 20% up to 20% up to 20% up to

Single Maximum $2,500 $2,500 N/A N/A
Two Person/Family Maximum $5,000 $5,000 N/A N/A

MEMBER COPAYMENT(S)
Primary Care (PCP) - Office Subject to Deductible/ Subject to Deductible/
$40 copay $40 copay
Visit Coinsurance Coinsurance
Subject to Deductible/ Subject to Deductible/
Virtual Visit $40 copay $40 copay
Coinsurance Coinsurance
Subject to Deductible/ Subject to Deductible/
Specialist - Office Visit $60 copay $60 copay
Coinsurance Coinsurance
Subject to Deductible/ Subject to Deductible/
Urgent Care Facility $60 copay $60 copay
Coinsurance Coinsurance
$250 copay $250 copay Subject to Deductible/ Subject to Deductible/
Emergency Room Visit
(waived if admitted) (waived if admitted) Coinsurance Coinsurance

OUT-OF-POCKET (OOP)
Single Maximum $6,350 $6,350 $2,250 $4,500
Two Person/Family Maximum $12,700 $12,700 $4,500 $9,000
EMPLOYEE CONTRIBUTIONS (based on 26 Pay Periods)
Single $23.44 $10.19 $11.48 $0.53
Employee + Child $73.45 $41.64 $35.13 $1.15
Employee + Spouse $108.76 $76.95 $40.51 $6.54
Employee + Children $124.41 $84.65 $66.98 $14.90
Family $139.08 $99.32 $101.23 $49.15
Medical/RX Opt Out Credit
$100 credit per pay
(Employee)
Medical/RX Opt Out Credit
(Spouse) $23.08 credit per pay

7 | BENEFITS GUIDE
 PRESCRIPTION DRUGS
BLUE CROSS BLUE SHIELD OF MICHIGAN (BCBSM) |
RX PLAN INFORMATION

Rx PPO HSA PPO

PPO 250 PPO 1000
Copays 1400 HSA 3500
TRADITIONAL DRUGS
TIER 1 (GENERIC) | Lowest copay: Most drugs in $15 after $15 after
TIER 1 $15 $15
this category are generic drugs. Members pay the deductible deductible
lowest copay for generics, making these drugs the
most cost-effective option for treatment. $30 after $30 after
TIER 2 $30 $30
deductible deductible
TIER 2 | Higher copay: This category includes
preferred, brand name drugs that don't yet have a $60 after $60 after
generic equivalent. These drugs are more expensive TIER 3 $60 $60
deductible deductible
than generics, and a higher copay.
$60 after $60 after
TIER 3 | Highest copay: In this category are TIER 4 $60 $60
nonpreferred brand name drugs for which there is
deductible deductible
either a generic alternative or a more cost-effective
$60 after $60 after
preferred brand. These drugs have the highest TIER 5 $60 $60
copay. Make sure to check for mail order
deductible deductible
discounts that may be available.

SPECIALTY DRUGS WHERE CAN I FIND A DRUG LIST?

TIER 4 | Lowest specialty drug copay: Tier 4 Typically, a full listing of covered drugs is found on your provider’s website. A drug list,
specialty drugs are generally more effective and less also called a formulary, is a list of generic and brand-name drugs covered by a health
expensive than nonpreferred specialty drugs in tier plan. Although a drug may be on the drug list, it might not be covered under every
5. plan. Review the plan materials for details on specific benefits.
TIER 5 | Highest specialty drug copay: These You can use drug lists to see if a medication is covered by your health insurance plan.
drugs have the highest copay for specialty drugs, You can also find out if the medication is available as a generic, needs prior
usually because there may be a more cost-effective authorization, has quantity limits and more.
generic or preferred brand available.
Please reach out to the Benefits team at benefits@Rivian.com for a copy of the
formulary.

Save Money Helpful Rx Cost Savings Tools & Tips:

With Generic
(Tier 1) Drugs
MAIL ORDER - Many drugs are available in a 90 day supply, rather than the 30
day retail supply. Typically, you will pay less if you choose to get a mail order
90 day supply.
GOOD Rx - There are many tools online that you can use in order to save on
Ask your doctor if it’s appropriate to use prescription costs. One being GoodRx.com, an online Rx database that allows
you to find what pharmacy is the cheapest for your specific prescription.
a generic drug rather than a brand. Additionally, you may be able to find a coupon that will greatly reduce your cost.
It is important to remember that many of the coupons can only be used outside
Generic drugs are less expensive, and of your plan (will not count towards your maximums).
according to the FDA, they contain the ASK YOUR DOCTOR – Make sure to ask if there are cost savings alternatives
same active ingredients and are to the prescription they are providing. Many times there are generic or different
manufacturers that will save you money at the pharmacy.
identical in dose, form and
administrative method as a brand name.

8 | BENEFITS GUIDE
 ONLINE HEALTHCARE
24/7 | VIRTUAL DOCTOR VISITS

WHEN CAN I USE A VIRTUAL VISIT?

When you have a non-emergency condition and:
No crowded –
–
your doctor is not available
you become ill while traveling

waiting rooms. – When you are considering visiting a hospital emergency

room for a non-emergency health condition

No Driving.
*Your covered children may also use Virtual Visits when a parent
or legal guardian is present for the visit.

Examples of Non-Emergency Conditions:

See a doctor when
 Bladder infection  Rash
you need a doctor.  Bronchitis  Seasonal flu
 Diarrhea  Sinus
 Fever  Sore throat
 Pink eye  Stomach
A virtual visit lets you see and talk to
a doctor from your mobile device or HOW DOES IT WORK?
computer. When you use one of the Each time you have a virtual visit, you will be asked some brief
medical questions, including questions about your current medical
provider groups in our virtual visit concern. If appropriate, you will then be connected using secure live
network, you have benefit coverage audio and video technology to a doctor licensed to deliver care in the
state you are in at the time of your visit. You and the doctor will
for certain non-emergency medical discuss your medical issue, and, if appropriate, the doctor may write
conditions. Costs must be paid by a prescription* for you.

you at the time of the virtual visit and Virtual Visits doctors use e-prescribing to submit prescriptions to the
pharmacy of your choice. Costs for the virtual visit and prescription
will apply toward your deductible drugs are based on, and payable under, your medical and pharmacy
and out-of-pocket maximum. benefit. They are not covered as part of your Virtual Visits benefit.
*Prescription services may not be available in all states.

HOW DO I GET ACCESS?

For questions regarding 1. Launch the online visits app or website, and log in to your
online health care, contact: account
2. Choose a service: Medical, Therapy or Psychiatry
1-844-606-1608 or 3. Pick a doctor or begin a scheduled visit and enter your
bcbsmonlinevisits.com 4.
payment information
Meet with your doctor or therapist online
5. Get a prescription, if appropriate, sent to a local pharmacy
6. Send a visit summary to your primary care doctor or other
health care provider at the end of your online visit

DOWNLOAD THE APP

Get the information you need on the go by
downloading the BCBSM Online Visits
App from the App Store for AppleSM
products or on the Google PlayTM Store
for Android products.

9 | BENEFITS GUIDE
 HEALTH SAVINGS ACCOUNT
HSA | Available through Health Equity for Blue Cross Blue Shield of Michgian
(BCBS)M Members

ENROLLED IN A HSA ELIGIBLE HEALTH PLAN?

Take charge of your health care spending with a Health Savings Account (HSA).
Contributions to an HSA are tax-free, and no matter what, the money in the account is yours!

 A Health Savings Account (HSA) is a tax-free savings account is owned by you, is 100% vested
from day one, and let’s you build up savings for future needs.

 The funds may be used to pay for qualifying healthcare expenses not covered by insurance or
any other plan for yourself, your spouse, or tax dependents.

 You decide how much you would like to contribute, when and how to spend the money on
eligible expenses, and how to invest the balance.

HSA ELIGIBILITY REQUIREMENTS UNDERSTANDING YOUR HSA

 Pre-tax contributions are deducted through
 To be eligible to open and contribute to an
payroll and deposited into your HSA account
HSA, you must have coverage under a
qualified High Deductible Health Plan  You can use your HSA available funds to
(HDHP). pay for qualified medical expenses tax-free
 Participants cannot be covered by any other  HSA funds can be used for non-eligible
health insurance plan (this exclusion does expenses but will be subject to regular
not apply to certain other types of insurance, income taxes and a 20% excise tax penalty
such as dental, vision, disability or long-term
 Unused funds remain in your account for
care coverage)
future use and roll over each calendar year
 Participants cannot participate in a
 HSAs remain with you even if you change
Healthcare FSA or spouse/domestic
health plans or companies. If you open an
partner’s Healthcare FSA or Health
HSA and later become ineligible to make
Reimbursement Account (HRA), but are
contributions, you can still use your
eligible to participate in a Limited Purpose
remaining funds
FSA for Dental and Vision expenses
 You can change your HSA contribution at
 Participants cannot be enrolled in Medicare
any time during the plan year for any reason
or Medicaid (including dependents)
 You cannot be eligible to be claimed as a
dependent on someone else’s tax return
 You have not received Department of
Veterans Affairs Medical benefits in the past
90 days

10 | BENEFITS GUIDE
 HEALTH SAVINGS ACCOUNT
HSA | TAX SAVING VEHICLE

2021 HSA FUNDING LIMITS ELIGIBLE HSA EXPENSES*

 Acupuncture
Each year, the IRS places a limit on the maximum amount  Alcoholism treatment
 Ambulance
that can be contributed to HSA accounts  Artificial limb
 Automobile modifications for a physically
handicapped person
 Birth control pills
HSA Contribution Limits  Blood pressure monitoring device
 Braille books & magazines
 Chiropractic care
$3,600 Christian science practitioner
Team Member 
 COBRA premiums
Two Person/Family  Contact lenses & related materials
$7,200  Crutches
 Dental treatment
HSA “Catch-Up” Contributions  Dentures
 Diagnostic services
 Drug addiction treatment
Age 55 or older Additional $1,000 a year  Eye examination
 Eyeglasses & related materials
 Fertility treatment
Employer HSA Contribution BCBS Plans  Flu shot
 Guide dog or other animal aide
 Hearing aids
 Hospital services
PLAN PPO HSA 1400 PPO HSA 3500  Immunization
 Insulin
$750 $1,250  Laboratory fees
Team Member
 Laser eye surgery
Two Person/Family  Long-term care premiums or expenses
$1,500/$2,000 $2,500/$3,000  Medical testing device
 Nursing services
 Obstetrical expenses
 Organ transplant
 Orthodontia (not for cosmetic reasons)
 Oxygen
 Physical exam
 Physical therapy
 Prescription drugs
 Psychiatric care
MAINTAINING RECORDS 

Retiree medical insurance premiums
Smoking cessation program
 Surgery
To protect yourself in the event that you are audited by the IRS,  Transportation for medical care
keep records of all HSA documentation and itemized receipts  Weight loss program
 Wheelchairs and more*.
for at least as long as your income tax return is considered
open (subject to an audit), or as long as you maintain the
account, whichever is longer. *A full list of qualified expenses
can be found in IRS Publication
HSA funds may be used for non-eligible expenses, but will be
502 at www.irs.gov.
subject to regular income taxes and a 20% excise tax penalty.

11 | BENEFITS GUIDE
 FLEXIBLE SPENDING ACCOUNT
FSA | TAX SAVING VEHICLE

Flexible Spending Accounts (FSA) allow you to reduce your taxable income by
setting aside pre-tax dollars from each paycheck to pay for eligible out-of-pocket IMPORTANT FSA CHANGES
health care and dependent care expenses* for yourself, your spouse and your
dependent children.
In order to participate in the FSA, you must enroll each year. Your annual
contribution stays in effect during the entire year (January 1st through
December 31st). The only time you can change your election is during the
enrollment period or if you experience a change-in-status event. Also, you must For the 2020 and 2021 Plan years
elect this benefit within 30 days of your hire date or first date of benefits the ‘use it or lose it’ language
eligibility.
has been removed and any
unused FSA balance that is in
HEALTH CARE & LIMITED PURPOSE FSA your account at the end of the
MAXIMUM ANNUAL CONTRIBUTION | $2,750 plan year will automatically be
rolled over into the next plan
All eligible health care expenses – such as deductibles, medical and year.
prescription copays, dental expenses, and vision expenses – can be
reimbursed from your general purpose FSA account. This includes Health FSA,
With the Health Care FSA or Limited Purpose FSA, you can spend up to the
Limited Purpose FSA and
full amount of your annual election as soon as your account has been set up. Dependent Care FSA plans!
LIMITED PURPOSE FSA | ADDITIONAL REQUIREMENTS
 If you open or contribute to a Health Saving Account (HSA), you may only enroll in
a Limited Purpose FSA.
For the 2021 plan year,
 If you enroll in a HDHP (High Deductible Health Plan) and elect a Health FSA, you Dependent Care FSA maximum
will automatically be enrolled in the Limited Purpose FSA. contributions have been
 A limited purpose FSA will reimburse you for dental and vision expenses, but you
cannot claim the same expense on both the FSA and HSA Accounts.
increased to $10,500 (married
filing jointly) or $5,520 (married
DEPENDENT CARE FSA filing separately).
The Dependent Care FSA allows you to pay for eligible dependent care
expenses with tax-free dollars so that you and your spouse can work or
attend school FT.
Questions? Call iSolved
Unlike the Health Care FSA, funds in a Dependent Care FSA are only
available once they have been deposited into your account and you cannot Customer Service (866) 370.3040
use the funds ahead of time.
 You may set aside up to $10,500 annually in pre-tax dollars, or $5,250 if
you are married and file taxes separately from your spouse.
 If you participate in a Dependent Care FSA, you cannot apply the same
expenses for a dependent care tax credit when you file your income ‘CARE’ IS DEFINED AS:
taxes.  In-home baby-sitting services (not by an
individual you claim as a dependent)
Transit and Parking Plans  Care of a preschool child by a licensed
Monthly Max | $270 nursery or day care provider
Transit and parking plans allow you to set aside your hard-earned dollars on  Before and after-school care
a pre-tax basis to pay for the expense of getting to and from work.  Summer day camp (provided it is not
Transportation plans cover qualified parking, transit passes, and vanpooling. overnight)
 Effective first of the month following date of hire  In-home dependent day care
 Eligible to enroll at any time during the year

12 | BENEFITS GUIDE
 FLEXIBLE SPENDING ACCOUNT
FSA | TAX SAVING VEHICLE

ELIGIBLE HEALTH
HERE’S HOW IT WORKS FSA EXPENSES*
An employee earning $30,000 elects to place $1,000 into a Health Care
FSA. The payroll deduction is $110.42 based on a 24 pay period schedule.
As a result, the insurance premiums and health care expenses are paid with  Acupuncture
tax-free dollars, giving the employee a tax savings of $574.  Alcoholism treatment
 Artificial teeth/dentures
 Blood pressure monitors
Without FSA With FSA  Braces
 Braille-books & magazines
Gross Income $30,000 $30,000
 Breast pumps & lactation supplies
 Chiropractors
FSA Contributions $0 -$2,650  Co-insurance, co-pay & deductibles
TAXABLE INCOME $30,000 $27,350  Cost of operations & related treatments
 Crutches
Estimated Taxes
 Diabetic supplies
Federal $3,090* -$2,817*  Drug addiction treatment
State $1,104** $1,106**  Eye exams, eye glasses, contacts
FICA $2,295 $2,092
 Hearing devices & batteries
 Hospital services
AFTER TAX EARNINGS $23,511 $21,435  Operations
 Pregnancy tests
Eligible Out-Of-Pocket Expenses $2,650 $0
 Radial keratotomy & lasik eye surgery
AVAILABLE/SPENDABLE INCOME $20,861 $21,435
 Smoking cessation programs
 Speech therapy
 Surgical fees
That’s a savings of $574 for the year! 

Vaccines
Walkers & wheelchairs
 X-rays and more.
This example is for illustrative purposes only. Every situation varies and it is recommended
you consult a tax advisor for all tax advice.
*A full list of qualified expenses can be
*Varies, assumes 10.30%; found in IRS Publication 502 at www.irs.gov.
**Varies, assumes 3.68%

OVER-THE-COUNTER (OTC) MEDICATION IMPORTANT: PAYING FOR

ELIGIBLE SERVICES &
REMINDER EXPENSES
Effective for purchases on or after January 1, 2020, thousands of items, Visit the FSA Store at www.FSAstore.com,
including pain relievers, cold and flu medications, antacids, acne where you can purchase FSA-eligible
remedies, and allergy medicines are now reimbursable from an FSA, products without a prescription online.
Section 213 HRA or HSA without a prescription. In addition to Although you do not need to file for reimbursement
eliminating the prescription requirement on OTC drugs and medicine, when using your FSA debit card, you may be
the CARES Act has added hundreds of menstrual products to the list of required to submit documentation, so be sure to
approved expenses. save your receipts.

If you use a personal form of payment to pay for

Certain items may still require a “prescription” in order to be considered eligible expenses out-of-pocket, you can submit
an eligible Health Care FSA expense. an FSA claim form along with your original
receipts for reimbursement.
A full list of qualified expenses can be found in IRS publication 502 at
www.irs.gov

13 | BENEFITS GUIDE
 KINDBODY
FERTILITY BENEFITS

Say Hi to Your New Family Planning Benefit!

Meet Kindbody, we are your modern-day fertility and family planning provider helping you understand and take
control of your family planning and future. Kindbody’s mission is to make access to fertility and family-building
services more accessible to individuals, couples, LGBTQ+ people. We’re reimagining family planning to put the
power back in your hands.

Your Kindbody benefit gives you coverage on gynecology, fertility, and family-building services - from
preconception through postpartum.
Who is eligible?
Kindbody is available to all Rivian benefit eligible US employees!

Your Kindbody benefit through Rivian includes:

• 2 Fertility Cycle Coverage including fertility medication
• Network of partner clinics in locations where you work and live
• A dedicated Care Navigation Team available to guide you through your journey
• End-to-end fertility services from standard gynecological care to conception, nutrition & mental wellness in
reimagined clinics.
• 5 virtual coaching sessions covered to support prepartum to postpartum coaching.
• A first-of-its-kind personalized patient portal giving you convenient and transparent around-the- clock
visibility.
• Rivian is also providing an additional benefit for adoption, donor and surrogacy expenses up to a lifetime
maximum of $10,000.

Surrogacy and Adoption:

• This benefit is separate and apart from medical services included in the fertility and family planning benefit
and does not apply to any of the medical complements included in the ART cycle.
• All medical services for the covered employee or spouse would fall under the fertility bundle benefits, and
in this case, count towards your eligible cycle. All Cycles can be used with donor eggs, embryos, and/or
sperm when applicable.
• All Cycles apply to both Kindbody clinics and partner clinics and include PGT testing when applicable.

How can I enroll?

Step 1: Head over to http://kindbody.com/rivianbenefits to get started
Step 2: Sign up with your name and any email
Step 3: Confirm eligibility by entering your unique ID* (this is your Rivian email, less ‘@Rivian.com’) and
access code (case sensitive) – choose one of the below:
• If you elected to participate in a Medical plan without a HSA component or if you opted out of Medical
coverage or have coverage elsewhere use access code: KINDRIVIAN
• If you elected to participate in a Medical plan with a HSA component use access code:KINDRIVIANHSA
• Spouses/partners to use the unique ID of primary benefit holder (Rivian employee)

Have questions? We’ve got your answers.

Email us at employeebenefits@kindbody.com or call 844-956-1655
14 | BENEFITS GUIDE
 CORE DENTAL PLAN
COVERAGE OVERVIEW

You have the freedom to select the dentist of your choice; however when you visit a
participating in-network dentist, you will have lower out-of-pocket costs, no balance billing,
COMMON TERMS and claims will be submitted by your dentist on your behalf.

PPO Network Premier Network Out-of-Network

PRE-TREATMENT ESTIMATE
If your dental care is extensive and PLAN FEATURES
you want to plan ahead for the cost, Dentists who do not
you can ask your dentist to submit a Network Details PPO Dentists Premier Dentists participate in either
pre-treatment estimate. While it is not network.
a guarantee of payment, a pre- Benefit Period Calendar Year
treatment estimate can help you
DEDUCTIBLE
predict your out-of-pocket costs.
Single $50
DUAL COVERAGE Two Person $100
You might have benefits from more Family $150
than one dental plan, which is called When receiving Basic or Major services
When does it apply?
dual coverage. In this situation, the (Does not apply for Preventive services)
total amount paid by both plans can’t COVERED SERVICES
exceed 100% of your dental expenses.
CLASS I: Preventive Services
And in some cases, depending on the Covered at 100%
Routine oral exams and Covered at
specifics of the plans, your coverage Covered at 100% With possible balance
cleanings, x-rays (bitewing), 100%
may not total 100%. billing
sealants & fluoride treatments
CLASS II: Basic Services
LIMITATIONS AND EXCLUSIONS
Periodontics (surgical & non-
Dental plans are intended to cover part Covered at 80%
surgical), endodontics (root Covered at
of your dental expenses, so coverage Covered at 80% With possible balance
canals), oral surgery, prosthetic 80%
may not extend to your every dental billing
maintenance & x-rays (full
need. A typical plan has limitations
mouth)
such as the number of times you can
receive a cleaning each year. In CLASS III: Major Services Covered at 50%
addition, some procedures may be not Prosthodontics, crowns, Covered at With possible balance
Covered at 50%
be covered under your plan, which is inlays/onlays, dentures, 50% billing
referred to as an exclusion. implants & bridges
CLASS IV: Orthodontia
Services Covered at 50%
(for dependent children up to Up to $1,000 once per lifetime
age 19)
ANNUAL MAXIMUM
Maximum Benefit
$1,000 per covered individual
Allowed per Benefit Period
PREVENTION FIRST!
EMPLOYEE CONTRIBUTIONS (Based on 26 pay periods)
Your dental health is an important part of
your overall health. Make sure you take Single $0.00
advantage of your preventive dental Two Person $14.91
visits. Family $45.17
Preventive care services are covered at
100% if you visit an In-Network provider.
They are also not subject to the annual How do I find an In-Network Provider?
deductible.
This dental plan offers deeper discounts when you visit a provider that is In-
Network. In-Network providers can be found on www.deltadentalmi.com under
“Find a Dentist”. Choose the network based on the plan type you are choosing.

15 | BENEFITS GUIDE
 BUY-UP DENTAL PLAN
COVERAGE OVERVIEW

You have the freedom to select the dentist of your choice; however when you visit a
participating in-network dentist, you will have lower out-of-pocket costs, no balance
COMMON TERMS billing, and claims will be submitted by your dentist on your behalf.

PRE-TREATMENT ESTIMATE PPO Network Premier Network Out-of-Network

If your dental care is extensive and PLAN FEATURES
you want to plan ahead for the cost,
you can ask your dentist to submit a Dentists who do not
pre-treatment estimate. While it is not Network Details PPO Dentists Premier Dentists participate in either
a guarantee of payment, a pre- network.
treatment estimate can help you Benefit Period Calendar Year
predict your out-of-pocket costs. DEDUCTIBLE
Single $50
DUAL COVERAGE Two Person $100
You might have benefits from more Family $150
than one dental plan, which is called
When receiving Basic or Major services
dual coverage. In this situation, the When does it apply?
(Does not apply for Preventive services)
total amount paid by both plans can’t
exceed 100% of your dental expenses. COVERED SERVICES
And in some cases, depending on the CLASS I: Preventive Services
specifics of the plans, your coverage Covered at 100%
Routine oral exams and Covered at
may not total 100%. Covered at 100% With possible balance
cleanings, x-rays (bitewing), 100%
billing
sealants & fluoride treatments
LIMITATIONS AND EXCLUSIONS CLASS II: Basic Services
Dental plans are intended to cover part Periodontics (surgical & non-
of your dental expenses, so coverage Covered at 90%
surgical), endodontics (root Covered at
may not extend to your every dental Covered at 90% With possible balance
canals), oral surgery, prosthetic 90%
need. A typical plan has limitations billing
maintenance & x-rays (full
such as the number of times you can mouth)
receive a cleaning each year. In
CLASS III: Major Services Covered at 60%
addition, some procedures may be not
Prosthodontics, crowns, Covered at With possible balance
be covered under your plan, which is Covered at 60%
inlays/onlays, 60% billing
referred to as an exclusion.
dentures, implants & bridges
CLASS IV: Orthodontia
Services Covered at 50%
(for dependent children up to Up to $1,500 once per lifetime
age 19)
ANNUAL MAXIMUM
Maximum Benefit
PREVENTION FIRST! Allowed per Benefit Period
$2,000 per covered individual

Your dental health is an important part of EMPLOYEE CONTRIBUTIONS (Based on 26 pay periods)
your overall health. Make sure you take
advantage of your preventive dental Single $3.57
visits. Two Person $21.67
Family $57.37
Preventive care services are covered at
100% if you visit an In-Network provider.
They are also not subject to the annual How do I find an In-Network Provider?
deductible.
This dental plan offers deeper discounts when you visit a provider that is In-
Network. In-Network providers can be found on www.deltadentalmi.com
under “Find a Dentist”. Choose the network based on the plan type you are
choosing.

16 | BENEFITS GUIDE
 CORE EYEMED VISION PLAN
COVERAGE OVERVIEW

Under this plan, you may use the eye care professional of your choice. However, when you visit a participating in-network provider, you
receive higher levels of coverage.
• If you choose a PLUS provider, you get the highest level of benefit
• If you choose to receive services from an out-of-network provider, you will be required to pay that provider at the time of service and
submit a claim form for reimbursement
IN-NETWORK OUT-OF-NETWORK
PROVIDER PROVIDER
PLAN FEATURES
Vision Exam $5 copay Up to $40
COVERED SERVICES - LENSES
Single Lenses $10 copay Up to $30
Bifocals $10 copay Up to $50
Trifocals $10 copay Up to $70
$130 retail allowance; 20% off balance over
Frames Up to $91
$130
COVERED SERVICES
$130 retail allowance; 15% off balance over $130
Contact Lenses for conventional contacts; no additional discount Up to $91
on disposable contacts
Contacts – Medically Necessary $0; Covered in full Up to $210

BENEFIT FREQUENCY
Exam Once every 12 Months Once every 12 Months
Lenses Once every 12 Months Once every 12 Months
Frames Once every 12 Months Once every 12 Months
Contacts Once every 12 Months Once every 12 Months
EMPLOYEE CONTRIBUTIONS (Based on 26 pay periods)
Employee Only $0.00
Employee + Spouse $1.84
Employee + Child(ren) $4.04
Family $5.15

Did you know your eyes Savings for EyeMed Vision Care Members:
can tell an eye care
• 40% off additional pairs of glasses and a 15%
provider a lot about you?
discount on conventional lenses once funded
benefit is used
In addition to eye disease, a routine eye exam can
help detect signs of serious health conditions like • 20% off any item not covered by the plan,
diabetes and high cholesterol. This is important, since including non-prescription sunglasses
you won’t always notice the symptoms yourself and
since some of these diseases cause early and • 15% off retail price or 5% off promotional price
irreversible damage. for Lasik or PRK from US Laser Network

17 | BENEFITS GUIDE
 CORE VSP VISION PLAN
COVERAGE OVERVIEW

Under this plan, you may use the eye care professional of your choice. However, when you visit a participating in-network
provider, you receive higher levels of coverage.
• For the most out of your coverage, see a VSP Choice Network Provider
• If you choose to receive services from an out-of-network provider, you will be required to pay that provider at the time of
service and submit a claim form for reimbursement

IN-NETWORK OUT-OF-NETWORK
PROVIDER PROVIDER
PLAN FEATURES
Vision Exam $5 copay Up to $45
COVERED SERVICES - LENSES
Single Lenses $10 copay Up to $30
Bifocals $10 copay Up to $50
Trifocals $10 copay Up to $65
$130 retail allowance; 20% off balance over
Frames Up to $70
$130
COVERED SERVICES
Contact Lenses $130 retail allowance Up to $105

Contacts – Medically Necessary $10 materials copay; Covered in full after copay Up to $210

BENEFIT FREQUENCY
Exams Once every 12 Months Once every 12 Months
Lenses Once every 12 Months Once every 12 Months
Frames Once every 12 Months Once every 12 Months
Contacts Once every 12 Months Once every 12 Months
EMPLOYEE CONTRIBUTIONS (Based on 26 pay periods)
Employee Only $1.66
Employee + Spouse $5.15
Employee + Child(ren) $5.64
Family $10.11

VSP Membership has many perks including: LASIK & Hearing Savings:
• Save 20% on ready-made blue light glasses • 25% off Custom LASIK & Custom PRK at
The Lasik Vision Institute
• Get an extra $20 on featured frame brands
• 20% off LASIK at TLC Laser Eye Centers
• Save 20% on additional pairs of glasses
• Save up to 60% on Top of the line Hearing
• Bausch + Lomb contact discounts and rebates Aids from TruHearing

• Extra savings on a variety of lens types • Save on hearing aid batteries from
TruHearing
• Visit vsp.com/offers for more information

18 | BENEFITS GUIDE
 BUY-UP EYEMED VISION PLAN
COVERAGE OVERVIEW

Under this plan, you may use the eye care professional of your choice. However, when you visit a participating in-network provider,
you receive higher levels of coverage.
• If you choose a PLUS provider, you get the highest level of benefit
• If you choose to receive services from an out-of-network provider, you will be required to pay that provider at the time of service
and submit a claim form for reimbursement

IN-NETWORK OUT-OF-NETWORK
PROVIDER PROVIDER
PLAN FEATURES
Vision Exam $0 copay Up to $40
COVERED SERVICES - LENSES
Single Lenses $0 copay Up to $30
Bifocals $0 copay Up to $50
Trifocals $0 copay Up to $70
$200 retail allowance; 20% off balance
Frames Up to $140
over $200
COVERED SERVICES
$200 retail allowance; 15% off balance over
Contact Lenses $200 for conventional contacts; no additional Up to $140
discount on disposable contacts
Contacts – Medically Necessary $0; Covered in full Up to $210

BENEFIT FREQUENCY
Exam Once every 12 Months Once every 12 Months
Lenses Once every 12 Months Once every 12 Months
Frames Once every 12 Months Once every 12 Months
Contacts Once every 12 Months Once every 12 Months
EMPLOYEE CONTRIBUTIONS (Based on 26 pay periods)
Employee Only $2.70
Employee + Spouse $7.25
Employee + Child(ren) $12.69
Family $15.42

Need to locate a Additional perks for EyeMed Vision Care

participating In-Network Members:
provider??
• Hearing Care – 40% off hearing exams and
• Go to www.eyemed.com and click on ‘Find a low price guarantee on discounted
an eye doctor’ hearing aids through Amplifon Hearing
• Search by location or Doctor under the Health Care Network
‘Insight Network’

19 | BENEFITS GUIDE
 BUY-UP VSP VISION PLAN
COVERAGE OVERVIEW

Under this plan, you may use the eye care professional of your choice. However, when you visit a participating in-network provider,
you receive higher levels of coverage.
• For the most out of your coverage, see a VSP Choice Network Provider
• If you choose to receive services from an out-of-network provider, you will be required to pay that provider at the time
of service and submit a claim form for reimbursement
• The VSP Buy-Up plan includes ‘Easy Options’ which allows each patient to choose one of four items: a higher frame
allowance, progressive lenses covered in full, anti-reflective coating covered in full or a higher elective contact lenses
allowance.
IN-NETWORK OUT-OF-NETWORK
PROVIDER PROVIDER
PLAN FEATURES
Vision Exam $0 copay Up to $40
COVERED SERVICES - LENSES
Single Lenses $0 copay Up to $30
Bifocals $0 copay Up to $50
Trifocals $0 copay Up to $70
$150 retail allowance for a wide selection of
frames or $250 with Easy Options
allowance; $200 retail allowance for featured
Frames Up to $140
frame brands or $300 with Easy Options
allowance; 20% off balance over your
allowance
COVERED SERVICES
$150 retail allowance or $200 with Easy
Contact Lenses Up to $140
Options allowance
Contacts – Medically Necessary $0; Covered in full Up to $210

BENEFIT FREQUENCY
Exams Once every 12 Months Once every 12 Months
Lenses Once every 12 Months Once every 12 Months
Frames Once every 12 Months Once every 12 Months
Contacts Once every 12 Months Once every 12 Months
EMPLOYEE CONTRIBUTIONS (Based on 26 pay periods)
Employee Only $4.72
Employee + Spouse $11.28
Employee + Child(ren) $12.19
Family $20.58

Need to locate a participating In-Network provider??

• Go to vsp.com/eye-doctor
• To ensure you see an in-network eye Doctor, create a VSP member
account or login to your account
• Search by location, office or Doctor under the ‘Choice Network’
• You can filter for specific services or products as well

20 | BENEFITS GUIDE
 BASIC LIFE
COVERAGE OVERVIEW

COMPANY PAID BASIC LIFE INSURANCE

BENEFICIARY(IES)
A Beneficiary is the person you Life insurance is an important part of your financial security. Life
designate to receive your life insurance insurance helps protect your family from financial risk and sudden
benefits in the event of your death. It is loss of income in the event of your death. AD&D insurance is equal
important that your beneficiary to your Life benefit in the event of your death being a result of an
designation is clear so there is no accident and may also pay benefits for certain injuries sustained.
question as to your intentions.

It’s very important to designate CORE Company Paid Benefit:

beneficiaries. Taking a few minutes to
designate your beneficiaries now will
LIFE/AD&D Provided to you at no cost
help ensure that your assets will be
distributed according to your
Coverage Amount 1 times Salary to $500,000
direction.

It is also important that you name a Accidental Death

Primary and Contingent Beneficiary. A and
contingent beneficiary will receive the Amount equal to your Life benefit
Dismemberment
benefits of your life insurance if the (AD&D)
primary beneficiary cannot. You can
change beneficiaries at any time.
Your insurance will reduce to:
Benefit Reduction
 65% of the original amount at age 65
Schedule
 50% of the original amount at age 70
You should review your beneficiary
elections on a regular basis to
ensure they are updated as life ADDITIONAL PLAN PROVISIONS
changes. Even if you are single, your
If your employment ends or you retire,
beneficiary can use your Life
Portability you may be eligible to continue your
Insurance to pay off your debts, such
term insurance at group rates.
as: credit cards, mortgages, and
other expenses.
When coverage ends under the plan, you
*You designate your beneficiary(ies) when Conversion can convert to an individual permanent life
enrolling for your benefits.
policy without evidence of insurability.

WHAT WILL MY BENEFICIARY RECEIVE?

In The Event That Death Occurs:
– Your Basic Life insurance is paid to your beneficiary
– If death occurs from an accident: 100% of the AD&D benefit would be payable to
your beneficiary(ies) in addition to your Basic Life insurance

21 | BENEFITS GUIDE
 SUPPLEMENTAL LIFE
COVERAGE OPTIONS FOR YOU & THE FAMILY

Employees have the opportunity to enroll in Supplemental Life insurance. If you choose to enroll in employee
coverage, this will be in addition to your employer provided Basic Life coverage.

• Coverage is also available for your spouse and/or child dependents

• You must elect coverage for yourself in order to be eligible for coverage on your dependents

OPTIONAL LIFE/AD&D Voluntary Benefit - Employee is responsible for 100% of the cost

Premiums are based on age-rated tables and paid by the employee every
Cost of Coverage pay period through a payroll deduction. These premiums are post-tax benefits, so you will
receive the maximum benefit of the plan.

Coverage Options Employee Coverage Spouse Coverage Dependent Coverage

Choose in $10,000 Choose in $10,000 Choose in $2,500 increments
increments up to the lesser of increments up to 100% of the up to $25,000
5x your annual salary or amount you elect for yourself
$500,000 to a max of $250,000

Do I have to take a If you and your dependents enroll in coverage at your initial eligibility date,
health exam to get you may increase one increment of coverage at Open Enrollment without proof of good health
coverage? (EOI). Late entrants and any amount over the Guaranteed Issue amount require EOI.

Employee Spouse Dependent

Guaranteed Issue $350,000 $50,000 $25,000

ADDITIONAL PLAN PROVISIONS

Cost Calculation Age Rated Benefit (Spouse Life based on employee's age)

Employee Coverage Will Reduce To: Spouse Coverage Will Reduce By:
Benefit Reduction
– 65% of the original amount at age 65 The same amount and at the same time
Schedule
– 50% of the original amount at age 70 your coverage reduces

If your employment ends or you retire, you may be eligible to

Portability
continue your term insurance at group rates.

When coverage ends under the plan, you can convert to an

Conversion
individual permanent life policy without evidence of insurability.

*Guaranteed Issue (GI) and Evidence of Insurability (EOI)

When you are first eligible (at hire) for Voluntary Life and AD&D, you may purchase up to $350,000 Guaranteed Issue
(GI) for yourself and up to $50,000 for your spouse without providing proof of good health (EOI). At Open Enrollment,
employees can increase one increment of coverage with no EOI.
Any amount elected over the GI will require EOI. If you elect optional life coverage, and are required to complete an EOI,
it is your responsibility to complete the EOI and submit it to Human Resources within 30 days of your election.
Employees who request coverage at a later date are subject to EOI.
In addition, your spouse will need to provide EOI to be eligible for coverage amounts over GI, or if coverage is requested
at a later date.

22 | BENEFITS GUIDE
 LONG TERM DISABILITY INSURANCE
FEATURES

Serious illnesses or accidents can come out of nowhere. They can interrupt your life, and your
ability to work for months – even years. Long Term Disability provides financial protection for
you by paying a portion of your income, so you have financial support to manage your disability
and your household.
Now you can further increase your income protection with the Voluntary Buy-Up Plan which
provides an additional 10% of covered monthly benefit tax-free if you choose to enroll.

PLAN FEATURES CORE LONGTERM DISABILITY (LTD) VOLUNTARY LTD BUY-UP OPTION

Core LTD Benefit is a company paid Voluntary Buy-Up Benefit is employee

Cost of Coverage
benefit paid

Covers 60% of your monthly

Covers 70% of your monthly
income,
Coverage Amount income, up to a maximum benefit of
up to a maximum benefit of
$10,000 per month.
$10,000 per month.
Elimination Period
This is the number of days that must pass
between your first day of a covered disability Your elimination period is 90 days
& the day you can begin to receive your
disability benefits.

Payments will last for as long as you are disabled,

Benefit Duration or until you reach Retirement Age (age 65),
The maximum number of weeks whichever is sooner
you can receive benefits while You must be sick or disabled for the duration
you are sick or disabled. of the elimination period before you can
receive a benefit payment.

A variety of conditions and injuries.

What's covered? Typical claims would include: cancer, back disorders, injuries and poison,
cardiovascular, joint disorders.

Base Salary
Definition of Earnings
(excludes commissions and bonuses)

ADDITIONAL PLAN PROVISIONS

Monthly benefit may be reduced

Benefit Payment Frequency
or offset by other sources of income.

Cost Calculation Covered by Employer $0.221 per $100 of covered payroll

If you're disabled and receiving benefit payments, the employer paid LTD premium cost
Waiver of Premium
may be waived until you return to work.

You have a pre-existing condition if you have received: medical treatment,

consultation, care or services including diagnostic measures for the condition, or took
Pre-Existing Condition Limitation prescribed drugs or medicines for it in the 3 months just prior to your effective date of
coverage; and the disability begins in the first 12 months after your effective date of
coverage.
Certain exclusions and any pre-existing condition limitations may apply.
Please refer to the Providers detailed benefit summary for details.

23 | BENEFITS GUIDE
 SHORT TERM DISABILITY INSURANCE
FEATURES

Everyday illnesses or injuries can interfere with your ability to work. Even a few weeks away from
work can make it difficult to manage household costs.

Short Term Disability coverage provides financial protection for you by paying a portion of your
income, so you can focus on getting better and worry less about keeping up with your bills.

PLAN FEATURES SHORT-TERM DISABILITY (STD)

Company Paid Benefit

Cost of Coverage
Provided to you at no cost

Who is Eligible All salary paid employees All hourly paid employees

Elimination Period
This is the number of days that must pass between your Benefits begin on the
first day of a covered disability & the day you can begin 1st day of an accident / 8th day after an illness
to receive your disability benefits.

Benefit Duration Payments may last up to 12 weeks Payments may last up to 13 weeks
The maximum number of weeks You must be sick or disabled for the duration You must be sick or disabled for the duration
you can receive benefits while of the waiting period before you can of the waiting period before you can
you are sick or disabled. receive a benefit payment. receive a benefit payment.

Covers 70% of your weekly pay up to

Coverage Amount Covers 100% of your weekly pay
$1,650

A variety of conditions and injuries.

What's covered?
Typical claims would include: pregnancy, injuries, joint, back and digestive disorders.

Base Salary
Definition of Earnings
(excludes commissions and bonuses)

ADDITIONAL PLAN PROVISIONS

Weekly benefit may be reduced

Benefit Payment Frequency
or offset by other sources of income.
Certain exclusions and any pre-existing condition limitations may apply.
Please refer to the Providers detailed benefit summary for details.

24 | BENEFITS GUIDE
 MENTAL HEALTH & WELL-BEING
MODERN HEALTH | SIBLY

Modern Health is your mental wellness platform Sibly. Someone to talk to

that provides access to personalized 1:1, group,
and self-serve resources for your wellbeing. Sibly is dedicated to helping everyone handle their
feelings and cope with life’s daily challenges.
Modern Health makes it simple for you and your family to
Through Sibly’s secure app, you text back and forth
get support in the areas that matter to you, in a way that
works best for you. Once you answer a few questions
with a specifically trained coach who will listen, ask
about your well-being and your preferences for type of questions and help you think things through. These
care, Modern Health will develop a personalized care plan are live text chat conversations with real human
for you. beings.

At no cost, employees & their family members have At no cost, U.S. employees & family members (age 18 &
access to: up) have access to:
• 8 one-on-one video sessions (per year) with certified mental • Empathetic coaching
health, professional or financial well-being coaches • Easy-to-use texting
• 8 one-on-one video or in-person sessions (per year) with licensed • Helpful, personal conversations - no limit on number of texts
clinical therapists
• Carefully selected, rigorously trained human coaches
• Unlimited group support sessions (known as Circles), designed to
be safe spaces for sharing & learning with others • Available 24/7 – no appointments
• A library of self-serve resources, including guided meditations and • No cost to you & private and confidential – all family members are
digital courses on managing stress related to COVID, encouraged to sign up with their own account
management, resilience, parenting, sleep, building health habits,
communication, and more. Sibly is designed to help sort a wide range of issues
• Ongoing well-being assessments to check-in on your well-being causing mild to moderate distress including, but not
over time limited to, issues like the following:
What can Modern Health help you with? • Relationships & Conflict
• Stress & Anxiety • Mood & Mind
• Relationships & Work Performance • Emotions & Habits
• Mindfulness & Meditation • Life Changes & Well-Being
• Inclusion & Belonging
• Work Changes
• Financial Wellbeing

To sign up, download the

Getting started with Modern Health app from your mobile
• Use the QR code to download the device app store.
Modern Health app on your mobile Use access code: Rivian21
device, or go to my.modernhealth.com
• Sign up with your work email and
‘Rivian’ as your company name
• Once you register, invite family
members to join by choosing “invite
Dependents” in the Settings section

If you have trouble registering for Modern Health, please don’t hesitate to
In the unlikely event you experience a technical difficulty with the app, email
reach out to help@modernhealth.com with a note or screen shot.
care@sibly.com for help desk support

Note: Similar to your other health benefits, while Rivian provides both of these resources, they are completely confidential.

25 | BENEFITS GUIDE
 MENTAL HEALTH & WELL-BEING
HEADSPACE | UNUM EMPLOYEE ASSISTANCE PROGRAM | THORNE

Rivian offers an Employee Assistance

Ready for some calm? Meet headspace.
Program (EAP) through UNUM’s Personal
Headspace is a mindfulness and meditation app that Advantage EAP at no charge to all
helps you achieve a clearer and calmer mind, making employees
your day a little lighter, your focus a little sharper and Stressful situations can affect your health, wellbeing and
showing up as your best self a little easier. ability to focus on what’s important. EAP Services are
available to all employees, their spouses or domestic partners,
Rivian has partnered with Headspace to offer our
dependent children, parents & parents-in-law
employees a free subscription!
Confidential EAP services provide:
• To get started: -Unlimited access to professional consultants by telephone 24/7
• Go to work.headspace.com/Rivian/member-enroll -Online tools and resources
• All you need is your Rivian email address -Up to 3 face-to-face visits with a consultant for help with a short-term
problem
Frequently Asked Questions:
Help for personal challenges, big and small, including:
• How do I merge my personal headspace account with my
-Stress, depression, anxiety
company’s membership? -Anger, grief, loss
• Go to https://work.headspace.com/Rivian/member-enroll – -Personal or work relationships
create a personal headspace account if you don’t have one -Family and parenting problems
already or login to your pre-existing headspace account You’ll have unlimited online access to
• Verify your eligibility for the headspace plus membership by
https://www.unum.com/employees/services/life-balance
inputting your Rivian email address
where you can:
• Now that I’ve enrolled, how do I gain access to my
Headspace Plus membership? -Use financial calculators, retirement planners, worksheets and more
• Complete enrollment, download the headspace app from -Use health management online calculators and other healthy living tools
the App Store or Google Play and login to the headspace -Listen to podcasts, watch videos and online seminars
app with the new or pre-existing personal headspace -Locate schools, camps, eldercare and childcare facilities
account you merged with Rivian’s membership upon 24/7 Toll-free access at 1.800.854.1446
enrollment
• If I was a paid headspace member before, do I receive a
refund for my membership?
• Please review the below scenarios and contact
teamsupport@headspace.com with any additional Thorne Health Tech is the premier company in the nutritional
questions: supplement industry.
• If you purchased a headspace plus subscription on They are trusted by the Mayo Clinic, CrossFit, UFC, 11 different U.S.
headspace.com within 30 days, you can contact headspace Olympic teams, all 4 major sports leagues, and health-care practitioners
for a refund around the world to provide unparalleled support for your health and
• If you purchased your headspace subscription via the wellness.
Google Play Store and you wish to submit a refund request, 35% off Supplements
contact Headspace for a refund 1. Go to https://www.thorne.com/u/rivian
• If you purchased your headspace subscription via iTunes or 2. Create an account. Confirm Rivian is populated in the How were
you referred to Thorne? field.
Spotify, you must contact them directly with questions or
3. Shop for products. The discounts will show in your shopping cart.
refund requests
• If you made an annual purchase more than 30 days ago,
please contact teamsupport@headspace.com. We can
provide you a complimentary 1-year voucher to share with a
friend or family member.

26 | BENEFITS GUIDE
 VOLUNTARY BENEFITS
IDENTITY THEFT PROTECTION | LEGAL ADVICE

IDShield Plan Highlights LegalShield Plan Highlights

360 Degree Protection Direct Access to a dedicated provider law firm
IDShield monitors your identity, credit, financial You will receive unlimited legal consultation and
accounts, social media accounts, and provides online advice on personal legal matters, 100% of matters are
privacy reputation management services. covered in-network and your provider firm is even
available for emergency situations.
Real-Time Alerts
• If a threat is detected to your identity or credit you will Document Review and Preparation
receive an alert • An attorney can help you review and prepare common
• You can view your alerts on the IDShield mobile app, legal documents for Wills, Trusts, and more
member portal and receive them by email Court Representation
Full-Service Restoration and Unlimited Consultation • You will receive representation for legal matters such
• If your identity is stolen IDShield provides you direct as traffic tickets and even house closings
access to a dedicated Licensed Private Investigator, Letters and Phone Calls
who will restore your identity to its pre-theft status,
• Letters and phone calls can be made on your behalf to
guaranteed
resolve legal maters such as warranty disputes or a
• You can also talk to an identity theft specialist about any dispute with a creditor
identity theft or online privacy concerns, in the event of
Speeding Ticket Assistance
an emergency, IDShield provides 24/7 emergency
assistance • Your provider law firm will review your speeding ticket
and even attend court on your behalf if required. You
Financial Protection
can easily upload your ticket using the LegalShield
• Financial account monitoring and a $1 Million Identity mobile app
Fraud Protection Plan for unauthorized electronic fund
transfers and identity theft related expenses

IDShield Mobile App Features LegalShield Mobile App Features

The IDShield mobile app makes it easy for you to protect • Direct access to a dedicated law firm
your identity and privacy. App features include:
• Begin the process to have your will prepared
• Identity threat & credit inquiry alerts
• Speeding ticket review
• Credit score tracker – updated monthly
• Access legal forms
Sign up today through this link: benefits.legalshield.com/rivian

27 | BENEFITS GUIDE
 VALUE ADDED BENEFITS
VOLUNTARY PET INSURANCE | TRAVEL ASSISTANCE | KINSIDE

NATIONWIDE PET PROTECTION TRAVEL ASSISTANCE SERVICES

GET CASH BACK ON ELIGIBLE VET BILLS If you experienced a medical emergency while traveling,
who would you know to call?
How does it work?
• Choose from three levels of reimbursement: 90%, Whenever you travel 100 miles or more from home – to another
70% or 50% country or just another city – be sure to pack your worldwide
emergency travel assistance phone number. Add the number to your
• Use at any vet, no networks or pre-approval contacts so its always close.
required
• Covered services include: Use your travel assistance phone number to access:
• Accidents including poisonings & allergic • Hospital admission assistance*
reactions • Emergency medical evacuation
• Hereditary congenital conditions • Prescription replacement assistance
• Transportation for a friend or family member to join a
• Surgeries & hospitalizations
hospitalized patient
• X-rays, MRIs & CT scans • Care and transport of unattended minor children
• Flea & tick prevention and more • Emergency message services
• Critical care monitoring
GET STARTED! • Legal and interpreter referrals
For a no obligation quote today go to: • Passport replacement assistance
https://benefits.petinsurance.com/rivian
24/7 Services Anywhere in the World
Unum’s travel assistance services are provided by Assist America, Inc.
Enjoy these extras when you protect your pet Assist America’s medically certified personnel are ready to help 24 hours
with a nationwide pet insurance policy: a day, 365 days a year, and can connect you with trained medical
providers anywhere in the world.
 Vet Helpline – unlimited 24/7 access to a
veterinary professional With the Assist America Mobile App, you can:
 Multiple pet discounts available • Call Assist America’s Operation Center from anywhere in the
world
 Mobile claim submission with the free VitusVet • Access pre-trip information & country guidelines
app • Search for local pharmacies (U.S only)
 Fast convenient electronic claim payments • Download a membership card
• Search for the nearest U.S. embassy
TO ENROLL YOUR BIRD, RABBIT, REPTILE
• Within the US: 1-800-872-1414
OR OTHER PET CALL 877.738.7874
• Outside the US: +1 609-986-1234
• Email: medservices@assistamerica.com

We’re pleased to have partnered with Kinside, the national trusted child care network!

Kinside connects you with open spots and discounts of up to 20% at daycares. Search Kinside using the criteria you care
about like current or future availability, COVID-19 precautions, budget, location and more. You can also view full safety
and inspection reports for any in-network daycare or preschool in the U.S.

• To get started: Visit kinside.com/parents and create an account with your Rivian email
Need help? Access Kinside concierge, your single point of contact in your childcare search. They can help you with
anything from scheduling tours to finding openings at options outside of their network.
• Email: concierge@kinside.com

28 | BENEFITS GUIDE
RIVIAN Automotive LLC 401(k) Plan
To begin contributing to the plan, you must be at least 18 year of age. You are eligible to participate in
the Plan on or after your first day of employment and can change your contributions and investment
allocations to the plan at any time.

Pretax deferrals
Pretax deferrals are contributed into the plan on a pretax basis. Unlike the compensation you actually receive,
pretax deferrals will not be taxed at the time they are paid by your employer. Instead, these deferrals and any
earnings accumulated while invested in the plan will be taxable to you when withdrawn from the plan. This will
reduce your taxable income for each year that you make a contribution. Through payroll deduction, you can
contribute from 1% up to 100% of your salary pretax as long as the amount does not exceed $19,500, which is
the maximum limit for 2021 set by the Internal Revenue Service (IRS).

Roth deferrals
Roth deferrals are contributed to the plan from amounts that have already been treated as taxable income. Roth
deferrals will not reduce your taxable income in the year in which you contribute a portion of your compensation
into the plan. You may contribute from 1% up to 100% of your salary as a Roth deferral as long as the total
amount, when combined with any pretax deferrals, does not exceed the IRS contribution limit of $19,500 for
2021. When Roth deferrals are withdrawn, distributions—including contributions and any earnings—are tax free
as long as certain requirements are met. In order to receive tax-free withdrawals, generally your money must
remain in the account for five years and you must have reached age 59½, die, or become disabled.

Catch-up contributions
If you are age 50 or older, you are entitled to contribute an additional “catch-up contribution” beyond the
maximum IRS limit of $19,500 for 2021. This is intended to help employees boost their savings prior to
retirement. The maximum catch-up contribution is $6,500 for 2021.

Employer matching contributions

Rivian will match 50% of your combined pre-tax and Roth contributions up to the first 4% of eligible earnings,
subject to applicable IRS limits. All employer match contributions vest immediately. The money that you
contribute from your salary and any rollover contributions are always 100% vested.

Rollovers
You are allowed to roll over money from other qualifying retirement accounts into this account. Please reach out
to the Benefits team at benefits@rivian.com to initiate the rollover process. There are important factors to
consider when rolling over assets from an IRA or an employer retirement plan account. These factors include,
but are not limited to, investment options in each type of account, fees and expenses, available services,
potential withdrawal penalties, protection from creditors and legal judgements, required minimum distributions,
and tax consequences of rolling over employer stock.

Log into the Vanguard portal through this link:

https://my.vanguardplan.com/vanguard/account/login

29 | BENEFITS GUIDE
RIVIAN PAYROLL CALENDAR
2021

30 | BENEFITS GUIDE
 IMPORTANT
CONTACT
INFORMATION
PROVIDER CONTACT INFORMATION

(313) 225-9000 – then press 2

Blue Cross Blue Shield of Michigan Medical Plans
www.bcbsm.com

(800) 464-4000 or TTY 711

Kaiser Permanente (800) 788-0616 (Spanish)
www.kaiserpermanente.org
(844) 956-1655
Kindbody
http://kindbody.com/rivianbenefits

(800) 524-0149
Delta Dental
www.deltadentalmi.com

(844) 225-3107
EyeMed Vision
www.eyemed.com

1.800.877.7195
VSP Vision Member Services
www.vsp.com

(800) 854-1446
UNUM
https://www.unum.com/employees/services/life-
Employee Assistance Plan (EAP)
balance

UNUM (800) 872-1414

Travel Assist www.unum.com

UNUM
(866) 679-3054
Life/STD & LTD
www.unum.com
Voluntary Supplemental Life & Disability Insurance

Health Savings Accounts (866) 346-5800

Blue Cross Blue Shield (BCBS) ENROLLEES www.healthequity.com

Health Savings Accounts (877) 761-3399

KAISER ENROLLEES Kp.org/healthpayment

Flexible Spending Account (866) 370.3040

Transit and Parking www.isolvedbenefitservices.com

(877) 662.7447
401(K) Plan https://my.vanguardplan.com/vanguard/account/l
ogin
Questions?

Please see the chart above for provider customer service phone numbers and website addresses.

If you need any other assistance, contact benefits@Rivian.com

31 | BENEFITS GUIDE
REQUIRED
NOTICES
& FEDERAL MANDATES

32 | BENEFITS GUIDE
REQUIRED IRS CODE SECTION 125

NOTICES
Premiums for medical, dental, vision insurance, and/or certain supplemental plans
and contributions to FSA accounts (Health Care and Dependent Care FSAs) are
deducted through a Cafeteria Plan established under Section 125 of the Internal
Revenue Code (IRC) and are pre-tax to the extent permitted. Under Section 125,
changes to an employee's pre-tax benefits can be made ONLY during the Open
Federal regulations require employers to provide Enrollment period unless the employee or qualified dependents experience a
qualifying event and the request to make a change is made within 30 days of the
certain notifications and disclosures to all eligible qualifying event.
employees. This section of your benefit guide is Under certain circumstances, employees may be allowed to make changes to benefit
dedicated to those disclosures for 01.01.2021- elections during the plan year, if the event affects the employee, spouse, or
dependent’s coverage eligibility. An “eligible” qualifying event is determined by the
12.31.2021. If you have any questions or concerns Internal Revenue Service (IRS) Code, Section 125. Any requested changes must be
please contact your plan administrator as follows: consistent with and on account of the qualifying event.

benefits@Rivian.com Examples Of Qualifying Events:

 Legal marital status (for example, marriage, divorce, legal separation,
annulment);
 Number of eligible dependents (for example, birth, death, adoption, placement
for adoption);
 Employment status (for example, strike or lockout, termination, commencement,
leave of absence, including those protected under the FMLA);
 Work schedule (for example, full-time, part-time);
FAMILY MEDICAL LEAVE ACT (FMLA)  Death of a spouse or child;
 Change in your child’s eligibility for benefits (reaching the age limit);
The Family and Medical Leave Act (FMLA) of 1993 was designed to provide  Change in your address or location that may affect the coverage for which you
eligible employees with up to 12 workweeks per year of job-protected leave are eligible;
to address critical personal and family matters. It is the policy of your  Significant change in coverage or cost in your, your spouse’s or child’s benefit
employer and its U.S. subsidiaries to provide eligible employees with a leave plans;
of absence in accordance with the provisions of FMLA.  A covered dependent’s status (that is, a family member becomes eligible or
ineligible for benefits under the Plan);
You are eligible for an FMLA leave of absence under this policy if you  Becoming eligible for Medicare or Medicaid; or
meet the following requirements:  Your coverage or the coverage of your Spouse or other eligible dependent under
 You have completed at least 12 months of employment (need not be a Medicaid plan or state Children’s Health Insurance Program (“CHIP”) is
consecutive, but employment prior to a continuous break in service of terminated as a result of loss of eligibility and you request coverage under this
seven or more years may not be counted). Plan no later than 60 days after the date the Medicaid or CHIP coverage
terminates; or
 You have worked at least 1,250 hours during the 12-month period  You, your spouse or other eligible dependent become eligible for a premium
immediately preceding the commencement of the requested leave. assistance subsidy in this Plan under a Medicaid plan or state CHIP (including
 You are employed at a work site where 50 or more employees are any waiver or demonstration project) and you request coverage under this Plan
employed by the Company within 75 miles of that work site (“eligible no later than 60 days after the date you are determined to be eligible for such
employees”). assistance.
To the extent permitted by law, leave taken pursuant to FMLA will run Qualifying Events, which ARE NOT available for a Health Care FSA program, if
concurrently with Workers’ Compensation, Short Term Disability, and all applicable:
other Company leave policies.
 Coverage by your spouse or other covered dependent permitted under the
The “break in service cap” doesn’t apply if it: spouse’s or covered dependent’s employer’s benefit plan due to a Change
 is attributable to fulfillment of National Guard or Reserve military service Event;
obligations; or  The availability of benefit options or coverage under any of the Benefit Programs
 is addressed in a written agreement, including a collective bargaining under the Plan (for example, an HMO is added to or deleted from the Medical
agreement, that expresses the employer’s intent to rehire the employee Program);
after the break in service, such as a break to pursue education or raise  An election made by your spouse or other covered dependent during an open
children. enrollment period under your spouse’s or other covered dependent’s employer’s
benefit plan that relates to a period that is different from the Plan Year for this
Procedure for Applying for FMLA Leave Plan (for example, your spouse’s open enrollment period is in July and your
spouse changes coverage); or
If you desire and require an FMLA leave of absence under this policy, you  The cost of coverage during the Plan Year, but only if it is a significant increase
must notify your manager and your Human Resources Department and call or decrease.
your FMLA Administrator at least 30 calendar days in advance of the start of Available for Dependent Care FSA Only, If applicable:
the leave when the need for such leave is reasonably foreseeable (as in the
 Your dependent care provider or cost of dependent care (a significant increase
case of a birth, the placement for adoption of a son or daughter, or a planned
or decrease).
medical treatment for a serious health condition).
Additional Change Events For Health Care Options:
However, if the date of the birth, placement, or planned medical treatment In addition to the above Change Events, you may also change elections for the
requires leave to begin in less than 30 calendar days, you must provide such Medical, Dental, Vision and Health Care FSA Programs if:
notice to the aforementioned parties as soon as it is both possible and
practicable. Failure to provide timely notice may result in a delay or denial of  You, your spouse, or other covered dependent become eligible for continuation
FMLA leave. coverage under COBRA or USERRA;
 A judgment, decree, or order resulting from a divorce, legal separation,
annulment, or change in legal custody (including a Qualified Medical Child
Support Order), is entered by a court of competent jurisdiction that requires
accident or health coverage for your child;
 You, your spouse, or other covered dependent become enrolled under Part A,
Part B, or Part D of Medicare or under Medicaid (other than coverage solely with
respect to the distribution of pediatric vaccines); or
 You, your spouse, or other covered dependent become eligible for a Special
Enrollment Period.

33 | BENEFITS GUIDE
REQUIRED NOTICES

HEALTH COVERAGE REMINDER MICHELLE’S LAW NOTICE

The Patient Protection and Affordable Care Act (PPACA) requires most The health plan may extend medical coverage for dependent children if they
individuals to have minimum essential health coverage or pay a penalty. You lose eligibility for coverage because of a medically necessary leave of
may obtain coverage through your employer or through the Marketplace. absence from school. Coverage may continue for up to a year, unless your
 Depending on your income and the coverage offered by your employer, child’s eligibility would end earlier for another reason.
you may be able to obtain lower cost private insurance in the Marketplace. Extended coverage is available if a child’s leave of absence from school — or
 If you buy insurance through the Marketplace, you may lose any change in school enrollment status (for example, switching from full-time to
employer contribution to your health benefits. part-time status) — starts while the child has a serious illness or injury, is
medically necessary, and otherwise causes eligibility for student coverage
Visit www.healthcare.gov for Marketplace information.
under the plan to end. Written certification from the child’s physician stating
that the child suffers from a serious illness or injury and the leave of absence
WOMEN’S HEALTH & CANCER RIGHTS ACT is medically necessary may be required.

(WHCRA) If your child will lose eligibility for coverage because of a medically necessary
leave of absence from school and you want his or her coverage to be
In October 1998, Congress enacted the Women’s Health and Cancer Rights extended, contact your Human Resource Department as soon as the need for
Act of 1998. This notice explains some important provisions of the Act. the leave is recognized. In addition, contact your child’s health plan to see if
If you have had or are going to have a mastectomy, you may be entitled to any state laws requiring extended coverage may apply to his or her benefits.
certain benefits under the Women’s Health and Cancer Rights Act of 1998
(WHCRA). For individuals receiving mastectomy-related benefits, coverage will
be provided in a manner determined in consultation with the attending THE GENETIC INFORMATION NON-
physician and the patient, for: DISCRIMINATION ACT (GINA)
 All stages of reconstruction of the breast on which the mastectomy was Genetic Information Non-Discrimination Act (GINA) prohibits discrimination by
performed; health insurers and employers based on individuals' genetic information.
 Surgery and reconstruction of the other breast to produce a symmetrical Genetic information includes the results of genetic tests to determine whether
appearance; and someone is at increased risk of acquiring a condition in the future, as well as
 Prostheses and treatment of physical complications of the mastectomy, an individual's family medical history. GINA imposes the following restrictions:
including lymphedema. prohibits the use of genetic information in making employment decisions;
restricts the acquisition of genetic information by employers and others;
Health plans must determine the manner of coverage in consultation with the
imposes strict confidentiality requirements; and prohibits retaliation against
attending physician and the patient. Coverage for breast reconstruction and
individuals who oppose actions made unlawful by GINA or who participate in
related services may be subject to deductibles and coinsurance amounts that
proceedings to vindicate rights under the law or aid others in doing so.
are consistent with those that apply to other benefits under the plan.

NOTICE OF ELIGIBILITY FOR HEALTH PLANS

SPECIAL ENROLLMENT NOTICE RELATED TO MILITARY LEAVE
This notice is being provided to ensure that you understand your right to apply
for group health insurance coverage. You should read this notice even if you If you take a military leave, the Uniformed Services Employment and
plan to waive coverage at this time. Reemployment Rights Act (USERRA) provides the following rights:

Loss of Other Coverage or Becoming Eligible for Medicaid or a state  If you take a leave from your job to perform military service, you have the
Children’s Health Insurance Program (CHIP) right to elect to continue your existing employer-based health plan
coverage at your cost for you and your dependents for up to 24 months
If you are declining coverage for yourself or your dependents because of other during your military service; or
health insurance or group health plan coverage, you may be able to later enroll  If you don’t elect to continue coverage during your military service, you
yourself and your dependents in this plan if you or your dependents lose have the right to be reinstated in the Plan when you are reemployed within
eligibility for that other coverage (or if the employer stops contributing toward the time period specified by USERRA, without any additional waiting
your or your dependents’ other coverage). However, you must enroll within 31 period or exclusions (e.g., pre-existing condition exclusions) except for
days after your or your dependents’ other coverage ends (or after the service-connected illnesses or injuries.
employer that sponsors that coverage stops contributing toward the other
coverage). The Plan Administrator can provide you with information about how to elect
Continuation Coverage Under USERRA.
If you or your dependents lose eligibility under a Medicaid plan or CHIP, or if
you or your dependents become eligible for a subsidy under Medicaid or CHIP,
you may be able to enroll yourself and your dependents in this plan. You must NEWBORNS’ AND MOTHERS’ HEALTH
provide notification within 60 days after you or your dependent is terminated PROTECTION ACT NOTICE
from, or determined to be eligible for such assistance.
Group Health plans and health insurance issuers generally may not, under
Marriage, Birth or Adoption Federal law, restrict benefits for any hospital length of stay in connection with
If you have a new dependent as a result of a marriage, birth, adoption, or childbirth for the mother or newborn child to less than 48 hours following a
placement for adoption, you may be able to enroll yourself and your vaginal delivery or less than 96 hours following a cesarean section. However,
dependents. However, you must enroll within 31 days after the marriage, birth, Federal law generally does not prohibit the mother’s or newborn’s attending
or placement for adoption. 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
For More Information or Assistance authorization from the plan or the insurance issuer for prescribing a length of
To request special enrollment or obtain more information, contact Human stay not in excess of 48 hours (or 96 hours).
Resource Department

34 | BENEFITS GUIDE
 REQUIRED NOTICES
CREDITABLE COVERAGE (PART D MEDICARE)

MEDICARE PART D CREDITABLE COVERAGE NOTICE

Your Prescription Drug Coverage and Medicare

Important Notice from Rivian about Your Prescription Drug Coverage When Will You Pay A Higher Premium (Penalty) To Join A
and Medicare Please read this notice carefully and keep it where you can Medicare Drug Plan? You should also know that if you drop or
find it. This notice has information about your current prescription drug lose your current coverage with Rivian and don’t join a Medicare
coverage with Rivian and about your options under Medicare’s
drug plan within 63 continuous days after your current coverage
prescription drug coverage. This information can help you decide whether
or not you want to join a Medicare drug plan. ends, you may pay a higher premium (a penalty) to join a
Medicare drug plan later. If you go 63 continuous days or longer
If you are considering joining, you should compare your current coverage, without creditable prescription drug coverage, your monthly
including which drugs are covered at what cost, with the coverage and premium may go up by at least 1% of the Medicare base
costs of the plans offering Medicare prescription drug coverage in your beneficiary premium per month for every month that you did not
area. Information about where you can get help to make decisions about have that coverage. For example, if you go nineteen months
your prescription drug coverage is at the end of this notice. There are two without creditable coverage, your premium may consistently be at
important things you need to know about your current coverage and
least 19% higher than the Medicare base beneficiary premium.
Medicare’s prescription drug coverage:
You may have to pay this higher premium (a penalty) as long as
1. Medicare prescription drug coverage became available in 2006 to you have Medicare prescription drug coverage. In addition, you
everyone with Medicare. You can get this coverage if you join a may have to wait until the following October to join.
Medicare Prescription Drug Plan or join a Medicare Advantage Plan
(like an HMO or PPO) that offers prescription drug coverage. All For More Information About This Notice Or Your Current Prescription
Medicare drug plans provide at least a standard level of coverage set Drug Coverage contact the Human Resources Department.
by Medicare. Some plans may also offer more coverage for a higher
monthly premium. NOTE: You’ll get this notice each year. You will also get it before the next
2. Rivian has determined that the prescription drug coverage offered by period you can join a Medicare drug plan, and if this coverage through
the BCBSM Medical Plans are, on average for all plan participants, Rivian changes. You also may request a copy of this notice at any time.
expected to pay out as much as standard Medicare prescription drug
coverage pays and is therefore considered Creditable Coverage. More detailed information about Medicare plans that offer prescription drug
Because your existing coverage is Creditable Coverage, you can coverage is in the “Medicare & You” handbook. You’ll get a copy of the
keep this coverage and not pay a higher premium (a penalty) if you handbook in the mail every year from Medicare. You may also be
later decide to join a Medicare drug plan. contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov
When Can You Join A Medicare Drug Plan? You can join a Medicare • Call your State Health Insurance Assistance Program (see the
drug plan when you first become eligible for Medicare and each year from inside back cover of your copy of the “Medicare & You” handbook
October 15th to December 7th . However, if you lose your current for their telephone number) for personalized help
creditable prescription drug coverage, through no fault of your own, you • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-
will also be eligible for a two (2) month Special Enrollment Period (SEP) to 877-486-2048.
join a Medicare drug plan.
If you have limited income and resources, extra help paying for Medicare
What Happens To Your Current Coverage If You Decide to Join A prescription drug coverage is available. For information about this extra
Medicare Drug Plan? If you decide to join a Medicare drug plan, your help, visit Social Security on the web at www.socialsecurity.gov, or call
current Rivian coverage will not be affected. If you do decide to join a them at 1-800-772-1213 (TTY 1-800-325-0778).
Medicare drug plan and drop your current Rivian coverage, be aware that
you and your dependents will be able to get this coverage back.
Remember: Keep this Creditable Coverage notice. If you decide to join
one of the Medicare drug plans, you may be required to provide a copy of
this notice when you join to show whether or not you have maintained
creditable coverage and, therefore, whether or not you are required to pay
a higher premium (a penalty).

CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995,
no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0990. The
time required to complete this information collection is estimated to average 8 hours per response
initially, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

35 | BENEFITS GUIDE
REQUIRED NOTICES
COBRA

REMINDER: This is a courtesy copy of the Initial Rights notice provided to qualified beneficiaries.

COBRA COVERAGE What Is COBRA Continuation Coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would
otherwise end because of a life event. This is also called a “qualifying event.”
Federal law requires your employer to offer employees and their families the Specific qualifying events are listed later in this notice. After a qualifying
opportunity for a temporary extension of health coverage (called “continuation event, COBRA continuation coverage must be offered to each person who is
coverage”) at group rates in certain instances where coverage under the plan a “qualified beneficiary.” You, your spouse, and your dependent children
would otherwise end. could become qualified beneficiaries if coverage under the Plan is lost
because of the qualifying event. Under the Plan, qualified beneficiaries who
To Qualify For COBRA Coverage: elect COBRA continuation coverage must pay for COBRA continuation
Employees – As an employee of your employer covered by our health plans, coverage.
you have the right to elect this continuation coverage if you lose your group If you’re an employee, you’ll become a qualified beneficiary if you lose your
health coverage because of a reduction in your hours of employment or the coverage under the Plan because of the following qualifying events:
termination of your employment (for reasons other than gross misconduct  Your hours of employment are reduced, or
on your part).  Your employment ends for any reason other than your gross misconduct.
 If you’re the spouse of an employee, you’ll become a qualified
Spouses – As the spouse of an employee covered by our health plans, you beneficiary if you lose your coverage under the Plan because of the
have the right to choose continuation coverage for yourself if you lose group following qualifying events:
health coverage under our health plans, for any of the following reasons:  Your spouse dies
 The death of your spouse who was a your employer employee;  Your spouse’s hours of employment are reduced;
 A termination of your spouse’s employment (for reasons other than  Your spouse’s employment ends for any reason other than his or her
gross misconduct); gross misconduct;
 A reduction in your spouse’s hours of employment;  Your spouse becomes entitled to Medicare benefits (under Part A, Part
 Divorce or legal separation from your spouse; or B, or both); or
 Your spouse becomes entitled to Medicare.  You become divorced or legally separated from your spouse.
 Your dependent children will become qualified beneficiaries if they lose
Dependent Children coverage under the Plan because of the following qualifying events:
Dependent children of your employer employees covered by our health  The parent-employee dies;
plans, have the right to continuation coverage if group health coverage under  The parent-employee’s hours of employment are reduced;
our plans, is lost for any of the following reasons:  The parent-employee’s employment ends for any reason other than his
or her gross misconduct;
 The death of a parent who was a your employer employee;
 The parent-employee becomes entitled to Medicare benefits (Part A,
 The termination of a parent’s employment (for reasons other than gross
Part B, or both);
misconduct) or reduction in a parent’s hours of employment with your
 The parents become divorced or legally separated; or
employer;
 The child stops being eligible for coverage under the Plans as a
 Parents’ divorce or legal separation;
“dependent child.”
 A parent who is an employee of your employer becomes entitled to
Medicare; or When Is COBRA Continuation Coverage Available?
 The dependent ceases to be a “dependent child” under the terms of the
our health plans. The Plan will offer COBRA continuation coverage to qualified beneficiaries
only after the Plan Administrator has been notified that a qualifying event has
Please note that it is the employee’s responsibility to notify the Human occurred. The employer must notify the Plan Administrator of the following
Resources/Benefits Department of any communication regarding loss of qualifying events:
coverage and communication regarding such between the employee and the  The end of employment or reduction of hours of employment;
insurance carrier. Please note that employees must also provide notice of  Death of the employee;
other events (e.g., divorce) to the Human Resources Department.  The employee’s becoming entitled to Medicare benefits (under Part A,
Part B, or both).
Continuation of Coverage Rights Under COBRA
For all other qualifying events (divorce or legal separation of the employee
The right to COBRA continuation coverage was created by a federal law, the and spouse or a dependent child’s losing eligibility for coverage as a
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA dependent child), you must notify the Plan Administrator within 60 days after
continuation coverage can become available to you and other members of the qualifying event occurs.
your family when group health coverage would otherwise end. For more
information about your rights and obligations under the Plan and under
federal law, you should review the Plan’s Summary Plan Description or How Is COBRA Continuation Coverage Provided?
contact the Plan Administrator.
Once the Plan Administrator receives notice that a qualifying event has
occurred, COBRA continuation coverage will be offered to each of the
You may have other options available to you when you lose group
qualified beneficiaries. Each qualified beneficiary will have an independent
health coverage.
right to elect COBRA continuation coverage. Covered employees may elect
For example, you may be eligible to buy an individual plan through the Health COBRA continuation coverage on behalf of their spouses, and parents may
Insurance Marketplace. By enrolling in coverage through the Marketplace, elect COBRA continuation coverage on behalf of their children.
you may qualify for lower costs on your monthly premiums and lower out-of- COBRA continuation coverage is a temporary continuation of coverage that
pocket costs. Additionally, you may qualify for a 30-day special enrollment generally lasts for 18 months due to employment termination or reduction of
period for another group health plan for which you are eligible (such as a hours of work. Certain qualifying events, or a second qualifying event during
spouse’s plan), even if that plan generally doesn’t accept late enrollees. the initial period of coverage, may permit a beneficiary to receive a maximum
of 36 months of coverage.
There are also ways in which this 18-month period of COBRA continuation
coverage can be extended:

36 | BENEFITS GUIDE
REQUIRED NOTICES
COBRA

COBRA COVERAGE (cont.)

Disability Extension Of 18-month Period Of COBRA Continuation

Coverage
If you or anyone in your family covered under the Plan is determined by Social
Security to be disabled and you notify the Plan Administrator in a timely fashion,
you and your entire family may be entitled to get up to an additional 11 months
of COBRA continuation coverage, for a maximum of 29 months. The disability
would have to have started at some time before the 60th day of COBRA
continuation coverage and must last at least until the end of the 18-month
period of COBRA continuation coverage.

Second Qualifying Event Extension Of 18-month Period Of Continuation

Coverage
If your family experiences another qualifying event during the 18 months of
COBRA continuation coverage, the spouse and dependent children in your
family can get up to 18 additional months of COBRA continuation coverage, for
a maximum of 36 months, if the Plan is properly notified about the second
qualifying event. This extension may be available to the spouse and any
dependent children getting COBRA continuation coverage if the employee or
former employee dies; becomes entitled to Medicare benefits (under Part A,
Part B, or both); gets divorced or legally separated; or if the dependent child
stops being eligible under the Plan as a dependent child. This extension is only
available if the second qualifying event would have caused the spouse or
dependent child to lose coverage under the Plan had the first qualifying event
not occurred.

Are There Other Coverage Options Besides COBRA Continuation

Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other
coverage options for you and your family through the Health Insurance
Marketplace, Medicaid, or other group health plan coverage options (such as a
spouse’s plan) through what is called a “special enrollment period.” Some of
these options may cost less than COBRA continuation coverage. You can learn
more about many of these options at www.healthcare.gov.

If you have questions concerning your Plan or your COBRA continuation

coverage rights should be addressed to the contact or contacts identified
below. For more information about your rights under the Employee Retirement
Income Security Act (ERISA), including COBRA, the Patient Protection and
Affordable Care Act, and other laws affecting group health plans, contact the
nearest Regional or District Office of the U.S. Department of Labor’s Employee
Benefits Security Administration (EBSA) in your area or visit www. dol.gov/ebsa.
(Addresses and phone numbers of Regional and District EBSA Offices are
available through EBSA’s website.)
For more information about the Marketplace, visit www.healthcare.gov.

**Keep Your Plan Administrator Informed Of Address Changes**

To protect your family’s rights, let the Plan Administrator know about any
changes in the addresses of family members. You should also keep a copy, for
your records, of any notices you send to the Plan Administrator.

37 | BENEFITS GUIDE
REQUIRED NOTICES
CHIP

Premium Assistance Under Medicaid and the Children’s Health INDIANA – Medicaid
Insurance Program (CHIP) Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/
If you or your children are eligible for Medicaid or CHIP and you’re Phone: 1-877-438-4479
eligible for health coverage from your employer, your state may have a All other Medicaid
premium assistance program that can help pay for coverage, using Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
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
IOWA – Medicaid and CHIP (Hawki)
premium assistance programs but you may be able to buy individual
insurance coverage through the Health Insurance Marketplace. For Medicaid Website:
more information, visit www.healthcare.gov. https://dhs.iowa.gov/ime/members
Medicaid Phone: 1-800-338-8366
Hawki Website:
If you or your dependents are already enrolled in Medicaid or CHIP and
http://dhs.iowa.gov/Hawki
you live in a State listed below, contact your State Medicaid or CHIP Hawki Phone: 1-800-257-8563
office to find out if premium assistance is available.
KANSAS – Medicaid
If you or your dependents are NOT currently enrolled in Medicaid or Website: http://www.kdheks.gov/hcf/default.htm
Phone: 1-800-792-4884
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 KENTUCKY – Medicaid
dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP)
apply. If you qualify, ask your state if it has a program that might help Website:
you pay the premiums for an employer-sponsored plan. https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx
Phone: 1-855-459-6328
If you or your dependents are eligible for premium assistance under Email: KIHIPP.PROGRAM@ky.gov
Medicaid or CHIP, as well as eligible under your employer plan, your
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx
employer must allow you to enroll in your employer plan if you aren’t Phone: 1-877-524-4718
already enrolled. This is called a “special enrollment” opportunity, and
you must request coverage within 60 days of being determined Kentucky Medicaid Website: https://chfs.ky.gov
eligible for premium assistance. If you have questions about enrolling
in your employer plan, contact the Department of Labor at LOUISIANA – Medicaid
www.askebsa.dol.gov or call 1-866-444-EBSA (3272). Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp
Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
ALABAMA – Medicaid Phone: 1-800-442-6003
Website: http://myalhipp.com/ TTY: Maine relay 711
Phone: 1-855-692-5447
ALASKA – Medicaid MASSACHUSETTS – Medicaid and CHIP
The AK Health Insurance Premium Payment Program Website: http://www.mass.gov/eohhs/gov/departments/masshealth/
Website: http://myakhipp.com/ Phone: 1-800-862-4840
Phone: 1-866-251-4861
MINNESOTA – Medicaid
Email: CustomerService@MyAKHIPP.com
Website:
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-
care-programs/programs-and-services/medical-assistance.jsp [Under
ARKANSAS – Medicaid
ELIGIBILITY tab, see “what if I have other health insurance?”]
Website: http://myarhipp.com/
Phone: 1-800-657-3739
Phone: 1-855-MyARHIPP (855-692-7447)
CALIFORNIA – Medicaid
MISSOURI – Medicaid
Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx
Phone: 1-800-541-5555
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Phone: 573-751-2005
Child Health Plan Plus (CHP+) MONTANA – Medicaid
Health First Colorado Website: https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center: Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
1-800-221-3943/ State Relay 711 Phone: 1-800-694-3084
CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus
NEBRASKA – Medicaid
CHP+ Customer Service: 1-800-359-1991/ State Relay 711
Website: http://www.ACCESSNebraska.ne.gov
FLORIDA – Medicaid Phone: 1-855-632-7633
Website: http://flmedicaidtplrecovery.com/hipp/ Lincoln: 402-473-7000
Phone: 1-877-357-3268 Omaha: 402-595-1178
GEORGIA – Medicaid NEVADA – Medicaid
Website: https://medicaid.georgia.gov/health-insurance-premium-payment- Medicaid Website: http://dhcfp.nv.gov
program-hipp Medicaid Phone: 1-800-992-0900
Phone: 678-564-1162 ext 2131

38 | BENEFITS GUIDE
 REQUIRED NOTICES
CHIP

NEW HAMPSHIRE – Medicaid SOUTH CAROLINA – Medicaid

Website: https://www.dhhs.nh.gov/oii/hipp.htm
Phone: 603-271-5218 Website: https://www.scdhhs.gov
Toll free number for the HIPP program: 1-800-852-3345, ext 5218 Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid

NEW JERSEY – Medicaid and CHIP
Medicaid Website: Website: http://dss.sd.gov
http://www.state.nj.us/humanservices/ Phone: 1-888-828-0059
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392 TEXAS – Medicaid
CHIP Website: http://www.njfamilycare.org/index.html
Website: http://gethipptexas.com/
CHIP Phone: 1-800-701-0710
Phone: 1-800-440-0493
NEW YORK – Medicaid UTAH – Medicaid and CHIP
Website: https://www.health.ny.gov/health_care/medicaid/ Medicaid Website: https://medicaid.utah.gov/
Phone: 1-800-541-2831 CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
NORTH CAROLINA – Medicaid
Website: https://medicaid.ncdhhs.gov/ VERMONT– Medicaid
Phone: 919-855-4100 Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
NORTH DAKOTA – Medicaid
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ VIRGINIA – Medicaid and CHIP
Phone: 1-844-854-4825
Website: https://www.coverva.org/hipp/
OKLAHOMA – Medicaid and CHIP Medicaid Phone: 1-800-432-5924
Website: http://www.insureoklahoma.org CHIP Phone: 1-855-242-8282
Phone: 1-888-365-3742
WASHINGTON – Medicaid
OREGON – Medicaid Website: https://www.hca.wa.gov/
Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-562-3022
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075 WEST VIRGINIA – Medicaid
Website: http://mywvhipp.com/
PENNSYLVANIA – Medicaid Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
Website:
WISCONSIN – Medicaid and CHIP
https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-
Program.aspx Website:
Phone: 1-800-692-7462 https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002
RHODE ISLAND – Medicaid and CHIP
WYOMING – Medicaid
Website: http://www.eohhs.ri.gov/
Website: https://wyequalitycare.acs-inc.com/
Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
Phone: 307-777-7531

To see if any other states have added a premium assistance program since January 31, 2020,
or for more information on special enrollment rights, contact either:

U.S. Department of Labor

Employee Benefits Security Administration
www.dol.gov/ebsa
P: 866.444.EBSA (3272)

U.S. Department and Human Services Center for

Medicare & Medicaid Services
www.cms.hhs.gov
P: 877.267.2323 Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a
collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal
agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number,
and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also,
notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information
does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are
encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden,
to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution
Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 1/31/2023)

39 | BENEFITS GUIDE
GLOSSARY OF TERMS

Dependent Verification Services (DVS) – Service used to verify In-Network – The term “in-network” refers to health care services or
dependent proof of relationship when adding dependents to benefit items provided by your Primary Care Physician (PCP) or services/items
plans. provided by another participating provider and authorized by your PCP or
the review organization. Authorization by your PCP or the review
Beneficiary – A person designated by you, the participant of a benefit organization is not required in the case of mental health and substance
plan, to receive the benefits of the plan in the event of the participant’s abuse treatment other than hospital confinement solely for detoxification.
death.
• Primary Beneficiary – A person who is designated to receive the Emergency Care that meets the definition of “emergency services” and
benefits of a benefit plan in the event of the participant’s death is authorized as such by either the PCP or the review organization is
considered in-network.
• Contingent Beneficiary – A person who is designated to receive the
benefits of a benefit plan in the event of the Primary Beneficiary’s
death Out-of-Network - The term “out-of-network” refers to care that does not
qualify as in-network.
Charges – The term “charges” means the actual billed charges. It also
Maximum Out of Pocket — The most money you will pay during a year
means an amount negotiated by a provider, directly or indirectly, if that
for coverage. It includes deductibles, copayments and coinsurance, but
amount is different from the actual billed charges.
is in addition to your regular premiums. Beyond this amount, the
insurance company will pay all expenses for the remainder of the year.
Coinsurance – The percentage of charges for covered expenses that
an insured person is required to pay under the plan (separate from
copayments) Medically Necessary/Medical Necessity – Required to diagnose or
treat an illness, injury, disease, or its symptoms; in accordance with
Deductible – The amount of money you must pay each year to cover generally accepted standards of medical practice; clinically appropriate
eligible expenses before your insurance policy starts paying. in terms of type, frequency, extent, site, and duration; not primarily for
the convenience of the patient, physician, or other health care provider;
Dependents – Dependents are your: and rendered in the least intensive setting that is appropriate for the
delivery of the services and supplies.
• Lawful spouse through a marriage that is lawfully
recognized.
Participating Provider – A hospital, physician, or any other health care
• Unmarried partner of the same or opposite sex or Domestic practitioner or entity that has a direct or indirect contractual arrangement
Partner with Cigna to provide covered services with regard to a particular plan
• Dependent child (married or unmarried) under the age of 26 including under which the participant is covered.
stepchildren and legally adopted children.

Proof of relationship documentation will be required in order to add Post-Tax – An option to have the payment to your benefits deducted
dependents to your plan(s). Employees will receive request for from your gross pay after your taxes have been withheld. Therefore,
documentation. your tax contributions will be calculated based on a higher amount. Your
statutory deductions (federal income tax, Social Security, Medicare) will
be calculated based on a higher amount.
Emergency Services – Medical, psychiatric, surgical, hospital, and
related health care services and testing, including ambulance service, Pre-Tax – An option to have the payment to your benefits deducted from
that are required to treat a sudden, unexpected onset of a bodily injury your gross pay before your taxes have been withheld. Therefore, your
or serious sickness that could reasonably be expected by a prudent tax contributions will be calculated based on a lesser amount. Your
layperson to result in serious medical complications, loss of life, or statutory deductions (federal income tax, Social Security, Medicare) will
permanent impairment to bodily functions in the absence of immediate be calculated based on a lesser amount.
medical attention. Examples of emergency situations include
uncontrolled bleeding, seizures or loss of consciousness, shortness of Primary Care Dentist (PCD) – The term “Primary Care Dentist” means a
breath, chest pains or severe squeezing sensations in the chest, dentist who (a) qualifies as a participating provider in general practice,
suspected overdose of medication or poisoning, sudden paralysis or referrals, or specialized care; and (b) has been selected by you, as
slurred speech, burns, cuts, and broken bones. authorized by the provider organization, to provide or arrange for dental
care for you or any of your insured dependents.
The symptoms that led you to believe you needed emergency care, as
coded by the provider and recorded by the hospital, or the final
Primary Care Physician (PCP) – The term “Primary Care
diagnosis – whichever reasonably indicated an emergency medical
Physician” means a physician who (a) qualifies as a participating
condition – will be the basis for the determination of coverage provided
provider in general practice, obstetrics/gynecology, internal
such symptoms reasonably indicate an emergency.
medicine, family practice, or pediatrics; and (b) has been selected
by you, as authorized by the provider organization, to provide or
Evidence of Insurability (EOI) – Proof that you are insurable based on
arrange for medical care for you or any of your insured
the requirements of the insurance carrier. For example, the results of a
dependents.
blood test or a doctor’s signature on a form may be required for you to be
covered by/for Optional Life insurance.
Proof of Relationship Documentation – Documents that show a
Explanation of Benefits — The health insurance company’s written dependent is lawfully your dependent. Documents can include
explanation of how a medical claim was paid. It contains detailed marriage certificates, birth certificates, adoption agreements, previous
information about what the company paid and what portion of the costs years’ tax returns, court orders, and/or divorce decrees showing your
are your responsibility. or your spouse’s responsibility for the dependent.

Health Reimbursement Account (HRA) – The Health Reimbursement

Account (HRA) is an employer-funded account that reimburses you for
eligible out-of-pocket medical expenses. The HRA is only available to
employees who are enrolled in the HRA Plan.

40 | BENEFITS GUIDE
NOTES

41 | BENEFITS GUIDE
 This Benefit Enrollment Guide Is Provided By:

NFP © 2020. All rights reserved.