A guide to your Wells Fargo benefits Benefits Book*

A guide to your Wells Fargo benefits

Benefits Book*

Effective January 1, 2023

* For eligible employees on U.S. payroll

HRS48995 (02/23)

Contents

Chapter 1: Eligibility, Enrollment, and More 1-1

Contacts 1-2 The basics 1-3 Who's eligible to enroll 1-5 Cost and funding 1-13 How to enroll 1-16 When coverage begins 1-20 Coordination with other coverage 1-23 Changing coverage 1-25 Coverage when you are not working 1-51 When coverage ends 1-52

Chapter 2: Medical Plans 2-1

Contacts 2-4 Medical plans by location 2-5 The basics 2-6 Providers and provider networks 2-9 Important terms 2-12 How the Copay Plan with HRA works 2-14 How the Higher Use Plan with HSA, the Lower Use Plan with HSA, the Narrow Network Plan with HSA, and Flex HDHP work 2-23 How the Narrow Network Copay Plan works 2-32 Health and wellness activities 2-37 Other programs, tools, and resources 2-41 Pre-service authorization requirements 2-43 What the medical plans cover 2-47 Services covered under the medical plans 2-50 Surprise billing protections 2-133 Exclusions 2-134 Claims and appeals 2-138 Right of recovery 2-141 The basics 2-143 Covered prescriptions 2-145 Your ID card 2-150 Accredo, your specialty pharmacy 2-150 Some prescriptions may require pre-service authorization, step therapy, or quantity limits 2-151 Prescriptions that are not covered 2-154 Prescription drug coordination of benefits 2-156 Prescription drug claims and appeals 2-156 Prescription drug right of recovery 2-157 Other things you should know 2-157

Chapter 3: Dental Plan 3-1 Contacts 3-2 The basics 3-3 How the Delta Dental coverage options work 3-4 Pretreatment estimate 3-4 What the Delta Dental coverage options cover 3-5 What is not covered 3-8 Claims and appeals 3-9 Right of recovery 3-11

Chapter 4: Vision Plan 4-1 Contacts 4-2 The basics 4-3 How the vision plan works 4-4 What the vision plan covers 4-6 What is not covered 4-7 Coordination of benefits 4-8 Claims and appeals 4-8 Right of recovery 4-8

Chapter 5: Health Care Flexible Spending Account Plan 5-1 Contacts 5-2 The basics 5-3 Health Care FSA Plan options 5-3 Who's eligible 5-4 Some rules to know 5-4 Your contributions 5-7 How to enroll 5-8 Changing participation 5-8 When participation ends 5-9 Using the Full-Purpose Health Care FSA and Limited Dental/Vision FSA 5-10 Claims and appeals 5-16

Chapter 6: Day Care Flexible Spending Account 6-1 Contacts 6-2 The basics 6-3 Who's eligible 6-3 Day Care FSA rules 6-3 Your contributions 6-6 How to enroll 6-7 Changing participation 6-7 When participation ends 6-8 Using the Day Care FSA 6-9 Claims and requests for review 6-10

Contentsv1.0

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Chapter 7: Life Insurance Plan 7-1 Contacts 7-2 The basics 7-3 Who's eligible 7-8 How to enroll 7-8 Delayed effective date 7-9 Statement of Health 7-9 Changing coverage 7-10 Cost 7-11 Beneficiaries 7-12 Plan benefits 7-13 What is not covered 7-15 Life Insurance Plan claims and appeals 7-16 Benefits when you're not working 7-17 When coverage ends 7-18 After coverage ends: Your options 7-18

Chapter 8: Business Travel Accident Plan 8-1 Contacts 8-2 The basics 8-3 Who's eligible 8-4 How to enroll 8-4 Changing coverage 8-5 Cost 8-5 Beneficiaries 8-5 BTA Plan benefits 8-6 What is not covered 8-9 BTA Plan claims and appeals 8-10 Benefits when you're not working 8-11 When coverage ends 8-11 Conversion 8-11

Chapter 9: Accidental Death and Dismemberment Plan 9-1

Contacts 9-2 The basics 9-3 Who's eligible 9-5 Who's not eligible 9-5 How to enroll 9-5 Changing or canceling coverage 9-5 Cost 9-6 Beneficiaries 9-6 AD&D Plan benefits 9-7 What is not covered 9-11 AD&D Plan claims and appeals 9-11 Benefits when you're not working 9-12 When coverage ends 9-13 Portability 9-13

Chapter 10: Short-Term Disability Plan 10-1

Contacts 10-2 The basics 10-3 Who's eligible 10-3 Cost and funding 10-3 How to enroll 10-3 When coverage begins 10-4 When coverage ends 10-4 Coverage when you're not working 10-5 How STD benefits coordinate with leave of absences 10-5 How to file a claim for STD benefits 10-6 How the STD Plan works 10-7 If you are disabled and working (reduced work schedule) 10-10 STD Plan benefits 10-11 Claims and appeals 10-14

Chapter 11: Short-Term Disability Top-Up Plan 11-1

Contacts 11-2 The basics 11-3 Who's eligible 11-3 Cost 11-4 How to enroll 11-4 When coverage begins 11-4 When coverage ends 11-4 Coverage when you're not working 11-5 How STD Top-Up benefits coordinate with leave of absences: 11-5 How to file a claim for STD benefits 11-6 How the STD Top-Up Plan works 11-7 If you are disabled and working (reduced work schedule) 11-10 STD Plan benefits 11-11 Claims and appeals 11-14

Chapter 12: Long-Term Disability Plan 12-1

Contacts 12-2 The basics 12-3 Who's eligible 12-3 Cost 12-3 How to enroll 12-4 When coverage begins 12-4 Actively at work definition 12-5 How the LTD Plan works 12-5 LTD Plan benefits 12-7 If you are disabled and working 12-10 Limitations and exclusions 12-11 Coverage when you're not working 12-11 Claims and appeals 12-12 When coverage ends 12-15 Other LTD definitions 12-15

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Contents

Chapter 13: Legal Services Plan 13-1 Contacts 13-2 The basics 13-3 How the Legal Services Plan works 13-4 Plan exclusions and limitations 13-21 When coverage ends 13-21 Claims and appeals 13-22 Legal action 13-23

Chapter 14: Critical Illness Insurance Plan 14-1 Contacts 14-2 The basics 14-3 Critical Illness Insurance Plan at a glance 14-4 Who's eligible 14-6 How to enroll and when coverage begins 14-6 Delayed effective date 14-6 Changing or canceling coverage 14-6 Cost 14-7 Taxation of Basic Critical Illness Benefits 14-8 Beneficiaries 14-8 Critical Illness Insurance Plan benefits 14-8 Critical Illness Insurance Plan claims and appeals 14-8 Named claims fiduciary 14-9 Legal action 14-9 Right of recovery 14-9 Benefits when you're not working 14-9 When coverage ends 14-9

Chapter 15: Optional Accident Insurance Plan 15-1 Contacts 15-2 The basics 15-3 Who's eligible 15-5 How to enroll and when coverage begins 15-5 Delayed effective date 15-5 Changing or canceling coverage 15-6 Cost 15-6 Beneficiaries 15-6 Optional Accident Insurance Plan benefits 15-6 Optional Accident Insurance Plan claims and appeals 15-6 Named claims fiduciary 15-7 Legal action 15-7 Right of recovery 15-7 Benefits when you're not working 15-7 When coverage ends 15-7

Appendix A: Claims and Appeals A-1 Claims A-3 Appealing an adverse benefit determination -- claims A-11 External reviews -- appeals for medical claims only A-17 Legal action A-19 Appealing an adverse benefit determination -- rescission of coverage A-19 Claims determinations and dispute resolution with respect to out-of-network emergency care and eligible non-emergency services A-19

Appendix B: Important Notifications and Disclosures B-1 Your rights under ERISA B-2 Other notifications for group health plan coverage B-3 Plan information B-4 Disclosure about health savings accounts B-5 Participating employers B-6 Future of the plans B-6 ERISA plans sponsored by Wells Fargo B-7

Appendix C: Health Savings Accounts C-1 Introduction C-2 About the HSAs C-3 Who is eligible to open and contribute to an HSA C-3 Contributions C-4 Qualified medical expenses C-7 Using the HSA for nonqualified expenses C-8 Additional information about the HSA C-8

Appendix D: Leaves of Absence and Your Benefits D-1 General information D-2 Eligibility to participate in benefits during leaves of absence D-2 Annual Benefits Enrollment D-3 Paying for your benefits while on a leave D-3 Family Medical Leave Act (FMLA) D-5 Uniformed Services Employment and Reemployment Rights Act (USERRA) D-5

Appendix E: Continuing Coverage Under COBRA E-1 COBRA general notice E-2 COBRA administrative information E-5 Notice regarding state continuation of coverage E-12

Appendix F: Severance Plan F-1 Contacts F-2 The basics F-3 Who's eligible F-3 Qualifying event F-4 How the Plan works F-6 Claims and Appeals F-9 When coverage ends F-10 Plan administration F-10

Contents

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Chapter 1: Eligibility, Enrollment, and More

Contents

Contacts 1-2

The basics 1-3 Summary Plan Descriptions 1-3 Employment classifications 1-3 Benefit plan options 1-4

Who's eligible to enroll 1-5 Eligible employees 1-5 Eligible dependents 1-6 Ineligible dependents 1-9 Dependent eligibility verification 1-9 Consequences of fraudulent enrollment or failure to provide acceptable proof of dependent eligibility 1-11 Medical Child Support Orders and National Medical Support Notices -- information for Wells Fargo employees 1-12

Cost and funding 1-13 Cost 1-13 Paying for coverage -- regular and fixed term employees 1-14 Paying for coverage -- interns and flexible employees 1-15 Funding arrangements for the plans 1-15

How to enroll 1-16 General information 1-16 Initial enrollment -- regular and fixed term employees 1-17 Initial enrollment -- interns and flexible employees 1-17 When to enroll 1-17 Review benefit elections after you enroll 1-18 Enrollment and eligibility disputes 1-18

When coverage begins 1-20 New employees 1-20 Rehired employees 1-21 Rehire while on Severance 1-22 Rehired retirees 1-22 Employment classification changes 1-23 Enrollment election changes 1-23 COBRA continuation coverage 1-23

Coordination with other coverage 1-23 General coordination of benefits 1-23 Coordination with Medicare 1-24

Changing coverage 1-25 What changes can you make during the year? 1-25 How to enroll -- changing coverage 1-25 Enrolling a newborn or newly adopted child 1-26 Covered employee becomes enrolled as a dependent of another employee 1-26 Annual Benefits Enrollment 1-26 If you move 1-27 Special enrollment rights 1-27 Qualified Events 1-29 Dropping ineligible dependents 1-49 Dropping your coverage 1-50

Coverage when you are not working 1-51 Coverage while on a leave of absence 1-51 Coverage if your employment terminates 1-51 Coverage for terminated employees who are receiving Wells Fargo severance pay 1-51 Coverage if you retire 1-51 Coverage if you die 1-51

When coverage ends 1-52 Employees 1-52 Dependents 1-52

Chapter 1: Eligibility, Enrollment, and Morev3.0

1-1

Contacts

Information about your plan

Information about employee enrollment, eligibility, making coverage changes, or plan rates and comparisons

Information about COBRA enrollment

Retiree coverage (This Benefits Book does not contain information about the retiree health care coverage options under the Wells Fargo & Company Retiree Plan.)

Your plan's member services phone number or website (see the applicable chapter in this Benefits Book for contact phone number and website information)

HR Services & Support site Employee Care 1-877-HRWELLS (1-877-479-3557), option 2 Employee Care accepts all relay service calls, including 711.

BenefitConnectTM | COBRA 1-877-29-COBRA (26272) [(858) 314-5108 International callers only] Relay service calls are accepted.

The Wells Fargo Retirement Service Center 1-877-HRWELLS (1-877-479-3557), option 1 Relay service calls are accepted.

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Chapter 1: Eligibility, Enrollment, and More

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