2025 Summary HCCSC Anthem HealthSync PPO 2

Your summary of benefits Anthem® Blue Cross and Blue Shield Your Plan: Huntington County Community School Corporation Employee Benefit Trust: Anthem POS 3 Tier Your Network: HealthSync Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge Mental Health & Substance Use Disorder Services No charge Specialist care $30 copay per visit deductible does not apply Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Overall Deductible $3,000 person / $6,000 person / $18,000 person / $6,000 family $12,000 family $36,000 family Overall Out-of-Pocket Limit $7,350 person / $7,350 person / $22,050 person / $14,700 family $14,700 family $44,100 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit. All medical deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Out-of-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. The deductibles for Preferred Network and In-Network cross apply. Satisfying one helps satisfy the other. The out-of-pocket limits for Preferred Network and In-Network cross apply as well. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and $15 copay per visit $40 copay per visit 50% coinsurance after Substance Use Disorder Services virtual and deductible does not deductible does not deductible is met office apply apply Specialist Care virtual and office $30 copay per visit $80 copay per visit 50% coinsurance after deductible does not deductible does not deductible is met apply apply Page 1 of 10

Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Other Practitioner Visits Maternity Doctor services (prenatal/postnatal 20% coinsurance after 40% coinsurance after 50% coinsurance after care and delivery) deductible is met deductible is met deductible is met Retail Health Clinic for routine care and $15 copay per visit $40 copay per visit 50% coinsurance after treatment of common illnesses; usually found in deductible does not deductible does not deductible is met major pharmacies or retail stores. apply apply Manipulation Therapy $30 copay per visit $80 copay per visit 50% coinsurance after Coverage is limited to 12 visits per benefit deductible does not deductible does not deductible is met period. apply apply Other Services in an Office Allergy Testing 20% coinsurance after 40% coinsurance after 50% coinsurance after When Allergy injections are billed separately by deductible is met deductible is met deductible is met network providers, the member is responsible for a $10 copay. When billed as part of an office visit, there is no additional cost to the member for the injection. Prescription Drugs Dispensed in the office 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Surgery $30 copay per visit $80 copay per visit 50% coinsurance after deductible does not deductible does not deductible is met ‡ ‡ apply apply Preventive care / screenings / immunizations No charge No charge 50% coinsurance after deductible is met Preventive Care for Chronic Conditions per No charge No charge 50% coinsurance after IRS guidelines deductible is met Diagnostic Services Lab Office No charge No charge 50% coinsurance after deductible is met Freestanding Lab/Reference Lab No charge No charge 50% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met X-Ray Office No charge No charge 50% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Page 2 of 10

Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Freestanding Radiology Center 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Emergency and Urgent Care Urgent Care includes doctor services. $75 copay per visit 40% coinsurance after 50% coinsurance after Additional charges may apply depending on the deductible does not deductible is met deductible is met care provided. apply Emergency Room Facility Services $250 copay per visit $250 copay per visit Covered as In-Network Your copay will be waived if admitted. and then 20% and then 20% coinsurance after coinsurance after deductible is met deductible is met Emergency Room Doctor and Other 20% coinsurance after 20% coinsurance after Covered as In-Network Services deductible is met deductible is met Ambulance 20% coinsurance after 20% coinsurance after Covered as In-Network Authorized Out-of-Network non-emergency deductible is met deductible is met ambulance services are limited to an Anthem maximum payment of $50,000 per trip. Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Doctor Services 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Outpatient Surgery Facility Fees Hospital 20% coinsurance after $250 copay per visit 50% coinsurance after deductible is met and then 40% deductible is met coinsurance after deductible is met Page 3 of 10

Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Ambulatory Surgical Center 20% coinsurance after $250 copay per visit 50% coinsurance after deductible is met and then 40% deductible is met coinsurance after deductible is met Physician and other services including surgeon fees Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Ambulatory Surgical Center 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) If readmitted within 72 hours for the same condition, no additional facility copay is required. If transferred between facilities, only one copay will apply. Facility Fees 20% coinsurance after $500 copay per 50% coinsurance after deductible is met admission and then deductible is met 40% coinsurance after deductible is met Human Organ and Tissue Transplants No charge No charge 50% coinsurance after Cornea transplants are treated the same as any deductible is met other illness and subject to the medical benefits. Physician and other services including 20% coinsurance after 40% coinsurance after 50% coinsurance after surgeon fees deductible is met deductible is met deductible is met Home Health Care 20% coinsurance after 40% coinsurance after 50% coinsurance after Coverage is limited to 120 visits per benefit deductible is met deductible is met deductible is met period. Limits are combined for all home health services. Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical and occupational therapies is limited to 40 visits combined per benefit period. Coverage for speech therapy is limited to 20 visits per benefit period. Office $30 copay per visit $80 copay per visit 50% coinsurance after deductible does not deductible does not deductible is met apply apply Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Page 4 of 10

Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Pulmonary rehabilitation Coverage is limited to 20 visits per benefit period. Office $30 copay per visit $80 copay per visit 50% coinsurance after deductible does not deductible does not deductible is met apply apply Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office $30 copay per visit $80 copay per visit 50% coinsurance after deductible does not deductible does not deductible is met apply apply Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Dialysis/Hemodialysis Office No charge No charge 50% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Chemo/Radiation Therapy Office $30 copay per visit $80 copay per visit 50% coinsurance after deductible does not deductible does not deductible is met ‡ ‡ apply apply Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Skilled Nursing Care (facility) 20% coinsurance after $500 copay per 50% coinsurance after Coverage for Skilled Nursing, Outpatient deductible is met admission and then deductible is met Rehabilitation and Inpatient Rehabilitation 40% coinsurance after facility settings is limited to 150 days combined deductible is met per benefit period. Inpatient Hospice No charge No charge No charge Durable Medical Equipment 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Page 5 of 10

Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Prosthetic Devices 20% coinsurance after 40% coinsurance after 50% coinsurance after Coverage for wigs is limited to 1 item after deductible is met deductible is met deductible is met cancer treatment per benefit period. Cost if you use a Cost if you use an In- Cost if you use an Covered Prescription Drug Benefits Preferred Network Network Pharmacy Out-of-Network Pharmacy Pharmacy Pharmacy Deductible Combined with In-Network medical deductible Combined with Out-of- Network medical deductible Pharmacy Out-of-Pocket Limit Combined with In-Network medical out-of-pocket Combined with Out-of- limit Network medical out-of- pocket limit Prescription Drug Coverage Network: TRUESCRIPTS TEAM – ASSIST WITH INSERTING LANGUAGE HERE Drug List: TRUESCRIPTS TEAM – ASSIST WITH INSERTING LANGUAGE HERE Day Supply Limits: TRUESCRIPTS TEAM – ASSIST WITH INSERTING LANGUAGE HERE Tier 1 – Generic $10 / $25 copay Not Applicable (Retail/Mail Order) Tier 2 - Preferred Brand $75 / $187.50 copay Not Applicable (Retail/Mail Order) Tier 3 - Non-Preferred Brand $150 / $375 copay Not Applicable (Retail/Mail Order) Tier 4 - Specialty $400 copay Not Applicable (Retail/Mail Order) Notes: • Dependent Age Limit: to the end of the month in which the child attains age 26. • Members are encouraged to always obtain prior approval when using Out-of-Network Providers. Precertification will help the member know if the services are considered not medically necessary. • No charge means no deductible / copayment / coinsurance up to the maximum allowable amount. 0% means no coinsurance up to the maximum allowable amount. However, when choosing an Out-of-Network Provider, the member is responsible for any balance due after the plan payment. • If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”. Page 6 of 10

• Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • ‡ You will pay the PCP's office visit copay when services are provided in their office. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Questions: (833) 578-4441 or visit us at www.anthem.com Page 7 of 10

Your Plan: Huntington County Community School Corporation Employee Benefit Trust: Anthem POS 3 Tier Your Network: HealthSync This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. By signing this Summary of Benefits, I agree to the benefits for the product selected as of the effective date indicated. Authorized group signature (if applicable) Date Underwriting signature (if applicable) Date IN/LG/Anthem POS 3 Tier/8X5X/01-01-2025 Page 8 of 10

Language Access Services: Get help in your language Curious to know what all this says? We would be too. Here’s the English version: If you have any questions about this document, you have the right to get help and information in your language at no cost. To talk to an interpreter, call (833) 578-4441 Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. (TTY/TDD: 711) . (833) 578-4441 Armenian (հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք անվճար ստանալ օգնություն և տեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար զանգահարեք հետևյալ հեռախոսահամարով՝ (833) 578-4441: Chinese(中文)：如果您對本文件有任何疑問，您有權使用您的語言免費獲得協助和資訊。如需與譯員通 話，請致電(833) 578-4441。 (833) 578-4441 French (Français) : Si vous avez des questions sur ce document, vous avez la possibilité d’accéder gratuitement à ces informations et à une aide dans votre langue. Pour parler à un interprète, appelez le (833) 578-4441. Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele (833) 578-4441. Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero (833) 578- 4441. (833) 578-4441 Korean (한국어): 본 문서에 대해 어떠한 문의사항이라도 있을 경우, 귀하에게는 귀하가 사용하는 언어로 무료 도움 및 정보를 얻을 권리가 있습니다. 통역사와 이야기하려면(833) 578-4441로 문의하십시오. (833) 578-4441. Page 9 of 10

Language Access Services: Polish (polski): W przypadku jakichkolwiek pytań związanych z niniejszym dokumentem masz prawo do bezpłatnego uzyskania pomocy oraz informacji w swoim języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer: (833) 578- 4441. (833) 578-4441 (833) 578-4441. Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar con un intérprete, llame al (833) 578-4441. Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Makipag-usap sa isang tagapagpaliwanag, tawagan ang (833) 578-4441. Vietnamese (Tiếng Việt): Nếu quý vị có bất kỳ thắc mắc nào về tài liệu này, quý vị có quyền nhận sự trợ giúp và thông tin bằng ngôn ngữ của quý vị hoàn toàn miễn phí. Để trao đổi với một thông dịch viên, hãy gọi (833) 578-4441. It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Page 10 of 10