2027 COBRA Benefit Guide

Plan Resource Hub 2027 COBRA Benefit Guide

Retiree Monthly Costs Surest Plan Core HDHP Basic HDHP Dental Vision Retiree Only $919.49 $769.69 $707.46 $36.67 $5.76 + Spouse $2,265.50 $1,948.96 $1,749.19 $73.31 $11.52 + Child(ren) $1,735.49 $1,495.24 $1,339.01 $97.77 $11.64 Family $2,484.21 $2,136.19 $1,918.56 $146.00 $18.57

For 2027, Noblesville is offering a choice between two HDHP plans available through UnitedHealthcare, and a PPO plan available through Surest. Medical Coverage UHC & SUREST UHC Member Portal Surest Member Portal

No-Mystery Medical Costs Surest Intro Video • Coverage from day one • No deductible, no coinsurance • Easily search your symptoms within the app/site • Access the broad, national UHC provider network • See prices before scheduling appointments Transparency with Surest SUREST Get Started Download App

Surest Plan Core HDHP Basic HDHP | In-Network | In-Network | In-Network | | Embedded Deductible (Single/Family) | N/A | N/A | $5,000 / $10,000 | | Non-Embedded Deductible (Single/Family) | N/A | $2,200 / $4,400 | N/A | | Out-of-Pocket Maximum (Single/Family) | N/A | $2,200 / $4,400 | $5,000 / $10,000 | | Coinsurance | 0% | 20% | 0% | | Preventive Care | $10 - $65 copay | 100% covered | 100% covered | | Primary Care Visit | $10 - $65 copay | Ded + 20% | Ded + 0% | | Specialist Visit | $35 copay | Ded + 20% | Ded + 0% | | Urgent Care | $375 copay | Ded + 20% | Ded + 0% | Emergency Room $75 - $525 copay / $1,600 copay Ded + 20% Ded + 0% Hospital Services $0 / $0 Ded + 20% Ded + 0% View the Summary of Benefits & Coverage Documents to see out-of-network costs for different services.

For 2027, CVS Caremark will continue to be our dedicated partner for pharmacy management. Caremark’s network includes pharmacies such as Walgreens, CVS, and Walmart. Mail-order prescriptions can be ordered directly through Caremark by using the member portal below. Prescription Benefits CVS CAREMARK Caremark Member Portal

| Surest Plan | Core HDHP | Basic HDHP | | In-Network | In-Network | In-Network | | Rx Out-of-Pocket Maximum | $3,000 / $6,000 | Embedded w/ medical | Embedded w/ medical | | Preventive Prescriptions | Not covered | $0 copay | $0 copay | | Generic (Retail) | $10 copay | 20% after deductible | 0% after deductible | | Preferred (Retail) | $30 copay | 20% after deductible | 0% after deductible | | Non-Preferred (Retail) | $75 copay | 20% after deductible | 0% after deductible | | Generic (Mail-order) | $10 copay | 20% after deductible | 0% after deductible | | Preferred (Mail-order) | $65 copay | 20% after deductible | 0% after deductible | | Non-Preferred (Mail-order) | $145 copay | 20% after deductible | 0% after deductible | | Specialty Medications | $300 copay | 20% after deductible | 0% after deductible | View the Summary of Benefits & Coverage Documents to see out-of-network costs for different services.

Rx cost control resources Search your Prescription(s) Free Rx Cost Analysis Rx Help Centers The Rx Help Centers provide members with assistance in finding resources for high-cost, brand-name medications by advocating directly on their behalf with drug manufacturers. CostPlus Drug Company Mark Cuban’s online pharmacy bypasses PBMs by offering generic medications directly to consumers with transparent pricing models: the cost of drug + 15% markup + pharmacy fee. Search your Prescription(s) GoodRx Compare prescription drug prices and find discounts at local pharmacies. You simply search for your medication, choose a pharmacy, and show the GoodRx coupon when you pay.

Find providers, view your ID card, and more online or using the Delta Dental member portal below. Dental Coverage DELTA DENTAL Delta Member Portal

Delta Dental Plan In-Network Out-of-Network Deductible (Single/Family) None $25 / $75 Annual Plan Maximum $1,250/person $1,250/person Preventive Services You pay 0% You pay 0% Basic Services You pay 10% You pay 15% Major Services You pay 40% You pay 45% Orthodontia Services You pay 50% You pay 50% Orthodontia Lifetime Maximum $1,250 $1,000

Download the App Delta Dental’s free mobile app makes it easy for you to make the most of your dental benefits so you can maximize your oral health, wherever you are. Download the Delta Dental App DELTA DENTAL • Check benefits and claims • Find a dentist near you • View mobile ID card • Toothbrush timer APP FEATURES

View copays and deductibles, check on claims, find an eye doctor and get special offers for vision care. Vision Coverage EYEMED EyeMed Member Portal

EyeMed Vision Plan In-Network Out-of-Network Benefit Frequency Eye Exam $10 copay Up to $40 reimbursement 1x every year $130 allowance, then Eyeglass Frames 20% of remaining balance Up to $65 reimbursement 1x every 2 years Lenses (Single/Bifocal/Trifocal/Lenticular) $15 copay $30 - $70 reimbursement 1x every year Contact Lenses (Conventional) $130 allowance, then Up to $65 reimbursement 1x every year 15% of remaining balance Contact Lenses (Medically-necessary) 100% covered Up to $300 reimbursement 1x every year

Download the App Get the most from your EyeMed vision benefit. The EyeMed mobile app makes it easy for you to manage your benefits, find vision care, and more. Download the EyeMed App EYEMED • See benefits/eligibility at a glance • Find an in-network eye doctor • View your ID Card • Set upcoming exams • Contact lens replacement reminders • Access interactive vision guides APP FEATURES

Username: First name initial + 1st 6 letters of last name + last 4 digits of SSN. Password: Birthday in format of YYYY/MM/DD. Enroll In Your Benefits PLANSOURCE Get Started