2027 PPO Plan SBC

This document provides an overview of benefits, coverage details, and costs for a particular health plan, including deductible and out-of-pocket limits.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2027 - 12/31/2027 UMR: MT. VERON COMMUNITY SCHOOL CORP: 7670-00-417302 001 Coverage for: Individual + Family / Plan Type: PPO Page 1 of 8 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.umr.com or by calling 1-800-207-3172. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.umr.com or call 1-800-207-3172 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $1,500 person / $3,000 family Hancock Regional & Community Hospital (Tier 1) $3,000 person / $6,000 family UHC (Tier 2) $6,000 person / $12,000 family Out-of-network (Tier 3) Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles No. You don’t have to meet deductibles for specific services. for specific services? What is the out–of–pocket limit for this plan? $4,000 person / $8,000 family Hancock Regional & Community Hospital (Tier 1) $5,000 person / $10,000 family UHC (Tier 2) $12,000 person / $24,000 family Out-of-network (Tier 3) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out–of–pocket limit? Penalties, premiums, balance billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of- pocket limit. Will you pay less if you use a network provider? Yes. See www.umr.com or call 1-800-207-3172 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist?

Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Tier 1 Tier 2 Tier 3 Information If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $30 copay per visit; deductible waived $60 copay per visit; 50% coinsurance None deductible waived $50 copay per visit; Specialist visit deductible waived $100 copay per visit; 50% coinsurance None deductible waived Preventive care/ screening/ immunization No charge; deductible waived No charge; 50% coinsurance deductible waived You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge; deductible waived labs office setting; 10% coinsurance x-rays office setting & outpatient setting 20% coinsurance 50% coinsurance None Imaging (CT/PET scans, MRIs) 10% coinsurance 20% coinsurance 50% coinsurance Preauthorization is required for Advanced imaging, excluding basic CT & MRI.

Page 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Tier 1 Tier 2 Tier 3 Information If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at https://www.tru escripts.com/m embers Generic drugs (Tier 1) Benefits are applied by outside vendor Benefits are applied by outside vendor Benefits are applied by outside vendor None Preferred brand drugs (Tier 2) Benefits are applied by outside vendor Benefits are applied by outside vendor Benefits are applied by outside vendor Non-preferred brand drugs (Tier 3) Benefits are applied by outside vendor Benefits are applied by outside vendor Benefits are applied by outside vendor Specialty drugs (Tier 4) Benefits are applied by outside vendor Benefits are applied by outside vendor Benefits are applied by outside vendor If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 20% coinsurance 50% coinsurance Preauthorization is required. Physician/surgeon 10% coinsurance 20% coinsurance 50% coinsurance fees If you need immediate medical attention Emergency room care $250 copay per visit; 10% coinsurance $250 copay per visit; 10% coinsurance $250 copay per visit; 10% coinsurance Tier 1 deductible applies to Tier 2 & Tier 3 benefits; Copay may be waived if admitted Emergency medical 10% coinsurance 10% coinsurance 10% coinsurance transportation Tier 1 deductible applies to Tier 2 & Tier 3 benefits; Preauthorization is required for Non- emergent Air services. Urgent care $75 copay per visit; 20% coinsurance 50% coinsurance None deductible waived

Page 4 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Tier 1 Tier 2 Tier 3 Information If you have a hospital stay Facility fee 10% coinsurance 20% coinsurance 50% coinsurance (e.g., hospital room) Preauthorization is required. Physician/surgeon 10% coinsurance 20% coinsurance 50% coinsurance fees If you need mental health, behavioral health, or substance abuse services Outpatient services $30 copay per visit; deductible waived office visits; 10% coinsurance other outpatient services $60 copay per visit; deductible waived office visits; 20% coinsurance other outpatient services 50% coinsurance Preauthorization is required for Partial hospitalization. Inpatient services 10% coinsurance 20% coinsurance 50% coinsurance Preauthorization is required. If you are pregnant Office visits No charge; deductible waived No charge; 50% coinsurance deductible waived Cost sharing does not apply for preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services 10% coinsurance 20% coinsurance 50% coinsurance Childbirth/delivery 10% coinsurance 20% coinsurance 50% coinsurance facility services

Page 5 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Tier 1 Tier 2 Tier 3 Information If you need help recovering or have other special health needs Home health care 10% coinsurance 20% coinsurance 50% coinsurance 60 visits per calendar year combined with private-duty nursing Rehabilitation services 10% coinsurance 20% coinsurance 50% coinsurance 25 visits per calendar year OT; 25 visits per calendar year PT; 25 visits per calendar year ST; Visit limits will not apply to behavioral health; Habilitation services 10% coinsurance 20% coinsurance 50% coinsurance Habilitation services for Learning Disabilities are not covered. Skilled nursing care 10% coinsurance 20% coinsurance 50% coinsurance 150 days per calendar year; Preauthorization is required. Durable medical 10% coinsurance 20% coinsurance 50% coinsurance equipment Preauthorization is required for DME in excess of $500 for rentals or $1,500 for purchases. Hospice service No charge; deductible waived No charge; deductible waived No charge; None deductible waived If your child needs dental or eye care Children’s eye exam No charge; deductible waived No charge; deductible waived No charge to age 19; reimbursed up to $42 from age 19; deductible waived 1 exam per calendar year Children’s glasses Not covered Not covered Not covered None Children’s dental Not covered Not covered Not covered None check-up

Page 6 of 8 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Dental care (Adult) • Routine foot care • Bariatric surgery • Infertility treatment • Weight loss programs • Cosmetic surgery • Long-term care Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care – 12 visits per calendar year • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult) – 1 exam per calendar year • Hearing aids • Private-duty nursing (Outpatient care) – 60 visits per calendar year combined with Home health care Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal or a grievance for any reason to your plan. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.dol.gov/ebsa/healthreform and http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/. Does this plan Provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan Meet the Minimum Value Standard? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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