64 8) Certain Providers Service you get from Providers that are not licensed by law to provide Covered Services as defined in this Booklet. Examples include, but are not limited to, masseurs or masseuses (massage therapists), and physical therapist technicians. 9) Charges Not Supported by Medical Records Charges for services not described in your medical records. 10) Charges Over the Maximum Allowed Amount Charges over the Maximum Allowed Amount for Covered Services except for Surprise Billing Claims as outlined in the “Consolidated Appropriations Act of 2021 Notice” in the front of this Booklet. 11) Chats or Texts Chats and texting are not a Covered Service unless appropriately provided via a secure and compliant application, according to applicable legal requirements. 12) Clinical Trial Non-Covered Services Any Investigational drugs or devices, non-health services required for you to receive the treatment, the costs of managing the research, or costs that would not be a Covered Service under this Plan for non-Investigational treatments. 13) Clinically-Equivalent Alternatives Certain Prescription Drugs may not be covered if you could use a clinically equivalent Drug, unless required by law. “Clinically equivalent” means Drugs that for most Members, will give you similar results for a disease or condition. If you have questions about whether a certain Drug is covered and which Drugs fall into this group, please call the number on the back of your Identification Card, or visit our website at www.anthem.com. If you or your Doctor believes you need to use a different Prescription Drug, please have your Doctor or pharmacist get in touch with us. The Plan will cover the other Prescription Drug only if agreed that it is Medically Necessary and appropriate over the clinically equivalent Drug. Benefits will be reviewed for the Prescription Drug from time to time to make sure the Drug is still Medically Necessary. 14) Complications of/or Services Related to Non-Covered Services Services, supplies, or treatment related to or, for problems directly related to a service that is not covered by this Plan. Directly related means that the care took place as a direct result of the non-Covered Service and would not have taken place without the non-Covered Service. 15) Compound Ingredients Compound ingredients that are not FDA approved or do not require a prescription to dispense, and the compound medication is not essentially the same as an FDA- approved product from a drug manufacturer. Exceptions to non-FDA approved compound ingredients may include multi-source, non-proprietary vehicles and/or pharmaceutical adjuvants. 16) Cosmetic Services Treatments, services, Prescription Drugs, equipment, or supplies given for cosmetic services. Cosmetic services are meant to preserve, change, or improve how you look or are given for social reasons. No benefits are available for surgery or treatments to change the texture or look of your skin or to change the size, shape or look of facial or body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts). This Exclusion does not apply to reconstructive surgery for breast symmetry after a mastectomy and surgery to correct birth defects and birth abnormalities. 17) Court Ordered Testing Court ordered testing or care unless Medically Necessary. 18) Crime Treatment of an injury or illness that results from a crime you committed, or tried to commit. This Exclusion does not apply if your involvement in the crime was solely the result of a medical or mental condition, or where you were the victim of a crime, including domestic violence. 19) Cryopreservation Charges associated with the cryopreservation of eggs, embryos, or sperm, including collection, storage, and thawing. 20) Custodial Care Custodial Care, convalescent care or rest cures. This Exclusion does not apply to Hospice services. 21) Delivery Charges Charges for delivery of Prescription Drugs. 22) Dental Devices for Snoring Oral appliances for snoring.

Anthem Blue Access PPO HSA Option E6 IN PPO Large 96R6 01 01 2025 L12026MR02 L12026 English EOC CY - Page 65 Anthem Blue Access PPO HSA Option E6 IN PPO Large 96R6 01 01 2025 L12026MR02 L12026 English EOC CY Page 64 Page 66