IN/LG/ Richmond Community School Trust HealthSync Opt POS HSA 3 Tier Opt E2 Rx Carved out-Custom /BASE -914D/2026 Page 6 of 7 Your Plan: Anthem HealthSync Options POS HSA 3 Tier Option E2 with Rx Option T12 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