IN/LG/ Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom 916K/2026 Page 8 of 9 Your Plan: Anthem HealthSync Options POS 3 Tier Option 4 with Rx Option T10 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