Anthem Summary of Benefits PPO Plan

Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom Page 1 of 9 Your summary of benefits Anthem® Blue Cross and Blue Shield Effective: 1/1/2026 Your Plan: Anthem HealthSync Options POS 3 Tier Richmond Community School Trust Your Network: HealthSync Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge medical deductible does not apply Mental Health & Substance Use Disorder Services No charge medical deductible does not apply Specialist care $30 copay per visit medical deductible does not apply Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Overall Deductible $2,000 person / $4,000 family $5,000 person / $10,000 family $15,000 person / $30,000 family Overall Out-of-Pocket Limit $7,000 person / $14,000 family $7,000 person / $14,000 family $21,000 person / $42,000 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Out-of-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. The deductibles for Preferred Network and In-Network cross apply. Satisfying one helps satisfy the other. The out-of-pocket limits for Preferred Network and In-Network cross apply as well. Doctor Visits (virtual and office) Your plan requires the selection of a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder Services virtual and office $15 copay per visit medical deductible does not apply $40 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Specialist Provider virtual and office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Practitioner Visits Maternity Doctor services (prenatal/postpartum care and delivery) 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Retail Health Clinic for routine care and treatment of common illnesses; usually found in major pharmacies or retail stores. $15 copay per visit medical deductible does not apply $40 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met

Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom Page 2 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Other Services in an Office Allergy Testing When Allergy injections are billed separately by network providers, the member is responsible for a $10 copay. When billed as part of an office visit, there is no additional cost to the member for the injection. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Prescription Drugs Dispensed in the office 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Surgery $30 copay per visit medical deductible does not apply‡ $80 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Preventive care / screenings / immunizations No charge No charge 50% coinsurance after medical deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge No charge Cost share is based on the setting services are received. Diagnostic Services Lab Office No charge No charge 50% coinsurance after medical deductible is met Freestanding Lab/Reference Lab No charge No charge 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Diagnostic Services X-Ray Office No charge No charge 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Diagnostic Services Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met

Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom Page 3 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Freestanding Radiology Center 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply depending on the care provided. $75 copay per visit medical deductible does not apply 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Emergency Room Facility Services Your copay will be waived if admitted. $250 copay per visit and then 20% coinsurance after medical deductible is met Same as In-Network Tier 1 Covered as In-Network Emergency Room Doctor and Other Services 20% coinsurance after medical deductible is met Same as In-Network Tier 1 Covered as In-Network Ambulance Authorized Out-of-Network non-emergency ambulance services are limited to an Anthem maximum payment of $50,000 per trip. The $50,000 limit does not apply to air ambulance services. 20% coinsurance after medical deductible is met Same as In-Network Tier 1 Covered as In-Network Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Doctor Services 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Surgery Facility Fees Hospital 20% coinsurance after medical deductible is met $250 copay per visit and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Ambulatory Surgical Center 20% coinsurance after medical deductible is met $250 copay per visit and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met

Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom Page 4 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Physician and other services including surgeon fees Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Ambulatory Surgical Center 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) If readmitted within 72 hours for the same condition, no additional facility copay is required. If transferred between facilities, only one copay will apply. Facility Fees 20% coinsurance after medical deductible is met $500 copay per admission and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Human Organ and Tissue Transplants Cornea transplants are treated as medical procedures, with benefits and cost sharing determined by the setting in which the services are received. No charge No charge 50% coinsurance after medical deductible is met Physician and other services including surgeon fees 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Home Health Care Coverage is limited to 120 visits per benefit period. Limits are combined for all home health services. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Therapy Services Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical and occupational therapies is limited to 40 visits combined per benefit period. Coverage for speech therapy is limited to 20 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met

Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom Page 5 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Manipulation Therapy Coverage is limited to 12 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Pulmonary rehabilitation Coverage is limited to 20 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Dialysis/Hemodialysis Office No charge No charge 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Chemo/Radiation Therapy Office $30 copay per visit medical deductible does not apply‡ $80 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met

Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom Page 6 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Skilled Nursing Care (facility) Coverage for Skilled Nursing, Outpatient Rehabilitation and Inpatient Rehabilitation facility settings is limited to 150 days combined per benefit period. 20% coinsurance after medical deductible is met $500 copay per admission and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Inpatient Hospice No charge No charge No charge Additional Services, Equipment and Devices Durable Medical Equipment 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Prosthetic Devices 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Wigs Coverage for wigs is limited to 1 item after cancer treatment per benefit period. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Covered Vision Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider This is a brief outline of your vision coverage. To receive the In-Network benefit, you must use a Blue View Vision Provider. Only children's vision services count towards your out-of-pocket limit. Children’s Vision exam (up to age 19) Limited to 1 exam per benefit period. No charge $0 copayment up to plan's Maximum Allowed Amount Adult Vision exam (age 19 and older) Limited to 1 exam per benefit period. No charge Reimbursed Up to $42 Notes: • Dependent Age Limit: to the end of the month in which the child attains age 26. • Members are encouraged to always obtain prior approval when using Out-of-Network Providers. Precertification will help the member know if the services are considered not medically necessary. • No charge means no deductible / copayment / coinsurance up to the maximum allowable amount. 0% means no coinsurance up to the maximum allowable amount. However, when choosing an Out-of-Network Provider, the member is responsible for any balance due after the plan payment. • If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”. • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • ‡ You will pay your PCP or Specialist office visit copay for certain services provided in their office.

Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom Page 7 of 9 • The representations of benefits in this document are subject to Indiana Department of Insurance (IN DOI) approval and are subject to change. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Questions: (833) 578-4441 or visit us at www.anthem.com

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

63658MUMENMUB 10/24 #AG-GEN-001# Page 9 of 9 We’re here for you – in many languages The law requires us to include a message in all of these different languages. Curious what they say? Here’s the English version: “You have the right to get help in your language for free. Just call the Member Services number on your ID card.” Visually impaired? You can also ask for other formats of this document TTY/TTD:711 It’s important we treat you fairly We follow federal civil rights laws in our health programs and activities. Members can get reasonable modifications as well as free auxiliary aids and services if you have a disability. We don’t discriminate, on the basis of race, color, national origin, sex, age or disability. For people whose primary language isn’t English (or have limited proficiency), we offer free language assistance services like interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711) or visit our website. If you think we failed in any areas or to learn more about grievance procedures, you can mail a complaint to: Compliance Coordinator, P.O. Box 27401, Richmond, VA 23279, or directly to the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201. You can also call 1-800- 368-1019 (TDD: 1-800-537-7697) or visit https://ocrportal.hhs.gov/ocr/portal/lobby.jsf