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