****Class Only Model Document ***

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 UMR: DEPAUW UNIVERSITY: 7670-00-413597 004 005 Coverage for: Individual + Family | Plan Type: HDHP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.umr.com or by calling 1-800-207-3172. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.umr.com or call 1-800-207-3172 to request a copy. Important Questions Answers Why this Matters: What is the overall $2,000 person / $4,000 family In-network Generally, you must pay all the costs from providers up to the deductible amount deductible? $3,500 person / $7,000 family Out-of-network before this plan begins to pay. If you have other family members on the plan, the overall family deductible must be met before the plan begins to pay. This plan covers some items and services even if you haven’t yet met the deductible Are there services covered Yes. Preventive care services are covered amount. But a copayment or coinsurance may apply. For example, this plan covers before you meet your before you meet your deductible. certain preventive services without cost-sharing and before you meet your deductible? deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles No. You don’t have to meet deductibles for specific services. for specific services? What is the out–of–pocket $3,500 person / $7,000 family In-network The out-of-pocket limit is the most you could pay in a year for covered services. limit for this plan? $7,000 person / $14,000 family Out-of-network If you have other family members in this plan, the overall family out-of-pocket limit must be met. What is not included in the Penalties, premiums, balance billing charges, Even though you pay these expenses, they don’t count toward the out-of-pocket out–of–pocket limit? and health care this plan doesn’t cover. limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you Will you pay less if you use Yes. See www.umr.com or call 1-800-207-3172 might receive a bill from a provider for the difference between the provider’s charge a network provider? for a list of network providers. and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? Page 1 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Important Medical Event Services You May Need In-network Out-of-network Information (You will pay the least) (You will pay the most) Primary care visit to treat an 20% Coinsurance 40% Coinsurance None injury or illness If you visit a health care Specialist visit 20% Coinsurance 40% Coinsurance None provider’s office or clinic You may have to pay for services that aren't Preventive care/screening/ No charge; 40% Coinsurance preventive. Ask your provider if the services immunization Deductible Waived needed are preventive. Then check what your plan will pay for. Diagnostic test 20% Coinsurance 40% Coinsurance None (x-ray, blood work) If you have a test Imaging 20% Coinsurance 40% Coinsurance None (CT/PET scans, MRIs) Page 2 of 7

Common What You Will Pay Limitations, Exceptions, & Other Important Medical Event Services You May Need In-network Out-of-network Information (You will pay the least) (You will pay the most) If you need drugs to treat Generic drugs (Tier 1) 0% Coinsurance after 40% Coinsurance after your illness or Deductible. Deductible. condition. More Preferred brand drugs (Tier 2) 40% Coinsurance after 40% Coinsurance after Pharmacy Benefits are administered by information Deductible. Deductible. CVS/Caremark. about prescription drug coverage Non-preferred brand drugs 50% Coinsurance after 40% Coinsurance after is available at (Tier 3) Deductible. Deductible. www.caremark. com. Facility fee (e.g., ambulatory 20% Coinsurance 40% Coinsurance None If you have surgery center) outpatient surgery Physician/surgeon fees 20% Coinsurance 40% Coinsurance None Emergency room care 20% Coinsurance 20% Coinsurance In-network deductible applies to Out-of-network benefits If you need immediate Emergency medical 20% Coinsurance 20% Coinsurance In-network deductible applies to medical transportation Out-of-network benefits attention Urgent care 20% Coinsurance 40% Coinsurance None Page 3 of 7

Common What You Will Pay Limitations, Exceptions, & Other Important Medical Event Services You May Need In-network Out-of-network Information (You will pay the least) (You will pay the most) Facility fee 20% Coinsurance 40% Coinsurance (e.g., hospital room) If you have a Preauthorization is required. hospital stay Physician/surgeon fees 20% Coinsurance 40% Coinsurance If you have Outpatient services 20% Coinsurance 40% Coinsurance Preauthorization is required for Partial mental health, hospitalization. behavioral health, or substance abuse Inpatient services 20% Coinsurance 40% Coinsurance Preauthorization is required. services Office visits No charge; 40% Coinsurance Deductible Waived Cost sharing does not apply for preventive services. Depending on the type of services, If you are Childbirth/delivery 20% Coinsurance 40% Coinsurance deductible, copayment or coinsurance may pregnant professional services apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery facility 20% Coinsurance 40% Coinsurance services Page 4 of 7

Common What You Will Pay Limitations, Exceptions, & Other Important Medical Event Services You May Need In-network Out-of-network Information (You will pay the least) (You will pay the most) Home health care 20% Coinsurance 40% Coinsurance 100 Maximum visits per calendar year; Preauthorization is required. Rehabilitation services 20% Coinsurance 40% Coinsurance None If you need Habilitation services 20% Coinsurance 40% Coinsurance Habilitation services for Learning Disabilities help are not covered. recovering or have other 60 Maximum days per calendar year; special health Skilled nursing care 20% Coinsurance 40% Coinsurance Preauthorization is required. needs Durable medical equipment 20% Coinsurance 40% Coinsurance Preauthorization is required for DME in excess of $500 for rentals or $1,500 for purchases. Hospice service No charge No charge None Children’s eye exam No charge; 40% Coinsurance 1 Maximum exam per calendar year Deductible Waived If your child needs dental Children’s glasses Not covered Not covered None or eye care Children’s dental check-up Not covered Not covered None Page 5 of 7

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Dental care (Adult) • Long-term care • Bariatric surgery • Hearing aids • Routine foot care • Cosmetic surgery • Infertility treatment • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care • Private-duty nursing (Outpatient care only when • Routine eye care (Adult) provided through home care services) • Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.HealthCare.gov and http://cciio.cms.gov/programs/consumer/capgrants/index.html. Does this plan Provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan Meet the Minimum Value Standard? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 6 of 7

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) controlled condition) care)  The plan's overall deductible $2,000  The plan's overall deductible $2,000  The plan's overall deductible $2,000  Specialist coinsurance 20%  Specialist coinsurance 20%  Specialist coinsurance 20%  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Other coinsurance 20%  Other coinsurance 20%  Other coinsurance 20% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (pre-natal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic tests (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $2,000 Deductibles* $1,100 Deductibles* $2,000 Copayments $0 Copayments $0 Copayments $0 Coinsurance $1,500 Coinsurance $0 Coinsurance $200 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $70 Limits or exclusions $4,300 Limits or exclusions $10 The total Peg would pay is $3,570 The total Joe would pay is $5,400 The total Mia would pay is $2,210 Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: www.umr.com or call 1-800-207-3172. *Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”" row above. The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 7