[HDHP Basic] UHC Medical Plan Summary

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, call 1-833-354-0944 or visit welcometouhc.com. 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.healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2026 – 12/31/2026 HSA Choice Plus HDHP Basic Coverage For: Family | Plan Type: PS1 Important Questions Answers Why This Matters: What is the overall deductible? Network: $5,000 Individual / $10,000 Family Out-of-Network: $10,000 Individual / $20,000 Family Per calendar year. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Preventive Care Services is covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the annual deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www. healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? Network: $5,000 Individual / $10,000 Family Out-of-Network: $10,000 Individual / $20,000 Family Per calendar year. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of- pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn’t cover and penalties for failure to obtain preauthorization for services. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See www.myuhc.com or call 1-833-354-0944 for a list of network providers. 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 might receive a bill from a provider for the difference between the provider’s charge 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 see a specialist? No You can see the specialist you choose without a referral. Page 1 of 7

Page 2 of 7 * For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 0% coinsurance 30% coinsurance None Specialist visit 0% coinsurance 30% coinsurance None Preventive care/ screening/ immunization No Charge 30% coinsurance You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x- ray, blood work) 0% coinsurance 30% coinsurance Preauthorization is required out-of-network for certain services or benefit reduces to 50% of allowed amount. Imaging (CT/PET scans, MRIs) 0% coinsurance 30% coinsurance Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.

Page 3 of 7 * For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need drugs to treat your illness or condition Tier 1 - Your Lowest Cost Option Not Covered Not Covered No coverage for prescription drugs with UnitedHealthcare. Tier 2 - Your Mid- Range Cost Option Not Covered Not Covered Tier 3 - Your Mid- Range Cost Option Not Covered Not Covered Tier 4 - Your Highest Cost Option Not Applicable Not Applicable If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 30% coinsurance Preauthorization is required out-of-network for certain services or benefit reduces to 50% of allowed amount. Physician/ surgeon fees 0% coinsurance 30% coinsurance None If you need immediate medical attention Emergency room care 0% coinsurance *0% coinsurance *Network deductible applies. Emergency medical transportation 0% coinsurance *0% coinsurance *Network deductible applies. Urgent Care 0% coinsurance 30% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 30% coinsurance Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount. Physician/ surgeon fees 0% coinsurance 30% coinsurance None

Page 4 of 7 * For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse services Outpatient services 0% coinsurance 30% coinsurance Network All Other: 0% coinsurance. See your policy or plan document for additional information about Employee Assistance Program (EAP) benefits. Inpatient services 0% coinsurance 30% coinsurance Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount. See your policy or plan document for additional information about EAP benefits. If you are pregnant Office Visits No Charge 30% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery professional services 0% coinsurance 30% coinsurance Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Childbirth/delivery facility services 0% coinsurance 30% coinsurance Inpatient Preauthorization applies out-of-network if stay exceeds 48 hours (C-Section: 96 hours) or benefit reduces to 50% of allowed amount. If you need help recovering or have other special health needs Home health care 0% coinsurance 30% coinsurance Limited to 90 visits per calendar year. Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount. Rehabilitation services 0% coinsurance 30% coinsurance Limits per calendar year: Cardiac: 36 visits; Physical, Occupational, Speech, Pulmonary: Unlimited. Habilitative services 0% coinsurance 30% coinsurance Services are provided under Rehabilitation Services above. Skilled nursing care 0% coinsurance 30% coinsurance Limited to 60 days per calendar year (combined with inpatient rehabilitation). Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.

Page 5 of 7 * For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Durable medical equipment 0% coinsurance 30% coinsurance Preauthorization is required out-of-network for DME over $1,000 or no coverage. Hospice services 0% coinsurance 30% coinsurance Preauthorization is required out-of-network before admission for an Inpatient Stay in a hospice facility or benefit reduces to 50% of allowed amount. If your child needs dental or eye care Children’s eye exam Not Covered Not Covered No coverage for Children’s eye exams. Children’s glasses Not Covered Not Covered No coverage for Children’s glasses. Children’s dental check-up Not Covered Not Covered No coverage for Children’s dental check-up.

Page 6 of 7 * For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Excluded Services & Other Covered Services: • Acupuncture • Bariatric surgery • Cosmetic Surgery • Dental Care • Glasses • Hearing aids • Infertility Treatment • Long Term Care • Non-emergency care when traveling outside - the US • Prescription drugs • Routine Eye Care • Routine foot care - Except as covered for Diabetes • Weight loss programs 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, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.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 on how 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: the Member Service number listed on the back of your ID card or myuhc.com. Additionally, a consumer assistance program may help you file your appeal. Contact dol.gov/ebsa/healthreform. 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 Standards? 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. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-833-354-0944. Traditional Chinese (中文): 如果需要中文的幫助, 請撥打這個號碼 1-833-354-0944. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-833-354-0944. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-833-354-0944. Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf 1-833-354-0944 uff. Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-833-354-0944. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-833-354-0944. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-833-354-0944. • Private duty nursing - 84 visits per calendar year Outpatient only • Chiropractic (manipulative) care Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) To see examples of how this plan might cover costs for a sample medical situation, see the next section.

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 7 Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance Mia’s Simple Fracture (in-network emergency room visit and follow up care) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance Cost Sharing Deductibles $5,000 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,060 Cost Sharing Deductibles $1,100 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Joe would pay is $1,100 Cost Sharing Deductibles $2,800 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,800 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. About these Coverage Examples: $5,000 0% 0% 0% This EXAMPLE event includes services like: $5,000 0% 0% 0% This EXAMPLE event includes services like: This EXAMPLE event includes services like: $5,000 0% 0% 0% Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Total Example Cost $12,700 Total Example Cost $5,600 $2,800 Total Example Cost