HSA Plan - Summary of Benefits & Coverage

HSA Qualified Health Plan Summary of Benefits and Coverage Effective 01/01/2027 Benefits Anthem BlueCard PPO Network Out-of-Network Plan Year January 1 through December 31 Deductible Individual or EE+CH*/Family $3,000 or $6,000 $3,000 or $6,000 EE+CH/Family coverage requires that the full EE+CH/Family deductible to be met before coinsurance applies; the individual deductible does not apply to EE+CH/Family coverage. Non-Preventive Prescription expenses are included in the medical deductible. Member Coinsurance 20% 50% Out-of-Pocket Maximum (OOPM*) *Amount Includes Deductible Individual Plan (Employee Only) = $5,250 EE+CH/Family = $9,000 (Individual Max OOP of $7,600) Individual = $6,450 EE+CH/Family = $12,900 Office Services Office Exam Physician – Illness Injury 20% after deductible 50% after deductible Office Exam Nurse Practitioner – Illness Injury 20% after deductible 50% after deductible Chronic Disease Illness Visits 20% after deductible 50% after deductible Preventive Services1 Routine exams, tests and immunizations No Charge 50% after deductible Routine Mammograms, pap tests and colonoscopies No Charge 50% after deductible Tobacco Cessation No Charge 50% after deductible Lab Charges2 LabCorp, Quest Diagnostic/LabCard and American Health Network No Charge after deductible Diagnostic Lab Charges – Physician/Facility 20% after deductible 50% after deductible Outpatient Services Surgical Expenses – Facility 20% after deductible 50% after deductible Surgical Expenses – Physician 20% after deductible 50% after deductible Diagnostic X-ray Expenses – Facility 20% after deductible 50% after deductible Diagnostic X-ray Expenses – Physician 20% after deductible 50% after deductible Manipulation Therapy 20% after deductible; 24 Day Visit Limitation 50% after deductible; 24 Day Visit Limitation Physical, Speech and Occupational Therapy 20% after deductible; 60 Day Visit Limitation 50% after deductible; 60 Day Visit Limitation Cardiac Rehabilitation 20% after deductible; 36 Day Visit Limitation 50% after deductible; 36 Day Visit Limitation