HSA Qualified Health Plan BAAG Effective 01012026

HSA Qualified Health Plan Summary of Benefits and Coverage Effective 01/01/2026 Benefits Anthem BlueCard PPO Network Out-of-Network Plan Year January 1 through December 31 Deductible Individual or EE+CH*/Family $2,500 or $5,000 $2,500 or $5,000 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) = $4,750 EE+CH/Family = $8,250 (Individual Max OOP of $7,150) 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

HSA Qualified Health Plan Summary of Benefits and Coverage Effective 01/01/2026 Pulmonary Rehabilitation 20% after deductible; 20 Day Visit Limitation 50% after deductible; 20 Day Visit Limitation Inpatient Services Pre-Admission Testing – Facility 20% after deductible 50% after deductible Pre-Admission Testing – Physician 20% after deductible 50% after deductible Surgical Expenses – Facility 20% after deductible 50% after deductible Surgical Expenses – Physician 20% after deductible 50% after deductible Inpatient Care – Facility 20% after deductible 50% after deductible Inpatient Care – Physician 20% after deductible 50% after deductible Skilled Nursing Facility 20% after deductible 50% after deductible Additional Services Emergency Room Illness and Accident Benefit 20% after $200 copay after deductible (copay is waived if admitted)-must satisfy emergency criteria Ambulance Benefit 20% after deductible Substance Abuse Benefit 20% after deductible 50% after deductible Mental Health Benefit 20% after deductible 50% after deductible Durable Medical Equipment 20% after deductible 50% after deductible Prosthetics/Orthotics 20% after deductible 50% after deductible Home Health Care 20% after deductible 50% after deductible Hospice Care 20% after deductible 50% after deductible Bariatric Services for Morbid Obesity 20% after deductible; additional criteria required 50% after deductible; additional criteria required ConditionCare Disease Management Solution Program N/A N/A Anthem Engage Cost & Quality Tool N/A N/A Advanced Imaging Management (AIM) N/A N/A *Abbreviations: EE+CH = Employee Plus Children INN = In-Network OOPM = Out-of-Pocket-Maximum 1 Preventive care is provided when there are no current symptoms or history of medical conditions associated with a particular screening; all preventive services are limited to one of each service per year per covered member. 2 This benefit is for blood work lab charges only.