2025 Medical Benefit Overview Traditional Plan HDHP 3500 (HSA) HDHP 4500 (HSA) All plan information provided below is for IN-Network Providers. Deductible Embedded Embedded Embedded Single $1,500 $3,500 $4,500 Family $3,000 $7,000 $9,000 Coinsurance 20% 20% 20% Out-of-Pocket Maximum Embedded Embedded Embedded Single $5,000 $5,000 $6,000 Family $10,000 $10,000 $12,000 Preventive Care 100% Coverage 100% Coverage 100% Coverage Physician Office Visit $25 Copay 20% after deductible 20% after deductible Specialist Office Visit $40 Copay 20% after deductible 20% after deductible Virtual Care - MDLIVE $25 Copay 20% after deductible 20% after deductible Virtual Specialist Visit $40 Copay 20% after deductible 20% after deductible Urgent Care Centers $50 Copay 20% after deductible 20% after deductible ER Services $300 Copay 20% after deductible 20% after deductible Hospital Services 20% after deductible 20% after deductible 20% after deductible Out-Patient Services 20% after deductible 20% after deductible 20% after deductible Maternity Services 20% after deductible 20% after deductible 20% after deductible Lab and Radiology 20% after deductible 20% after deductible 20% after deductible Preventive RX - Free Retail Pharmacy Generic $10 Copay 20% after deductible 20% after deductible Preferred $50 Copay 20% after deductible 20% after deductible Non-Preferred $90 Copay 20% after deductible 20% after deductible Non-Preferred 40% to $250 Copay 20% after deductible 20% after deductible Mail Order Pharmacy Generic $25 Copay 20% after deductible 20% after deductible Preferred $125 Copay 20% after deductible 20% after deductible Non-Preferred $225 Copay 20% after deductible 20% after deductible Specialty Rx 40% to $250 Copay 20% after deductible 20% after deductible *Embedded Deductible— Each family member has an individual deductible within the overall family deductible. Meaning if an individual in the family reaches his or her deductible before the family deductible is reached, that person will start paying coinsurance. Page 5 | Inotiv | Plan Year 2025 This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.