How to notifyCMS Thisinformationmustalso berecordedwith CMS. Gotocms.hhs.gov/creditablecoverageandcompletethe DisclosuretoCMSFormunlessyourorganizationisexempt,asoutlinedinthedisclosuretoCMSguidance. Employers must submit the online disclosure form at thefollowing times: ◦ Within60days aftertheplanyear effectivedate. ◦ Within30days aftertheterminationoftheprescriptiondrugplan. ◦ Within30days afteranychangeinthecreditablecoveragestatusofthedrugplan. You can find details about creditable coverage, such as rules, forms, model disclosure notice language for beneficiaries, and requirementsforyour CMSdisclosurenotice,atcms.hhs.gov/creditablecoverage. Nextsteps ◦ Youmaygetasecondletterifyouhavemorethanoneprescriptiondrugplanandoneofthemisnoncreditable. ◦ If you decide to changeyour current prescriptiondrug benefit, contact your account representative. ◦ More information about creditable coverage is available at the CMS website atcms.hhs.gov/creditablecoverage. Are your planscreditable? Thecreditablecoveragestatusoftheprescriptiondrug benefitsincludedin the plan(s) your groupoffers is outlined below: 2024 PlanNames Contract Codes Creditable coverage status PPO Option 12 76VA Creditable PPO Option 5 76X2 Creditable PPO HSA Option E4 76V9 Creditable PPO HSA Option 1 76VC Creditable If you have any questions, contact your Anthemrepresentative. Sincerely, Your AnthemTeam Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Georgia:Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. and Community Care Health Plan of Georgia, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire:Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In 17 southeastern counties of New York: Anthem HealthChoice Assurance, Inc. and Anthem HealthChoice HMO, Inc.In these same counties AnthemBlue Cross and Blue Shield HP is the trade name of AnthemHP, LLC.In Ohio:Community Insurance Company.In Virginia:AnthemHealth Plans of Virginia, Inc.trades as AnthemBlue Cross and Blue Shield, and its affiliate HealthKeepers, Inc. trades as Anthem HealthKeepers providing HMO coverage, and their service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin:Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out-of-network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC).Compcare Page 28 Noblesville Schools Plan Year 2025 underwritesor administers HMO or POS policies;WCIC underwritesor administers Well Priority HMO or POS policies.Independent licensees of the Blue Crossand Blue Shield Association.Anthem is a registeredtrademarkof Anthem InsuranceCompanies,Inc This Compliance Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.