Plan 1 - 2000

PHP Schedule of Benefits for CUSTOM 2000 Sample Plan Benefit Overview In-Network Out-of-Network* Per Member Deductible $2,000 $4,000 Per Family Deductible $4,000 $8,000 Per Member Out-of-Pocket Limit $5,000 $10,000 Per Family Out-of-Pocket Limit $8,000 $16,000 There may be more than one Deductible and Out-of-Pocket Limit set forth in the Contract. Deductibles and Out-of-Pocket Limits are based on a Calendar Year benefit period, unless otherwise indicated herein. In-Network: The In-Network Deductible and In-Network Out-of-Pocket Limit apply to all In-Network Covered Health Services unless otherwise stated. In-Network Copays do not count toward the In-Network Deductible. The In-Network Deductible, Copays and Coinsurance count toward the In-Network Out-of- Pocket Limit. If a Provider, a facility, or anyone else reduces or waives the required cost sharing (Deductible, Copays, Coinsurance) for a particular claim, we reserve the right to adjust the amount charged, the amount eligible under the terms of the policy, your Deductible and/or Out-of-Pocket Limit, to accurately reflect the amount actually charged for that claim. This Plan is embedded: PHP will pay for a Member’s Covered Health Services once the “per Member” Deductible is met by that Member. When the “per family” Deductible is met, PHP will pay for Covered Health Services for all Covered family Members. Copays and Coinsurance for a Member’s Covered Health Services are not required for the rest of the Calendar Year once the “per Member” Out-of-Pocket Limit is met by that Member. When the “per family” Out-of-Pocket Limit is met, Copays and Coinsurance for Covered Health Services are not required for the rest of the Calendar Year for all Covered family Members. Out-of-Network: The Out-of-Network Deductible and Out-of-Network Out-of-Pocket Limit apply to all Out-of- Network Covered Health Services unless otherwise stated. The Out-of-Network Deductible and Coinsurance count toward the Out-of-Network Out-of-Pocket Limit. If a Provider, a facility, or anyone else reduces or waives the required cost sharing (Deductible, Copays, Coinsurance) for a particular claim, we reserve the right to adjust the amount charged, the amount eligible under the terms of the policy, your Deductible and/or Out-of-Pocket Limit, to accurately reflect the amount actually charged for that claim. This Plan is embedded: PHP will pay for a Member’s Out-of-Network Covered Health Services once the Out-of- Network “per Member” Deductible is met by that Member. When the Out-of-Network “per family” Deductible is met, PHP will pay for Out-of-Network Covered Health Services for all Covered family Members. Coinsurance for a Member’s Out-of-Network Covered Health Services is not required for the rest of the Calendar Year once the Out-of-Network “per Member” Total Out-of-Pocket Limit is met by that Member. When the Out-of-Network “per family” Total Out-of-Pocket Limit is met, Coinsurance for Out-of-Network Covered Health Services is not required for the rest of the Calendar Year for all Covered family Members. Expenses you incur on non-Covered Services do not count toward the applicable In-Network or Out-of- Network Deductible or toward the applicable In-Network or Out-of-Network Out-of-Pocket Limit. This schedule is a summary of the benefits available to you. It also may help you understand how much you may have to pay for a particular service. Before getting any Health Services, you should review your Certificate of Coverage and contact us to check your Coverage. PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024

PHP Schedule of Benefits for Legacy 1500 POS 9 Medical Benefits In-Network You Pay Doctor’s Office Visit Illness, Injury or Sickness. Emergency services in a Doctor’s office. Prior Authorization required for specific surgeries and specific drugs. Additional Copays, Deductible or Coinsurance may apply when you receive other services during a Doctor’s office visit. Office Visit Charge for Par Doctor of primary care practice areas of family practice, pediatrics, internal medicine, obstetrics and gynecology. Office Visit Charge for Par Doctor of specialty care. Other Services 20% after Deductible. The Out-of- Pocket Limit applies.Goto 20% after Deductible. The Out-of- Pocket Limit applies. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Other Practitioner Visits Chiropractor services are limited to 45 visits combined In- Network and Out-of-Network per Calendar Year across outpatient and other professional visits. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. LabCorp Routine Labs Routine lab services, such as but not limited to: pregnancy test; blood test; or urine test performed at a freestanding LabCorp facility. Urine drug screenings are limited to a total of 24 screenings per Calendar Year. No Charge Deductible waived 50% after Deductible. The Out-of- Pocket Limit applies. Diagnostic Routine radiology services, such as but not limited to: chest x-ray or MRI. Routine lab services, such as but not limited to: pregnancy test; blood test; or urine test performed at a facility other than LabCorp or in a Hospital (inpatient or outpatient) setting. Urine drug screenings are limited to a total of 24 screenings per Calendar Year. Prior Authorization required for specific radiology services. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Preventive Care Services rated 'A' or 'B' by the U.S. Preventive Services Task Force. Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Preventive care and screenings for women and children as recommended by the Health Resources and Services Administration. Visit www.phpni.com or call PHP Customer Service for a list of No Charge Deductible waived 50% after Deductible. The Out-of- Pocket Limit applies. preventive services. Outpatient Prior Authorization required for specific surgeries and specific drugs. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Inpatient Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024 Out-of-Network* You Pay

PHP Schedule of Benefits for Legacy 1500 POS 9 Emergency Health Services - Outpatient For Emergency Health Services, 20% after Deductible. The Out- of- Pocket Limit applies. Services received may not be covered unless diagnosis is emergent in nature. Emergency Services are Covered as an In-Network Benefit. Services received may not be covered unless diagnosis is emergent in nature. Urgent Care Center Urgent Care services received within the Service Area must be received at a Par Provider to be Covered as In-Network Benefits. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Ambulance 20% after Deductible. The Out-of- Pocket Limit applies. Ambulance is always paid at the in- network benefit however, non- contracted providers may bill you for charges that exceed our payment amount. Covered as an In-Network Benefit. Home Health Care 100 visits combined In-Network and Out-of-Network Calendar Year limit. Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Hospice Care and Services 180 consecutive days per lifetime. Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. Not Covered Inpatient Transitional Care Unit 30 day combined In-Network and Out-of-Network Calendar Year limit. Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Durable Medical Equipment, Prosthetics, Orthotic Appliances and Ostomy Supplies Prior Authorization required for specific DME, prosthetics and Orthotic Appliances. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Outpatient Therapy Services - Rehabilitation Services Combined In-Network and Out-of-Network limit per Calendar Year: - Physical therapy: 40 visits - Occupational therapy: 40 visits - Speech therapy: 40 visits - Cardiac Rehabilitation: 36 visits - Pulmonary Rehabilitation: 20 visits 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Outpatient Therapy Services - Habilitation Services Combined In-Network and Out-of-Network limit per Calendar Year: - Physical therapy: 40 visits - Occupational therapy: 40 visits - Speech therapy: 40 visits 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Inpatient Therapy Services (Rehabilitation/Habilitation Services) 60 day combined In-Network and Out-of-Network Calendar Year limit. Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024

PHP Schedule of Benefits for Legacy 1500 POS 9 Transplant Procedure Services Transplant services must be performed at a Designated Transplant Center of Excellence. Prior Authorization required. Benefits and cost share are based on the setting in which Covered Services are received as outlined on this Schedule of Benefits. Not Covered Temporomandibular or Craniomandibular Joint Disorder and Craniomandibular Jaw Disorder Services Limited to one treatment per side of head per lifetime. Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. Covered as an In-Network Benefit. Maternity Services Inpatient Delivery does not require Prior Authorization unless it exceeds normal delivery times of 48 hours or 96 hours for C-section. Benefits and cost share are based on the setting in which Covered Services are received as outlined on this Schedule of Benefits. 50% after Deductible. The Out-of- Pocket Limit applies. Diabetes Services Refer to the specific service. Refer to the specific service. Cancer Chemotherapy Treatment $30 Copay The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024

PHP Schedule of Benefits for Legacy 1500 POS 9 Outpatient Prescription Drug Benefits To the extent a Provider, drug manufacturer, Pharmacy, or third-party (other than family) waives, discounts, reduces or pays (directly or indirectly) the required cost sharing (Deductible, Copay, or Coinsurance) for a particular claim, the applicable cost sharing met by the Member on the claim will be reduced to reflect the amount of such waiver, discount, reduction or third-party payment. Prescription Drug Copays do not count toward the medical Deductible. Prescription Drug Copays/Coinsurance count toward the medical Out-of-Pocket Limit. Certain Prescription Drugs require the use of an alternate Prescription Drug before they are Covered. The alternate Prescription Drug must have been used within a specified number of days. This process is called Step Therapy. Prior Authorization required for specific Specialty Prescription Drugs. In-Network You Pay Retail Prescription Drugs (Up to a 30 Day Supply) Tier 1 Prescription Drug - Not Covered Per Prescription or refill (except when manufacturer’s $15 Copay per Prescription Drug packaging further limits the supply). Includes diabetic The Copay does not apply to the supplies and a one unit limit for inhaler aid devices such as Deductible. The Out-of-Pocket Limit but not limited to: Aerochambers, Inspirease and applies. Breathancer. (Member is required to pay the price difference between Tier 2 Prescription Drug - Brand Name and Generic Drug, in addition to the $15 Copay per Prescription Drug Copay/Coinsurance, if the Brand Name Drug is ordered or The Copay does not apply to the requested and generic is available.) Deductible. The Out-of-Pocket Limit applies. Prior Authorization required for specific Specialty Prescription Drugs. Tier 3 Prescription Drug - $30 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Tier 4 Prescription Drug - $60 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Specialty Prescription Drugs (Self-Administered) 20% per Prescription Drug after Deductible up to a maximum of $350. The Out-of-Pocket Limit applies. PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024 Out-of-Network* You Pay

PHP Schedule of Benefits for Legacy 1500 POS 9 Retail Prescription Drugs (Up to a 90 Day Supply) Per Prescription or refill (except when manufacturer’s packaging further limits the supply). Includes diabetic supplies. (Member is required to pay the price difference between Brand Name and Generic Drug, in addition to the Copay, if the Brand Name Drug is ordered or requested and generic is available.) Not all retail prescription drugs are available with a 90 day supply. No Specialty Prescription Drugs are available with a 90 day supply. Tier 1 Prescription Drug - $45 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Tier 2 Prescription Drug - $45 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Tier 3 Prescription Drug - $90 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Tier 4 Prescription Drug - $180 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Not Covered Specialty Drugs Office Administered Specialty Drugs only. Prior Authorization required for specific Specialty Drugs. 20% per Office Administered Specialty Drug only after Deductible up to a maximum of $350. The Out-of-Pocket Limit applies. 50% per Office Administered Specialty Drug only after Deductible. The Out-of-Pocket Limit applies. Mail Order Prescription Drugs (Up to a 90 Day Supply) Per Prescription or refill (except when manufacturer’s packaging further limits the supply). Includes diabetic supplies. (Member is required to pay the price difference between Brand Name and Generic Drug, in addition to the Copay, if the Brand Name Drug is ordered or requested and generic is available.) No Specialty Prescription Drugs are available for Mail Order Prescription Drugs. Tier 1 Prescription Drug - $30 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Tier 2 Prescription Drug - $30 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Tier 3 Prescription Drug - $60 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Tier 4 Prescription Drug - $120 Copay per Prescription Drug The Copay does not apply to the Deductible. The Out-of-Pocket Limit applies. Not Covered Mail Order Inhaler Aid Devices; Nail Fungus Drugs; Specialty Drugs Not Covered Not Covered PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024

PHP Schedule of Benefits for Legacy 1500 POS 9 Behavioral Health and Mental Health and Substance Use Disorder Benefits In-Network You Pay Out-of-Network* You Pay Outpatient Services Individual or interactive diagnostic interview exams or testing; crisis intervention; therapeutic services; individual and/or group outpatient evaluations. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Intensive Outpatient Partial Hospitalization Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Inpatient Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. * All services listed under Out-of-Network are subject to Reasonable and Customary Charges, except for Out-of- Network Emergency benefits. The information contained in this Schedule of Benefits is not intended to provide a full description of eligible benefits, requirements and limitations. The full description, requirements and limitations are reflected in the Certificate of Coverage. A copy of the Certificate of Coverage and any Amendments will be provided to you upon enrollment or upon request. If you have questions, please refer to your Certificate of Coverage or contact our Customer Service Department at (260) 432-6690, extension 11; 1-800-982-6257, extension 11; or custsvc@phpni.com (e-mail). To the extent that this Schedule of Benefits, description of eligible benefits, requirements, and limitations conflict with those in your Certificate of Coverage as amended from time to time, the terms of your Certificate of Coverage shall govern. PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024