PLAN ltr 01 01 2024 00

115 W Wausau Ave Wausau WI 54401-2875 PO Box 8046 Wausau WI 54402-8046 DEPAUW UNIVERSITY April 12, 2024 Plan Number: 7670-00-413597 Dear Valued Customer: With this letter, we are sending your modified Health summary plan description (SPD). This SPD, referred to as the plan document, will be the basis for the administration of your Health Plan. Also enclosed is the Acceptance Page, which formally approves the plan document. Please sign, retain a copy for your records, and return one copy to your UMR strategic account executive as soon as possible. Note, however, that since the corresponding system changes have been implemented, this document is considered final, whether or not a signature is received. This document will be posted to the UMR member web portal upon UMR’s receipt of your signature, or within 14 days of your receipt of the document if a signature is not received by UMR. Please note that UMR will not print booklets until a signature is received. It is also important that the information in your formally approved plan document agrees with any material distributed to your employees since this document will contain the terms of plan coverage. Any applicable stop loss policies typically rely on the last formally approved plan document when determining coverage. If the plan document distributed to your employees does not accurately describe the way your plan is actually being administered, the result can be a lapse or delay in stop loss coverage. Important: To prevent such lapses or delays in coverage, be sure to return the signed Acceptance Page to your UMR strategic account executive as soon as possible. If applicable, submit a copy of the Acceptance Page along with a copy of your current plan document to your stop loss carrier, which will constitute required notice of plan terms and conditions. Please keep a copy for your records. If you have any questions, please contact your UMR strategic account executive. Thank you for your business. Japeth Alibo Case Installations Enclosure 715.841.2000 / 866.881.0800 (T) www.UMR.com

April 12, 2024 SUMMARY OF MODIFICATIONS As requested, effective January 1, 2024, the following provision(s) were updated in, added to, or deleted from your Health Plan document. The change(s) are shaded in the plan document, with the exception of deleted wording: • Medical Schedule of Benefits, Benefit Plan(s) 001. • Medical Schedule of Benefits, Benefit Plan(s) 002, 003. • Medical Schedule of Benefits, Benefit Plan(s) 004, 005. • Medical Schedule of Benefits, Benefit Plan(s) 006. • Covered Medical Benefits. • Teladoc Services. • UMR CARE: Clinical Advocacy Relationships to Empower. As required, effective January 1, 2024, the following changes were made to your Health Plan document. The change(s) are shaded in the plan document, with the exception of deleted wording: • As part of Non-Quantitative Treatment Limitations (NQTL), the following have been revised throughout the document to add clarity and directive: ➢ Alternative / Complementary Treatment. ➢ Conditions Listed in the most recent American Psychiatric Association Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases – Clinical Modification (ICD-CM) manual (most recent revision) in the following categories: Personality disorders, behavior and impulse control disorders, “Z” codes. ➢ Developmental Delays. ➢ Mental Health Benefits: Mental Health Exclusions – the entire section – has been removed as items are included in classification sections. ➢ Nocturnal Enuresis Alarm. ➢ Substance Use Disorder and Chemical Dependency Benefits: Substance Use Disorder Exclusions – the entire section has been removed as items are included in classification sections. • Eligibility and Enrollment: Eligibility Requirements language has been revised to be broader to meet the requirements of any of the Affordable Care Act (ACA) Measurement Methods. • COBRA Continuation of Coverage: ➢ Making an Election to Continue Group Health Coverage: Language has been added regarding online election, if available, so that such election will not be rejected by stop loss. ➢ Payment for Continuation of Coverage: Language has been added regarding online elections so that such elections will not be rejected by stop loss. • Provider Network: Provider agreements and/or network providers entering into agreements for only certain covered health services, not all covered health services, has been removed. This language was unnecessary and was causing member confusion. • Covered Medical Benefits: ➢ Ambulance Transportation: Language has been clarified for coverage of emergency ambulance transportation to an appropriate hospital for consistency with No Surprises Act coverage of emergencies. ➢ Gender Dysphoria: A clarifying change has been made to the existing benefit description to supplement the general statement of coverage with sufficient benefit detail to better align with the current administration of this benefit. ➢ Hospital Services language has been revised to clarify coverage for semi-private and private rooms and that rate reductions may apply. ➢ Therapy Services: Speech Therapy has been revised to align with current policies and procedures and remove specific references to Autism Spectrum Disorder. • Telemedicine Services – OC24health: Behavioral Health Program language regarding the Covered Person Follow-Up procedure has been removed because the process has been discontinued.

April 12, 2024 • UMR CARE: Clinical Advocacy Relationships to Empower: UMR’s specialty injectables program name was updated to UMR Medical Specialty Drug Program. Language was updated to be applied more broadly and also account for customers who modify the program in the following section(s): ➢ Services Requiring Prior Authorization • UMR CARE: Clinical Advocacy Relationships to Empower: ➢ Language has been added to the following areas to provide flexibility in accommodating certain providers that may not be required to obtain prior authorization on certain services: o Prior Authorization / Notification Requirements. o Definitions. o Penalties for Not Obtaining Prior Authorization. o Retrospective Review. ➢ Prior Authorization / Notification Requirements: Language has been enhanced to better define the roles and responsibilities of the member and provider. ➢ Special Notes: Language has been clarified to provide a more accurate description pertaining to prior authorization notification in emergency circumstances. ➢ Definitions: A Managed Care UnitedHealthcare Network Provisions definition has been added. ➢ Services Requiring Prior Authorization: Access via the website for prior authorizations before receiving services has been added. ➢ Ongoing Condition CARE: Language has been revised to remove the specific reference to high- risk since members do not need to know which risks receive outreach. • Coordination of Benefits: ➢ The types of plans that the plan will coordinate benefits with has been revised to align with the national standard Coordination of Benefit rules. ➢ The bullet regarding married dependent children has been clarified. In order to reduce plan-to- plan conflicts for Coordination of Benefits rules, this change has been made to confirm the plan’s alignment with the national standard Coordination of Benefits rules, which were revised to apply the longer/shorter rule in those situations where a child is covered simultaneously as a dependent until age 26 under both a parent’s plan and a spouse’s plan. • Right of Subrogation, Reimbursement, and Offset: ➢ References to “You” or “Your” have been clarified. ➢ Language has been revised to use the broader term “recoveries” versus “settlement funds.” ➢ “Alleged/Allegedly” language has been added to reduce the burden of proof. ➢ Language has been added for cases of occupational illness or injury. • General Exclusions: ➢ Language has been clarified as exclusions relate to the No Surprises Act. ➢ Self-Administered Services: Language has been revised to clarify that the exclusion generally includes self-infused medications, with certain exceptions. ➢ Workers’ Compensation language has been revised to reflect current industry standard language that appropriately accommodates the varying regulatory requirements for entities to have applicable coverages in place. • Claims and Appeal Procedures: ➢ Types of Claims and Definitions: Pre-Service claim language has been revised to clarify that either the Covered Person or the provider is to obtain approval. ➢ How Health Benefits Are Calculated: Language has been added to refer to the Protection from Balance Billing section. ➢ Reimbursement: Language changes have been made for consistency and alignment for out-of- network reimbursement program methodologies. • Glossary of Terms: ➢ Ambulance Transportation language has been clarified for coverage of emergency ambulance transportation to an appropriate hospital for consistency with No Surprises Act coverage of emergencies. ➢ Medical Specialty Medications (including gene therapy and CAR-T therapy) has been changed to align with internal processes and to account for drugs that may not be injectables / infusions.

April 12, 2024 ACCEPTANCE PAGE Health Plan 7670-00-413597 DEPAUW UNIVERSITY acknowledges that we have reviewed the plan document effective January 1, 2024, and agree that the provisions contained in the plan document will be the basis for the administration of our Health Plan. The Plan Sponsor further represents that the plan document accurately reflects the intent of the Plan Sponsor and agrees that UMR may rely on such document in the administration of the Plan. Accepted by the Plan Sponsor on Date Authorized Signature and Title DEPAUW UNIVERSITY