PPO #2 Summary

Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 1 of 9 Your summary of benefits Anthem® Blue Cross and Blue Shield Huntington County Community School Corp Effective 01/01/2026 Your Plan: Anthem HealthSync Options POS 3 Tier Your Network: HealthSync Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge medical deductible does not apply Mental Health & Substance Use Disorder Services No charge medical deductible does not apply Specialist care $30 copay per visit medical deductible does not apply Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Overall Deductible $3,000 person / $6,000 family $6,000 person / $12,000 family $18,000 person / $36,000 family Overall Out-of-Pocket Limit $7,350 person / $14,700 family $7,350 person / $14,700 family $22,050 person / $44,100 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Out-of-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. The deductibles for Preferred Network and In-Network cross apply. Satisfying one helps satisfy the other. The out-of-pocket limits for Preferred Network and In-Network cross apply as well. Doctor Visits (virtual and office) Your plan requires the selection of a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder Services virtual and office $15 copay per visit medical deductible does not apply $40 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Specialist Provider virtual and office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Practitioner Visits Maternity Doctor services (prenatal/postpartum care and delivery) 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met

Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 2 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Retail Health Clinic for routine care and treatment of common illnesses; usually found in major pharmacies or retail stores. $15 copay per visit medical deductible does not apply $40 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Services in an Office Allergy Testing When Allergy injections are billed separately by network providers, the member is responsible for a $10 copay. When billed as part of an office visit, there is no additional cost to the member for the injection. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Prescription Drugs Dispensed in the office 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Surgery $30 copay per visit medical deductible does not apply‡ $80 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Preventive care / screenings / immunizations No charge No charge 50% coinsurance after medical deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge No charge Cost share is based on the setting services are received. Diagnostic Services Lab Office No charge No charge 50% coinsurance after medical deductible is met Freestanding Lab/Reference Lab No charge No charge 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Diagnostic Services X-Ray Office No charge No charge 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met

Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 3 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Diagnostic Services Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Freestanding Radiology Center 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply depending on the care provided. $75 copay per visit medical deductible does not apply 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Emergency Room Facility Services Your copay will be waived if admitted. $250 copay per visit and then 20% coinsurance after medical deductible is met Same as In-Network Tier 1 Covered as In-Network Emergency Room Doctor and Other Services 20% coinsurance after medical deductible is met Same as In-Network Tier 1 Covered as In-Network Ambulance Authorized Out-of-Network non-emergency ambulance services are limited to an Anthem maximum payment of $50,000 per trip. The $50,000 limit does not apply to air ambulance services. 20% coinsurance after medical deductible is met Same as In-Network Tier 1 Covered as In-Network Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Doctor Services 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met

Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 4 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Outpatient Surgery Facility Fees Hospital 20% coinsurance after medical deductible is met $250 copay per visit and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Ambulatory Surgical Center 20% coinsurance after medical deductible is met $250 copay per visit and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Physician and other services including surgeon fees Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Ambulatory Surgical Center 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) If readmitted within 72 hours for the same condition, no additional facility copay is required. If transferred between facilities, only one copay will apply. Facility Fees 20% coinsurance after medical deductible is met $500 copay per admission and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Human Organ and Tissue Transplants Cornea transplants are treated as medical procedures, with benefits and cost sharing determined by the setting in which the services are received. No charge No charge 50% coinsurance after medical deductible is met Physician and other services including surgeon fees 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Home Health Care Coverage is limited to 120 visits per benefit period. Limits are combined for all home health services. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Therapy Services

Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 5 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical and occupational therapies is limited to 40 visits combined per benefit period. Coverage for speech therapy is limited to 20 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Manipulation Therapy Coverage is limited to 12 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Pulmonary rehabilitation Coverage is limited to 20 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Dialysis/Hemodialysis Office No charge No charge 50% coinsurance after medical deductible is met

Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 6 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Chemo/Radiation Therapy Office $30 copay per visit medical deductible does not apply‡ $80 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Skilled Nursing Care (facility) Coverage for Skilled Nursing, Outpatient Rehabilitation and Inpatient Rehabilitation facility settings is limited to 150 days combined per benefit period. 20% coinsurance after medical deductible is met $500 copay per admission and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Inpatient Hospice No charge No charge No charge Additional Services, Equipment and Devices Durable Medical Equipment 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Prosthetic Devices 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Wigs Coverage for wigs is limited to 1 item after cancer treatment per benefit period. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Notes: • Dependent Age Limit: to the end of the month in which the child attains age 26. • Members are encouraged to always obtain prior approval when using Out-of-Network Providers. Precertification will help the member know if the services are considered not medically necessary. • No charge means no deductible / copayment / coinsurance up to the maximum allowable amount. 0% means no coinsurance up to the maximum allowable amount. However, when choosing an Out-of-Network Provider, the member is responsible for any balance due after the plan payment. • If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”. • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • ‡ You will pay your PCP or Specialist office visit copay for certain services provided in their office. • The representations of benefits in this document are subject to Indiana Department of Insurance (IN DOI) approval and are subject to change.

Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 7 of 9 This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Questions: (833) 578-4441 or visit us at www.anthem.com