PPO Plan - Summary of Benefits & Coverage

| Retiree Over 65 Health Plan Summary of Benefits and Coverage | Effective 01/01/2027 | | Benefits | Anthem Blue Traditional | | Plan Year | January 1 through December 31 | | Deductible | | Individual | $400 | | Member Coinsurance | 20% | | Out-of-Pocket Maximum (OOPM) | | *Amount Includes Deductible and is per person | $1,500 | Office Services Office Exam Physician – Illness Injury 20% after deductible Office Exam Nurse Practitioner – Illness Injury 20% after deductible Preventive Services1 Routine exams, tests and immunizations No Charge Routine Mammograms, pap tests and No Charge colonoscopies Tobacco Cessation No Charge Lab Charges2 LabCorp, Quest Diagnostic/LabCard and American No Charge Health Network Diagnostic Lab Charges – Physician/Facility 20% after deductible Outpatient Services Surgical Expenses – Facility 20% after deductible Surgical Expenses – Physician 20% after deductible Diagnostic X-ray Expenses – Facility 20% after deductible Diagnostic X-ray Expenses – Physician 20% after deductible Chiropractic/Manipulation Services 20% after deductible Physical, Speech and Occupational Therapy 20% after deductible Inpatient Services Pre-Admission Testing – Facility 20% after deductible Pre-Admission Testing – Physician 20% after deductible Surgical Expenses – Facility 20% after deductible

Retiree Over 65 Health Plan Summary of Benefits and Coverage Effective 01/01/2027 Surgical Expenses – Physician 20% after deductible Inpatient Care – Facility 20% after deductible Inpatient Care – Physician 20% after deductible Skilled Nursing Facility 20% after deductible Additional Services Emergency Room Illness and Accident Benefit 20% after $200 copay after deductible (copay is waived if admitted) Ambulance Benefit 20% after deductible Substance Abuse Benefit 20% after deductible Mental Health Benefit 20% after deductible Durable Medical Equipment 20% after deductible Prosthetics/Orthotics 20% after deductible Home Health Care 20% after deductible Hospice Care 20% after deductible *Employee Plus Children Important Medical Plan Contacts Phone Web or Email Address Anthem Customer Service 1-855-871-4901 www.anthem.com Anthem Web Support Helpdesk 1-866-755-2680 Web_support@Anthem.com Ball State University Employee Benefits 765-285-8461 www.bsu.edu/payroll or peb@bsu.edu 1Preventive care is provided when there are no current symptoms or history of medical conditions associated with a particular screening; all preventive services are limited to one of each service per year per covered member. 2This benefit is for blood work lab charges only.