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