PPO Plan - Summary of Benefits & Coverage

PPO Health Plan Summary of Benefits and Coverage Effective 01/01/2027 | Benefits | Anthem BlueCard PPO Network | Out-of-Network | | Plan Year | January 1 through December 31 | | Deductible | $2,000 or $4,000 (3X the Individual) | $2,600 or $7,800 (2X the INN* Deductibles) | | Individual or EE+CH*/Family | Only an individual portion of the family deductible ($2,000 or $2,600) can be met by any one family member; once an | | individual family member’s deductible is met, that family member’s benefits are paid at the appropriate coinsurance amount | | Member Coinsurance | 20% | 50% | | Out-of-Pocket Maximum (OOPM*) | Individual = | $5,050 | Individual = | $12,150 (3X INN OOPM) | *Amount Includes Deductible EE+CH/Family = $10,750 EE+CH/Family = $29,250 (3X INN OOPM) Office Services Office Exam Physician – Illness Injury 20% after deductible 50% after deductible Office Exam Nurse Practitioner – Illness Injury 20% after deductible 50% after deductible Chronic Disease Illness Visits 20% after deductible 50% after deductible Preventive Services1 Routine exams, tests and immunizations No Charge 50% after deductible Routine Mammograms, pap tests and No Charge 50% after deductible colonoscopies Tobacco Cessation No Charge 50% after deductible Lab Charges2 LabCorp, Quest Diagnostic/LabCard and American No Charge Health Network Diagnostic Lab Charges – Physician/Facility 20% after deductible 50% after deductible Outpatient Services Surgical Expenses – Facility 20% after deductible 50% after deductible Surgical Expenses – Physician 20% after deductible 50% after deductible Diagnostic X-ray Expenses – Facility 20% after deductible 50% after deductible Diagnostic X-ray Expenses – Physician 20% after deductible 50% after deductible Manipulation Therapy 20% after deductible; 24 Day Visit Limitation 50% after deductible; 24 Day Visit Limitation Physical, Speech and Occupational Therapy 20% after deductible; 60 Day Visit Limitation 50% after deductible; 60 Day Visit Limitation Cardiac Rehabilitation 20% after deductible; 36 Day Visit Limitation 50% after deductible; 36 Day Visit Limitation Pulmonary Rehabilitation 20% after deductible; 20 Day Visit Limitation 50% after deductible; 20 Day Visit Limitation Inpatient Services

PPO Health Plan Summary of Benefits and Coverage Effective 01/01/2027 Pre-Admission Testing – Facility 20% after deductible 50% after deductible Pre-Admission Testing – Physician 20% after deductible 50% after deductible Surgical Expenses – Facility 20% after deductible 50% after deductible Surgical Expenses – Physician 20% after deductible 50% after deductible Inpatient Care – Facility 20% after deductible 50% after deductible Inpatient Care – Physician 20% after deductible 50% after deductible Skilled Nursing Facility 20% after deductible 50% after deductible Additional Services Emergency Room Illness and Accident Benefit 20% after $200 copay after deductible (copay is waived if admitted)-must satisfy emergency criteria Ambulance Benefit 20% after deductible Substance Abuse Benefit 20% after deductible 50% after deductible Mental Health Benefit; Includes Residential Care 20% after deductible 50% after deductible Durable Medical Equipment 20% after deductible 50% after deductible Prosthetics/Orthotics 20% after deductible 50% after deductible Home Health Care 20% after deductible 50% after deductible Hospice Care 20% after deductible 50% after deductible Bariatric Services for Morbid Obesity 20% after deductible; additional criteria required 50% after deductible; additional criteria required Condition Care Disease Management Solution Program N/A N/A Estimate Your Cost Tool N/A N/A Advanced Imaging Management (AIM) N/A N/A *Abbreviations: EE+CH = Employee Plus Children INN = In-Network OOPM = Out-of-Pocket-Maximum 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.