Retiree Over 65 Health Plan Summary of Benefits and Coverage Effective 01/01/2026 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 1 Preventive 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. 2 This benefit is for blood work lab charges only.