Retiree Health Plan Benefits Summary

Retiree Over 65 Health Plan Summary of Benefits and Coverage Effective 01/01/2026 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 colonoscopies No Charge Tobacco Cessation No Charge Lab Charges2 LabCorp, Quest Diagnostic/LabCard and American Health Network No Charge 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