PPO Health Plan Summary of Benefits and Coverage Effective 01/01/2026 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 ConditionCare 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 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.