Summary of Benefits and Coverage: HSA Qualified Health Plan

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 1 of " Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2026– 12/31/2026 Ball State University: 002 = HSA Qualified Health Plan Coverage for: All Coverage Types | Plan Type: CDHP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (855) 871-4901 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $2,500/individual or $5,000/family. All Providers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay. Are there services covered before you meet your deductible? Yes. Preventive care for In- Network Providers. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- pocket limit for this plan? $4,750/individual (employee only) or $7,150/individual on family or $8,250/family for In- Network Providers. $6,450/individual (employee only) or $12,900/individual on family or $12,900/family for Out-of-Network Providers. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Services deemed not medically necessary by Medical Management and/or Anthem, Premiums, balance-billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if Yes, Blue Card PPO. See This plan uses a provider network. You will pay less if you use a provider in the plan’s