Summary of Benefits and Coverage Plan B

IN/LG/PPO Plan B/W0NT/01-25 Page 1 of 11 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2025 - 12/31/2025 Coverage for: Individual + Family | Plan Type: PPO Goshen Community Schools: PPO Plan B 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 (833) 578-4441 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $2,000/person or $4,000/family for In-Network Providers. $2,000/person or $4,000/family for Out-of-Network 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 plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Primary Care. Specialist Visit. Preventive Care. For more information see below. 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? $6,000/person or $12,000/family for In-Network Providers. $10,000/person or $20,000/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, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? 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 you use a network provider? Yes. See www.anthem.com/find- care/?alphaprefix=AJS or call (833) 578-4441 for a list of network providers. Costs may vary by site of service and how the provider bills. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an Out-of-Network Provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an Out-of-Network Provider for some services (such as lab work). Check with your provider before you get services.

* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 2 of 11 Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $40/visit, deductible does not apply 30% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit $45/visit, deductible does not apply 30% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 30% coinsurance, deductible does not apply You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.navitus.com Typically Generic (Tier 1) Greater of $10 or 15% coinsurance, deductible does not apply (retail and home delivery) Greater of $10 or 15% coinsurance, deductible does not apply (retail) and Not covered (home delivery) *See Prescription Drug section. Typically Preferred Brand & Non-Preferred Generic Drugs (Tier 2) Greater of $40 or 40% coinsurance, deductible does not apply (retail and home delivery) Greater of $40 or 40% coinsurance, deductible does not apply (retail) and Not covered (home delivery) Typically Non-Preferred Brand and Generic drugs (Tier 3) Greater of $60 or 60% coinsurance, deductible does not apply (retail and home delivery) Greater of $60 or 60% coinsurance, deductible does not apply (retail) and Not covered (home delivery) Typically Preferred Specialty (brand and generic) (Tier 4) 20% coinsurance, deductible does not apply (retail and home delivery) 30% coinsurance, deductible does not apply (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $150/visit; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply --------none--------

* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 3 of 11 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees $150/visit; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply 20% coinsurance for Outpatient Anesthesia In-Network Providers. 30% coinsurance for Outpatient Anesthesia Out-of- Network Providers. If you need immediate medical attention Emergency room care $200/visit; then 20% coinsurance, deductible does not apply Covered as In-Network Copayment waived if admitted. Emergency medical transportation 20% coinsurance Covered as In-Network --------none-------- Urgent care $40/visit, deductible does not apply 30% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) $200/admission; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply --------none-------- Physician/surgeon fees $150/visit; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply 20% coinsurance for Inpatient Anesthesia In-Network Providers. 30% coinsurance for Inpatient Anesthesia Out-of- Network Providers. If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit $45/visit, deductible does not apply Other Outpatient 20% coinsurance Office Visit 30% coinsurance Other Outpatient 40% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services $200/admission; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply --------none-------- If you are pregnant Office visits $40/visit, deductible does not apply 30% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services $150/visit; then 20% coinsurance 30% coinsurance Childbirth/delivery facility services $200/admission; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply If you need help recovering or Home health care 20% coinsurance 40% coinsurance --------none-------- Rehabilitation services 20% coinsurance 40% coinsurance *See Therapy Services section.

* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 4 of 11 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) have other special health needs Habilitation services 20% coinsurance 40% coinsurance Skilled nursing care 20% coinsurance 30% coinsurance 120 days/benefit period for skilled nursing services. Durable medical equipment 20% coinsurance 40% coinsurance *See Durable Medical Equipment section. Hospice services 20% coinsurance, deductible does not apply 40% coinsurance, deductible does not apply --------none-------- If your child needs dental or eye care Children’s eye exam Not covered Not covered --------none-------- Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Dental care (Adult) • Hearing aids • Routine eye care (Adult) • Children’s dental check-up • Eye exams for a child • Infertility treatment • Routine foot care unless medically necessary • Cosmetic surgery • Glasses for a child • Long-term care • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery 1 surgery/ lifetime • Private-duty nursing Facility Setting only • Chiropractic care 12 visits/benefit period • Most coverage provided outside the United States. See www.bcbsglobalcore.com Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: State of Indiana Department of Insurance, 311 W. Washington Street, Suite 300, Indianapolis, Indiana 46204, (800) 622-4461, (317) 232-2395, www.in.gov/idoi/3008.htm, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, www.cciio.cms.gov, or contact Anthem at the number on the back of your ID card. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan

Page 5 of 11 documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: ATTN: Grievances and Appeals, P.O. Box 105568, Atlanta GA 30348-5568 Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, www.cciio.cms.gov Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes/No. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section.

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 11 Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)  The plan’s overall deductible $2,000  Specialist copayment $45  Hospital (facility) coinsurance 20%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $2,000 Copayments $200 Coinsurance $700 What isn’t covered Limits or exclusions $70 The total Peg would pay is $2,970  The plan’s overall deductible $2,000  Specialist copayment $45  Hospital (facility) coinsurance 20%  Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $100 Copayments $400 Coinsurance $0 What isn’t covered Limits or exclusions $4,300 The total Joe would pay is $4,800  The plan’s overall deductible $2,000  Specialist copayment $45  Hospital (facility) coinsurance 20%  Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $1,700 Copayments $400 Coinsurance $80 What isn’t covered Limits or exclusions $10 The total Mia would pay is $2,190 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

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Language Access Services: Page 11 of 11 It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368- 1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.