Summary of Benefits and Coverage: Retiree Over Age 65/Medicare Disabled EGWP Disenrolled Health Plan CMM

IN/L/A/BallStateUniverstyRtrOvrAge65M-Indemnity/NA/FXNU7/NA/01-19 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: 005 = Retiree Over Age 65/Medicare Disabled EGWP Disenrolled Health Plan CMM Coverage for: Individual + Family | Plan Type: Indemnity 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? $400/individual. 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 plan, each family member must meet their own individual deductible. Are there services covered before you meet your deductible? Yes. Preventive care. All 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? $1,500/individual. All 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. 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 you use a network provider? Not Applicable. This plan does not use a provider network. You can receive covered services from any provider. 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.