[UHC] HDHP Basic - Medical Plan Summary

Noblesville Schools Medical Choice Plus Plan HDHP Basic Effective: January 1, 2026 Group Number: 942654

i Table of Contents Summary Plan Description........................................................................1 What Is the Summary Plan Description? ..................................................................................................1 Can This SPD Change?............................................................................................................................1 Other Information You Should Have .........................................................................................................1 Introduction to Your SPD...........................................................................2 What Are Defined Terms?.........................................................................................................................2 How Do You Use This Document? ...........................................................................................................2 How Do You Contact the Claims Administrator? ......................................................................................2 Your Responsibilities.................................................................................3 Enrollment and Required Contributions ....................................................................................................3 Be Aware the Plan Does Not Pay for All Health Care Services................................................................3 Decide What Services You Should Receive .............................................................................................3 Choose Your Physician.............................................................................................................................3 Obtain Prior Authorization.........................................................................................................................3 Pay Your Share.........................................................................................................................................3 Pay the Cost of Excluded Services...........................................................................................................3 Show Your ID Card ...................................................................................................................................4 File Claims with Complete and Accurate Information ...............................................................................4 Use Your Prior Health Care Coverage......................................................................................................4 Claims Administrator and Plan Sponsor Responsibilities .....................5 Determine Benefits....................................................................................................................................5 Process Payment for the Plan's Portion of the Cost of Covered Health Care Services............................5 Process Plan Payment to Network Providers ...........................................................................................5 Process Plan Payment for Covered Health Care Services Provided by Out-of-Network Providers .........5 Review and Determine Benefits in Accordance with the Claims Administrator's Reimbursement Policies ..................................................................................................................................................................5 Offer Health Education Services to You....................................................................................................6 United Healthcare Services, Inc. ...............................................................7 Schedule of Benefits ..................................................................................7 How Do You Access Benefits? .................................................................................................................7 Does Prior Authorization Apply? ...............................................................................................................7 Care Management ....................................................................................................................................8 Special Note Regarding Medicare ............................................................................................................8 What Will You Pay for Covered Health Care Services?............................................................................8 Payment Term and Description Table.......................................................................................................9 Schedule of Benefits Table .....................................................................................................................12 Allowed Amounts ....................................................................................................................................34 Designated Network Benefits and Network Benefits...............................................................................35 Out-of-Network Benefits..........................................................................................................................35 Advocacy Services..................................................................................................................................36 Provider Network.....................................................................................................................................37 Designated Providers..............................................................................................................................37 Health Care Services from Out-of-Network Providers Paid as Network Benefits ...................................38 Limitations on Selection of Providers......................................................................................................38 Section 1: Covered Health Care Services ..............................................39 When Are Benefits Available for Covered Health Care Services?..........................................................39 Ambulance Services ...............................................................................................................................39 Cellular and Gene Therapy.....................................................................................................................40 Chronic Pain Management......................................................................................................................40

ii Clinical Trials...........................................................................................................................................40 Congenital Heart Disease (CHD) Surgeries............................................................................................42 Dental Services - Accident Only..............................................................................................................42 Diabetes Services ...................................................................................................................................43 Durable Medical Equipment (DME), Orthotics and Supplies ..................................................................43 Emergency Health Care Services - Outpatient .......................................................................................44 Enteral Nutrition ......................................................................................................................................45 Gender Dysphoria...................................................................................................................................45 Habilitative Services................................................................................................................................45 Home Health Care ..................................................................................................................................46 Hospice Care ..........................................................................................................................................46 Hospital - Inpatient Stay..........................................................................................................................46 Lab, X-Ray and Diagnostic - Outpatient..................................................................................................47 Major Diagnostic and Imaging - Outpatient.............................................................................................47 Mental Health Care and Substance-Related and Addictive Disorders Services.....................................47 Non-Preventive Nutritional Counseling ...................................................................................................48 Ostomy Supplies.....................................................................................................................................48 Pharmaceutical Products - Outpatient ....................................................................................................49 Physician Fees for Surgical and Medical Services .................................................................................49 Physician's Office Services - Sickness and Injury...................................................................................49 Pregnancy - Maternity Services ..............................................................................................................50 Preventive Care Services........................................................................................................................50 Prosthetic Devices ..................................................................................................................................50 Reconstructive Procedures.....................................................................................................................51 Rehabilitation Services - Outpatient Therapy and Manipulative Treatment............................................51 Scopic Procedures - Outpatient Diagnostic and Therapeutic .................................................................52 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services ...........................................................52 Surgery - Outpatient................................................................................................................................53 Temporomandibular Joint (TMJ) Services ..............................................................................................53 Therapeutic Treatments - Outpatient ......................................................................................................54 Transplantation Services.........................................................................................................................54 Urgent Care Center Services..................................................................................................................55 Urinary Catheters....................................................................................................................................55 Virtual Care Services ..............................................................................................................................55 Wigs ........................................................................................................................................................55 Section 2: Exclusions and Limitations...................................................56 How Are Headings Used in this Section? ...............................................................................................56 Plan Does Not Pay Benefits for Exclusions ............................................................................................56 Where Are Benefit Limitations Shown?...................................................................................................56 Alternative Treatments............................................................................................................................56 Dental......................................................................................................................................................56 Devices, Appliances and Prosthetics......................................................................................................57 Drugs.......................................................................................................................................................58 Experimental or Investigational or Unproven Services ...........................................................................59 Foot Care ................................................................................................................................................59 Gender Dysphoria...................................................................................................................................59 Medical Supplies and Equipment............................................................................................................60 Nutrition...................................................................................................................................................60 Personal Care, Comfort or Convenience ................................................................................................61 Physical Appearance ..............................................................................................................................62 Procedures and Treatments....................................................................................................................62 Providers.................................................................................................................................................63 Reproduction...........................................................................................................................................63 Services Provided under another Plan....................................................................................................64

iii Transplants .............................................................................................................................................64 Travel ......................................................................................................................................................64 Types of Care, Supportive Services, and Housing .................................................................................65 Vision and Hearing..................................................................................................................................65 All Other Exclusions................................................................................................................................66 Section 3: When Coverage Begins .........................................................68 How Do You Enroll?................................................................................................................................68 Cost of Coverage ....................................................................................................................................68 What If You Are Hospitalized When Your Coverage Begins?.................................................................68 What If You Are Eligible for Medicare? ...................................................................................................69 Who Is Eligible for Coverage?.................................................................................................................69 Eligible Person ........................................................................................................................................69 Dependent...............................................................................................................................................69 When Do You Enroll and When Does Coverage Begin?........................................................................70 Initial Enrollment Period ..........................................................................................................................70 Open Enrollment Period..........................................................................................................................70 New Eligible Persons ..............................................................................................................................70 Adding New Dependents ........................................................................................................................70 Special Enrollment Period.......................................................................................................................70 Section 4: When Coverage Ends ............................................................72 General Information about When Coverage Ends ..................................................................................72 What Events End Your Coverage? .........................................................................................................72 Fraud or Intentional Misrepresentation of a Material Fact.......................................................................73 Coverage for a Disabled Dependent Child..............................................................................................73 Continuation of Coverage .......................................................................................................................73 Uniformed Services Employment and Reemployment Rights Act ..........................................................74 Section 5: How to File a Claim ................................................................75 Claims Procedures..................................................................................................................................75 How Are Covered Health Care Services from Network Providers Paid?................................................75 How Are Covered Health Care Services from an Out-of-Network Provider Paid?..................................75 Required Information...............................................................................................................................75 Payment of Benefits................................................................................................................................76 Section 6: Questions, Complaints and Appeals....................................77 What if You Have a Question?................................................................................................................77 What if You Have a Complaint?..............................................................................................................77 How Do You Appeal a Claim Decision?..................................................................................................77 Post-service Claims ................................................................................................................................77 Pre-service Requests for Benefits...........................................................................................................77 How to Request an Appeal .....................................................................................................................77 Appeal Process.......................................................................................................................................78 Appeals Determinations..........................................................................................................................78 Pre-service Requests for Benefits and Post-service Claim Appeals.......................................................78 Urgent Appeals that Require Immediate Action......................................................................................79 External Review Program .......................................................................................................................79 Standard External Review.......................................................................................................................80 Expedited External Review .....................................................................................................................81 Urgent Care Request for Benefits*..........................................................................................................82 Type of Request for Benefits or Appeal ..................................................................................................82 Timing .....................................................................................................................................................82 Pre-Service Request for Benefits* ..........................................................................................................82 Type of Request for Benefits or Appeal ..................................................................................................82 Timing .....................................................................................................................................................82 Post-Service Claims................................................................................................................................83

iv Type of Claim or Appeal..........................................................................................................................83 Timing .....................................................................................................................................................83 Section 7: Coordination of Benefits .......................................................84 Benefits When You Have Coverage under More than One Plan............................................................84 When Does Coordination of Benefits Apply?..........................................................................................84 What Are the Rules for Determining the Order of Benefit Payments?....................................................84 How Are Benefits Paid When This Plan is Secondary?..........................................................................86 How is the Allowable Expense Determined when this Plan is Secondary? ............................................86 What is Different When You Qualify for Medicare?.................................................................................87 Medicare Crossover Program .................................................................................................................87 Right to Receive and Release Needed Information?..............................................................................88 Does This Plan Have the Right of Recovery?.........................................................................................88 Section 8: General Legal Provisions ......................................................90 What Is Your Relationship with the Claims Administrator and Plan Sponsor? .......................................90 What Is the Claims Administrator's Relationship with Providers and Plan Sponsors? ...........................90 What Is Your Relationship with Providers and Plan Sponsors?..............................................................91 Notice......................................................................................................................................................91 Statements by the Plan Sponsor or Participants.....................................................................................91 Does the Claims Administrator Pay Incentives to Providers?.................................................................91 Are Incentives Available to You? ............................................................................................................92 Does the Claims Administrator Receive Rebates and Other Payments? ...............................................92 Who Interprets Benefits and Other Provisions under the Plan?..............................................................92 Who Provides Administrative Services? .................................................................................................92 What is the Future of the Plan?...............................................................................................................93 Amendments to the Plan.........................................................................................................................93 How Does the Claims Administrator Use Information and Records?......................................................93 Does the Plan Require Examination of Covered Persons? ....................................................................94 Is Workers' Compensation Affected?......................................................................................................94 How Are Benefits Paid When You Are Medicare Eligible? .....................................................................94 Subrogation and Reimbursement ...........................................................................................................95 When Does the Plan Receive Refunds of Overpayments? ....................................................................98 Is There a Limitation of Action?...............................................................................................................98 What Is the Entire Plan? .........................................................................................................................99 Section 9: Defined Terms ......................................................................100 Clinical Programs and Resources ........................................................112 Care Management Solutions.................................................................................................................112 Personal Health Support.......................................................................................................................112 Complex Medical Conditions, Programs and Services .........................................................................113 Cancer Resource Services (CRS) Program..........................................................................................113 Kidney Disease Programs.....................................................................................................................113 Transplant Resource Services (TRS) Program.....................................................................................113 Complex Medical Conditions Travel and Lodging Assistance Program for the Covered Health Services Described Below ...................................................................................................................................114 Decision Support...................................................................................................................................114 Disease Management ...........................................................................................................................115 Reminder Programs..............................................................................................................................116 Consumer Solutions and Self-Service Tools.........................................................................................116 www.myuhc.com...................................................................................................................................116 UnitedHealth Premium® Designation Program.....................................................................................117 Amendments, Riders and Notices (As Applicable)

v Federal Notice

Noblesville Schools Medical Plan 1 Summary Plan Description Summary Plan Description United Healthcare Services, Inc. What Is the Summary Plan Description? This Summary Plan Description (SPD) is a summary of the Covered Health Care Services available to you under the Noblesville Schools ("Plan Sponsor") Self-Funded health benefit plan. This SPD is a legal document that describes Benefits for the portion of the Plan for which United Healthcare Services, Inc. ("Claims Administrator") administers claims payment, either directly or in conjunction with one of the Claims Administrator's affiliates. For the purposes of this provision "Self-Funded" means that the Plan Sponsor, on behalf of the Plan, has the sole responsibility to pay, and provide funds, to pay for all Plan benefits. The Claims Administrator has no liability or responsibility to provide these funds. The Claims Administrator is a private healthcare claims administrator. The Claims Administrator is not the Plan Administrator for the Plan. Although the Claims Administrator will assist you in many ways, it does not guarantee any Benefits. The Plan Sponsor is solely responsible for the benefit plan design and funding payment of Benefits. In addition to this SPD, the Plan includes: • The Schedule of Benefits. • Amendments. • Addendums. • Summary Material Modifications (SMM). If there should be an inconsistency between the contents of this summary and the Plan, your rights shall be determined under the Plan and not under this summary. A copy of the plan document is available for your inspection during regular business hours in the office of the Plan Administrator. You (or your personal representative) may obtain a copy of the official plan document by written request to the Plan Administrator, for a nominal charge. Can This SPD Change? The Plan Sponsor may, from time to time, change this SPD by attaching legal documents called SMMs and/or Amendments that may change certain provisions of this SPD. When this happens the Plan Sponsor will send you a new SPD, Amendment, Addendums or SMMs. Other Information You Should Have The Plan Sponsor intends to continue this Plan, but reserves the right, in its sole discretion, to change, interpret, withdraw or add Benefits, or to end the Plan, as permitted by law, without your approval subject to any collective bargaining agreements, if applicable. On its effective date, this SPD replaces and overrules any SPD that the Plan Sponsor may have previously issued to you. This SPD will in turn be overruled by any SPD issued to you in the future. The Plan is not subject to ERISA. To the extent other federal law (e.g. PHSA, IRC) does not apply, IN- Indiana law governs the Plan.

Noblesville Schools Medical Plan 2 Introduction to Your SPD Introduction to Your SPD This SPD and the other Plan documents describe your Benefits, as well as your rights and responsibilities, under the Plan. What Are Defined Terms? Certain capitalized words have special meanings. The Plan Sponsor has defined these words in Section 9: Defined Terms. When the Plan Sponsor uses the words "you" and "your," the Plan Sponsor is referring to people who are Covered Persons, as that term is defined in Section 9: Defined Terms. How Do You Use This Document? Read your entire SPD and any attached Amendments, Addendums or SMMs. You may not have all of the information you need by reading just one section. Keep your SPD and Schedule of Benefits and any attachments in a safe place for your future reference. You can also get this SPD at www.myuhc.com. Review the Benefit limitations of this SPD by reading the attached Schedule of Benefits along with Section 1: Covered Health Care Services and Section 2: Exclusions and Limitations. Read Section 8: General Legal Provisions to understand how this SPD and your Benefits work. Call the Claims Administrator if you have questions about the limits of the coverage available to you. If there is a conflict between this SPD and any summaries provided to you by the Plan Sponsor, this SPD controls. Please be aware that your Physician is not responsible for knowing or communicating your Benefits. How Do You Contact the Claims Administrator? Call the telephone number listed on your identification (ID) card. Throughout the document you will find statements that encourage you to contact the Claims Administrator for more information.

Noblesville Schools Medical Plan 3 Your Responsibilities Your Responsibilities Enrollment and Required Contributions Benefits are available to you if you are enrolled for coverage under the Plan. Your enrollment options, and the corresponding dates that coverage begins, are listed in Section 3: When Coverage Begins. To be enrolled and receive Benefits, both of the following apply: • Your enrollment must be in accordance with the requirements of the Plan issued to your Plan Sponsor, including the eligibility requirements. • You must qualify as a Participant or a Dependent as those terms are defined in Section 9: Defined Terms. Your Plan Sponsor may require you to make certain payments to them, in order for you to remain enrolled under the Plan. If you have questions about this, contact your Plan Sponsor. Be Aware the Plan Does Not Pay for All Health Care Services The Plan does not pay for all health care services. Benefits are limited to Covered Health Care Services. The Schedule of Benefits will tell you the portion you must pay for Covered Health Care Services. Decide What Services You Should Receive Care decisions are between you and your Physician. The Claims Administrator and the Plan Sponsor do not make decisions about the kind of care you should or should not receive. Choose Your Physician It is your responsibility to select the health care professionals who will deliver your care. The Claims Administrator arranges for Physicians and other health care professionals and facilities to participate in a Network. The Claims Administrator's credentialing process confirms public information about the professionals' and facilities' licenses and other credentials, but does not assure the quality of their services. These professionals and facilities are independent practitioners and entities that are solely responsible for the care they deliver. Obtain Prior Authorization Some Covered Health Care Services require prior authorization. Physicians and other health care professionals who participate in a Network are responsible for obtaining prior authorization. However, if you choose to receive Covered Health Care Services from an out-of-Network provider, you are responsible for obtaining prior authorization before you receive the services. For detailed information on the Covered Health Care Services that require prior authorization, please refer to the Schedule of Benefits. Pay Your Share You must meet any applicable deductible and pay a Copayment and/or Coinsurance for most Covered Health Care Services. These payments are due at the time of service or when billed by the Physician, provider or facility. Any applicable deductible, Copayment and Coinsurance amounts are listed in the Schedule of Benefits. Pay the Cost of Excluded Services You must pay the cost of all excluded services and items. Review Section 2: Exclusions and Limitations to become familiar with the Plan's exclusions.

Noblesville Schools Medical Plan 4 Your Responsibilities Show Your ID Card You should show your ID card every time you request health care services. If you do not show your ID card, the provider may fail to bill the correct entity for the services delivered. File Claims with Complete and Accurate Information When you receive Covered Health Care Services from an out-of-Network provider, you are responsible for requesting payment from the Plan. You must file the claim in a format that contains all of the information the Claims Administrator requires to process the claim, as described in Section 5: How to File a Claim. Use Your Prior Health Care Coverage If you have prior coverage that extends benefits for a particular condition or a disability, the Plan will not pay Benefits for health care services for that condition or disability until the prior coverage ends. Benefits for that particular condition or disability are subject to your prior coverage.

Noblesville Schools Medical Plan 5 Claims Administrator and Plan Sponsor Responsibilities Claims Administrator and Plan Sponsor Responsibilities Determine Benefits Plan Sponsor and the Claims Administrator make administrative decisions regarding whether the Plan will pay for any portion of the cost of a health care service you intend to receive or have received. Plan Sponsor's and the Claims Administrator's decisions are for payment purposes only. Plan Sponsor and the Claims Administrator do not make decisions about the kind of care you should or should not receive. You and your providers must make those treatment decisions. Plan Sponsor and the Claims Administrator have the discretion to do the following: • Interpret Benefits and the other terms, limitations and exclusions set out in this SPD, the Schedule of Benefits and any SMMs and/or Amendments. • Make factual determinations relating to Benefits. Plan Sponsor and the Claims Administrator may assign this discretionary authority to other persons or entities including Claims Administrator's affiliates that may provide administrative services for the Plan, such as claims processing. The identity of the service providers and the nature of their services may be changed from time to time in Plan Sponsor's and the Claims Administrator's discretion. In order to receive Benefits, you must cooperate with those service providers. Process Payment for the Plan's Portion of the Cost of Covered Health Care Services The Claims Administrator processes the Plan's payment of Benefits for Covered Health Care Services as described in Section 1: Covered Health Care Services and in the Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and Limitations. This means the Claims Administrator processes only the payment of the Plan's portion of the cost of Covered Health Care Services. It also means that not all of the health care services you receive may be paid for (in full or in part) by the Plan. Process Plan Payment to Network Providers It is the responsibility of Network Physicians and facilities to file for payment from the Plan. When you receive Covered Health Care Services from Network providers, you do not have to submit a claim to the Plan. Process Plan Payment for Covered Health Care Services Provided by Out-of-Network Providers The Claims Administrator processes the Plan's payment of Benefits after receiving your request for payment that includes all required information. See Section 5: How to File a Claim. Review and Determine Benefits in Accordance with the Claims Administrator's Reimbursement Policies The Claims Administrator adjudicates claims consistent with industry standards. The Claims Administrator develops its reimbursement policy guidelines, in its sole discretion, generally in accordance with one or more of the following methodologies: • As shown in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS).

Noblesville Schools Medical Plan 6 Claims Administrator and Plan Sponsor Responsibilities • As reported by generally recognized professionals or publications. • As used for Medicare. • As determined by medical staff and outside medical consultants pursuant to other appropriate sources or determinations that the Claims Administrator accepts. Following evaluation and validation of certain provider billings (e.g., error, abuse and fraud reviews), the Claims Administrator's reimbursement policies are applied to provider billings. The Claims Administrator shares its reimbursement policies with Physicians and other providers in the Claims Administrator's Network through the Claims Administrator's provider website. Network Physicians and providers may not bill you for the difference between their contract rate (as may be modified by the Claims Administrator's reimbursement policies) and the billed charge. However, out-of-Network providers may bill you for any amounts the Plan does not pay, including amounts that are denied because one of the Claims Administrator's reimbursement policies does not reimburse (in whole or in part) for the service billed. You may get copies of the Claims Administrator's reimbursement policies for yourself or to share with your out-of-Network Physician or provider by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. The Claims Administrator may apply a reimbursement methodology established by OptumInsight and/or a third party vendor, which is based on CMS coding principles, to determine appropriate reimbursement levels for Emergency Health Care Services. The methodology is usually based on elements reflecting the patient complexity, direct costs, and indirect costs of an Emergency Health Care Service. If the methodology(ies) currently in use become no longer available, the Claims Administrator will use comparable methodology(ies). The Claims Administrator and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to the Claims Administrator's website at www.myuhc.com for information regarding the vendor that provides the applicable methodology. Offer Health Education Services to You The Claims Administrator may provide you with access to information about additional services that are available to you, such as disease management programs, health education and patient advocacy. It is solely your decision whether to take part in the programs, but it is recommended that you discuss them with your Physician.

Noblesville Schools Medical Plan 7 Schedule of Benefits Set 001 UnitedHealthcare Choice Plus United Healthcare Services, Inc. Schedule of Benefits How Do You Access Benefits? You can choose to receive Designated Network Benefits, Network Benefits or Out-of-Network Benefits. Designated Network Benefits apply to Covered Health Care Services that are provided by a provider or facility that has been identified as a Designated Provider. Designated Network Benefits are available only for specific Covered Health Care Services as shown in the Schedule of Benefits table below. Network Benefits apply to Covered Health Care Services that are provided by a Network Physician or other Network provider. You are not required to select a Primary Care Physician in order to obtain Network Benefits. Out-of-Network Benefits apply to Covered Health Care Services that are provided by an out-of-Network Physician or other out-of-Network provider, or Covered Health Care Services that are provided at an out- of-Network facility. Emergency Health Care Services provided by an out-of-Network provider will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. Covered Health Care Services provided at certain Network facilities by an out-of-Network Physician, when not Emergency Health Care Services, will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. For these Covered Health Care Services, "certain Network facility" is limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary. Air Ambulance transport provided by an out-of-Network provider will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. Ground Ambulance transport provided by an out-of-Network provider will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. You must show your identification card (ID card) every time you request health care services from a Network provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled under the Plan. As a result, they may bill you for the entire cost of the services you receive. Additional information about the network of providers and how your Benefits may be affected appears at the end of this Schedule of Benefits. If there is a conflict between this Schedule of Benefits and any summaries provided to you by the Plan Sponsor, this Schedule of Benefits will control. Does Prior Authorization Apply? The Claims Administrator requires prior authorization for certain Covered Health Care Services. Network providers are responsible for obtaining prior authorization before they provide these services to you. Network facilities and Network providers cannot bill you for services they do not prior authorize as required. You can call the Claims Administrator at the telephone number on your ID card.

Noblesville Schools Medical Plan 8 Schedule of Benefits Set 001 When you choose to receive certain Covered Health Care Services from out-of-Network providers, you are responsible for obtaining prior authorization before you receive these services. Note that your obligation to obtain prior authorization is also applicable when an out-of-Network provider intends to admit you to a Network facility or to an out-of-Network facility or refers you to other Network or out-of-Network providers. Once you have obtained the authorization, please review it carefully so that you understand what services have been authorized and what providers are authorized to deliver the services that are subject to the authorization. Services for which you are required to obtain prior authorization are shown in the Schedule of Benefits table within each Covered Health Care Service category. To obtain prior authorization, call the telephone number on your ID card. This call starts the utilization review process. The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review or similar programs. Please note that prior authorization timelines apply. Refer to the applicable Benefit description in the Schedule of Benefits table to find out how far in advance you must obtain prior authorization. For Covered Health Care Services that do not require you to obtain prior authorization, when you choose to receive services from out-of-Network providers, Noblesville Schools urges you to confirm with the Claims Administrator that the services you plan to receive are Covered Health Care Services. That's because in some instances, certain procedures may not be Medically Necessary or may not otherwise meet the definition of a Covered Health Care Service, and therefore are excluded. In other instances, the same procedure may meet the definition of Covered Health Care Services. By calling before you receive treatment, you can check to see if the service is subject to limitations or exclusions. If you request a coverage determination at the time prior authorization is provided, the determination will be made based on the services you report you will be receiving. If the reported services differ from those received, the Claims Administrator's final coverage determination will be changed to account for those differences, and the Plan will only pay and the Claims Administrator will only process payments for Benefits based on the services delivered to you. If you choose to receive a service that has been determined not to be a Medically Necessary Covered Health Care Service, you will be responsible for paying all charges and no Benefits will be paid. Care Management When you seek prior authorization as required, the Claims Administrator will work with you to put in place the care management process and to provide you with information about additional services that are available to you, such as disease management programs, health education, and patient advocacy. Special Note Regarding Medicare If you are enrolled in Medicare on a primary basis (Medicare pays before the Claims Administrator processes payments for Benefits under the Plan), the prior authorization requirements do not apply to you. Since Medicare is the primary payer, the Claims Administrator will process payments for the Plan as secondary payer as described in Section 7: Coordination of Benefits. You are not required to obtain prior authorization before receiving Covered Health Care Services. What Will You Pay for Covered Health Care Services? Benefits for Covered Health Care Services are described in the tables below. Annual Deductibles are calculated on a calendar year basis. Out-of-Pocket Limits are calculated on a calendar year basis.

Noblesville Schools Medical Plan 9 Schedule of Benefits Set 001 When Benefit limits apply, the limit stated refers to any combination of Designated Network Benefits, Network Benefits and Out-of-Network Benefits unless otherwise specifically stated. Benefit limits are calculated on a calendar year basis unless otherwise specifically stated. Payment Term and Description Table Payment Term And Description Amounts The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network Annual Deductible The amount you pay for Covered Health Care Services per year before you are eligible to receive Benefits. The Annual Deductible applies to Covered Health Care Services under the Plan as indicated in this Schedule of Benefits, including Covered Health Care Services provided under the outpatient prescription drug plan. Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible. Amounts paid toward the Annual Deductible for Covered Health Care Services that are subject to a visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. The amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. The Annual Deductible does not include any amount that exceeds the Allowed Amount. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. $5,000 per Covered Person, not to exceed $10,000 for all Covered Persons in a family. $10,000 per Covered Person not to exceed $20,000 for all Covered Persons in a family. Out-of-Pocket Limit The maximum you pay per year for the Annual Deductible, Copayments or Coinsurance. Once you reach the Out-of- Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that year. The Out-of-Pocket Limit applies to Covered Health Care Services under the Plan as indicated in this Schedule of Benefits, including Covered Health Care Services $5,000 per Covered Person, not to exceed $10,000 for all Covered Persons in a family. The Out-of-Pocket Limit includes the Annual Deductible. $10,000 per Covered Person, not to exceed $20,000 for all Covered Persons in a family. The Out-of-Pocket Limit includes the Annual Deductible.

Noblesville Schools Medical Plan 10 Schedule of Benefits Set 001 Payment Term And Description Amounts The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network provided under the outpatient prescription drug plan. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The Out-of-Pocket Limit does not include any of the following and, once the Out-of-Pocket Limit has been reached, you still will be required to pay the following: • Any charges for non-Covered Health Care Services. • The amount you are required to pay if you do not obtain prior authorization as required. • Charges that exceed Allowed Amounts, or the Recognized Amount when applicable. • Copayments or Coinsurance for any Covered Health Care Service shown in the Schedule of Benefits table that does not apply to the Out-of-Pocket Limit. Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Out-of-Pocket Limit. Copayment Copayment is the amount you pay (calculated as a set dollar amount) each time you receive certain Covered Health Care Services. When Copayments apply, the amount is listed on the following pages next to the description for each Covered Health Care Service. Please note that for Covered Health Care Services, you are responsible for paying the lesser of: • The applicable Copayment. • The Allowed Amount, or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Coinsurance

Noblesville Schools Medical Plan 11 Schedule of Benefits Set 001 Payment Term And Description Amounts The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network Coinsurance is the amount you pay (calculated as a percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive certain Covered Health Care Services. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table.

Noblesville Schools Medical Plan 12 Schedule of Benefits Set 001 Schedule of Benefits Table When Benefit limits apply, the limit refers to any combination of Designated Network Benefits, Network Benefits and Out-of-Network Benefits unless otherwise specifically stated. Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in Section 9: Defined Terms. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount. Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Ambulance Services Prior Authorization Requirement In most cases, the Claims Administrator will initiate and direct non-Emergency ambulance transportation. For Out-of-Network Benefits, if you are requesting non-Emergency Air Ambulance services (including any affiliated non-Emergency ground ambulance transport in conjunction with non-Emergency Air Ambulance transport), you must obtain prior authorization as soon as possible before transport. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. Emergency Ambulance What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. Ground Ambulance: None Air Ambulance: None Same as Network Does the Amount You Pay Apply to the Out-of-Pocket Limit? Ground Ambulance: Yes Air Ambulance: Yes Same as Network Does the Annual Deductible Apply? Ground Ambulance: Yes Air Ambulance: Yes Same as Network Allowed Amounts for ground and Air Ambulance transport provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits.

Noblesville Schools Medical Plan 13 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Non-Emergency Ambulance What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. Ground Ambulance: None Air Ambulance: None Ground Ambulance: Same as Network Air Ambulance: Same as Network Does the Amount You Pay Apply to the Out-of-Pocket Limit? Ground Ambulance: Yes Air Ambulance: Yes Ground Ambulance: Same as Network Air Ambulance: Same as Network Does the Annual Deductible Apply? Ground Ambulance: Yes Air Ambulance: Yes Ground Ambulance: Same as Network Air Ambulance: Same as Network Ground or Air Ambulance, as the Claims Administrator determines appropriate. Allowed Amounts for ground and Air Ambulance transport provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Cellular and Gene Therapy Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of a Cellular or Gene Therapy arises. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits, you must contact the Claims Administrator 24 hours before admission for scheduled admissions or as soon as is reasonably possible for non-scheduled admissions. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. For Network Benefits, Cellular or Gene Therapy services must be received from a Designated Provider. Chronic Pain Management

Noblesville Schools Medical Plan 14 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Clinical Trials Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of participation in a clinical trial arises. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon the Covered Health Care Service, Benefit limits are the same as those stated under the specific Benefit category in this Schedule of Benefits. Benefits are available when the Covered Health Care Services are provided by either Network or out-of- Network providers. Congenital Heart Disease (CHD) Surgeries Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of a CHD surgery arises. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. It is important that you notify the Claims Administrator regarding your intention to have surgery. Your notification will open the opportunity to become enrolled in programs that are designed to achieve the best outcomes for you. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. For Network Benefits, CHD surgeries must be received from a Designated Provider.

Noblesville Schools Medical Plan 15 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Dental Services - Accident Only What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None Same as Network Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Same as Network Does the Annual Deductible Apply? Yes Same as Network Diabetes Services Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization before obtaining any DME for the management and treatment of diabetes that costs more than $1,000 (either retail purchase cost or cumulative retail rental cost of a single item). If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. Diabetes Self- Management and Training/Diabetic Eye Exams/Foot Care Depending upon where the Covered Health Care Service is provided, Benefits for diabetes self- management and training/diabetic eye exams/foot care will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits for diabetes self- management and training/diabetic eye exams/foot care will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.

Noblesville Schools Medical Plan 16 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Diabetes Self- Management Items For diabetes equipment, Benefits will be the same as those stated under Durable Medical Equipment (DME), Orthotics and Supplies. For diabetes supplies, you pay none of the Allowed Amount and the Annual Deductible applies. For diabetes equipment, Benefits will be the same as those stated under Durable Medical Equipment (DME), Orthotics and Supplies. For diabetes supplies, you pay 30% of the Allowed Amount and the Annual Deductible applies. Coinsurance applies to the Out-of- Pocket Limit. Benefits for diabetes equipment that meets the definition of DME are subject to the limit stated under Durable Medical Equipment (DME), Orthotics and Supplies. Durable Medical Equipment (DME), Orthotics and Supplies Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization before obtaining any DME or orthotic that costs more than $1,000 (either retail purchase cost or cumulative retail rental cost of a single item). If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Shoe inserts, arch supports, shoe orthotics and shoes (standard or custom), lifts and wedges limited to one pair or one shoe, as needed, per year. To receive Network Benefits, you must obtain the DME or orthotic from the vendor the Claims Administrator identifies or from the prescribing Network Physician. Emergency Health Care Services - Outpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None Same as Network Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify the Claims Administrator within one business day or on the same day of

Noblesville Schools Medical Plan 17 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Same as Network Does the Annual Deductible Apply? Yes Same as Network admission if reasonably possible. The Claims Administrator may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date the Claims Administrator decides a transfer is medically appropriate, Network Benefits will not be provided. Out-of-Network Benefits may be available if the continued stay is determined to be a Covered Health Care Service. If you are admitted as an inpatient to a Hospital directly from the Emergency room, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Copayment, Coinsurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Enteral Nutrition What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30%

Noblesville Schools Medical Plan 18 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Gender Dysphoria Prior Authorization Requirement for Surgical Treatment For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of surgery arises. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits, you must contact the Claims Administrator 24 hours before admission for an Inpatient Stay. It is important that you notify the Claims Administrator as soon as the possibility of surgery arises. Your notification allows the opportunity for the Claims Administrator to provide you with additional information and services that may be available to you and are designed to achieve the best outcomes for you. Prior Authorization Requirement for Non-Surgical Treatment Depending upon where the Covered Health Care Service is provided, any applicable prior authorization requirements will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Habilitative Services Prior Authorization Requirement For Out-of-Network Benefits, for a scheduled admission, you must obtain prior authorization five business days before admission, or as soon as is reasonably possible for non-scheduled admissions. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits, you must contact the Claims Administrator 24 hours before admission for scheduled admissions or as soon as is reasonably possible for non-scheduled admissions.

Noblesville Schools Medical Plan 19 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Inpatient Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Inpatient services limited per year as follows: • Limit will be the same as, and combined with, those stated under Skilled Nursing Facility/Inpatient Rehabilitation Services. Outpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Outpatient therapies: • Physical therapy. • Occupational therapy. • Manipulative Treatment. • Speech therapy. • Post-cochlear implant aural therapy. • Cognitive therapy. For the above outpatient therapies: Limits will be the same as, and combined with, those stated under Rehabilitation Services - Outpatient Therapy. Home Health Care Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization five business days before receiving services or as soon as is reasonably possible. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Limited to 90 visits per year. One visit equals up to four hours of skilled care services. This visit limit does not include any service which is billed only for the administration of

Noblesville Schools Medical Plan 20 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes intravenous infusion To receive Network Benefits for the administration of intravenous infusion, you must receive services from a provider the Claims Administrator identifies. Hospice Care Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization five business days before admission for an Inpatient Stay in a hospice facility or as soon as is reasonably possible. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits, you must contact the Claims Administrator within 24 hours of admission for an Inpatient Stay in a hospice facility. What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None Same as Network Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Same as Network Does the Annual Deductible Apply? Yes Same as Network Hospital - Inpatient Stay Prior Authorization Requirement For Out-of-Network Benefits, for a scheduled admission, you must obtain prior authorization five business days before admission, or as soon as is reasonably possible for non-scheduled admissions. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits you must contact the Claims Administrator 24 hours before admission for scheduled admissions or as soon as is reasonably possible for non-scheduled admissions.

Noblesville Schools Medical Plan 21 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Lab, X-Ray and Diagnostic - Outpatient Prior Authorization Requirement For Out-of-Network Benefits, for Genetic Testing, and sleep studies, you must obtain prior authorization five business days before scheduled services are received. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. Lab Testing - Outpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes

Noblesville Schools Medical Plan 22 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? X-Ray and Other Diagnostic Testing - Outpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Major Diagnostic and Imaging - Outpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Mental Health Care and Substance-Related and Addictive Disorders Services

Noblesville Schools Medical Plan 23 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Prior Authorization Requirement For Out-of-Network Benefits, for a scheduled admission for Mental Health Care and Substance-Related and Addictive Disorders Services, including an admission for services at a Residential Treatment facility, you must obtain prior authorization five business days before admission or as soon as is reasonably possible for non-scheduled admissions. In addition, for Out-of-Network Benefits you must obtain prior authorization before the following services are received: Partial Hospitalization/Day Treatment/High Intensity Outpatient; Intensive Outpatient Program(s); Intensive Behavioral Therapy, including Applied Behavior Analysis (ABA); psychological testing and transcranial magnetic stimulation. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. Inpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Outpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. Office Visits None All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs None Intensive Behavioral Therapy None Office Visits 30% All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs 30% Intensive Behavioral Therapy 30%

Noblesville Schools Medical Plan 24 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Office Visits Yes All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs Yes Intensive Behavioral Therapy Yes Office Visits Yes All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs Yes Intensive Behavioral Therapy Yes Does the Annual Deductible Apply? Office Visits Yes All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs Yes Intensive Behavioral Therapy Yes Office Visits Yes All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs Yes Intensive Behavioral Therapy Yes Virtual Behavioral Health Therapy and Coaching What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. Designated Network AbleTo None Out-of-Network Benefits are not available. Except for the initial consultation, Covered Persons with a high deductible health plan (HDHP) must meet their Annual Deductible before they are able to receive Benefits for these services. There are no deductibles, Copayments or Coinsurance for the initial consultation.

Noblesville Schools Medical Plan 25 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Out-of-Network Benefits are not available. Does the Annual Deductible Apply? Yes, only for treatments after the initial consultation. Out-of-Network Benefits are not available. Non-Preventive Nutritional Counseling Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Benefits for non- preventive nutritional counseling services for mental health and substance-related and addictive disorders will follow mental health and substance-related and addictive disorders services office visit. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Benefits for non- preventive nutritional counseling services for mental health and substance-related and addictive disorders will follow mental health and substance-related and addictive disorders services office visit. Ostomy Supplies What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Pharmaceutical Products - Outpatient

Noblesville Schools Medical Plan 26 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Physician Fees for Surgical and Medical Services What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Covered Health Care Services provided by an out-of-Network Physician in certain Network facilities will apply the same cost sharing (Copayment, Coinsurance and applicable deductible) as if those services were provided by a Network provider; however Allowed Amounts will be determined as described below under Allowed Amounts in this Schedule of Benefits. Physician's Office Services - Sickness and Injury What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes

Noblesville Schools Medical Plan 27 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Annual Deductible Apply? Yes Yes Pregnancy - Maternity Services Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization as soon as reasonably possible if the Inpatient Stay for the mother and/or the newborn will be more than 48 hours for the mother and newborn child following a normal vaginal delivery, or more than 96 hours for the mother and newborn child following a cesarean section delivery. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. It is important that you notify the Claims Administrator regarding your Pregnancy. Your notification will open the opportunity to become enrolled in prenatal programs that are designed to achieve the best outcomes for you and your baby. Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay. Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay. Preventive Care Services Physician office services What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? No Yes Does the Annual Deductible Apply? No Yes

Noblesville Schools Medical Plan 28 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Lab, X-ray or other preventive tests What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? No Yes Does the Annual Deductible Apply? No Yes Breast pumps What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? No Yes Does the Annual Deductible Apply? No Yes Prosthetic Devices Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization before obtaining prosthetic devices that exceed $1,000 in cost per device. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts.

Noblesville Schools Medical Plan 29 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Benefits are limited to a single purchase of each type of prosthetic device every three years. Repair and/or replacement of a prosthetic device would apply to this limit in the same manner as a purchase. Once this limit is reached, Benefits continue to be available for items required by the Women's Health and Cancer Rights Act of 1998. Reconstructive Procedures Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization five business days before a scheduled reconstructive procedure is performed or, for non-scheduled procedures, within one business day or as soon as is reasonably possible. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits you must contact the Claims Administrator 24 hours before admission for scheduled inpatient admissions or as soon as is reasonably possible for non-scheduled inpatient admissions. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Limited per year as follows: • 36 visits of cardiac rehabilitation therapy.

Noblesville Schools Medical Plan 30 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Scopic Procedures - Outpatient Diagnostic and Therapeutic What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Prior Authorization Requirement For Out-of-Network Benefits, for a scheduled admission, you must obtain prior authorization five business days before admission, or as soon as is reasonably possible for non-scheduled admissions. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits, you must contact the Claims Administrator 24 hours before admission for scheduled admissions or as soon as is reasonably possible for non-scheduled admissions. What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes 60 days per year in a Skilled Nursing Facility. 60 days per year in an Inpatient Rehabilitation Facility.

Noblesville Schools Medical Plan 31 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Annual Deductible Apply? Yes Yes Surgery - Outpatient Prior Authorization Requirement For Out-of-Network Benefits, for sleep apnea surgery you must obtain prior authorization five business days before scheduled services are received or, for non-scheduled services, within one business day or as soon as is reasonably possible. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Temporomandibular Joint (TMJ) Services Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Therapeutic Treatments - Outpatient Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization for the following outpatient therapeutic services five business days before scheduled services are received or, for non-scheduled services, within one business day or as soon as is reasonably possible. Services that require prior authorization: dialysis, IV infusion, intensity modulated radiation therapy, and MR-guided focused ultrasound. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts.

Noblesville Schools Medical Plan 32 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Transplantation Services Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of a transplant arises (and before the time a pre-transplantation evaluation is performed at a transplant center). If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits you must contact the Claims Administrator 24 hours before admission for scheduled admissions or as soon as is reasonably possible for non-scheduled admissions. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. For Network Benefits, transplantation services must be received from a Designated Provider or Network Provider. The Claims Administrator does not require that cornea transplants be received from a Designated Provider in order for you to receive Network Benefits. Urgent Care Center Services What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30%

Noblesville Schools Medical Plan 33 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Urinary Catheters What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Virtual Care Services What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None Out-of-Network Benefits are not available. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Out-of-Network Benefits are not available. Does the Annual Deductible Apply? Yes Out-of-Network Benefits are not available. Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Network Provider by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. Wigs

Noblesville Schools Medical Plan 34 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None Same as Network Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Same as Network Does the Annual Deductible Apply? Yes Same as Network Limited to one wig per year. Allowed Amounts Allowed Amounts are the amount the Claims Administrator determines that the Plan will pay for Benefits. • For Designated Network Benefits and Network Benefits for Covered Health Care Services provided by a Network provider, except for your cost sharing obligations, you are not responsible for any difference between Allowed Amounts and the amount the provider bills. • For Out-of-Network Benefits, except as described below, you are responsible for paying, directly to the out-of-Network provider, any difference between the amount the provider bills you and the amount the Claims Administrator will pay for Allowed Amounts. ▪ For Covered Health Care Services that are Ancillary Services received at certain Network facilities on a non-Emergency basis from out-of-Network Physicians, you are not responsible, and the out-of-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD. ▪ For Covered Health Care Services that are non-Ancillary Services received at certain Network facilities on a non-Emergency basis from out-of-Network Physicians who have not satisfied the notice and consent criteria or for unforeseen or urgent medical needs that arise at the time a non-Ancillary Service is provided for which notice and consent has been satisfied as described below, you are not responsible, and the out-of- Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD. ▪ For Covered Health Care Services that are Emergency Health Care Services provided by an out-of-Network provider, you are not responsible, and the out-of-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD. ▪ For Covered Health Care Services that are Air Ambulance services provided by an out- of-Network provider, you are not responsible, and the out-of-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider, which is based on the Recognized Amount as defined in the SPD.

Noblesville Schools Medical Plan 35 Schedule of Benefits Set 001 Allowed Amounts are determined in accordance with the Claims Administrator's reimbursement policy guidelines, or as required by law, as described in the SPD. Designated Network Benefits and Network Benefits Allowed Amounts are based on the following: • When Covered Health Care Services are received from a Designated Network and Network provider, Allowed Amounts are our contracted fee(s) with that provider. • When Covered Health Care Services are received from an out-of-Network provider as arranged by the Claims Administrator, including when there is no Network provider who is reasonably accessible or available to provide Covered Health Care Services, Allowed Amounts are an amount negotiated by the Claims Administrator or an amount permitted by law. Please contact the Claims Administrator if you are billed for amounts in excess of your applicable Coinsurance, Copayment or any deductible. The Plan will not pay excessive charges or amounts you are not legally obligated to pay. Out-of-Network Benefits When Covered Health Care Services are received from an out-of-Network provider as described below, Allowed Amounts are determined as follows: • For non-Emergency Covered Health Care Services received at certain Network facilities from out-of-Network Physicians when such services are either Ancillary Services, or non- Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Health Service Act with respect to a visit as defined by the Secretary (including non- Ancillary Services that have satisfied the notice and consent criteria but unforeseen urgent medical needs arise at the time the services are provided), the Allowed Amount is based on one of the following in the order listed below as applicable: ▪ The reimbursement rate as determined by a state All Payer Model Agreement. ▪ The reimbursement rate as determined by state law. ▪ The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the out-of-Network provider and the Claims Administrator. ▪ The amount determined by Independent Dispute Resolution (IDR). For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary. IMPORTANT NOTICE: For Ancillary Services, non-Ancillary Services provided without notice and consent, and non-Ancillary Services for unforeseen or urgent medical needs that arise at the time a service is provided for which notice and consent has been satisfied, you are not responsible, and an out-of-Network Physician may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD. • For Emergency Health Care Services provided by an out-of-Network provider, the Allowed Amount is based on one of the following in the order listed below as applicable: ▪ The reimbursement rate as determined by a state All Payer Model Agreement. ▪ The reimbursement rate as determined by state law. ▪ The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the out-of-Network provider and the Claims Administrator. ▪ The amount determined by Independent Dispute Resolution (IDR).

Noblesville Schools Medical Plan 36 Schedule of Benefits Set 001 IMPORTANT NOTICE: You are not responsible, and an out-of-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD. • For Air Ambulance transportation provided by an out-of-Network provider, the Allowed Amount is based on one of the following in the order listed below as applicable: ▪ The reimbursement rate as determined by a state All Payer Model Agreement. ▪ The reimbursement rate as determined by state law. ▪ The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the out-of-Network provider and the Claims Administrator. ▪ The amount determined by Independent Dispute Resolution (IDR). IMPORTANT NOTICE: You are not responsible, and an out-of-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider, which is based on the Recognized Amount as defined in the SPD. • For Emergency ground ambulance transportation provided by an out-of-Network provider, the Allowed Amount, which includes mileage, is a rate agreed upon by the out-of-Network provider or, unless a different amount is required by applicable law, determined based upon the median amount negotiated with Network providers for the same or similar service. IMPORTANT NOTICE: Out-of-Network providers may bill you for any difference between the provider’s billed charges and the Allowed Amount described here. When Covered Health Care Services are received from an out-of-Network provider, except as described above, Allowed Amounts are determined as follows: (i) an amount negotiated by the Claims Administrator, (ii) a specific amount required by law (when required by law), or (iii) an amount the Claims Administrator has determined is typically accepted by a healthcare provider for the same or similar service or an amount that is greater than such rate when elected or directed by the Plan. The Plan will not pay excessive charges. You are responsible for paying, directly to the out-of-Network provider, the applicable Coinsurance, Copayment or any deductible. Please contact the Claims Administrator if you are billed for amounts in excess of your applicable Coinsurance, Copayment or any deductible to access the Advocacy Services as described below. Following the conclusion of the Advocacy Services described below, any responsibility to pay more than the Allowed Amount (which includes your Coinsurance, Copayment, and deductible) is yours. Advocacy Services The Plan has contracted with the Claims Administrator to provide advocacy services on your behalf with respect to out-of-network providers that have questions about the Allowed Amounts and how the Claims Administrator determined those amounts. Please call the Claims Administrator at the number on your ID card to access these advocacy services, or if you are billed for amounts in excess of your applicable Coinsurance or Copayment. In addition, if the Claims Administrator, or its designee, reasonably concludes that the particular facts and circumstances related to a claim provide justification for reimbursement greater than that which would result from the application of the Allowed Amount, and the Claims Administrator, or its designee, determines that it would serve the best interests of the Plan and its Participants (including interests in avoiding costs and expenses of disputes over payment of claims), the Claims Administrator, or its designee, may use its sole discretion to increase the Allowed Amount for that particular claim.

Noblesville Schools Medical Plan 37 Schedule of Benefits Set 001 Provider Network The Claims Administrator or its affiliates arrange for health care providers to take part in a Network. Network providers are independent practitioners. They are not Noblesville Schools or the Claims Administrator's employees. It is your responsibility to choose your provider. The Claims Administrator's credentialing process confirms public information about the providers' licenses and other credentials, but does not assure the quality of the services provided. Before obtaining services you should always verify the Network status of a provider. A provider's status may change. You can verify the provider's status by calling the telephone number on your ID card. A directory of providers is available by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card to request a copy. If you receive a Covered Health Care Service from an out-of-Network provider and were informed incorrectly prior to receipt of the Covered Health Care Service that the provider was a Network provider, either through a database, provider directory, or in a response to your request for such information (via telephone, electronic, web-based or internet-based means), you may be eligible for Network Benefits. It is possible that you might not be able to obtain services from a particular Network provider. The network of providers is subject to change. Or you might find that a particular Network provider may not be accepting new patients. If a provider leaves the Network or is otherwise not available to you, you must choose another Network provider to get Network Benefits. However, if you are currently receiving treatment for Covered Health Care Services from a provider whose network status changes from Network to out-of-Network during such treatment due to expiration or nonrenewal of the provider's contract, you may be eligible to request continued care from your current provider at the Network Benefit level for specified conditions and timeframes. This provision does not apply to provider contract terminations for failure to meet applicable quality standards or for fraud. If you would like help to find out if you are eligible for continuity of care Benefits, please call the telephone number on your ID card. If you are currently undergoing a course of treatment using an out-of-Network Physician or health care facility, you may be eligible to receive transition of care Benefits. This transition period is available for specific medical services and for limited periods of time. If you have questions regarding this transition of care reimbursement policy or would like help to find out if you are eligible for transition of care Benefits, please call the telephone number on your ID card. Do not assume that a Network provider's agreement includes all Covered Health Care Services. Some Network providers contract with the Claims Administrator to provide only certain Covered Health Care Services, but not all Covered Health Care Services. Some Network providers choose to be a Network provider for only some of the Claims Administrator's products. Refer to your provider directory or contact the Claims Administrator for help. Designated Providers If you have a medical condition that the Claims Administrator believes needs special services, the Claims Administrator may direct you to a Designated Provider chosen by the Claims Administrator. If you require certain complex Covered Health Care Services for which expertise is limited, the Claims Administrator may direct you to a Network facility or provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Care Services from a Designated Provider, the Plan may reimburse certain travel expenses. In both cases, Network Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by the Claims Administrator. You or your Network Physician must notify the Claims Administrator of special service needs (such as transplants or cancer treatment) that might warrant referral to a Designated Provider. If you do not notify the Claims Administrator in advance, and if you receive services from an out-of-Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Network Benefits will

Noblesville Schools Medical Plan 38 Schedule of Benefits Set 001 not be paid. Out-of-Network Benefits may be available if the special needs services you receive are Covered Health Care Services for which Benefits are provided under the Plan. Health Care Services from Out-of-Network Providers Paid as Network Benefits If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Network Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify the Claims Administrator and, if the Claims Administrator confirms that care is not available from a Network provider, the Claims Administrator will work with you and your Network Physician to coordinate care through an out-of-Network provider. Limitations on Selection of Providers If the Claims Administrator determines that you are using health care services in a harmful or abusive manner, or with harmful frequency, your selection of Network providers may be limited. If this happens, the Claims Administrator may require you to select a single Network Physician to provide and coordinate all future Covered Health Care Services. If you don't make a selection within 31 days of the date the Claims Administrator notifies you, the Claims Administrator will select a single Network Physician for you. If you do not use the selected Network Physician, Covered Health Care Services will be paid as Out-of- Network Benefits.

Noblesville Schools Medical Plan 39 Section 1: Covered Health Care Services Section 1: Covered Health Care Services When Are Benefits Available for Covered Health Care Services? Benefits are available only when all of the following are true: • The health care service, including supplies or Pharmaceutical Products, is only a Covered Health Care Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Care Service in Section 9: Defined Terms.) • You receive Covered Health Care Services while the Plan is in effect. • You receive Covered Health Care Services prior to the date that any of the individual termination conditions listed in Section 4: When Coverage Ends occurs. • The person who receives Covered Health Care Services is a Covered Person and meets all eligibility requirements specified in the Plan. The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a Covered Health Care Service under the Plan. Benefits are provided for services delivered via Telehealth/Telemedicine. Benefits are also provided for Remote Physiologic Monitoring. Benefits for these services are provided to the same extent as an in- person service under any applicable Benefit category in this section unless otherwise specified in the Schedule of Benefits. This section describes Covered Health Care Services for which Benefits are available. Please refer to the attached Schedule of Benefits for details about: • The amount you must pay for these Covered Health Care Services (including any Annual Deductible, Copayment and/or Coinsurance). • Any limit that applies to these Covered Health Care Services (including visit, day and dollar limits on services). • Any limit that applies to the portion of the Allowed Amount or the Recognized Amount when applicable, you are required to pay in a year (Out-of-Pocket Limit). • Any responsibility you have for obtaining prior authorization or notifying the Claims Administrator. Please note that in listing services or examples, when the Plan says "this includes," it is not the Claims Administrator's intent to limit the description to that specific list. When the Plan does intend to limit a list of services or examples, the Plan states specifically that the list "is limited to." Ambulance Services Emergency ambulance transportation by a licensed ambulance service (either ground or Air Ambulance) to the nearest Hospital where the required Emergency Health Care Services can be performed. Non-Emergency ambulance transportation by a licensed ambulance service (either ground or Air Ambulance, as the Claims Administrator determines appropriate) between facilities only when the transport meets one of the following: • From an out-of-Network Hospital to the closest Network Hospital when Covered Health Care Services are required. • To the closest Network Hospital that provides the required Covered Health Care Services that were not available at the original Hospital.

Noblesville Schools Medical Plan 40 Section 1: Covered Health Care Services • From a short-term acute care facility to the closest Network long-term acute care facility (LTAC), Network Inpatient Rehabilitation Facility, or other Network sub-acute facility where the required Covered Health Care Services can be delivered. For the purpose of this Benefit the following terms have the following meanings: ▪ "Long-term acute care facility (LTAC)" means a facility or Hospital that provides care to people with complex medical needs requiring long-term Hospital stay in an acute or critical setting. ▪ "Short-term acute care facility" means a facility or Hospital that provides care to people with medical needs requiring short-term Hospital stay in an acute or critical setting such as for recovery following a surgery, care following sudden Sickness, Injury, or flare-up of a chronic Sickness. ▪ "Sub-acute facility" means a facility that provides intermediate care on short-term or long- term basis. Cellular and Gene Therapy Cellular Therapy and Gene Therapy received on an inpatient or outpatient basis at a Hospital or on an outpatient basis at an Alternate Facility or in a Physician's office. Benefits for CAR-T therapy for malignancies are provided as described under Transplantation Services. Chronic Pain Management Benefits are provided for evidence based health care products and services, prescribed by a Covered Person's treating practitioner, intended to relieve chronic pain that has lasted for at least three (3) months. This includes: • Physical therapy. • Occupational therapy. • Chiropractic care. • Osteopathic manipulative treatment. • Athletic trainer services. As used in this section "chronic pain" means pain that: • Persists beyond the usual course of an acute disease or healing of an Injury; or. • May be associated with an acute or chronic pathologic process that causes continuous or intermittent pain for a period of months or years. Clinical Trials Routine patient care costs incurred while taking part in a qualifying clinical trial for the treatment of: • Cancer or other life-threatening disease or condition. For purposes of this Benefit, a life-threatening disease or condition is one which is likely to cause death unless the course of the disease or condition is interrupted. • Cardiovascular disease (cardiac/stroke) which is not life threatening, when the Claims Administrator determines the clinical trial meets the qualifying clinical trial criteria stated below. • Surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, when the Claims Administrator determines the clinical trial meets the qualifying clinical trial criteria stated below.

Noblesville Schools Medical Plan 41 Section 1: Covered Health Care Services • Other diseases or disorders which are not life threatening, when the Claims Administrator determines the clinical trial meets the qualifying clinical trial criteria stated below. Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat complications arising from taking part in a qualifying clinical trial. Benefits are available only when you are clinically eligible, as determined by the researcher, to take part in the qualifying clinical trial. Routine patient care costs for qualifying clinical trials include: • Covered Health Care Services for which Benefits are typically provided absent a clinical trial. • Covered Health Care Services required solely for the following: ▪ The provision of the Experimental or Investigational Service(s) or item. ▪ The clinically appropriate monitoring of the effects of the service or item, or ▪ The prevention of complications. • Covered Health Care Services needed for reasonable and necessary care arising from the receipt of an Experimental or Investigational Service(s) or item. Routine costs for clinical trials do not include: • The Experimental or Investigational Service(s) or item. The only exceptions to this are: ▪ Certain Category B devices. ▪ Certain promising interventions for patients with terminal illnesses. ▪ Other items and services that meet specified criteria in accordance with the Claims Administrator's medical and drug policies. • Items and services provided solely to meet data collection and analysis needs and that are not used in the direct clinical management of the patient. • A service that clearly does not meet widely accepted and established standards of care for a particular diagnosis. • Items and services provided by the research sponsors free of charge for any person taking part in the trial. With respect to cancer or other life-threatening diseases or conditions, a qualifying clinical trial is a Phase I, Phase II, Phase III, or Phase IV clinical trial. It takes place in relation to the prevention, detection or treatment of cancer or other life-threatening disease or condition. It meets any of the following criteria in the bulleted list below. With respect to cardiovascular disease, musculoskeletal disorders of the spine, hip and knees and other diseases or disorders which are not life-threatening, a qualifying clinical trial is a Phase I, Phase II, or Phase III clinical trial. It takes place in relation to the detection or treatment of such non-life-threatening disease or disorder. It meets any of the following criteria in the bulleted list below. • Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following: ▪ National Institutes of Health (NIH). (Includes National Cancer Institute (NCI).) ▪ Centers for Disease Control and Prevention (CDC). ▪ Agency for Healthcare Research and Quality (AHRQ). ▪ Centers for Medicare and Medicaid Services (CMS).

Noblesville Schools Medical Plan 42 Section 1: Covered Health Care Services ▪ A cooperative group or center of any of the entities described above or the Department of Defense (DOD) or the Veterans Administration (VA). ▪ A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants. ▪ The Department of Veterans Affairs, the Department of Defense or the Department of Energy if the study or investigation has been reviewed and approved through a system of peer review. The peer review system is determined by the Secretary of Health and Human Services to meet both of the following criteria: ♦ Comparable to the system of peer review of studies and investigations used by the National Institutes of Health. ♦ Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review. • The study or investigation takes place under an investigational new drug application reviewed by the U.S. Food and Drug Administration. • The study or investigation is a drug trial that is exempt from having such an investigational new drug application. • The clinical trial must have a written protocol that describes a scientifically sound study. It must have been approved by all relevant institutional review boards (IRBs) before you are enrolled in the trial. The Claims Administrator may, at any time, request documentation about the trial. • The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a Covered Health Care Service and is not otherwise excluded under the Plan. Congenital Heart Disease (CHD) Surgeries CHD surgeries which are ordered by a Physician. CHD surgical procedures include surgeries to treat conditions such as: • Coarctation of the aorta. • Aortic stenosis. • Tetralogy of Fallot. • Transposition of the great vessels. • Hypoplastic left or right heart syndrome. Benefits include the facility charge and the charge for supplies and equipment. Benefits for Physician services are described under Physician Fees for Surgical and Medical Services. Surgery may be performed as open or closed surgical procedures or may be performed through interventional cardiac catheterization. You can call the Claims Administrator at the telephone number on your ID card for information about the Claims Administrator's specific guidelines regarding Benefits for CHD services. Dental Services - Accident Only Dental services when all of the following are true: • Treatment is needed because of accidental damage. • You receive dental services from a Doctor of Dental Surgery or Doctor of Medical Dentistry.

Noblesville Schools Medical Plan 43 Section 1: Covered Health Care Services • The dental damage is severe enough that first contact with a Physician or dentist happened within 72 hours of the accident. (You may request this time period be longer if you do so within 60 days of the Injury and if extenuating circumstances exist due to the severity of the Injury.) Please note that dental damage that happens as a result of normal activities of daily living or extraordinary use of the teeth is not considered an accidental Injury. Benefits are not available for repairs to teeth that are damaged as a result of such activities. Dental services to repair damage caused by accidental Injury must follow these time-frames: • Treatment is started within three months of the accident, or if not a Covered Person at the time of the accident, within the first three months of coverage under the Plan, unless extenuating circumstances exist (such as prolonged hospitalization or the presence of fixation wires from fracture care). • Treatment must be completed within 12 months of the accident, or if not a Covered Person at the time of the accident, within the first 12 months of coverage under the Plan. Benefits for treatment of accidental Injury are limited to the following: • Emergency exam. • Diagnostic X-rays. • Endodontic (root canal) treatment. • Temporary splinting of teeth. • Prefabricated post and core. • Simple minimal restorative procedures (fillings). • Extractions. • Post-traumatic crowns if such are the only clinically acceptable treatment. • Replacement of lost teeth due to Injury with implant, dentures or bridges. Diabetes Services Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care Outpatient self-management training for the treatment of diabetes, education and medical nutrition therapy services. Services must be ordered by a Physician and provided by appropriately licensed or registered health care professionals. Benefits also include medical eye exams (dilated retinal exams) and preventive foot care for diabetes. Diabetic Self-Management Items Insulin pumps and supplies and continuous glucose monitors for the management and treatment of diabetes, based upon your medical needs. An insulin pump is subject to all the conditions of coverage stated under Durable Medical Equipment (DME), Orthotics and Supplies. Benefits for blood glucose meters, including continuous glucose monitors, insulin syringes with needles, blood glucose and urine test strips, ketone test strips and tablets and lancets and lancet devices may be available through the outpatient prescription drug plan. Durable Medical Equipment (DME), Orthotics and Supplies Benefits are provided for DME and certain orthotics and supplies. If more than one item can meet your functional needs, Benefits are available only for the item that meets the minimum specifications for your needs. If you purchase an item that exceeds these minimum specifications, the Plan will pay only the

Noblesville Schools Medical Plan 44 Section 1: Covered Health Care Services amount that the Plan would have paid for the item that meets the minimum specifications, and you will be responsible for paying any difference in cost. DME and Supplies Examples of DME and supplies include: ▪ Equipment to help mobility, such as a standard wheelchair. ▪ A standard Hospital-type bed. ▪ Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks). ▪ Negative pressure wound therapy pumps (wound vacuums). ▪ Mechanical equipment needed for the treatment of long term or sudden respiratory failure (except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters and personal comfort items are excluded from coverage). ▪ Burn garments. ▪ Insulin pumps and all related needed supplies as described under Diabetes Services. ▪ External cochlear devices and systems. Benefits for cochlear implantation are provided under the applicable medical/surgical Benefit categories in this SPD. ▪ Shoe inserts, arch supports and shoe orthotics when prescribed by a Physician. ▪ Shoes (standard or custom), lifts and wedges. Benefits include lymphedema stockings for the arm as required by the Women's Health and Cancer Rights Act of 1998. Benefits also include dedicated speech-generating devices and tracheo-esophageal voice devices required for treatment of severe speech impairment or lack of speech directly due to Sickness or Injury. Benefits for the purchase of these devices are available only after completing a required three-month rental period. Benefits are limited as stated in the Schedule of Benefits. Orthotics Orthotic braces, including needed changes to shoes to fit braces. Braces that stabilize an injured body part and braces to treat curvature of the spine are a Covered Health Care Service. The Claims Administrator will decide if the equipment should be purchased or rented. Benefits are available for repairs and replacement, except as described in Section 2: Exclusions and Limitations, under Medical Supplies and Equipment. These Benefits apply to external DME. Unless otherwise excluded, items that are fully implanted into the body are a Covered Health Care Service for which Benefits are available under the applicable medical/surgical Covered Health Care Service categories in this SPD. Emergency Health Care Services - Outpatient Services that are required to stabilize or begin treatment in an Emergency. Emergency Health Care Services must be received on an outpatient basis at a Hospital or Alternate Facility. Benefits include the facility charge, supplies and all professional services required to stabilize your condition and/or begin treatment. This includes placement in an observation bed to monitor your condition (rather than being admitted to a Hospital for an Inpatient Stay). Benefits are available for services to treat a condition that does not meet the definition of an Emergency.

Noblesville Schools Medical Plan 45 Section 1: Covered Health Care Services Enteral Nutrition Benefits are provided for specialized enteral formulas administered either orally or by tube feeding for certain conditions under the direction of a Physician. Gender Dysphoria Benefits for the treatment of gender dysphoria provided by or under the direction of a Physician. For the purpose of this Benefit, "gender dysphoria" is a disorder characterized by the specific diagnostic criteria classified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Habilitative Services For purposes of this Benefit, "habilitative services" means Skilled Care services that are part of a prescribed plan of treatment to help a person with a medical or behavioral disabling condition to learn or improve skills and functioning for daily living. The Claims Administrator will decide if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. Therapies provided for the purpose of general well-being or conditioning in the absence of a medical or behavioral disabling condition are not considered habilitative services. Habilitative services are limited to: • Physical therapy. • Occupational therapy. • Manipulative Treatment. • Speech therapy. • Post-cochlear implant aural therapy. • Cognitive therapy. Benefits are provided for habilitative services for both inpatient services and outpatient therapy when you have a medical or behavioral disabling condition when both of the following conditions are met: • Treatment is administered by any of the following: ▪ Licensed speech-language pathologist. ▪ Licensed audiologist. ▪ Licensed occupational therapist. ▪ Licensed physical therapist. ▪ Physician. • Treatment must be proven and not Experimental or Investigational. The following are not habilitative services: • Custodial Care. • Respite care. • Day care. • Therapeutic recreation. • Educational/vocational training. • Residential Treatment.

Noblesville Schools Medical Plan 46 Section 1: Covered Health Care Services • A service or treatment plan that does not help you meet functional goals. • Services solely educational in nature. • Educational services otherwise paid under state or federal law. The Claims Administrator may require the following be provided: • Medical records. • Other necessary data to allow the Claims Administrator to prove that medical treatment is needed. When the treating provider expects that continued treatment is or will be required to allow you to achieve progress the Claims Administrator may request additional medical records. • Frequency of treatment plan updates. Habilitative services provided in your home by a Home Health Agency are provided as described under Home Health Care. Habilitative services provided in your home other than by a Home Health Agency are provided as described under this section. Benefits for DME and prosthetic devices, when used as a part of habilitative services, are described under Durable Medical Equipment (DME), Orthotics and Supplies and Prosthetic Devices. Home Health Care Services received from a Home Health Agency that are all of the following: • Ordered by a Physician. • Provided in your home by a registered nurse, or provided by either a home health aide or licensed practical nurse and supervised by a registered nurse. • Provided on a part-time, Intermittent Care schedule. • Provided when Skilled Care is required. The Claims Administrator will determine if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. Hospice Care Hospice care that is recommended by a Physician. Hospice care is an integrated program that provides comfort and support services for the terminally ill. It includes the following: • Physical, psychological, social, spiritual and respite care for the terminally ill person. • Short-term grief counseling for immediate family members while you are receiving hospice care. Benefits are available when you receive hospice care from a licensed hospice agency. You can call the Claims Administrator at the telephone number on your ID card for information about the Claims Administrator's guidelines for hospice care. Hospital - Inpatient Stay Services and supplies provided during an Inpatient Stay in a Hospital. Benefits are available for: • Supplies and non-Physician services received during the Inpatient Stay. • Room and board in a Semi-private Room (a room with two or more beds).

Noblesville Schools Medical Plan 47 Section 1: Covered Health Care Services • Physician services for radiologists, anesthesiologists, pathologists and Emergency room Physicians. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Lab, X-Ray and Diagnostic - Outpatient Services for Sickness and Injury-related diagnostic purposes, received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office include: • Lab and radiology/X-ray. • Mammography. Benefits include: • The facility charge and the charge for supplies and equipment. • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) • Genetic Testing ordered by a Physician which results in available medical treatment options following Genetic Counseling. • Presumptive Drug Tests and Definitive Drug Tests. Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services. CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services are described under Major Diagnostic and Imaging - Outpatient. Major Diagnostic and Imaging - Outpatient Services for CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office. Benefits include: • The facility charge and the charge for supplies and equipment. • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Mental Health Care and Substance-Related and Addictive Disorders Services The Mental Health/Substance-Related and Addictive Disorders Delegate (the Delegate) administers Benefits for Mental Health and Substance-Related and Addictive Disorders Services. If you need assistance with coordination of care, locating a provider, and confirmation that services you plan to receive are Covered Health Care Services, you can contact the Delegate at the telephone number on your ID card. Mental Health Care and Substance-Related and Addictive Disorders Services include those received on an inpatient or outpatient basis in a Hospital, an Alternate Facility or in a provider's office. All services must be provided by or under the direction of a behavioral health provider who is properly licensed and qualified by law and acting within the scope of their licensure. Benefits include the following levels of care: • Inpatient treatment. • Residential Treatment. • Partial Hospitalization/Day Treatment/High Intensity Outpatient.

Noblesville Schools Medical Plan 48 Section 1: Covered Health Care Services • Intensive Outpatient Programs. • Outpatient treatment. Inpatient treatment and Residential Treatment includes room and board in a Semi-private Room (a room with two or more beds). Services include the following: • Diagnostic evaluations, assessment and treatment, and/or procedures. • Medication management. • Individual, family, and group therapy. • Crisis intervention. • Mental Health Care Services for Autism Spectrum Disorder (including Intensive Behavioral Therapies such as Applied Behavior Analysis (ABA)) that are the following: ▪ Focused on the treatment of core deficits of Autism Spectrum Disorder. ▪ Provided by a Board Certified Behavior Analyst (BCBA) or other qualified provider under the appropriate supervision. ▪ Focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others and property, and impairment in daily functioning. This section describes only the behavioral component of treatment for Autism Spectrum Disorder. Medical treatment of Autism Spectrum Disorder is a Covered Health Care Service for which Benefits are available under the applicable medical Covered Health Care Services categories in this SPD. Virtual Behavioral Health Therapy and Coaching Specialized virtual behavioral health care provided by AbleTo, Inc. ("AbleTo Therapy360 Program") for Covered Persons with certain co-occurring behavioral and medical conditions. AbleTo Therapy360 Program provides behavioral Covered Health Care Services through virtual therapy and coaching services that are individualized and tailored to your specific health needs. Virtual therapy is provided by licensed therapists. Coaching services are provided by coaches who are supervised by licensed professionals. If you would like information regarding these services, you may contact the Claims Administrator at the telephone number on your ID Card. Non-Preventive Nutritional Counseling Non-preventive nutritional counseling services for mental health and substance-related and addictive disorders and medical diagnosis that are provided as part of treatment for a disease by appropriately licensed or registered health care professionals. When nutritional counseling services are billed as a preventive care service, these services will be paid as described under Preventive Care Services in this section. Ostomy Supplies Benefits for ostomy supplies are limited to the following: • Pouches, face plates and belts. • Irrigation sleeves, bags and ostomy irrigation catheters. • Skin barriers.

Noblesville Schools Medical Plan 49 Section 1: Covered Health Care Services Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive remover, or other items not listed above. Pharmaceutical Products - Outpatient Pharmaceutical Products for Covered Health Care Services administered on an outpatient basis in a Hospital, Alternate Facility, Physician's office, or in your home. Benefits are provided for Pharmaceutical Products which, due to their traits (as determined by the Claims Administrator), are administered or directly supervised by a qualified provider or licensed/certified health professional. Depending on where the Pharmaceutical Product is administered, Benefits will be provided for administration of the Pharmaceutical Product under the corresponding Benefit category in this SPD. If you require certain Pharmaceutical Products the Claims Administrator may direct you to a Designated Dispensing Entity. Such Designated Dispensing Entities may include an outpatient pharmacy, Specialty pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or hemophilia treatment center contracted pharmacy. If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to get your Pharmaceutical Product from a Designated Dispensing Entity, Network Benefits are not available for that Pharmaceutical Product. Certain Pharmaceutical Products are subject to step therapy requirements. This means that in order to receive Benefits for such Pharmaceutical Products, you must use a different Pharmaceutical Product and/or prescription drug product first. You may find out whether a particular Pharmaceutical Product is subject to step therapy requirements by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. The Claims Administrator may have certain programs in which you may receive an enhanced or reduced Benefit based on your actions such as adherence/compliance to medication or treatment regimens and/or participation in health management programs. You may access information on these programs by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. Physician Fees for Surgical and Medical Services Physician fees for surgical procedures and other medical services received on an outpatient or inpatient basis in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility, or for Physician house calls. Physician's Office Services - Sickness and Injury Services provided in a Physician's office for the diagnosis and treatment of a Sickness or Injury. Benefits are provided regardless of whether the Physician's office is freestanding, located in a clinic or located in a Hospital. Covered Health Care Services include medical education services that are provided in a Physician's office by appropriately licensed or registered health care professionals. Covered Health Care Services include Genetic Counseling. Benefits include allergy injections. Covered Health Care Services for preventive care provided in a Physician's office are described under Preventive Care Services. When a test is performed or a sample is drawn in the Physician's office, Benefits for the analysis or testing of a lab, radiology/X-ray or other diagnostic service, whether performed in or out of the Physician’s office, are described under Lab, X-ray and Diagnostic - Outpatient.

Noblesville Schools Medical Plan 50 Section 1: Covered Health Care Services Pregnancy - Maternity Services Benefits for Pregnancy include all maternity-related medical services for prenatal care, postnatal care, delivery and any related complications. Both before and during a Pregnancy, Benefits include the services of a genetic counselor when provided or referred by a Physician. These Benefits are available to all Covered Persons in the immediate family. Covered Health Care Services include related tests and treatment. The Plan will pay Benefits for an Inpatient Stay of at least: • 48 hours for the mother and newborn child following a normal vaginal delivery. • 96 hours for the mother and newborn child following a cesarean section delivery. If the mother agrees, the attending provider may discharge the mother and/or the newborn child earlier than these minimum time frames. Preventive Care Services Preventive care services provided on an outpatient basis at a Physician's office, an Alternate Facility or a Hospital encompass medical services that have been demonstrated by clinical evidence to be safe and effective in either the early detection of disease or in the prevention of disease, have been proven to have a beneficial effect on health outcomes and include the following as required under applicable law: • Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force. • Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. • With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. • With respect to women, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Benefits defined under the Health Resources and Services Administration (HRSA) requirement include one breast pump per Pregnancy in conjunction with childbirth. Breast pumps must be ordered by or provided by a Physician. You can find more information on how to access Benefits for breast pumps by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. If more than one breast pump can meet your needs, Benefits are available only for the most cost effective pump. The Claims Administrator will determine the following: ▪ Which pump is the most cost effective. ▪ Whether the pump should be purchased or rented (and the duration of any rental). ▪ Timing of purchase or rental. Prosthetic Devices External prosthetic devices that replace a limb or a body part, limited to: • Artificial arms, legs, feet and hands. • Artificial face, eyes, ears and nose.

Noblesville Schools Medical Plan 51 Section 1: Covered Health Care Services • Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998. Benefits include mastectomy bras. Benefits for lymphedema stockings for the arm are provided as described under Durable Medical Equipment (DME), Orthotics and Supplies. Benefits are provided only for external prosthetic devices and do not include any device that is fully implanted into the body. Internal prosthetics are a Covered Health Care Service for which Benefits are available under the applicable medical/surgical Covered Health Care Service categories in this SPD. If more than one prosthetic device can meet your functional needs, Benefits are available only for the prosthetic device that meets the minimum specifications for your needs. If you purchase a prosthetic device that exceeds these minimum specifications, the Plan will pay only the amount that the Plan would have paid for the prosthetic that meets the minimum specifications, and you will be responsible for paying any difference in cost. The prosthetic device must be ordered or provided by, or under the direction of a Physician. Benefits are available for repairs and replacement, except as described in Section 2: Exclusions and Limitations, under Devices, Appliances and Prosthetics. Reconstructive Procedures Reconstructive procedures when the primary purpose of the procedure is either of the following: • Treatment of a medical condition. • Improvement or restoration of physiologic function. Reconstructive procedures include surgery or other procedures which are related to an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not a changed or improved physical appearance. Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that you may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure. Please note that Benefits for reconstructive procedures include breast reconstruction following a mastectomy, and reconstruction of the non-affected breast to achieve symmetry. Other services required by the Women's Health and Cancer Rights Act of 1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same level as those for any other Covered Health Care Service. You can call the Claims Administrator at the telephone number on your ID card for more information about Benefits for mastectomy-related services. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment Short-term outpatient rehabilitation services limited to: • Physical therapy. • Occupational therapy. • Manipulative Treatment. • Speech therapy. • Pulmonary rehabilitation therapy. • Cardiac rehabilitation therapy. • Post-cochlear implant aural therapy. • Cognitive rehabilitation therapy.

Noblesville Schools Medical Plan 52 Section 1: Covered Health Care Services Rehabilitation services must be performed by a Physician or by a licensed therapy provider. Benefits include rehabilitation services provided in a Physician's office or on an outpatient basis at a Hospital or Alternate Facility. Rehabilitative services provided in your home by a Home Health Agency are provided as described under Home Health Care. Rehabilitative services provided in your home other than by a Home Health Agency are provided as described under this section. Benefits can be denied or shortened when either of the following applies: • You are not progressing in goal-directed rehabilitation services. • Rehabilitation goals have previously been met. Benefits are not available for maintenance/preventive treatment. Scopic Procedures - Outpatient Diagnostic and Therapeutic Diagnostic and therapeutic scopic procedures and related services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office. Diagnostic scopic procedures are those for visualization, biopsy and polyp removal. Examples of diagnostic scopic procedures include: • Colonoscopy. • Sigmoidoscopy. • Diagnostic endoscopy. Please note that Benefits do not include surgical scopic procedures, which are for the purpose of performing surgery. Benefits for surgical scopic procedures are described under Surgery - Outpatient. Benefits include: • The facility charge and the charge for supplies and equipment. • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for all other Physician services are described under Physician Fees for Surgical and Medical Services.) Benefits that apply to certain preventive screenings are described under Preventive Care Services. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Services and supplies provided during an Inpatient Stay in a Skilled Nursing Facility or Inpatient Rehabilitation Facility. Benefits are available for: • Supplies and non-Physician services received during the Inpatient Stay. • Room and board in a Semi-private Room (a room with two or more beds). • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Please note that Benefits are available only if both of the following are true: • If the first confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility was or will be a cost effective option to an Inpatient Stay in a Hospital. • You will receive Skilled Care services that are not primarily Custodial Care. The Claims Administrator will determine if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. Benefits can be denied or shortened when either of the following applies: • You are not progressing in goal-directed rehabilitation services.

Noblesville Schools Medical Plan 53 Section 1: Covered Health Care Services • Discharge rehabilitation goals have previously been met. Surgery - Outpatient Surgery and related services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office. Benefits include certain scopic procedures. Examples of surgical scopic procedures include: • Arthroscopy. • Laparoscopy. • Bronchoscopy. • Hysteroscopy. Examples of surgical procedures performed in a Physician's office are mole removal, ear wax removal, and cast application. Benefits include: • The facility charge and the charge for supplies and equipment. • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Temporomandibular Joint (TMJ) Services Services for the evaluation and treatment of TMJ and associated muscles. Diagnosis: Exam, radiographs and applicable imaging studies and consultation. Non-surgical treatment including: • Clinical exams. • Oral appliances (orthotic splints). • Arthrocentesis. • Trigger-point injections. Benefits are provided for surgical treatment if the following criteria are met: • There is radiographic evidence of joint abnormality. • Non-surgical treatment has not resolved the symptoms. • Pain or dysfunction is moderate or severe. Benefits for surgical services include: • Arthrocentesis. • Arthroscopy. • Arthroplasty. • Arthrotomy. • Open or closed reduction of dislocations. Benefits for surgical services also include FDA-approved TMJ prosthetic replacements when all other treatment has failed.

Noblesville Schools Medical Plan 54 Section 1: Covered Health Care Services Therapeutic Treatments - Outpatient Therapeutic treatments received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office, including: • Dialysis (both hemodialysis and peritoneal dialysis). • Intravenous chemotherapy or other intravenous infusion therapy. • Radiation oncology. Covered Health Care Services include medical education services that are provided on an outpatient basis at a Hospital or Alternate Facility by appropriately licensed or registered health care professionals. Benefits include: • The facility charge and the charge for related supplies and equipment. • Physician services for anesthesiologists, pathologists and radiologists. Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services. Transplantation Services Organ and tissue transplants, including CAR-T cell therapy for malignancies, when ordered by a Physician. Benefits are available for transplants when the transplant meets the definition of a Covered Health Care Service, and is not an Experimental or Investigational or Unproven Service. Examples of transplants for which Benefits are available include: • Bone marrow, including CAR-T cell therapy for malignancies. • Heart. • Heart/lung. • Lung. • Kidney. • Kidney/pancreas. • Liver. • Liver/small intestine. • Pancreas. • Small intestine. • Cornea. Donor costs related to transplantation are Covered Health Care Services and are payable through the organ recipient's coverage under the Plan, limited to donor: • Identification. • Evaluation. • Organ removal. • Direct follow-up care. You can call the Claims Administrator at the telephone number on your ID card for information about the Claims Administrator's specific guidelines regarding Benefits for transplant services.

Noblesville Schools Medical Plan 55 Section 1: Covered Health Care Services Urgent Care Center Services Covered Health Care Services received at an Urgent Care Center. When services to treat urgent health care needs are provided in a Physician's office, Benefits are available as described under Physician's Office Services - Sickness and Injury. Urinary Catheters Benefits are provided for external, indwelling, and intermittent urinary catheters for incontinence or retention. Benefits include related urologic supplies for indwelling catheters limited to: • Urinary drainage bag and insertion tray (kit). • Anchoring device. • Irrigation tubing set. Virtual Care Services Virtual care for Covered Health Care Services that includes the diagnosis and treatment of less serious conditions. Virtual care provides communication of medical information in real-time between the patient and a distant Physician or health specialist, outside of a medical facility (for example, from home or from work). Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Network Provider by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. • Benefits are available for urgent on-demand health care delivered through live audio with video or audio only technology for treatment of acute but non-emergency needs. Please Note: Not all conditions can be treated through virtual care. The Designated Virtual Network Provider will identify any condition for which treatment by in-person Physician contact is needed. Benefits do not include email, or fax and standard telephone calls, or for services that occur within medical facilities (CMS defined originating facilities). Wigs Wigs and other scalp hair prostheses regardless of the reason for hair loss.

Noblesville Schools Medical Plan 56 Section 2: Exclusions and Limitations Section 2: Exclusions and Limitations How Are Headings Used in this Section? To help you find exclusions, this section contains headings (for example A. Alternative Treatments below). The headings group services, treatments, items, or supplies that fall into a similar category. Exclusions appear under the headings. A heading does not create, define, change, limit or expand an exclusion. All exclusions in this section apply to you. Plan Does Not Pay Benefits for Exclusions The Plan will not pay Benefits for any of the services, treatments, items or supplies described in this section, even if either of the following is true: • It is recommended or prescribed by a Physician. • It is the only available treatment for your condition. The services, treatments, items or supplies listed in this section are not Covered Health Care Services, except as may be specifically provided for in Section 1: Covered Health Care Services or through an SMM or Amendment to the Plan. Where Are Benefit Limitations Shown? When Benefits are limited within any of the Covered Health Care Service categories described in Section 1: Covered Health Care Services, those limits are stated in the corresponding Covered Health Care Service category in the Schedule of Benefits. Limits may also apply to some Covered Health Care Services that fall under more than one Covered Health Care Service category. When this occurs, those limits are also stated in the Schedule of Benefits table. Please review all limits carefully, as the Plan will not pay Benefits for any of the services, treatments, items or supplies that exceed these Benefit limits. Please note that in listing services or examples, when the exclusion or limitation says that "this includes," it is not the Plan's intent to limit the description to that specific list. When the Plan does intend to limit a list of services or examples, the exclusion or limitation will state specifically that the list "is limited to." Alternative Treatments 1. Acupressure and acupuncture. 2. Aromatherapy. 3. Hypnotism. 4. Massage therapy. 5. Rolfing. 6. Other forms of alternative treatment as defined by the National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health. This exclusion does not apply to Manipulative Treatment and non-manipulative osteopathic care for which Benefits are provided as described in Section 1: Covered Health Care Services. Dental 1. Dental care (which includes dental X-rays, supplies and appliances and all related expenses, including hospitalizations). This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only in Section 1: Covered Health Care Services.

Noblesville Schools Medical Plan 57 Section 2: Exclusions and Limitations This exclusion does not apply to dental anesthesia for Covered Persons under age 19 or to Covered Persons who are physically or mentally disabled. This exclusion does not apply to dental care (oral exam, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Plan, limited to: ▪ Transplant preparation. ▪ Prior to the initiation of immunosuppressive drugs. ▪ The direct treatment of acute traumatic Injury, cancer or cleft palate. Dental care that is required to treat the effects of a medical condition, but that is not necessary to directly treat the medical condition, is excluded. Examples include treatment of tooth decay or cavities resulting from dry mouth after radiation treatment or as a result of medication. Endodontics, periodontal surgery and restorative treatment are excluded. 2. Preventive care, diagnosis, treatment of or related to the teeth, jawbones or gums. Examples include: ▪ Removal, restoration and replacement of teeth. ▪ Medical or surgical treatments of dental conditions. ▪ Services to improve dental clinical outcomes. This exclusion does not apply to preventive care for which Benefits are provided under the United States Preventive Services Task Force requirement or the Health Resources and Services Administration (HRSA) requirement. This exclusion also does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only in Section 1: Covered Health Care Services. This exclusion does not apply to the extraction of impacted wisdom teeth. 3. Dental implants, bone grafts and other implant-related procedures. This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only in Section 1: Covered Health Care Services. 4. Dental braces (orthodontics). 5. Treatment of congenitally missing, malpositioned or supernumerary teeth, even if part of a Congenital Anomaly. Devices, Appliances and Prosthetics 1. Devices used as safety items or to help performance in sports-related activities. 2. Orthotic appliances that straighten or re-shape a body part. Examples include foot orthotics and some types of braces, including over-the-counter orthotic braces. This exclusion does not apply to cranial molding helmets and cranial banding that meet clinical criteria. This exclusion does not apply to braces for which Benefits are provided as described under Durable Medical Equipment (DME), Orthotics and Supplies in Section 1: Covered Health Care Services. 3. The following items are excluded, even if prescribed by a Physician: ▪ Blood pressure cuff/monitor. ▪ Enuresis alarm. ▪ Non-wearable external defibrillator. ▪ Trusses.

Noblesville Schools Medical Plan 58 Section 2: Exclusions and Limitations ▪ Ultrasonic nebulizers. 4. Devices and computers to help in communication and speech except for dedicated speech- generating devices and tracheo-esophageal voice devices for which Benefits are provided as described under Durable Medical Equipment (DME), Orthotics and Supplies in Section 1: Covered Health Care Services. 5. Oral appliances for snoring. 6. Repair or replacement of prosthetic devices due to misuse, malicious damage or gross neglect or to replace lost or stolen items. 7. Diagnostic or monitoring equipment purchased for home use, unless otherwise described as a Covered Health Care Service. 8. Powered and non-powered exoskeleton devices. 9. Over-the-counter continuous glucose monitors. Drugs 1. Prescription drug products for outpatient use that are filled by a prescription order or refill. 2. Self-administered or self-infused medications. This exclusion does not apply to medications which, due to their traits (as determined by the Claims Administrator), must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an outpatient setting. This exclusion does not apply to certain hemophilia treatment centers that are contracted with a specific hemophilia treatment center fee schedule that allows medications used to treat bleeding disorders to be dispensed directly to Covered Persons for self-administration. 3. Non-injectable medications given in a Physician's office. This exclusion does not apply to non- injectable medications that are required in an Emergency and used while in the Physician's office. 4. Over-the-counter drugs and treatments. 5. Growth hormone therapy. 6. Certain New Pharmaceutical Products and/or new dosage forms until the date as determined by the Claims Administrator or the Claims Administrator's designee, but no later than December 31st of the following calendar year. This exclusion does not apply if you have a life-threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment). If you have a life-threatening Sickness or condition, under such circumstances, Benefits may be available for the New Pharmaceutical Product to the extent provided in Section 1: Covered Health Care Services. 7. A Pharmaceutical Product that contains (an) active ingredient(s) available in and therapeutically equivalent (having essentially the same efficacy and adverse effect profile) to another covered Pharmaceutical Product. Such determinations may be made up to six times during a calendar year. 8. A Pharmaceutical Product that contains (an) active ingredient(s) which is (are) a modified version of and therapeutically equivalent (having essentially the same efficacy and adverse effect profile) to another covered Pharmaceutical Product. Such determinations may be made up to six times during a calendar year. 9. A Pharmaceutical Product with an approved biosimilar or a biosimilar and therapeutically equivalent (having essentially the same efficacy and adverse effect profile) to another covered Pharmaceutical Product. For the purpose of this exclusion a "biosimilar" is a biological Pharmaceutical Product approved based on showing that it is highly similar to a reference product (a biological Pharmaceutical Product) and has no clinically meaningful differences in terms of safety and effectiveness from the reference product. Such determinations may be made up to six times per calendar year.

Noblesville Schools Medical Plan 59 Section 2: Exclusions and Limitations 10. Certain Pharmaceutical Products for which there are therapeutically equivalent (having essentially the same efficacy and adverse effect profile) alternatives available to another Pharmaceutical Product, unless otherwise required by law or approved by the Claims Administrator. Such determinations may be made up to six times during a calendar year. 11. Certain Pharmaceutical Products that have not been prescribed by a Specialist. 12. Compounded drugs that contain certain bulk chemicals. Compounded drugs that are available as a similar commercially available Pharmaceutical Product. 13. Certain Specialty medications ordered by a Physician through your Plan Sponsor’s designated specialty pharmacy administrator. Experimental or Investigational or Unproven Services Experimental or Investigational and Unproven Services and all services related to Experimental or Investigational and Unproven Services are excluded. The fact that an Experimental or Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental or Investigational or Unproven in the treatment of that particular condition. This exclusion does not apply to Covered Health Care Services provided during a clinical trial for which Benefits are provided as described under Clinical Trials in Section 1: Covered Health Care Services. Foot Care 1. Routine foot care. Examples include: ▪ Cutting or removal of corns and calluses. ▪ Nail trimming, nail cutting, or nail debridement. ▪ Hygienic and preventive maintenance foot care including cleaning and soaking the feet and applying skin creams in order to maintain skin tone. This exclusion does not apply to preventive foot care due to conditions associated with metabolic, neurologic or peripheral vascular disease. 2. Treatment of flat feet. 3. Treatment of subluxation of the foot. Gender Dysphoria 1. Cosmetic Procedures, including the following: ▪ Abdominoplasty. ▪ Blepharoplasty. ▪ Body contouring, such as lipoplasty. ▪ Brow lift. ▪ Calf implants. ▪ Cheek, chin, and nose implants. ▪ Injection of fillers or neurotoxins. ▪ Face lift, forehead lift, or neck tightening. ▪ Facial bone remodeling for facial feminizations.

Noblesville Schools Medical Plan 60 Section 2: Exclusions and Limitations ▪ Hair removal, except as part of a genital reconstruction procedure by a physician for the treatment of Gender Dysphoria. ▪ Hair transplantation. ▪ Lip augmentation. ▪ Lip reduction. ▪ Liposuction. ▪ Mastopexy. ▪ Pectoral implants for chest masculinization. ▪ Rhinoplasty. ▪ Skin resurfacing. Medical Supplies and Equipment 1. Prescribed or non-prescribed medical supplies and certain disposable supplies. This exclusion does not apply to: ▪ Disposable supplies necessary for the effective use of DME or prosthetic devices for which Benefits are provided as described under Durable Medical Equipment (DME), Orthotics and Supplies and Prosthetic Devices in Section 1: Covered Health Care Services. This exception does not apply to supplies for the administration of medical food products. ▪ Diabetic supplies for which Benefits are provided as described under Diabetes Services in Section 1: Covered Health Care Services. ▪ Ostomy supplies for which Benefits are provided as described under Ostomy Supplies in Section 1: Covered Health Care Services. ▪ Urinary catheters and related urologic supplies for which Benefits are provided as described under Urinary Catheters in Section 1: Covered Health Care Services. 2. Tubings and masks except when used with DME as described under Durable Medical Equipment (DME), Orthotics and Supplies in Section 1: Covered Health Care Services. 3. Prescribed or non-prescribed publicly available devices, software applications and/or monitors that can be used for non-medical purposes. 4. Repair or replacement of DME or orthotics due to misuse, malicious damage or gross neglect or to replace lost or stolen items. Nutrition 1. Non-preventive nutritional counseling that is non-disease specific nutritional education such as general good eating habits. This exclusion does not apply to preventive care for which Benefits are provided under the United States Preventive Services Task Force or to Benefits provided under Non-Preventive Nutritional Counseling as described in Section 1: Covered Health Care Services. 2. Food of any kind, infant formula, standard milk-based formula, and donor breast milk. This exclusion does not apply to specialized enteral formula for which Benefits are provided as described under Enteral Nutrition in Section 1: Covered Health Care Services. 3. Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements and other nutrition-based therapy. Examples include supplements and electrolytes.

Noblesville Schools Medical Plan 61 Section 2: Exclusions and Limitations Personal Care, Comfort or Convenience 1. Television. 2. Telephone. 3. Beauty/barber service. 4. Guest service. 5. Supplies, equipment and similar incidental services and supplies for personal comfort. Examples include: ▪ Air conditioners, air purifiers and filters and dehumidifiers. ▪ Batteries and battery chargers. ▪ Breast pumps. This exclusion does not apply to breast pumps for which Benefits are provided under the Health Resources and Services Administration (HRSA) requirement. ▪ Car seats. ▪ Chairs, bath chairs, feeding chairs, toddler chairs, chair lifts and recliners. ▪ Exercise equipment. ▪ Home modifications such as elevators, handrails and ramps. ▪ Hot and cold compresses. ▪ Hot tubs. ▪ Humidifiers. ▪ Jacuzzis. ▪ Mattresses. ▪ Medical alert systems. ▪ Motorized beds. ▪ Music devices. ▪ Personal computers. ▪ Pillows. ▪ Power-operated vehicles. ▪ Radios. ▪ Safety equipment. ▪ Saunas. ▪ Stair lifts and stair glides. ▪ Strollers. ▪ Treadmills. ▪ Vehicle modifications such as van lifts. ▪ Video players. ▪ Whirlpools.

Noblesville Schools Medical Plan 62 Section 2: Exclusions and Limitations Physical Appearance 1. Cosmetic Procedures. See the definition in Section 9: Defined Terms. Examples include: ▪ Pharmacological regimens, nutritional procedures or treatments. ▪ Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion procedures). ▪ Skin abrasion procedures performed as a treatment for acne. ▪ Liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple. This exclusion does not apply to liposuction for which Benefits are provided as described under Reconstructive Procedures in Section 1: Covered Health Care Services. ▪ Treatment for skin wrinkles or any treatment to improve the appearance of the skin. ▪ Treatment for spider veins. ▪ Sclerotherapy treatment of veins. ▪ Hair removal or replacement by any means. 2. Replacement of an existing breast implant if the earlier breast implant was performed as a Cosmetic Procedure. Note: Replacement of an existing breast implant is considered reconstructive if the first breast implant followed mastectomy. See Reconstructive Procedures in Section 1: Covered Health Care Services. 3. Treatment of benign gynecomastia (abnormal breast enlargement in males). 4. Physical conditioning programs such as athletic training, body-building, exercise, fitness, or flexibility. 5. Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded. Procedures and Treatments 1. Removal of hanging skin on any part of the body. Examples include plastic surgery procedures called abdominoplasty and brachioplasty. 2. Medical and surgical treatment of excessive sweating (hyperhidrosis). 3. Medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea. 4. Rehabilitation services and Manipulative Treatment to improve general physical conditions that are provided to reduce potential risk factors, where improvement is not expected, including routine, long-term or maintenance/preventive treatment. 5. Habilitative services or therapies for the purpose of general well-being or condition in the absence of a medical or behavioral disabling condition. 6. Physiological treatments and procedures that result in the same therapeutic effects when performed on the same body region during the same visit or office encounter. 7. Biofeedback. 8. The following services for the diagnosis and treatment of TMJ: surface electromyography; Doppler analysis; vibration analysis; computerized mandibular scan or jaw tracking; craniosacral therapy; orthodontics; occlusal adjustment; and dental restorations.

Noblesville Schools Medical Plan 63 Section 2: Exclusions and Limitations 9. Upper and lower jawbone surgery, orthognathic surgery, and jaw alignment. This exclusion does not apply to reconstructive jaw surgery when there is a facial skeletal abnormality and associated functional medical impairment. 10. Surgical and non-surgical treatment of obesity. 11. Stand-alone multi-disciplinary tobacco cessation programs. These are programs that usually include health care providers specializing in tobacco cessation and may include a psychologist, social worker or other licensed or certified professionals. The programs usually include intensive psychological support, behavior modification techniques and medications to control cravings. 12. Breast reduction surgery except as coverage is required by the Women's Health and Cancer Rights Act of 1998 for which Benefits are described under Reconstructive Procedures in Section 1: Covered Health Care Services. This exclusion does not apply to breast reduction surgery for treatment of gender dysphoria. 13. Helicobacter pylori (H. pylori) serologic testing. 14. Intracellular micronutrient testing. 15. Cellular and Gene Therapy services not received from a Designated Provider. Providers 1. Services performed by a provider who is a family member by birth or marriage. Examples include a spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. 2. Services performed by a provider with your same legal address. 3. Services provided at a Freestanding Facility or diagnostic Hospital-based Facility without an order written by a Physician or other provider. Services which are self-directed to a Freestanding Facility or diagnostic Hospital-based Facility. Services ordered by a Physician or other provider who is an employee or representative of a Freestanding Facility or diagnostic Hospital-based Facility, when that Physician or other provider: ▪ Has not been involved in your medical care prior to ordering the service, or ▪ Is not involved in your medical care after the service is received. This exclusion does not apply to mammography. Reproduction 1. Health care services and related expenses for infertility treatments, including assisted reproductive technology, regardless of the reason for the treatment.. 2. The following services related to a Gestational Carrier or Surrogate: ▪ Fees for the use of a Gestational Carrier or Surrogate. ▪ Insemination costs of or InVitro fertilization procedures for Surrogate or transfer of an embryo to Gestational Carrier. ▪ Pregnancy services for a Gestational Carrier or Surrogate who is not a Covered Person. 3. Donor, Gestational Carrier or Surrogate administration, agency fees or compensation. 4. The following services related to donor services for donor sperm, ovum (egg cell) or oocytes (eggs), or embryos (fertilized eggs): ▪ Known egg donor (altruistic donation i.e., friend, relative or acquaintance) - The cost of donor eggs. Medical costs related to donor stimulation and egg retrieval. This refers to

Noblesville Schools Medical Plan 64 Section 2: Exclusions and Limitations purchasing or receiving a donated egg that is fresh, or one that has already been retrieved and is frozen. ▪ Purchased egg donor (i.e., clinic or egg bank) – The cost of donor eggs. Medical costs related to donor stimulation and egg retrieval. This refers to purchasing a donor egg that has already been retrieved and is frozen or choosing a donor who will then undergo an egg retrieval once they have been selected in the database. ▪ Known donor sperm (altruistic donation i.e., friend, relative or acquaintance) – The cost of sperm collection, cryopreservation and storage. This refers to purchasing or receiving donated sperm that is fresh, or that has already been obtained and is frozen. ▪ Purchased donor sperm (i.e., clinic or sperm bank) – The cost of procurement and storage of donor sperm. This refers to purchasing donor sperm that has already been obtained and is frozen or choosing a donor from a database. 5. Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular tissue and ovarian tissue. 6. The reversal of voluntary sterilization. 7. InVitro fertilization regardless of the reason for treatment. 8. Assisted Reproductive Technology procedures done for non-genetic disorder sex selection or eugenic (selective breeding) purposes. Services Provided under another Plan 1. Health care services for when other coverage is required by federal, state or local law to be bought or provided through other arrangements. Examples include coverage required by workers' compensation, or similar legislation. If coverage under workers' compensation or similar legislation is optional for you because you could elect it, or could have it elected for you, Benefits will not be paid for any Injury, Sickness or Mental Illness that would have been covered under workers' compensation or similar legislation had that coverage been elected. 2. Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a medical expense payment provision of an automobile insurance policy. 3. Health care services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. 4. Health care services during active military duty. Transplants 1. Health care services for organ and tissue transplants, except those described under Transplantation Services in Section 1: Covered Health Care Services. 2. Health care services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. (Donor costs that are directly related to organ removal are payable for a transplant through the organ recipient's Benefits under the Plan.) 3. Health care services for transplants involving animal organs. Travel 1. Travel or transportation expenses, even though prescribed by a Physician, except as identified under Complex Medical Conditions Travel and Lodging Assistance Program in Clinical Programs

Noblesville Schools Medical Plan 65 Section 2: Exclusions and Limitations and Resources. Some travel expenses related to Covered Health Care Services received from a Designated Provider or other Network provider may be paid back at the Claims Administrator's discretion. This exclusion does not apply to ambulance transportation for which Benefits are provided as described under Ambulance Services in Section 1: Covered Health Care Services. 2. Health care services provided in a foreign country, unless required as Emergency Health Care Services. Types of Care, Supportive Services, and Housing 1. Multi-disciplinary pain management programs provided on an inpatient basis for sharp, sudden pain or for worsened long term pain. 2. Custodial Care or maintenance care. 3. Domiciliary care. 4. Private Duty Nursing Inpatient. 5. Private Duty Nursing Outpatient. 6. Respite care. This exclusion does not apply to respite care for which Benefits are provided as described under Hospice Care in Section 1: Covered Health Care Services. 7. Rest cures. 8. Services of personal care aides. 9. Independent living services. 10. Assisted living services. 11. Educational counseling, testing, and support services including tutoring, mentoring, tuition, and school-based services for children and adolescents required to be provided by or paid for by the school under the Individual with Disabilities Education Act. 12. Vocational counseling, testing, and support services including job training, placement services, and work hardening programs (programs designed to return a person to work or to prepare a person for specific work). 13. Transitional Living services (including recovery residences). Vision and Hearing 1. Cost and fitting charge for eyeglasses and contact lenses except for the first pair following surgical removal of the lens(es) of the eyes. 2. Routine vision exams, including refractive exams to determine the need for vision correction. 3. Implantable lenses used only to fix a refractive error (such as Intacs corneal implants). 4. Eye exercise or vision therapy. 5. Surgery that is intended to allow you to see better without glasses or other vision correction. Examples include radial keratotomy, laser and other refractive eye surgery. 6. Cost and related fitting and testing charges for hearing aids, bone anchored hearing aids and all other hearing assistive devices. 7. Over-the-counter hearing aids.

Noblesville Schools Medical Plan 66 Section 2: Exclusions and Limitations All Other Exclusions 1. Health care services and supplies that do not meet the definition of a Covered Health Care Service. Covered Health Care Services are those health services, including services, supplies, or Pharmaceutical Products, which the Claims Administrator determines to be all of the following: ▪ Provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, substance-related and addictive disorders, condition, disease or its symptoms. ▪ Medically Necessary. ▪ Described as a Covered Health Care Service in this SPD under Section 1: Covered Health Care Services and in the Schedule of Benefits. ▪ Not otherwise excluded in this SPD under Section 2: Exclusions and Limitations. 2. Physical, psychiatric or psychological exams, testing, all forms of vaccinations and immunizations or treatments that are otherwise covered under the Plan when: ▪ Required only for school, sports or camp, travel, career or employment, insurance, marriage or adoption. ▪ Related to judicial or administrative proceedings or orders unless Medically Necessary. ▪ Conducted for purposes of medical research. This exclusion does not apply to Covered Health Care Services provided during a clinical trial for which Benefits are provided as described under Clinical Trials in Section 1: Covered Health Care Services. ▪ Required to get or maintain a license of any type. 3. Health care services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. This exclusion does not apply if you are a civilian injured or otherwise affected by war, any act of war, or terrorism in non-war zones. 4. Health care services received after the date your coverage under the Plan ends. This applies to all health care services, even if the health care service is required to treat a medical condition that started before the date your coverage under the Plan ended. 5. Health care services when you have no legal responsibility to pay, or when a charge would not ordinarily be made in the absence of coverage under the Plan. 6. Health care services when the Copayments, Coinsurance and/or deductible are waived, not pursued, or not collected by an out-of-Network provider. 7. Charges in excess of the Allowed Amount, when applicable, or in excess of any specified limitation. 8. Long term (more than 30 days) storage. Examples include cryopreservation of tissue, blood and blood products. 9. Autopsy. 10. Foreign language and sign language interpretation services offered by or required to be provided by a Network or out-of-Network provider. 11. Health care services related to a non-Covered Health Care Service: When a service is not a Covered Health Care Service, all services related to that non-Covered Health Care Service are also excluded. This exclusion does not apply to services the Claims Administrator would otherwise determine to be Covered Health Care Services if the service treats complications that arise from the non-Covered Health Care Service. For the purpose of this exclusion, a "complication" is an unexpected or unanticipated condition that is superimposed on an existing disease and that affects or modifies the prognosis of the original

Noblesville Schools Medical Plan 67 Section 2: Exclusions and Limitations disease or condition. Examples of a "complication" are bleeding or infections, following a Cosmetic Procedure, that require hospitalization.

Noblesville Schools Medical Plan 68 Section 3: When Coverage Begins Section 3: When Coverage Begins How Do You Enroll? Eligible Persons must complete an enrollment form given to them by the Plan Sponsor. The Plan Sponsor will submit the completed forms to the Claims Administrator, along with any required contribution. The Plan will not provide Benefits for health care services that you receive before your effective date of coverage. To enroll, call the Plan Sponsor within 31 days of the date you first become eligible for medical Plan coverage. If you do not enroll within 31 days, you will need to wait until the next annual Open Enrollment to make your benefit elections. Each year during annual Open Enrollment, you have the opportunity to review and change your medical election. If you wish to change your benefit elections due to your marriage, birth, adoption of a child, placement for adoption of a child or other family status change, you must contact the Plan Sponsor within 31 days of the event. Otherwise, you will need to wait until the next annual Open Enrollment to change your elections. If you do not wish to change your benefit election due to the birth of a newborn, the automatic coverage for the newborn will terminate immediately following day 31 after birth. You will need to wait until the next annual Open Enrollment to change your election if coverage has not been selected within 31 days. Cost of Coverage You and the Plan Sponsor share in the cost of the Plan. Your contribution amount depends on the Plan you select and the family members you choose to enroll. Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld. In most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you. Your contributions are subject to review and the Plan Sponsor reserves the right to change your contribution amount from time to time. You can obtain current contribution rates by calling the Plan Sponsor. What If You Are Hospitalized When Your Coverage Begins? The Plan will pay Benefits for Covered Health Care Services when all of the following apply: • You are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day your coverage begins. • You receive Covered Health Care Services on or after your first day of coverage related to that Inpatient Stay. • You receive Covered Health Care Services in accordance with the terms of the Plan. These Benefits are subject to your previous carrier's obligations under state law or contract. You should notify the Claims Administrator of your hospitalization within 48 hours of the day your coverage begins, or as soon as reasonably possible. For plans that have a Network Benefit level, Network Benefits are available only if you receive Covered Health Care Services from Network providers.

Noblesville Schools Medical Plan 69 Section 3: When Coverage Begins What If You Are Eligible for Medicare? Your Benefits may be reduced if you are eligible for Medicare but do not enroll in and maintain coverage under both Medicare Part A and Part B. Your Benefits may also be reduced if you are enrolled in a Medicare Advantage (Medicare Part C) plan but do not follow the rules of that plan. Please see How Are Benefits Paid When You Are Medicare Eligible in Section 8: General Legal Provisions for more information about how Medicare may affect your Benefits. Who Is Eligible for Coverage? The Plan Sponsor determines who is eligible to enroll and who qualifies as a Dependent. Eligible Person Eligible Person usually refers to an employee of the Plan Sponsor who (or other person whose connection with the Plan Sponsor) meets the eligibility rules. When an Eligible Person enrolls, the Claims Administrator refers to that person as a Participant. For a complete definition of Eligible Person, Plan Sponsor and Participant, see Section 9: Defined Terms. You are eligible to enroll in the Plan if you are a regular full-time employee who is scheduled to work at least 30 hours per week or a person who retires while covered under the Plan. Eligible Persons must live within the United States. If both spouses are Eligible Persons under the Plan Sponsor's Plan, each may enroll as a Participant or be covered as an Enrolled Dependent of the other, but not both. Dependent Dependent generally refers to the Participant's spouse and children. When a Dependent enrolls, the Claims Administrator refers to that person as an Enrolled Dependent. For a complete definition of Dependent and Enrolled Dependent, see Section 9: Defined Terms. Dependents of an Eligible Person may not enroll unless the Eligible Person is also covered under the Plan. If both parents of a Dependent child are enrolled as a Subscriber, only one parent may enroll the child as a Dependent. Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be: • Your Spouse. • Your or your Spouse's child who is under age 26, including a natural child, stepchild, a legally adopted child, a child placed for adoption or a child for whom you or your Spouse are the legal guardian. • An unmarried child age 26 or over who is or becomes disabled and dependent upon you. To be eligible for coverage under the Plan, a Dependent must reside within the United States. Note: Your Dependents may not enroll in the Plan unless you are also enrolled. In addition, if you and your Spouse are both covered under the Plan, you may each be enrolled as a Participant or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Plan, only one parent may enroll your child as a Dependent. A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order.

Noblesville Schools Medical Plan 70 Section 3: When Coverage Begins When Do You Enroll and When Does Coverage Begin? Except as described below, Eligible Persons may not enroll themselves or their Dependents. Initial Enrollment Period When the Plan Sponsor purchases coverage under the Plan from the Claims Administrator, the Initial Enrollment Period is the first period of time when Eligible Persons can enroll themselves and their Dependents. Coverage begins on the date shown in the Plan. The Plan Sponsor must receive the completed enrollment form and any required contribution within 31 days of the date the Eligible Person becomes eligible. Open Enrollment Period The Plan Sponsor sets the Open Enrollment Period. During the Open Enrollment Period, Eligible Persons can enroll themselves and their Dependents. Coverage begins on the date identified by the Plan Sponsor. The Plan Sponsor must receive the completed enrollment form and any required contribution within 31 days of the date the Eligible Person becomes eligible. New Eligible Persons Coverage for a new Eligible Person and his or her Dependents begins on the date agreed to by the Plan Sponsor. The Plan Sponsor must receive the completed enrollment form and any required contribution within 31 days of the date the new Eligible Person first becomes eligible. Adding New Dependents Participants may enroll Dependents who join their family because of any of the following events: • Birth. • Legal adoption. • Placement for adoption. • Marriage. • Legal guardianship. • Court or administrative order. Coverage for the Dependent begins on the date of the event. The Plan Sponsor must receive the completed enrollment form and any required contribution within 31 days of the event. Special Enrollment Period An Eligible Person and/or Dependent may also be able to enroll during a special enrollment period. A special enrollment period is not available to an Eligible Person and his or her Dependents if coverage under the prior plan ended for cause, or because premiums were not paid on a timely basis. An Eligible Person and/or Dependent does not need to elect COBRA continuation coverage to preserve special enrollment rights. Special enrollment is available to an Eligible Person and/or Dependent even if COBRA is not elected. A special enrollment period applies to an Eligible Person and any Dependents when one of the following events occurs:

Noblesville Schools Medical Plan 71 Section 3: When Coverage Begins • Birth. • Legal adoption. • Placement for adoption. • Marriage. A special enrollment period also applies for an Eligible Person and/or Dependent who did not enroll during the Initial Enrollment Period or Open Enrollment Period if any of the following are true: • The Eligible Person previously declined coverage under the Plan, but the Eligible Person and/or Dependent becomes eligible for a premium assistance subsidy under Medicaid or Children's Health Insurance Program (CHIP). Coverage will begin only if the Plan Sponsor receives the completed enrollment form and any required contribution within 60 days of the date of determination of subsidy eligibility. • The Eligible Person and/or Dependent had existing health coverage under another plan at the time they had an opportunity to enroll during the Initial Enrollment Period or Open Enrollment Period and coverage under the prior plan ended because of any of the following: ▪ Loss of eligibility (including legal separation, divorce or death). ▪ The employer stopped paying the contributions. This is true even if the Eligible Person and/or Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer. ▪ In the case of COBRA continuation coverage, the coverage ended. ▪ The Eligible Person and/or Dependent no longer resides, lives or works in an HMO service area if no other benefit option is available. ▪ The plan no longer offers benefits to a class of individuals that includes the Eligible Person and/or Dependent. ▪ The Eligible Person and/or Dependent loses eligibility under Medicaid or Children's Health Insurance Program (CHIP). Coverage will begin only if the Plan Sponsor receives the completed enrollment form and any required contribution within 60 days of the date coverage ended. When an event takes place (for example, a birth, marriage or determination of eligibility for state subsidy), coverage begins on the date of the event. The Plan Sponsor must receive the completed enrollment form and any required contribution within 31 days of the event unless otherwise noted above. For an Eligible Person and/or Dependent who did not enroll during the Initial Enrollment Period or Open Enrollment Period because they had existing health coverage under another plan, coverage begins on the day following the day coverage under the prior plan ends. Except as otherwise noted above, coverage will begin only if the Plan Sponsor receives the completed enrollment form and any required contribution within 31 days of the date coverage under the prior plan ended.

Noblesville Schools Medical Plan 72 Section 4: When Coverage Ends Section 4: When Coverage Ends General Information about When Coverage Ends As permitted by law, the Plan Sponsor may end the Plan and/or all similar benefit plans at any time for the reasons explained in the Plan. Your right to Benefits automatically ends on the date that coverage ends, even if you are hospitalized or are otherwise receiving medical treatment on that date. When your coverage ends, the Claims Administrator will still process Plan payments on claims for Covered Health Care Services that you received before the date your coverage ended. However, once your coverage ends, the Claims Administrator will not process Plan payments on claims for any health care services received after that date (even if the medical condition that is being treated occurred before the date your coverage ended). Unless otherwise stated, an Enrolled Dependent's coverage ends on the date the Participant's coverage ends. What Events End Your Coverage? Coverage ends on the earliest of the dates specified below: • The Entire Plan Ends Your coverage ends on the date the Plan ends. In this event, the Plan Sponsor is responsible for notifying you that your coverage has ended. • You Are No Longer Eligible Your coverage ends on the last day of the calendar month in which you are no longer eligible to be a Participant or Enrolled Dependent. Coverage for your Enrolled Dependent Spouse ends on the last day of the month your Enrolled Dependent Spouse no longer qualifies as a Dependent under this Plan. Coverage for your Enrolled Dependent child ends on the last day of the year your Enrolled Dependent child no longer qualifies as a Dependent under this Plan. Please refer to Section 9: Defined Terms for definitions of the terms "Eligible Person," "Participant," "Dependent" and "Enrolled Dependent." • The Claims Administrator Receives Notice to End Coverage The Plan Sponsor is responsible for providing the required notice to the Claims Administrator to end your coverage. Your coverage ends on the last day of the calendar month in which the Claims Administrator receives the required notice from the Plan Sponsor to end your coverage, or on the date requested in the notice, if later. • Participant Retires or Is Pensioned The Plan Sponsor is responsible for providing the required notice to the Claims Administrator to end your coverage. Your coverage ends the last day of the calendar month in which the Participant is retired or receiving benefits under the Plan Sponsor's pension or retirement plan. This provision applies unless there is specific coverage classification for retired or pensioned persons in the Plan, and only if the Participant continues to meet any applicable eligibility requirements. The Plan Sponsor can provide you with specific information about what coverage is available for retirees.

Noblesville Schools Medical Plan 73 Section 4: When Coverage Ends Fraud or Intentional Misrepresentation of a Material Fact The Plan will provide at least 30 days advance required notice to the Participant that coverage will end on the date identified in the notice because you committed an act, practice, or omission that constituted fraud, or an intentional misrepresentation of a material fact. Examples include knowingly providing incorrect information relating to another person's eligibility or status as a Dependent. You may appeal this decision during the notice period. The notice will contain information on how to appeal the decision. If the Claims Administrator and the Plan Sponsor find that you have performed an act, practice, or omission that constitutes fraud, or have made an intentional misrepresentation of material fact the Plan Sponsor has the right to demand that you pay back all Benefits the Plan paid to you, or paid in your name, during the time you were incorrectly covered under the Plan. Coverage for a Disabled Dependent Child Coverage for an unmarried Enrolled Dependent child who is disabled will not end just because the child has reached a certain age. The Plan will extend the coverage for that child beyond this age if both of the following are true: • The Enrolled Dependent child is not able to support him/herself because of mental, developmental or physical disability. • The Enrolled Dependent child depends mainly on the Participant for support. Coverage will continue as long as the Enrolled Dependent child is medically certified as disabled and dependent unless coverage otherwise ends in accordance with the terms of the Plan. You must furnish the Plan Sponsor with proof of the medical certification of disability within 31 days of the date coverage would have ended because the child reached a certain age. Before the Plan Sponsor agrees to this extension of coverage for the child, the Plan Sponsor may require that a Physician examine the child. The Plan Sponsor will choose the Physician and the Plan will pay for that examination. The Plan Sponsor may continue to ask you for proof that the child continues to be disabled and dependent. Such proof might include medical exams at the Plan's expense. The Plan Sponsor will not ask for this information more than once a year. If you do not provide proof of the child's disability and dependency within 31 days of the Plan Sponsor's request as described above, coverage for that child will end. Continuation of Coverage If your coverage ends under the Plan, you may have the right to elect continuation coverage (coverage that continues on in some form) in accordance with federal law. Continuation coverage under COBRA (the federal Consolidated Omnibus Budget Reconciliation Act) is available only to Plan Sponsors that are subject to the terms of COBRA. Contact your plan administrator to find out if your Plan Sponsor is subject to the provisions of COBRA. If you chose continuation coverage under a prior plan which was then replaced by coverage under the Plan, continuation coverage will end as scheduled under the prior plan or in accordance with federal or state law, whichever is earlier. The Claims Administrator is not the Plan Sponsor's designated "plan administrator" as that term is used in federal law, and the Claims Administrator does not assume any responsibilities of a "plan administrator" according to federal law. The Claims Administrator is not obligated to provide continuation coverage to you if the Plan Sponsor or its plan administrator fails to perform its responsibilities under federal law. Examples of the responsibilities of the Plan Sponsor or its plan administrator are: • Notifying you in a timely manner of the right to elect continuation coverage.

Noblesville Schools Medical Plan 74 Section 4: When Coverage Ends • Notifying the Claims Administrator in a timely manner of your election of continuation coverage. Uniformed Services Employment and Reemployment Rights Act A Participant who is absent from employment for more than 30 days by reason of service in the Uniformed Services may elect to continue Plan coverage for the Participant and the Participant's Dependents in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended (USERRA). The terms "Uniformed Services" or "Military Service" mean the Armed Forces, the Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency. If qualified to continue coverage pursuant to the USERRA, Participants may elect to continue coverage under the Plan by notifying the Plan Administrator in advance and providing payment of any required contribution for the health coverage. This may include the amount the Plan Administrator normally pays on a Participant's behalf. If a Participant's Military Service is for a period of time less than 31 days, the Participant may not be required to pay more than the regular contribution amount, if any, for continuation of health coverage. A Participant may continue Plan coverage under USERRA for up to the lesser of: • The 24-month period beginning on the date of the Participant's absence from work. • The day after the date on which the Participant fails to apply for, or return to, a position of employment. Regardless of whether a Participant continues health coverage, if the Participant returns to a position of employment, the Participant's health coverage and that of the Participant's eligible Dependents will be reinstated under the Plan. No exclusions or waiting period may be imposed on a Participant or the Participant's eligible Dependents in connection with this reinstatement, unless a Sickness or Injury is determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of military service. You should call the Plan Administrator if you have questions about your rights to continue health coverage under USERRA.

Noblesville Schools Medical Plan 75 Section 5: How to File a Claim Section 5: How to File a Claim Claims Procedures You can obtain a claim form by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. If you do not have a claim form, attach the bill from your provider to a brief letter of explanation. Verify that your provider's bill contains the Required Information listed below. If any Required Information is missing from the bill, you can include it in your letter. How Are Covered Health Care Services from Network Providers Paid? The Claims Administrator processes payment to Network providers directly for your Covered Health Care Services. If a Network provider bills you for any Covered Health Care Service, contact the Claims Administrator. However, you are required to meet any applicable deductible and to pay any required Copayments and Coinsurance to a Network provider. How Are Covered Health Care Services from an Out-of-Network Provider Paid? When you receive Covered Health Care Services from an out-of-Network provider, you are responsible for requesting payment from the Claims Administrator. You must file the claim in a format that contains all of the information the Claims Administrator requires, as described below. You should submit a request for payment of Benefits within 90 days after the date of service. If you don't provide this information to the Claims Administrator within one year of the date of service, Benefits for that health care service will be denied or reduced, in the Claims Administrator's discretion. This time limit does not apply if you are legally incapacitated. If your claim relates to an Inpatient Stay, the date of service is the date your Inpatient Stay ends. Required Information When you request payment of Benefits from the Claims Administrator, you must provide the Claims Administrator with all of the following information: • The Participant's name and address. • The patient's name and age. • The number stated on your ID card. • The name and address of the provider of the service(s). • The name and address of any ordering Physician. • A diagnosis from the Physician. • An itemized bill from your provider that includes the Current Procedural Terminology (CPT) codes or a description of each charge. • The date the Injury or Sickness began. • A statement indicating either that you are, or you are not, enrolled for coverage under any other health plan or program. If you are enrolled for other coverage you must include the name of the other carrier(s). The above information should be filed with the Claims Administrator at the address on your ID card.

Noblesville Schools Medical Plan 76 Section 5: How to File a Claim Payment of Benefits You may not assign, transfer, or in any way convey your Benefits under the Plan or any cause of action related to your Benefits under the Plan to a provider or to any other third party. Nothing in this Plan shall be construed to make the Plan, Plan Sponsor, or Claims Administrator or its affiliates liable for payments to a provider or to a third party to whom you may be liable for payments for Benefits. The Plan will not recognize claims for Benefits brought by a third party. Also, any such third party shall not have standing to bring any such claim independently, as a Covered Person or beneficiary, or derivatively, as an assignee of a Covered Person or beneficiary. References herein to "third parties" include references to providers as well as any collection agencies or third parties that have purchased accounts receivable from providers or to whom accounts receivables have been assigned. As a matter of convenience to a Covered Person, and where practicable for the Claims Administrator (as determined in its sole discretion), the Claims Administrator may make payment of Benefits directly to a provider. Any such payment to a provider: • is NOT an assignment of your Benefits under the Plan or of any legal or equitable right to institute any proceeding relating to your Benefits; and • is NOT a waiver of the prohibition on assignment of Benefits under the Plan; and • shall NOT estop the Plan, Plan Sponsor, or Claims Administrator from asserting that any purported assignment of Benefits under the Plan is invalid and prohibited. If this direct payment for your convenience is made, the Plan's obligation to you with respect to such Benefits is extinguished by such payment. If any payment of your Benefits is made to a provider as a convenience to you, the Claims Administrator will treat you, rather than the provider, as the beneficiary of your claim for Benefits, and the Plan reserves the right to offset any Benefits to be paid to a provider by any amounts that the provider owes the Plan (including amounts owed as a result of the assignment of other plans' overpayment recovery rights to the Plan), pursuant to Refund of Overpayments in Section 7: Coordination of Benefits. Allowed Amounts due to an out-of-Network provider for Covered Health Care Services that are subject to the No Surprises Act of the Consolidated Appropriations Act (P.L. 116-260) are paid directly to the provider. Form of Payment of Benefits Payment of Benefits under the Plan shall be in cash or cash equivalents, or in a form of other consideration that the Claims Administrator in its discretion determines to be adequate. Where Benefits are payable directly to a provider, such adequate consideration includes the forgiveness in whole or in part of the amount the provider owes to other plans for which the Claims Administrator processes payments, where the Plan has taken an assignment of the other plans' recovery rights for value.

Noblesville Schools Medical Plan 77 Section 6: Questions, Complaints and Appeals Section 6: Questions, Complaints and Appeals To resolve a question, complaint, or appeal, just follow these steps: What if You Have a Question? Call the telephone number shown on your ID card. Representatives are available to take your call during regular business hours, Monday through Friday. What if You Have a Complaint? Call the telephone number shown on your ID card. Representatives are available to take your call during regular business hours, Monday through Friday. If you would rather send your complaint to the Claims Administrator in writing, the representative can provide you with the address. If the representative cannot resolve the issue over the phone, he/she can help you prepare and submit a written complaint. The Claims Administrator will notify you of the decision regarding your complaint within 60 days of receiving it. How Do You Appeal a Claim Decision? Post-service Claims Post-service claims are claims filed for payment of Benefits after medical care has been received. Pre-service Requests for Benefits Pre-service requests for Benefits are requests that require prior authorization or benefit confirmation prior to receiving medical care. How to Request an Appeal If you disagree with a pre-service request for Benefits determination, post-service claim determination or a rescission of coverage determination, you can contact the Claims Administrator in writing to request an appeal. Your request for an appeal should include: • The patient's name and the identification number from the ID card. • The date(s) of medical service(s). • The provider's name. • The reason you believe the claim should be paid. • Any documentation or other written information to support your request for claim payment. Your first appeal request must be submitted to the Claims Administrator within 180 days after you receive the denial of a pre-service request for Benefits or the claim denial. For medical claims, the appeals address is: UnitedHealthcare - Appeals P.O. Box 30432 Salt Lake City, Utah 84130-0432

Noblesville Schools Medical Plan 78 Section 6: Questions, Complaints and Appeals Appeal Process A qualified individual who was not involved in the decision being appealed will be chosen to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with expertise in the field, who was not involved in the prior determination. The Claims Administrator may consult with, or ask medical experts to take part in the appeal process. You consent to this referral and the sharing of needed medical claim information. Upon request and free of charge, you have the right to reasonable access to and copies of all documents, records and other information related to your claim for Benefits. If any new or additional evidence is relied upon or generated by the Claims Administrator during the determination of the appeal, the Claims Administrator will provide it to you free of charge and in advance of the due date of the response to the adverse benefit determination. Appeals Determinations Pre-service Requests for Benefits and Post-service Claim Appeals For procedures related to urgent requests for Benefits, see Urgent Appeals that Require Immediate Action below. You will be provided written or electronic notification of the decision on your appeal as follows: • For appeals of pre-service requests for Benefits as defined above, the first level appeal will take place and you will be notified of the decision within 15 days from receipt of a request for appeal of a denied request for Benefits. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal. This request must be submitted to the Claims Administrator within 60 days from receipt of the first level appeal decision. The second level appeal will take place and you will be notified of the decision within 15 days from receipt of a request for review of the first level appeal decision. • For appeals of post-service claims as defined above, the first level appeal will take place and you will be notified of the decision within 30 days from receipt of a request for appeal of a denied claim. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal. This request must be submitted to the Claims Administrator within 60 days from receipt of the first level appeal decision. The second level appeal will take place and you will be notified of the decision within 30 days from receipt of a request for review of the first level appeal decision. Please note that the Claims Administrator's decision is based only on whether or not Benefits are available under the Plan for the proposed treatment or procedure. You may have the right to external review through an Independent Review Organization (IRO) upon the completion of the internal appeal process. Instructions regarding any such rights, and how to access those rights, will be provided in the decision letter to you. Upon written request and free of charge, any Covered Persons may examine their claim and/or appeals file(s). Covered Persons may also submit evidence, opinions and comments as part of the internal claims review process. The Claims Administrator will review all claims in accordance with the rules established by the U.S. Department of Labor. Any Covered Person will be automatically provided, free of charge, and sufficiently in advance of the date on which the notice of final internal adverse benefit determination is required, with: (i) any new or additional evidence considered, relied upon or generated by the Plan in connection with the claim; and, (ii) a reasonable opportunity for any Covered Person to respond to such new evidence or rationale.

Noblesville Schools Medical Plan 79 Section 6: Questions, Complaints and Appeals Urgent Appeals that Require Immediate Action Your appeal may require urgent action if a delay in treatment could increase the risk to your health, or the ability to regain maximum function, or cause severe pain. In these urgent situations: • The appeal does not need to be submitted in writing. You or your Physician should call the Claims Administrator as soon as possible. • The Claims Administrator will provide you with a written or electronic determination within 72 hours following receipt of your request for review of the determination, taking into account the seriousness of your condition. • If the Claims Administrator needs more information from your Physician to make a decision, the Claims Administrator will notify you of the decision by the end of the next business day following receipt of the required information. The appeal process for urgent situations does not apply to prescheduled treatments, therapies or surgeries. External Review Program You may be entitled to request an external review of the Claims Administrator's determination after exhausting your internal appeals if either of the following apply: • You are not satisfied with the determination made by the Claims Administrator. • The Claims Administrator fails to respond to your appeal within the timeframe required by the applicable regulations. If one of the above conditions is met, you may request an external review of adverse benefit determinations based upon any of the following: • Clinical reasons. • The exclusions for Experimental or Investigational Service(s) or Unproven Service(s). • Rescission of coverage (coverage that was cancelled or discontinued retroactively). • As otherwise required by applicable law. You or your representative may request a standard external review by sending a written request to the address listed in the determination letter. You or your representative may request an expedited external review, in urgent situations as defined below, by contacting the Claims Administrator at the telephone number on your ID card or by sending a written request to the address listed in the determination letter. A request must be made within four months after the date you received the Claims Administrator's final appeal decision. An external review request should include all of the following: • A specific request for an external review. • Your name, address, and insurance ID number. • Your designated representative's name and address, when applicable. • The service that was denied. • Any new, relevant information that was not provided during the internal appeal. An external review will be performed by an Independent Review Organization (IRO). The Claims Administrator has entered into agreements with three or more IROs that have agreed to perform such reviews. There are two types of external reviews available:

Noblesville Schools Medical Plan 80 Section 6: Questions, Complaints and Appeals • A standard external review. • An expedited external review. Standard External Review A standard external review includes all of the following: • A preliminary review by the Claims Administrator of the request. • A referral of the request by the Claims Administrator to the IRO. • A decision by the IRO. After receipt of the request, the Claims Administrator will complete a preliminary review within the applicable timeframe, to determine whether the individual for whom the request was submitted meets all of the following: • Is or was covered under the Plan at the time the health care service or procedure that is at issue in the request was provided. • Has exhausted the applicable internal appeals process. • Has provided all the information and forms required so that the Claims Administrator may process the request. After the Claims Administrator completes this review, the Claims Administrator will issue a notification in writing to you. If the request is eligible for external review, the Claims Administrator will assign an IRO to conduct such review. The Claims Administrator will assign requests by either rotating the assignment of claims among the IROs or by using a random selection process. The IRO will notify you in writing of the request's eligibility and acceptance for external review and if necessary, for any additional information needed to conduct the external review. You will generally have to submit the additional information in writing to the IRO within ten business days after the date you receive the IRO's request for the additional information. The IRO is not required to, but may, accept and consider additional information submitted by you after ten business days. The Claims Administrator will provide to the assigned IRO the documents and information considered in making the Claims Administrator's determination. The documents include: • All relevant medical records. • All other documents relied upon by the Claims Administrator. • All other information or evidence that you or your Physician submitted. If there is any information or evidence you or your Physician wish to submit that was not previously provided, you may include this information with your external review request. The Claims Administrator will include it with the documents forwarded to the IRO. In reaching a decision, the IRO will review the claim as new and not be bound by any decisions or conclusions reached by the Claims Administrator. The IRO will provide written notice of its determination (the "Final External Review Decision") within 45 days after it receives the request for the external review (unless they request additional time and you agree). The IRO will deliver the notice of Final External Review Decision to you and the Claims Administrator, and it will include the clinical basis for the determination. If the Claims Administrator receives a Final External Review Decision reversing the Claims Administrator's determination, the Plan will provide coverage or payment for the Benefit claim at issue according to the terms and conditions of the Plan, and any applicable law regarding plan remedies. If the

Noblesville Schools Medical Plan 81 Section 6: Questions, Complaints and Appeals Final External Review Decision agrees with the determination, the Plan will not be obligated to provide Benefits for the health care service or procedure. Expedited External Review An expedited external review is similar to a standard external review. The main difference between the two is that the time periods for completing certain portions of the review process are much shorter for the expedited external review, and in some instances you may file an expedited external review before completing the internal appeals process. You may make a written or verbal request for an expedited external review, separately or at the same time you have filed a request for an expedited internal appeal, if you receive either of the following: • An adverse benefit determination of a claim or appeal that involves a medical condition for which the time frame for completion of an expedited internal appeal would either jeopardize: ▪ The life or health of the individual. ▪ The individual's ability to regain maximum function. In addition, you must have filed a request for an expedited internal appeal. • A final appeal decision, that either: ▪ Involves a medical condition where the timeframe for completion of a standard external review would either jeopardize the life or health of the individual or jeopardize the individual's ability to regain maximum function. ▪ Concerns an admission, availability of care, continued stay, or health care service, procedure or product for which the individual received emergency care services, but has not been discharged from a facility. Immediately upon receipt of the request, the Claims Administrator will determine whether the individual meets both of the following: • Is or was covered under the Plan at the time the health care service or procedure that is at issue in the request was provided. • Has provided all the information and forms required so that the Claims Administrator may process the request. After the Claims Administrator completes the review, the Claims Administrator will send a notice in writing to you. Upon a determination that a request is eligible for expedited external review, the Claims Administrator will assign an IRO in the same manner the Claims Administrator utilizes to assign standard external reviews to IROs. The Claims Administrator will provide all required documents and information the Claims Administrator used in making the adverse benefit determination or final adverse benefit determination to the assigned IRO electronically or by telephone or facsimile or any other available method in a timely manner. The IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the same type of information and documents considered in a standard external review. In reaching a decision, the IRO will review the claim as new and not be bound by any decisions or conclusions reached by the Claims Administrator. The IRO will provide notice of the final external review decision for an expedited external review as quickly as the claimant's medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request. If the IRO's final external review decision is first communicated verbally, the IRO will follow-up with a written confirmation of the decision within 48 hours of that verbal communication. You may call the Claims Administrator at the telephone number on your ID card for more information regarding external review rights, or if making a verbal request for an expedited external review.

Noblesville Schools Medical Plan 82 Section 6: Questions, Complaints and Appeals Urgent Care Request for Benefits* Type of Request for Benefits or Appeal Timing If your request for Benefits is incomplete, the Claims Administrator must notify you within: 24 hours You must then provide completed request for Benefits to the Claims Administrator within: 48 hours after receiving notice of additional information required The Claims Administrator must notify you of the benefit determination within: 72 hours If the Claims Administrator denies your request for Benefits, you must appeal an adverse benefit determination no later than: 180 days after receiving the adverse benefit determination The Claims Administrator must notify you of the appeal decision within: 72 hours after receiving the appeal *You do not need to submit urgent care appeals in writing. You should call the Claims Administrator as soon as possible to appeal an urgent care request for Benefits. Pre-Service Request for Benefits* Type of Request for Benefits or Appeal Timing If your request for Benefits is filed improperly, the Claims Administrator must notify you within: 5 days If your request for Benefits is incomplete, the Claims Administrator must notify you within: 15 days You must then provide completed request for Benefits information to the Claims Administrator within: 45 days The Claims Administrator must notify you of the benefit determination: • if the initial request for Benefits is complete, within: 15 days • after receiving the completed request for Benefits (if the initial request for Benefits is incomplete), within: 15 days You must appeal an adverse benefit determination no later than: 180 days after receiving the adverse benefit determination The Claims Administrator must notify you of the first level appeal decision within: 15 days after receiving the first level appeal You must appeal the first level appeal (file a second level appeal) within: 60 days after receiving the first level appeal decision

Noblesville Schools Medical Plan 83 Section 6: Questions, Complaints and Appeals Pre-Service Request for Benefits* Type of Request for Benefits or Appeal Timing The Claims Administrator must notify you of the second level appeal decision within: 15 days after receiving the second level appeal *The Claims Administrator may require a one-time extension for the initial claim determination, of no more than 15 days, only if more time is needed due to circumstances beyond control of the Plan. Post-Service Claims Type of Claim or Appeal Timing If your claim is incomplete, the Claims Administrator must notify you within: 30 days You must then provide completed claim information to the Claims Administrator within: 45 days The Claims Administrator must notify you of the benefit determination: • if the initial claim is complete, within: 30 days • after receiving the completed claim (if the initial claim is incomplete), within: 15 days You must appeal an adverse benefit determination no later than: 180 days after receiving the adverse benefit determination The Claims Administrator must notify you of the first level appeal decision within: 30 days after receiving the first level appeal You must appeal the first level appeal (file a second level appeal) within: 60 days after receiving the first level appeal decision The Claims Administrator must notify you of the second level appeal decision within: 30 days after receiving the second level appeal

Noblesville Schools Medical Plan 84 Section 7: Coordination of Benefits Section 7: Coordination of Benefits Benefits When You Have Coverage under More than One Plan This section describes how Benefits under the Plan will be coordinated with those of any other plan that provides benefits to you. When Does Coordination of Benefits Apply? This Coordination of Benefits (COB) provision applies to you if you are covered by more than one health benefits plan, including any one of the following: • Another employer sponsored health benefits plan. • A medical component of a group long-term care plan, such as skilled nursing care. • No-fault or traditional "fault" type medical payment benefits or personal injury protection benefits under an auto insurance policy. • Medical payment benefits under any premises liability or other types of liability coverage. • Medicare or other governmental health benefit. If coverage is provided under two or more plans, COB determines which plan is primary and which plan is secondary. The plan considered primary pays its benefits first, without regard to the possibility that another plan may cover some expenses. Any remaining expenses may be paid under the other plan, which is considered secondary. The secondary plan may determine its benefits based on the benefits paid by the Primary Plan. How much this Plan will reimburse you, if anything, will also depend in part on the Allowable Expense. The term, “Allowable Expense,” is further explained below. What Are the Rules for Determining the Order of Benefit Payments? Order of Benefit Determination Rules The order of benefit determination rules determine whether This Plan is a Primary Plan or Secondary Plan when the person has health care coverage under more than one Plan. When This Plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other Plan's benefits. When This Plan is secondary, it determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable Expense. The order of benefit determination rules below govern the order in which each Plan will pay a claim for benefits. • Primary Plan. The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses. • Secondary Plan. The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable Expense. Allowable Expense is defined below. When a person is covered by two or more Plans, the rules for determining the order of benefit payments are as follows: A. This Plan will always be secondary to medical payment coverage or personal injury protection coverage under any auto liability or no-fault insurance policy. B. When you have coverage under two or more medical plans and only one has COB provisions, the plan without COB provisions will pay benefits first.

Noblesville Schools Medical Plan 85 Section 7: Coordination of Benefits C. Each Plan determines its order of benefits using the first of the following rules that apply: 1. Non-Dependent or Dependent. The Plan that covers the person other than as a dependent, for example as an employee, former employee under COBRA, policyholder, subscriber or retiree is the Primary Plan and the Plan that covers the person as a dependent is the Secondary Plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a dependent; and primary to the Plan covering the person as other than a dependent (e.g. a retired employee); then the order of benefits between the two Plans is reversed so that the Plan covering the person as an employee, policyholder, subscriber or retiree is the Secondary Plan and the other Plan is the Primary Plan. 2. Dependent Child Covered Under More Than One Coverage Plan. Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows: a) For a dependent child whose parents are married or are living together, whether or not they have ever been married: (1) The Plan of the parent whose birthday falls earlier in the calendar year is the Primary Plan; or (2) If both parents have the same birthday, the Plan that covered the parent longest is the Primary Plan. b) For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married: (1) If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the Plan of that parent has actual knowledge of those terms, that Plan is primary. If the parent with responsibility has no health care coverage for the dependent child's health care expenses, but that parent's spouse does, that parent's spouse's plan is the Primary Plan. This shall not apply with respect to any plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision. (2) If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of subparagraph a) above shall determine the order of benefits. (3) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subparagraph a) above shall determine the order of benefits. (4) If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows: (a) The Plan covering the Custodial Parent. (b) The Plan covering the Custodial Parent's spouse. (c) The Plan covering the non-Custodial Parent. (d) The Plan covering the non-Custodial Parent's spouse. For purpose of this section, Custodial Parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the

Noblesville Schools Medical Plan 86 Section 7: Coordination of Benefits parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. c) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under subparagraph a) or b) above as if those individuals were parents of the child. d) (i) For a dependent child who has coverage under either or both parents' plans and also has his or her own coverage as a dependent under a spouse's plan, the rule in paragraph (5) applies. (ii) In the event the dependent child's coverage under the spouse's plan began on the same date as the dependent child's coverage under either or both parents' plans, the order of benefits shall be determined by applying the birthday rule in subparagraph (a) to the dependent child's parent(s) and the dependent's spouse. 3. Active Employee or Retired or Laid-off Employee. The Plan that covers a person as an active employee, that is, an employee who is neither laid off nor retired is the Primary Plan. The same would hold true if a person is a dependent of an active employee and that same person is a dependent of a retired or laid-off employee. If the other Plan does not have this rule, and, as a result, the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled C.1. can determine the order of benefits. 4. COBRA or State Continuation Coverage. If a person whose coverage is provided pursuant to COBRA or under a right of continuation provided by state or other federal law is covered under another Plan, the Plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member, subscriber or retiree is the Primary Plan, and the COBRA or state or other federal continuation coverage is the Secondary Plan. If the other Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled C.1. can determine the order of benefits. 5. Longer or Shorter Length of Coverage. The Plan that covered the person the longer period of time is the Primary Plan and the Plan that covered the person the shorter period of time is the Secondary Plan. 6. If the preceding rules do not determine the order of benefits, the Allowable Expenses shall be shared equally between the Plans meeting the definition of Plan. In addition, This Plan will not pay more than it would have paid had it been the Primary Plan. How Are Benefits Paid When This Plan is Secondary? If this Plan is secondary, it determines the amount it will pay for a Covered Health Care Services by following the steps below. • The Plan determines the amount it would have paid based on the allowable expense. • If this Plan would have paid the same amount or less than the Primary Plan paid, this Plan pays no Benefits. • If this Plan would have paid more than the Primary Plan paid, the Plan will pay the difference. You will be responsible for any applicable Copayment, Coinsurance or Deductible payments as part of the COB payment. The maximum combined payment you can receive from all plans may be less than 100% of the allowable expense. How is the Allowable Expense Determined when this Plan is Secondary? Determining the Allowable Expense If this Plan is Secondary

Noblesville Schools Medical Plan 87 Section 7: Coordination of Benefits What is an allowable expense? For purposes of COB, an allowable expense is a health care expense that is covered at least in part by one of the health benefit plans covering you. When the provider is a Network provider for both the Primary Plan and this Plan, the allowable expense is the Primary Plan's network rate. When the provider is a network provider for the Primary Plan and an out- of-Network provider for this Plan, the allowable expense is the Primary Plan's network rate. When the provider is an out-of-Network provider for the Primary Plan and a Network provider for this Plan, the allowable expense is the reasonable and customary charges allowed by the Primary Plan. When the provider is an out-of-Network provider for both the Primary Plan and this Plan, the allowable expense is the greater of the two Plans' reasonable and customary charges. If this plan is secondary to Medicare, please also refer to the discussion in the section below, titled " Determining the Allowable Expense When this Plan is Secondary to Medicare ". What is Different When You Qualify for Medicare? Determining Which Plan is Primary When You Qualify for Medicare As permitted by law, this Plan will pay Benefits second to Medicare when you become eligible for Medicare, even if you don't elect it. There are, however, Medicare-eligible individuals for whom the Plan pays Benefits first and Medicare pays benefits second: • Employees with active current employment status age 65 or older and their Spouses age 65 or older (however, domestic partners are excluded as provided by Medicare). • Individuals with end-stage renal disease, for a limited period of time. • Disabled individuals under age 65 with current employment status and their Dependents under age 65. Determining the Allowable Expense When this Plan is Secondary to Medicare If this Plan is secondary to Medicare, the Medicare approved amount is the allowable expense, as long as the provider accepts reimbursement directly from Medicare. If the provider accepts reimbursement directly from Medicare, the Medicare approved amount is the charge that Medicare has determined that it will recognize and which it reports on an "explanation of Medicare benefits" issued by Medicare (the "EOMB") for a given service. Medicare typically reimburses such providers a percentage of its approved charge - often 80%. If the provider does not accept assignment of your Medicare benefits, the Medicare limiting charge (the most a provider can charge you if they don't accept Medicare - typically 115% of the Medicare approved amount) will be the allowable expense. Medicare payments, combined with Plan Benefits, will not exceed 100% of the allowable expense. If you are eligible for, but not enrolled in, Medicare, and this Plan is secondary to Medicare, or if you have enrolled in Medicare but choose to obtain services from a provider that does not participate in the Medicare program (as opposed to a provider who does not accept assignment of Medicare benefits), Benefits will be paid on a secondary basis under this Plan and will be determined as if you timely enrolled in Medicare and obtained services from a Medicare participating provider. When calculating the Plan's Benefits in these situations, and when Medicare does not issue an EOMB, for administrative convenience the Claims Administrator will use Medicare's Allowable Expense or Medicare's limiting charge for covered services as the Allowable expense for both the Plan and Medicare. Medicare Crossover Program The Plan offers a Medicare Crossover program for Medicare Part A and Part B and Durable Medical Equipment (DME) claims. Under this program, you no longer have to file a separate claim with the Plan to receive secondary benefits for these expenses. Your Dependent will also have this automated Crossover, as long as he or she is eligible for Medicare and this Plan is your only secondary medical coverage.

Noblesville Schools Medical Plan 88 Section 7: Coordination of Benefits Once the Medicare Part A and Part B and DME carriers have reimbursed your health care provider, the Medicare carrier will electronically submit the necessary information to the Claims Administrator to process the balance of your claim under the provisions of this Plan. You can verify that the automated crossover took place when your copy of the explanation of Medicare benefits (EOMB) states your claim has been forwarded to your secondary carrier. This crossover process does not apply to expenses that Medicare does not cover. You must continue to file claims for these expenses. For information about enrollment or if you have questions about the program, call the telephone number listed on your ID card. Right to Receive and Release Needed Information? Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under this Plan and other plans. The Claims Administrator may get the facts needed from, or give them to, other organizations or persons for the purpose of applying these rules and determining benefits payable under this Plan and other plans covering the person claiming benefits. The Claims Administrator does not need to tell, or get the consent of, any person to do this. Each person claiming benefits under this Plan must give the Claims Administrator any facts needed to apply those rules and determine benefits payable. If you do not provide the Claims Administrator the information needed to apply these rules and determine the Benefits payable, your claim for Benefits will be denied. Does This Plan Have the Right of Recovery? Overpayment and Underpayment of Benefits If you are covered under more than one medical plan, there is a possibility that the other plan will pay a benefit that the Plan should have paid. If this occurs, the Plan may pay the other plan the amount owed. If the Plan pays you more than it owes under this COB provision, you should pay the excess back promptly. Otherwise, the Plan Sponsor may recover the amount in the form of salary, wages, or benefits payable under any Plan Sponsor-funded benefit plans, including this Plan. The Plan Sponsor also reserves the right to recover any overpayment by legal action or offset payments on future Allowed Amounts. If the Plan overpays a health care provider, the Claims Administrator reserves the right to recover the excess amount from the provider pursuant to Refund of Overpayments, below. Refund of Overpayments If the Plan pays for Benefits for expenses incurred on account of you, you, or any other person or organization that was paid, must make a refund to the Plan if: • The Plan's obligation to pay Benefits was contingent on the expenses incurred being legally owed and paid by you, but all or some of the expenses were not paid by you or did not legally have to be paid by you. • All or some of the payment the Plan made exceeded the Benefits under the Plan. • All or some of the payment was made in error. The amount that must be refunded equals the amount the Plan paid in excess of the amount that should have been paid under the Plan. If the refund is due from another person or organization, you agree to help the Plan get the refund when requested. If the refund is due from you and you do not promptly refund the full amount owed, the Plan may recover the overpayment by reallocating the overpaid amount to pay, in whole or in part, future Benefits for you that are payable under the Plan. If the refund is due from a person or organization other than you, the

Noblesville Schools Medical Plan 89 Section 7: Coordination of Benefits Plan may recover the overpayment by reallocating the overpaid amount to pay, in whole or in part, (i) future Benefits that are payable in connection with services provided to other Covered Persons under the Plan; or (ii) future Benefits that are payment in connection with services provided to persons under other plans for which the Claims Administrator processes payments, pursuant to a transaction in which the Plan's overpayment recovery rights are assigned to such other plans in exchange for such plans' remittance of the amount of the reallocated payment. The reallocated payment amount will either: • equal the amount of the required refund, or • if less than the full amount of the required refund, will be deducted from the amount of refund owed to the Plan. The Plan may have other rights in addition to the right to reallocate overpaid amounts and other enumerated rights, including the right to commence a legal action.

Noblesville Schools Medical Plan 90 Section 8: General Legal Provisions Section 8: General Legal Provisions What Is Your Relationship with the Claims Administrator and Plan Sponsor? It is important for you to understand the Claims Administrator's role with respect to the Plan and how it may affect you. The Claims Administrator helps administer the claims payment for the Plan Sponsor's Plan in which you are enrolled. The Claims Administrator and the Plan Sponsor do not provide medical services or make treatment decisions. This means: • The Claims Administrator communicates to you decisions about whether the Plan will cover or pay for the health care that you may receive. The Plan pays for Covered Health Care Services, which are more fully described in this SPD. • The Plan may not pay for all treatments you or your Physician may believe are needed. If the Plan does not pay, you will be responsible for the cost. The Plan Sponsor and the Claims Administrator may use individually identifiable information about you to identify for you (and you alone) procedures, products or services that you may find valuable. The Plan Sponsor and the Claims Administrator will use individually identifiable information about you as permitted or required by law, including in the Claims Administrator's operations and in the Claims Administrator's research. The Plan Sponsor and the Claims Administrator will use de-identified data for commercial purposes including research. Please refer to the Claims Administrator's Notice of Privacy Practices for details. What Is the Claims Administrator's Relationship with Providers and Plan Sponsors? The Claims Administrator has agreements in place that govern the relationships between it and Plan Sponsors and Network providers, some of which are affiliated providers. Network providers enter into agreements with the Claims Administrator to provide Covered Health Care Services to Covered Persons. Plan Sponsors and the Claims Administrator do not provide health care services or supplies, or practice medicine. Plan Sponsors and the Claims Administrator arrange for health care providers to participate in a Network and the Claims Administrator processes the Plan's payment of Benefits. Network providers are independent practitioners who run their own offices and facilities. The Claims Administrator's credentialing process confirms public information about the providers' licenses and other credentials. It does not assure the quality of the services provided. Network providers are not the Plan Sponsor's employees. Network providers are not the Claims Administrator's employees. The Plan Sponsor and the Claims Administrator are not responsible for any act or omission of any provider. The Claims Administrator is not considered to be an employer for any purpose with respect to the administration or provision of benefits under the Plan Sponsor's Plan. The Claims Administrator is not responsible for fulfilling any duties or obligations of an employer with respect to the Plan Sponsor's Plan. The Plan Sponsor is solely responsible for all of the following: • Enrollment and classification changes (including classification changes resulting in your enrollment or the termination of your coverage). • The timely payment of the Plan's Service Fee to the Claims Administrator. • The funding of Benefits on a timely basis. • Notifying you of when the Plan ends.

Noblesville Schools Medical Plan 91 Section 8: General Legal Provisions What Is Your Relationship with Providers and Plan Sponsors? The relationship between you and any provider is that of provider and patient. You are responsible for all of the following: • Choosing your own provider. • Paying, directly to your provider, any amount identified as a participant responsibility, including Copayments, Coinsurance, any deductible and any amount that exceeds the Allowed Amount, when applicable. • Paying, directly to your provider, the cost of any non-Covered Health Care Service. • Deciding if any provider treating you is right for you. This includes Network providers you choose and providers that they refer. • Deciding with your provider what care you should receive. Your provider is solely responsible for the quality of the services provided to you. The relationship between you and the Plan Sponsor is that of employer and employee, Dependent or other classification as defined in the Plan. Notice When the Claims Administrator provides written notice regarding administration of the Plan to an authorized representative of the Plan Sponsor, that notice is deemed notice to all affected Participants and their Enrolled Dependents. The Plan Sponsor is responsible for giving notice to you. Statements by the Plan Sponsor or Participants All statements made by the Plan Sponsor or by a Participant shall, in the absence of fraud, be deemed representations and not warranties. The Claims Administrator will not use any statement made by the Plan Sponsor to void the Plan after it has been in force for two years unless it is a fraudulent statement. Does the Claims Administrator Pay Incentives to Providers? The Claims Administrator pays Network providers through various types of contractual arrangements. Some of these arrangements may include financial incentives to promote the delivery of health care in a cost efficient and effective manner. These financial incentives are not intended to affect your access to health care. Examples of financial incentives for Network providers are: • Bonuses for performance based on factors that may include quality, member satisfaction and/or cost-effectiveness. • Capitation - a group of Network providers receives a monthly payment from the Claims Administrator for each Covered Person who selects a Network provider within the group to perform or coordinate certain health care services. The Network providers receive this monthly payment regardless of whether the cost of providing or arranging to provide the Covered Person's health care is less than or more than the payment. • Bundled payments - certain Network providers receive a bundled payment for a group of Covered Health Care Services for a particular procedure or medical condition. The applicable Copayment and/or Coinsurance will be calculated based on the provider type that received the bundled payment. The Network providers receive these bundled payments regardless of whether the cost of providing or arranging to provide the Covered Person's health care is less than or more than the payment. If you receive follow-up services related to a procedure where a bundled payment is made, an additional Copayment and/or Coinsurance may not be required if such follow-up services

Noblesville Schools Medical Plan 92 Section 8: General Legal Provisions are included in the bundled payment. You may receive some Covered Health Care Services that are not considered part of the inclusive bundled payment and those Covered Health Care Services would be subject to the applicable Copayment and/or Coinsurance as described in your Schedule of Benefits. The Claims Administrator uses various payment methods to pay specific Network providers. From time to time, the payment method may change. If you have questions about whether your Network provider's contract with the Claims Administrator includes any financial incentives, the Claims Administrator encourages you to discuss those questions with your provider. You may also call the Claims Administrator at the telephone number on your ID card. The Claims Administrator can advise whether your Network provider is paid by any financial incentive, including those listed above. Are Incentives Available to You? Sometimes the Claims Administrator may offer coupons, enhanced Benefits, or other incentives to encourage you to take part in various programs, including wellness programs or certain disease management programs, surveys, discount programs, administrative programs, and/or programs to seek care in a more cost effective setting and/or from Designated Providers. In some instances, these programs may be offered in combination with a non-UnitedHealthcare entity. The decision about whether or not to take part in a program is yours alone. However, you should discuss taking part in such programs with your Physician. Contact the Claims Administrator at www.myuhc.com or the telephone number on your ID card if you have any questions. Does the Claims Administrator Receive Rebates and Other Payments? The Plan Sponsor and the Claims Administrator may receive rebates for certain drugs that are administered to you in your home or in a Physician's office, or at a Hospital or Alternate Facility. This includes rebates for those drugs that are administered to you before you meet any applicable deductible. The Plan Sponsor and the Claims Administrator may pass a portion of these rebates on to you. When rebates are passed onto you, they may be taken into account in determining your Copayment and/or Coinsurance. Who Interprets Benefits and Other Provisions under the Plan? The Plan Sponsor and the Claims Administrator have the sole and exclusive discretion to do all of the following: • Interpret Benefits under the Plan. • Interpret the other terms, conditions, limitations and exclusions set out in the Plan, including this SPD, the Schedule of Benefits and any Addendums, SMMs, and/or Amendments. • Make factual determinations related to the Plan and its Benefits. The Plan Sponsor and the Claims Administrator may assign this discretionary authority to other persons or entities including Claims Administrator's affiliates that may provide services in regard to the administration of the Plan. In certain circumstances, for purposes of overall cost savings or efficiency, the Plan Sponsor may, in its discretion, offer Benefits for services that would otherwise not be Covered Health Care Services. The fact that the Plan Sponsor does so in any particular case shall not in any way be deemed to require the Plan Sponsor to do so in other similar cases. Who Provides Administrative Services? The Claims Administrator provides claims administrative services or, as the Claims Administrator determines, the Claims Administrator may arrange for various persons or entities to provide claims

Noblesville Schools Medical Plan 93 Section 8: General Legal Provisions administrative services, such as claims processing. The identity of the service providers and the nature of the services they provide may be changed from time to time as the Claims Administrator determines. The Claims Administrator is not required to give you prior notice of any such change, nor is the Claims Administrator required to obtain your approval. You must cooperate with those persons or entities in the performance of their responsibilities. What is the Future of the Plan? Although Plan Sponsor expects to continue the Plan indefinitely, it reserves the right to discontinue, alter or modify the Plan in whole or in part, at any time and for any reason, at its sole determination. The Plan Sponsor's decision to terminate or amend a Plan may be due to changes in federal or state laws governing employee benefits, the requirements of the Internal Revenue Code, or any other reason. A plan change may transfer plan assets and debts to another plan or split a plan into two or more parts. If the Plan Sponsor does change or terminate a plan, it may decide to set up a different plan providing similar or different benefits. If this Plan is terminated, Covered Persons will not have the right to any other Benefits from the Plan, other than for those claims incurred prior to the date of termination, or as otherwise provided under the Plan. In addition, if the Plan is amended, Covered Persons may be subject to altered coverage and Benefits. The amount and form of any final benefit you receive will depend on any Plan document or contract provisions affecting the Plan and Plan Sponsor decisions. After all Benefits have been paid and other requirements of the law have been met, certain remaining Plan assets will be turned over to the Plan Sponsor and others as may be required by any applicable law. Amendments to the Plan To the extent permitted by law, the Plan Sponsor has the right, as it determines and without your approval, to change, interpret, withdraw or add Benefits or end the Plan. Any provision of the Plan which, on its effective date, is in conflict with the requirements of applicable state law provisions not otherwise preempted by ERISA or federal statutes or regulations (of the jurisdiction in which the Plan is delivered) is amended to conform to the minimum requirements of such statutes and regulations. No other change may be made to the Plan unless it is made by an Amendment or SMM. All of the following conditions apply: • Amendments to the Plan are effective upon the Plan's next anniversary date, except as otherwise permitted by law. • SMMs to the Plan are effective on the date the Plan Sponsor specifies. • No agent has the authority to change the Plan or to waive any of its provisions. • No one has authority to make any oral changes or amendments to the Plan. How Does the Claims Administrator Use Information and Records? The Claims Administrator may use your individually identifiable health information as follows: • To administer the Plan and pay claims. • To identify procedures, products, or services that you may find valuable. • As otherwise permitted or required by law. The Claims Administrator may request additional information from you to decide your claim for Benefits. The Claims Administrator will keep this information confidential. The Claims Administrator may also use

Noblesville Schools Medical Plan 94 Section 8: General Legal Provisions de-identified data for commercial purposes, including research, as permitted by law. More detail about how the Claims Administrator may use or disclose your information is found in the Claims Administrator's Notice of Privacy Practices. By accepting Benefits under the Plan, you authorize and direct any person or institution that has provided services to you to furnish the Claims Administrator with all information or copies of records relating to the services provided to you, including provider billing and provider payment records. The Claims Administrator has the right to request this information at any reasonable time. This applies to all Covered Persons, including Enrolled Dependents whether or not they have signed the Participant's enrollment form. The Claims Administrator agrees that such information and records will be considered confidential. The Claims Administrator has the right to release records concerning health care services when any of the following apply: • Needed to put in place and administer the terms of the Plan. • Needed for medical review or quality assessment. • Required by law or regulation. During and after the term of the Plan, the Claims Administrator and the Claims Administrator's related entities may use and transfer the information gathered under the Plan in a de-identified format for commercial purposes, including research and analytic purposes. Please refer to the Claims Administrator's Notice of Privacy Practices. For complete listings of your medical records or billing statements you may contact your health care provider. Providers may charge you reasonable fees to cover their costs for providing records or completing requested forms. If you request medical forms or records from the Claims Administrator, the Claims Administrator also may charge you reasonable fees to cover costs for completing the forms or providing the records. In some cases, as permitted by law, the Claims Administrator will designate other persons or entities to request records or information from or related to you, and to release those records as needed. The Claims Administrator's designees have the same rights to this information as the Claims Administrator has. Does the Plan Require Examination of Covered Persons? In the event of a question or dispute regarding your right to Benefits, the Plan Sponsor may require that a Network Physician of its choice examine you at the Plan's expense. Is Workers' Compensation Affected? Benefits provided under the Plan do not substitute for and do not affect any requirements for coverage by workers' compensation insurance. How Are Benefits Paid When You Are Medicare Eligible? Benefits under the Plan are not intended to supplement any coverage provided by Medicare. Nevertheless, in some circumstances Covered Persons who are eligible for or enrolled in Medicare may also be enrolled under the Plan. If you are eligible for or enrolled in Medicare, please read the following information carefully. If you are eligible for Medicare on a primary basis (Medicare pays before Benefits under the Plan), you should enroll in and maintain coverage under both Medicare Part A and Part B. If you don't enroll and maintain that coverage, and if the Plan Sponsor's Plan is the secondary payer as described in Section 7: Coordination of Benefits, the Claims Administrator will process the Plan Sponsors payment of Benefits

Noblesville Schools Medical Plan 95 Section 8: General Legal Provisions under the Plan as if you were covered under both Medicare Part A and Part B. As a result, you will be responsible for the costs that Medicare would have paid and you will incur a larger out-of-pocket cost. If you are enrolled in a Medicare Advantage (Medicare Part C) plan on a primary basis (Medicare pays before Benefits under the Plan), you should follow all rules of that plan that require you to seek services from that plan's participating providers. When the Plan Sponsor's Plan is the secondary payer, the Claims Administrator will process the Plan Sponsor's payment of any Benefits available to you under the Plan as if you had followed all rules of the Medicare Advantage plan. You will be responsible for any additional costs or reduced Benefits that result from your failure to follow these rules, and you will incur a larger out- of-pocket cost. Subrogation and Reimbursement The Plan has the right to subrogation and reimbursement. References to "you" or "your" in this Subrogation and Reimbursement section shall include you, your estate and your heirs and beneficiaries unless otherwise stated. Subrogation applies when the Plan has paid Benefits on your behalf for a Sickness or Injury for which any third party is allegedly responsible. The right to subrogation means that the Plan is substituted to and shall succeed to any and all legal claims that you may be entitled to pursue against any third party for the Benefits that the Plan has paid that are related to the Sickness or Injury for which any third party is considered responsible. Subrogation Example: Suppose you are injured in a car accident that is not your fault, and you receive Benefits under the Plan to treat your injuries. Under subrogation, the Plan has the right to take legal action in your name against the driver who caused the accident and that driver's insurance carrier to recover the cost of those Benefits. The right to reimbursement means that if it is alleged that any third party caused or is responsible for a Sickness or Injury for which you receive a settlement, judgment, or other recovery from any third party, you must use those proceeds to fully return to the Plan 100% of any Benefits you receive for that Sickness or Injury. The right of reimbursement shall apply to any benefits received at any time until the rights are extinguished, resolved or waived in writing. Reimbursement Example: Suppose you are injured in a boating accident that is not your fault, and you receive Benefits under the Plan as a result of your injuries. In addition, you receive a settlement in a court proceeding from the individual who caused the accident. You must use the settlement funds to return to the Plan 100% of any Benefits you received to treat your injuries. The following persons and entities are considered third parties: • A person or entity alleged to have caused you to suffer a Sickness, Injury or damages, or who is legally responsible for the Sickness, Injury or damages. • Any insurer or other indemnifier of any person or entity alleged to have caused or who caused the Sickness, Injury or damages. • Your employer in a workers' compensation case or other matter alleging liability. • Any person or entity who is or may be obligated to provide benefits or payments to you, including benefits or payments for underinsured or uninsured motorist protection, no-fault or traditional auto insurance, medical payment coverage (auto, homeowners or otherwise), workers' compensation coverage, other insurance carriers or third party administrators.

Noblesville Schools Medical Plan 96 Section 8: General Legal Provisions • Any person or entity against whom you may have any claim for professional and/or legal malpractice arising out of or connected to a Sickness or Injury you allege or could have alleged were the responsibility of any third party. • Any person or entity that is liable for payment to you on any equitable or legal liability theory. You agree as follows: • You will cooperate with the Plan in protecting the Plan's legal and equitable rights to subrogation and reimbursement in a timely manner, including, but not limited to: ▪ Notifying the Plan, in writing, of any potential legal claim(s) you may have against any third party for acts which caused Benefits to be paid or become payable. ▪ Providing any relevant information requested by the Plan. ▪ Signing and/or delivering such documents as the Plan or the Plan's agents reasonably request to secure the subrogation and reimbursement claim. ▪ Responding to requests for information about any accident or injuries. ▪ Making court appearances. ▪ Obtaining the Plan's consent or the Plan's agents' consent before releasing any party from liability or payment of medical expenses. ▪ Complying with the terms of this section. Your failure to cooperate with the Plan is considered a breach of contract. As such, the Plan has the right to terminate or deny future Benefits, take legal action against you, and/or set off from any future Benefits the value of Benefits the Plan has paid relating to any Sickness or Injury alleged to have been caused or caused by any third party to the extent not recovered by the Plan due to you or your representative not cooperating with the Plan. If the Plan incurs attorneys' fees and costs in order to collect third party settlement funds held by you or your representative, the Plan has the right to recover those fees and costs from you. You will also be required to pay interest on any amounts you hold which should have been returned to the Plan. • The Plan has a first priority right to receive payment on any claim against any third party before you receive payment from that third party. Further, the Plan's first priority right to payment is superior to any and all claims, debts or liens asserted by any medical providers, including but not limited to hospitals or emergency treatment facilities, that assert a right to payment from funds payable from or recovered from an allegedly responsible third party and/or insurance carrier. • The Plan's subrogation and reimbursement rights apply to full and partial settlements, judgments, or other recoveries paid or payable to you or your representative, your estate, your heirs and beneficiaries, no matter how those proceeds are captioned or characterized. Payments include, but are not limited to, economic, non-economic, pecuniary, consortium and punitive damages. The Plan is not required to help you to pursue your claim for damages or personal injuries and no amount of associated costs, including attorneys' fees, shall be deducted from the Plan's recovery without the Plan's express written consent. No so-called "Fund Doctrine" or "Common Fund Doctrine" or "Attorney's Fund Doctrine" shall defeat this right. • Regardless of whether you have been fully compensated or made whole, the Plan may collect from you the proceeds of any full or partial recovery that you or your legal representative obtain, whether in the form of a settlement (either before or after any determination of liability) or judgment, no matter how those proceeds are captioned or characterized. Proceeds from which the Plan may collect include, but are not limited to, economic, non-economic, and punitive damages. No "collateral source" rule, any "Made-Whole Doctrine" or "Make-Whole Doctrine," claim of unjust enrichment, nor any other equitable limitation shall limit the Plan's subrogation and reimbursement rights.

Noblesville Schools Medical Plan 97 Section 8: General Legal Provisions • Benefits paid by the Plan may also be considered to be Benefits advanced. • If you receive any payment from any party as a result of Sickness or Injury, and the Plan alleges some or all of those funds are due and owed to the Plan, you and/or your representative shall hold those funds in trust, either in a separate bank account in your name or in your representative's trust account. • By participating in and accepting Benefits under the Plan, you agree that (i) any amounts recovered by you from any third party shall constitute Plan assets (to the extent of the amount of Benefits provided on behalf of the Covered Person), (ii) you and your representative shall be fiduciaries of the Plan (within the meaning of ERISA) with respect to such amounts, and (iii) you shall be liable for and agree to pay any costs and fees (including reasonable attorney fees) incurred by the Plan to enforce its reimbursement rights. • The Plan's right to recovery will not be reduced due to your own negligence. • By participating in and accepting Benefits from the Plan, you agree to assign to the Plan any benefits, claims or rights of recovery you have under any automobile Plan - including no-fault benefits, PIP benefits and/or medical payment benefits - other coverage or against any third party, to the full extent of the Benefits the Plan has paid for the Sickness or Injury. By agreeing to provide this assignment in exchange for participating in and accepting benefits, you acknowledge and recognize the Plan's right to assert, pursue and recover on any such claim, whether or not you choose to pursue the claim, and you agree to this assignment voluntarily. • The Plan may, at its option, take necessary and appropriate action to preserve the Plan's rights under these provisions, including but not limited to, providing or exchanging medical payment information with an insurer, the insurer's legal representative or other third party; filing an ERISA reimbursement lawsuit to recover the full amount of medical benefits you receive for the Sickness or Injury out of any settlement, judgment or other recovery from any third party considered responsible; and filing suit in your name or your estate's name, which does not obligate the Plan in any way to pay you part of any recovery the Plan might obtain. Any ERISA reimbursement lawsuit stemming from a refusal to refund Benefits as required under the terms of the Plan is governed by a six-year statute of limitations. • You may not accept any settlement that does not fully reimburse the Plan, without the Plan's written approval. • The Plan has the authority and discretion to resolve all disputes regarding the interpretation of the language stated herein. • In the case of your death, giving rise to any wrongful death or survival claim, the provisions of this section apply to your estate, the personal representative of your estate, and your heirs or beneficiaries. In the case of your death the Plan's right of reimbursement and right of subrogation shall apply if a claim can be brought on behalf of you or your estate that can include a claim for past medical expenses or damages. The obligation to reimburse the Plan is not extinguished by a release of claims or settlement agreement of any kind. • No allocation of damages, settlement funds or any other recovery, by you, your estate, the personal representative of your estate, your heirs, your beneficiaries or any other person or party, shall be valid if it does not reimburse the Plan for 100% of the Plan's interest unless the Plan provides written consent to the allocation. • The provisions of this section apply to the parents, guardian, or other representative of a Dependent child who incurs a Sickness or Injury caused by any third party. If a parent or guardian brings a claim for damages arising out of a minor's Sickness or Injury, the terms of this subrogation and reimbursement clause shall apply to that claim.

Noblesville Schools Medical Plan 98 Section 8: General Legal Provisions • If any third party causes or is alleged to have caused you to suffer a Sickness or Injury while you are covered under the Plan, the provisions of this section continue to apply, even after you are no longer covered. • In the event that you do not abide by the terms of the Plan pertaining to reimbursement, the Plan may terminate Benefits to you, your dependents or the participant, deny future Benefits, take legal action against you, and/or set off from any future Benefits the value of Benefits the Plan has paid relating to any Sickness or Injury alleged to have been caused or caused by any third party to the extent not recovered by the Plan due to your failure to abide by the terms of the Plan. If the Plan incurs attorneys' fees and costs in order to collect third party settlement funds held by you or your representative, the Plan has the right to recover those fees and costs from you. You will also be required to pay interest on any amounts you hold which should have been returned to the Plan. • The Plan and all Administrators administering the terms and conditions of the Plan's subrogation and reimbursement rights have such powers and duties as are necessary to discharge its duties and functions, including the exercise of the Plan's discretionary authority to (1) construe and enforce the terms of the Plan's subrogation and reimbursement rights and (2) make determinations with respect to the subrogation amounts and reimbursements owed to the Plan. When Does the Plan Receive Refunds of Overpayments? If the Plan pays Benefits for expenses incurred on your account, you, or any other person or organization that was paid, must make a refund to the Plan if any of the following apply: • All or some of the expenses were not paid or did not legally have to be paid by you. • All or some of the payment the Plan made exceeded the Benefits under the Plan. • All or some of the payment was made in error. The refund equals the amount the Plan paid in excess of the amount the Plan should have paid under the Plan. If the refund is due from another person or organization, you agree to help the Plan get the refund when requested. If the refund is due from you and you do not promptly refund the full amount, the Plan may recover the overpayment by reallocating the overpaid amount to pay, in whole or in part, your future Benefits that are payable under the Plan. If the refund is due from a person or organization other than you, the Plan may recover the overpayment by reallocating the overpaid amount to pay, in whole or in part; (i) future Benefits that are payable in connection with services provided to other Covered Persons under the Plan; or (ii) future Benefits that are payable in connection with services provided to persons under other plans for which the Claims Administrator processes payments, pursuant to a transaction in which the Plan's overpayment recovery rights are assigned to such other plans in exchange for such plans' remittance of the amount of the reallocated payment. The reductions will equal the amount of the required refund. The Plan may have other rights in addition to the right to reduce future benefits. Is There a Limitation of Action? You cannot bring any legal action against the Plan or the Claims Administrator to recover reimbursement until you have completed all the steps in the appeal process described in Section 6: Questions, Complaints and Appeals. After completing that process, if you want to bring a legal action against the Plan or the Claims Administrator you must do so within three years of the date the Plan notified you of its final decision on your appeal or you lose any rights to bring such an action against the Plan or the Claims Administrator.

Noblesville Schools Medical Plan 99 Section 8: General Legal Provisions What Is the Entire Plan? The SPD, the Schedule of Benefits, and any Addendums, SMMs and/or Amendments, make up the entire Plan.

Noblesville Schools Medical Plan 100 Section 9: Defined Terms Section 9: Defined Terms Addendum - any attached written description of additional or revised provisions to the Plan. The Benefits and exclusions of this SPD and any amendments thereto shall apply to the Addendum except that in the case of any conflict between the Addendum and SPD and/or Amendments to the SPD, the Addendum shall be controlling. Air Ambulance - medical transport by rotary wing Air Ambulance or fixed wing Air Ambulance as defined in 42 CFR 414.605. Allowed Amounts - for Covered Health Care Services, incurred while the Plan is in effect, Allowed Amounts are determined by the Claims Administrator or as required by law as shown in the Schedule of Benefits. Allowed Amounts are determined in accordance with the Claims Administrator's reimbursement policy guidelines or as required by law. The Claims Administrator develops these guidelines, in its discretion, after review of all provider billings generally in accordance with one or more of the following methodologies: • As shown in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS). • As reported by generally recognized professionals or publications. • As used for Medicare. • As determined by medical staff and outside medical consultants pursuant to other appropriate source or determination that the Claims Administrator accepts. Alternate Facility - a health care facility that is not a Hospital. It provides one or more of the following services on an outpatient basis, as permitted by law: • Surgical services. • Emergency Health Care Services. • Rehabilitative, laboratory, diagnostic or therapeutic services. It may also provide Mental Health Care Services or Substance-Related and Addictive Disorders Services on an outpatient or inpatient basis. Amendment - any attached written description of added or changed provisions to the Plan. It is effective only when distributed by the Plan Sponsor or Plan Administrator. It is subject to all conditions, limitations and exclusions of the Plan, except for those that are specifically amended. Ancillary Services - items and services provided by out-of-Network Physicians at a Network facility that are any of the following: • Related to emergency medicine, anesthesiology, pathology, radiology, and neonatology; • Provided by assistant surgeons, hospitalists, and intensivists; • Diagnostic services, including radiology and laboratory services, unless such items and services are excluded from the definition of Ancillary Services as determined by the Secretary; • Provided by such other specialty practitioners as determined by the Secretary; and • Provided by an out-of-Network Physician when no other Network Physician is available. Annual Deductible - the total of the Allowed Amount, or the Recognized Amount when applicable, you must pay for Covered Health Care Services per year before the Plan will begin paying for Benefits. It does not include any amount that exceeds Allowed Amounts or the Recognized Amount when applicable.

Noblesville Schools Medical Plan 101 Section 9: Defined Terms The Schedule of Benefits will tell you if your plan is subject to payment of an Annual Deductible and how it applies. Autism Spectrum Disorder - a condition marked by enduring problems communicating and interacting with others, along with restricted and repetitive behavior, interests or activities, and as listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Benefits - your right to payment for Covered Health Care Services that are available under the Plan. Cellular Therapy - administration of living whole cells into a patient for the treatment of disease. Claims Administrator - the organization that provides certain claim administration and other services for the Plan. Coinsurance - the charge, stated as a percentage of the Allowed Amount or the Recognized Amount when applicable, that you are required to pay for certain Covered Health Care Services. Congenital Anomaly - a physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Copayment - the charge, stated as a set dollar amount, that you are required to pay for certain Covered Health Care Services. Please note that for Covered Health Care Services, you are responsible for paying the lesser of the following: • The Copayment. • The Allowed Amount, or the Recognized Amount when applicable. Cosmetic Procedures - procedures or services that change or improve appearance without significantly improving physiological function. Covered Health Care Service(s) - health care services, including supplies or Pharmaceutical Products, which the Claims Administrator determines to be all of the following: • Provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, substance-related and addictive disorders, condition, disease or its symptoms. • Medically Necessary. • Described as a Covered Health Care Service in this SPD under Section 1: Covered Health Care Services and in the Schedule of Benefits. • Not excluded in this SPD under Section 2: Exclusions and Limitations. Covered Person - the Participant or a Dependent, but this term applies only while the person is enrolled under the Plan. The Plan Sponsor uses "you" and "your" in this SPD to refer to a Covered Person. Custodial Care - services that are any of the following non-Skilled Care services: • Non health-related services such as help with daily living activities. Examples include eating, dressing, bathing, transferring and ambulating. • Health-related services that can safely and effectively be performed by trained non-medical personnel and are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function, as opposed to improving that function to an extent that might allow for a more independent existence. Definitive Drug Test - test to identify specific medications, illicit substances and metabolites and is qualitative or quantitative to identify possible use or non-use of a drug.

Noblesville Schools Medical Plan 102 Section 9: Defined Terms Dependent - the Participant's legal spouse or a child of the Participant or the Participant's spouse. As described in Section 3: When Coverage Begins, the Plan Sponsor determines who is eligible to enroll and who qualifies as a Dependent. The term "child" includes: • A natural child. • A stepchild. • A legally adopted child. • A child placed for adoption. • A child for whom legal guardianship has been awarded to the Participant or the Participant's spouse. • A child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order. The Plan Sponsor is responsible for determining if an order meets the criteria of a Qualified Medical Child Support Order. The following conditions apply: • A dependent includes a child listed above under age 26. A child who meets the requirements set forth above ceases to be eligible as described in Section 4: When Coverage Ends. The Participant must reimburse the Plan for any Benefits paid during a time a child did not satisfy these conditions. A Dependent does not include anyone who is also enrolled as a Participant. No one can be a Dependent of more than one Participant. Designated Dispensing Entity - a pharmacy provider, or facility that has entered into an agreement with the Claims Administrator, or with an organization contracting on the Claims Administrator's behalf, to provide Pharmaceutical Products for the treatment of specified diseases or conditions. Not all Network pharmacies, providers, or facilities are Designated Dispensing Entities. Designated Network Benefits - the description of how Benefits are paid for certain Covered Health Care Services provided by a provider or facility that has been identified as a Designated Provider. The Schedule of Benefits will tell you if your plan offers Designated Network Benefits and how they apply. Designated Provider - a provider and/or facility that: • Has entered into an agreement with the Claims Administrator, or with an organization contracting on the Claims Administrator's behalf, to provide Covered Health Care Service for the treatment of specific diseases or conditions; or • The Claims Administrator has identified through the Claims Administrator's designation programs as a Designated Provider. Such designation may apply to specific treatments, conditions and/or procedures. A Designated Provider may or may not be located within your geographic area. Not all Network Hospitals or Network Physicians are Designated Providers. You can find out if your provider is a Designated Provider by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. Designated Virtual Network Provider - a provider or facility that has entered into an agreement with the Claims Administrator, or with an organization contracting on the Claims Administrator's behalf, to deliver Covered Health Care Services through live audio with video technology or audio only. Durable Medical Equipment (DME) - medical equipment that is all of the following: • Ordered or provided by a Physician for outpatient use primarily in a home setting.

Noblesville Schools Medical Plan 103 Section 9: Defined Terms • Used for medical purposes. • Not consumable or disposable except as needed for the effective use of covered DME. • Not of use to a person in the absence of a disease or disability. • Serves a medical purpose for the treatment of a Sickness or Injury. • Primarily used within the home. Eligible Person - an employee of the Plan Sponsor or other person connected to the Plan Sponsor who meets the eligibility requirements shown in both the Plan Sponsor's Plan and supporting documents. An Eligible Person must live within the United States. Emergency - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: • Placing the health of the Covered Person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; • Serious impairment to bodily functions; or • Serious dysfunction of any bodily organ or part. Emergency Health Care Services - with respect to an Emergency: • An appropriate medical screening exam (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd or as would be required under such section if such section applied to an Independent Freestanding Emergency Department) that is within the capability of the emergency department of a Hospital, or an Independent Freestanding Emergency Department, as applicable, including ancillary services routinely available to the emergency department to evaluate such Emergency, and • Such further medical exam and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital or an Independent Freestanding Emergency Department, as applicable, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd(e)(3)) or as would be required under such section if such section applied to an Independent Freestanding Emergency Department, to stabilize the patient (regardless of the department of the Hospital in which such further exam or treatment is provided). For the purpose of this definition, “to stabilize” has the meaning as given such term in section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)). • Emergency Health Care Services include items and services otherwise covered under the Plan when provided by an out-of-Network provider or facility (regardless of the department of the Hospital in which the items are services are provided) after the patient is stabilized and as part of outpatient observation, or as a part of an Inpatient Stay or outpatient stay that is connected to the original Emergency unless the following conditions are met: a) The attending Emergency Physician or treating provider determines the patient is able to travel using nonmedical transportation or non-Emergency medical transportation to an available Network provider or facility located within a reasonable distance taking into consideration the patient’s medical condition. b) The provider furnishing the additional items and services satisfies notice and consent criteria in accordance with applicable law. c) The patient is in such a condition, as determined by the Secretary, to receive information as stated in b) above and to provide informed consent in accordance with applicable law. d) The provider or facility satisfies any additional requirements or prohibitions as may be imposed by state law.

Noblesville Schools Medical Plan 104 Section 9: Defined Terms e) Any other conditions as specified by the Secretary. The above conditions do not apply to unforeseen or urgent medical needs that arise at the time the service is provided regardless of whether notice and consent criteria has been satisfied Enrolled Dependent - a Dependent who is properly enrolled under the Plan. Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health, substance-related and addictive disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time the Claims Administrator makes a determination regarding coverage in a particular case, are determined to be any of the following: • Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified as appropriate for the proposed use in any of the following: ▪ AHFS Drug Information (AHFS DI) under therapeutic uses section; ▪ Elsevier Gold Standard's Clinical Pharmacology under the indications section; ▪ DRUGDEX System by Micromedex under the therapeutic uses section and has a strength recommendation rating of class I, class IIa, or class IIb; or ▪ National Comprehensive Cancer Network (NCCN) drugs and biologics compendium category of evidence 1, 2A, or 2B. • Subject to review and approval by any institutional review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not Experimental or Investigational.) • The subject of an ongoing clinical trial that meets the definition of a Phase I, II or III clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight. • Only obtainable, with regard to outcomes for the given indication, within research settings. Exceptions: • Clinical trials for which Benefits are available as described under Clinical Trials in Section 1: Covered Health Care Services. • The Claims Administrator may at its discretion, consider an otherwise Experimental or Investigational Service to be a Covered Health Care Service for that Sickness or condition if: ▪ You are not a participant in a qualifying clinical trial, as described under Clinical Trials in Section 1: Covered Health Care Services: and ▪ You have a Sickness or condition that is likely to cause death within one year of the request for treatment. Prior to such a consideration, the Claims Administrator must first establish that there is sufficient evidence to conclude that, even though unproven, the service has significant potential as an effective treatment for that Sickness or condition. Freestanding Facility - an outpatient, diagnostic or ambulatory center or independent laboratory which performs services and submits claims separately from a Hospital. Gene Therapy - therapeutic delivery of nucleic acid (DNA or RNA) into a patient's cells as a drug to treat a disease. Genetic Counseling - counseling by a qualified clinician that includes: • Identifying your potential risks for suspected genetic disorders; • An individualized discussion about the benefits, risks and limitations of Genetic Testing to help you make informed decisions about Genetic Testing; and

Noblesville Schools Medical Plan 105 Section 9: Defined Terms • Interpretation of the Genetic Testing results in order to guide health decisions. Certified genetic counselors, medical geneticists and physicians with a professional society's certification that they have completed advanced training in genetics are considered qualified clinicians when Covered Health Care Services for Genetic Testing require Genetic Counseling. Genetic Testing - exam of blood or other tissue for changes in genes (DNA or RNA) that may indicate an increased risk for developing a specific disease or disorder, or provide information to guide the selection of treatment of certain diseases, including cancer. Gestational Carrier - A female who becomes pregnant by having a fertilized egg (embryo) implanted in her uterus for the purpose of carrying the fetus to term for another person. The Gestational Carrier does not provide the egg and is therefore not biologically related to the child. Home Health Agency - a program or organization authorized by law to provide health care services in the home. Hospital - an institution that is operated as required by law and that meets both of the following: • It is mainly engaged in providing inpatient health care services, for the short term care and treatment of injured or sick persons. Care is provided through medical, diagnostic and surgical facilities, by or under the supervision of a staff of Physicians. • It has 24-hour nursing services. A Hospital is not mainly a place for rest, Custodial Care or care of the aged. It is not a nursing home, convalescent home or similar institution. Hospital-based Facility - an outpatient facility that performs services and submits claims as part of a Hospital. Independent Freestanding Emergency Department - a health care facility that: • Is geographically separate and distinct and licensed separately from a Hospital under applicable law; and • Provides Emergency Health Care Services. Initial Enrollment Period - the first period of time when Eligible Persons may enroll themselves and their Dependents under the Plan. Injury - damage to the body, including all related conditions and symptoms. Inpatient Rehabilitation Facility - any of the following that provides inpatient rehabilitation health care services (including physical therapy, occupational therapy and/or speech therapy), as authorized by law: • A long term acute rehabilitation center, • A Hospital, or • A special unit of a Hospital designated as an Inpatient Rehabilitation Facility. Inpatient Stay - a continuous stay that follows formal admission to a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility. Intensive Behavioral Therapy (IBT) - outpatient Mental Health Care Services that aim to reinforce adaptive behaviors, reduce maladaptive behaviors and improve the mastery of functional age appropriate skills in people with Autism Spectrum Disorders. The most common IBT is Applied Behavior Analysis (ABA). Intensive Outpatient Program(s) - a structured outpatient treatment program. • For Mental Health Care Services, the program may be freestanding or Hospital-based and provides services for at least three hours per day, two or more days per week.

Noblesville Schools Medical Plan 106 Section 9: Defined Terms • For Substance-Related and Addictive Disorders Services, the program provides nine to nineteen hours per week of structured programming for adults and six to nineteen hours for adolescents, consisting primarily of counseling and education about addiction related and mental health problems. Intermittent Care - skilled nursing care that is provided either: • Fewer than seven days each week. • Fewer than eight hours each day for periods of 21 days or less. Exceptions may be made in certain circumstances when the need for more care is finite and predictable. Manipulative Treatment (adjustment) - a form of care provided by chiropractors and osteopaths for diagnosed muscle, nerve and joint problems. Body parts are moved either by hands or by a small instrument to: • Restore or improve motion. • Reduce pain. • Increase function. Medicaid - a federal program administered and operated individually by participating state and territorial governments. The program provides medical benefits to eligible low-income people needing health care. The federal and state governments share the program's costs. Medically Necessary - health care services that are all of the following as determined by the Claims Administrator or its designee, within the Claims Administrator's sole discretion: • In accordance with Generally Accepted Standards of Medical Practice. • Clinically appropriate, in terms of type, frequency, extent, service site and duration, and considered effective for your Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms. • Not mainly for your convenience or that of your doctor or other health care provider. • Not more costly than an alternative drug, service(s), service site or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms. Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes. If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. The Claims Administrator has the right to consult expert opinion in determining whether health care services are Medically Necessary. The decision to apply Physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within the Claims Administrator's sole discretion. The Claims Administrator develops and maintains clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting the Claims Administrator's determinations regarding specific services. These clinical policies (as developed by the Claims Administrator and revised from time to time), are available to Covered Persons through www.myuhc.com or the telephone number on your ID card. They are also available to Physicians and other health care professionals on www.UHCprovider.com.

Noblesville Schools Medical Plan 107 Section 9: Defined Terms Medicare - Parts A, B, C and D of the insurance program established by Title XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended. Mental Health Care Services - services for the diagnosis and treatment of those mental health or psychiatric categories that are listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The fact that a condition is listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association does not mean that treatment for the condition is a Covered Health Care Service. Mental Health/Substance-Related and Addictive Disorders Delegate - the organization or individual, designated by the Claims Administrator, that provides or arranges Mental Health Care Services and Substance-Related and Addictive Disorders Services. Mental Illness - those mental health or psychiatric diagnostic categories that are listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The fact that a condition is listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association does not mean that treatment for the condition is a Covered Health Care Service. Network - when used to describe a provider of health care services, this means a provider that has a participation agreement in effect (either directly or indirectly) with the Claims Administrator or with the Claims Administrator's affiliate to participate in the Claims Administrator's Network. This does not include those providers who have agreed to discount their charges for Covered Health Care Services. The Claims Administrator's affiliates are those entities affiliated with the Claims Administrator through common ownership or control with the Claims Administrator or with the Claims Administrator's ultimate corporate parent, including direct and indirect subsidiaries. A provider may enter into an agreement to provide only certain Covered Health Care Services, but not all Covered Health Care Services, or to be a Network provider for only some of the Claims Administrator's products. In this case, the provider will be a Network provider for the Covered Health Care Services and products included in the participation agreement and an out-of-Network provider for other Covered Health Care Services and products. The participation status of providers will change from time to time. Network Benefits - the description of how Benefits are paid for Covered Health Care Services provided by Network providers. The Schedule of Benefits will tell you if your plan offers Network Benefits and how Network Benefits apply. New Pharmaceutical Product - a Pharmaceutical Product or new dosage form of a previously approved Pharmaceutical Product. It applies to the period of time starting on the date the Pharmaceutical Product or new dosage form is approved by the U.S. Food and Drug Administration (FDA) and ends on the earlier of the following dates: • The date as determined by the Claims Administrator or the Claims Administrator's designee, which is based on when the Pharmaceutical Product is reviewed and when utilization management strategies are implemented; or • December 31st of the following calendar year. Open Enrollment Period - a period of time, after the Initial Enrollment Period, when Eligible Persons may enroll themselves and Dependents under the Plan. The Plan Sponsor sets the period of time that is the Open Enrollment Period. Out-of-Network Benefits - the description of how Benefits are paid for Covered Health Care Services provided by out-of-Network providers. The Schedule of Benefits will tell you if your plan offers Out-of- Network Benefits and how Out-of-Network Benefits apply.

Noblesville Schools Medical Plan 108 Section 9: Defined Terms Out-of-Pocket Limit - the maximum amount you pay every year. The Schedule of Benefits will tell you if your plan is subject to an Out-of-Pocket Limit and how the Out-of-Pocket Limit applies. Partial Hospitalization/Day Treatment/High Intensity Outpatient - a structured ambulatory program. The program may be freestanding or Hospital-based and provides services for at least 20 hours per week. Participant - a full-time Participant of the Employer who meets the eligibility requirements specified in the Plan. A Participant must live and/or work in the United States. Pharmaceutical Product(s) - U.S. Food and Drug Administration (FDA)-approved prescription medications or products administered in connection with a Covered Health Care Service by a Physician. Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law. Please Note: Any podiatrist, dentist, psychologist, chiropractor, optometrist, or other provider who acts within the scope of his or her license will be considered on the same basis as a Physician. The fact that the Claims Administrator describes a provider as a Physician does not mean that Benefits for services from that provider are available to you under the Plan. Plan - the Plan Sponsor's Self-Funded group health benefit plan. The "What Is the Summary Plan Description?" provision of the SPD will tell you who the Plan Sponsor of this Plan is. Plan Sponsor - the employer, or other defined or otherwise legally established group, to whom the Plan is issued. The "What Is the Summary Plan Description?" provision of the SPD will tell you who the Plan Sponsor of this Plan is. Pregnancy - includes all of the following: • Prenatal care. • Postnatal care. • Childbirth. • Any complications associated with Pregnancy. Presumptive Drug Test - test to determine the presence or absence of drugs or a drug class in which the results are indicated as negative or positive result. Primary Care Physician - a Physician who has a majority of his or her practice in general pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine. Private Duty Nursing - nursing care that is provided to a patient on a one-to-one basis by licensed nurses in an inpatient or home setting when any of the following are true: • Services exceed the scope of Intermittent Care in the home. • The service is provided to a Covered Person by an independent nurse who is hired directly by the Covered Person or his/her family. This includes nursing services provided on an inpatient or home- care basis, whether the service is skilled or non-skilled independent nursing. • Skilled nursing resources are available in the facility. • The Skilled Care can be provided by a Home Health Agency on a per visit basis for a specific purpose. Recognized Amount - the amount which Copayment, Coinsurance and applicable deductible, is based on for the below Covered Health Care Services when provided by out-of-Network providers: • Out-of-Network Emergency Health Care Services.

Noblesville Schools Medical Plan 109 Section 9: Defined Terms • Non-Emergency Covered Health Care Services received at certain Network facilities by out-of- Network Physicians, when such services are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Health Service Act. For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary. The amount is based on one of the following in the order listed below as applicable: 1. An All Payer Model Agreement if adopted, 2. State law, or 3. The lesser of the qualifying payment amount as determined under applicable law or the amount billed by the provider or facility. The Recognized Amount for Air Ambulance services provided by an out-of-Network provider will be calculated based on the lesser of the qualifying payment amount as determined under applicable law or the amount billed by the Air Ambulance service provider. Note: Covered Health Care Services that use the Recognized Amount to determine your cost sharing may be higher or lower than if cost sharing for these Covered Health Care Services were determined based upon an Allowed Amount. Remote Physiologic Monitoring - the automatic collection and electronic transmission of patient physiologic data that are analyzed and used by a licensed Physician or other qualified health care professional to develop and manage a plan of treatment related to a chronic and/or acute health illness or condition. The plan of treatment will provide milestones for which progress will be tracked by one or more Remote Physiologic Monitoring devices. Remote Physiologic Monitoring must be ordered by a licensed Physician or other qualified health professional who has examined the patient and with whom the patient has an established, documented, and ongoing relationship. Remote Physiologic Monitoring may not be used while the patient is inpatient at a Hospital or other facility. Use of multiple devices must be coordinated by one Physician. Residential Treatment - a program of Mental Health Care Services or Substance-Related and Addictive Disorders Services that meets all of the following requirements: • Provides a program of treatment, under the active participation and direction of a Physician. • Offers organized treatment services that feature a planned and structured regimen of care in a 24- hour setting and provides at least the following basic services: ▪ Room and board. ▪ Evaluation and diagnosis. ▪ Counseling. ▪ Referral and orientation to specialized community resources. Residential Treatment Facility - a Hospital or facility, licensed and operated as required by law, that provides Residential Treatment. Secretary - as that term is applied in the No Surprises Act of the Consolidated Appropriations Act (P.L. 116-260). Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is a Covered Health Care Service, the difference in cost between a Semi-private Room and a private room is a Benefit only when a private room is Medically Necessary, or when a Semi-private Room is not available.

Noblesville Schools Medical Plan 110 Section 9: Defined Terms Service Fee - the periodic fee required for each Participant and each Enrolled Dependent, in accordance with the terms of the Plan. Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this SPD includes Mental Illness or substance-related and addictive disorders. Skilled Care - skilled nursing, skilled teaching, skilled habilitation and skilled rehabilitation services when all of the following are true: • Must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient. • Ordered by a Physician. • Not delivered for the purpose of helping with activities of daily living, including dressing, feeding, bathing or transferring from a bed to a chair. • Requires clinical training in order to be delivered safely and effectively. • Not Custodial Care, which can safely and effectively be performed by trained non-medical personnel. Skilled Nursing Facility - a Hospital or nursing facility that is licensed and operated as required by law. Specialist - a Physician who has a majority of his or her practice in areas other than general pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine. Specialty Pharmaceutical Products - Pharmaceutical Products that are generally high cost biotechnology drugs used to treat patients with certain illnesses. Spouse - an individual to whom you are legally married. Substance-Related and Addictive Disorders Services - services for the diagnosis and treatment of alcoholism and substance-related and addictive disorders that are listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The fact that a disorder is listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association does not mean that treatment of the disorder is a Covered Health Care Service. Summary Material Modification (SMM) - any attached written description of additional Covered Health Care Services not described in this SPD. Covered Health Care Services provided by a SMM may be subject to payment of additional Service Fees. SMMs are subject to all conditions, limitations and exclusions of the Plan except for those that are specifically amended in the SMM. Surrogate - a female who becomes pregnant by artificial insemination or transfer of a fertilized egg (embryo) for the purpose of carrying the fetus for another person. A surrogate provides the egg and therefore is biologically (genetically) related to the child. Telehealth/Telemedicine - live, interactive audio with visual transmissions, and/or transmissions through federally compliant secure messaging applications of a Physician-patient encounter from one site to another using telecommunications technology. The site may be a CMS defined originating facility or another location such as a Covered Person's home or place of work. Telehealth/Telemedicine does not include virtual care services provided by a Designated Virtual Network Provider. Transitional Living - Mental Health Care Services and Substance-Related and Addictive Disorders Services provided through facilities, group homes and supervised apartments which provide 24-hour supervision, including those defined in the American Society of Addiction Medicine (ASAM) Criteria and are either:

Noblesville Schools Medical Plan 111 Section 9: Defined Terms • Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. They provide stable and safe housing, an alcohol/drug-free environment and support for recovery. They may be used as an addition to ambulatory treatment when it doesn't offer the intensity and structure needed to help you with recovery. • Supervised living arrangements which are residences such as facilities, group homes and supervised apartments. They provide stable and safe housing and the opportunity to learn how to manage activities of daily living. They may be used as an addition to treatment when it doesn't offer the intensity and structure needed to help you with recovery. Please note: these living arrangements are also known as supportive housing (including recovery residences). Unproven Service(s) - services, including medications, and devices, regardless of U.S. Food and Drug Administration (FDA) approval, that are not determined to be effective for treatment of the medical or behavior health condition or not determined to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-designed randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature. • Well-designed systematic reviews (with or without meta-analyses) of multiple well-designed randomized controlled trials. • Individual well-designed randomized controlled trials. • Well-designed observational studies with one or more concurrent comparison group(s) including cohort studies, case-control studies, cross-sectional studies, and systematic reviews (with or without meta-analyses) of such studies. The Claims Administrator has a process by which the Claims Administrator compiles and reviews clinical evidence with respect to certain health care services. From time to time, the Claims Administrator issues medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can view these policies at www.myuhc.com and liveandworkwell.com. Please note: • If you have a life-threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment) the Claims Administrator may, at its discretion, consider an otherwise Unproven Service to be a Covered Health Care Service for that Sickness or condition. Prior to such a consideration, the Claims Administrator must first establish that there is sufficient evidence to conclude that, even though unproven, the service has significant potential as an effective treatment for that Sickness or condition. Urgent Care Center - an entity that provides Covered Health Care Services that are required to prevent serious deterioration of your health. These services are required as a result of an unforeseen Sickness, Injury, or the onset of sudden or severe symptoms.

Noblesville Schools Medical Plan 112 Clinical Programs and Resources Clinical Programs and Resources Care Management Solutions Personal Health Support The Claims Administrator provides a program called Personal Health Support designed to encourage personalized, efficient care for you and your covered Dependents. Personal Health Support Nurses center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available. If you are living with a chronic condition or dealing with complex health care needs, the Claims Administrator may assign to you a primary nurse, referred to as a Personal Health Support Nurse, to guide you through your treatment. This assigned nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with their telephone number so you can call them with questions about your conditions, or your overall health and well-being. Personal Health Support Nurses will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components are subject to change without notice. When the Claims Administrator is called as required, they will work with you to implement the Personal Health Support process and to provide you with information about additional services that are available to you, such as disease management programs, health education, and patient advocacy. As of the publication of this SPD, the Personal Health Support program includes: • Admission counseling - Personal Health Support Nurses are available to help you prepare for a successful surgical admission and recovery. Call the number on your ID card for support. • Inpatient care management - If you are hospitalized, Personal Health Support Nurses will work with your Physician to make sure you are getting the care you need and that your Physician's treatment plan is being carried out effectively. • Readmission Management - This program serves as a bridge between the Hospital and your home if you are at high risk of being readmitted. After leaving the Hospital, if you have a certain chronic or complex condition, you may receive a phone call from a Personal Health Support Nurse to confirm that medications, needed equipment, or follow-up services are in place. The Personal Health Support Nurse will also share important health care information, reiterate and reinforce discharge instructions, and support a safe transition home. • Risk Management - Designed for participants with certain chronic or complex conditions, this program addresses such health care needs as access to medical specialists, medication information, and coordination of equipment and supplies. Participants may receive a phone call from a Personal Health Support Nurse to discuss and share important health care information related to the participant's specific chronic or complex condition. • Cancer Management - You have the opportunity to engage with a nurse that specializes in cancer, education and guidance throughout your care path. • Kidney Management - You have the opportunity to engage with a nurse that specializes in kidney disease, education and guidance with CKD stage 4/5 or ESRD throughout your care path. If you do not receive a call from a Personal Health Support Nurse but feel you could benefit from any of these programs, please call the number on your ID card.

Noblesville Schools Medical Plan 113 Clinical Programs and Resources Complex Medical Conditions, Programs and Services Cancer Resource Services (CRS) Program Your Plan offers Cancer Resource Services (CRS) program to provide you with access to information and member assistance through a team of specialized cancer nurse consultants and access to one of the nation's leading cancer centers. To learn more about CRS, visit www.myoptumhealthcomplexmedical.com or call the number on your ID card or call the program directly at 1-866-936-6002. Coverage for oncology services and oncology-related services are based on your health plan's terms, exclusions, limitations and conditions, including the plan's eligibility requirements and coverage guidelines. Participation in this program is voluntary. Your Plan Sponsor is providing you with Travel and Lodging assistance. Refer to the Complex Medical Conditions Travel and Lodging Assistance Program. Kidney Disease Programs Kidney Resource Services (KRS) program End-Stage Renal Disease (ESRD) The Kidney Resource Services program provides Covered Persons with access to a kidney case manager who specializes in helping individuals experiencing End Stage Renal Disease. Participants engage with a case manager who will provide you with knowledgeable care management, education including transplantation, and personalized support. The kidney case manager also helps you manage other conditions, such as diabetes, high blood pressure, and cardiovascular disease. He or she may also help you find doctors, specialists and dialysis centers. The interdisciplinary team includes a medical director, diabetic nutritional educator, and social worker. This voluntary program is designed to help you be your own best advocate for your health. You may have been referred to the kidney program by your medical provider or from past claim information. As part of your health insurance benefits, it’s available at no extra cost to you. The kidney program provides access to nearby quality affordable dialysis centers based on your preferred dialysis modality type. You will receive treatment based on a “best practices” approach from health care professionals with demonstrated expertise. There are thousands of contracted dialysis centers across the country. In situations where you cannot conveniently access a contracted dialysis center, CKS may negotiate affordable patient-specific agreements on your behalf. KRS case manager advocates are available Monday through Friday toll-free at 1-866-561-7518 (TTY: 711). Coverage for dialysis and kidney-related services are based on your health plan’s terms, exclusions, limitations and conditions, including the plan’s eligibility requirements and coverage guidelines. Participation in this program is voluntary. Transplant Resource Services (TRS) Program Your Plan offers Transplant Resource Services (TRS) program to provide you with access to one of the nation's leading transplant programs. Receiving transplant services through this program means your transplant treatment is based on a "best practices" approach from health care professionals with extensive expertise in transplantation. To learn more about Transplant Resource Services, visit www.myoptumhealthcomplexmedical.com or call the number on your ID card.

Noblesville Schools Medical Plan 114 Clinical Programs and Resources Coverage for transplant and transplant-related services are based on your health plan's terms, exclusions, limitations and conditions, including the plan's eligibility requirements and coverage guidelines. Participation in this program is voluntary. Your Plan Sponsor is providing you with Travel and Lodging assistance. Refer to the Complex Medical Conditions Travel and Lodging Assistance Program. Complex Medical Conditions Travel and Lodging Assistance Program for the Covered Health Services Described Below Your Plan Sponsor may provide you with Travel and Lodging assistance for certain Covered Health Care Services. Travel and Lodging assistance is only available for you or your eligible family member if you meet the qualifications for the benefit, including receiving care at a Designated Provider and the requisite distance from your home address to the facility is at least 50 miles. Allowed Amounts are reimbursed after the expense forms have been completed and submitted with the appropriate receipts. If you have specific questions regarding the Travel and Lodging Assistance Program, please call the number on your ID card. Travel and Lodging Expenses The Plan covers expenses for travel and lodging for the Covered Person and a travel companion, provided the Covered Person is not covered by Medicare as follows: • Transportation of the Covered Person and one companion who is traveling on the same day(s) to and/or from the site of the qualified procedure provided by a Designated Provider for care related to one of the programs listed below. • The Allowed Amount for lodging for the Covered Person (while not a Hospital inpatient) and one companion. • If the Covered Person is an enrolled Dependent minor child, the transportation expenses of two companions will be covered. • Travel and lodging expenses are only available if the Covered Person resides at least 50 miles from the Designated Provider. • Reimbursement for certain lodging expenses for the Covered Person and his/her companion(s) may be included in the unearned taxable income of the Plan participant if the reimbursement exceeds the per diem rate. • The cancer, congenital heart disease and transplant programs offer a combined overall lifetime maximum of $10,000 per Covered Person for all transportation and lodging expenses incurred by you and reimbursed under the Plan in connection with all qualified procedures. Lodging Reimbursement Assistance • A per diem rate, up to $50.00 per day, for the Covered Person or the caregiver if the Covered Person is in the Hospital. • A per diem rate, up to $100.00 per day, for the Covered Person and one caregiver. When a child is the Covered Person, two persons may accompany the child. Decision Support In order to help you make informed decisions about your health care, the Claims Administrator has a program called Decision Support. This program targets specific conditions as well as the treatments and procedures for those conditions. This program offers:

Noblesville Schools Medical Plan 115 Clinical Programs and Resources • Access to health care information. • Support by a nurse to help you make more informed decisions in your treatment and care. • Expectations of treatment. • Information on providers and programs. Conditions for which this program is available include: • Back pain. • Knee & hip replacement. • Prostate disease. • Prostate cancer. • Benign uterine conditions. • Breast cancer. • Coronary disease. Participation is completely voluntary and without extra charge. If you think you may be eligible to participate or would like additional information regarding the program, please contact the number on your ID card. Second Opinion Service The Plan offers a voluntary second opinion education service, which is a live interactive video experience, powered by 2nd.MD. A dedicated nurse will oversee medical records collection, selection, and scheduling with a post- consultation support. For additional information regarding the program, please contact the number on your ID card. Disease Management If you have been diagnosed with certain chronic medical conditions you may be eligible to participate in a disease management program at no additional cost to you. The heart failure, coronary artery disease, diabetes, asthma and Chronic Obstructive Pulmonary Disease (COPD) programs are designed to support you. This means that you will receive free educational information, and may even be called by a registered nurse who is a specialist in your specific medical condition. This nurse will be a resource to advise and help you manage your condition. These programs offer: • Educational materials that provide guidance on managing your specific chronic medical condition. This may include information on symptoms, warning signs, self-management techniques, recommended exams and medications. • Access to educational and self-management resources on a consumer website. • An opportunity for the disease management nurse to work with your Physician to ensure that you are receiving the appropriate care. • Access to and one-on-one support from a registered nurse who specializes in your condition. Examples of support topics include: ▪ Education about the specific disease and condition. ▪ Medication management and compliance. ▪ Reinforcement of on-line behavior modification program goals.

Noblesville Schools Medical Plan 116 Clinical Programs and Resources ▪ Preparation and support for upcoming Physician visits. ▪ Review of psychosocial services and community resources. ▪ Caregiver status and in-home safety. ▪ Use of mail-order pharmacy and Network providers. Participation is completely voluntary and without extra charge. If you think you may be eligible to participate or would like additional information regarding the program, please contact the number on your ID card. Reminder Programs To help you stay healthy, the Claims Administrator may send you and your covered Dependents reminders to schedule recommended screening exams. Examples of reminders include: • Mammograms for women. • Pediatric and adolescent immunizations. • Cervical cancer screenings for women. • Comprehensive screenings for individuals with diabetes. • Influenza/pneumonia immunizations for enrollees. There is no need to enroll in this program. You will receive a reminder automatically if you have not had a recommended screening exam. Consumer Solutions and Self-Service Tools Plan Sponsor believes in giving you tools to help you be an educated health care consumer. To that end, Plan Sponsor has made available several convenient educational and support services, accessible by phone and the Internet, which can help you to: • Take care of yourself and your family members. • Manage a chronic health condition. • Navigate the complexities of the health care system. NOTE: Information obtained through the services identified in this section is based on current medical literature and on Physician review. It is not intended to replace the advice of a doctor. The information is intended to help you make more informed health care decisions and take a greater responsibility for your own health. The Claims Administrator and the Plan Sponsor are not responsible for the results of your decisions from the use of the information, including, but not limited to, your choosing to seek or not to seek professional medical care, your choosing of which provider to seek professional medical care from or your choosing or not choosing specific treatment. www.myuhc.com UnitedHealthcare's member website, www.myuhc.com provides information at your fingertips anywhere and anytime you have access to the Internet. www.myuhc.com opens the door to a wealth of health information and self-service tools. With www.myuhc.com you can: • Research a health condition and treatment options to get ready for a discussion with your Physician. • Search for Network providers available in your Plan through the online provider directory.

Noblesville Schools Medical Plan 117 Clinical Programs and Resources • Use the treatment cost estimator to obtain an estimate of the costs of various procedures in your area. • Use the Hospital comparison tool to compare Hospitals in your area on various patient safety and quality measures. Registering on www.myuhc.com If you have not already registered on www.myuhc.com, simply go to www.myuhc.com and click on "Register Now." Have your ID card handy. The enrollment process is quick and easy. Visit www.myuhc.com and: • Make real-time inquiries into the status and history of your claims. • View eligibility and Plan Benefit information. • View and print all of your Explanation of Benefits (EOBs) online. • Order a new or replacement ID card or print a temporary ID card. Want to learn more about a condition or treatment? Log on to www.myuhc.com and research health topics that are of interest to you. Learn about a specific condition, what the symptoms are, how it is diagnosed, how common it is, and what to ask your Physician. UnitedHealth Premium® Designation Program To help people make more informed choices about their health care, the UnitedHealth Premium® designation program recognizes Network Physicians who meet criteria for quality and cost efficiency. UnitedHealthcare uses national standardized measures to evaluate quality. The cost efficiency criteria rely on local market benchmarks for the efficient use of resources in providing care. For details on the UnitedHealth Premium® designation program including how to locate a Premium Care Physician, log onto www.myuhc.com or call the number on your ID card. Note: you may have access to certain mobile apps for personalized support to help live healthier. Please call the number on your ID card or visit www.myuhc.com for additional information.

118 Federal Notice Federal Notice Language Assistance Services ATTENTION: If you speak English, free language assistance services and free communications in other formats, such as large print, are available to you. Call 1-866-633-2446. (TTY: 711).

119 Federal Notice Notice of Non-Discrimination The Claims Administrator1 complies with applicable civil rights laws and does not discriminate on the basis of race, color, national origin, age, or sex (including pregnancy, sexual orientation, and gender identity). The Claims Administrator does not exclude people or treat them less than favorably because of race, color, national origin, age, disability or sex. The Claims Administrator provides free aids and services to help you communicate with them. You can ask for interpreters and/or for communications in other languages or formats such as large print. The Claims Administrator also provides reasonable modifications for persons with disabilities. If you need these services, please call 1-866-633-2446 or the toll-free member phone number on your member ID card, TTY/RTT 711. If you believe that the Claims Administrator failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to the Civil Rights Coordinator: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 UHC_Civil_Rights@uhc.com

120 Federal Notice If you need help filing a complaint, please call 1-866-633-2446 or the toll-free member phone number listed on your ID card, TTY 711. You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1For purposes of this Non-Discrimination Notice ("Notice"), "The Claims Administrator" refers to the entities listed in Footnote 2 of the Notice of Privacy Practices and Footnote 3 of the Financial Information Privacy Notice. Please note that not all entities listed are covered by this Notice. Important Notices under the Patient Protection and Affordable Care Act (PPACA) Changes in Federal Law that Impact Benefits There are changes in Federal law which may impact coverage and Benefits stated in the Summary Plan Description (SPD) and Schedule of Benefits. A summary of those changes and the dates the changes are effective appear below. These changes will apply to any "non-grandfathered" plan. Contact your Plan Administrator to determine whether or not your plan is a "grandfathered" or a "non-grandfathered plan". Under the Patient Protection and Affordable Care Act (PPACA) to be grandfathered a plan must have been in effect on March 23, 2010 and had no substantial changes in the benefit design as described in the Interim Final Rule on Grandfathered Health Plans at that time(among other requirements). Patient Protection and Affordable Care Act (PPACA) Effective for policies that are new or renewing on or after September 23, 2010, the requirements listed below apply. • Lifetime limits on the dollar amount of essential benefits available to you under the terms of your plan are no longer permitted. Essential benefits include the following: Ambulatory patient services; emergency services, hospitalization; laboratory services; maternity and newborn care, mental health care and substance-related and addictive disorder services (including behavioral health treatment); prescription drugs; rehabilitative and habilitative services and devices; preventive and wellness services and long-term disease management; and pediatric services, including oral and vision care. • On or before the first day of the first plan year beginning on or after September 23, 2010, the enrolling group will provide a 30 day enrollment period for those individuals who are still eligible under the plan's eligibility terms but whose coverage ended by reason of reaching a lifetime limit on the dollar value of all benefits. • Essential health benefits for plan years beginning on or after January 1, 2014 cannot be subject to annual or lifetime dollar limits. • Coverage for enrolled dependent children is no longer conditioned upon full-time student status or other dependency requirements and will remain in place until the child's 26th birthday. As of September 23, 2010, if you have a grandfathered plan, the group is not required to extend coverage to age 26 if the child is eligible to enroll in an eligible employer-sponsored health plan (as defined by law). For plan years beginning January 1, 2014 and beyond, Grandfathered plans are

121 Federal Notice required to cover dependents up to age 26, regardless of their eligibility for other employer sponsored coverage. On or before the first day of the first plan year beginning on or after September 23, 2010, the group will provide a 30 day dependent child special open enrollment period for dependent children who are not currently enrolled under the policy and who have not yet reached age 26. During this dependent child special open enrollment period, subscribers who are adding a dependent child and who have a choice of coverage options will be allowed to change options. • If your plan includes coverage for enrolled dependent children beyond the age of 26, which is conditioned upon full-time student status, the following applies: Coverage for enrolled dependent children who are required to maintain full-time student status in order to continue eligibility under the plan is subject to the statute known as Michelle's Law. This law amends ERISA, the Public Health Service Act, and the Internal Revenue Code and requires group health plans, which provide coverage for dependent children who are post-secondary school students, to continue such coverage if the student loses the required student status because he or she must take a medically necessary leave of absence from studies due to a serious illness or Injury. • If you do not have a grandfathered plan, network benefits for preventive care services described below will be paid at 100%, and not subject to any deductible, Coinsurance or Copayment. If you have pharmacy benefit coverage, your plan may also be required to cover preventive care medications that are obtained at a network pharmacy at 100%, and not subject to any deductible, Coinsurance or Copayment, as required by applicable law under any of the following: ▪ Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force. ▪ Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. ▪ With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. ▪ With respect to women, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. • Retroactive rescission of coverage under the plan is permitted, with 30 days advance written notice, only in the following two circumstances: ▪ The individual performs an act, practice or omission that constitutes fraud. ▪ The individual makes an intentional misrepresentation of a material fact. • Other changes provided for under the PPACA do not impact your plan because your plan already contains these benefits. These include: ▪ Direct access to OB/GYN care without a referral or authorization requirement. ▪ The ability to designate a pediatrician as a primary care physician (PCP) if your plan requires a PCP designation. ▪ Prior authorization is not required before you receive services in the emergency department of a hospital. If you seek emergency care from out-of-network providers in the emergency department of a hospital your cost sharing obligations (Copayments/Coinsurance) will be the same as would be applied to care received from network providers.

122 Federal Notice Effective for plans that are new or renewing on or after January 1, 2014, the requirements listed below apply: If your plan includes coverage for Clinical Trials, the following applies: The clinical trial benefit has been modified to distinguish between clinical trials for cancer and other life threatening conditions and those for non-life threatening conditions. For trials for cancer/other life threatening conditions, routine patient costs now include those for covered persons participating in a preventive clinical trial and Phase IV trials. This modification is optional for certain grandfathered health plans. Refer to your plan documents to determine if this modification has been made to your plan. Pre-Existing Conditions: Any pre-existing condition exclusions (including denial of benefit or coverage) will not apply to covered persons regardless of age. Some Important Information about Appeal and External Review Rights under PPACA If you are enrolled in a non-grandfathered plan with an effective date or plan year anniversary on or after September 23, 2010, the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended, sets forth new and additional internal appeal and external review rights beyond those that some plans may have previously offered. Also, certain grandfathered plans are complying with the additional internal appeal and external review rights provisions on a voluntary basis. Please refer to your benefit plan documents, including amendments and notices, or speak with your employer or UnitedHealthcare for more information on the appeal rights available to you. (Also, please refer to the Claims and Appeal Notice section of this document.) What if I receive a denial, and need help understanding it? Please call the Claims Administrator at the number listed on your health plan ID card. What if I don't agree with the denial? You have a right to appeal any decision to not pay for an item or service. How do I file an appeal? The first denial letter or Explanation of Benefits that you receive from the Claims Administrator will give you the information and the timeframe to file an appeal. What if my situation is urgent? If your situation is urgent, your review will take place as quickly as possible. If you believe your situation is urgent, you may request an expedited review, and, if applicable, file an external review at the same time. For help call the Claims Administrator at the number listed on your health plan ID card. Generally, an urgent situation is when your health may be in serious jeopardy. Or when, in the opinion of your doctor, you may be experiencing severe pain that cannot be controlled while you wait for a decision on your appeal. Who may file an appeal? Any member or someone that member names to act as an authorized representative may file an appeal. For help call the Claims Administrator at the number listed on your health plan ID card. Can I provide additional information about my claim? Yes, you may give the Claims Administrator additional information supporting your claim. Send the information to the address provided in the first denial letter or Explanation of Benefits. Can I request copies of information relating to my claim? Yes. There is no cost to you for these copies. Send your request to the address provided in the first denial letter or Explanation of Benefits. What happens if I don't agree with the outcome of my appeal? If you appeal, the Claims Fiduciary will review its decision. The Claims Fiduciary will also send you its written decision within the time allowed. If

123 Federal Notice you do not agree with the decision, you may be able to request an external review of your claim by an independent third party. If so, the Claims Fiduciary will review the denial and issue a final decision. If I need additional help, what should I do? For questions on your appeal rights, you may call the Claims Administrator at the number listed on your health plan ID card for assistance. You may also contact the support groups listed below. Are verbal translation services available to me during an appeal? Yes. Call the Claims Administrator at the number listed on your health plan ID card. Ask for verbal translation services for your questions. Is there other help available to me? For questions about appeal rights, an unfavorable benefit decision, or for help, you may also call the Employee Benefits Security Administration at 1-866-444-EBSA (3272). Your state consumer assistance program may also be able to help you. (http://www.dol.gov.ebsa/healthreform/ - click link for Consumer Assistance Programs). For information on appeals and other PPACA regulations, visit www.healthcare.gov. If your plan includes coverage for Mental Health Care or Substance - Related and Addictive Disorder Services, the following applies: Mental Health Care/Substance-Related and Addictive Disorder Services Parity Effective for grandfathered and non-grandfathered large group Plans that are new or renewing on or after July 1, 2010, Benefits are subject to final regulations supporting the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Benefits for mental health care conditions and substance-related and addictive disorder conditions that are Covered Health Care Services under the Plan must be treated in the same manner and provided at the same level as Covered Health Care Services for the treatment of other Sickness or Injury. Benefits for Mental Health Care Services and Substance-Related and Addictive Disorders Services are not subject to any annual maximum benefit limit (including any day, visit or dollar limit). MHPAEA requires that the financial requirements for Coinsurance and Copayments for mental health care and substance-related and addictive disorder conditions must be no more restrictive than those Coinsurance and Copayment requirements for substantially all medical/surgical benefits. MHPAEA requires specific testing to be applied to classifications of benefits to determine the impact of these financial requirements on mental health care and substance-related and Addictive disorder benefits. Based upon the results of that testing, it is possible that Coinsurance or Copayments that apply to mental health care conditions and substance-related and addictive disorder conditions in your benefit plan may be reduced.

124 Federal Notice Women's Health and Cancer Rights Act of 1998 As required by the Women's Health and Cancer Rights Act of 1998, Benefits under the Plan are provided for mastectomy, including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema). If you are receiving Benefits in connection with a mastectomy, Benefits are also provided for the following Covered Health Care Services, as you determine appropriate with your attending Physician: • All stages of reconstruction of the breast on which the mastectomy was performed, • Surgery and reconstruction of the other breast to produce a symmetrical appearance, • Prostheses and treatment of physical complications of the mastectomy, including lymphedema. The amount you must pay for such Covered Health Care Services (including Copayments, Coinsurance and any deductible) are the same as are required for any other Covered Health Care Service. Limitations on Benefits are the same as for any other Covered Health Care Service. Statement of Rights under the Newborns' and Mothers' Health Protection Act Under Federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict Benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g. your Physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under Federal law, plans and issuers may not set the level of Benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under Federal law, require that a Physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain prior authorization. For information on prior authorization, contact your issuer.

125 Federal Notice Claims and Appeal Notice This Notice is provided to you in order to describe our responsibilities under Federal law for making benefit determinations and your right to appeal adverse benefit determinations. To the extent that state law provides you with more generous timelines or opportunities for appeal, those rights also apply to you. Please refer to your benefit documents for information about your rights under state law. Benefit Determinations Post-service Claims Post-service claims are those claims that are filed for payment of Benefits after medical care has been received. If your post-service claim is denied, you will receive a written notice from the Claims Administrator within 30 days of receipt of the claim, as long as all needed information was provided with the claim. The Claims Administrator will notify you within this 30 day period if additional information is needed to process the claim, and may request a one time extension not longer than 15 days and pend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame, and the claim is denied, the Claims Administrator will notify you of the denial within 30 days after the information is received. If you don't provide the needed information within the 45-day period, your claim will be denied. A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, and provide the claim appeal procedures. If you have prescription drug Benefits and are asked to pay the full cost of a prescription when you fill it at a retail or mail-order pharmacy, and if you believe that it should have been paid under the Plan, you may submit a claim for reimbursement according to the applicable claim filing procedures. If you pay a Copayment and believe that the amount of the Copayment was incorrect, you also may submit a claim for reimbursement according to the applicable claim filing procedures. When you have filed a claim, your claim will be treated under the same procedures for post-service group health plan claims as described in this section. Post-Service Claims Type of Claim or Appeal Timing If your claim is incomplete, the Claims Administrator must notify you within: 30 days You must then provide completed claim information to the Claims Administrator within: 45 days The Claims Administrator must notify you of the benefit determination: if the initial claim is complete, within: 30 days after receiving the completed claim (if the initial claim is incomplete), within: 30 days You must appeal an adverse benefit determination no later than: 180 days after receiving the adverse benefit determination The Claims Administrator must notify you of the first level appeal decision within: 30 days after receiving the first level appeal

126 Federal Notice Post-Service Claims Type of Claim or Appeal Timing You must appeal the first level appeal (file a second level appeal) within: 60 days after receiving the first level appeal decision The Claims Fiduciary must notify you of the second level appeal decision within: 30 days after receiving the second level appeal Pre-service Requests for Benefits Pre-service requests for Benefits are those requests that require notification or approval prior to receiving medical care. If you have a pre-service request for Benefits, and it was submitted properly with all needed information, the Claims Administrator will send you written notice of the decision from the Claims Administrator within 15 days of receipt of the request. If you filed a pre-service request for Benefits improperly, the Claims Administrator will notify you of the improper filing and how to correct it within five days after the pre-service request for Benefits was received. If additional information is needed to process the pre-service request, the Claims Administrator will notify you of the information needed within 15 days after it was received, and may request a one time extension not longer than 15 days and pend your request until all information is received. Once notified of the extension you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame, the Claims Administrator will notify you of the determination within 15 days after the information is received. If you don't provide the needed information within the 45-day period, your request for Benefits will be denied. A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, and provide the appeal procedures. If you have prescription drug Benefits and a retail or mail order pharmacy fails to fill a prescription that you have presented, you may file a pre-service health request for Benefits according to the applicable claim filing procedure. When you have filed a request for Benefits, your request will be treated under the same procedures for pre-service group health plan requests for Benefits as described in this section. Pre-Service Request for Benefits* Type of Request for Benefits or Appeal Timing If your request for Benefits is filed improperly, the Claims Administrator must notify you within: 5 days If your request for Benefits is incomplete, the Claims Administrator must notify you within: 15 days You must then provide completed request for Benefits information to the Claims Administrator within: 45 days The Claims Administrator must notify you of the benefit determination: • if the initial request for Benefits is complete, within: 15 days • after receiving the completed request for Benefits (if the initial request for Benefits is incomplete), within: 15 days You must appeal an adverse benefit determination no later than: 180 days after receiving the adverse benefit determination The Claims Administrator must notify you of the first level appeal decision within: 15 days after receiving the first level appeal

127 Federal Notice Pre-Service Request for Benefits* Type of Request for Benefits or Appeal Timing You must appeal the first level appeal (file a second level appeal) within: 60 days after receiving the first level appeal decision The Claims Fiduciary must notify you of the second level appeal decision within: 15 days after receiving the second level appeal *The Claims Administrator may require a one-time extension for the initial claim determination, of no more than 15 days, only if more time is needed due to circumstances beyond control of the Plan. Urgent Requests for Benefits that Require Immediate Attention Urgent requests for Benefits are those that require notification or a benefit determination prior to receiving medical care, where a delay in treatment could seriously jeopardize your life or health, or the ability to regain maximum function or, in the opinion of a Physician with knowledge of your medical condition, could cause severe pain. In these situations, you will receive notice of the benefit determination in writing or electronically within 72 hours after the Claims Administrator receives all necessary information, taking into account the seriousness of your condition. If you filed an urgent request for Benefits improperly, the Claims Administrator will notify you of the improper filing and how to correct it within 24 hours after the urgent request was received. If additional information is needed to process the request, the Claims Administrator will notify you of the information needed within 24 hours after the request was received. You then have 48 hours to provide the requested information. You will be notified of a benefit determination no later than 48 hours after: • The Claims Administrator's receipt of the requested information. • The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time. A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, and provide the claim appeal procedures. Urgent Care Request for Benefits* Type of Request for Benefits or Appeal Timing If your request for Benefits is incomplete, the Claims Administrator must notify you within: 24 hours You must then provide completed request for Benefits to the Claims Administrator within: 48 hours after receiving notice of additional information required The Claims Administrator must notify you of the benefit determination within: 72 hours If the Claims Administrator denies your request for Benefits, you must appeal an adverse benefit determination no later than: 180 days after receiving the adverse benefit determination The Claims Administrator must notify you of the appeal decision within: 72 hours after receiving the appeal *You do not need to submit urgent care appeals in writing. You should call the Claims Administrator as soon as possible to appeal an urgent care request for Benefits.

128 Federal Notice Concurrent Care Claims If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an urgent request for Benefits as defined above, your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the end of the approved treatment. The Claims Administrator will make a determination on your request for the extended treatment within 24 hours from receipt of your request. If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will be treated as an urgent request for Benefits and decided according to the timeframes described above. If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new request and decided according to post-service or pre-service timeframes, whichever applies. Questions or Concerns about Benefit Determinations If you have a question or concern about a benefit determination, you may informally contact call the Claims Administrator at the telephone number on your ID card before requesting a formal appeal. If the representative cannot resolve the issue to your satisfaction over the phone, you may submit your question in writing. However, if you are not satisfied with a benefit determination as described above, you may appeal it as described below, without first informally contacting a representative. If you first informally contact the Claims Administrator and later wish to request a formal appeal in writing, you should again contact the Claims Administrator and request an appeal. If you request a formal appeal, a representative will provide you with the appropriate address. If you are appealing an urgent claim denial, please refer to Urgent Appeals that Require Immediate Action below and contact the Claims Administrator, immediately. How Do You Appeal a Claim Decision? If you disagree with a pre-service request for Benefits determination or post-service claim determination or a rescission of coverage determination after following the above steps, you can contact the Claims Administrator in writing to formally request an appeal. Your request for an appeal should include: • The patient's name and the identification number from the ID card. • The date(s) of medical service(s). • The provider's name. • The reason you believe the claim should be paid. • Any documentation or other written information to support your request for claim payment. Your denial of pre-service request for benefits or a first appeal request must be submitted to the Claims Administrator within 180 days after you receive the denial of pre-service request for benefits or a claim denial. Appeal Process A qualified individual who was not involved in the decision being appealed will be chosen to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with expertise in the field, who was not involved in the prior determination. The Claims Administrator may consult with, or ask medical experts to take part in the appeal resolution process. You consent to this referral and the sharing of needed medical claim information. Upon request and free of charge, you have the right to reasonable access to and copies of all documents, records, and other information related to your claim for Benefits. If any new or additional evidence is relied upon or

129 Federal Notice generated by the Claims Administrator during the determination of the appeal, the Claims Administrator will provide it to you free of charge in advance of the due date of the response to the adverse benefit determination. Appeals Determinations Pre-service Requests for Benefits and Post-service Claim Appeals You will be provided written or electronic notification of the decision on your appeal as follows: • For appeals of pre-service requests for Benefits as shown above, the first level appeal will take place and you will be notified of the decision within 15 days from receipt of a request for appeal of a denied request for Benefits. The second level appeal will be conducted and you will be notified of the decision within 15 days from receipt of a request for review of the first level appeal decision. • For appeals of post-service claims as shown above, the first level appeal will take place and you will be notified of the decision within 30 days from receipt of a request for appeal of a denied claim. The second level appeal will be conducted and you will be notified of the decision within 30 days from receipt of a request for review of the first level appeal decision. For procedures related to with urgent requests for Benefits, see Urgent Appeals that Require Immediate Action below. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal. Your second level appeal request must be submitted to the Claims Administrator within 60 days from receipt of the first level appeal decision. Please note that the Claims Administrator's decision is based only on whether or not Benefits are available under the Plan for the proposed treatment or procedure. The decision to obtain the proposed treatment or procedure regardless of the Claims Administrator's decision is between you and your Physician. Urgent Appeals that Require Immediate Action Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health, or the ability to regain maximum function, or cause severe pain. If your situation is urgent, your review will be conducted as quickly as possible. If you believe your situation is urgent, you may request an expedited review, and, if applicable, file an external review at the same time. For help call the Claims Administrator at the number listed on your health plan ID card. Generally, an urgent situation is when your life or health may be in serious jeopardy. Or when, in the opinion of your doctor, you may be experiencing severe pain that cannot be adequately controlled while you wait for a decision on your claim or appeal. In these urgent situations: • The appeal does not need to be submitted in writing. You or your Physician should call the Claims Administrator as soon as possible. • The Claims Administrator will provide you with a written or electronic determination within 72 hours following receipt of your request for review of the determination, taking into account the seriousness of your condition. • If the Claims Administrator needs more information from your Physician to make a decision, the Claims Administrator will notify you of the decision by the end of the next business day following receipt of the required information. The appeal process for urgent situations does not apply to prescheduled treatments, therapies or surgeries.

130 Federal Notice HEALTH PLAN NOTICES OF PRIVACY PRACTICES MEDICAL INFORMATION PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective January 1, 2023 The Claims Administrator2 is required by law to protect the privacy of your health information. The Claims Administrator is also required to send you this notice, which explains how the Claims Administrator may use information about you and when the Claims Administrator can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice. The Claims Administrator is required by law to abide by the terms of this notice. The terms "information" or "health information" in this notice include any information the Claims Administrator maintains that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care. The Claims Administrator will comply with the requirements of applicable privacy laws relating to notifying you in the event of a breach of your health information. The Claims Administrator has the right to change its privacy practices and the terms of this notice. If the Claims Administrator makes a material change to its privacy practices, the Claims Administrator will provide to you, in the Claims Administrator's next annual distribution, either a revised notice or information about the material change and how to obtain a revised notice. The Claims Administrator will provide you with this information either by direct mail or electronically in accordance with applicable law. In all cases, if the Claims Administrator maintains a website for your particular health plan, the Claims Administrator will post the revised notice on your health plan website, such as www.myuhc.com. The Claims Administrator reserves the right to make any revised or changed notice effective for information the Claims Administrator already has and for information that the Claims Administrator receives in the future. UnitedHealth Group collects and maintains oral, written and electronic information to administer the Claims Administrator's business and to provide products, services and information of importance to Plan enrollees. The Claims Administrator maintains physical, electronic and procedural security safeguards in the handling and maintenance of Plan enrollee's information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction or misuse.

131 Federal Notice How the Claims Administrator Uses or Discloses Information The Claims Administrator must use and disclose your health information to provide that information: • To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice. • To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. The Claims Administrator has the right to use and disclose health information for your treatment, to pay for your health care and to operate the Claims Administrator's business. For example, the Claims Administrator may use or disclose your health information: • For Payment of service fees due the Claims Administrator, to determine your coverage, and to process claims for health care services you receive, including for subrogation or coordination of other benefits you may have. For example, the Claims Administrator may tell a doctor whether you are eligible for coverage and what percentage of the bill may be covered. • For Treatment. The Claims Administrator may use or disclose health information to aid in your treatment or the coordination of your care. For example, the Claims Administrator may disclose information to your physicians or hospitals to help them provide medical care to you. • For Health Care Operations. The Claims Administrator may use or disclose health information as needed to operate and manage its business activities related to providing and managing your health care coverage. For example, the Claims Administrator might talk to your physician to suggest a disease management or wellness program that could help improve your health or the Claims Administrator may analyze data to determine how the Claims Administrator can improve its services. The Claims Administrator may also de-identify health information in accordance with applicable laws. After that information is de-identified, the information is no longer subject to this notice and the Claims Administrator may use the information for any lawful purpose. • To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. • For Plan Sponsors. If your coverage is through an employer sponsored group health plan, the Claims Administrator may share summary health information and enrollment and disenrollment information with the plan sponsor. In addition, the Claims Administrator may share other health information with the plan sponsor for plan administration purpose if the plan sponsor agrees to special restrictions on its use and disclosure of the information in accordance with federal law. • For Underwriting Purposes. The Claims Administrator may use or disclose your health information for underwriting purposes; however, the Claims Administrator will not use or disclose your genetic information for such purposes. • For Reminders. The Claims Administrator may use or disclose health information to send you reminders about your benefits or care, such as appointment reminders with providers who provide medical care to you. • For Communications to You. The Claims Administrator may communicate, electronically or via telephone, these treatment, payment or health care operation messages using telephone numbers or email addresses you provide to the Claims Administrator. The Claims Administrator may use or disclose your health information for the following purposes under limited circumstances: • As Required by Law. The Claims Administrator may disclose information when required to do so by law.

132 Federal Notice • To Persons Involved With Your Care. The Claims Administrator may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity. If you are unavailable or unable to object, the Claims Administrator will use its best judgment to decide if the disclosure is in your best interests. Special rules apply regarding when the Claims Administrator may disclose health information to family members and others involved in a deceased individual's care. The Claims Administrator may disclose health information to any persons involved, prior to the death, in the care or payment for care of a deceased individual, unless the Claims Administrator is aware that doing so would be inconsistent with a preference previously expressed by the deceased. • For Public Health Activities such as reporting or preventing disease outbreaks to a public health authority. • For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency. • For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations. • For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena. • For Law Enforcement Purposes. The Claims Administrator may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime. • To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster. • For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others. • For Workers' Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness. • For Research Purposes such as research related to the review of certain treatments or the prevention of disease or disability, if the research study meets federal privacy law requirements. • To Provide Information Regarding Decedents. The Claims Administrator may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. The Claims Administrator may also disclose information to funeral directors as needed to carry out their duties. • For Organ Procurement Purposes. The Claims Administrator may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation. • To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if needed (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. • To Business Associates that perform functions on the Claims Administrator's behalf or provide the Claims Administrator with services if the information is needed for such functions or services. The Claims Administrator's business associates are required, under contract with the Claims Administrator, and according to federal law, to protect the privacy of your information and are not

133 Federal Notice allowed to use or disclose any information other than as shown in the Claims Administrator's contract and as permitted by federal law. • Additional Restrictions on Use and Disclosure. Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. Such laws may protect the following types of information: 1. Alcohol and Substance Abuse 2. Biometric Information 3. Child or Adult Abuse or Neglect, including Sexual Assault 4. Communicable Diseases 5. Genetic Information 6. HIV/AIDS 7. Mental Health 8. Minor's Information 9. Prescriptions 10. Reproductive Health 11. Sexually Transmitted Diseases If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to the Claims Administrator, it is the Claims Administrator's intent to meet the requirements of the more stringent law. Except for uses and disclosures described and limited as stated in this notice, the Claims Administrator will use and disclose your health information only with a written authorization from you. This includes, except for limited circumstances allowed by federal privacy law, not using or disclosing psychotherapy notes about you, selling your health information to others, or using or disclosing your health information for certain promotional communications that are prohibited marketing communications under federal law, without your written authorization. Once you give the Claims Administrator authorization to release your health information, the Claims Administrator cannot guarantee that the recipient to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at any time in writing, except if the Claims Administrator has already acted based on your authorization. To find out where to mail your written authorization and how to revoke an authorization, call the phone number listed on your health plan ID card. What Are Your Rights The following are your rights with respect to your health information: • You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. The Claims Administrator may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while the Claims Administrator will try to honor your request and will permit requests consistent with the Claims Administrator's policies, the Claims Administrator is not required to agree to any restriction. • You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address). The Claims Administrator will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you. In certain circumstances, the Claims Administrator will accept your verbal request to receive confidential

134 Federal Notice communications, however; the Claims Administrator may also require you confirm your request in writing. In addition, any requests to modify or cancel a previous confidential communication request must be made in writing. Mail your request to the address listed below. • You have the right to see and get a copy of certain health information the Claims Administrator maintains about you such as claims and case or medical management records. If the Claims Administrator maintains your health information electronically, you will have the right to request that the Claims Administrator send a copy of your health information in an electronic format to you. You can also request that the Claims Administrator provide a copy of your information to a third party that you identify. In some cases, you may receive a summary of this health information. You must make a written request to inspect and copy your health information or have your information sent to a third party. Mail your request to the address listed below. In certain limited circumstances, the Claims Administrator may deny your request to inspect and copy your health information. If the Claims Administrator denies your request, you may have the right to have the denial reviewed. The Claims Administrator may charge a reasonable fee for any copies. • You have the right to ask to amend certain health information the Claims Administrator maintains about you such as claims and case or medical management records, if you believe the health information about you is wrong or incomplete. Your request must be in writing and provide the reasons for the requested amendment. Mail your request to the address listed below. If the Claims Administrator denies your request, you may have a statement of your disagreement added to your health information. • You have the right to receive an accounting of certain disclosures of your information made by the Claims Administrator during the six years prior to your request. This accounting will not include disclosures of information made: (i) for treatment, payment, and health care operations purposes; (ii) to you or pursuant to your authorization; and (iii) to correctional institutions or law enforcement officials; and (iv) other disclosures for which federal law does not require the Claims Administrator to provide an accounting. • You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may get a copy of this notice on your health plan website, such as www.myuhc.com. Exercising Your Rights • Contacting your Health Plan. If you have any questions about this notice or want information about exercising your rights, please call the toll- free member phone number on your health plan ID card or you may call the Claims Administrator at 1-866-633-2446 or TTY 711. • Submitting a Written Request. You can mail your written requests to exercise any of your rights, including modifying or cancelling a confidential communication, for copies of your records, or requesting amendments to your record, to the Claims Administrator at the following address: UnitedHealthcare Customer Service - Privacy Unit PO Box 740815 Atlanta, GA 30374-0815 • Timing. The Claims Administrator will respond to your telephonic or written request within 30 business days of receipt. • Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with the Claims Administrator at the address listed above.

135 Federal Notice You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. The Claims Administrator will not take any action against you for filing a complaint. 2This Medical Information Notice of Privacy Practices applies to the following health plans that are affiliated with UnitedHealth Group: ACN Group of California, Inc.; All Savers Insurance Company; All Savers Life Insurance Company of California; AmeriChoice of New Jersey, Inc.; Arizona Physicians IPA, Inc.; Care Improvement Plus of Texas Insurance Company; Care Improvement Plus South Central Insurance Company; Care Improvement Plus Wisconsin Insurance Company; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.; Golden Rule Insurance Company; Health Plan of Nevada, Inc.; MAMSI Life and Health Insurance Company; MD - Individual Practice Association, Inc.; Medical Health Plans of Florida, Inc.; Medica HealthCare Plans, Inc.; National Pacific Dental, Inc.; Neighborhood Health Partnership, Inc.; Nevada Pacific Dental; Optimum Choice, Inc.; Optum Insurance Company of Ohio, Inc.; Oxford Health Insurance, Inc.; Oxford Health Plans (CT), Inc.; Oxford Health Plans (NJ), Inc.; Oxford Health Plans (NY), Inc.; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company; PacifiCare of Arizona, Inc.; PacifiCare of Colorado, Inc.; PacifiCare of Nevada, Inc.; Physicians Health Choice of Texas, LLC; Preferred Care Partners, Inc.; Rocky Mountain Health Maintenance Organization, Incorporated; Rocky Mountain Health Management Corporation; Rocky Mountain HealthCare Options, Inc.; Sierra Health and Life Insurance Company, Inc.; UHC of California; U.S. Behavioral Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New York; Unison Health Plan of Delaware, Inc.; Unison Health Plan of the Capital Area, Inc.; UnitedHealthcare Benefits of Texas, Inc.; UnitedHealthcare Community Plan of Georgia, Inc.; UnitedHealthcare Community Plan of Ohio, Inc.; UnitedHealthcare Community Plan, Inc.; UnitedHealthcare Community Plan of Texas, L.L.C.; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance Company of Illinois; UnitedHealthcare Insurance Company of New York; UnitedHealthcare Insurance Company of the River Valley; UnitedHealthcare Life Insurance Company; UnitedHealthcare of Alabama, Inc.; UnitedHealthcare of Arizona, Inc.; UnitedHealthcare of Arkansas, Inc.; UnitedHealthcare of Colorado, Inc.; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare of Kentucky, Ltd.; UnitedHealthcare of Louisiana, Inc.; UnitedHealthcare of the Mid-Atlantic, Inc.; UnitedHealthcare of the Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.; United HealthCare of Mississippi, Inc.; UnitedHealthcare of New England, Inc.; UnitedHealthcare of New Mexico, Inc.; UnitedHealthcare of New York, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of Oregon, Inc.; UnitedHealthcare of Pennsylvania, Inc.; UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Utah, Inc.; UnitedHealthcare of Washington, Inc.; UnitedHealthcare of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc. This list of health plans is complete as of the effective date of this notice. For a current list of health plans subject to this notice go to www.uhc.com/privacy/entities- fn-v1. FINANCIAL INFORMATION PRIVACY NOTICE THIS NOTICE DESCRIBES HOW FINANCIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY. Effective January 1,2023 The Claims Administrator3 is committed to maintaining the confidentiality of your personal financial information. For the purposes of this notice, "personal financial information" means information, other than health information, about an enrollee or an applicant for health care coverage that identifies the individual, is not generally publicly available and is collected from the individual or is obtained in connection with providing health care coverage to the individual. Information We Collect Depending upon the product or service you have with the Claims Administrator, the Claims Administrator may collect personal financial information about you from the following sources:

136 Federal Notice • Information the Claims Administrator receives from you on applications or other forms, such as name, address, age, medical information and Social Security number. • Information about your transactions with the Claims Administrator, the Claims Administrator's affiliates or others, such as premium payment and claims history. • Information from a consumer reporting agency. Disclosure of Information The Claims Administrator does not disclose personal financial information about the Plan's enrollees or former enrollees to any third party, except as required or permitted by law. For example, in the course of the Claims Administrator's general business practices, the Claims Administrator may, as permitted by law, disclose any of the personal financial information that the Claims Administrator collects about you without your authorization, to the following types of institutions: • To the Claims Administrator's corporate affiliates, which include financial service providers, such as other insurers, and non-financial companies, such as data processors. • To nonaffiliated companies for the Claims Administrator's everyday business purposes, such as to process your transactions, maintain your account(s), or respond to court orders and legal investigations. • To nonaffiliated companies that perform services for the Claims Administrator, including sending promotional communications on the Claims Administrator's behalf. Confidentiality and Security The Claims Administrator maintains physical, electronic and procedural safeguards in accordance with applicable state and federal standards to protect your personal financial information against risks such as loss, destruction or misuse. These measures include computer safeguards, secured files and buildings, and restrictions on who may access your personal financial information. Questions about this Notice If you have any questions about this notice, please call the toll-free member phone number on your health plan ID card or call the Claims Administrator at 1-866-633-2446 or TTY 711. 3For purposes of this Financial Information Privacy Notice, the "Claims Administrator" refers to the entities listed in footnote 2, beginning on the first page of the Health Plan Notices of Privacy Practices, plus the following UnitedHealthcare affiliates: AmeriChoice Health Services, Inc.; CNIC Health Solutions, Inc.; Dental Benefit Providers, Inc.; gethealthinsurance.com Agency, Inc.; Golden Outlook, Inc.; HealthAllies, Inc.; LifePrint East, Inc.; Life Print Health, Inc.; MAMSI Insurance Resources, LLC; Managed Physical Network, Inc.; OneNet PPO, LLC; OptumHealth Care Solutions, Inc.; Optum Women's and Children's Health, LLC; OrthoNet, LLC; OrthoNet of the Mid-Atlantic, Inc.; OrthoNet West, LLC; OrthoNet of the South, Inc.; Oxford Benefit Management, Inc.; Oxford Health Plans LLC; POMCO Network, Inc.; POMCO of Florida, Ltd.; POMCO West, Inc.; POMCO, Inc.; Spectera, Inc.; UMR, Inc.; Unison Administrative Services, LLC; United Behavioral Health; United Behavioral Health of New York I.P.A., Inc.; United HealthCare Services, Inc.; UnitedHealth Advisors, LLC; UnitedHealthcare Service LLC; UnitedHealthcare Services Company of the River Valley, Inc. This Financial Information Privacy Notice only applies where required by law. Specifically, it does not apply to (1) health care insurance products offered in Nevada by Health Plan of Nevada, Inc. and Sierra Health and Life Insurance Company, Inc.; or (2) other UnitedHealth Group health plans in states that provide exceptions for HIPAA covered entities or health insurance products. This list of health plans is complete as of the effective date of this notice. For a current list of health plans subject to this notice go to www.uhc.com/privacy/entities-fn-v1.

137 Federal Notice Administrative Statement If the Plan is not subject to ERISA, the following information applies to you. Claims Fiduciary: The Claims Administrator is your Plan's Claims Fiduciary and has been delegated this responsibility by your Plan Sponsor. Your Claims Fiduciary has the authority to require eligible individuals to furnish it with information necessary for the proper administration of your Plan. The Claims Fiduciary shall not be deemed or construed as an employer for any purpose with respect to the administration or provision of benefits under the Plan Sponsor's Plan. The Claims Fiduciary shall not be responsible for fulfilling any duties or obligations of an employer with respect to the Plan Sponsor's Plan. Type of Administration of the Plan: Your Plan is self-funded. The Plan Sponsor provides certain administrative services in connection with its Plan. The Plan Sponsor may, from time to time in its sole discretion, contract with outside parties to arrange for the provision of other administrative services including arrangement of access to a Network Provider; claims processing services, including coordination of benefits and subrogation; utilization management and complaint resolution assistance. This external administrator is referred to as the Claims Fiduciary. For Benefits as described in this Summary Plan Description, the Plan Sponsor also has selected a provider network established by UnitedHealthcare Insurance Company. The named fiduciary of Plan is Noblesville Schools, the Plan Sponsor. The Plan Sponsor has selected a provider Network established by UnitedHealthcare Insurance Company United Healthcare Services, Inc. 9900 Bren Road East Minnetonka, MN 55343 952-936-1300 Person designated as Agent for Service of Legal Process: Noblesville Schools

51823484 Set 001 Final - 12/15/2025