09 NATA $5000 $8000 8060 $30 $60 Plan 9 SBC

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2024 – 09/30/2025 SM Regence BlueCross BlueShield of Oregon: Regence Classic Coverage for: Individual and Eligible Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to https://regence.com or call 1 (888) 367-2116. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1 (888) 367-2116 to request a copy. Important Questions Answers Why This Matters: In-network provider: $5,000 individual / Generally, you must pay all of the costs from providers up to the deductible amount What is the overall $10,000 family per calendar year. before this plan begins to pay. If you have other family members on the plan, each deductible? Out-of-network provider: $10,000 individual / family member must meet their own individual deductible until the total amount of $20,000 family per calendar year. deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven't yet met the Are there services covered Yes. Certain preventive care, prescription drug deductible amount. But a copayment or coinsurance may apply. For example, before you meet your coverage and those services listed below as this plan covers certain preventive services without cost sharing and before you deductible? "deductible does not apply." meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services? In-network provider: $8,000 individual / The out-of-pocket limit is the most you could pay in a year for covered services. If you What is the out-of-pocket $16,000 family per calendar year. have other family members in this plan, they have to meet their own out-of-pocket limits limit for this plan? Out-of-network provider: $16,000 individual / until the overall family out-of-pocket limit has been met. $32,000 family per calendar year. What is not included in the Premiums, balance-billing charges, and health Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? care this plan doesn't cover. This plan uses a provider network. You will pay less if you use a provider in the plan's Yes. See https://regence.com/go/OR/Preferred network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use or call 1 (888) 367-2116 for a list of network receive a bill from a provider for the difference between the provider's charge and what a network provider? providers. your plan pays (balance billing). Be aware, your network provider might use an out-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? Page 1 of 7 Northwest Automotive Trades Association OO0124SCLAX

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Services You May In-Network Provider Out-of-Network Provider Limitations, Exceptions, & Other Important Event Need (You will pay the least) (You will pay the most) Information $5 copay, deductible does not apply / first 3 upfront visits / year; Primary care visit to $30 copay / office visit after 40% coinsurance treat an injury or illness 3 upfront visits, deductible First 3 upfront visits combined for primary care and does not apply; behavioral health services. If you visit a health Copayment applies to each in-network provider office care provider's office 20% coinsurance for all visit only. All other services are covered at the or clinic other services coinsurance specified, after deductible. $60 copay / office visit, deductible does not apply; Specialist visit 40% coinsurance 20% coinsurance for all other services Preventive No charge, deductible does You may have to pay for services that aren't care/screening/ not apply 40% coinsurance preventive. Ask your provider if the services needed immunization are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, 20% coinsurance 40% coinsurance If you have a test blood work) None Imaging (CT/PET scans, 20% coinsurance 40% coinsurance MRIs) $10 copay, deductible does $10 copay, deductible does Prescription drugs not on the Drug List are not If you need drugs to not apply / retail not apply / retail covered, unless an exception is approved. treat your illness or prescription; prescription; 90-day supply / retail prescription (your cost share is condition per 30-day supply) More information about Tier 1 (Typically, generic $20 copay, deductible does $20 copay, deductible does 90-day supply / home delivery prescription prescription drug drugs with highest not apply / home delivery not apply / home delivery 30-day supply / specialty drug prescription coverage is available at overall value) prescription; prescription; Specialty drugs are not available through home https://regence.com/go/ delivery. 2024/OR/4tier $10 copay, deductible does $10 copay, deductible does Coverage includes compound medications at 50% not apply / self- not apply / self- coinsurance, deductible does not apply. administrable cancer administrable cancer Page 2 of 7

Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) chemotherapy prescription chemotherapy prescription Cost shares for insulin will not exceed $85 / 30-day $50 copay, deductible does $50 copay, deductible does supply retail prescription or $255 / 90-day supply home not apply / retail not apply / retail delivery prescription. prescription; prescription; No charge, deductible does not apply for certain preventive drugs, contraceptives and immunizations at Tier 2 (Typically, brand $100 copay, deductible $100 copay, deductible a participating pharmacy. drugs with moderate does not apply / home does not apply / home If you fill a brand drug or specialty drug when there is overall value) delivery prescription; delivery prescription; an equivalent generic drug or specialty biosimilar drug available, you pay the difference in cost in addition to $50 copay, deductible does $50 copay, deductible does the copayment and/or coinsurance. not apply / self- not apply / self- The first fill of specialty drugs may be provided by a administrable cancer administrable cancer retail pharmacy; additional refills must be provided by a chemotherapy prescription chemotherapy prescription specialty pharmacy. $75 copay, deductible does $75 copay, deductible does not apply / retail not apply / retail prescription; prescription; Tier 3 (Typically, brand $150 copay, deductible $150 copay, deductible drugs with lower overall does not apply / home does not apply / home value) delivery prescription; delivery prescription; $100 copay, deductible $100 copay, deductible does not apply / self- does not apply / self- administrable cancer administrable cancer chemotherapy prescription chemotherapy prescription 50% coinsurance, 50% coinsurance, deductible does not apply / deductible does not apply / specialty drug; specialty drug; Tier 4 (Specialty drugs) $100 copay, deductible $100 copay, deductible does not apply / self- does not apply / self- administrable cancer administrable cancer chemotherapy prescription chemotherapy prescription Page 3 of 7

Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) 10% coinsurance for Facility fee (e.g., ambulatory surgery ambulatory surgery centers; 40% coinsurance center) 20% coinsurance for all If you have outpatient other facilities None surgery 10% coinsurance for ambulatory surgery center Physician/surgeon fees physicians; 40% coinsurance 20% coinsurance for all other physicians In-network deductible applies to in-network provider 20% coinsurance after 20% coinsurance after and out-of-network provider services. Emergency room care $250 copay / visit $250 copay / visit Copayment applies to facility charge for each visit (waived if admitted), whether or not the deductible has been met. If you need immediate Emergency medical 20% coinsurance 20% coinsurance In-network deductible applies to in-network provider medical attention transportation and out-of-network provider services. $60 copay / office visit, $60 copay / office visit, deductible does not apply; deductible does not apply; Copayment applies to each office visit only. All other Urgent care services are covered at the coinsurance specified, after 20% coinsurance for all 40% coinsurance for all deductible. other services other services If you have a hospital Facility fee (e.g., 20% coinsurance 40% coinsurance stay hospital room) None Physician/surgeon fees 20% coinsurance 40% coinsurance $5 copay, deductible does not apply / first 3 upfront First 3 upfront visits combined for primary care and If you need mental visits / year; behavioral health services. health, behavioral Outpatient services 40% coinsurance Copayment applies to each in-network provider office / health, or substance $30 copay / office visit after psychotherapy visit only. All other services are covered abuse services 3 upfront visits, deductible at the coinsurance specified, after deductible. does not apply; Page 4 of 7

Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) 20% coinsurance for all other services Inpatient services 20% coinsurance 40% coinsurance None Office visits 20% coinsurance 40% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery 20% coinsurance 40% coinsurance Depending on the type of services, a copayment, If you are pregnant professional services coinsurance or deductible may apply. Maternity care Childbirth/delivery 20% coinsurance 40% coinsurance may include tests and services described elsewhere in facility services the SBC (i.e. ultrasound). Home health care 20% coinsurance 40% coinsurance 130 visits / year 30 inpatient days / year $30 copay / outpatient visit, 30 outpatient visits / year deductible does not apply; Copayment applies to each in-network provider Rehabilitation services 40% coinsurance outpatient visit only. All inpatient services are covered 20% coinsurance for at the coinsurance specified, after deductible. inpatient services Includes physical therapy, occupational therapy and If you need help speech therapy. recovering or have 30 neurodevelopmental visits / year other special health Neurodevelopmental therapy limited to individuals needs $30 copay / visit, deductible under age 18. Habilitation services does not apply 40% coinsurance Copayment applies to each in-network provider visit only. Includes physical therapy, occupational therapy and speech therapy. Skilled nursing care 20% coinsurance 40% coinsurance 60 inpatient days / year Durable medical 20% coinsurance 40% coinsurance None equipment Hospice services 20% coinsurance 40% coinsurance 14 respite inpatient or outpatient days / lifetime Children's eye exam Not covered Not covered If your child needs Children's glasses Not covered Not covered None dental or eye care Children's dental check- Not covered Not covered up Page 5 of 7

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Bariatric surgery • Infertility treatment • Routine eye care • Cosmetic surgery, except congenital anomalies • Long-term care • Routine foot care, except for diabetic patients • Dental care • Private-duty nursing • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Abortion • Chiropractic care • Non-emergency care when traveling outside the • Acupuncture, 24 visits / year U.S. • • Hearing aids (individuals up to age 26), 1 per ear / year Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform, or the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1 (877) 267-2323 ext. 61565 or cciio.cms.gov or your state insurance department. You may also contact the plan at 1 (888) 367-2116. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call 1 (800) 318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the plan at 1 (888) 367-2116 or visit regence.com or the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform. You may also contact the Oregon Division of Financial Regulation by calling 1 (503) 947-7984 or the toll-free message line at 1 (888) 877-4894; by writing to the Oregon Division of Financial Regulation, Consumer Advocacy Unit, P.O. Box 14480, Salem, OR 97309-0405; through the Internet at: dfr.oregon.gov/help/complaints-licenses/Pages/file- complaint.aspx; or by E-mail at: [email protected]. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1 (888) 367-2116. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 6 of 7

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe's Type 2 Diabetes Mia's Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) controlled condition) care)  The plan's overall deductible $5,000  The plan's overall deductible $5,000  The plan's overall deductible $5,000  Specialist copayment $60  Specialist copayment $60  Specialist copayment $60  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Other coinsurance 20%  Other coinsurance 20%  Other coinsurance 20% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $5,000 Deductibles $900 Deductibles $1,800 Copayments $10 Copayments $1,000 Copayments $600 Coinsurance $1,400 Coinsurance $0 Coinsurance $0 What isn't covered What isn't covered What isn't covered Limits or exclusions $60 Limits or exclusions $200 Limits or exclusions $0 The total Peg would pay is $6,470 The total Joe would pay is $2,100 The total Mia would pay is $2,400 The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 7

NONDISCRIMINATION NOTICE Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Regence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Regence: Provides free aids and services to people with disabilities to communicate effectively with us, such as:  Qualified sign language interpreters  Written information in other formats (large print, audio, and accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as:  Qualified interpreters  Information written in other languages If you need these services listed above, You can also file a civil rights complaint with the please contact: U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Medicare Customer Service Office for Civil Rights Complaint Portal at 1-800-541-8981 (TTY: 711) https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: Customer Service for all other plans 1-888-344-6347 (TTY: 711) U.S. Department of Health and Human Services 200 Independence Avenue SW, If you believe that Regence has failed to Room 509F HHH Building provide these services or discriminated in Washington, DC 20201 another way on the basis of race, color, national origin, age, disability, or sex, you can 1-800-368-1019, 800-537-7697 (TDD). file a grievance with our civil rights coordinator below: Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Medicare Customer Service Civil Rights Coordinator MS: B32AG, PO Box 1827 Medford, OR 97501 1-866-749-0355, (TTY: 711) Fax: 1-888-309-8784 [email protected] Customer Service for all other plans Civil Rights Coordinator MS CS B32B, P.O. Box 1271 Portland, OR 97207-1271 1-888-344-6347, (TTY: 711) [email protected] 01012017.04PF12LNoticeNDMARegence

Language assistance ATENCIÓN: si habla español, tiene a su disposición ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, servicios gratuitos de asistencia lingüística. Llame al បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ 1-888-344-6347 (TTY: 711). គឺអាចមានសំរារ់រំបរអ្ើ នក។ ចូរ ទូរស័ព្ទ 1-888-344- 6347 (TTY: 711)។ 注意：如果您使用繁體中文，您可以免費獲得語言 援助服務。請致電1-888-344-6347 (TTY: 711)。 ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱਚ CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-888-344- trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888- 6347 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ। 344-6347 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen 주의: 한국어를 사용하시는 경우, 언어 지원 Ihnen kostenlose Sprachdienstleistungen zur 서비스를 무료로 이용하실 수 있습니다. 1-888- Verfügung. Rufnummer: 1-888-344-6347 (TTY: 711) 344-6347 (TTY: 711) 번으로 전화해 주십시오. ማስታወሻ:- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፤ በሚከተለው ቁጥር kang gumamit ng mga serbisyo ng tulong sa wika nang ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው:- 711)፡፡ walang bayad. Tumawag sa 1-888-344-6347 (TTY: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної ВНИМАНИЕ: Если вы говорите на русском языке, служби мовної підтримки. Телефонуйте за то вам доступны бесплатные услуги перевода. номером 1-888-344-6347 (телетайп: 711) Звоните 1-888-344-6347 (телетайп: 711). ध्यान दिनहोस: तपा्ሷलें नेपाली बोल्नहन्छ भने तपा्ሷकों दनदतत भाषा सहायता सेवाहरू ु ् ATTENTION : Si vous parlez français, des services ु ु दनिःशल्क रूपमा उपलब्ध छ । फोन गनुहोस 1-888-344-6347 (दिदिवा्ሷ: ् d'aide linguistique vous sont proposés gratuitement. ु ु Appelez le 1-888-344-6347 (ATS : 711) 711 ATENȚIE: Dacă vorbiți limba română, vă stau la 注意事項：日本語を話される場合、無料の言語支 援をご利用いただけます。1-888-344-6347 dispoziție servicii de asistență lingvistică, gratuit. （TTY:711）まで、お電話にてご連絡ください。 Sunați la 1-888-344-6347 (TTY: 711) MAANDO: To a waawi [Adamawa], e woodi ballooji- ti’go Diné ma to ekkitaaki wolde caahu. Noddu 1-888-344-6347 Bizaad, saad (TTY: 711) 1-888-344-6347 (TTY: 711.) ่ FAKATOKANGA’I: Kapau ‘oku ke Lea- โปรดทราบ: ถา้ คุณพดู ภาษาไทย คุณสามารถใชบ้ ริการชวยเหลือทางภาษาไดฟ้ รี โทร 1-888-344-6347 (TTY: 711) Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea te ke lava ‘o ma’u ia. ້ ໂປດຊາບ: ຖາວາ ທານເວາພາສາ ລາວ, ້ ່ ່ ha’o telefonimai mai ki he fika 1-888-344-6347 (TTY: ່ ການບລການຊວຍເຫອດານພາສາ, ໂດຍບເສຽຄາ, ແມນມພອມໃຫທານ. ໍ ່ ້ ໍ ່ ່ ້ ້ ່ ິ ຼື ີ 711) ັ ໂທຣ 1-888-344-6347 (TTY: 711) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa usluge jezičke pomoći dostupne su vam besplatno. afaanii tola ni jira. 1-888-344-6347 (TTY: 711) tiin Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa bilbilaa. oštećenim govorom ili sluhom: 711) امش یارب ناگیار تروصب ینابز تلایهست ،دینک یم تبحص یسراف نابز هب رگا :هجوت .دیریگب سامت 1-888-344-6347 (TTY: 711) اب .دشاب یم مهارف 1-888-344-6347 مقرب لصتا .ناجملاب كل رفاوتت ةیوغللا ةدعاسملا تامدخ نإف ،ةغللا ركذاف ثدحتت تنك اذإ :ةظوحلم (TTY: 711 مكبلاو مصلا فتاه مقر( 01012017.04PF12LNoticeNDMARegence