Anthem Select HMO Elements Choice 1500 (TES)

Your summary of benefits Anthem® Blue Cross Your Plan: Anthem Select HMO Elements Choice 1500 Your Network: Select HMO Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge medical deductible does not apply Mental Health & Substance Use Disorder Services No charge medical deductible does not apply Specialist care $50 copay per visit medical deductible does not apply Covered Medical Benefits Cost if you use an In-Network Provider Overall Deductible $1,500 person / Your plan applies a separate Pharmacy Deductible to prescription drugs $3,000 family obtained at a pharmacy. See the Covered Prescription Drug Benefits section. Overall Out-of-Pocket Limit $6,400 single / $12,800 family To get benefits under this Plan, you must use In-Network Providers. Services from Out-of-Network Providers are not covered, except for Emergency or Urgent Care, Authorized Services, or when required by law. Please be sure to contact us if you are not sure if we have approved an Authorized Service. The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per single out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per single out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. Doctor Visits (virtual and office) Your plan requires the selection of a Primary Care Physician (PCP). A referral from your Primary Care Physician (PCP) is required for Specialist care and most other providers for select covered services. Primary Care (PCP) and Mental Health and Substance Use Disorder $25 copay per visit medical deductible does not Services virtual and office apply Specialist Care virtual and office $50 copay per visit medical deductible does not apply Other Practitioner Visits Maternity services Prenatal and Postnatal care $25 copay per visit medical deductible does not apply CA/LG/Anthem Select HMO Elements Choice 1500/88E3/01-01-2025 Page 1 of 10

Covered Medical Benefits Cost if you use an In-Network Provider Delivery 30% coinsurance after medical deductible is met Retail Health Clinic for routine care and treatment of common illnesses; $25 copay per visit medical deductible does not usually found in major pharmacies or retail stores. apply Manipulation Therapy $25 copay per visit medical deductible does not Coverage is limited to 20 visits per benefit period. apply Acupuncture $25 copay per visit medical deductible does not Coverage is limited to 20 visits per benefit period. apply Other Services in an Office Allergy Testing $25 copay per visit medical deductible does not apply Prescription Drugs Dispensed in the office 30% coinsurance medical deductible does not Maximum of $250 member cost share per drug. apply Surgery $25 copay per surgery medical deductible does not apply Preventive care / screenings / immunizations No charge Preventive Care for Chronic Conditions per IRS guidelines No charge Diagnostic Services Lab Office No charge Freestanding Lab No charge Outpatient Hospital 30% coinsurance after medical deductible is met X-Ray Office No charge Freestanding Radiology Center No charge Outpatient Hospital 30% coinsurance after medical deductible is met Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office $125 copay per visit medical deductible does not apply Freestanding Radiology Center $125 copay per visit medical deductible does not apply Page 2 of 10

Covered Medical Benefits Cost if you use an In-Network Provider Outpatient Hospital $125 copay per visit medical deductible does not apply Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply In-Network and Out-of-Network Providers: depending on the care provided. $25 copay per visit medical deductible does not apply Emergency Room Facility Services In-Network and Out-of-Network Providers: Your copay will be waived if admitted. $250 copay per visit and 30% coinsurance after medical deductible is met Emergency Room Doctor and Other Services In-Network and Out-of-Network Providers: No charge Ambulance In-Network and Out-of-Network Providers: $150 copay per trip medical deductible does not apply Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge Doctor Services No charge Outpatient Surgery Facility Fees Hospital 30% coinsurance after medical deductible is met Ambulatory Surgical Center 30% coinsurance after medical deductible is met Physician and other services including surgeon fees Hospital No charge Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Facility Fees 30% coinsurance after medical deductible is met Physician and other services including surgeon fees No charge Home Health Care $25 copay per visit medical deductible does not Coverage is limited to 100 visits per benefit period. apply Page 3 of 10

Covered Medical Benefits Cost if you use an In-Network Provider Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical and occupational therapies is limited to 40 visits combined per benefit period. Coverage for speech therapy is limited to 20 visits per benefit period. Office $25 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Pulmonary rehabilitation Office $25 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office $25 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Dialysis/Hemodialysis Office $50 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Chemo/Radiation Therapy Office $50 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Skilled Nursing Care (facility) 30% coinsurance after medical deductible is met Coverage for Inpatient rehabilitation and skilled nursing services is limited to 150 days combined per benefit period. Inpatient Hospice No charge Durable Medical Equipment 20% coinsurance medical deductible does not apply Page 4 of 10

Covered Medical Benefits Cost if you use an In-Network Provider Prosthetic Devices No charge Cost if you use an In- Cost if you use an Covered Prescription Drug Benefits Network Pharmacy Out-of-Network Pharmacy Pharmacy Deductible $500 person / Not covered $1,500 family (does not apply to Tier 1a, Tier 1b drugs) Pharmacy Out-of-Pocket Limit Combined with In- Not covered Network medical out- of-pocket limit Prescription Drug Coverage Network: Base Network Drug List: CA Essential DMHC Day Supply Limits: Retail Pharmacy 30 day supply (cost shares noted below) Retail 90 Pharmacy 90 day supply (3 times the 30 day supply cost share(s) charged at In-Network Retail Pharmacies noted below applies). Home Delivery Pharmacy 90 day supply (maximum cost shares noted below). Maintenance medications are available through our home delivery pharmacy. You will need to call us on the number on your ID card to sign up when you first use the service. Specialty Pharmacy 30 day supply (cost shares noted below for retail and home delivery apply). We may require certain drugs with special handling, provider coordination or patient education be filled by our designated specialty pharmacy. Tier 1a - Typically Lower Cost Generic $5 copay per Not covered (retail and prescription, Pharmacy home delivery) deductible does not apply (retail) and $10 copay per prescription, Pharmacy deductible does not apply (home delivery) Tier 1b - Typically Generic $20 copay per Not covered (retail and prescription, Pharmacy home delivery) deductible does not apply (retail) and $40 copay per prescription, Pharmacy deductible does not apply (home delivery) Tier 2 - Typically Preferred Brand $50 copay per Not covered (retail and prescription after home delivery) Pharmacy deductible is met (retail) and $125 Page 5 of 10

Cost if you use an In- Cost if you use an Covered Prescription Drug Benefits Network Pharmacy Out-of-Network Pharmacy copay per prescription after Pharmacy deductible is met (home delivery) Tier 3 - Typically Non-Preferred Brand $75 copay per Not covered (retail and prescription after home delivery) Pharmacy deductible is met (retail) and $188 copay per prescription after Pharmacy deductible is met (home delivery) Tier 4 - Typically Specialty (brand and generic) 30% coinsurance up to Not covered (retail and $250 per prescription home delivery) after Pharmacy deductible is met (retail and home delivery) Cost if you use an In- Cost if you use an Covered Vision Benefits Network Provider Out-of-Network Provider This is a brief outline of your vision coverage. To receive the In-Network benefit, you must use a Blue View Vision Provider. Only children's vision services count towards your out-of-pocket limit. Children’s Vision exam (up to age 19) No charge Not covered Limited to 1 exam per benefit period. Adult Vision exam (age 19 and older) No charge Not covered Limited to 1 exam per benefit period. Notes: • If you have an office visit with your Primary Care Physician, Specialist or Urgent Care at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”. • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to, injections, cryopreservation and storage for both male and female members when a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. • The representations of benefits in this document are subject to California Department of Managed Health Care (DMHC) approval and are subject to change. Page 6 of 10

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Anthem Blue Cross HMO benefits are covered only when services are provided or coordinated by the primary care physician and authorized by the participating medical group or independent practice association (IPA); except OB/GYN services received within the member's medical group/IPA, and services for mental health and substance use disorders. Benefits are subject to all terms, conditions, limitations, and exclusions of the EOC. Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca Page 7 of 10

Page 8 of 10

Get help in your language Language Assistance Services Curious to know what all this says? We would be too. Here’s the English version: IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at 1-888-254-2721. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish IMPORTANTE: ¿Puede leer esta carta? De lo contrario, podemos hacer que alguien lo ayude a leerla. También puede recibir esta carta escrita en su idioma. Para obtener ayuda gratuita, llame de inmediato al 1-888-254-2721. (TTY/TDD: 711) Arabic Armenian ՈՒՇԱԴՐՈՒԹՅՈՒՆ. Կարողանո՞ւմ եք ընթերցել այս նամակը: Եթե ոչ, մենք կարող ենք տրամադրել ինչ-որ մեկին, ով կօգնի Ձեզ՝ կարդալ այն: Կարող ենք նաև այս նամակը Ձեզ գրավոր տարբերակով տրամադրել: Անվճար օգնություն ստանալու համար կարող եք անհապաղ զանգահարել 1-888-254-2721 հեռախոսահամարով: (TTY/TDD: 711) Chinese 重要事項：您能看懂這封信函嗎？如果您看不懂，我們能夠找人協助您。您有可能可以獲得以您的語言而寫的本信函。如需免 費協助，請立即撥打1-888-254-2721。(TTY/TDD: 711) Farsi Hindi Hmong TSEEM CEEB: Koj puas muaj peev xwm nyeem tau daim ntawv no? Yog hais tias koj nyeem tsis tau, peb muaj peev xwm cia lwm tus pab nyeem rau koj mloog. Tsis tas li ntawd tej zaum koj kuj tseem yuav tau txais daim ntawv no sau ua koj hom lus thiab. Txog rau kev pab dawb, thov hu tam sim no rau tus xov tooj 1-888-254-2721. (TTY/TDD: 711) Japanese Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4644CML 06/16 DMHC3 DMHCW #CA-DMHC-001# Page 9 of 10

重要：この書簡を読めますか？もし読めない場合には、内容を理解するための支援を受けることができます。また、この書 簡を希望する言語で書いたものを入手することもできます。次の番号にいますぐ電話して、無料支援を受けてください。 1-888-254-2721 (TTY/TDD: 711) Khmer Korean 중요: 이 서신을 읽으실 수 있으십니까? 읽으실 수 없을 경우 도움을 드릴 사람이 있습니다. 귀하가 사용하는 언어로 쓰여진 서신을 받으실 수도 있습니다. 무료 도움을 받으시려면 즉시 1-888-254-2721로 전화하십시오. (TTY/TDD: 711) Punjabi ਮਹੱਤਵਪੂਰਨ: ਕੀ ਤੁਸ￿ ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ￿, ਤਾਂ ਅਸ￿ ਇਸ ਨੂੰ ਪੜਹ੍ ਿਵੱਚ ਤੁਹਾਡੀ ਮਦਦ ਲਈ ਿਕਸੇ ਨੂੰ ਬੁਲਾ ਸਕਦਾ ਹਾਂ ਤੁਸ￿ ਸ਼ਾਇਦ ਪੱਤਰ ਨੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ਿਲਿਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ਾਪ ੍ਾਪ ਕਰ ਸਕਦੇ ਹੋ। ਮੁਫ਼ਤ ਮਦਦ ਲਈ, ਿਕਰਪਾ ਕਰਕੇ ਫੌਰਨ 1-888-254-2721 ਤੇ ਕਾਲ ਕਰੋ। (TTY/TDD: 711) Russian ВАЖНО. Можете ли вы прочитать данное письмо? Если нет, наш специалист поможет вам в этом. Вы также можете получить данное письмо на вашем языке. Для получения бесплатной помощи звоните по номеру 1-888-254-2721. (TTY/TDD: 711) Tagalog MAHALAGA: Nababasa ba ninyo ang liham na ito? Kung hindi, may taong maaaring tumulong sa inyo sa pagbasa nito. Maaari ninyo ring makuha ang liham na ito nang nakasulat sa ginagamit ninyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sa 1-888-254-2721. (TTY/TDD: 711) Thai หมายเหตุสำคัญ: ท่านสามารถอ่านจดหมายฉบับนี้หรือไม่ หากท่านไม่สามารถอ่านจดหมายฉบับนี้ เราสามารถจัดหาเจ้าหน้าที่มาอ่านให้ท่านฟังได้ ท่านยังอาจให้เจ้าหน้าที่ช่วยเขียนจดหมายในภาษาของท่านอีกด้วย หากต้องการความช่วยเหลือโดยไม่มีค่าใช้จ่าย โปรดโทรติดต่อที่หมายเลข 1-888-254-2721 (TTY/TDD: 711) Vietnamese QUAN TRỌNG: Quý vị có thể đọc thư này hay không? Nếu không, chúng tôi có thể bố trí người giúp quý vị đọc thư này. Quý vị cũng có thể nhận thư này bằng ngôn ngữ của quý vị. Để được giúp đỡ miễn phí, vui lòng gọi ngay số 1-888-254- 2721. (TTY/TDD: 711) It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4644CML 06/16 DMHC3 DMHCW #CA-DMHC-001# Page 10 of 10