Kaiser Permanente HSA-Qualified High Deductible Health Plan ("HDHP") HMO Benefits

Disclosure Form Part One (continues) 236688 Meyers Nave, a Professional Corporation Home Region: Southern California 1/1/26 through 12/31/26 Principal benefits for Kaiser Permanente HSA-Qualified High Deductible Health Plan (“HDHP”) HMO “Kaiser Permanente HSA-Qualified High Deductible Health Plan (“HDHP”) HMO” is a health benefit plan that meets the requirements of Section 223(c)(2) of the Internal Revenue Code. For a complete explanation, please refer to the EOC. Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Out-of-Pocket Maximums and Deductibles For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. For Services that are subject to the Plan Deductible or the Drug Deductible, you must pay Charges for covered Services you receive during the Accumulation Period until you reach the deductible amounts listed below. All payments you make toward your deductibles apply to the Plan Out-of-Pocket Maximum amounts listed below. Amounts Per Accumulation Period Self-Only Coverage (a Family of one Member) Family Coverage Each Member in a Family of two or more Members Family Coverage Entire Family of two or more Members Plan Out-of-Pocket Maximum $3,400 $3,400 $6,800 Plan Deductible $3,400 $3,400 $6,800 Drug Deductible Not applicable Not applicable Not applicable Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits ...... No charge after Plan Deductible Most Physician Specialist Visits ............................................................. No charge after Plan Deductible Routine physical maintenance exams, including well-woman exams .... No charge (Plan Deductible doesn’t apply) Well-child preventive exams (through age 23 months) .......................... No charge (Plan Deductible doesn’t apply) Routine eye exams with a Plan Optometrist .......................................... No charge (Plan Deductible doesn’t apply) Urgent care consultations, evaluations, and treatment .......................... No charge after Plan Deductible Most physical, occupational, and speech therapy .................................. No charge after Plan Deductible Telehealth Visits You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video or telephone .................................................................................. No charge after Plan Deductible Physician Specialist Visits by interactive video or telephone ................. No charge after Plan Deductible Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures .................. No charge after Plan Deductible Most immunizations (including the vaccine) ........................................... No charge (Plan Deductible doesn’t apply) Most X-rays and laboratory tests ............................................................ No charge after Plan Deductible Preventive X-rays, screenings, and laboratory tests as described in the EOC ................................................................................................ No charge (Plan Deductible doesn’t apply) Hospital Inpatient Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ..................................................................................................... No charge after Plan Deductible Emergency Services and Care You Pay Emergency department visits ................................................................. No charge after Plan Deductible Note: If you are admitted directly to the hospital as an inpatient for covered Services, you will pay the inpatient Cost Share instead of the emergency department Cost Share (see “Hospital Inpatient Services” for inpatient Cost Share) Ambulance Services You Pay Ambulance Services ............................................................................... No charge after Plan Deductible Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items (Tier 1) at a Plan Pharmacy or through our mail- order service ....................................................................................... No charge for up to a 100-day supply after Plan Deductible Most brand-name items (Tier 2) at a Plan Pharmacy or through our mail-order service ............................................................................... No charge for up to a 100-day supply after Plan Deductible Most specialty items (Tier 4) at a Plan Pharmacy ............................... No charge for up to a 30-day supply after Plan Deductible