Double Cheese SBC

Benefit Benefit Period Deductible (per Plan Year) Individual Family Member Pays - payment based on the plan allowance Total Maximum Out-of-Pocket (includes deductible, coinsurance, copays, prescription drug cost sharing and other qualified medical expenses. Once met, there is no cost sharing for covered services for the rest of the Plan Year). Individual Family Provider Plan Designated Direct Primary Care Physician, and all services ordered by the Plan Designated Direct Primary Care Physician, through the Collaborative Care Program Telemedicine (Includes Mental/Behavioral Health) Services rendered in a physician’s office Standard Benefit Enhanced Benefit Primary Care Physician/Provider $100 Copayment per Physician/Office visit No adjustment Specialists Including: Allergy (Testing and treatment) Dermatology Endocrinology (non-surgical treatment) Infectious Disease OB/GYN Pain Medicine Pulmonology Sleep Medicine $100 Copayment per Physician/Office visit No adjustment All Other Specialty Care visits: $200 Copayment per Physician/Office visit Collaborative Care may be able to reduce cost share Lab Services $200 Copayment per Physician/Office visit No adjustment X-Ray Services $200 Copayment per Physician/Office visit Collaborative Care may be able to reduce cost share Advanced Imaging Services (MRI/MRA, CT Scans, PET Scans, Nuclear Medicine, Ultrasounds) Injections and Infusions (Not Immunizations, see Preventive Care, Below. Preauthorization Required) Office/Clinic Based Surgery (With No Surgical Facility Charge.) Walk-In Retail/Convenience or Urgent Care Clinics not in a Hospital $100 Copayment per Physician/Office visit No adjustment General Plan Provisions Standard Benefit Plan Year (1/1/2026 –12/31/2026) $8,000 / $16,000 Some of the Plans are payable for an individual once the Individual Deductible is met. Each time an individual within the family pays toward his or her individual deductible, that amount is also credited toward the family deductible. Once the family deductible is met, benefits are payable for all family members even if their individual deductibles are not met. 0% Coinsurance to the Out-of-Pocket Maximum COLLABORATIVE CARE : In the following descriptions of benefits, certain benefits may be enhanced by participation in the Collaborative Care Program. Participation entails a discussion with the Collaborative Care Nurse and choosing providers who offer both the Participant and Plan enhanced savings opportunities. As an example, the member might have two or more options for where to have a diagnostic test, or surgery with one option being of both high quality and low cost. The Collaborative Care Program has discretion to reduce or waive member cost share if there is a great option for high quality care. Collaborative Care cannot waive all cost share but is a valuable tool if a Participant is ordered to receive typically higher cost services like surgery, specialty care, advanced imaging, durable medical equipment and consumable supplies, specialty medications, biologics and cancer care. Physician Office Services $200 Copayment at a non-facility-based site or clinic. Collaborative Care may be able to reduce member cost share Pediatrician services, age 0-18 $100 Copayment per Physician/Office visit No adjustment $9,100 / $18,200 Benefits are payable at 100% without any cost share for an individual once the Individual Out-of-Pocket Maximum is met. Each time an individual within the family pays toward his or her individual Out-of-Pocket Maximum, that amount is also credited toward the family Out-of-Pocket Maximum. Once the family Out-of-Pocket Maximum is met, benefits are payable for all family members even if their individual deductibles are not met. Enhanced Provider Benefits Enhanced Benefit No Charge No Charge $200 Copayment per Physician/Office visit Collaborative Care may be able to reduce member cost share $200 Copayment per Physician/Office visit No adjustment

Service Routine Pediatric/Adolescent Adult Physical Exams Adult, Pediatric and Adolescent Immunizations (including but not limited to Shingrix, Flu Shots with no age limitations and other standard US Task Force / CDC recommended Immunizations appropriate by age or frequency defined) Routine Vision Examinations (Not Including refraction, eyeglasses or contact lenses and their fitting) Mammograms (2D or 3D as Medically Appropriate) Family Planning and Contraceptive Management Routine Colonoscopy Other Routine Screenings according to US Preventive Task Force or Plan Guidelines Service Standard Benefit Enhanced Benefit Lab Services and Diagnostic Tests $100 Copayment per Office or Imaging Facility visit Collaborative Care may be able to reduce member cost share X-Ray Services not otherwise described $100 Copay per visit Collaborative Care may be able to reduce member cost share Advanced Imaging (MRI/MRA, CT Scans, PET Scans, Nuclear Medicine. Benefits for non-Emergent imaging tests are limited to the lowest cost available within 75 miles of the Plan Participant’s home address.) Service Emergency Room (Including Facility, ER Physician, Radiologist, & Pathologist. Copayment will be waived if patient is admitted to an overnight bed stay.) Urgent Care In A Hospital (Includes the facility charges, only. Physician charges are separate.) Emergent Ground or Air Ambulance and other Medically Necessary transportation Non-Emergent Air Ambulance (Preauthorization is Required or Coverage is not Available) Service Standard Benefit Enhanced Benefit Surgery Facility (Preauthorization Required) Surgeon (Preauthorization May be Required) Assistant Surgeon (Preauthorization May be Required) Anesthesiologist (Preauthorization is Required) Pathologist/Radiologist $200 Copayment per Treatment Date Collaborative Care may be able to reduce member cost share Preadmission Testing No Charge. (included in the admission or surgical facility copayment even if on a different date of service.) No adjustment Standard Benefit No Charge No Charge No Charge No Charge No Charge NOTE: Copayments apply to charges received from Physicians or from a Clinic, for each bill received by the Plan. As an example, if a Participant is treated in a Physician office or Clinic and has lab services, radiology services, an injection or medication, surgery or other covered services at the time of that visit, only one copayment will apply. Moreover, if a Participant visits a Physician office or Clinic just for a lab test, x-ray, injection, or other covered service even if no physician visit is performed on that date, a copayment will apply. NOTE: It the Physician splits the bill into two separate billings for the same Date of Service, every effort will be made to combine the bills to one and apply only one copayment for that date. If split services are billed by two different Physicians, a separate copayment will apply to each bill. A common example of this is when a Clinic bills for a Physician and you also receive a charge from a Radiologist or Pathologist, separately. One copayment would apply to each bill. Preventive Care Emergency Services Standard Benefit $500 Copayment per visit. $200 Copayment per visit. $500 Copayment per visit. $2,000 Copayment per visit. No Charge No Charge Preventive/Well Care is covered as defined in the Patient Protection and Affordable Care Act, as amended, and as described by the Health Resources and Services Administration (HRSA) Diagnostic Testing (Independent Laboratory & Freestanding Imaging Facility) $200 Copayment per Imaging Facility visit Collaborative Care may be able to reduce member cost share $200 Copayment per Treatment Date Collaborative Care may be able to reduce member cost share Ambulatory Surgical Center $1,000 Copayment per instance. Collaborative Care may be able to reduce member cost share $200 Copayment per Treatment Date Collaborative Care may be able to reduce member cost share $200 Copayment per Treatment Date Collaborative Care may be able to reduce member cost share

Service Standard Benefit Enhanced Benefit Acute Care Inpatient Facility (Preauthorization required) Inpatient Physician (Hospitalists, Therapists, Physicians, Specialists, Surgeon, Anesthesiologist Pathologists, Radiologists) Post Hospitalization Medical Rehab Facility (Preauthorization Required) Skilled Nursing Facility (60 days per Plan Year. Preauthorization Required. In certain circumstances, Collaborative Care may be able to waive or extend the day the limitation.) Transplant Services in a Facility (Only Covered when Pre-Authorized with Care provided through a Center Of Excellence.) Service Standard Benefit Enhanced Benefit Outpatient Hospital Facility (Procedures that require sedation or general anesthesia must be Pre-Authorized) Outpatient Hospital Observation (Emergent only) $2,000 Copayment per Observation Stay Collaborative Care may be able to reduce member cost share Lab Tests, only $200 Copayment per Date of Service Collaborative Care may be able to reduce member cost share X-ray Services and Diagnostic Tests $200 Copayment per Date of Service Collaborative Care may be able to reduce member cost share Advanced Imaging (MRI/MRA, CT Scans, PET Scans, Nuclear Medicine. Benefits for non-Emergent imaging tests are limited to the lowest cost available within 50 miles of the Plan Participant’s home address.) Chemotherapy (Preauthorization Required) Radiation Therapy (Preauthorization Required) Infusion Therapy (Preauthorization Required) Cardiac Rehabilitation (36 visit limit per Plan Year. Collaborative Care may be able to waive the limitation. Preauthorization Required for Phase III and Phase IV) Physical, Speech, Occupational Therapy, CBA, CBT, and ABA (Combined 30 visit limits per Plan Year. Collaborative Care may be able to waive the limitation in cases where treatment in lieu of this care is considered more advanced or invasive for the member.) $150 copayment per provider, per date of service, limited to 240 minutes of billable care per date of service. Collaborative Care may be able to reduce member cost share Pulmonary Rehab/Respiratory Therapy (30 visit limit per Plan Year. Collaborative Care may be able to waive the limitation) $150 copayment per provider, per date of service, limited to 5 copays per calendar month Collaborative Care may be able to reduce member cost share Hyperbaric Therapy (Preauthorization Required) Other Medically Necessary Outpatient Hospital Services described elsewhere in this Plan Document. $500 Copayment per Date of Service Collaborative Care may be able to reduce member cost share Service Prenatal Care - Physician Office Visits – Physician Global Prenatal Service Charge No Charge No adjustment Inpatient Hospital /Mothers Charges (Preauthorization Required, only when the stay exceeds 48 hours for a vaginal delivery or 96 hours for a cesarean section delivery.) Hospital Nursery/Newborn Charges (Newborn Admissions less than 5 nights are included in the mother’s $2,000 Copayment) $2,000 Copayment per admission No adjustment Physician - Global Delivery Charge No Charge No adjustment Physician - Newborn Services (Includes Evaluation & Management, Surgical Charges, and other covered services.) Nurse Midwife No Charge No adjustment Birthing Center No Charge No adjustment Medical Inpatient Services - Hospital, Medical Rehabilitation, Skilled Nursing Facility $2,000 copayment per admission No adjustment. No Charge as long as care is provided during a covered Inpatient Stay. No Adjustment. Medical Outpatient Hospital Services $2,000 Copayment per date of treatment (not Advanced Imaging or laboratory only services) Collaborative Care may be able to reduce member cost share $2,000 Copayment per visit. Collaborative Care may be able to reduce member cost share $200 copayment per admission (Copayment is in addition to the Acute Care Inpatient Copay) Collaborative Care may be able to reduce member cost share $2,000 copayment per admission (Copayment is in addition to the Acute Care Inpatient Copay) Collaborative Care may be able to reduce member cost share $2,000 Copayment per transplant episode. No adjustment $500 copayment per provider, per date of service, limited to 5 copays per calendar month Collaborative Care may be able to reduce member cost share Maternity Services Standard Benefit $100 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $200 copayment per date of service (Waived if care is in a clinic setting) Collaborative Care may be able to reduce member cost share $200 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $500 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $2,000 Copayment per admission No adjustment No Charge No adjustment

Lactation Counseling & Equipment No Charge No adjustment Service Standard Benefit Enhanced Benefit Acupuncture Treatment (Limited to post-procedure nausea, pain and vomiting due to surgery, anti-neoplastic agents, or postoperative dental pain.) Cardiac Rehabilitation Preauthorization Required for Phase III and Phase IV) Chemotherapy (Pre-Authorization Required) Chiropractic Care/Spinal Manipulations (30 visit limit per Plan Year. Collaborative Care may be able to waive the limitation.) $150 Copayment per Date of Service Collaborative Care may be able to extend the visit limitation Dialysis (Hemodialysis, Peritoneal Dialysis, Coordination of Billing and Supplies for Home Based Dialysis) Holistic or Homeopathic Medicine Not Covered No adjustment Hyperbaric Treatment (Must be Pre-authorized.) Infusion Specialty Medications (Must be Pre-Authorized. If purchased through the Prescription Plan, other rules may be applicable. See section VII- Prescription Drug Benefits) Infusion Therapy Not Specific to Cancer (Must be Pre-Authorized.) Massage Therapy Not Covered No adjustment Physical, Speech, Occupational Therapy, CBA, CBT, and ABA (Combined 30 visit limits per Plan Year. Collaborative Care may be able to waive the limitation in cases where treatment in lieu of this care is considered more advanced or invasive for the member.) $150 copayment per provider, per date of service, limited to 240 minutes of billable care per date of service. Collaborative Care may be able to reduce member cost share Pulmonary Rehab/Respiratory Therapy (30 visit limit per Plan Year. Collaborative Care may be able to waive the limitation) Vision Therapy (Up to 12 visits per calendar year, Subject to Medical Necessity. Preauthorization Required) Service Standard Benefit Enhanced Benefit Office Visit - Mental Health (Clinic Based) Inpatient Mental Health Services (Facility. Must be Pre-Authorized.) Inpatient Mental Health Services (Physician) No Charge, as long as services are received during a covered inpatient stay Collaborative Care may be able to reduce member cost share Other Physician Services (Including pathology & radiology services) Outpatient Mental Health Services (Including Psychotherapy, other therapies, testing. Facility Based) $500 Copayment per provider, per date of treatment Collaborative Care may be able to reduce member cost share Outpatient Mental Health Services (Physician / Practitioner) $150 Copayment per provider, per date of treatment Collaborative Care may be able to reduce member cost share Mental Health Residential Treatment (Facility & Physician. Must be Pre-Authorized.) $2,000 Copayment per confinement Collaborative Care may be able to reduce member cost share Mental Health Partial Hospitalization (Facility & Physician. Must be Pre-Authorized.) $2,000 Copayment per confinement Collaborative Care may be able to reduce member cost share Service Standard Benefit Enhanced Benefit Office Visit - Substance Abuse or Alcohol Abuse $150 Copayment per Provider, per Date of Service Collaborative Care may be able to reduce member cost share Inpatient Alcohol Detox (Facility. Must be Pre-Authorized.) Inpatient Alcohol Detox $100 Copayment per Date of Service Collaborative Care may be able to reduce member cost share No Charge Collaborative Care may be able to reduce member cost share Therapy and Rehabilitation Services - Office / Stand Alone Clinic Typically Excluded, but if approved by Collaborative Care, $150 Copayment per Date of Service No adjustment $150 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $150 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $150 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $150 Copayment per Date of Service No adjustment $200 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $2,000 Copayment per admission Collaborative Care may be able to reduce member cost share $0 included with inpatient facility admission copay Collaborative Care may be able to reduce member cost share Substance Abuse (Including Alcohol) $2,000 Copayment per admission Collaborative Care may be able to reduce member cost share $75 Copayment per Date of Service Collaborative Care may be able to reduce member cost share Mental Health Services $150 Copayment per Provider, per Date of Service Collaborative Care may be able to reduce member cost share No Charge, as long as services are received during a covered inpatient stay Collaborative Care may be able to reduce member cost share

(Physician charges.) Other Physician Services (Including labs, pathology & radiology services) Outpatient Hospital Alcohol Detox Services (Facility. Must be Pre-Authorized.) $500 Copayment per Date of Treatment Collaborative Care may be able to reduce member cost share Outpatient Hospital Alcohol Detox Services (Physician charges) $150 Copayment per Provider, Date of Treatment Collaborative Care may be able to reduce member cost share Inpatient Substance Abuse Rehab (Facility. Must be Pre-Authorized) $2,000 Copay per admission Collaborative Care may be able to reduce member cost share Inpatient Substance Abuse Rehab (Physician charges) No Charge, as long as services are received during a covered inpatient stay Collaborative Care may be able to reduce member cost share Outpatient Hospital Substance Abuse (Facility) $500 Copayment per Date of Treatment Collaborative Care may be able to reduce member cost share Outpatient Hospital Substance Abuse (Physician charges) $150 Copayment per Provider, Date of Treatment Collaborative Care may be able to reduce member cost share Substance Abuse Residential Treatment (Facility & Physician. Must be Pre-Authorized.) Substance Abuse Partial Hospitalization (Facility & Physician. Must be Pre-Authorized.) Service Standard Benefit Enhanced Benefit Assisted Fertilization Procedures Not Covered No adjustment Biofeedback Typically excluded, but $150 per date of service if approved by Collaborative Care No adjustment Cochlear Implants (Must Be Pre-Authorized. Covered only for Dependent Children through the age of 18.) Consumable Medical Supplies (Subject to Medical Necessity) Dental Facility Charge Related to Accidental Injury or for limited services (Please refer to Article III-Medical Benefits for a complete list of covered services. Subject to Preauthorization.) $500 Copayment per Date of Service Collaborative Care may be able to reduce member cost share Dental Oral Surgery (Physician or Dentist. Limited list of covered services, please refer to Article III, Medical Benefits for a complete list of covered services. Subject to Preauthorization) Diabetic Supplies $150 Copay, upt to 3 month supply Collaborative Care may be able to reduce member cost share Durable Medical Equipment and Prosthetics (Rental to the Purchase Price. Must be Pre-Authorized if the total cost of rental and/or purchase will exceed $1,500.) Genetic Counseling (Preauthorization is required) Genetic Testing (Preauthorization is required) Hearing Aids & Exams (Limited to a single purchase and/or repair per five years for Participants over 18 years of age, a single purchase and/or repair per four years for Participants ages 0 through 18, with up to four additional molds per year for Participants aged 0 to 2.) Home Health Care (Limited to 40 visits per Calendar Year. Collaborative Care may be able to waive the visit limitation.) Hospice Care (Requires Preauthorization) Nutritional Counseling (Must be by a Registered Dietician or Physician) Private Duty Nursing Not Covered No adjustment Sexual Function / Therapy (Therapeutic, Diagnostic, Pharmaceutical, Device and Surgical) Sleep Study (Clinic Setting) Sleep Study (Facility/Outpatient Hospital) $2,000 copayment per study Collaborative Care may be able to reduce member cost shar $2,000 Copayment per confinement Collaborative Care may be able to reduce member cost share Other Treatments/Services Not Categorized Elsewhere $2,000 copayment per implant, including physician and facility charges Collaborative Care may be able to reduce member cost share $150 Copayment Per Date of Purchase, up to a three-month supply Collaborative Care may be able to reduce member cost share No Charge, as long as services are received during a covered inpatient stay Collaborative Care may be able to reduce member cost share No Charge, as long as services are received during a covered inpatient stay Collaborative Care may be able to reduce member cost share $2,000 Copayment per confinement Collaborative Care may be able to reduce member cost share $2000 Copayment Per Provider, Date of Service No adjustment $150 Copayment per Provider, Date of Service for Exams and Diagnostic testing, $500 Copayment per provider, date of purchase for devices No adjustment $150 Copayment per visit Collaborative Care may be able to extend the visit limitation $150 Copayment Per Physician/Dentist, Date of Treatment Collaborative Care may be able to reduce member cost share $150 Copayment per calendar month for rental, $250 copayment per date of purchase of Durable Medical Equipment Collaborative Care may be able to reduce member cost share $150 Copayment Per Provider, Date of Service No adjustment $500 copayment per study Collaborative Care may be able to reduce member cost share $150 Copayment per visit No adjustment $150 Copayment per Provider, per date of service Collaborative Care may be able to reduce member cost share Not Covered No adjustment

Sleep Study (In-Home) Sterilization Procedures and Follow-up Testing. (Male or Female) No Charge No adjustment Wigs (Limited to2 per lifetime following Biologic, Genetic, Chemo or Radiation therapy.) Standard Benefit (30-Day Supply) Tier 1- Preferred Generic After Deductible is Met, $5 Copayment No adjustment Tier 2 - Preferred Brand After Deductible is Met, then $40 Copayment No adjustment Tier 3 - Non-Preferred Brand After Deductible is Met, then $80 Copayment No adjustment Tier 4 - Specialty Drugs After Deductible is Met, then $250 Copayment Contact Rescrybe at 866-401-1883 Prescription Drugs Standard Benefit $150 copayment per study Collaborative Care may be able to reduce member cost share $250 Copayment per wig purchased No adjustment