EPO

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 08/01/2025-07/31/2026 Salus Healthcare, LLC: Medical EPO Plan Coverage for: Employee, Employee + Spouse, Employee + Children, Family | Plan Type: EPO (HHS - OMB control number: 0938-1146/Expiration date: 05/31/2026) 1 of 8 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, www.myevhc.com. 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 https://www.healthcare.gov/sbc-glossary or call 1-877-877-3496 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Preferred Provider: $2,000/individual or $4,000/family per benefit period. Nonpreferred Provider: None. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Prescription drugs, and the following services by a preferred provider: Preventive care, urgent care, rehabilitative services, habilitative services, specialist, and primary care physician are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- pocket limit for this plan? Preferred Provider: $5,000/individual or $10,000/family per benefit period. Nonpreferred Provider: None. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of- pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Penalties for failure to obtain pre-certification for services, premiums, balance-billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See www.Anthem.com/ca or call 1-877-877- 3496 for a list of network providers. This plan uses a provider network. You will pay less if you use a preferred provider in the plan’s network. You will pay the most if you use a nonpreferred provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance-billing). Be aware, your preferred provider might use a nonpreferred provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

* For more information about limitations and exceptions, see the plan or policy document at www.myevhc.com. 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Preferred Provider (You will pay the least) Nonpreferred Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $25 copayment/visit (deductible does not apply) Not covered None. Specialist visit $50 copayment/visit (deductible does not apply) Not covered Chiropractic care limited to 20 visits per benefit period. Preventive care/screening/immunizati on 0% coinsurance (deductible does not apply) Not covered You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) Labs: $25 copayment (deductible does not apply) X-Ray: $150 copayment (deductible does not apply) Not covered None. Imaging (CT/PET scans, MRIs) $150 copayment (deductible does not apply) Not covered None.

* For more information about limitations and exceptions, see the plan or policy document at www.myevhc.com. 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Preferred Provider (You will pay the least) Nonpreferred Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.carelonrx.com or call 1-833-419-0530 Generic drugs Retail: $10 copayment/prescription (deductible does not apply) Mail order: $25 copayment/prescription (deductible does not apply) Retail & Mail Order: Not covered Copayment applies to a 31 day supply Retail or 32-90 day supply Mail-Order prescription. Copayment does not apply to preventive drugs required by the Affordable Care Act. Specialty drugs are limited to a 31 day supply for Retail or Mail Order. If you purchase a brand name drug when a generic drug is available, you must pay difference in cost. Preferred drugs Retail: $35 copayment/prescription (deductible does not apply) Mail order: $87.50 copayment/prescription (deductible does not apply) Retail & Mail Order: Not covered Non-preferred drugs Retail: $70 copayment/prescription (deductible does not apply) Mail order: $175 copayment/prescription (deductible does not apply) Retail & Mail Order: Not covered Specialty drugs Generic: $75 copayment/prescription (deductible does not apply) Brand: $250 copayment/prescription (deductible does not apply) Not covered

* For more information about limitations and exceptions, see the plan or policy document at www.myevhc.com. 4 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Preferred Provider (You will pay the least) Nonpreferred Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 30% coinsurance Not covered None. Physician/surgeon fees 30% coinsurance Not covered None. If you need immediate medical attention Emergency room care 30% coinsurance preferred provider benefit applies Non-emergency use of the emergency room is not covered. Emergency medical transportation $150 copayment (deductible does not apply) preferred provider benefit applies None. Urgent care $25 copayment/visit (deductible does not apply) $50 copayment/visit (deductible does not apply) None. If you have a hospital stay Facility fee (e.g., hospital room) 30% coinsurance Not covered Pre-certification is required. If pre- certification is not obtained, benefits are subject to a $300 penalty of the total cost of the service. Physician/surgeon fees 30% coinsurance Not covered None.

* For more information about limitations and exceptions, see the plan or policy document at www.myevhc.com. 5 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Preferred Provider (You will pay the least) Nonpreferred Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse services Outpatient services Office: $25 copayment/visit (deductible does not apply) Other Outpatient Services: 0% coinsurance (deductible does not apply) Office: Not covered Other Outpatient Services: Not covered None. Inpatient services 30% coinsurance Not covered Pre-certification is required. If pre- certification is not obtained, benefits are subject to a $300 penalty of the total cost of the service. If you are pregnant Office visits $25 copayment/visit (deductible does not apply) Not covered Dependent daughters are covered for this benefit. Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 30% coinsurance Not covered Childbirth/delivery facility services 30% coinsurance Not covered

* For more information about limitations and exceptions, see the plan or policy document at www.myevhc.com. 6 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Preferred Provider (You will pay the least) Nonpreferred Provider (You will pay the most) If you need help recovering or have other special health needs Home health care $25 copayment (deductible does not apply) Not covered Home health care visits limited to 100 visits per benefit period. Pre- certification is required. If pre- certification is not obtained, benefits are subject to a $300 penalty of the total cost of the service. Rehabilitation services $25 copayment/visit (deductible does not apply) Not covered None. Habilitation services $25 copayment/visit (deductible does not apply) Not covered None. Skilled nursing care 30% coinsurance Not covered Skilled nursing care limited to 100 days per benefit period. Pre- certification is required. If pre- certification is not obtained, benefits are subject to a $300 penalty of the total cost of the service. Durable medical equipment $70 copayment/procedure (deductible does not apply) Not covered None. Hospice services Inpatient: 30% coinsurance Outpatient: 0% coinsurance (deductible does not apply) Not covered Pre-certification is required. If pre- certification is not obtained, benefits are subject to a $300 penalty of the total cost of the service. If your child needs dental or eye care Children’s eye exam $25 copayment/visit (deductible does not apply) Not covered Limited to 1 exam per benefit period. Children’s glasses Not covered Not covered None. Children’s dental check-up Not covered Not covered None.

* For more information about limitations and exceptions, see the plan or policy document at www.myevhc.com. 7 of 8 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 • Private-duty nursing • Cosmetic surgery • Long-term care • Routine foot care • Dental care (Adult) • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (20 visits per benefit period) • Hearing aids ($5,000 per benefit period) • • Chiropractic care (20 visits per benefit period) • Routine eye care (Adult) (1 exam per benefit period) • 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: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. 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 www.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 on how 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: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. 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 1-877-877-3496. Traditional Chinese (中文): 如果需要中文的幫助, 請撥打這個號碼 1-877-877-3496. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-877-3496. Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf 1-877-877-3496 uff. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-877-3496. Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-877-877-3496. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-877-877-3496. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-877-877-3496. To see examples of how this plan might cover costs for a sample medical situation, see the next section. PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

The plan would be responsible for the other costs of these EXAMPLE covered services. 8 of 8 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 (9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $2,000 ◼ The plan’s overall deductible $2,000 ◼ The plan’s overall deductible $2,000 ◼ Specialist copayment $50 ◼ Specialist copayment $50 ◼ Specialist copayment $50 ◼ Hospital (facility) coinsurance 30% ◼ Hospital (facility) coinsurance 30% ◼ Hospital (facility) coinsurance 30% ◼ Other coinsurance 30% ◼ Other coinsurance 30% ◼ Other coinsurance 30% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) 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 $2,000 Deductibles $800 Deductibles $800 Copayments $700 Copayments $1,400 Copayments $500 Coinsurance $2,300 Coinsurance $0 Coinsurance $0 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0 The total Peg would pay is $5,060 The total Joe would pay is $2,220 The total Mia would pay is $1,300