Summary of Benefits and Coverage: Life Is Good PPO $2,000 Plan

v1.0 1 of 6 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2026 – 12/31/2026 Life Is Good: PPO $2,000 Plan Coverage for: Employee & Dependents | 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, call 1-877-906-5730. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider or other underlined terms see the Glossary. You may view the Glossary at healthcare.gov/sbc-glossary or call 1-877-906-5730 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? In-Network: Single Plan: $2,000 employee Family Plan: $2,000 person/$4,000 family Out-of-Network: Single Plan: $2,000 employee Family Plan: $2,000 person/$4,000 family 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. In-network preventive services and physician office visits are some of the services 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 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? In-Network: Single Plan: $6,600 employee Family Plan: $6,600 person/$13,200 family Out-of-Network: Single Plan: $6,600 employee Family Plan: $6,600 person/$13,200 family 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 is met. What is not included in the out-of-pocket limit? 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 hpiTPA.com or call 1-877-906-5730 for a list of network providers. This plan uses a provider network. You pay less if you use a provider in the plan’s network. You pay the most if you use an out-of-network 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 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 see a specialist? No. You may see a specialist you choose without a referral.

v1.0 2 of 6 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 In-Network Provider (You pay the least) Out-of-Network Provider (You pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $25 copay/visit; deductible waived 20% coinsurance You may have to pay for services that aren’t preventive. Ask your provider if services are preventive. Then check what your plan will pay. Telemedicine – Doctor On Demand $1 copay/visit; deductible waived 20% coinsurance Specialist visit $25 copay/visit; deductible waived 20% coinsurance Preventive care/screening/immunization No charge; deductible waived 20% coinsurance If you have a test Diagnostic test (x-ray, blood work) No charge; deductible waived 20% coinsurance None Imaging (CT/PET scans, MRIs) $150 copay/day; deductible waived 20% coinsurance If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at hpiTPA.com Generic drugs— Retail (30 days) Retail (90 days)/Mail Order (90 days) $5 copay/prescription $10 copay/prescription 20% coinsurance Deductible waived Preferred drugs— Retail (30 days) Retail (90 days)/Mail Order (90 days) $35 copay/prescription $70 copay/prescription 20% coinsurance Non-preferred drugs— Retail (30 days) Retail (90 days)/Mail Order (90 days) $50 copay/prescription $100 copay/prescription 20% coinsurance Specialty drugs---Retail/Mail Order (30 days) $50 copay/prescription 20% coinsurance If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) deductible only 20% coinsurance Preauthorization required for total joint replacement & non-emergent spine surgeries Physician/surgeon fees deductible only 20% coinsurance If you need immediate medical attention Emergency room care $150 copay/visit; deductible waived Copay waived if admitted Emergency medical transportation In-network deductible only None Urgent care $25 copay/visit; deductible waived 20% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) deductible only 20% coinsurance Preauthorization required Physician/surgeon fees deductible only 20% coinsurance

v1.0 3 of 6 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 In-Network Provider (You pay the least) Out-of-Network Provider (You pay the most) If you need mental health, behavioral health or substance abuse services Outpatient services— Office visit $25 copay/visit; deductible waived 20% coinsurance Preauthorization required for Intensive outpatient treatment & Inpatient services Inpatient services deductible only 20% coinsurance If you are pregnant Office visits No charge; deductible waived 20% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) Childbirth/delivery professional services deductible only 20% coinsurance Childbirth/delivery facility services deductible only 20% coinsurance If you need help recovering or have other special health needs Home health care deductible only 20% coinsurance Preauthorization required. Rehabilitation services— Inpatient Outpatient deductible only $25 copay/visit; deductible waived 20% coinsurance 60 days/yr. Preauthorization required for Inpatient & Speech therapy. $500 penalty for failure to precertify out-of-network speech therapy. Coverage is limited to an annual max of 20 visits for Physical therapy and 20 visits annual max for Chiropractic care services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies Habilitation services Physical therapy: $25 copay/visit; deductible waived 20% coinsurance Services are covered when Medically Necessary to treat a mental health condition (e.g. autism) or a congenital abnormality.

v1.0 4 of 6 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 In-Network Provider (You pay the least) Out-of-Network Provider (You pay the most) If you need help recovering or have other special health needs (continued) Hearing, Occupational, & Speech therapies: $25 copay/visit; deductible waived Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies $500 penalty for failure to precertify out-of-network speech therapy. When covered under the plan, early intervention services are covered until age 3 and plan limits and precertification requirements apply to coverage for developmental delays Skilled nursing care deductible only 20% coinsurance 60 days/yr. Preauthorization required Durable medical equipment deductible only 20% coinsurance Preauthorization required for rental over 3 months, equipment over $1,000, neuromuscular stimulator equipment & implantable loop recorders/defibrillators Hospice services deductible only 20% coinsurance Preauthorization required If your child needs dental or eye care Children’s eye exam Not covered Not covered n/a Children’s glasses Not covered Not covered n/a Children’s dental check-up Not covered Not covered n/a

v1.0 5 of 6 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.) • Cosmetic surgery • Non-emergency care when traveling outside U.S. • Routine foot care • Dental care (routine over age 13) • Private duty nursing • Weight loss programs • Long term care • Routine eye care (adult & child) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (20 visits/yr) • Hearing aids (1/aid/ear/3 yrs/up to $2,500/ear; 1 bone anchored hearing aid/lifetime up to age 18) • Bariatric Surgery ($50,000 lifetime max) • Infertility treatment ($30,000 Rx/lifetime & $50,000 medical/lifetime) • Chiropractic care (20 visits/yr) • Wigs (1 wig/yr when related to cancer, surgery, burns, or alopecia; up to $500) 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 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 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 1-877-906-5730. You may also contact the U.S. 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 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 1-877-906-5730; Portuguese (Portuguès): De assistència em Portuguès, ligue 1-877-906-5730 Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-906-5730 ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

v1.0 6 of 6 The plan would be responsible for the other costs of these EXAMPLE covered services. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) ◼ The plan’s overall deductible $2,000 ◼ Specialist copayment $25 ◼ Hospital (facility) deductible ◼ Other no charge 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) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $2,000 Copayments $10 Coinsurance $0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $2,070 ◼ The plan’s overall deductible $2,000 ◼ Specialist copayment $25 ◼ Hospital (facility) deductible ◼ Other deductible 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) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $2,000 Copayments $400 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $2,420 ◼ The plan’s overall deductible $2,000 ◼ Specialist copayment $25 ◼ Hospital (facility) deductible ◼ Other copayment $25 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $1,300 Copayments $400 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,900 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.